Regional Workshop on AMR in South ... - origin.searo.who.intorigin.searo.who.int/entity/antimicrobial_resistance/documents/... · Education, Symposium ) - Award to the best IPC of

27-Mar-18 National Health Laboratory

Yangon, Myanmar

1

Regional Workshop on AMR in

South East Asia

Penang (Malaysia):

26-28 March 2018

Prof : Htay Htay Tin

[email protected]

DDG ( Laboratory)

National Health Laboratory

National Focal Point for AMR

Ministry of Health and Sports

Myanmar


Yangon, Myanmar

2


Yangon, Myanmar

3

Myanmar National Action Plan on AMR

(NAP-AMR) in Line with Global Action Plan

on AMR ( GAP-AMR) as at 2018 January

Presence of national AMR multi-sectoral

committee and NAP-AMR in line with

GAP-AMR

- National AMR Multisectoral Committee

(Established) 2018 January

-NAP-AMR Launched ..2017 July

Awareness campaigns to the public -WAAW .. Held in 2017 November

-Some government-led activities in parts

of the country to raise awareness about

AMR and actions to address it

Education and training strategies for

professionals

-Relevant policies developed and ad-hoc

training courses in some disciplines


Yangon, Myanmar

4

National human AMR surveillance -Covering over 40 public hospitals

-Guidelines developed but not fully

implemented, limited quality data

Laboratory capacity

strengthening

-N.H.L is recognised as National AMR lab of Myanmar at present-DDG (Lab) is National Focal point of Laboratory capacity

strengthening

Early warning systems No effective system in place


Yangon, Myanmar

5

Rational use of antimicrobials and

surveillance of Use & Sale

National policy for control of human use

of antimicrobials (AMR Stewardship

Program, AMSP)

National Drug Policy 2001

But weak to develop a plan to

National AMSP

NRA/DRA system set up for oversight

but not fully functional

National policy & plan on surveillance of

use of antimicrobials under development

or developed & approved but less

implemented

Rational use of antimicrobials and

surveillance of Use & Sale

Indicator 4.4 Regulation of finished

antibiotic products and active

pharmaceutical ingredients (APIs)

Regulation with limited capacity but

strategic planning in place for capacity

building and appropriate budgeting

-


Yangon, Myanmar

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Infection Prevention Control & AMR

Stewardship program

Indicator 5.1 AMR stewardship program

in HCS

-Awareness of Infection Prevention

Control Committee and Team, SOPs,

Guidelines, Job Description and

Training to all level of health providers

-Weekly supervision with checklist


Stewardship program

Indicator 5.2 Surveillance of healthcare

associated infections (HAI)

- Weak surveillance of HAI


Yangon, Myanmar

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Stewardship program

Indicator 5.3 IPC program in HCS

-Capacity building plans implemented in

selected healthcare facilities

_But cannot cover all levels of HCS


Stewardship program

Indicator 5.4 Sanitation & hygiene and

vaccination in the community

-Formal campaign to enhance sanitation &

hygiene and vaccination is implemented

-Hand hygiene campaign , Health

Education, Symposium )

- Award to the best IPC of HCS

Research & Development to Combat

AMR

Indicator 6.1 Research & development

and innovation on AMR prevention and

containment

Very few R&D

-Existing structure has a plan to foster

research and innovation on AMR


Yangon, Myanmar

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27-Mar-18


Yangon, Myanmar

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20.1.2018 National Health Laboratory

Yangon, Myanmar

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27-Mar-18


Yangon, Myanmar

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Yangon, Myanmar

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2016, June


Yangon, Myanmar

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Yangon, Myanmar

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NAP Governance Structure in Myanmar


Yangon, Myanmar

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National Multisectoral Steering

Committee(NMSC) Combating AMR

Myanmar

Endorsed .. 2018 January

• Chairman.. Union Minister of Health and

Sports

• 19 members from multisectoral in

One-Health approach

• DDG ( Labs ) .. Secretary


Yangon, Myanmar

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Yangon, Myanmar

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Common Bacteria associated with

