Feasibility study on integrated surveillance systems on AMR and AMC encompassing human health, animal health, plant health, food, wastewater and the environment : case study : Belgium.
Date: 2025-11-13
Institutions: European Health and Digital Executive Agency, Instituto de Biomedicina de Sevilla, Università di Verona
Subjects: Belgium, One Health approach, animal disease, antibiotic, antimicrobial resistance, case study, data collection, disease prevention, drug surveillance, environmental protection, feasibility study, infectious disease, information system, nutrition, plant health treatment, report, veterinary medicinal product, wastewater

Feasibility study on integrated 
surveillance systems on AMR and AMC 
encompassing human health, animal 
health, plant health, food, wastewater and 
the environment  
Case study - Belgium

Written by Open Evidence, PwC EU Services EEIG, IBiS, and UNIVR 
For the Directorate General for Health and Food Safety 
July 18th 2025 
Final version 

for 

DG SANTE 

 
 
 
 
 
 
 
 
 
 
 
 
EUROPEAN COMMISSION 
Directorate General For Health and Food Safety 
Directorate A — One Health 
Unit A1 – Antimicrobial resistance, human nutrition 
E-mail: SANTE-CONSULT-A1@ec.europa.eu 
European Commission 
B-1049 Brussel

 
 
 
 
 
PROJECT TEAM 

Open Evidence (OE): Cristiano Codagnone (Project manager), Carlos Torrado Ortega (research coordinator), Silvia Grothe i 
Riera. 

PwC EU Services EEIG. 

Università di Verona (UNIVR) - Department of Diagnostics and Public Health: Evelina Tacconelli, and Alessandro Visentin. 

Instituto de Biomedicina de Sevilla (IBIS): Jesús Rodríguez Baños, José Miguel Cisneros Herreros, Zaira Palacios Baena, 
and Ana Belén Guisado Gil. 

Individual experts: Elena Mazzolini, and Fiona Walsh. 

Manuscript completed in July 2025 

First edition 

This document has been prepared for the European Commission however it reflects the views only of the 
authors, and the European Commission is not liable for any consequence stemming from the reuse of this 
publication. 

Luxembourg: Publications Office of the European Union, 2025 

© European Union, 2025 

The reuse policy of European Commission documents is implemented by Commission Decision 2011/833/EU 
of 12 December 2011 on the reuse of Commission documents (OJ L 330, 14.12.2011, p. 39). Unless 
otherwise noted, the reuse of this document is authorised under a Creative Commons Attribution 4.0 
International (CC BY 4.0) licence (https://creativecommons.org/licenses/by/4.0/). This means that reuse is 
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EN PDF  

ISBN 978-92-95239-50-0  doi:10.2925/7177451  HW-01-25-026-EN-N 

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Directorate General for Health and Food Safety 

Contents 

1  Executive summary ....................................................................................................... 1 
Introduction ................................................................................................................... 2 
2 
3  Methodological Approach .............................................................................................. 3 
Country ................................................................................................................................ 3 
4  Country-specific context ................................................................................................ 5 

4.1 

Country overview ................................................................................................... 5 

4.1.1 
4.1.2 
4.1.3 
4.1.4 

One Health approach definition ...................................................................... 5 
Regulatory framework .................................................................................... 6 
Key factors for an integrated surveillance system .......................................... 7 
Surveillance systems in place and initiatives ................................................. 7 

4.2 

Surveillance system for human health .................................................................. 9 

4.2.1 
4.2.2 

Antimicrobial resistance ................................................................................. 9 
Antimicrobial consumption and use ............................................................. 11 

4.3 

Surveillance system for animal health, plant health and food safety ................... 12 

4.3.1 
4.3.2 

Antimicrobial resistance ............................................................................... 12 
Antimicrobial consumption and use ............................................................. 14 

4.4 
4.5 

Surveillance system for AMR in the environment ................................................ 16 
Integration efforts and current state of interoperability ........................................ 17 

4.5.1 
4.5.2 
4.5.3 
4.5.4 

Ongoing efforts ............................................................................................. 17 
Planned actions ............................................................................................ 19 
Necessary Conditions to Ensure Interoperability ......................................... 20 
Expected impact of a further integrated system ........................................... 21 

5  Challenges and barriers .............................................................................................. 21 
6  Enablers and drivers ................................................................................................... 25 
7  Conclusions and lessons learnt .................................................................................. 26 
8  Annexes ...................................................................................................................... 29 

