Download Minutes, AMR Strategic Action Plan

Minutes
New Zealand Antimicrobial Resistance Action Plan
Development (First meeting)
Date:
2 March 2016
Time:
09.00am – 3.00pm
Location:
Freyberg building. (G.01) Wellington
Chairs:
Don Mackie (MoH) and Scott Gallacher (MPI)
Attendees:
Invitees:
Shirley Crawshaw, (MoH), Andrea McNeil (MoH), Jane Pryer (MoH) Chris Hewison
(ESR), Debbie Jowitt (HQSC), Katie Appleby (PHARMAC), Mark Thomas (Auckland
University), Nigel French (NZVA), Sharon Gardiner (AMR hospital pharmacist), Allan
Kinsella (MPI), Donald Campbell (MPI), David Holland (ASID), Murray Tilyard (BPAC),
Carolyn Clissold (NZNCIPC), Michelle Balm (NZMN), Virginia Hope (ESR), Mark Ross
(Agcarm)
Helen Heffernan (ESR) Deborah Williamson (ESR)
Apologies:
None.
Item
1
2
3
Welcome and introductions
Round the room introductions from all members of the group outlining
previous and current expertise in this area of work. Reiteration from Don and
Scott on the importance of the work and the opportunity for the Ministry of
Health and Ministry for Primary Industries to work collaboratively in this area
Group purpose:
MoH acknowledged that the work already undertaken in this area and the
need now to pull work together into a tight cohesive plan. Important not to
lose lessons learnt. Impressed by willingness of people to work at this.
Noted: Strong educational, guidelines and regulatory levers already in place to
ensure there is a unified approach
Terms of reference (ToR)
Discussion on ToR included
Purpose of group
Agreed
 World Health Organization 5 strategic aims to be included as an
appendix to form part of the purpose of the group.
1
AMR planning action group/Minutes/2 March 2016

Other international organisations need to be recognised in agriculture
and veterinarian AMR objectives.
 Office International des Epizooties (OIE) and Food and Agriculture
Organization FAO objectives to be included in the ToR (as appendix)
Consumer representation – Recognition that currently there is no
consumer representation on group. Discussion on how useful at this point
a consumer representative would be, as, primarily, group specifically
developing a strategic plan and requires technical expertise.
Agreed
 As work progresses, evaluation for a consumer representation will be
discussed and appointed as appropriate.
Group member representation – discussion around the importance of
expertise and knowledge from core members play a key part in the
formation of this group. Acknowledgement that people are here for their
key strengths and there will be opportunity for others to contribute to a
draft plan or strategy during this process.
Discussion on difficulties with variable consistency in the level of reporting
of antimicrobial resistance in common human pathogens between
community and DHB’s laboratories. National consistency essential and
should not be left to individual DHB’s.
Comment that NZMN is actively working in this area to address these
inconsistencies.
Agreement
Consistency needs to be mandated nationally.
Action
ToR to be updated to reflect changes and sent out to group.
A request was made from the group for clarity on the direction of how
work will progress over the next 12 months to ensure that the group
members have adequate opportunities to comment on and revise the
action plan at all stages of is development.
Response:
Goal to have an implementation plan that is not just a strategic frame
work or direction statement, but will produce a plan that details how to
implement this within the constraints and budgets of New Zealand setting.
Concern was raised that, there would be a lack of consultation with the
group for feedback or Input on key draft documents.
Agreed:
Formal process for feedback and consultation with group would be
followed
Action:
 Assurance from Co-chairs that this is a collaborative process. Time
table /plan of action to be drafted that clarifies key deliverables of
individual areas and sent to group on progress of work. (Jane and
Andrea)
 Strategy with recommendations that have outputs, outcomes and
mandate direction. (Shirley)
2
AMR planning action group/Minutes/2 March 2016
Financial backing:
The group asked whether there was any financial backing from Ministries.
Comment:
Currently cost unknown but once we have the elements of the plan it will help
outline what some of the costs could be which will be informative to
respective ministers.
Primary industries have a very deep interest and do already finance areas such
as research projects which will stop overlaps and duplication of work.
Noted:
 A clear tangible outline of what steps we are taking across health,
agriculture and veterinary sectors to reduce risks associated with
AMR.
 The requirements needed for a practicable implementation plan
 Next phase is to say how we are going to operationalise or plan,
how much is this going to cost.
4
Approach for the day:
Shirley gave an overview on the aim of today’s meeting, including;
 Providing a shared understanding on the work that is currently being
done in relation to AMR
Following this meeting, it was suggested that work would then be done to;
 Identify gaps in work that needed to be performed
 Identify where the group should focus its efforts in order to meet the
objectives
Noted:
Work will not be carried out in this meeting but is expected to be done by
smaller interest groups and fed back to AMR action planning group.
5
Surveillance of Organisms - Human
Dr Debbie Williamson invited to provide (Via teleconference) an update on
antimicrobial consumption in New Zealand.
Overview of presentation
 review of topical antimicrobial use
 currently no standardised surveillance system for antibiotic
consumption in New Zealand
Data is currently systematically collected on the overwhelming majority of
antibiotic prescriptions dispensed in the community. This data includes;
 to whom, where and when they are prescribed and;
 what specific antibiotics are prescribed, and in what dose and
duration
However, data on why they are prescribed is not available
Surveillance of Organisms – Animals & Agriculture
Ministry for primary Industries – Donald Campbell (no slides)
Donald provided an overview to of the differences in animal versus human
lab testing
3
AMR planning action group/Minutes/2 March 2016