(HAI ) Hospital Acquired Infections :

WHO High Priority Pathogens

• Staphylococcus aureus

• Pseudomonas aeruginosa

• Acinetobacter species

• Escherichia coli

• Klebsiella species

Antibiotic susceptibility patterns of Escherichia coli in

Myanmar (2016)


Yangon, Myanmar

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%89% 88%

83%78%

66%63%

56%52% 51%

44% 44%40% 40% 40%

34% 32% 32% 31% 29% 29% 27%

17%

8%

Pe

rce

nta

ge

Antibiotics

Antibiotic susceptibility patterns of Klebsiella species

in Myanmar (2016)


Yangon, Myanmar

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

86%82%

74%

68% 67%64%

60% 60%

53% 52% 52% 50% 48%

40% 39% 38% 36% 34%

28%Pe

rce

nta

ge

Antibiotics

Antibiotic susceptibility patterns of Pseudomonas

aeruginosa in Myanmar (2016)


Yangon, Myanmar

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

81% 81%75% 75%

65%

59% 57% 57%53% 53% 52%

49%

Pe

rce

nta

ge

Antibiotics

Antibiotic susceptibility patterns of Staphylococcus

species in Myanmar (2016)


Yangon, Myanmar

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100% 91%

79% 77% 74% 74% 74% 72% 71% 69% 67%

61% 60%56% 55% 54%

11%

Pe

rce

nta

ge

Antibiotics

*MRSA

Antibiotic susceptibility patterns of Acinetobacter

species in Myanmar (2016)


Yangon, Myanmar

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

79% 78% 78%

68%

62%

45%42% 41% 40%

35%

28%25% 24%

5%

Pe

rce

nta

ge

Antibiotics


Yangon, Myanmar

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WHO High Priority Pathogens in Myanmar

(ESBL producing Enterobacteriaceae, VRE and MRSA)(2016)

0%

10%

20%

30%

40%

50%

ESBL producing

Enterobacteriaceae, 47% Methicillin-resistant

Staphylococcus aureus, 40%

Vancomycin-resistant

Enterococcus species, 30%

Perc

en

tage

Pathogenic Bacteria


Yangon, Myanmar

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Yangon, Myanmar

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Yangon, Myanmar

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➢Myanmar National Policy on Health Laboratories had

been disseminated in September, 2016

➢Development of National Strategic plan for Health

Laboratories : NSPHL (2017-2022) was adopted in

line with National Policy on Health Laboratories

➢ National surveillance for AMR is highly listed in

NSPHL

➢National Action Plan : NAP for AMR was endorsed

in endorsed in July. 2017 according to GLASS.

➢NMSC is endorsed on 2018 January .. Union Minister

of MoHS is Chairperson


Yangon, Myanmar

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Role of NHL for AMR

➢ NEQAS – Identification and Antibiotic Sensitivity Testing of

Bacteria, (40) Central, Teaching, States, Regional and some

District Level Hospitals (2017)

➢ Participate in International EQAS, NIH, Thailand

➢ National Data collection from Hospitals and support to SOPs,

Guidelines

➢ Workshops on AMR (WHO)- Standard Laboratory Method

and Management of Data Entry (WHONET training)

➢ Standing as Reference Laboratory for AMR

Current activities on AMR

1.Collaboration with National Centre for Global Health and

Medicine (NCGM), Japan on their Whole Genome Sequencing of

Multi-drug resistant Gram Negative Bacteria

2.Technical Collaboration Agreement : Advancement in Clinical

practice through Microbiology Education” between Ministry of

Health and Sports, Myanmar & bioMérieux Pte.Ltd (Singapore) (

2018-2020)


Yangon, Myanmar

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Activities of World Antibiotic Awareness

