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A pilot programme to evaluate Indonesia’s antimicrobial resistance containment plan shows that progress is on the right track, but substantial strengthening is needed, say Harry Parathon and colleagues
In May 2015 member states at the World Health Assembly endorsed the World Health Organization’s global action plan on antimicrobial resistance (GAP-AMR).1 Through adoption of the GAP-AMR, member states committed to having a national action plan on antimicrobial resistance in place by May 2017.1 2 The South East Asia region has moved from having one (10%) country with a national action plan in December 2015 to 10 countries (90%) by May 2017. WHO supported the Indonesian Ministry of Health to develop a national action plan, first by conducting a review of current activities.3 The review focused on a situation analysis of challenges to tackling AMR. The South East Asia Regional Office (SEARO) of WHO has proposed a stepwise, incremental approach to implementing GAP-AMR, consisting of five phases. Phase 5 is defined as a fully operational AMR containment programme with evidence of a sustained funding mechanism and incorporating a functional monitoring and evaluation system. Here we evaluate Indonesia’s progress towards this goal.
With an estimated population of 258 million people, Indonesia is the fourth most populous country in the world and is categorised as a lower middle income country.4 Despite no formal estimation of its burden, AMR is thought to be high and on the rise. Data on AMR in Indonesia have been patchy, sporadic, and selective, commonly generated by a few laboratories from large universities, which are not connected in a national network.5
Epidemiological data on Streptococcus pneumoniae carriage and invasive disease are currently limited in Indonesia.6 In the mid 1990s studies reported 21% and 36% of penicillin non-susceptible and erythromycin resistant S pneumoniae, respectively, in Jakarta.7 In Lombok Island, the prevalence of S pneumoniae carriage was 48% in healthy children, of which all isolates were susceptible to penicillin and cefotaxime and 12% were non-susceptible to sulfamethoxazole or chloramphenicol.8 In 2000-01, the prevalence of tetracycline resistant S pneumoniae tested at the University of Jakarta’s microbiology laboratory was 46%, compared with 1-5% in studies from northern Europe.7 9 In Semarang, Indonesia, prevalence of S pneumoniae in 2010 was 43% in children aged 6-60 months and 11% in adults aged 45-75 years, of which isolates 24% were penicillin non-susceptible and 45% were resistant to cotrimoxazole.10
In 2001, E coli from rectal samples showed remarkably high resistance to ampicillin (73%), trimethoprim-sulfamethoxazole (56%) and ciprofloxacin (22%), especially at the time of hospital discharge.11 Until the late 1990s, extended spectrum β lactamase producing bacteria were mainly isolated in hospitals worldwide; later, resistance increased along with the emergence of genes related to CTX-M in hospitals and the community.12 13 In 2005 a survey in a hospital in Surabaya, Indonesia, found prevalences of extended spectrum β lactamases (including CTX-M) of 20% and 28% among clinical E coli and Klebsiella pneumoniae, respectively.14
Over the past decade the emergence of extended spectrum β lactamase producing bacteria and carbapenem resistant Enterobacteriaceae has become a worldwide threat to public health. From 2001 to 2012, resistance to imipenem rates reached 30% in some epidemic areas of the Middle East, while the top two Asian countries with the highest resistance rates to imipenem were Indonesia (6%) and the Philippines (4%).15 16 17 In 2009 the gene for New Delhi metallo-β-lactamase (blaNDM-1) was found in a sample of K pneumoniae in Indonesia.18
In 2001-02 the nasal carriage of Staphylococcus aureus was surveyed in two cities on Java island (Semarang and Surabaya); low prevalence of meticillin resistant S aureus (MRSA) (<1%) was found among 263 isolates from healthy people in the community.19 In 2007-08, 24% of surgical patients were screened for MRSA carriage at discharge in three teaching hospitals in Indonesia. Of these, 24% patients carried S Aureus, 4.3% of whom had MRSA. This was surprising low, as the prevalence of MRSA in some Asian countries, such as Taiwan and mainland China, is among the highest in the world, ranging from 28% to over 70%.20 21 Prevention of spread of MRSA is crucial in Indonesia because of the surprisingly high prevalence of the Panton-Valentine leukocidin genes (11%) among MRSA in the country, a virulence factor that is associated with skin infections and severe necrotising pneumonia.22
The challenges of AMR that Indonesia faces are similar as those of many other low and middle income countries in the region and beyond. Misuse and overuse of antibiotics in humans and in livestock and aquaculture are the key drivers of resistance in the country. With the economy prospering for the past decade and a growing demand for poultry products and the development of aquaculture exports, agricultural use probably exceeds medical use in Indonesia.23 Despite current policies related to antimicrobial use, common and unnecessary prescription of antibiotics by physicians, high rates of self medication, and over-the-counter purchase of antibiotics are common.24 Many contextual factors influencing antibiotic use are known, including weak policy enforcement and poor governance, lack of education, and easy access to cheap antibiotics.25
The Indonesian ministry of health agreed to pilot the situation analysis tool developed by SEARO, the objectives of which are to report on the baseline, development, implementation, monitoring, and evaluating progress made by the national AMR prevention and containment programme.3 The tool has seven focus areas consistent with the strategic objectives of the GAP-AMR: national AMR action plan in line with GAP-AMR; AMR awareness raising; national AMR surveillance; antimicrobial stewardship and surveillance of antimicrobial use and consumption in the community; infection prevention control in healthcare settings; research and innovation to combat AMR; and One Health engagement. Each focus area is composed of a list of indicators that are graded on five levels to show the incremental extent of AMR programme implementation.