8.1 
8.2 

Annex A: Case study interview questions ........................................................... 29 
Annex B: Interview summary ............................................................................... 31 

8.2.1 
8.2.2 

Overview ...................................................................................................... 31 
Discussion of responses .............................................................................. 32 

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1  Executive summary 

Over  the  past  decade,  Belgium  has  taken  important  steps  to  improve  surveillance  and 
stewardship  related  to  antimicrobial  resistance  (AMR)  and  antimicrobial  consumption 
(AMC), including the development of the National Action Plan on AMR (NAP-AMR 2020–
2024) (1) and the BELMAP report (2), published in 2021 for the first time. In Belgium, AMR 
and  AMC  are  monitored  in  various  settings  including  human  medicine,  food-producing 
animals, and the food supply chain and, though more rarely, in the environment (3). 

Belgium’s  surveillance  systems  in  human  and  animal  health  are  relatively  well-
established, with mandatory AMR surveillance for key pathogens and mandatory AMC data 
collection  via  health  insurance  records  and  veterinary  monitoring  systems,  according  to 
interviewed stakeholders. However, environmental surveillance is still limited to the EU 
Water  Framework  Directive  (WFD)  Watch  List  (4)  and  one-off  initiatives  (rather  than 
systematic monitoring) (5)(6)(7) and region-specific sampling. A core strength of Belgium’s 
approach is the presence of national coordination bodies, such as Sciensano, that provide 
institutional  capacity  for  AMR/AMC  surveillance  and  policy  development  (8).  Additionally, 
the decentralised governance model, while adding a level of complexity to the system, 
allows for tailored regional interventions while simultaneously posing a challenge for data 
harmonisation and national-level coordination (9). 

Key challenges reported in the implementation of AMR/AMC surveillance with a  One Health 
approach include fragmentation of data systems (10), limited interoperability within and 
across sectors (11), and a lack of shared objectives across sectors (12). While the BELMAP 
report(13)  has  improved  cross-sectoral  visibility,  stakeholders  report  that  it  still  lacks 
sufficient  granularity,  particularly  for  the  veterinary  sector.  Moreover,  a  major  obstacle 
remains the lack of a centralised digital platform and standardised protocols for cross-
sector data integration(14). 

Nonetheless,  several  enablers  are  driving  Belgium’s  progress.  Specific  funding  for 
BELMAP  and  the  NAP-AMR  facilitated  intersectoral  collaboration,  the  development  of 
shared  indicators,  and  coming  improvements  in  data  systems,  financial  and  technical 
support  was  also  identified  as  being  critical,  according  to  interviewed  stakeholders. 
Continued access to funding mechanisms such as EU-JAMRAI(15), supported Belgium to 
pilot new tools, scale up integration efforts, and build capacity in areas like data science, 
epidemiology, and IT development. For example, European HERA (2022-2024) funds the 
pilot  project  in  Belgium  to  create  a  digital  architecture  to  integrate  genomic  data  (which 
includes e.g. information about pathogens) and nominative data (such as patient identities, 
farms) in a secure environment – crucial for integrated surveillance systems to track, predict 

(1) Belgian “One health” national action plan on the fight against AMR 2020-2024. Available at: Link. 
(2) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(3) Ibid. 
(4) EU surface water Watch List Available at: Link. 
(5) Wallonie (n.d), Plan wallon environnement-santé 2019-2023. Available at: Link. 
(6)  Wallonie  environnement  SPW  (2018),  Recherche  des  substances  émergentes  dans  les  eaux  et  intéressant  la  santé 
publique et l’environnement, Programme de recherche IMHOTEP. Available at: Link. 
(7)  ILVO  (n.d),  Study  of  possible  future  pathways  for  livestock  farming  and  fisheries  in  Flanders,  based  on  dialogue  and 
science. Available at: Link. 
(8)  Mickaël  Cargnel  et  al  (2024).  Using  a  Stakeholder  Analysis  to  Implement  the  Belgian  One  Health  National  Report  for 
Antimicrobial Use and Resistance. Available at: Link. 
(9) Ibid. 
(10) Ibid. 
(11) Charlotte E Chong at el (2024). Conference report of the 2024 Antimicrobial Resistance Meeting. Available at: Link. 
(12) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(13) Ibid. 
(14)Ibid. 
(15) European Union Joint Action on Antimicrobial Resistance (AMR) and Healthcare-Associated Infections (HCAI). Available 
at: Link. 

