Canada’s Activities in Combatting

Antimicrobial Resistance

Presentation to the JPIAMR Management Board

March 29, 2017

AMR in Canada

• Surveillance data indicates that rates of infection for some resistant pathogens

have declined in recent years but remain above levels seen before 2007,

indicating more work needs to be done:

– MRSA rates in hospitals have decreased by 25% since 2008

– VRE incidence declined by 30% from 2012 to 2014

– C. difficile infection rates have also dropped 35% in the 3-year period from 2011 to

2014

• Neisseria gonorrhoeae is of particular concern: Canada has seen a 43.1%

increase in the rates of reported cases between 2004 and 2013, and over 50%

of isolates were shown to be resistant to at least one antibiotic, including higher

azithromycin resistance levels than in the US and UK (3.3% in 2014, up from

0.35% in 2009)

• Medically important AMU in animals is significant:

– 73% of antimicrobials distributed to animals in Canada were of the same classes as

those antimicrobials used in human medicine

– In 2014, approximately 82% of medically-important antimicrobials were distributed

and/or sold for use in food-producing animals.

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Federal Framework and Action Plan on AMR

• Launched in October 2014, the Antimicrobial Resistance and Use in

Canada: A Federal Framework for Action mapped out a coordinated,

collaborative federal approach for responding to AMR. In particular, it laid the

foundation for action across multiple sectors, and outlined the key focus areas

and plans for action of the Government of Canada.

• Subsequently, in March 2015 the Government of Canada followed up with the

Federal Action Plan on Antimicrobial Resistance and Use in Canada:

Building on the Federal Framework for Action. This document identifies

concrete steps that key departments and agencies of the federal government

will take to prevent, limit and control the emergence and spread of AMR.

Actions were particularly focused in the areas of surveillance, stewardship and

innovation.

• These documents set the stage for further action on AMR, and lay the

foundation for Canada’s national action plan, as committed to during the World

Health Assembly in 2015.

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Federal Response to AMR and AMU

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Federal Framework (2014) and Action Plan (2015) on AMR

• Key results to date:

Enhanced integrated surveillance activities (CARSS)

Initiation of pilot projects addressing surveillance gaps (AMRNet; ESAG)

Implementation of regulatory and policy changes for veterinary antimicrobials to

enhance regulatory oversight

Stewardship strengthened through engagement of practitioners via awareness

campaigns and learning activities, and updated clinical guidelines on STBBIs

Launch of research initiatives focused on AMR point-of-care diagnostics

F/P/T multi-sectoral governance established to deliver pan-Canadian Framework and

Action Plan

• Stakeholders are undertaking complementary actions:

HealthCareCAN: Stakeholder-led healthcare antimicrobial stewardship action plan

(human) and network

Canadian Veterinary Medical Association: Pan-Canadian framework on veterinary

oversight

National Farmed Animal Health and Welfare Council: National stewardship efforts in

the agri-food sector

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Towards a National Strategy: Pan-Canadian Framework on AMR

• The Pan-Canadian framework is a high level policy document outlining strategic

objectives, outcomes and potential action areas under each of the components

o Will guide and align collective actions within and across sectors with shared responsibility for

AMR

o Completion by May 2017 to meet Canada’s commitment under the Global Action Plan on

AMR

• With a Pan-Canadian framework we are trying to:o Coordinate and leverage actions being taken across sectors to eliminate siloes

o Share information and best practices

o Create opportunities for collaboration

o Establish a coherent approach that will guide our collective efforts and ensure we are

moving together in the same direction with clearly defined roles and responsibilities

o Involve and engage all levels of government

• The Framework development is being facilitated through a dedicated governance

structure that reflects a One Health approach with F/P/T government representation and

human and animal health stakeholders. Key elements of the structure include:

• The AMR Steering Committee (senior F/P/T representatives)

• Task Groups (expert stakeholders from industry, academia, non-governmental organization

and health and agricultural representatives from F/P/T governments)

• Deputy Minister Champions (human and animal health/agriculture from provincial and

federal governments)

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Foundation of pan-Canadian Framework on AMR