Week

Nay Pyi Taw

23.11.2017

27-Mar-18 29National Health Laboratory

Yangon, Myanmar


Week

23.11.2017


Yangon, Myanmar


Week

23.11.2017


Yangon, Myanmar

Current activities ( Symposium on

Antimicrobial Resistance awareness at

46th Myanmar Research Congress)


Yangon, Myanmar

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Laboratory perspective of combating AMR

(64th Myanmar Medical Conference)

(20.1.2018)


Yangon, Myanmar

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Yangon, Myanmar

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Challenges in NAPAMR Limited Laboratory Capacity for AMR

Human resource

➢ Skill and training regarding clinical microbiology laboratory

for Microbiologists and technicians, staff rotation

➢ Staff motivation

Machines, Materials & Instruments for C&S

➢ Conventional C& S

➢ Automated – Vitek2, Bact Alert (FOC ?/Budget ?)

➢ Limited number of Biosafety Safety Cabinet

➢ Budget for full laboratory capacity support??


Yangon, Myanmar

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Challenges in NAPAMR

Communication

➢ Communication between clinicians and the laboratory persons

in consulting antibiotic resistance pattern of various samples

➢Limited use of antibiogram result by clinician

➢ Clinical notes & diagnosis on request form.. Inadequate

➢ Unaffordable LIS Laboratory Information system effectively

➢ Data storage and Reporting- Limited IT facilities and internet

access in some labs (WHONET data analysis)


Yangon, Myanmar

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Challenges in NAPAMR Sample Collection & Transportation.. Quality and timely

transportation of sample are critical considerations to get qualifiedAMR results.

➢ Space- Not enough working space

➢ Storage- Not enough lab equipments like refrigerator, deep freezer etc in some labs for samples storage

➢ Less awareness about the laboratory / health care associated infection , partly effected by their heavy workload and duties

➢ Waste disposal

-Difficult to get uniform colour coated plastic bag and waste container according to biosafety guideline / autoclavable bag


Yangon, Myanmar

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Challenges in NAPAMR ➢ Limited use of antibiotic guidelines and antibiotic policy in some

hospitals ( AMU)

➢ Monthly CME and 3 monthly meeting in some hospitals but no regular meeting in some hospitals

➢ Less functional hospital Infection control committee meeting –annually/twice per year/Quarterly

➢ Unlimited access to laboratory working area

➢ Antibiotic Stewardship Program -not started yet in many hospitals

➢ Coordination between area of human and animal health based on one health approach

Health Care Associated Infection

Prevention and Control


Yangon, Myanmar

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Yangon, Myanmar

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HIC ,Strengthening Symposium

February 2018


Yangon, Myanmar

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HIC ,Strengthening Symposium

February 2018


Yangon, Myanmar

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Current activities of IPC(Analysis of hospitals data as at Feb 2018)

Building the Infection Prevention Control Committee and team in hospitals

Awareness of Infection Prevention Control Committee and Team, SOPs, Guidelines, Job Description and Training to all level of health providers

Weekly supervision with checklist

Review and Reward


Yangon, Myanmar

Current activities of IPC

(Analysis of hospitals data as at Feb 2018)

Providing the requirements to maintain the infection prevention control function

Fumigation of Operation theatre and labor room biannually

Following the hospital management guideline according to level of hospital

Health education about IPC to communities

Environmental sanitation activities collaborated with local authorities


Yangon, Myanmar

Ways Forward (Short term)

Hospital antibiotic policy guideline

Infection control meeting - 3 monthly

Monitoring and evaluation – 6 monthly

Cooperation between patients wards and supportive department

Training and health education

Clinicians and Laboartory cooperation in monthly basis upon hospital antibiogram analysis

Requisition of separate budget for IPC


Yangon, Myanmar

Ways Forward ( Short term)

Requisition of equipment and machines for IPC

Providing of clothing of patients and health providers

IPC checklist in every patients wards

Immunization of all health care providers with hepatitis B vaccine

Installation of exhausted fan at infectious patients room


Yangon, Myanmar

Ways Forward (Medium & Long term)

IPC documents

(IPC policy, strategy, plan and guidelines)

Need national level IPC committee at MoHS..