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Feasibility study on integrated surveillance systems on AMR and AMC encompassing 
human health, animal health, plant health, food, wastewater and the environment 

and respond to health threats by linking  biological and individual-level information in real 
time(16).  Furthermore,  according  to  interviewed  stakeholders,  the  EU’s  role  in  facilitating 
cross-border  collaboration  and  knowledge  exchange  helps  Belgium  align 
its 
surveillance with best practices and emerging standards, while also addressing shared risks 
- such as the cross-border spread of infectious diseases or AMR – that require coordinated 
responses. 

Moreover, there is also increasing interest in whole genome sequencing (WGS) for early 
AMR  detection  and  outbreak  tracing,  which  is  perceived  as  a  cornerstone  for  future 
integrated surveillance by the stakeholders interviewed (17). 

Looking ahead, stakeholders agree  on the need to adopt  a more integrated approach, 
which would enable more targeted and efficient analyses of AMR/AMC, the need for a long-
term funding model, and the development of  IT tools to streamline data collection and 
integration. The Belgian case underscores  the importance of maintaining strong national 
surveillance  systems  while  actively  contributing  to,  and  benefiting  from,  EU-level 
harmonisation  efforts.  Achieving  fully  integrated  One  Health  surveillance  in  Belgium  will, 
according to interviewed stakeholders, require both continued political will and systemic 
reforms in governance, infrastructure, and cross-sector collaboration. 

2  Introduction 

Antimicrobial  resistance  (AMR)  and  antimicrobial  consumption  (AMC)  are  major  public 
health challenges with implications that extend across human health, animal health, plant 
health, food safety, and the environment. Recognising the interconnected nature of these 
sectors,  the  European  Commission  has  emphasised  the  need  for  integrated  One  Health 
surveillance systems to better understand the emergence and spread of AMR and inform 
targeted interventions(18). 

This case study is part of a comprehensive study commissioned by the European Health 
and Digital Executive Agency (HaDEA) to assess the design and implementation of effective 
integrated  surveillance  systems  for  AMR  and  AMC  in  EU/EEA  Member  States.  The 
objectives of this case study include: 

  Conducting and in-depth analysis of the status of integration of surveillance systems in 

line with a One Health approach.  
Identifying barriers and challenges to integrate surveillance systems  

 
  Highlighting key enablers and drivers for successful integration of surveillance systems. 
  Extracting the key “lessons-learnt” that can support EU/EEA countries in their integration 

of One Health Surveillance.  

The following sections of the case study are structured as follows: 

  Section 3 provides a brief overview on the methodological approach for this case study, 

including the interviews conducted. 

  Section  4  provides  an  overview  of  the  country-specific  context  and  an  overview  of 

existing surveillance systems for AMR and AMC based on desk research. 

  Section 5 presents the challenges to establishing an integrated surveillance system for 

AMR and AMC extracted from the interviews conducted. 

(16)  Sciensano  (n.d.).  HERA-Incubator-WGS  –  National  Infrastructure  for  genomic  epidemiologic  surveillance  of  infectious 
diseases. Available at: Link. 
(17) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(18) European Commission (2017). A European One Health Action Plan against Antimicrobial Resistance. Available at: Link. 

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  Section  6  highlights  the  factors  that  have  facilitated  integration  efforts  in  Belgium 
towards integrated approach countries. It identifies key enablers, successful strategies, 
and  stakeholder  recommendations  for  further  development  and  implementation  of 
integrated surveillance systems in a one health approach. 

  Section  7  presents 
recommendations. 

the  conclusions  and  key 

lessons 

learnt,  and  potential 

3  Methodological Approach 

A total of 6 case studies were conducted in this phase for the following countries: 

Country 

Belgium 

Denmark 

Netherlands 

Spain 

Greece 

Category 

Advanced countries from the EU/EEA 

Start-up phase country 

Limited action or no action towards integrated 
surveillance 

Switzerland 

Advanced country outside of the EU/EEA 

For  each country, interviews were conducted in order to gather the perspective of those 
conducting  the  surveillance  and  reporting  activities  within  each  One  Health  Approach, 
including  both  AMR  and  AMC.  Interview  guides  were  tailored  according  to  the  specific 
country categories described above – the guide relevant to this case study is presented in 
the annex A. Interview questions had the objective to: 

• 

• 

Identify the main barriers to the integration of AMR and AMC surveillance in a One 
Health approach. 

Identify  the  key  enablers  to  successful  systems  integration  in  a  One  Health 
approach. 