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Desired Outcomes

Increase awareness and understanding

of AMR, and the role that infection

prevention and control play in limiting

the spread of infectious agents

Improve management practices to

reduce the need for antimicrobials

Increase awareness and understanding

of the importance of biosecurity

measures to limit the spread of

infectious agents and the need for

antimicrobial use

Support the development of rapid

diagnostics that guide the choice

of treatment and therapeutic use

Support clinical trials for drugs

that are already on the market,

and/or don’t have other support

Explore alternative and adjuvants

to antibiotics as a made in

Canada approach that addresses

both veterinary and human

medicine

Surveillance Stewardship Research and

Innovation

Potential Actions

Effectiveness of current

antimicrobial drugs of

importance to humans

maintained

Better tools and approaches to

detect and treat drug resistant

infections in humans and

animals

Support the development of a

centralized, harmonized

database platform to integrate

human and animal health data

Identify priority organisms that

contribute to AMR in animals

and humans

Enhance human AMR/AMU

data collection in community-

based settings

Enhanced understanding of

how AMR spreads in human

and animal settings

Comprehensive picture of

AMR and AMU in Canada

Health professionals and the

public adopt appropriate

antimicrobial use practices

Reduced infections in health care

and the community

Infection Prevention &

Control

Strengthen the promotion of

appropriate AMU in human and

animal medicine

Develop awareness, education

and training to improve

prescribing practices in human

and veterinary settings

Strengthen regulatory oversight

and framework on veterinary

medicines and medicated feeds

Framework Components

• Surveillance

– Goal: Create strong, integrated surveillance systems to provide a comprehensive

picture of AMR and AMU in Canada

– Areas of focus: development of clear objectives for AMR and AMU surveillance

throughout the collection process; fostering of shared ownership of surveillance

systems through active stakeholder engagement; promotion of centralized and

standardized data sharing platform to integrate data across sectors; creation of clear

technical guidance for all data-related activities, and standardized definitions for AMR

• Infection Prevention and Control

– Goal: Contain the spread of resistant organisms and reduce AMR and AMU, put in

place standardized infection prevention and control approaches, programs and

policies

– Areas of focus: development and delivery of effective communication, education,

and training programs and tools to improve IPC; facilitation of the application and

oversight of IPC best practices through regulations, guidelines, KT and education;

collaboration with affected groups to address inequalities impacting the delivery of

IPC programs; investments in IPC research to improve efficacy in both human and

animal health

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Framework Components• Stewardship

– Goal: Creation of programs and policies that highlight education, awareness raising

and increased regulatory oversight, to reduce inappropriate prescribing and use of

antimicrobials in humans and animals to conserve the effectiveness of new and

existing treatments

– Areas of focus: creation and funding of a pan-Canadian Antimicrobial Stewardship

Network; implementation of a robust AMU data collection system; implementation of

regulatory and policy changes to enhance regulatory oversight; development of pan-

Canadian harmonized governance tools; creation of enhanced educational curricula

for prescribers and public awareness programs focused on AMR

• Research and Innovation

– Goal: enable evidence-based responses to AMR through increased knowledge,

innovative tools and collaborative approaches to better understand resistance and

develop new treatments and strategies.

– Areas of focus: support for a multi-sectoral network that will facilitate discovery, best

practices and economic and production impact; investigation of alternatives and

adjuvants to antimicrobials and development of R&I capacity; support for clinical and

effectiveness trials of antimicrobials, alternatives and adjuvants; creation of a

supportive environment for research and innovation; incentivize pharmaceutical

investment in AMR by improving drug licencing processes

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Pan-Canadian Framework: Lessons Learned

• Governance Model

o Inclusion of federal, provincial and territorial governments, along with

representatives from academia, industry, and NGOs in the governance

structure fostered a shared sense of responsibility and ownership

• One Health Approach and cross-sectoral engagement

o By including representatives from the human health, animal health, and

agriculture in the development of the Framework, stakeholders have developed

relationships that are extending beyond collaborations on AMR

o Multi- and cross-sectoral engagement has also created interdisciplinary learning

opportunities

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Pan-Canadian Action Plan

• Once the Framework is complete the focus will turn to the development of an

Action Plan to support implementation of the Framework objectives

o The Action Plan will lay out the details of concrete deliverables, measurable

outcomes and timeframes

o On a longer track to provide opportunities for broad engagement and further

discussion about what stakeholders can contribute, from ideas to implementation,

within their sphere of influence

• Engagement may include events and activities such as stakeholder

consultations through forums or conferences; a series of workshops; discussion

guides for human and animal health stakeholders and/or government officials;

etc. The ultimate goal of these activities is mobilizing commitment to framework

implementation.

• In leading the development of the Action Plan, PHAC will continue to work with

F/P/T partners and stakeholders across sectors.

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Canadian Antimicrobial Resistance Surveillance System

• CARSS is the national coordinating program for PHAC’s surveillance systems and

programs that gather information about AMR and AMU in humans and animals

• CARSS uses data from PHAC’s existing surveillance systems and national

laboratory reference services to develop a national picture of AMR and AMU in

humans and animals

o This picture is intended to inform public health action (e.g., antimicrobial stewardship,

infection prevention and control), research, and innovation

• CARSS:o provides integrated information on AMR/AMU surveillance;

o informs the expansion of surveillance activities to areas of greatest need;

o provides useful and relevant information to stakeholders and the public in support of

antimicrobial stewardship interventions to further protect the health of Canadians

• Second CARSS Report released on September 12, 2016 (analysis of 2014 data)

http://healthycanadians.gc.ca/publications/drugs-products-medicaments-

produits/antibiotic-resistance-antibiotique/antimicrobial-surveillance-

antimicrobioresistance-eng.php

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Canadian AMR/AMU surveillance

information

Canadian Tuberculosis

Laboratory Surveillance

System (CTBLSS)

Canadian HIV Strain and Drug

Resistance Surveillance

Program

National surveillance of

antimicrobial

susceptibilities of

Neisseria gonorrhoae

Laboratory reference

services

Canadian Integrated

Program for Antimicrobial

Resistance Surveillance

(CIPARS)

Human antimicrobial use

(AMU) surveillance

Canadian Nosocomial

Infection Surveillance

Program (CNISP)

National surveillance of

Invasive Streptococcal

Disease

FluWatch

CARSS Contributors

Prudent Use of Antimicrobials in Humans

• Putting the Pieces Together – a Stakeholder-led Antimicrobial Stewardship

Action Plan

• Antibiotic resistance information and awareness materials for Canadians and

health care professionals through the Government of Canada website

• Pan-Canadian Public Health Network (PHN) Communicable and Infectious

Disease Steering Committee Task Group Report on Antimicrobial Use

Stewardship

• Do Bugs Need Drugs? - an education program for the community and

healthcare professionals, providing resources for physicians, pharmacists,

nurses, and the public

• Canadian Guidelines on Sexually Transmitted Infections (which include

diagnosis and treatment of antimicrobial resistant gonococcal infections)

• AntibioticAwareness.ca which offers practical tools and information to

practitioners and patients

• Choosing Wisely Canada, a campaign to help clinicians and patients

• Hospital-based stewardship programs

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Prudent Use of Antimicrobials in Animals

• Canada is taking steps to strengthen veterinary oversight of antimicrobial use

• Veterinary Oversight of Antimicrobial Use – A Pan-Canadian Framework for

Professional Standards for Veterinarians’ was developed by the Canadian

Veterinary Medical Association (CVMA)’s Veterinary Pharmaceutical

Stewardship Advisory Group and the Canadian Council of Veterinary Registrars

– Template of professional standards to be used by provincial and territorial veterinary

regulatory (licensing) bodies when developing their own regulations, guidelines, or

bylaws relating to veterinarians professional responsibilities in providing oversight of

use of antimicrobials in all circumstances. The framework is intended to contribute to

the development and implementation of uniform regulations across the country.

• Food animal producer associations are taking leadership in shaping their on-

farm food safety programs

– Chicken Farmers of Canada

– Canadian Cattlemen’s Association (CCA) Verified Beef Production Plus (VBP+)

– Canadian Pork Council (CPC) Canadian Quality Assurance Program (CQA)

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International initiatives related to AMR

• Canada (PHAC, CIHR, CFIA) is one of the countries that co-leads the Global

Health Security Agenda Action Package on AMR; will Chair starting in

September 2017

• Objective is to develop an integrated and global package of activities to combat

antimicrobial resistance, spanning human, animal, agricultural, food and

environmental aspects

• Canada collaborates with the US, EU, and Norway as part of the Trans-Atlantic

Task Force on AMR (TATFAR)

• Current (3rd) phase involves a series of Action Items in 3 key areas: appropriate

therapeutic use in human and veterinary medicine; prevention of drug resistant

infections; and strategies for improving the pipeline of antimicrobial drugs

• In the fall of 2016, Canada joined the Global Antimicrobial Surveillance System

(GLASS); established by the WHO to foster standardized AMR surveillance

globally

• There are currently 31 fully registered countries, with 11 more expressing interest

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Moving Forward

In the coming months, the emphasis will be on several key activities

• Finalizing the pan-Canadian Framework on AMR

• Launching the pan-Canadian Action Plan process

• Strengthening AMR and AMU surveillance systems

• Continuing to collaborate with domestic and international partners on multi-sectoral

initiatives to address the threat of AMR

• Ongoing exchanges of ideas with industry partners (how they could contribute to

our initiatives and programs, how we could support their ideas)

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