AMR Alliance Japan
Recommendations on the Domestic AMR Surveillance System
September 2020

Every year, approximately 700,000 people are estimated to die from antimicrobial resistance (AMR)
related causes globally. Without action on this issue, it is projected that this figure could rise to up
to 10 million people per year by 2050. AMR is a growing problem. In Japan, countermeasuresagainst AMR have been advanced by the Government to this point based on the “National Action
Plan on Antimicrobial Resistance 2016-2020,” which was presented by the Japanese Government’s
Ministerial Committee on Infectious Disease Control in April 2015. Over the five years of this plan,various efforts have been undertaken to strengthen AMR surveillance, including the Japan
Antimicrobial Resistant Bacterial Surveillance (JARBS) project, which was started by the National
InstituteofInfectious

Diseases(NIID)

toaccumulate

andanalyze

informationonantimicrobial-resistant bacteria within Japan and abroad; and the creation of the Japan Surveillance
for Infection Prevention and Healthcare Epidemiology (J-SIPHE) system, which is operated by theNational Center for Global Health and Medicine’s AMR Clinical Reference Center to track AMRcountermeasures within healthcare facilities. AMR infectious are also tracked by the Ministry ofHealth, Labour and Welfare’s Japan Nosocomial Infections Surveillance project (JANIS). According todata from this project, as many as 8,000 people die every year of AMR-related causes in Japan.
AMR Alliance Japan is grateful for the efforts of the Japanese Government thus far and the manyexperts who have made contributions to the fight against AMR. The creation of a sustainable andcomprehensive surveillance system is critical to efforts to accurately assess the risks posed by AMRand to evaluate countermeasures. It is also important for the development of AMR diagnostics, andpharmaceuticals for treating antimicrobial-resistant infections. Accordingly, based on policy
recommendations developed in July 2019 (“The Japanese Government’s Role in Promoting AMRCountermeasures”), AMR Alliance Japan has developed the following recommendations on policies
that could further improve the AMR surveillance system in Japan. These recommendations include
content related to the revision of the Act on the Prevention of Infectious Diseases and Medical Carefor Patients with Infectious Diseases, among other measures.

Please note that within this proposal, the “surveillance system” is defined as having the primaryrole of accurately monitoring the risks poses by antimicrobial-resistant infections.

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The significance of AMR surveillance•

Makes risk assessment for antimicrobial-resistant infections possible•

Makes the assessment of AMR countermeasures possible•

Contributes to the development of antimicrobials and new diagnostic technology

Problems stemming from the lack of a sustainable and comprehensive
AMR surveillance system⚫

There is a lack of information available on pathogens and outcomes related to people whohave contracted with antimicrobial-resistant infections, making it difficult to conduct
assessments of the risks posed by AMR within Japan.

⚫

The is an insufficient legal framework in place for AMR countermeasures, which has caused
there to be a shortage of human resources at NIID and public health centers across the country,
and made the implementation of comprehensive and appropriate AMR countermeasuresdifficult.

⚫

There is no system in place for information sharing about the status of specific regions related
to antimicrobial-resistant infections, making it difficult to implement rapid AMRcountermeasures.

⚫

There is no system in place to accurately monitor antimicrobial-resistant infections at elderly
care facilities (long-term care health facilities, special nursing homes for the elderly),
outpatient care facilities, or healthcare institutions with 200 beds or fewer. The state ofantimicrobial use at these facilities is unknown. This makes it difficult to implement
appropriate AMR countermeasures at these facilities.

⚫

There is insufficient information on AMR among humans, animals, and in the environment perregion. This makes it difficult to implement countermeasures from a One Health perspective.

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Recommendations on the construction
comprehensive AMR surveillance system⚫

In orderto gatherofasustainable

andthe information needed to conduct risk assessments on

antimicrobial-resistant infections, regulations on infectious disease reporting should be revised(this should include the revision of reporting methods for pathogen tests as well). New
regulations should require reports to include pathogen information (including geneticinformation), antimicrobial use, as well as outcomes and other patient information. Whenrevising regulations, it would be ideal to take into account lessons learned from research
conducted for COVID-19 Registry Japan, and set appropriate time periods at which to require
follow-up reports. Furthermore, as the aforementioned information would be beneficial to thedevelopment of new antimicrobials and other research efforts, considerations should be madetoward making the information available publicly so that it can be more actively used(including for the update of priority pathogen lists, among other initiatives).
⚫

To lessen the operational burden placed on NIID and public health centers by their
participation in the National Epidemiological Surveillance of Infectious Diseases (NESID)
project, and to streamline surveillance work, information related to infectious diseases,
including AMR, should be managed electronically starting from the time healthcare
institutions submit initial reports about patients. It would be ideal to make effective use of theinformation system established for Coronavirus Disease 2019 (COVID-19), the Health Center
Real-time information-sharing System on COVID-19 (HER-SYS), to improve information-sharing
related to infectious diseases in general, including antimicrobial-resistant infections. In doing
so, the Government should consider ways to improve HER-SYS and expand its use.

⚫

To help rapidly detect cases of AMR infectious at the regional level, the information held byNESID and JANIS should be linked at the patient level. This could be done using patient
identification numbers or other such information contained within Personal Health Records(PHRs).

⚫

Reports on infectious diseases required as part of efforts to implement the Act on thePrevention of Infectious Diseases and Medical Care for Patients with Infectious Diseases should
be required to include information on AMR. AMR-related information should be collected bymunicipal governments and collated by NIID’s Antimicrobial Resistance Research Center inorder to make it possible to grasp national trends (related to both resistance and virulence)3

in the domestic spread of antimicrobial-resistant organisms at the genetic or genomic level.
⚫

Systems to collect AMR-related information and systems to promote AMR countermeasures
should be created in parallel for elderly care facilities, (such as long-term care healthfacilities or special nursing homes for the elderly) and other healthcare institutions whereantimicrobial-resistant infections are not currently being tracked. For example, Japan would
benefit from the creation of a system for at special nursing homes for the elderly that could
simultaneously track diagnostic test information related to pneumonia, urinary tract infections,and so on, alongside information on the pharmaceuticals being used to treat those infections(including what antimicrobials were used, the amount of support received from the long-termcare service fee system, and so on). Furthermore, considerations should be advanced toward
requiring regional medical facilities with 200 care beds or fewer to report AMR-related
information to JANIS. This could be achieved by making such reports a requirement in order tobe eligible to receive “Infectious Disease Prevention Premium 1” in the medical service feesystem, or it could be undertaken within the MHLW “Regional AMR Committee” model
project.

⚫

Requiring only a relatively low effort on the part of medical facilities, the J-SIPHE platform
should be utilized more actively for the promotion of infectious disease countermeasuresacross Japan. In order to gather AMR-related information from a greater number of healthcare
facilities, it is important to design systems in a way that benefits the facilities that provide theinformation. Accordingly, the Government should consider ways that regional medical facilities
might be able to collaborate with Regional AMR Committees and other such bodies within
J-SIPHE to receive direct guidance from infectious disease specialists (including feedback on
the AMR countermeasures being implemented by each facility). Additionally, in light of lessons
learned from COVID-19, greater support should be given to regional public health centers.
Efforts should be made to establish cooperative frameworks between public health centersand related organizations (including schools and medical associations). It is conceivable thatsuch collaboration could create new possibilities for the fight against AMR, such as thedevelopment of new regional countermeasures by local medical associations and governments
based on data provided by local pharmacies on antimicrobial use. For that reason, it isespecially important for the Government to consider further support for regional cooperation.

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⚫

Revisions should be made to the Act on the Prevention of Infectious Diseases and MedicalCare for Patients with Infectious Diseases and other related regulations to achieve therecommendations described above and promote comprehensive AMR countermeasures. It is
important that legal revisions be undertaken from the perspective of making it possible tocontinuously sustain the AMR countermeasures that have been implemented in Japan overthe past few years. In particular, “antimicrobial-resistant infections” should be defined within
the Act on the Prevention of Infectious Diseases and Medical Care for Patients with
Infectious Diseases.

⚫

An understanding of the actual situation of antimicrobial use in Japan is indispensablefor the implementation of effective AMR countermeasures. A system should be built tomanage up-to-date information on antimicrobial use, and information needed for analyses
and assessments related to antimicrobial use (including information for Anatomical
Therapeutic Chemistry (ATC) classification).
⚫

Information in the AMR One Health Platform should be organized by prefecture such that it
can be used more effectively within each region. Further efforts should be made to grasp thedistribution of antimicrobial-resistant organisms in soil, water, and elsewhere in the naturalenvironment, with the results of such efforts being shared in the aforementioned platform.

⚫

A central control tower should be created to supervise nationwide surveillance of AMR. In
recognition of the threat that AMR poses to humanity on a global scale, that control towershould work to construct a sustainable and comprehensive surveillance system to be jointly
operated by industry, government, academia, and civil society.

5The Government should work to secure a sufficient budget and human resources in order toimplement the above measures. An educational system that can train the staff members of eventhe small-scale medical facilities located outside of major cities will be needed in order to securesufficient human resources for this challenge. Looking toward the future, it is crucial that the publicand private sector work together on the creation of an educational system that can foster thehuman resources Japan needs to respond to the challenges posed by infectious diseases, including
AMR.

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