In total, for Belgium, seven interviews were conducted, and are presented in the table below: 

One Health sector 

Number of Interviews Conducted 

One  health  coordination  and 
Human Health 

Human Health 

Animal Health(19) 

Environment  

Total Interviews 

1 

1 

4 

1 

7 

(19) Including plant health and food safety 

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Feasibility study on integrated surveillance systems on AMR and AMC encompassing 
human health, animal health, plant health, food, wastewater and the environment 

Moreover,  desk  research  was  conducted  to  complement  the  input  from  the  interviews. 
Relevant reports, policy documents and academic studies were consulted. 

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Directorate General for Health and Food Safety 

4  Country-specific context 

This section provides an overview of the national surveillance systems for AMR and AMC 
in  Belgium,  highlighting  the  extent  of  data  collection,  analysis,  and  integration  in  a  One 
Health approach. Information is categorised by sector (human health, animal health, plant 
health and food safety, and the environment) to offer an overview of the current system's 
functionality and maturity. 

4.1  Country overview 

AMR  is  a  significant  health  concern  in  Belgium,  primarily  due  to  a  high  antibiotic 
consumption in the human and animal sector (20). Despite a gradual decrease in antibiotic 
use  between  2016  and  2024,  Belgium  remains  one  of  the  largest  users  of  antibiotics  in 
Europe,  particularly  in  outpatient  care  and  livestock  farming,  which  continues  to  exert 
pressure on resistance levels (21).  

Given  Belgium’s  fragmented  health  system’s  governance  between  federal  and 
regional  levels,  it  has a  decentralised  surveillance  system  which  results  in  a diverse 
landscape  of  relevant  AMR/AMC  databases,  reports,  and  stakeholders  (22).  Therefore,  it 
was  reported  by  interviewed  stakeholders  that  it  is  often  challenging  to  retain  a  clear 
overview  of  the  evolution  of  AMR  and  AMC  across  sectors  and    time.  To  address  this 
challenge, one of the actions defined in the National Action Plan for AMR (2021–2024)(23) 
was the creation of a ‘One Health’ report on AMC and AMR, with the first such annual report, 
referred to as the BELMAP report(24). In Belgium, information related to AMR is collected 
from  clinical  laboratories,  veterinary  laboratories,  and  national  surveillance  systems, 
whereas  information  related  to  AMC  is  collected  from  hospital  pharmacy  records, 
community  pharmacy  sales,  sales  of  antimicrobial  products,  and  veterinary  prescription 
databases.  The  results  from  these  diverse  AMR/AMC  data  collection  programmes  are 
reported separately. 

4.1.1 One Health approach definition 

Belgium implemented a ‘One-Health’ National Action Plan against AMR (NAP-AMR)(25) 
for  2020  to  2024.  The  NAP-AMR  states  that  AMR  should  be  tackled  from  a  One-Health 
perspective in  recognition  that  human  health  is  linked  to  animal  health, the  safety  of  the 
food chain and the environment in general. Specifically, the NAP-AMR encourages: 

- 

Intersectoral  and 
the  public  and  private 
organisations  involved  in  the  different  pillars  of  AMR/AMC  health  (human  health, 
animal health, plant health and the environment), 

integrated  collaboration  between 

-  Structured  collaboration  with  other  policy  areas  (health  and  environment  policies 
have  a  global  and  international  impact,  affecting  society,  employment,  economy, 
education, mobility, taxation, trade, security policy, etc.), 

-  A long-term approach, given the systemic nature of all resistance determinants.(26) 

(20) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(21) Belgian “One health” national action plan on the fight against AMR 2020-2024. Available at: Link. 
(22)  Mickaël  Cargnel  et  al  (2024).  Using  a  Stakeholder  Analysis  to  Implement  the  Belgian  One  Health  National  Report  for 
Antimicrobial Use and Resistance. Available at: Link. 
(23) Belgian “One health” national action plan on the fight against AMR 2020-2024. Available at: Link. 
(24) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(25) Belgian “One health” national action plan on the fight against AMR 2020-2024. Available at: Link. 
(26) Belgian “One health” national action plan on the fight against AMR 2020-2024, page 14. Available at: Link. 

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The NAP-AMR has been developed to clarify and establish mechanisms for multi-sectoral 
cooperation. It states the objective to establish an effective and transparent surveillance of 
AMR and AMC, to enable timely and targeted responses.  

