Anti microbial program nepal

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NATIONAL ANTIMICROBIAL RESISTANCE
CONTAINMENT ACTION PLAN NEPAL
2016
Department of Health Services
Ministry of Health
Ram Shah Path, Kathmandu

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Foreword
Antibiotics have been a critical public health tool since the discovery of Penicillin in 1928, saving
the lives of millions of people around the world. In developing country like ours, where the
burden of treatable disease is very high and access to health facilities and laboratories is
difficult, antibiotics have long acted as miracle drugs. Today, however, the emergence of drug
resistance in bacteria is reversing the miracles of the past eighty years, with drug choices for the
treatment of many bacterial infections becoming increasingly limited, expensive, and in some
cases, nonexistent. Diseases previously regarded as relatively easy to manage are much
harder to treat as doctors must use “last-resort” drugs that are more costly, take longer to work
and are often unavailable or unaffordable in developing countries. Moreover, regular
prescription of antibiotics, random treatment, over the counter sales, inadequate dosage,
inclusion of antibiotics in animal feeds and agriculture has contributed equally to emergence of
antibiotics resistance as silent epidemic within the country.
To address this issue, the members of National Alliance for Prevention and Control of Antibiotic
resistance have prepared a National Action Plan for Combating Antibiotic-resistance which
provides a road map to guide the Nation in rising against this challenge. The National Action
Plan is also designed to guide action by public health, healthcare, and veterinary partners in a
common effort to address urgent and serious drug-resistant threats that affect people in the
country and to take urgent action at the national, regional, and local levels to combat resistance.
Implementation of the objectives and activities in the National Action Plan requires sustained,
coordinated and complementary efforts of individuals and groups around the world, including
health care providers, leaders, veterinarians, agriculture industry leaders, manufacturers,
policymakers and patients. This document aims to bridge the information gap related to AMR in
human and animal sectors and will further serve as an important baseline document for
developing plans, policies and programmes in AMR for government and other allied agencies.
All of us who depend on antibiotics must join in a common effort to detect, stop, and prevent the
emergence and spread of resistant bacteria.

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Contributors in the development of the action plan:
Mr. B. K Khakurel Director General , Department of Drug Administration, MoH
Dr. Geeta Shakya Director, National Public Health Laboratory
Dr. G. R. Lohani Ministry of Health, Curative Division
Dr Nihal Singh
Dr. Prakash Ghimire
World Health Organization, Nepal
World Health Organization, Nepal
Mr Narayan Dhakal
Ms. Jyoti Acharya
Department of Drug Administration, MoH
Co-chief Medical Technologist / Microbiologist- National Public
Health Laboratory
Ms. Nisha Rijal Microbiologist- National Public Health Laboratory

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LIST OF CONTENTS
S.no Title Page no.
Foreword 1
Acknowledgements
Contributors
List of acronyms
2
3
1. Introduction 6
1.1 Background 6
1.2 Current Situation
1.3 Rationale
2.0
2.1
2.2 Strategic objectives 8
3.0
8-9
4. Strategies to fulfill the objectives of National Antimicrobial
Resistance Action Plan
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4.1 Objective 1 10-11
5. References
Annexes
List of members of National Alliance

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ABBREVIATIONS
ACPN Association of Clinical Pathologists of Nepal
AM Antimicrobial
AMR Antimicrobial Resistance
APPON Association of pharmaceutical producers of Nepal
CHD Child Health Division
CVL Central Veterinary Laboratory
DDA Department of Drug Administration
DAH Directorate of Animal Health
DoHS Department of Health services
DoLS Department of Livestock Services
EDCD Epidemiology and Disease Control Division
MOA Ministry of Agriculture
MOH Ministry of Health
MoLD Ministry of Livestock Development
FHD Family Health Division
GARP Global Antibiotic Resistance Partnership
IOM Institute of Medicine
IPC Infection Prevention and Control
KMC Kathmandu Medical College
LCD Leprosy Control Division
LMD Logistics Management Division
MD Management Division
MELAN Medical Laboratory Association Nepal
MoE Ministry Of Education
NACARC National Advisory Committee on Antimicrobial Resistance and Containment
NAMC Nepal Ayurvedic Medical Council
NAMLS Nepal Association for Medical Laboratory Sciences
NAMS National Academy of Medical Sciences
NCASC National Centre for AIDS and STD Control
NGO Non-Governmental Organization
NHEICC National Health Education Information and Communication Center
NHPC Nepal Health Professional Council
NHTC National Health Training Centre
NMC Nepal Medical Council
NVC Nepal Veterinary Council
NNC Nepal Nursing Council
NNA Nursing Association of Nepal
NPA Nepal Pharmaceutical Association
NPC Nepal Pharmacy Council
NPHL National Public Health Laboratory
NTC National Tuberculosis Centre
PHSRD Primary Health Service Revitalization Division