Difference in laboratory testing protocols dependent on whom they
are servicing
MPI Animal Health Lab – focus on identification of suspected exotic,
new and emerging diseases of production, companion, aquatic
animals, wildlife and introduced fauna
MPI Plants and Environment Labs – focus on new pests and diseases
affecting plants and environment
Veterinary diagnostic labs – two commercial providers across New
Zealand (similar to human ‘community labs’). Fee for service for client
with culture and sensitivity separate cost
Industry have either their own labs or commercial providers to monitor
inputs’ and outputs’ quality and for process control
ESR receive some samples for further investigation, e.g.
epidemiological typing purposes.

Noted
 Little active monitoring of sensitivities, though of the salmonella
isolates typed at ESR about 20% are sensitivity tested with
approximately 30% from animals, feeds and foods
National Microbiological Database (NMD) – mandatory industry programme,
highly regulated, covers meat, poultry, game and ratites (wingless
birds). Ensures common microbiological, but not AMR, standards for food
sold within NZ and abroad. MPI operates an imported food monitoring
programme which is able to target sampling to emerging risk pathogens
Donald gave an overview of the previous 2 MAF/NFSA expert panels on AMR’s
surveillance recommendations.
There have been three surveys of AMR in food producing animals in NZ. Two
of poultry funded by industry and one broader one funded by NZFSA (200910). The latter showed low levels of AMR in both pathogens and commensals,
with challenges even identifying pathogenic organisms in some species.
Emergence of Campylobacter (ST6964 strain) and its associated AMR – a risk
profile examining the issue will shortly be published on the MPI web site
describing the problem and public health risks.
6
Discussion on understanding what the true picture is on the use of antibiotics
in industry :
 Does the use in individual animal health drive AMR? And how does this
affect human health.
 Does animals use lead to the generation of clones that then get into
humans
 Does human use drive persistence and spread?
4
AMR planning action group/Minutes/2 March 2016


Noted:
How do we report data to ensure that all different areas that could
benefit are able to utilise it?
How do we align surveillance systems










