UAE National AMR
Action Plan
Najiba M Abdulrazzaq
Internist
Head of medical department,
Al Kuwait Hospital Dubai
National AMR Committee Chair
pathways of transmission of resistant bacteria between animals, humans and the environment
1. water sanitation systems 2&3. use of animal manure on cultivated crops 4&5. Uptake and spread of resistant bacteria can occur through the food chain 6. water distribution infrastructure7. wildlife 8. tourism, migration and food imports (HAIs) At the healthcare facility level, resistant bacteria can spread by contact between patients or with healthcare staff, or through contaminated surfaces and medical devices
1. Improve awareness and understanding
of AMR
Risk
Communi-cation
Education
2. Strengthen knowledge
through surveillance and research
National AMR
surveillance
Laboratory capacities
Research and
development
3. Reduce the incidence of
infection through effective
hygiene & IPC
IPC in health care
Community level
prevention
Animal health:
prevention and control
4. Optimize the use of
antimicrobial medicines in
human & animal health
Access to qualified
antimicrobial
medicines, regulation,
AMS
Use in veterinary
and agriculture
5. Ensure sustainable investment
through research &
development
Measuring the burden
of AMR
Assessing investment
needs
Establishing procedures
for participation
Global Action Plan: Priority areas
• Strengthening surveillance and monitoring, and moving towards national ‘One Health’ surveillance systems
• Limiting the exposure of antimicrobial-resistant pathogens to the environment
• Fostering R&D of new antimicrobial therapies, diagnostics and vaccines
Relevant Stakeholders• Federal Ministries
• Ministry of Health and Prevention (MOHAP)• Ministry of Presidential Affairs (MOPA)• Ministry of Climate Change and Environment (MOCCE)
• Regional Health Authorities• Department of Health Abu Dhabi (DoH)• Dubai Health Authority (DHA)
• Regional Animal/food authorities• Abu Dhabi Food Control Authority• Dubai municipality
• Universities• United Arab Emirates University (UAEU)• Gulf Medical University (Ajman)
• Private sector
SWOT Analysis• More than 60% of facilities
have international accreditation
• Report to GLASS• Test food for Pathogenic
organism, imported food tested for AB residue
• Hospital standard mandate IPC and soon ASP
• No antibiotic dispensing without a prescription
• Many facilities with strong ASP&IPC
• Population mainly expats• Sustainability is a issue• Different cultures and
health background to deal with• Research and SDG
encouraged
• No national reference lab• Data mainly Abu Dhabi and
Dubai• Limited AMR surveillance in
animal• No national coordination
for IPC nor ASP• ASP is still fragmented in
hospitals• Need to audit
implementation
Strategic Plan
• Mandate has been issued for national AMR
committee that is multisectorial
• Political support achieved
• NAP AMR has been developed awaiting all sectors approvals
• Collaboration between human sector, food, animal and environment
• Budget to be allocated
AMR Education and awareness
• School
• Universities
• Healthcare workers
• Veterinarian, food and environment
• Public
1. Improve awareness and understanding
of AMR
Risk
Communication
Education
Healthcare workers Education
• Create a platform for broadcasting all the activities of the different axes of the AMR NAP- soon on MOHAP website
• Mandate for basic AMR education for all hospital staff in human, veterinary, food, agriculture and environment sectors upon employment and on yearly basis
• AMR Education will be requested for licensing and relicensing of health-related professions in human health, veterinary, food, agriculture and environment sectors
Awareness in Schools and Universities
• Ministry of Education to include AMR and Hygiene education in all school curricula
• Development of the core elements of AMR/Hygiene material to be included in school curricula
• Define the core components of educational material that should be included in different university curricula
AMR for Public Awareness• media material for all communication channels:
• TV/radio spots • Phone waiting time entertainment• SMS messages• Social media
• a year long schedule for broadcasting messages on national TV and Radio, social media (pop ups on Facebook, Instagram, etc.)
• Mandate from MOHAP to municipalities and from MOCCAE to farmers’ centers to do yearly mandatory session per each municipality or farmer center or ministry about AMR and hygiene
• Public figure associated with AMR awareness
2018 Awareness activities• Big Screen - the Emirates Airline Dubai Rugby Sevens:
• numbers of people each day who viewed19 000 on Thursday39 000 for Friday37 000 for Saturday
• Radio interview that was broadcasted every hour on the news updates
• 2 TV interviews for awareness in Public Programs
” sabah elkhair Dubai” on Dubai TV
and in News Update in Fujairah TV
• Dubai Frame was let in Blue for WAAW
• MOHAP social media were broadcasting messages.