Following  the  NAP-AMR,  the  BELMAP  report  assembles  publicly  available  national  data 
and  existing  surveillance  programmes  form  all  sectors  on  antimicrobial  usage  and 
resistance in humans, livestock, food, and the environment. It aims to provide an overview 
of the monitoring  of AMR and AMC in humans, food-producing animals, the food supply 
chain, sales of antimicrobial products for all animals and for non-medical use, as well as the 
detection of antimicrobial residues in the environment. 

During  the  interviews,  stakeholders  were  aligned  on  the  definition  of  an  integrated  One 
Health AMR/AMC surveillance system, describing it as a programme producing comparable 
data  and  therefore  able  to  perform  intersectoral  analyses  and  comparison  for  the  One 
Health approach. 

4.1.2 Regulatory framework 

The following regulatory frameworks were referenced by stakeholders as supporting their 
efforts to integrate One Health surveillance: 

•  The  governmental  body  referred  to  as  Belgian  Antibiotic  Policy  Coordination 
Committee  (BAPCOC)(27)  was  established  in  1999.  Its  primary  objective  is  to 
promote the sensible use of antibiotics in both human and veterinary medicine and 
to enhance infection control and hospital hygiene, aiming to reduce AMR. According 
to  the  NAP-AMR,  BAPCOC  fostered  interdisciplinary  leadership,  which  led  to 
evidence-based  interventions  including  publication  of  clinical  practice  guidelines, 
staffing and technical support for establishment of antibiotic management teams in 
hospitals and surveillance programmes on AMR and AMC in humans and animals. 
These activities and interventions resulted in a measurable decrease in AMR and 
AMC in the community and hospitals. 

•  The  Belgian  NAP-AMR  2020-2024  (28),  as  earlier  introduced,  is  a  collaboration 
between  federal,  community  and  regional  partner  administrations,  experts  and 
organisations  such  as  the  BAPCOC  and  stakeholders  in  the  animal  and 
environmental  sector.  The  action  plan  promoted  a  common  vision  to  ensure 
continuity  in  the  prevention  and  treatment  of  infectious  diseases  in  humans  and 
animals  through:  (I)  the  availability  and  responsible  use  of  effective,  safe  and 
accessible antimicrobial drugs and tools, (II) the establishment of a broad network 
of  partners  capable  of  preventing,  rapidly  detecting  and  responding  to  the 
development  and  transmission  of  AMR  in  humans,  animals  and  the  environment 
,(III) the use of the best available science, consideration of the source and not just 
the consequences of AMR. Ten strategic directions for combatting AMR have been 
elaborated. The NAP-AMR(29) follows the “One World One Health” approach. 

•  There are other plans that indirectly contributed to the development of integrated 
systems  such  as  the  eHealth  Action  Plan  2022-2024(30),  the  Third  National 

(27) Federal public service health, food chain safety and environment, BAPCOC. Available at: Link. 
(28) Belgian AMR One Health Action Plan 2020-2024. Available at: Link. 
(29) Belgian “One health” national action plan on the fight against AMR 2020-2024. Available at: Link. 
(30) Plan d’actions e-Santé 2022-2024. Available at: Link. 

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Environment-Health  Action  Plan  (NEHAP3)(31),  the  Generic  Preparedness  Plan 
HEALTH(32). Interviewed stakeholders explained a second NAP-AMR is on the way 
of being validated. 

4.1.3 Key factors for an integrated surveillance system  

The  stakeholders  and  the  NAP-AMR  ((33))  remarked  on  several  key  initiatives  that 
contributed towards their pursuit of integrated surveillance in Belgium:  

•  The World Health Organisation (WHO) conducted a Joint External Evaluation in 
Belgium  in  2007  to  evaluate  the  implementation  of  the  International  Health 
Regulations (IHR)(34). The evaluation suggested improvements to stewardship and 
coordination between the animal, environmental and health sectors around activities 
related to AMR. 

•  The  European  Centre  for  Disease  Prevention  and  Control  (ECDC)  and  the 
European Commission (DG SANTE) conducted a joint visit to Belgium in 2017 
to discuss the situation of AMR and AMC in Belgium. Both organisations concluded 
that Belgium had several good initiatives, benefits from high-level scientific expertise 
and  paved  the  way  on  AMR  in  many  aspects.  However,  the  overall  fragmented 
approach  of  AMR/AMC  surveillance  in  Belgium,  remaining  sector-specific,  was 
highlighted(35). 