cost containment within laboratory
In human practice the treatment of the individual
Surveillance
culture for surveillance purposes of anti-microbial susceptibility
should be preserved (add as part of the cost calculations and
the business module).
There is a lack of consistency in DHB lab contracts
privatisation of labs can make maintaining testing for public
health surveillance difficult
how is antibiotic prescribing impacted through laboratory
testing and surveillance
primary care would like direction on measures to reduce risk of
inappropriate antibiotic prescribing through specimen testing
(ie wound, swabs urine sampling)
primary care services – no national/ regional/consistency
surveillance systems or system in place for disseminating
information.
How should the One health approach be taken forward to
address problems identified including;
o interaction between the two surveillance systems,
o utility and use of point prevalence
Agreed:
 Need for and understanding of the surveillance processes in both
human and agriculture use
 Cost implication needs to be well understood if labs unable to test due
to financial restraints
Action:
 Further work through separate meeting/work shop to be organised to
identify gaps and understand how these processes align.
 (Shirley)
 Financial implications to be investigated through information on
laboratory surveillance – may discuss with economist
 (Co-Chairs)
 Surveillance information need to be shared community services –
(Michelle will take this up with NZMN)
7
Surveillance for antimicrobial drugs
PHARMAC- Katie Appleby (no slides)
PHARMAC’s Statutory Objective means that it has to get the best health
outcomes from within the budget available.
 Pharmacology and Therapeutics Advisory Committee (PTAC) and the
Anti-infective Sub- committee of PTAC provide objective clinical advice
5
AMR planning action group/Minutes/2 March 2016
to PHARMAC on application for funding in areas including risk of
antimicrobial resistance as a result of antimicrobial use.
PHARMAC has a number of mechanisms in place which can be used to target
antimicrobial use to ensure best health outcomes which include;
 subsidy via Special Authority
 restrictions limiting subsidised access by prescriber type –eg infectious
diseases specialist or clinical microbiologist only
 Restrictions in the hospital setting which limit access by indication or
prescriber type
 PHARMAC has access to MoH data on community dispensing’s of ,
subsidised medications down to a patient level
Limitations of the MoH data collected by PHARMAC include;
 difficulty in identifying some prescriber information
 PSO’s and bulk orders – the patient data is not captured
 hospital data is not currently as reliable as community -data has only
been collected since 2012, and, and it reflects purchase data as
opposed to dispensing and claiming data and is therefore not patient
specific and may not accurately reflect usage)
 Limitations in relation to capturing information on what the treatment
was prescribed for (unless a Special Authority is in place).
Noted: PHARMAC has the ability to initiate an audit of Special Authority
applications to ensure that they meet the required criteria.
General discussion took place on how auditing is undertaking internationally
and what some individual hospital have done including usefulness of point
prevalence studies/snap shot on a particular antibiotic.
The group was interested to know when hospital data would be available – it
was confirmed that when it would be available is unknown at this time.
Noted: PHARMAC has its own Statutory Objective and processes, and we need
to continue to understand this so that our collective goal aligns with
PHARMAC’s organisational goal for the country.
New Zealand Hospital Pharmacists Association - Sharon Gardiner (no slides)
Overview provided by Sharon on hospital antimicrobial consumption at
Canterbury DHB:
 currently, data collected is manually obtained –although the ability to
collect electronically and provide data back to the prescriber will be
available in the future
 PHARMAC hospital medicines list – provides guidance on stewardship
but implementation for some DHB’s difficult due to no dedicated
antimicrobial pharmacist or available micro/ID physician
 regional guidelines on AMS is underway by sharing of information
 implementation medicine charts provide some prescribing guidance
for clinicians
6
AMR planning action group/Minutes/2 March 2016
Noted: some DHB’s have undertaken antimicrobial consumption studies
which have shown a comparable rate with Australian hospitals (middle range).
Surveillance – Antimicrobial drugs – Animal and Agriculture (MPI)
Allan Kinsella – Ministry for Primary Industries (papers provided to group)
 Brief overview on antimicrobial data.
 Sales data on antimicrobial ingredients – annual reporting requirement
 2012 – 2015 report to be finalised
 Results show most categories of antimicrobials have a steady use
 Sales data does not currently look at antibiotic usage but work can be
done to extrapolate data to review what the usage is
Nigel –New Zealand Veterinary Association
Commented on work currently being funded by NZVA which is piloting a large
veterinary franchise group which will capture information from data bases to
give some overview of how and when antimicrobials are being used.
Noted summary of Antimicrobial use in the animal sector:
 internationally, New Zealand has a low antimicrobial use in industry
 pig, dairy and poultry biggest users of antimicrobials
 companion animals cats and dogs account for 25 % antimicrobial use
8
Discussion on transmission of antimicrobial resistant infections through
animal to animal, animal to human, human to animal. Measures to reduce
risk to both the overseas market and consumer include
 infection control measures
 national standards key in both human and animal sector in reducing
the risk of transmission.
 quality and assurance measures (MPI and NZVA)
9
Infection Prevention & Control, regulation and research to combat AMR
Health Quality & Safety Commission – Debbie Jowett (Slides appendix A)
Brief overview on role of HQSC and IPC activities across the sector.


55 FTE IPC practitioners in health sector
Legislative framework for IPC is through the NZ standards; NZ
8134.3.1:2008 Health and Disability Services (Infection Prevention and
Control Standards)
6 focus areas in the standard  System and processes including governance
 Implementing the IPC programme – designed for multidisciplinary
group
 Policies and procedure (reducing spread of multi-resistant organisms)
 Education
 Surveillance – broad appropriate to size of organisation
 Antimicrobial usage
7
AMR planning action group/Minutes/2 March 2016
HQSC IPC programmes commenced in 2011 target national IPC initiatives
Ministers 3 key platforms
 Build capability
 Ensure measure and evaluation used effectively
 Increase consumer engagement
Past and current IPC initiatives include
 CLAB Zero prevention of central line associated bacteraemia (Finished)
 Hand Hygiene 80 % adherence rates across DHB’s (public sector only at
this time (Current)
 Surgical Site Improvement Programme focused on reducing infection
following orthopaedic surgery (Current)
 Cardiac surgery (Planned)
The commission has also worked in;
 Previous review of antibiotic stewardship (2013) in NZ
 Linked in with the Australian Commission in 2014/15 for the annual
Antibiotic Awareness Week
 European CDC international AMR day
 Atlas of healthcare variation – it provides an overview of infections
after major surgery in a public hospital, postoperative sepsis rates and
community use of antibiotics in the 30 days after surgery in a public
hospital
There are limitations of the Atlas but does raise questions on prescribing
practices. Further work needs to be done in this area to understand what this
fully means. Auckland DHB are undertaking work with their area to do this.
Discussion – can the data from the Atlas be used in conjunction with other
data sets collected?
 Data needs to analysed further
 Acknowledgement that since the SSIIP, discussions with anaesthetists
and surgeons improved, in appropriateness for prophylactic
antimicrobial dosing for surgery, improvement in IPC ownership and
not just the role of IPC nurses.
Infection Prevention & Control NZNO – Carolyn Clissold (Slides Appendix B)
Discussion on impact of multi-drug resistant organism (MDRO)in NZ
Systems in place in DHB setting to reduce risk of transmission through
admission checklist and Alert system (a way of informing clinical and nonclinical staff of a MDRO. The Alert system has two primary functions;
 minimise transmission
 help with antibiotic prescribing
However, transfer of information between providers is not standardised.
The aged care section in the community does not have the same
representation visibility and connectivity.
IPC is becoming more multidisciplinary, less nurse focused
8
AMR planning action group/Minutes/2 March 2016
10
Veterinary use/Regulation
MPI -Allan Kinsella Regulation (Papers provided including work programme
and direction statement)
Over view provided on medicine regulation in animal/agriculture use following
key cornerstone work including:

11
equivalency with EU directives to ensure that medicines produced
meet same standards through audit regime
 tightening of veterinary dispensing of antimicrobials to remove or
reduce risk of resistance in human health
 tightening of labelling – therapeutic use only not for growth promotion
 removal of some antimicrobial combinations due to the importance of
human health
 process underway, to ensure classification of veterinary medicines is
appropriate
 AMR steering group (annual meeting) currently more of a watching
brief but looking to revise
 funding – industry invest in key areas including AMR
 opportunity to ensure that work not duplicated and there are no gaps,
cross over into human health through food safety.
Nigel French (NZVA) provided some background on the NZVA framework and
sector statement on the use of antimicrobial in animals by 2030.
Programme of activity includes:
 development of sector guidelines that will be available to all
practitioners.
 review of the trainee veterinary students curriculum.
 focus on alternatives to antibiotics in animal use of AB control
 vaccine use in animals
 review of the increasing use of biocides for infection control - could be
driving resistance in human health
Noted:
Challenges in industry to ensure that livestock healthy and vaccinated
appropriately but, as New Zealand is a smaller country, manufacturing of
vaccines is done to suit the majority of countries that will have a different
disease landscape in comparison to NZ.
Current awareness raising activities
Murray Tilyard (No slides)
Overview on community awareness and antimicrobial use including;
 use of written information documents such as BPACs Antibiotics :
Choices for Common Infections
 challenges on the use of pathways and guidelines due to how
information produced and distributed
 polypharmacy challenges
 continuity of care for patients
 information and education
9
AMR planning action group/Minutes/2 March 2016
Discussion on how prescribing can be addressed through different mediums
including training, I.T solutions
Mark Thomas raised the point that there is a general awareness in the
community and hospitals that a problem exists with regards antimicrobial
resistance, but this understanding is not yet driving changes in behaviour.
Current/past activities have included:
 PHARMAC “wise use of antibiotics campaign”
 HQSC International antibiotic awareness week campaign
 BPAC/NICE -Upper respiratory Tract Infection (URTI) guidelines–
collaboration
 ESR – national report on antimicrobial consumption (report to be
released soon)
 recently published study that measured antimicrobial prescribing in
several large NZ hospitals
 HRC -funding of a pilot on the availability of a smart phone app that
will allow Auckland’s 3 hospitals to easily share and access their
antimicrobial guidelines.
Discussion on how and what New Zealand could do to improve awareness
 education – incentives needed to change behaviour -International
example (UK)such as Letter sent to clinicians who ‘over-prescribe’
from the Chief Medical Officer (could work as a one off incentive
 need to motivate people to change – reporting back on performance
and feedback results clinicians/prescribers. –(data limitations were
noted eg, unable to link prescription to diagnosis)
 supporting work of AMR hospital pharmacists through committing to a
target such as an overall 1 % reduction in antibiotic consumption
 health targets –antimicrobial consumption, measurable and realistic
outcomes based on previous work done in areas such as childhood
vaccinations
 sharing of information what has worked what has not, lessons learnt
12
Research needs
Two recent completed studies (MPI – Risk profile on Campylobacter and ESR
Antimicrobial consumption New Zealand) soon to be released. Dissemination
of this information requires a communications plan.
13
Discussion/feedback from group
14
Summary from today and next steps
Areas of need;
Smaller sub working groups to target key areas including
Surveillance – human and animal health and ensuring alignment of both areas
of work.
10
AMR planning action group/Minutes/2 March 2016
Communication – development of communication strategy to inform
 Ministers
 public
 action group
 relevant stakeholders
15
Close of meeting
11
AMR planning action group/Minutes/2 March 2016