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OIE World Organization for Animal Health
PAHS Patan Academy of Health Sciences
RHD Regional Health Directorate
SOP Standard Operating Procedure
VSDAO Veterinary Standards and Drug Administration Office
VPHO Veterinary Public Health Office

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INTRODUCTION
Antimicrobials are the most effective treatment for infectious diseases; they are generally safe,
effective and to date, relatively inexpensive. Antimicrobial resistance is a natural microbial
survival mechanism; however, the overuse and misuse of antimicrobials has increased the rate
of resistance development and spread. Antimicrobial resistance (AMR) threatens the effective
prevention and treatment of an ever-increasing range of infections caused by bacteria,
parasites, viruses and fungi. The impact on particularly vulnerable patients is most obvious,
resulting in prolonged illness and increased mortality. Antimicrobial resistance is a growing
global public health threat. Some estimates of the economic effects of AMR have been
attempted, and the findings are disturbing. For example, the yearly cost to the US health system
alone has been estimated at US $21 to $34 billion dollars, accompanied by more than 8 million
additional days in hospital. Because AMR has effects far beyond the health sector, it was
projected, nearly 10 years ago, to cause a fall in real gross domestic product (GDP) of 0.4% to
1.6%, which translates into many billions of today’s dollars globally.
ANTIMICROBIAL RESISTANCE IS A GLOBAL CHALLENGE
The antimicrobial resistance phenomenon has become a global concern as geographic borders
among countries and continents have become less distinct. There are high proportions of
antibiotic resistance in bacteria that cause common infections (e.g. urinary tract infections,
pneumonia, bloodstream infections) in all regions of the world. A high percentage of hospital-
acquired infections are caused by highly resistant bacteria such as methicillin-resistant
Staphylococcus aureus (MRSA) or multidrug-resistant Gram-negative bacteria. Treatment
failures due to resistance to treatments of last resort for gonorrhoea (third-generation
cephalosporins) have been reported from ten countries. Gonorrhoea may soon become
untreatable as no vaccines or new drugs are in development. Patients with infections caused by
drug-resistant bacteria are generally at increased risk of worse clinical outcomes and death, and
consume more health-care resources than patients infected with the same bacteria that are not
resistant. More than half of all medicines worldwide are prescribed, dispensed, or sold
inappropriately, according to the WHO.
In September 2011, ministers of the South East Asian countries met in Jaipur India,
acknowledged antimicrobial resistance as a major global public health issue and expressed
commitment for Institution of a coherent, comprehensive and integrated national approach to
combat antimicrobial resistance through:
 Development of national antibiotic policy and formulating multi-sectoral national alliances
against antimicrobial resistance.
 Advocate for multidisciplinary approach by all sectors of the government, with the private
health sector providing desired information and following national guidelines.
 Study the emergence and spread of antimicrobial resistance and assess accurately its
impact on public health.
 Regulating the use of antimicrobial agents, both in public and private sectors to prolong

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and preserve their efficacy.
 Strengthen legislation to prevent the manufacture, sale and distribution of spurious and
substandard/not-of standard-quality and poor quality antimicrobial agents and the sale of
antibiotics.
 Promoting behavioral change in prescribers and communities through continuous
training, educational campaigns with process and outcome measures for rational use of
antimicrobial agents and emphasizing antimicrobial resistance in medical, dental
veterinary and pharmacy curricula.
 Build increased capacity for efficient surveillance of antimicrobial resistance and its
effective use in modifying antibiotic policy.
 Strengthen diagnostic facilities for microbial diseases to facilitate evidence-based
antimicrobial prescription.
 Strengthen infection control practices in health care facilities to reduce the burden of
microbial diseases and health-care associated infections.
 Ensure use of antimicrobial agents included in National Essential Drugs List, regulate
non-therapeutic use of antimicrobial agents and irrational use in the veterinary and
fishery sectors.
 Encourage basic and operational research in areas that enhance application of various
measures to combat antimicrobial resistance.
 Advocate healthy lifestyle, cost-effective and essential immunization and other non-
pharmaceutical measures to reduce the disease burden due to microbial diseases
 Develop national and regional mechanisms for regular data sharing, regulating cross-
border transfer of infectious materials and bacterial isolates, sharing best practices of
laboratory-based surveillance of antimicrobial resistance and practices promoting
rational use of antibiotics.
 Set up a regional mechanism for sharing of mutually agreed antimicrobial resistance
data of public health importance relevant to policy making.
 Develop a regional mechanism for a regular inter-country consultative process for
reviewing issue related to antimicrobial resistance including tracking of international
movement of resistant organisms both within the Region and among regions.
In May 2015, 68th
World Health Assembly approved the Global Action Plan on antimicrobial
resistance that underscores the need for an effective “one health” approach involving
coordination among numerous international sectors and actors, including human and veterinary
medicine, agriculture, finance, environment, and well informed consumers. The action plan
recognizes and addresses both the variable resources nations have to combat antimicrobial
resistance and the economic factors that discourage the development of replacement products
by the pharmaceutical industry.
Nepal’s Approach for containment of antimicrobial resistance (Rationale): Government of
Nepal, as a part of continued commitment to Jaipur declaration to contain the threat of
Antimicrobial resistance, has developed the current National Antimicrobial Resistance
Containment Action Plan. This Framework will serve as a starting point for cohesive
engagement and mobilization of all who are accountable for action on antimicrobial resistance