On  July  2nd  2018,  the  Ministers  of  Health  from  the  federal,  regional  and  community 
authorities therefore decided, in an inter-ministerial conference on health, to set up an inter-
cabinet working group, extended to include representatives of the Ministers responsible 
for the safety of the food chain, animal health and the environment, aimed at drawing up a 
National One Health Action Plan for the fight against AMR(36). 

Regarding  AMC,  the  interviewed  stakeholders  highlighted  that  AMCin  Belgium  remains 
high, with little significant improvement in the last ten years in the human health sector. In 
contrast,  stakeholders  did  highlight  that  AMC  in  the  veterinary  sector  was  decreasing. 
Stakeholders interviewed for this report agreed that adopting a more integrated approach 
would  enable  more  targeted  and  efficient  analyses  of  AMR.  Moreover,  according  to  the 
interviewed stakeholders, an integrated analysis will allow for a better understanding of the 
relationship between antibiotic use and the emergence of resistance across sectors.  

4.1.4 Surveillance systems in place and initiatives 

The table below list the surveillance systems for AMR and AMC that are already operational 
in Belgium, based on desk research and information shared by the different stakeholders 
through the interviews. 

(31)  Santé  publique  Sécurité  de  la  Chaîne  alimentaire  Environnement,  Troisième  Plan  d’Action  National-Santé  (NEHAP3), 
2024. Available at: Link. 
(32) Santé publique Sécurité de la Chaîne alimentaire Environnement, Generic Preparedness Plan Health), 2023. Available at 
Link. 
(33) Belgian “One health” national action plan on the fight against AMR 2020-2024. Available at: Link. 
(34) WHO, International Health Regulations, 2005. Available at: Link. 
(35) Belgian AMR One Health Action Plan 2020-2024. Available at: Link. 
(36) Belgian “One health” national action plan on the fight against AMR 2020-2024. Available at: Link. 

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Feasibility study on integrated surveillance systems on AMR and AMC encompassing 
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Table 1. Overview of surveillance systems in Belgium 

Sector 

Surveillance system 

Coordinating organisation 

Two  different  relevant  systems  are  in  place  for 
the  epidemiological  surveillance  of  AMR  in 
humans in Belgium: 

• 

Human - AMR 

the  Belgian  National  Surveillance  in 
Healthcare  settings 
-  Antimicrobial 
resistance (NSIH-AMR) surveillance(37) 
of  methicillin  resistant  Staphylococcus 
aureus  (MRSA),  multi-resistant  Gram-
and 
negative 
enterococci 
vancomycin 
(VRE). 

(MRGN), 

resistant 

bacilli 

• 

the  EU  Antimicrobial  Resistance 
for  Belgium 
Surveillance  Network 
(EARS-BE)(38). 

Two  different  relevant  systems  are  in  place  for 
AMC surveillance in humans in Belgium: 

• 

• 

The  national  Belgian  hospitals  – 
Surveillance 
Antimicrobial 
of 
Consumption (BeH-SAC)(39). 

The  EU  Surveillance  of  Antimicrobial 
Consumption  Network 
for  Belgium 
(ESAC-Net)(40). 

Human - AMC 

Animal - AMR 

Belgium  operates  three  main  AMR  surveillance 
programmes  in  the  animal  sector:  European 
monitoring  programme  (EARS-BE(41)),  national 
monitoring programme, and passive surveillance 
system. 

Animal - AMC 

of 
The  Belgian  Veterinary  Surveillance 
(BelVet-SAC)(42) 
Antibacterial  Consumption 
compile the sales data from the data collected at 
the level of the manufacturers of medicated feed 
(antimicrobial  premixes)  and  at  the  level  of  the 
holders  of  an  authorisation 
to  market 
antimicrobial medicines in Belgium (antimicrobial 
pharmaceuticals). 

Sciensano  (NSIH-AMR  and  EARS-
BE) 

Sciensano  (BeH-SAC  and  ESAC-
Net) 

Sciensano (EARS-BE) 

Federal Agency for the Safety of the 
Food  Chain 
(national 
monitoring programme) 

(FASFC) 

Passive 
(Sciensano) 

surveillance 

system 

Veterinary  Epidemiology  Unit  of  the 
faculty  of  Veterinary  Medicine  from 
the  Ghent  University  (sales  data) 
and  the  Data  Analysis  Unit  of  the 
centre  of  expertise  on  Antimicrobial 
Consumption  and  Resistance 
in 
Animals  (AMCRA)  (use  data)  under 
the  authority  of  the  Belgian  Federal 
Agency  for  Medicines  and  Health 
products (FAHMP). 

