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Perspectives: National Action Plan in Antimicrobial Resistance Using Framework Analysis for China

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通讯作者: 陈斌, bchen63@163.com
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    沈阳化工大学材料科学与工程学院 沈阳 110142

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National Action Plan in Antimicrobial Resistance Using Framework Analysis for China

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  • 1. School of Humanity and Social Science, School of Medicine, School of Data Science, The Chinese University of Hong Kong, Shenzhen, Shenzhen City, Guangdong Province, China
  • 2. NHC Key Laboratory of Food Safety Risk Assessment, China National Center for Food Safety Risk Assessment, Research Unit of Food Safety, Chinese Academy of Medical Sciences, Beijing, China
  • Corresponding author:

    Yongning Wu, wuyongning@cfsa.net.cn

  • Funding: supported by the National Natural Science Foundation of China (grant No. 22193064), and the Indus-try-University Cooperation Project for Collaborative Education from the Ministry of Education (grant No. 221004439103151)
  • Online Date: June 02 2023
    Issue Date: June 02 2023
    doi: 10.46234/ccdcw2023.093
    • The emergence of multi-antibiotic-resistant bacteria has turned bacterial resistance into a pressing global issue. Antibiotics that once effectively treated various infectious diseases are now becoming less efficient against a new class of bacteria known as “Super Bacteria,” including methicillin-resistant Staphylococcus aureus (1). It is estimated that one person dies every minute due to drug-resistant strains of disease, and by 2050, drug-resistant bacterial infections could become the leading cause of death in humans (2).

      Factors contributing to the antimicrobial resistance (AMR) crisis include insufficient development of new antibiotics, irrational antibiotic use, poor pharmaceutical waste disposal, and a lack of public awareness (3). Addressing AMR necessitates cooperation across public health departments and comprehensive governance solutions, which should involve increased oversight of environmental protection, medication development, drug production, distribution, and application (4).

      To confront this critical issue, the World Health Assembly published a global action plan (GAP) in May 2015, which aims to improve awareness and understanding, strengthen surveillance and research, reduce infection incidence, optimize the use of antimicrobial medicines, and promote sustainable financial support (4).

      China holds the distinction of being the world’s largest producer and consumer of antibiotics. Per capita antibiotic use in China is approximately ten times higher than in the United States, and the average daily intake of antibiotics per 1,000 individuals is six times greater (5). Since then, AMR management in China has evolved through three major phases: drug control-based management, clinical monitoring-based management, and a comprehensive management strategy involving multiple domains (6). In response to its first National Action Plan (NAP) on AMR (7), China implemented various policies and devoted significant efforts to enhance AMR monitoring. Following the completion of the first NAP, the NAP for 2022–2025 was released early in 2023.

      The Tripartite AMR Country Self-Assessment Survey (TrACSS), administered by the Food and Agriculture Organization (FAO), World Health Organization (WHO), and World Organisation for Animal Health (OIE), aims to monitor country progress in addressing antimicrobial resistance through a questionnaire survey (8). To date, there has been no third-party assessment to systematically review and evaluate the efforts made during the first NAP in China. The purpose of this article is to analyze the governance of AMR-related measures since 2016, including the first and updated NAPs implemented by various ministries in China. This analysis will generate insights from the NAP to inform future policy design recommendations.

    • In 2021, a research team from the National University of Singapore introduced a system for assessing the National Action Plan using line-by-line analysis, which is a method involving grounded theory to identify emerging trends from data line by line and develop a previously non-existent framework (9). Various sub-objectives are evaluated and discussed in each section of Figure 1, encompassing policy design, implementation tools, monitoring and evaluation, sustainability, and One Health engagement. Policy design concentrates on creating policy and action structures from the government to stakeholders. Implementation tools primarily serve to implement the designed policies, reduce AMR, control antibiotic usage, and raise public awareness. Moreover, monitoring and evaluation pertain to the effectiveness of the policies and the feedback after actions have been conducted, while sustainability focuses on the continuation of future planning. We analyzed the relevant departments in China and summarized them in Figure 2, accompanied by a brief introduction of each department in the annotations.

      Figure 1. 

      The analysis focuses on policy design, implementation tools, monitoring and evaluation, and sustainability toward the goal of One Health engagement.

      Note: Analysis framework generated from Chua et al. 2021 (9).
      Figure 2. 

      Departments chart summarized the involvement based on collected data.

      Note: All departments are under the leadership of State Council. MEE takes part in environmental AMR governance. MOA treats AMR problem in breeding, agriculture and graziery. CCVP specifically focuses on the fodder and treatment for animals. FSO in State Council pays part of its attention to AMR as well. CFSA follows the AMR situation in China. NHC develops and organizes the implementation of AMR prevention and control plans. GOSC follows the tendency of AMR domestically. NMPA is in charge of antibiotic management. MOFCOM participates in antibiotics selling control. NATCM has researched on Antibiotics treatment. NDRC focuses on novel drug discovery, MIIT and MOST turn it into practice.

      Abbreviation: MEE=Ministry of Ecology and Environment; MOA=Ministry of Agriculture and Rural Affairs; CCVP=Commission of Chinese Veterinary Pharmacopoeia; FSO=Food Safety Office; CFSA=China National Center for Food Safety Risk Assessment; NHC=National Health Commission; GOSC=General Office of State Council; NMPA=National Medical Products Administration; MOFCOM=Ministry of Commerce; NATCM=National Administration of Traditional Chinese Medicine; NDRC=National Development and Reform Commission; MIIT=Ministry of Industry and Information Technology; MOST=Ministry of Science and Technology.

      The successful implementation of the NAP requires collaboration among multiple and cross-sectional departments. The initial stage of our study involved identifying departments involved in AMR control, by analyzing their roles, daily operations, and activity participation. Based on the identified departments, we proceeded to follow the primary objectives of the NAP.

      Our research team utilized keywords such as AMR, antibiotic resistance, antibiotics, antimicrobials, and specific antibiotics, as well as references to meetings, to search for news articles, public interviews, and government documents. Two researchers then preprocessed the gathered information according to the relevant departments and validated the data by conducting duplicate determinations within the group.

      Subsequently, we categorized the actions and developed a framework for the Chinese action plan to facilitate policy analysis. We also conducted a thorough review of the collected resources. An additional proofreading and modification process was performed as we transformed the resources into coherent paragraphs for publication.

    • The major results are listed below and the details are placed in the supplementary materials with the suggestions for further actions.

    • Strategic vision: National Health Commission (NHC) conducted AMR situation analysis in clinical surveillance and release the annual report with AMR assessment (10).

      Accountability & coordination: The Ministry of Agriculture and Rural Affairs (MOA) and the Food Safety Office (FSO) have collaborated on rectification measures to address the issue of excess antibiotic and veterinary drug residues in agriculture (1112). NHC, National Medical Products Administration (NMPA), and Ministry of Industry and Information Technology (MIIT) have jointly worked on improving the system for ensuring antibiotic drug supply by enhancing and modernizing the mechanisms associated with antibiotic medication distribution (1316). Alongside the National Development and Reform Commission (NDRC), the Ministry of Science and Technology (MOST), and the Ministry of Commerce (MOFCOM), they have issued guidelines that aim to promote the improvement of the antibiotics industry in terms of quality, variety, and volume (17).

      Participation: NHC improved the management of antibiotics medicine approval, production, and distribution, with a particular focus on antibiotics drug sales in retail (18).

      Transparency: Transparency pertains to the accessibility of precise and current data (9). The MOA has established a database, which is centered on the surveillance of veterinary drug residues and the resistance profile of five key bacterial species (19).

      Equity: In addition to the stringent regulation of prescription drugs, the NHC implemented reforms in the medical system, which resulted in increased accessibility and availability of over-the-counter medications for the general public (20).

    • Surveillance: The Ministry of Ecology and Environment (MEE) has conducted a specialized investigation into the levels of antibiotic pollution in drinking water (21). The Global Antimicrobial Resistance and Use Surveillance System (GLASS) offers a standardized methodology for data collection, analysis, and dissemination, as well as supporting capacity building and monitoring the status of national surveillance systems (22). GLASS prioritizes pathogens such as Acinetobacter spp., Klebsiella pneumoniae, E. coli, Neisseria gonorrhoeae, Shigella spp., Streptococcus pneumoniae, Staphylococcus aureus, and Salmonella spp. (22). Although China did not participate in GLASS until 2022 (23), the NHC has collaborated in efforts to enhance monitoring of adverse reactions to antibiotic drugs (24) in China.

      Optimizing antibiotic usage: MEE has enhanced control over antibiotic discharge by regulating antibiotic manufacturing and pharmaceutical companies (25). MOA has prohibited four antibiotics for use in humans and animals (26). NHC has implemented drug classification management and overseen prescription and over-the-counter medications (27). Antibacterial medication usage in outpatient clinics in China declined from 19.4% in 2010 to 7.7% in 2017, while inpatient usage decreased from 67.3% in 2010 to 36.8% in 2017 (13).

      Infection prevention and control: The policies within this section predominantly focus on infection control, with less addressing prevention. The NHC has provided guidance for the clinical use of antibiotic drugs, encompassing both macro-level policies and detailed guidance (28).

      Education: NHC implemented educational efforts to address misconceptions regarding antibiotic usage and the risks associated with antibiotic misuse (29). Hospitals provided training on appropriate antibiotic administration for physicians and nurses (7,30).

      Research & innovations: MOA aims to develop a series of enhanced feed additives by decreasing the proportion of antibiotics and incorporating non-antibiotic agents that demonstrate efficacy in treating bacterial infections, as well as veterinary drugs and vaccines (31). Since 2018, NHC has been constructing comprehensive databases and traceability networks for drug resistance genes (32), while also promoting medication research and reforming the antibiotic review and approval system. Meanwhile, MOST supports the research and development of novel antibiotics and related technologies (7).

      International collaboration: China keeps connection with other countries by jointly funding totally 60 million RMB in the field of AMR (33).

    • Effectiveness: The evaluation of policies regarding AMR is not publicly accessible. In addition to modern medicine, MOST and associated departments have assessed the effectiveness of Chinese medicine in combating drug-resistant bacterial infections and examined the underlying mechanisms. The National Administration of Traditional Chinese Medicine (NATCM) has made preliminary progress in promoting innovation and conducting research on antibacterial medications within the realm of traditional Chinese medicine (10).

      Feedback mechanism: Although the NAP placed emphasis on generating feedback, it has been observed that the majority of actions and departments lack public and transparent feedback mechanisms (9).

      Reporting: NHC published AMR status and report through the national clinic surveillance network for monitoring and evaluation (10).

    • Fund and resource allocation: MOST established some fund and relevant allocation systems for AMR research (33).

      Expansion plans: This section emphasizes the importance of scaling and ensuring future sustainability in the context of expansion plans. The specific details of these plans will not be disclosed to the public until official publication. Prior research has underscored the significance of implementing NAPs in a manner that is both sustainable and yields a substantial impact (34).

    • The NAP analysis framework has demonstrated that in China, the implementation of NAP and the management of AMR-related actions exhibit both horizontal (within each institution) and intersectoral (across institutions) deficiencies in the design, execution, feedback, and regulation of these actions. Furthermore, we incorporated future actions for each governance area, as derived from the NAP analysis framework, into the updated NAP (2022–2025), which can be found in the Supplementary Tables S1S4 (35).

    • MOA has placed significant emphasis on monitoring antibiotic usage in growth chemicals or feed and on monitoring resistance in agricultural products (Supplementary Figure S1) (3638). However, limited information from sector actions and publicities reflects MOA’s efforts in policy design and subsequent implementation tracking. There is a lack of departmental accountability framework for addressing implementation failures. Another design flaw is related to ensuring equity. This component should be incorporated either in the department of action or before the majority of government actions to prioritize interests beyond those of the owners. Moreover, increased efforts could be directed towards developing various vaccines with high short-term efficacy, more injection sites, and addressing safety concerns associated with attenuated vaccinations (39). New vaccines should be developed based on the priority of bacterial diseases in each species and integrated with emerging technologies such as adjuvants and delivery (3040). Annually, NHC publishes a status report detailing the issues identified and providing recommendations for improvement. However, MOA lacks an action plan or agenda for future work. Limited data is available from the food and agriculture section, particularly in aquatic animal health and plant health. These findings were also corroborated by the results in TrACSS’s report from China (41).

      The management of antibiotic drugs and antibiotic therapy in the medical and healthcare field in China falls under the jurisdiction of the NHC and the NMPA, with a more multi-sectoral approach. The NHC has enhanced its implementation of drug equity, requiring all levels of the healthcare system to adhere to the principle and arrange for professionals to advise patients on appropriate drug usage. Detailed infection treatment methods and medication guidelines have been published to prevent improper utilization and overdoses throughout the infection diagnosis process. The development of new antibiotic medications has been supported and continues to yield positive results, with multinational collaborations being established. Nevertheless, the relevant literature provides limited information on the specifics of interdepartmental cooperation, role assignment, and required accountability.

      Intersectoral Analysis of Actions Among Departments Under the State Council: The core principle of One Health involves the cooperation among various government departments and the inclusion of additional stakeholders to achieve an efficient and large-scale impact. AMR governance cannot be addressed by a single sector or country; the essential requirement is the establishment of a coordinating department for cross-departmental collaboration and assigning responsibility and accountability across multiple departments. These aspects pose significant challenges in China’s execution of the NAP and remain the objective for the 2022–2025 NAP (35).

      There is a lack of intersectoral communication concerning initiatives related to AMR in China. Each department implements its own measures, leading to inconsistencies in the approaches taken. Our study identified considerable disparities in both the quantity and quality of work performed by various departments. The inconsistent attitudes and abilities of the departments contribute to incongruent deployment and completion of AMR-related actions. As a result, there is a need for an intermediary coordinating department at the national level to facilitate cross-sectoral collaboration, reduce resource waste, and improve governance effectiveness. This issue is also emphasized in the updated NAP.

    • In summary, China has made significant progress in AMR governance over the past five years, as evidenced by the development of a comprehensive surveillance and governance framework. A substantial number of publications have emerged addressing clinical usage of antibiotics, animal breeding, and treatment, with considerable investments allocated to AMR research. Despite these advancements, challenges remain due to inadequate interdepartmental collaboration and insufficient policy sustainability, leading to compromised effectiveness in AMR management. Additional efforts are required to address food safety and environmental concerns.

      Drawing from the One Health approach and international experiences, such as those provided by the WHO, future initiatives should prioritize interdepartmental cooperation to enhance the sustainability and effectiveness of national action plans. In 2022, China developed its second NAP for 2022–2025, incorporating contributions from several multisectoral departments (32). The plan encompasses new areas of focus, including vaccination, AMR treatment in environmental settings, and the establishment of an intersectoral collaboration mechanism.

      To further address AMR challenges, China should seek to play a more prominent role in international cooperation by joining global networks and adopting standardized laboratory and surveillance methodologies.

Reference (41)

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