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and use. Given the global nature of this issue, the Action Plan, in line with the one- health
concept, highlights the need for Nepal to work with international organizations and groups to
develop solutions applicable to domestic production and use and importation from global
market.
This Action Plan is presented in three sections:
 The first section explains what antimicrobial resistance is, how it is spread and why it is a
problem.
 Section two outlines the strategic areas of focus for the Government of Nepal and
associated priority actions.
 The third section describes the roles and responsibilities of different agencies involved.
Section -I

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What is an antimicrobial?
An antimicrobial is a natural, semi-synthetic or synthetic substance that is capable of killing or
inhibiting the growth of microorganisms (e.g., bacteria, virus, parasites, fungi). The term
antimicrobial will be used throughout this document to refer to: antibiotics, antivirals, antifungals,
and antiparasitics.
What is antimicrobial resistance and how does it develop?
Antimicrobial resistance simply means that the antimicrobial drugs that used to be effective
against a particular microbe no longer work because the microbe’s biological makeup has
changed; it has become resistant to the treatment. The problem can occur naturally, or when an
infection is treated with an antimicrobial which kills only some of the microbes. Those that can
resist the treatment survive and multiply. Over time, more and more of the resistant microbes
remain in our environment, eventually leading to the emergence of new strains of disease-
causing microbes that are partially or fully resistant to antimicrobial treatment.
How does antimicrobial resistance spread?
Antimicrobial resistant microbes move and spread in the same way that all infectious disease
causing microbes do; through direct contact (person, animal, and environment), contaminated
food or water, or contact with body fluids. Resistant microbes are generally found where
antimicrobial use is higher and disease conditions more common.
Why is antimicrobial resistance (AMR)a problem?
Antimicrobial Resistance (AMR) is a problem because:
 AMR kills: Infections caused by resistant microorganisms often fail to respond to the
standard treatment, resulting in prolonged illness, higher health care expenditures, and a
greater risk of death.
 AMR hampers the control of infectious diseases: AMR reduces the effectiveness of
treatment; thus patients remain infectious for a longer time, increasing the risk of
spreading resistant microorganisms to others.
 AMR increases the costs of health care: When infections become resistant to first-line
drugs, more expensive therapies are used, longer duration of illness and treatment
increases health care costs as well as the economic burden on families and societies.
 AMR jeopardizes health-care gains to society: The achievements of modern
medicine are put at risk by AMR. Without effective antimicrobials for prevention and
treatment of infections, the success of organ transplantation, cancer chemotherapy and
major surgery would be compromised.
 AMR threatens health security, and damages trade and economies: The growth of
global trade and travel allows resistant microorganisms to be spread rapidly to distant
countries and continents through humans and food.