(37)  Belgian  National  Surveillance  in  Healthcare  settings  -  Antimicrobial  resistance  (NSIH-AMR)  surveillance.  Available  at: 
Link. 
(38) European (EU) Antimicrobial Resistance Surveillance Network for Belgium (“EARS-BE”). Available at: Link. 
(39) Belgian hospitals – Surveillance of Antimicrobial Consumption (BeH-SAC). Available at: Link. 
(40) European (EU) Surveillance of Antimicrobial Consumption Network for Belgium (ESAC-Net). Available at: Link. 
(41) European (EU) Antimicrobial Resistance Surveillance: Belgium (EARS-BE). Available at: Link. 
(42) Belgian Veterinary Surveillance of Antibacterial Consumption (BelVet-SAC). Available at: Link. 

8 

 
 
 
 
Directorate General for Health and Food Safety 

Sector 

Surveillance system 

Coordinating organisation 

Environment 

Environmental  AMR  surveillance  in  Belgium  is 
limited,  with  water  surveillance  of  some 
antibiotics. The surveillance was adopted based 
upon  the  EU  surface  water  Watch  List  (43)  and 
some one-off projects(44)(45). 

Federal  Public  Service  for  Health 
Food Chain Safety and Environment 
(FPS HFCSE) 

Apart  from  the  programmes  mentioned  above,  Belgium  has  a  Transversal  Steering 
Group(46),  which  ensures  early  detection  of  emerging  AMR  threats  by  facilitating 
collaboration  among  various  stakeholders, 
the 
management  committee  of  the  antibiotic  convention  in  the  animal  sector,  the  Technical 
Committee  MultiDrug  Resistant  Organisms  (TC-MDRO),  the  Outbreak  Support  Team 
(OST),  the  Comité  National  des  Antimicrobiens  (NAC),  the  Medical-technical  Advisory 
Board (MTAB) and the Risk Assessment Group (RAG) Risk Management Group (RMG). 

including  AMCRA, 

the  FAMHP, 

Belgium actively contributes to European and international efforts in combating AMR and 
AMC  through  systematic  data  submission  to  various  networks.  Belgium  reports  human 
health  data  on  AMR  and  AMC  to  the  ECDC  through  EARS-BE  (47)  and  ESAC-Net  (48). 
Moreover, Belgium submits data to the  WHO's Global Antimicrobial Resistance and Use 
Surveillance System (GLASS)(49). In the animal sector, Belgium submits AMR data related 
to healthy animals at slaughterhouses to the European Food Safety Authority (EFSA) and 
actively participates in the Food- and Waterborne Diseases and Zoonoses Network (FWD-
Net), coordinated by ECDC (50). Belgium provides data on antimicrobial consumption and 
use in veterinary medicine to the European Medicines Agency (EMA) as part of the newly 
established Antimicrobial and Use (ASU) platform (51). Belgium submits data to the WOAH 
Global database on antimicrobial agents intended for use in animals (ANIMUSE)(52). 

4.2  Surveillance system for human health 

4.2.1 Antimicrobial resistance 

AMR surveillance system in Belgium is coordinated at the national level by Sciensano, a 
public  health  institution  (53).  Clinical  microbiology  laboratories  and  National  Reference 
Centers (NRCs) collect the AMR data and share it with Sciensano, which then analysis and 
report  the  data.  The  AMR  surveillance  protocol  is  defined  by  the  ‘Healthcare-associated 
infections  and  antimicrobial  resistance  service’  (NSIH)(54)  of  Sciensano,  in  collaboration 
with the relevant National Reference Laboratories. 

The  national  surveillance  of  AMR  in  human  health  began  in  1994  with  the  monitoring  of 
MRSA  in  hospitals  (55).  This  initiative  was  organised  by  NSIH.  Participation  in  MRSA 

(43) EU surface water Watch List Available at: Link. 
(44) ILVO Vlaadeen, Innovative decision-making tool for defining the most suitable manure management strategies to achieve 
a sustainable livestock farming system during the whole value chain. Available at: Link. 
(45) ILVO Vlaaderen, Probing antibiotic residues and resistance transfer in aquatic environments. Available at: Link. 
(46) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(47) Sciensano (n.d.). EARS-BE – European Antimicrobial Resistance Surveillance: Belgium. Available at: Link. 
(48) Sciensano (n.d.) ESAC-Net – European Antimicrobial Consumption Surveillance: Belgium. Available at: Link. 
(49) WHO (n.d.) GLASS Country Participation. Available at: Link. 
(50) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(51) Regulation (EU) 2019/6 of the European Parliament and of the Council of 11 December 2018 on veterinary medicinal 
products. Available at: Link. 
(52) WOAH (n.d). ANIMUSE. Available at: Link. 
(53) Sciensano (n.d.). AMR coordination. Available at: Link. 
(54)  Belgian  National  Surveillance  in  Healthcare  settings  -  Antimicrobial  resistance  (NSIH-AMR)  surveillance.  Available  at: 
Link. 
(55) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 