Social media campaignAMR Campaign main objective was to grab quantitative data about UAE residents and citizens and their percentage of awareness about Antibiotic Resistance
Also, provide audience with medical facts and advices to raise their awareness about the seriousness of Antibiotic Resistance
How we reached our audience?
Total Reach Total Clicks
Total Questionnaire
Responses
~ 403.2 K ~ 5.8 K
377
Campaign Impact Overview
70%
30%
Male
Female
Social Media Campaign survey outcome
34%
63%
3% 20–30
31–49
50–70
180
75
122
BACTERIA
VIRUSES
ALL MICROBES
73%
27% Yes
No
103
43
231
STOP TAKING THE …
REDUCE THE DOSE …
COMPLETE THE …
If feel better after a few doses of the
antibiotics course?
Antibiotics are powerful medicines
that help to fight • About 52% have a false belief that antibiotics can
treat viruses or all microbes
• 73% knew that they should consult the physician
before taking an antibiotic
• 27% of the responders don’t consult physicians
• 61% complete the full antibiotics course
• 11% reduce the course without getting back to
physician
• 28% stop antibiotic course
Other activities
Total
Spots
Weekly Reach
Weekend Reach
~ 154 K
~ 246 K
10 Spots
Uni
Aim
Fatma college of health sciences
Raise awareness (AMR) and (ASP)
efforts among higher education
undergraduates and teaching
faculty in health sciences field.
Target
Audie
nce
FCHS faculty staff members and
pharmacy undergraduate students
Offered activities
1. Video presentation about AMR.
2. Oral presentations titled;
(Antibiotic Resistance: a Race Against
Time)
(Antimicrobial Stewardship Program
(ASP), Corniche Hospital Experience)
1. Antibiotics jeopardy game for
undergraduate pharmacy students
MBRUResearch project on
crisis of antibiotics usage in the UAEby 3rd Year MBBS student
41% of viral infections in 349 children received AB
Augmentin was the highest 35.6%
Radio Campaign
AMR surveillance• Organization of manpower to carry on the activities of AMR
surveillance axis in humans and animal
• Standardize AMR surveillance across all participating laboratories
• Stepwise capacity building plan for the hospitals that are not ready for inclusion in GLASS
• Generate local surveillance report that will direct professionals in putting local guidelines
• Generate a stratified surveillance report of data from:• Community vs. hospitals• Tertiary vs. primary care• Different Emirates
• Surveillance of the burden of AMR such as %HAI with MDROs
2. Strengthen knowledge through
surveillance and research
National AMR surveillance
Laboratory capacities
Laboratory capacities
UAE AMR Surveillance Sites: Geographical distributionEmirate Hospitals Clinics Total
SitesLabs
Abu Dhabi 25 53 78 12
Dubai 9 37 46 8
Sharjah 2 12 14 1
Ajman 4 -- 4 1
Um Al Quwain 2 -- 2 1
Ras Al Khaimah 5 16 21 2
Fujairah 1 4 5 1
Total 48 122 170 26
• All seven Emirates are represented in the UAE National AMR Surveillance System
• Private sector, and some Emirates (Dubai, Sharjah, Ajman) are still underrepresented
Surveillance Site (Hospital)
MZ
LW
MI
DL
SAGH
SKM
MQH
COH
NROYNSAD
MAN MAR
RAH
Abu Dhabi City (n=10)
Al Ain City (n=6)
WAGTWH
MAJMAA
CCAD DAE
Dubai City (n=9)
DH
IR
RH
ABHLH
NSAN NDIP
PR
AAH NSAA
FUJ
UAE National AMR Surveillance, 2017 [not published] courtesy of Dr Jens Thompson, DoH
UAE AMR Surveillance: Key Resistance Rates, 2017Priority 1: CRITICAL*
Priority 2: HIGH*
Priority 3: MEDIUM*
*WHO, 2017 [1]. **UAE National AMR Surveillance, 2017 (not published). %Res = percent of isolates fully resistant
Priority 3: MEDIUM
Organism Antibiotic N (isolates) % Res
S. pneumoniae Penicillin G, non-susc. (I+R) 674 59.6
H. influenzae Ampicillin 761 9.3
Shigella spp. Fluoroquinolones 72 22.2
Priority: 2 HIGH
Organism Antibiotic N (isolates) % Res
Enterococcus faecium Vancomycin 258 8.1
S. aureus MRSA 10,105 36.0
Salmonella spp. Fluoroquinolones (CIP) 624 18.9
Neisseria gonorrhoeae 3rd gen. Cephalosp. 51 0
Neisseria gonorrhoeae Fluoroquinolones (CIP) 73 74.0
Priority 1: CRITICAL
Organism Antibiotic N (isolates) % Res
A. baumannii IPM or MEM 1,218 35.9
P. aeruginosa IPM or MEM 5,407 19.7
Enterobacteriaceae IPM or MEM 30,075 4.8
Enterobacteriaceae ESBL 16,917 31.3
United Arab Emirates (2017)**
Emergence of Carbapenem-resistant Enterobacteriaceae (CRE)Abu Dhabi, 2010-Q2/2018
48%
21%
21%
5%
3%
1%1%
K. pneumoniae
E. coli
Enterobacter spp.