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Section-II
NEPAL’S COMMITMENT TO ACTION
Nepal’s action on antimicrobial resistance, including those addressing antimicrobial use, are
aligned in line with international organizations guidelines and commitments. Government of
Nepal Ministries, departments and agencies will work together and with other jurisdictions and
sectors including private sectors to focus on reducing the public health risks and impacts of
antimicrobial resistance.
Laboratory based AMR Surveillance:
In Nepal, AMR surveillance started as early as 1999 with limited number of participant
laboratories and organisms under surveillance. The program has grown up with the current
network of 20 laboratories covering all five regions of the country and expanded to 8 pathogens
of interest as of now viz. Salmonella species, Shigella species, Vibrio cholerae, Streptococcus
pneumoniae, Neisseria gonorrhoeae, Haemophilus influenza type b, Extended Spectrum Beta
Lactamase (ESBL) producing E. coli and Methicillin Resistant Staphylococcus aureus (MRSA).
WHO has been supporting NPHL for AMR surveillance in the country since 2006. The program
has provided significant contribution in the treatment policy / guideline formulation / review at the
national level and uniformity in testing at the local level. Moreover, it has contributed to regional
and global AMR database.
Current Status: Comprehensive study findings on antibiotic resistance in Nepal are limited.
There is limited information on total production, importation and use of different categories of
antimicrobials in the country, although Department of Drug administration has some information
on production licensing amounts of antimicrobials within the country. There have been a couple
of focused studies noting tetracycline resistant Vibrio cholerae, quinolone resistant Salmonella
and Shigella, methicillin-resistant Staphylococcus aureus, MDR pneumococci, Acinetobacter,
and Klebsiella pneumoniae.
Last ten years laboratory based AMR surveillance data from 20 participating laboratories in the
network has revealed:
 Increased resistance to Ciprofloxacin in Salmonella from 0% in 2003 to 85% in 2014.
 A five-fold increase in MDR in Shigella spp.
 Increased resistance to Ceftriaxone in pneumococci (from 0% in 2006 to 13% by 2013)
 Methicillin resistant Staphylococcus aureus (MRSA) infections are on the rise (80%
increase in the number of reported cases in 2015 as compared to 2013).
 Increased resistance to first line (Ciprofloxacin and Erythromycin) and second line drugs
in MRSA (Vancomycin and Linezolid).
A SHARED RESPONSIBILITY
Addressing the growing threat of antimicrobial resistance is a shared responsibility. The
Government of Nepal’s role in protecting the health of Nepalese against disease threats of
national concern is essential to this multi-sector collaboration. The Government’s role includes

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promoting health, preventing and controlling disease, brokering knowledge and facilitating
innovation, tracking and monitoring disease threats, ensuring the safety of antimicrobial
products and all foods sold and prepared in Nepal, along with collaboration with international
partners. In the recent days a new concept of one health Hub has been put forward, through a
strategic framework for cabinet consideration, under review.
Ministry of Health is and will continue to take lead in coordinating related departments/centres
under the ministry of health, other related ministries and line agencies in bringing all together for
the cause of preventing and combating the spread of antimicrobial resistance. In this context, it
has recently formed a high level steering committee and alliance with the participation of most of
the stakeholders in the field including public, private and non-state participants. The
coordination through Ministry of Health will be mainly focused towards bringing all together in
harmonizing the guidelines/protocols/regulatory frameworks taking into consideration rational
use of antibiotics in all settings. Ministry will continue organizing annual meetings of the steering
committees and alliances separately in view of reviewing the progress and bottlenecks and
coordinate in promulgation of directives/acts as necessary.
The National Public Health Laboratory under the department of health services, Ministry of
Health acts as a focal point in AMR and leads the laboratory based AMR surveillance. It works
with domestic and international partners in areas of surveillance, laboratory analysis, infectious
disease outbreaks confirmation, awareness and public health guidance development together
with Epidemiology & Disease Control Division of the DOHS. Outbreaks related to foodborne
diseases will be investigated by EDCD and laboratory support for disease diagnosis will be
provided by NPHL. NPHL will continue its existing laboratory based AMR surveillance as well as
the supporting laboratory services, in support of efforts to combat AMR. This will include regular
indicator based timely monitoring, review and required adjustments (e.g. incorporating additional
data sources and new technologies)
Department of Drug Administration, under the Ministry of Health, regulates the approval of
antimicrobial drugs for production and sale in Nepal that are used in humans and animals. Its
capacity in regulating the strict prescription based sale of medicines, i.e. restricting over the
counter availability of antibiotics, needs to be strengthened.
Department of Food Technology and Quality Control (DFTQC) under the Ministry of
Agriculture is responsible for establishing policies and standards related to the safety and
nutritional quality of the food supply, monitoring the quality of food items as per food law. The
capacity and functioning of DFTQC will be enhanced in such a way that it will be able to
regulate non-therapeutic use of antibiotics, e.g. use of antibiotics in food items, use of antibiotics
as small animal growth promoters.
Department of Health (DoH): Respective divisions under the DOHS, i.e. EDCD, CHD, FHD,
will develop/revise the related treatment protocols, standard guidelines for respective sectors,
taking into consideration the rational use of antibiotics.

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Department of Livestock Services(DoLS): DOLS under the Ministry of Agriculture Livestock
Development, will be responsible for development / revision of the related treatment/case
management protocols, standard guidelines related to livestock, taking into consideration
rational use of antibiotics, particularly discouraging the use of low doses of antibiotics in animal
feeds as growth promoters.
Nepal Health Research Council and Academia: Academic and NHRC will support Govt. of
Nepal in conducting research for generating evidences for policy changes as and when
required.
Fighting the spread of antimicrobial resistance depends on the involvement and collaboration
of multiple jurisdictions, levels (local, national and international) and sectors (e.g. public health,
private, and agricultural sectors). The Government of Nepal is committed to working with all
jurisdictions in addressing the problem.

