Global Surveillance on AMR and

One Health Approach

Siswanto
Coordinator, Research and Innovation
WHO South-East Asian Region
 Why does Antimicrobial resistance matter?

• Antibiotic resistance is one of the biggest threats to global health,

food security, and development today.
• Antibiotic resistance can affect anyone, of any age, in any country.
• Antibiotic resistance occurs naturally, but misuse of antibiotics in
KEY FACTS

humans and animals is accelerating the process.

• A growing number of infections – such as pneumonia, tuberculosis,
gonorrhoea, and salmonellosis – are becoming harder to treat as
the antibiotics used to treat them become less effective.
• Antibiotic resistance leads to longer hospital stays, higher medical
costs and increased mortality.

Source: WHO
IHME Study
(Jan 2022)

• There has been estimated 4·95 million (3·62–6·57) deaths associated with bacterial AMR in
2019, including 1·27 million (95% UI 0·911–1·71) deaths attributable to bacterial AMR.
• By the Regions, it was estimated the all-age death rate attributable to resistance to be
highest in western subSaharan Africa, at 27·3 deaths per 100000 (20·9–35·3), and lowest in
Australasia, at 6·5 deaths (4·3–9·4) per 100000.
• Lower respiratory infections accounted for more than 1·5 million deaths associated with
resistance in 2019, making it the most burdensome infectious syndrome.
• The six leading pathogens for deaths associated with resistance (Escherichia coli, followed
by Staphylococcus aureus, Klebsiella pneumoniae, Streptococcus pneumoniae,
Acinetobacter baumannii, and Pseudomonas aeruginosa) were responsible for 929000
(660 000–1270 000) deaths attributable to AMR and 3·57 million (2·62–4·78) deaths
associated with AMR in 2019.
AMR BoD
by Regions
AMR BoD
by
Pathogens
How are the Policy Framework and
the operationalization of AMR
containment?
 Global Strategic Policy and National Governance on AMR
Five Objectives of the GAP on AMR National Action Plan on AMR
Objective 1: Improve awareness and
Objective 1: Improve awareness and understanding of antimicrobial resistance through

NATIONAL GOVERNANCE ON AMR

GLOBAL ACTION PLAN ON AMR

understanding of antimicrobial resistance through effective communication, education and training

effective communication, education and training Objective 2: Strengthen the knowledge and
evidence base through surveillance and research
Objective 2: Strengthen the knowledge and Objective 3: Reduce the incidence of infection
evidence base through surveillance and research through effective sanitation, hygiene and infection
Objective 3: Reduce the incidence of infection prevention measures
through effective sanitation, hygiene and infection Objective 4: Optimize the use of antimicrobial
prevention measures medicines in human and animal health
Objective 5: R&D and investment in new
Objective 4: Optimize the use of antimicrobial medicines, diagnostic tools, vaccines and other
medicines in human and animal health interventions
Objective 5: Develop the economic case for
sustainable investment that takes account of the Coordination and operationalization:
needs of all countries, and increase investment in NCC on AMR | AMR Working Group | AMR Task
new medicines, diagnostic tools, vaccines and Force | AMR containment team at health facilities
other interventions (hospitals), etc
 Conceptual Framework of One Health Approach
One Health is a collaborative, multidisciplinary, and multisectoral approach that can
Definition address urgent, ongoing, or potential health threats at the human-animal-
environment interface at subnational, national, global, and regional levels.
Tripartite
Zoonotic • Response to AMR is more efficient and effective
Guidance • Information can be shared by all relevant sectors
• Decisions are based on accurate and shared assessments of the situation.
Benefits of One • All sectors can work in harmony for the agreed goals
Health Approach
• Regulations, policies, and guidelines are realistic, acceptable, and implementable by all sectors.
• Each of the sectors understands its specific roles and responsibilities in the collaboration.
• Gaps in infrastructure, capacity, and information can be shared and filled.
• Advocacy for funds, policies, and programs is more effective.

SECTORS INVOLVED (Indonesia) AREAS

• Ministry of Health • Human health
• Ministry of Agriculture, Ministry of Marine and Fisheries • Animal health
• Ministry of Agriculture • Plant health
• Ministry of Forestry and Environment • Environmental health
• National Agency of Food and Drug Control (POM) • Food chain/ food security
 National NA on ─ Raise awareness and understanding
Governance FDC ─ Generate evidence through surveillance and
research
─ Reduce the incidence of infection through IPC and
Indonesia Context MoA MoH One health WASH
─ Optimized use of antimicrobials in human, animal,
Sub- and plants
National Mo
Governance ─ R&D investment in investment in new medicines,
(Prov and F&E
District) diagnostic tools, vaccines, and other interventions