Serratia spp.
Citrobacter spp.
Salmonella spp.
Proteus spp.
Morganella spp.
Providencia spp.
Pantoea spp.
CRE, by species
UAE National AMR Surveillance, 2017 [not published] courtesy of Dr Jens
Thompson, DoH
%NS (IPM or MEM)%R (IPM or MEM)%R (IPM and MEM)
% CRE
P. aeruginosa: Resistance to Carbapenems By Emirate
Abu Dhabi Ajman Dubai Fujairah RAK Sharjah UAQ
14.17.2
13.412.6 15.0
10.0
24.4
AJM
P. aeruginosa, percent of isolates with resistance to Carbapenems (%R,
Meropenem)
By Emirate, United Arab Emirates, 2017, N=5,879
UAE National AMR Surveillance, 2017 [not published] courtesy of Dr Jens
Thompson, DoH
A. baumannii, percent of isolates with resistance to Carbapenems (%R, Meropenem)
By Emirate, United Arab Emirates, 2017, N=1,440
A. baumannii: Resistance to Carbapenems By Emirate
Dubai
Abu Dhabi Ajman Dubai Fujairah RAK Sharjah UAQ
28.5
38.231.2 31.8
56.3 58.0 56.0
RAKUAQSHA
UAE National AMR Surveillance, 2017 [not published] courtesy of Dr Jens
Thompson, DoH
Staph. aureus: Resistance to Oxacillin (%MRSA) By Emirate
Staph. aureus, percent of isolates with resistance to Oxacillin (%MRSA)
By Emirate, United Arab Emirates, 2017, N=9,864
Dubai
RAK
Abu Dhabi Ajman Dubai Fujairah RAK Sharjah UAQ
37.8 33.931.4
35.3 37.8 35.6 34.6
Sharjah
Ajman
UAQ
FUJ
Abu Dhabi
UAE National AMR Surveillance, 2017 [not published] courtesy of Dr Jens
Thompson, DoH
National reference laboratory
• Currently there is no NRL-AMR
• evaluation of the current situation for establishing reference lab(s) in the country to be guided by WHO EMRO
• Building laboratory capacity for all related sectors
• Proposed functions and required methods have been identified
• ADFCA has proposed to act as NRL for animal/food sector for AMR
• Collaboration between NAP steering committee, MOHAP and universities regarding research in AMR surveillance
Infection prevention and control• Establish IPC/AMR Department in MOHAP to
oversee all activities in all Emirates in all fields (human, veterinary, food and environment)
• Assigned focal points in different sectors of the country:
• climate change and environment
• human sector including the MOHAP, DoH, DHA and private
• Establish /adopt national IPC guidelines
• Capacity building for the personnel in charge
of IPC at hospital/emirate/national levels
Infection prevention and control
• Mandate that all healthcare staff have basic IPC training as pre-requisite for work
• Mandate from Ministry of Higher Education to include IPC in undergraduate training of nurses, physicians, veterinary care providers, and food handlers
• Universities to provide IPC diplomas or master’s programs and include IPC in research agenda
• licensing authorities to include IPC prerequisites (inclusive programs, on line training) for licensing & relicensing of health professionals
Infection prevention and control
• Mandate already published for IPC program for licensing and relicensing of hospitals
• IPC for in long term care facilities (LTCF)
• Adopt/adapt international or regional guidelines
• Conduct surveillance of HAI:• Process indicators:
• Hand Hygiene
• Bundles for SSI, CAUTI, CLABSI and VAP
• Outcome indicators:• SSI, CAUTI, CLABSI and VAP
Infection prevention and control in animal/food/environment• Establish inter-ministerial communication regarding
AMR and IPC
• Review and adaptation of biosafety legislation in veterinary world agriculture and food safety to cover all aspects of IPC
• Present a detailed report about the applied biosafety
• Monitoring of the application of biosafety laws and the identified gaps if any
IPC Programs at Designated HospitalsComponent MOHAP HAAD DHA
Availability of functioning IPC policy& SOPs
Availability of isolation units at tertiary hospitals.
Availability of guidelines for the protection of HCW from HAI
Availability of surveillance within high risk groups to detect cluster of HAI
Availability of designated IPC professionals in all tertiary hospitals.
Availability of system to regularly evaluate the effectiveness of IPC program
2.305
1.604
1.956
0.704
3.9
2.6
3
0
1
2
3
4
5
VAP CLABSI CAUTI SSI
2018 Result Benchmark
Indicator
2018
Result Benchmark
VAP 2.305 1.9
CLABSI 1.604 3.9
CAUTI 1.956 2.6
SSI 0.704 3
Healthcare associated Infections 2018
Ventilator Associated Pneumonia(VAP)
12.3
1.56
0
1.94
1.15
0
2.96
10.14
0
2.85
0 0
3.34
0
3.07
0
2
4
6
8
10
12
14
VAP Benchmark
1.9
Hospital 1 Hospital 3 Hospital 4 Hospital 5 Hospital 6 Hospital 7Hospital 2 Hospital 12Hospital 11Hospital 10Hospital 9Hospital 8 Hospital 14Hospital 13 Hospital 15
Central Line Associated Blood Stream Infection (CLABSI)
5.3
0.88
0
2.9
0.51
0 0 0
2.61
0.81
3.69
0.95
4.38
0
2.462.6 2.6 2.6 2.6 2.6 2.6 2.6 2.6 2.6 2.6 2.6 2.6 2.6 2.6 2.6
0
1
2
3
4
5
6
CLABSI Benchmark
Hospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5 Hospital 6 Hospital 7 Hospital 8 Hospital 9 Hospital 10 Hospital 11 Hospital 12 Hospital 13 Hospital 14 Hospital 15
Urinary Catheter Associated Infection(CAUTI)
3.6
0.93
1.64
2.152.49
12.74
0.3
10.26
2.041.76
3.63 3.77
1
0
1.11
3.9 3.9 3.9 3.9 3.9 3.9 3.9 3.9 3.9 3.9 3.9 3.9 3.9 3.9 3.9
0
2
4
6
8
10
12
14
CAUTI BenchmarkHospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5 Hospital 6 Hospital 7 Hospital 8 Hospital 9 Hospital 10 Hospital 11 Hospital 12 Hospital 13 Hospital 14 Hospital 15
Surgical Site Infection(SSI)
0.74
0 0
1.63
0.24
0
0.64
0.43
0
0.680.8
0.21
0.94
0
2.09
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3
0
0.5
1
1.5
2
2.5
3
3.5
SSI BenchmarkHospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5 Hospital 6 Hospital 7 Hospital 8 Hospital 9 Hospital 10 Hospital 11 Hospital 12 Hospital 13 Hospital 14 Hospital 15
Antibiotic Stewardship
• National sub-committee represents different healthcare sectors including MOHAP, DoH, Abu Dhabi, DHA and private healthcare facilities, in addition to the veterinary, agriculture and environment
• ASP mandated (Abu Dhabi) – March 2016
• Promote self-governance by requiring strong commitment from hospital leadership offering support to ASP activities
• Legislation of ASP to be a requirement in licensing standards of hospitals
ASP
Infectious Diseases
Nursing
Pharmacy Clinical Microbiology
Infection Prevention and Control
Antibiotic Stewardship - hospitals
• Surgical antibiotic prophylaxis
• Mandate to hospitals to report to national AMR committee the KPI results of surgical antibiotic prophylaxis
• Develop national guidelines for common infections
• Surveillance of antibiotics use in humans
• Audit of baseline situation of ASP in hospitals and follow up
Prospective Audit with Intervention
and Feedback
Pre-authorization of antimicrobials
Facility Specific Clinical Practice
Guidelines
Optimizing Dosing of Antimicrobials
Rapid DiagnosticsComputerized
Clinical Decision Support
IV to PO Therapy Conversion
Education and Training
Antibiotic Stewardship – outpatient clinics
• outpatient clinics should participate in ASP activities related to outpatients
• provide outpatient clinics with National Guidelines for common outpatient ID
• ABX consumption or point prevalence
Antibiotic Stewardship – Animal/food sectors
• Laws for antibiotic use in animals
• Quantify and trend antibiotic use in the veterinary practice
• Improve the awareness of veterinarians and farmers on the use of antibiotic
• Submit a yearly list of educational activities about antibiotic use in animals and agriculture through the country and use of alternatives
• Encourage research about alternatives to antibiotic in animals
• To present the results of antibiotic residue in food to ASP committee
ASP survey in Government Facilities
54%
88%
42%
50%
62%
33%
42%
67%
33%29%
92%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Facility 1 Facility 2 Facility 3 Facility 4 Facility 5 Facility 6 Facility 7 Facility 8 Facility 9 Facility 10 Facility 11
54%
71%
96%
62.50%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Facility 1 Facility 2 Facility 3 Facility 4
ASP survey in Private Facilities
Research
• Include IPC and ASP research in national research agenda
• Encourage Literature review of the impact of early diagnosis in ID and ASP on expenditure of antibiotics, length of hospitals stay and other hospital-related economics
• Conduct local studies on clinical and economic impact of ASP
515.3
382.4
247.5 235.4 240. 225. 230.