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Feasibility study on integrated surveillance systems on AMR and AMC encompassing 
human health, animal health, plant health, food, wastewater and the environment 

surveillance became mandatory by Royal Decree (56) in 2006 for acute care hospitals. The 
surveillance was expanded in 2000 to include multidrug-resistant gram-negative bacteria, 
MRGN,  with  mandatory  participation  starting  in  2014  (57).  Nevertheless,  even  though 
participation in MRSA and MRGN surveillance is mandatory, the interviewees reported that 
there are no existing penalties for not reporting data. Additionally, the surveillance of VRE 
was introduced as optional programmes in 2014, from which hospitals must choose one to 
participate in (58). 

Belgium monitors the pathogens required by the ECDC since 2000 through EARS-BE(59) 
surveillance, by having NSIH collecting and submitting  the data to EARS-Net. EARS-BE 
data is collected annually, microbiology laboratories are asked to specify data up to the level 
of  individual  combinations  of  the  antimicrobial  tests  performed  and  to  transfer  this  file  to 
Sciensano (60). EARS-BE follows the development of AMR in positive cultures of human 
origin using results from clinical laboratories in Belgium provided to Sciensano. Sciensano 
then reports to EARS-Net and GLASS. In addition to the EARS-Net requirement, Belgium 
performs  antimicrobial  susceptibility  tests  (AST)  on  urinary  isolates  (in  addition  to 
blood/CSF  samples),  includes  the  fungal/bacterial  pathogen  Proteus  mirabilis  and 
distiguished  between  Acinetobacter  baumannii  and  other  all  Acinetobacter  species,  in 
recognition  that  A.baumannii  is  the  predominant  species  associated  with  AMR.  Unlike 
EARS-Net,  EARS-BE  (61)  system  allows  stratification  by  hospital  type.  In  acute  care 
hospitals, AMR surveillance is mandatory surveillance and conducted in acute throughout 
the year. In ambulatory care and long-term care facilities, AMR surveillance is conducted 
through  ad  hoc  projects  (62).  In  long-term  care  facilities,  systems  like  HALT  (63)  provide 
granular insights into antimicrobial resistance. 

Stakeholders interviewed on the human health considered that there was a sufficient legal 
basis  for  health  surveillance,  since  Belgium  has  national  regulations  and  since  the 
European regulation 2022/2371 on cross-border threats (64) is directly applicable legislation 
in  the  Member  States,  without  the  need  for  transposition.  Nevertheless,  some  actors 
continued to argue that there was a lack of sanctions for not collecting the data. 

Aside  from  the  two  main  resistance  surveillances  (NSIH-AMR  and  EARS-BE),  clinical 
laboratories  can  voluntarily  send  isolates  to  NRCs  for  phenotypic  and  genotypic 
characterisation  (including  resistance  profiles  and  confirmation  of  relevant  resistance 
mechanisms) and/or molecular typing. These NRCs publish annual reports, from which data 
on resistance was extracted for inclusion in the BELMAP report. 

Following  the  European  Council  recommendation  2023/C  220/01  on  stepping  up  EU 
actions  to  combat  antimicrobial  resistance  in  a  One  Health  approach  (65),  Belgium  set 
targets  for  the  incidence  of  resistant  bloodstream  infections  for  MRSA,  3rd  generation 

(56) 10th September 2020 - Arrêté royal modifiant l'arrêté royal du 25 avril 2002 relatif à la fixation et à la liquidation du budget 
des moyens financiers des hôpitaux. Available at: Link. 
(57) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(58) 25th April 2002 - Arrêté royal relatif à la fixation et à la liquidation du budget des moyens financiers des hôpitaux. Available 
at: Link. 
(59) European (EU) Antimicrobial Resistance Surveillance Network for Belgium (“EARS-BE”). Available at: Link. 
(60) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(61) European (EU) Antimicrobial Resistance Surveillance Network for Belgium (“EARS-BE”). