1. Antibiotic resistance: National actions contribute to a global solution NEPAL Professor Paras K Pokharel Vice Chair GARP Nepal

2. AMR Activities in Nepal: How it Began 1978: GoN, Drug Act 1995: GoN, National Drug Policy, Nepal 1998: GoN, Infectious Disease Control Program launched – to develop a sustainable national surveillance of AMR 1999: GoN, NPHL started Laboratory Based AMR Surveillance – Network of 13 laboratories 1999: APUA (Alliance for Prudent Use of Antibiotics) – Nepal was formed 2001: National Drug Policy Amended- “prudent use of antibiotics added” 2013: Global Antibiotic Resistance Partnership (GARP)-Nepal was formed; CDDEP & NPHF collaboration 2014: GoN, National Antibiotics Treatment Guidelines

3. Before GARP Nepal APUA Nepal – Started with Assisting GoN with drafting of National Antibiotic Policy (Major Contributor) – Pharmacologist & Microbiologists mostly from Kathmandu – Prudent use of Antibiotics; Major Focus Laboratory Surveillance : NPHL – Laboratory Based Surveillance Network ; Many hospitals around the country (Training Laboratorians, Quality Assuarance)

4. GARP Nepal GARP: International network that sensitizes AMR issues locally and gives Nepal a voice in antibiotic resistance in the international arena. GARP-Nepal Working Group formed 2013 – Civil Society, National Public Health Body Engagement: NPHF – Academicians/Practitioners in Public Health, Medicine, Microbiology, Policy, Lab Science, Veterinary Medicine, from all over the country.

5. GARP Nepal Long-term goal: – To lay the groundwork for a national action plan for antibiotic resistance in Nepal Specific objectives: – Carry out situation analysis of antibiotic use, resistance and related topics—human and animal—in Nepal – Develop Policy Brief(s) for mitigating antibiotic resistance in humans and animals

6. AMR This is not just about rational use of drugs. Not confined to hospital practice and medical specialty. Broadly anything that reduces the need for antibiotics will reduce antibiotic resistance.

7. AMR Vaccines (both antibacterial and antiviral) Clean water Sewage Disposal Rapid Diagnostics (reliable ones, not Widal tests, more like Gene Xpert vs AFB stains) Sub therapeutic use of Antibiotics in Animal/bird/fish farming Phasing out widespread use of antibiotics in poultry, cattle and fish farms.

8. AMR Hospitals are not “off the hook” Hospital-acquired infections are the most resistant: NDM1, for example. Hand washing between patients ( Not standard practice in Nepal) Antibiotics “ just in case”

9. GARP-Nepal Situation Analysis, 2014 Respiratory infections (one-half of the cases were resistant) Diarrhea (one-third of the cases were resistant) Bloodstream infections, STDs, UTI: no better

10. GARP-Nepal Situation Analysis, 2014 “By prescription only” laws have limited usefulness in Nepal Not enough for only a small group of people to know about AMR. Health care workers at all levels, ( humans and veterinarians) in collaboration with professionals and policy makers. Government support is critical.

11. GARP-Nepal Situation Analysis, 2014 Multi-sectoral engagement – Health Academia/Research – Medical Practitioners/ Lab Scientists – Agriculture/Veterinary Sectors – Policy Makers – Ministry of Health Owned Health Sciences Universities Policy Advocacy one of the objectives Engaging Government support at Ministerial Level Global Network – Celebrated Global Antibiotics Awareness Week 2015 – Health Sciences University, Agricultural University & Civil Society Engagement in Awareness & Campaigns

12. Working with Government Autonomous/Semiautonomous Govt bodies represented on GARP-Nepal Working Group GoN, MoHP on board since 2014, since the Situation Analysis was launched. Interest of MoH remains; supported by current minister as well

13. Challenges Political Instability / Humanitarian crisis National Health Policy 2071 (2014) Implementation plan for transition between the old policy and new policy Lack of National coordination body mandated by Government

14. Way Forward Engagement of local stakeholders Community based research – Participatory (Qualitative) research – Behavior change Initiatives for people/drug shops Generate more research from animal/fish sectors Partner with existing rational drug use & laboratory surveillance networks esp. National Public Health Laboratory, GoN Engage more private sector health groups

15. Way Forward National Action Plan for Antibiotic Resistance Collaborative, covering all sectors, building on GARP framework

16. Mount Fish Tail

17. Thank you