-Compliance with IPC measures

-Routine surveillance of hospital acquired infection

Work closely with other national structure / department/ committee ( Multilateral cooperation)


Yangon, Myanmar

Myanmar NEQAS of AST

• Started .. Since 2005

• National Health Laboratory is EQAS provider and

analyzer

• Now.. around 40 teaching hospitals , specialist

hospitals and State / Regional level public hospitals

are participated

• Then provide the data to WHONET


Yangon, Myanmar

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Joint External Evaluation Process , GHSA

1• Stakeholders Meeting for JEE (6-2-2017)

2• Training on Internal Assessment Teams (21-2-2017) to (22-2-2017)

3• Internal Assessment Teams Visit (15-3-2017) to (22-3-201&)

4• Internal Assessment Teams Debriefing (6-4-2017)

5• Report to WHO (10-4-2017)

6• External Team Visit (3-5-2017) to (9-5-2017)

7• 5 years Strategic Plan for JEE (11-9-2017) to (15-9-2017)


Yangon, Myanmar

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DDG ( Laboratory)

National Focal point of JEE / IHR in 3 areas

1.National Laboratory System strengthening

2. AMR

3. Biosafety


Yangon, Myanmar

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JEE Report on

Antimicrobial Resistance , Myanmar

•27-Mar-18 National Health Laboratory

Yangon, Myanmar

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JEE Recommendations on AMR,

Myanmar • Launch and disseminate the National action plan for

detection and reporting of priority AMR pathogen ( Done

at 2017 July)

• Sustain the quality and services of laboratories that are

able to detect and report priority AMR pathogen aligned

with the GLASS

( NHL as National AMR lab and WHONET courses)


Yangon, Myanmar

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• Establish an evidence-based public communications

program targeting audiences in policy making, human

and animal health practice, the general public and

professional on prudent use of antimicrobials

( Underway)

• Sustain the surveillance capacity of existing 25 (human)

and 3 (animal) laboratory ( Now more on Human Health

surveillance laboratory to 40 numbers )


Yangon, Myanmar

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JEE Recommendations on AMR, Myanmar

• Sustain the quality assessment scheme of NEQAS

• Develop surveillance system for usage of antimicrobial in human and animal

sectors (OH approach)

• Disseminate the National action plan that includes Hospital infection

prevention and control program ( Done )

• Implement according to the Hospital infection prevention and control

program in NAP ( Underway)

• Achieve a national steering committee for AMR and technical working

groups to coordinate and implement each objectives

( Established NMSC 0n 2018 Jan .. TWGs are developed accordingly)


Yangon, Myanmar

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Yangon, Myanmar

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Future Works To Be Done

➢ National AMR Surveillance

➢ National Laboratory Network Strengthening

➢ Early Warning System for emerging drug resistance trends

➢ Strengthening of IPC and AMR Stewardship Programe in

Healthcare Setting

➢ WHONET....continuously implemented for epidemiological and

laboratory AMR surveillance data entry, storage and transmission in

human and animal sector labs

➢ & GLASS IT platform.. Will start soonest

Future Work To Be Done

Surveillance of rational antimicrobial use

• Establish a systematic, standardized process to collect, assess

and share data, maps and trends on AMR hazards

➢Promoting establishment of One health surveillance

➢ Cooperate AMR knowledge in undergraduate and post

graduate medical , nursing and basic health teaching curriculum


Yangon, Myanmar

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Yangon, Myanmar

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Documents

Regional Workshop on AMR in South ... - origin.searo.who.intorigin.searo.who.int/entity/antimicrobial_resistance/documents/... · Education, Symposium ) - Award to the best IPC of