Mo
Mo
M&F
M&F ─ Strengthen national capacities to address AMR
─ Support countries to establish appropriate policy,
institutional and regulatory frameworks and
OIE networks;
─ Support harmonized AMR surveillance;
One
health ─ Promote R&D of new antimicrobial agents,
FAO diagnostics and vaccines, and new approaches;
WHO ─ Support efforts to fight against circulation of poor
Global Context quality or counterfeit antimicrobials;
─ Promote improved infection prevention and control
measures
 Vertical Program Versus Horizontal Program
Characteristics Diseases program (TB) AMR program
Design Vertical program >> clear structure from Horizontal program >> not clear structure, in the
WHO until MOH, Special Division form of Committee, Task Force
Population Specific >> diseases based Not specific >> people with suspect of infection
(very broad)
Technical guidance Disease based (syndromic based) Specimen based, pathogen based
Laboratory Specific >> Targeted Culture, AST, molecular based (?)
Focal Point of activities Department, Clinic Microbiology laboratory
How the program is Linear structure/ vertical structure Cross-cutting structured (horizontal structure)
being organized?
Positive/ Negative Task description (who do what) >> clear Task description (who do what) >> not clear
Working in Silo Working collaboratively
Solution?
Strategies: MATRIX MODEL OF “ORGANIZING” FOR EACH OBJECTIVE OF THE NAP
• Strengthening the
organization structure
• Improving capacity of HR
Region: AMR Working Groups, AMR Focal Point
• To promote NMC, TF, Sub- WCO and MS: WCO AMR Focal Point
National TF, WGs, etc. to
function National Multisectoral Committee, Nat. Task Force, Sub-Nat 10
• Creating leader for each TF Committee, Sub-Nat. Task Force, Operational Team in Frontline
Organization (health facilities, veterinary health posts, etc.)
 STRUCTURE OF ACTIVITIES IN AMR (IPOO PERSPECTIVE)
INPUTS ACTIVITIES OUTPUT OUTCOME
AMR NAP (5 YEARS)

ANNUAL PLAN (?) Quantity (Number) of 1. Reduced AMC/U

AM Stewardship activities being done 2. Reduced AM
Understanding and the coverage of Residues in
Funding activities (targeted
and Awareness countries/
environment
3. Reduced the
Technical Guidance of AMR IPC and WASH population) prevalence AMR
pathogens
Human resources

Infrastructure (Lab,
consumables, etc) REGULATION/ POLICIES/ ACTIONS

MONEV FUNCTION

AMR SURVEILLANCE
and RESEARCH
• GLASS AMR
• GLASS AMC/ AMU
• One Health Surveillance
(Tricycle, Tricycle Epi-X)
• TISSA
• Operational research
11
 How is One Health approach
monitoring/ surveillance done?
 Global TrACSS
Global GLASS AMR Global GLASS AMC

Participating Countries in the GLASS-AMR (2018-19) Participating Countries in the GLASS-AMC (2019-20)
across the Regions across the Regions
 One Health situational analysis on the progress of NAP Implementation in SEAR
NAP Development AMR Surveillance and Labratory
1. Phase 1 –
Exploration and
Adoption,
2. Phase 2 – Program
Installation,
3. Phase 3 – Initial
Implementation,
4. Phase 4 – Full
Operation, and
5. Phase 5- Sustainable
Operation

Raising awareness IPC and AMSP

GLASS Surveillance regionally
and globally (human)
 AMR Surveillance in SEARO

• By April 2021, all Member States in the Region had enrolled in GLASS-
AMR and had entered information from national surveillance systems
in GLASS.
• Regional EQA was conducted in NRLs in 50% of surveillance sites in the
Maldives and 100% of those in Bangladesh, Bhutan, India, Indonesia,
Myanmar, Nepal, Sri Lanka, and Thailand.
• Innovative models of integrated One Health AMR surveillance have
been piloted in Indonesia (and are ready to start in India and Nepal),
including the ESBL E. coli Tricycle project.
• Indonesia, Maldives, Nepal, and Timor-Leste are now formally enrolled
in GLASS-AMC.
 Antibiotic resistance for BSI of E Coli and MRSA (global)

58

33

17
15

The proportion of patients with BSIs caused by E. coli resistant to The proportion of patients with BSIs caused by MRSA by country
3rd generation cephalosporins by country income level income level
The proportion of patients with BSIs caused by resistant Acinetobacter spp (global)
The proportion of patients with BSIs caused by resistant E. coli (global)
Proportion of patients with BSIs caused by resistant K. pneumoniae (global)
Proportion of patients with BSIs caused by resistant S. pneumoniae (global)
The proportion of patients with UTIs caused by K. pneumoniae Proportion of patients with UTIs caused by E. coli resistant to
resistant to ciprofloxacin by infection origin (global) co-trimoxazole by infection origin (global)
 Conclusion and
Recommendation
 Conclusion

1. Global BoD study on AMR: it was estimated 4·95 million deaths associated with
bacterial AMR in 2019, including 1·27 million deaths attributable to bacterial AMR
2. The complexity of AMR stems from human behavior (human, animal, plant,
environment sector), needing One Health approach >> a collaborative, multisectoral,
and multidisciplinary approach
3. With a management approach, the governance of AMR is comprising inputs (NAP,
funding, HR, laboratories, instruments/ tools), intervention activities (Awareness
raising, Optimized use, IPC-WASH, R&D for new AM), information system (research and
surveillance), outcome (reduced AM use, reduced prevalence of AMR pathogens)
4. The GLASS data has shown the pattern of AMR resistance (Antibiogram) by pathogens
and by Antimicrobials
 Recommendation
1. One health approach, characterized by collaboration, multisector, and
multidiscipline, should be implemented consistently in an overarching programmatic
action
2. To reduce AM use and to reduce the prevalence of AMR pathogens, it is crucial to
use a management of approach of AMR, by using evidence from research and
surveillance for better AMR interventions
3. As AMR Containment programs are horizontal approach, it is of importance to
implement “a matrix model of the organization of AMR”
4. To encourage AMR into a programmatic action, AMR containment program should
be incorporated into the day-to-day management of the institutions concerned
(health facilities, farmers (poultries, fisheries), food industries, etc
5. The core of interventions should be able to change the human behavior (human
sector, animal sector, plant sector, and environment sector)
Email address:
siswantos1960@gmail.com