The situation analysis process consists of guided discussions between members of the ministry of health’s AMR control committee, senior technical leaders of the national health authorities, the veterinary, agriculture and food sector, and a WHO team. The situation analysis focuses on the level of development of the national AMR containment programme in terms of governance structure, policy, and systems. It is a broad system analysis rather than assessing quality of official documents such as guidelines, regulations, and policies. Details of the definitions and methodology of the situation analysis tool are described elsewhere.3
The results of situation analysis are summarised in table 11.. The review confirmed that the AMR containment programme is in the early phase of implementation, ranging from programme installation to full operation phases for most of the core activities of the GAP-AMR. Since 2016 the ministry of health has boosted the programme, with substantial funding for the national AMR control committee. The AMR prevention and control programme is on the right track but needs further strengthening.
The Indonesian authorities are committed to supporting AMR containment activities and understand the complexity of AMR and its challenges in Indonesia, particularly multisectoral coordination and policy enforcement issues. This review of the situation was useful in several ways. Firstly, it emphasised among multidisciplinary participants that a comprehensive One Health approach—that is, coordination and collaboration between the human, animal, and the environmental health sectors—is non-negotiable to contain AMR in the country.2 Secondly, by highlighting common challenges it provides a sense of direction when building systems among all people and groups. Finally, we support the definition of what constitutes “sustainable operation” as provided by the tool, which includes funded programme operation bundled with a monitoring and evaluation mechanism for detecting, measuring, and interpreting changes over time.
Much has happened in the country on combating AMR since 2005. As shown, some concrete measures have been taken by the government. The ministry of health has recently developed the 2015-19 strategic plans for implementing existing regulations and guidelines and rolling out AMR related activities nationwide. These initiatives include piloting hospital and community based strategies to promote rational use of antibiotics. Local public awareness initiatives have also been taken up by non-governmental organisations and medical associations. Nevertheless, we acknowledge the urgent need to develop a comprehensive multisector national action plan, while simultaneously implementing existing evidence based AMR prevention and containment interventions. The immediate way forward is to establish an overarching governance system for AMR that will provide proper oversight of the problem and will implement sustainable strategies and interventions to policy makers. Also the AMR containment programme needs to urgently tackle three priority areas: surveillance of AMR and antimicrobial use in human health and livestock, a comprehensive strategy for raising awareness, and transforming national level policies to community outreach implementation across the country. Operational plans are being developed as part of the national action plan to tackle these priorities.
Our review has some limitations. Firstly, our findings are just a snapshot of the programme’s situation, which is dynamic and can change for better or worse. These findings are as accurate and complete as the quality and diversity of the participants. This baseline analysis should be seen as the first step in a long process of a monitoring the national action plan led by WHO. We support this tool and its approach, which gives people working on the programmes the opportunity to share their perceptions of the challenges and needs and to discuss grading with external partners. This review provides a sense of direction for our national programme.
Secondly, the findings are based on broad review of systems, structures, and organisations rather than a quality analysis of documents or direct observations of performance. A good level of implementation or functionality indicates that the country is taking steps to ensure that the programme is moving towards sustainable operation, in alignment with the GAP-AMR. Moreover, a fully operational programme is not necessarily effective—a step that needs further evaluations as part of the WHO roadmap. Thirdly, some areas were not well covered by the review, such as the sanitation and hygiene programme in the community and further assessment of activities in the livestock sector. Further collaboration between the Food and Agriculture Organisation of the United Nations and WHO is warranted, as is further work on harmonising the present tool with that of WHO’s Joint External Evaluation (JEE) under the International Health Regulations (2005). Lastly, we hope that other countries are encouraged by this transparent and constructive process, where WHO and national participants worked together in interactive sessions to reach a consensus.
Contributors and sources: All authors actively participated in a two day situational analysis meeting conducted in May 2016 in Jakarta, Indonesia. SV wrote the draft and all authors contributed and agreed on the contents and conclusion of the article. SV is the guarantor.
Competing interests: All authors declared no conflict of interest.
Provenance and peer review: Commissioned; externally peer reviewed.
This article is one of a series commissioned by The BMJ based on an idea from WHO SEARO. The BMJ retained full editorial control over commissioning, external peer review, editing, and publication.