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Section -III
GOAL
To protect Nepalese from the health risks related to antimicrobial resistance
KEY AREAS OF FOCUS
The Government of Nepal, in collaboration with its partners, seeks to reduce the health risks
associated with antimicrobial resistance by focusing its efforts on these five pillars: Awareness,
Surveillance, Infection Prevention & Control, Stewardship, and Innovation. These pillars have
been selected based on WHO resolution and Nepal’s commitments in different forums.
1. Improve awareness and understanding of AMR through effective communication,
education and training.
2. Strengthen the knowledge and evidence base through research and surveillance.
3. Reduce the incidence of infection through effective hygiene and infection prevention
measures.
4. Optimize the use of antimicrobial medicines in human and animal health.
5. Develop the economic case for sustainable investment that takes account of the
needs of all countries, as well as the need for investment in new medicines,
diagnostic tools, vaccines and other interventions.
1. AWARENESS
ACTION 1: Improve awareness of the user population on the understanding of antimicrobial
resistance through effective communication:
 Antimicrobial resistance (AMR) awareness week will be celebrated every November,
acknowledging its global importance and also to raise awareness in Nepalese
population, on the problem and ways to address it.
 Behaviour change and communication messages, targeting rational use of antibiotics will
be promoted through appropriate media. NHEICC/MOH, Directorate of training and
extension/ MOLD and Agriculture information centre/MOA in coordination with Ministry of
Information, Press council and concerned stakeholder organizations working for AMR
containment will be responsible.
 MoH/AMR steering committee will take the responsibility of developing and
disseminating annual performance reports in coordination with all stakeholders.
 Consumer awareness programs on AMR and rational use of antimicrobials will be
promoted mobilizing GOs and NGOs.
ACTION 2: Improve the awareness and understanding of antimicrobial resistance through
education and training
 Rational use of antibiotics in academic curricula of various levels of education will be

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reviewed and updated (School, College, Professional, Medical, Veterinary and
Agriculture).
 Continuing Education (CE) on the rational use of antibiotics, for professionals of Human
health, Animal health and Agriculture will be organized at regular intervals by the
respective departments/centers.
 Prescribers, pharmaceutical manufacturers and dispensers will be trained on the rational
use of antibiotics. Respective professional associations/councils will be brought into loop
in organizing such orientations.
 Effective implementation of GCP, GVP, GHP, GAP, GMP and GLP will be promoted
through respective ministries and line agencies.
 Infection prevention and control education programs to targeted audience in human and
animal health will be promoted.
2. SURVEILLANCE
Detecting and monitoring trends and threats in order to inform strategies to reduce the risks and
impacts of antimicrobial resistance are possible with sensitive surveillance system.
Through the Epidemiology & Disease Control Division of the Department of Health Services,
national surveillance programs monitor different infectious diseases and respond to the
outbreaks with diagnostic support from National Public Health laboratory. National Public Health
laboratory through its existing 20 network laboratories monitors antimicrobial resistance among
the possible isolates from patients (AMR surveillance network). However, the existing AMR
surveillance system is yet to include collection of specimens from animals and the food supply,
which are vital steps in the spread of resistant organisms to the communities. Surveillance
information facilitates policy decisions on the management of antimicrobials at all levels of
health care system.
ACTION 3: Strengthen and expand the existing surveillance systems to identify new threats or
changing patterns in antimicrobial resistance and use, in human and animal settings.
 National Antimicrobial Surveillance Center will be established at NPHL/MOH, targeting
towards detection and characterization of antimicrobial resistance in all aspects of one
health (animal, human, antimicrobial residues in human/animal food, and environment).
This includes Quality Assurance (International & national), data quality & sensitivity of
surveillance system through monthly monitoring the reports from the network labs
(human, animal, food & agriculture) and their performance quality.
 Number of organisms and sites for AMR surveillance will be expanded to effectively
cover the entire country.
 The Central Veterinary Laboratory capacity to conduct epidemic investigations and
animal disease surveillance in veterinary sectors taking into account emerging and
reemerging zoonotic diseases.
 DDA capacity in monitoring production, import, prescription, dispensing etc. for
improvement in prescription & consumption practices to support AMR containment
program will be strengthened.
 National protocols for infectious disease control and monitor its adherence in use

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through regular surveillance by DOHS/EDCD in human health, DOLS in Animal health,
DFTQC in food & supplements, AM residues in Agriculture & crops.
ACTION 4: Strengthen the knowledge and evidence base through operational research:
 Operational research on antibiotics production, prescription, consumption, and
antimicrobial resistance development in human and non-human sectors will be promoted
through academic & stakeholders collaboration, to generate evidence for policy making.
 Baseline information on various areas of antibiotics (production, prescription, use,
resistance) will be explored and updated regularly, which will be able to update
respective policies.
3. INFECTION PREVENTION AND CONTROL
Infection prevention and control measures in health facilities as well as outside (in community)
reduce the risk of transmission of infections and minimizes the need for AMs. This reduces the
selective pressure and the subsequent emergence of resistant strains. Furthermore, infection
prevention and control measures diminish the spread of the resistant microbes once resistance
has emerged.
ACTION 5: Reduce the incidence of infection through effective sanitation and hygiene:
 Basic Sanitation, hygiene and IPC practice in health care practice in all settings will be
audited and appropriate actions for improvement will be made mandatory.
 As part of advocacy for sanitation and hygiene activities such as hand washing events
will be promoted.
 Sanitation, biosafety and biosecurity measures in all sectors will be made mandatory.
ACTION 6: Reduce the incidence of infection through infection prevention measures
 Every level of hospitals will have Infection Prevention and Control (IPC) committees,
which will be responsible for adhering to standard IPC protocols and practice.
 Occupational safety of staff in different sectors (OSHA) will be promoted through
appropriate preventive measures including vaccinations through respective departments.
 Infection prevention guidelines and protocols (e.g., setting minimum standards) will be
updated, implemented, monitored, and evaluated from time to time.
 Bio-safety and waste disposal guidelines and its adherence will be audited and regularly
updated for hazard mitigation.
 Preventive immunization programs in human and animal health will be in place and
monitored.
 Occupational hazard minimization will be promoted through respective councils.
 Minimum accreditation standards for infrastructure of health facilities to promote infection
prevention and control will be updated and regulated.

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4. STEWARDSHIP:
ACTION 7: Optimize the use of antibiotics in human health, animal health and food processing:
 MoH/DDA/DOLS will regulate antibiotics prescription, use and sales at different levels of
health system, including private sectors. The regulations will be updated regularly based
on surveillance information.
 The guidelines will include primary, secondary and tertiary line of treatments, along with
last resort antibiotics strictly for use under Infectious Disease Physician/expert
prescription, based on the evidences for need. Practice of antibiotics use will be solely
based on culture and susceptibility testing results from accredited microbiology
laboratory.
 DDA will develop evidence-based legislative framework/act for empowering National
regulatory authorities to assure quality, production, sale and distribution of antibiotics.
 Veterinary drug use will be efficiently regulated as per existing and updated country
regulations.
 Country regulatory mechanisms and HR capacity will be strengthened, through
appropriate trainings in regulating antibiotics production/packaging, buying, selling,
supplying, and receiving in donation in human health.
ACTION 8: Minimize the non- therapeutic use of antimicrobials in animals and food items
 Ministry of Agriculture, livestock and other line ministries will be brought into main stream
for AMR action. The legislation/act/policy to regulate non-therapeutic use of antibiotics in
animals, food, animal feed and agriculture sector will be promulgated.
 National standards for food items/animal breeding elements will be updated by the
DOLS, DFTQC and DOA to restrict the use of antibiotics as growth promoters.
5. ECONOMY & INNOVATION:
ACTION 9: Develop the economic case for sustainable investment that takes into account the
needs of the country, and increase investment in new medicines, diagnostic tools, vaccines and
other interventions
 Rapid and reliable diagnostic testing for infectious diseases will be improved through
creation/addition of posts of infectious disease physicians, microbiologists, pharmacists,
veterinarians and trained technologists at all levels. The posts will be filled by priority in a
phase wise manner, through MoH/PSC process.
 Procurement and supply of equipment, media, reagents and chemicals will be regulated
for nationally important infectious disease pathogens.
 Point of care RDTs at peripheral level health institutions with back up of the confirmatory
testing at central level will be promoted through regular Govt. of Nepal program planning
cycles, on a priority basis.
 Operational research on economic impact of diagnostics and antibiotics use in case
management will be done on regular intervals for inclusion of new tests and medicines in
the system, or dropping off any medicines from the prescription list.

