POLICY BRIEF

The construction of a domestic AMR surveillance and crisis
management system
Executive Summary• Surveillance of antimicrobial resistance and antimicrobial usage can inform therapy decisions and reduce unnecessary
antimicrobial use.
• In Japan, both the Japan Nosocomial Infections Surveillance (JANIS) and National Epidemiological Surveillance of Infectious
Disease (NESID) monitor infectious diseases in hospitals, but surveillance has been inadequate outside of hospitals and is not
uniform across sectors.
• Crisis management of antimicrobial resistance outbreaks and other infectious diseases depends on the resources of individual
medical institutions.
• Greater investment is needed into the AMR surveillance system, especially for facilities not yet implementing surveillance.

Introduction
The surveillance of antimicrobial resistance involves the identification of high-risk patients, the promotion of antimicrobials
stewardship, and the detection of outbreaks. Surveillance helps identify antimicrobial resistance patterns and provides
information that can limit the unnecessary use of antimicrobials.
The “surveillance loop” for infectious diseases consists of data collection, reporting, analysis, and response.1 If AMR issuspected in a hospital, laboratories will use diagnostic technology and automatic susceptibility testing to detect AMR organisms.
Next, surveillance systems such as Japan Nosocomial Infections Surveillance (JANIS) integrate, analyze, and report the results.2
These reports can be utilized by healthcare workers to strengthen antimicrobial stewardship programs. In addition, by setting
common indicators, such as Drug Resistance Index or Defined Daily Dose (DDD),* comparisons can be made across institutions
and countries. 3
Crisis management is the systematic process by which a government or institution deals with the outbreak of AMR organisms.
In Japan, hospital-based outbreaks are largely the responsible of Infectious Control Teams (ICTs) and Antimicrobial StewardshipTeams (ASTs).4 For large scale outbreaks, hospitals collaborate closely with health centers, with the Government setting up a
countermeasure headquarter if needed. Responses to infectious disease outbreaks are prescribed by the Infectious Disease
Control Law, which depends on the infectivity and severity of the disease. 5

Background of the Issue: Japan
Currently, Japan has two major AMR surveillance systems created by the Ministry of Health, Labour, and Welfare (MHLW): theJapan Nosocomial Infections Surveillance (JANIS) and the National Epidemiological Surveillance of Infectious Disease (NESID).
In 2000, the JANIS Clinical Laboratory Division was established to voluntary collect data from hospital-based diagnostic
microbiology laboratories for AMR surveillance.2 Once collected, clinical microbiological data is analyzed, and hospital-specific
AMR prevalence is reported. In addition, this data can be examined at the national level, examining geographical trends in AMR
prevalence. However, JANIS only monitors in-patients and does not collect data on clinics and nursing care facilities. As ofJanuary 2020, 2,358 medical institutions participated in JANIS.6 For FY2020, MHLW requested ¥82 million (US$750,000) for the*Defined Daily Doses – assumed average maintenance dose per day for a drug used for its main indication in adults

surveillance of AMR by JANIS. 7
In accordance with the Infectious Disease Control Law of 1999, NESID requires the reporting of seven antimicrobial-resistantbacteria infections (vancomycin-resistant enterococcus, vancomycin-resistant Staphylococcus aureus, carbapenem-resistantEnterobacteriaceae, multi-drug resistant Acinetobacter, penicillin-resistant Streptococcus pneumonia, methicillin-resistant
Staphylococcus aureus, multi-drug resistant Pseudomonas aeruginosa) which are all classified as category V infectious diseases.8
Of these seven pathogens, four (vancomycin-resistant enterococcus, vancomycin-resistant Staphylococcus aureus, carbapenemresistant Enterobacteriaceae, multi-drug resistant Acinetobacter) are reported by all physicians and three are reported by theapproximately 500 designated sentinel sites across Japan. NESID analyzes these reports and the results are rapidly provided andpublished to medical practitioners and the general public.
While JANIS and NESID cover specific antimicrobial-resistant organisms (AROs), some antimicrobial-resistant organisms, suchas drug-resistant bacilli, tuberculosis, fluoroquinolone-resistant Salmonella, and Shigella are not covered by these systems.9 As aresult, there is limited, if any, information available to manage outbreaks due to these AROs. Moreover, these surveillancesystems are not linked and cannot provide case histories of patients who have received antimicrobials. Without the integration ofsurveillance systems and harmonization of data input, capturing real-time information for the rapid management of AMR
outbreaks remains a challenge.
Since 2006, the Three Academic Societies Joint Antimicrobial Susceptibility program has conducted annual nationwide
surveys for target diseases and their related infectious disease, including AMR-related diseases such as respiratory infection,
urethritis, and simple cystitis.10 In addition to surveillance, the program measures minimum inhibitory concentration (MIC) of
antimicrobial drugs on microorganisms.
Furthermore, under the One Health approach, Japan monitors AMR in food-producing animals. The most notable of thesesurveillance systems are the Japanese Veterinary Antimicrobial Resistance Monitoring System (JVARM) and the National
Veterinary Assay Laboratory (NVAL). 8
In 2015, to generate reliable antimicrobial consumption data, MHLW created the Japan Antimicrobial Surveillance (JACS), a
web-based system that aims to identify the volume of antimicrobial use and infection status in Japan, and to provide information
for strengthening infection control. Data collected from pharmacist and wholesalers is used to calculate AUD (Antimicrobial Use
Density) and DOT (Days of Therapy). 8 While surveillance of antimicrobial use is largely conducted in in-patient settings,
antimicrobial usage in outpatients is largely unknown, which accounts for 90% of prescriptions.
In hospitals, crisis management of AMR outbreaks is under the purview of hospital-based Infection Control Teams (ICTs) andAntimicrobial Stewardship Teams (ASTs). For small- and medium-sized hospitals that lack the resources to set up Antimicrobial
Stewardship Teams, the AMR Clinical Reference Center has released guidelines for AMR crisis management in March 2019. 11 The
Japanese Government provides appropriate support depending on the specific needs of the hospital, for instance, related toepidemiological expertise needs. For large scale outbreaks, the Government is empowered to set up countermeasure
headquarters, headed by the Prime Minister, with the Chief Cabinet Secretary and Minister of Health as vice-chiefs. 5

Stakeholders and Countermeasure: Japan
Stakeholder

Countermeasure

Ministry of Health, Labour, andWelfare• Invests in surveillance technology and capacity building in hospitals.
• Sets standards and goals for antimicrobial resistance and antimicrobial usage. 9• Establishes guidelines and standards for crisis management.

AMR Clinical Reference Center• J-SIPHE: online common infectious disease countermeasure platform. 12 J-SIPHE combines,
quantifies, and visualizes data on infectious disease treatment status, infection countermeasures,
efforts to promote proper antibacterial usage, occurrence of medical-related AMR infections,occurrence of major bacteria and drug-resistant bacteria, and use of antibacterial agents.
• AMR Clinical Reference Center also creates crisis management guidelines for small- and mediumsized hospitals. 11

Japan Society for Chemotherapy,
The Japanese Association for
Infectious Disease, and The
Japanese Society for ClinicalMicrobiology• Three Academic Society Joint Antimicrobial Stewardship Program: collects national data on
antimicrobial resistance infections across academic societies. 10 Measures minimum inhibitory
concentration (MIC). This program has previously studied infectious disease includes respiratory
infections, urinary tract infections, and otorhinolaryngology infections.

Public-private partnerships• Public institutions, such as the National Institute of Infectious Diseases, has worked with private
partners to improve the surveillance of AMR in Japan. Automatic detection of AMR outbreaks(WHONET-SaTScan system). 13

Background of the Issue: Global
Antimicrobial resistant organisms are not bounded by national borders, and consistent surveillance must be conductedamong countries with varying levels of personnel and resources. Global and regional AMR surveillance systems are supported byinternational collaboration and strengthened by national surveillance systems. The largest and most comprehensive of these isthe Global Antimicrobial Resistance Surveillance System (GLASS), created by the World Health Organization. 14
Established in October 2015, GLASS provides a standardized approach for collecting, analyzing, and sharing global AMR
and antimicrobial consumption data. As of 2020, 87 countries participate in GLASS, including Japan.15 GLASS harmonizes AMR
data across countries and supports national AMR surveillance by developing a National Coordination Centre (NCC), National
Reference Laboratory (NRL), and sentential surveillance sites for collecting diagnostic results and epidemiological data . 14
International surveillance on AMR has made major strides at the regional level. The European Centre for Diseases Prevention
and Control created the European Antimicrobial Resistance Surveillance Network (EARS-NET), which, in turn, inspired the Central
Asia and Eastern Europe Surveillance of Antimicrobial Resistance (CAESAR).16 Concomitantly, the Latin American Network for
Antimicrobial Resistance Surveillance (ReLAVRA) aggregates AMR surveillance information from 19 Latin American countries.17
These regional collaborations disseminate know-how and support the development of national antimicrobial surveillancesystems.
Although the World Health Association (WHO), Food and Agriculture Organization (FAO), and World Organization for Animal
Health (OIE) have produced guidelines on the development of National Action Plans on AMR, the creation of such plans and theimplementation of infection prevention and control (IPC) measures has been inconsistent across regions.18 As of 2019, only 70
countries have created National Action Plans. 19 Also, budgets for AMR surveillance vary by country. For example, for the FY2020,
the Center of Disease Control and Prevention (US) allocated US$170 million for AMR activities, including the surveillance of AMR
organisms and the strengthening of state, local, and national capacities.20 In comparison, many countries have AMR surveillanceplans but no defined budget (Figure 1). 14

Existing with budget

Existing with no budget

No existing25

Number of countries

1
20
15
10

1

1

13

4
11

5
0

4

9

AFR

1

8

2

2

AMR/PAHO

EMR

EUR

4

6

SEAR

WPR

WHO Regions
Figure 1. Existence of functioning national AMR surveillance plan per
country by region 14*AFR – WHO African Region; AMR/PAHO – WHO Americas/Pan American Health Organization Region; EMR – WHO
Eastern Mediterranean Region; EUR – WHO Europe Region; SEAR – WHO South-East Asia Region; WPRO – WHOWestern Pacific Region

Stakeholder and Countermeasures: Global
Stakeholder

Countermeasure

World Health Organization• Global Antimicrobial Resistance Surveillance System (GLASS) - collects, analyzes, and shares global
AMR and antimicrobial consumption data, and supports national surveillance capacities.21 Currently,
GLASS is creating estimates from data provided by 64,000 surveillance sites across 66 countries,
covering more than 2 million patients. Furthermore, GLASS has released a protocol toward theestablishment of a prospective cohort study. 22• Global Infection Prevention and Control Network - support low- and middle-income countries andhelp develop local and national surveillance systems as an issue of human security. 23

G20• 2018 G20 Summit Argentina - health ministers from the G20 countries participated in a crisis
simulation on cross-border antimicrobial resistant E. coli. Tested leaders’ and countries’ ability to
rapidly respond to a pandemic, and revealed the pressures placed on health systems
and economies. 24

European Centre for Disease
Prevention and control• European Antimicrobial Resistance Surveillance Network (EARS-Net): EU’s leading surveillancesystem for antimicrobial resistance infections that cause serious infections. 25

Stakeholder

Countermeasure

Private sector initiatives• AMR Industry Alliance – Davos Declaration to share surveillance data with public health bodies andhealthcare professionals. 26• HealthMap, and the Center for Disease, Dynamics, Economics, and Policy (US) - private-public
partnerships to combine skills and resources to monitor national AMR patterns. 27• Surveillance Partnership to Improve Data for Action on Antimicrobial Resistance (SPIDAAR): Pfizer
Japan Inc. and the Wellcome Trust formed a private-public partnership with governments of Ghana,
Kenya, Malawi and Uganda to track antimicrobial resistance patterns and investigate the effects of
antimicrobial resistant bacteria on patients living in low- and middle-income countries. 28

Public-academic partnerships• The National Institute of Infectious Diseases, Teikyo University, Tottori University, Nagoya University,
Brigham and Women’s Hospital University, and WHO Collaborating Centers in Boston have beenworking together to automated detection of antimicrobial-resistant infections in Japan using the
WHONET-SaTScan system. 13

AMR Alliance Japan Recommendations• The Government should recognize AMR as a global-scale threat to humanity and take responsibility for the creation of asustainable and comprehensive surveillance system operated through public-private cooperation. The Government should
invest appropriately in that system based on that recognition.
• In constructing such a system, the Government should take into consideration the following points.
▶ The system should be able to capture detailed and real-time info on AMR and antimicrobial usage (including strain data andmeasurements of antimicrobial usage)▶ The system should make use of a format that makes the effective transfer and collection of data easy, based on the opinionsof clinical facilities, and a consideration of the burden the system might place on them.
▶ The system should link clinical information, strain data, antimicrobial usage and so on in order to make it possible to follow
the case histories of patients that receive antimicrobials• Data from facilities not currently implementing surveillance measures is of vital importance. A system should also beconstructed to provide support to those facilities so that they can hire the personnel needed for surveillance work, which is ofparticular importance for the surveillance of outpatient facilities.

References
1.
2.

Japan International Cooperation Agency, “Surveillance” (Tokyo, Japan, 2018)
Tsutsui, Atsuko, and Satowa Suzuki. "Japan nosocomial infections surveillance (JANIS): a model of sustainable national antimicrobial resistancesurveillance based on hospital diagnostic microbiology laboratories." BMC health services research 18, no. 1 (2018): 799.
3. World Health Organization. “AMR Indicators and their relevance to the global indicator framework for the SDGs and targets for the 2030 Agenda
for Sustainable Development”, (Geneva, Switzerland, 2018)
4. Center Hospital of the National Center for Global Health and Medicine, “ICT and AST”, (Tokyo, Japan)
5. Ministry of Health, Labour, and Welfare “Infectious Disease Control Law” (Tokyo, Japan, 2013)
6. Ministry of Health, Labour, and Welfare. “JANIS: List of participating institutions” (Tokyo, Japan, 2020)
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10. Three Academic Societies Joint Antimicrobial Susceptibility Surveillance Program. “Database” (Tokyo, Japan)
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2019)
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platform” (Tokyo, Japan, 2019)
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424-430
17. Pan American Health Organization. “ReLARVA - Países miembros” (Washington, US, 2020)
18. World Health Organization, Food and Agriculture Organization of the United Nations, World Organization for Animal Health. “Antimicrobial
resistance: A manual for developing national action plans” (Geneva, Switzerland, 2016)
19. World Health Organization. “Library of national action plans” (Geneva, Switzerland, 2019)20. Center for Disease Control and Prevention. “U.S. National Action Plan for Combating Antibiotic-Resistant Bacteria (National Action Plan)” (Atlanta,
US, 2020)
21. World Health Organization. “Record number of countries contribute data revealing disturbing rates of antimicrobial resistance” (Geneva,
Switzerland, 2020)
22. World Health Organization. “GLASS method for estimating attributable mortality of antimicrobial resistant bloodstream infections” (Geneva,
Switzerland, 2020)23. World Health Organization. “Global Infection Prevention and Control Network Meeting Report” (Geneva, Switzerland, 2018)24. Blanchard, Sam. “G20 experts stage a fake superbug pandemic to test how the world would react to a deadly outbreak of an antibiotic-resistantdisease” Daily Mail (London, UK, 2018)25. European Centre for Disease Prevention and Control “Surveillance of antimicrobial resistance in Europe 2018” (Kingdom of Sweden, 2019)26. AMR Industry Alliance. “Declaration by Pharmaceutical, Biotechnology and Diagnostic Industries on Combating Antimicrobial Resistance” (Geneva,
Switzerland, 2016)
27. O’Neill, Jim. "Infection prevention, control and surveillance: Limiting the development and spread of drug resistance - review on antimicrobial
resistance." (London, UK, 2016)28. Pfizer Inc. “Pfizer and Wellcome Launch Surveillance Program to Combat Growing Threat of Antimicrobial Resistance in Sub-Saharan Africa” (NewYork City, US, 2020