0
150
300
450
600
2009 2010 2011 2012 2013 2014 2015
DD
D/1
000 Inpatient
Da
ys
Trend In Inpatient Antibiotic Consumption 2009-2015
ASP IN Tawam Hospital
54% reduction in global use1. AED 4 million savings/year in direct drug cost alone2. Indirect benefits: Decreased LOS, better outcomes,
reduced resistance.
Carbapenem use fell by 57.7%
3rd&4th gen cephalosporin use by 74.8%
fluoroquinolone use by 90.5%
Courtecy of Dr Reyhan Hashimi
ASP in Al Baraha Hospital Dubai
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
May-1
5
Ju
ne-
15
Ju
ly-1
5
Au
gu
st-1
5
Sep
tem
ber
-15
Octo
ber-
15
Novem
ber
-15
Dec
emb
er-1
5
Jan
uary
-16
Feb
ruary
-16
March
-16
Ap
ril-
16
May-1
6
Ju
ne-
16
Ju
ly-1
6
Au
gu
st-1
6
Sep
tem
ber
-16
Octo
ber-
16
Novem
ber
-16
Dec
emb
er-1
6
Jan
uary
-17
Feb
ruary
-17
March
-17
Ap
ril-
17
May-1
7
Ju
ne-
17
Ju
ly-1
7
Au
gu
st-1
7
Sep
tem
ber
-17
Octo
ber-
17
Novem
ber
-17
DD
D/1
00
in
pa
tien
t d
ay
s
Piperacillin/ Tazobactam General
Consumption
Befor
eAfter
AS
0.00
2000.00
4000.00
6000.00
8000.00
10000.00
12000.00
14000.00
16000.00
18000.00
20000.00
Jan
-16
Feb
-16
Mar-1
6
Ap
r-16
May
-16
Ju
n-1
6
Ju
l-16
Au
g-1
6
Sep
-16
Oct
-16
Nov-1
6
Dec
-16
Jan
-17
Feb
-17
Mar-1
7
Ap
r-17
May
-17
Ju
n-1
7
Ju
l-17
Au
g-1
7
Sep
-17
Oct
-17
Nov-1
7
Co
st i
n A
ED
Month
Piperacillin/Tazobactam Monthly CostBef
ore
AS
After
AS17400 AED
3621 AED
ASP in Sheikh Khalifa Medical City
• Results: Among 386 patients analyzed, 206 were admitted in the preintervention and180 in the postintervention period
• Reduce 18% in total antimicrobial cost (P , 0.0001)
• 40% decrease in ICU length of stay (P 5 0.1)
• 33% decrease in overall hospital length of stay (P 5 0.03)
• 34% decrease in mortality (0.04) from preintervention to postintervention period
• Among those not seen by ID, there was a 39% decrease in cost among those not seen by ID(P , 0.0001)
Remember…. Antibiotics are a limited, precious resource
• Antibiotic resistance is happening now, and it’s happening here
• Antibiotic Resistance threatens to return us to the pre-antibiotic era
• We all have a role to play in preserving the effectiveness of antibiotics
• If we don’t all take action today …….
there may be no cure tomorrow…
Summary
• AMR is a problem in UAE as part of global problem
• National AMR committee has drafted a plan
• The Plan is based on WHO GAP AMR
and has one health approach
• The plan is in its final stages of being
a combined ministerial decree
• Together will fight AMR
References
• WHO Global Action Plan on AMR
• CDC Core Elements of Hospital Antibiotic Stewardship Programs
• guidelines on core components of infection prevention and control
• AD AMR Surveillance System, AD public healthcare facilities (SEHA), 2010-2016
Thank [email protected]