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 Further research for new vaccine/diagnostics/antimicrobials development in all related
sectors (human, animal, and environment) will be encouraged.
 Collaborative participation in multi-country/multi-centric activities will be promoted.
EXPECTED OUTCOMES
Stakeholders from various sectors will be engaged in the effective implementation of the action
plan with efforts to preserve the effectiveness of antimicrobial medicines through conservation
and stewardship programmes.
Target By 2020 A.D:
 Provision of culture and diagnosis of selected bacterial pathogens and AMR surveillance
will be made available up to the district level. Monthly reporting of AMR data from district
to NPHL/MOH will be made mandatory, based on which a monthly update on AMR will
be made available on NPHL website for the reference of the treating physicians and
related authorities. Hospitals with capacity of more than 100 beds and Medical college
Hospitals will be brought under the AMR Surveillance Network.
 Protocols for management of infectious diseases and its proper implementation will be
ensured at every level of the health system.
 Update of data from AMR network sites in WHONET will be made mandatory.
 The National Antibiotic Guideline will be updated by MOH/DDA/NPHL annually on the
basis of AMR surveillance data.
 National treatment protocol will be strictly adhered at all levels of the health system.
 Over the counter sale of antibiotics will be interrupted, through effective regulatory
mechanism in place led by DDA supplemented with effective BCC activities on
consumer awareness led by NHEICC and partners
 Non-therapeutic use of medically important antibiotics for growth promotion in animals
will be eliminated.
Target By 2025 A.D:
 AMR surveillance will be expanded and made mandatory for both public and private
sector health care providers.
 Veterinary, livestock and agriculture sectors will be incorporated under national AMR
network for monthly reporting of the AMR status in each sector, contributing to one
national AMR framework.
 DDA will have a strong regulatory mechanism in place for complete interruption of the
non-prescription sale of antibiotics.
 No antibiotics will be distributed/sold without prescription so that over the counter sale of
antibiotics is restricted.
PROGRESS INDICATORS
It is important to ensure that antibiotics are only used where they are needed therefore extra
guidance needs to be put in place to ensure this happens. This can be initiated by checking the
basic metrics in certain time duration:

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 Comparing antibiotic resistance trend of a certain antibiotic against a certain
microorganism over the years and assessing whether the resistance has decreased or
not.
 Over the counter sales of antibiotics is zero or near zero.
 Tracking whether the number of hospitals with Infection Prevention and control
committees (including all core members i.e., pharmacists, microbiologist, physicians,
hospital authorities) has increased over the years or not.
As data improves, further measures will be implemented to assess the overall status of IPC,
antimicrobial prescribing and antimicrobial stewardship activity. Appropriately targeted local
information will be provided against which future progress can be more firmly evaluated and
monitored. The possibility of developing a new integrated indicator is also being explored
which can be used to communicate local and national standards for HCAI and antimicrobial
resistance and improve patient outcomes.
WAY FORWARD
Nepal’s antimicrobial resistance surveillance systems are not adequate to capture possible
emergence of antimicrobial resistance at the very beginning and to the molecular level of the
resistance mechanism.
Moving forward, the Government of Nepal is committed to ensuring surveillance systems that
are better coordinated with a clear plan for improving antimicrobial resistance surveillance in
partnership with other key stakeholders. This means linkages will be made to create a complete
national picture of antimicrobial resistance in human and animal settings and within the food
system in Nepal. Building on the surveillance successes across the country, systems will be
expanded to support the identification of emerging threats, disease trends, and provide the
information required to deal with known problems.
CONCLUSION
Significant activities of antimicrobial resistance continment have been initiated in the country.
However, to further minimize the risk of AMR, there is a need of multi-sectoral governmental
partnership with involvement of non-government public sectors. The contribution from all sectors
will provide synergistic value in health promotion and safety of all

21
ANNEX- I
ADMINSTRATIVE ARRANGEMENTS FOR OPERATIONALIZATION OF THE FRAMEWORK
The list of members of National Multi-sectoral Steering committee:
1. Chairperson Secretary, MoH
2. Member Secretary Chief of Curative Division
3. Joint secretary Representative from Ministry of Agriculture and
Ministry of Livestock Development
4. Members DG of Department of Drug Administration
DG of Department of Livestock Services
DG of Department of Ayurveda
Director, National Public Health Laboratory
(NPHL)
5. Representatives Association of Private Health Institutions of Nepal
(ANPHIN)
Nepal Pharmacy Council
Teaching Hospital Association
Association of Non-governmental Hospitals in
Nepal (ANGHOS)
Alliance for Prudent Use of Antibiotics (APUA)
Consumer forum
6. Invitees WHO Representative
FAO Representative
ANNEX-II
Members of National AMR Alliance
S.
no.
Designation Affiliation
1. Chairperson Secretary MoH
2. Member
Secretary
Chief of Curative Service Division
3. Members DG from Department of Drug Administration
DG from Department of Health services (DoHS)
DG from Department of Livestock Services (DoLS)
DG from Department of Food Technology and Quality Control
DG from Department of Agriculture(DOA)
DG from Department of Wild Life and National Parks
DG from Department of Ayurveda
Director, National Public Health Laboratory (NPHL)
Director, National Centre For AIDS and STD Control (NCASC)
Director, National Health Education information and communication
center (NHEICC)
Director, Epidemiology and Disease control Division (EDCD)
Program Director, Directorate of Animal Health(DAH)

22
Director, Logistics Management Division (LMD)
Director, Child Health Division (CHD)
Director, Family Health Division (FHD)
Director, Management Division (MD)
Director, Leprosy Control Division (LCD)
Director, Primary Health Service Revitalization Division (PHSRD)
Chief, Central Veterinary Laboratory (CVL)
Chief, Veterinary Standards and Drug Administration Office(VSDAO)
Director, National Tuberculosis Centre (NTC)
Director, National Health Training Centre (NHTC)
Chief Drug Manager, MoH
Director, National Drug Laboratory
Chief, Veterinary Public Health Office(VPHO)
4. Representatives Joint Secretary from Curriculum Development
Nepal Medical Council (NMC)
Nepal Veterinary Council(NVC)
Nepal Nursing Council( NNC)
Nepal Pharmacy Council( NPC)
Nepal Health Professional Council (NHPC)
Nepal Ayurvedic Medical Council (NAMC)
Nepal Association for Medical Laboratory Sciences (NAMLS)
Medical Laboratory Association Nepal (MELAN)
Association of Clinical Pathologists of Nepal (ACPN)
Nursing Association of Nepal (NNA)
Nepal Pharmaceutical Association (NPA)
Nepal Veterinary Association(NVA)
Nepal Animal Science Association(NASA)
Nepal Para-veterinary and Livestock Association(NEVLA)
5. Representatives Tribhuwan University (TU), Central Department of Microbiology
Agriculture and Forest University(AFU)
Kathmandu University (KU), Microbiology Deprtment
Pokhara University (PU), Microbiology Department
Purvanchal University, Microbiology Department
Kathmandu Medical College (KMC)
Nepal Medical College (NMC)
Patan Academy of Health Sciences (PAHS)
KIST Medical College
Institute of Medicine (IOM)
National Academy of Medical Sciences (NAMS)
Director, Bir Hospital
Joint Secretary, Animal Health division, Ministry of Agriculture
DG of Department of Livestock Services
DG of Department of Food Technology and Quality Control
Drug Suppliers Association(Human and Veterinary sectors)
Association of pharmaceutical producers of Nepal (APPON)
Director, Global Antibiotic Resistance Partnership (GARP)

23
ANNEX-III
Role of different stakeholders for development of National Action Plan
Ministry of Health
 Approval of policy and guidelines against AMR.
 Inter-ministerial co-ordination on organization of the activities for AMR surveillance,
rational use and containment through departments/centres, steering committee and
alliance.
Department of Health Services
 Respective divisions/centres under DoHS will develop/revise and implement the policies,
guidelines and action plan.
 Promote Antibiotic stewardship by auditing prescribing practices.
National Public Health Laboratory
 Strengthen and expand the national laboratory-based surveillance of antimicrobial
resistance by gradual inclusion of more participating laboratories.
 Develop guidelines on antibiotic panels to be tested for organisms of AMR interest to
bring uniformity in antimicrobial susceptibility testing.
 Capacity strengthening of participating laboratories by providing technical support for
investigation, refresher trainings and logistic support in case of need.
 Organize and Facilitate quality assurance for AMR surveillance.
 Monthly, quarterly and annual dissemination of AMR surveillance findings through
media(like website, newsletter or bulletins)and respective professional councils.
 Identify nodal laboratories in case of outbreaks for investigation.
Epidemiology and Disease Control division
 Development/Revision of treatment protocol for all infectious diseases.
 Development and implementation of infection prevention protocols.
 Orientation of health workers on the above protocols and facilitate NPHL in AMR
surveillance and response.
Department of Food technology and Quality control
 Development of standards, guidelines, protocols for surveillance of micro-organisms in
food items.
 Effectively implement the above policies/guideline/regulatory frameworks
Department of Drug Administration
 Develop National policy guidelines on antibiotics prescription, use and sales at different
levels of health system, including private sectors.
 Develop legislative framework/act for empowering National regulatory authorities to

24
assure quality, production, sale and distribution of antibiotics.
 Effectively implement the above policies/guideline/regulatory frameworks.
Department of Livestock services
 Develop standard guidelines, protocols for surveillance of non-therapeutic use of
antibiotics.
 Update veterinary drug use regulations and guidelines.
 Effectively implement the above policies/guideline/regulatory frameworks

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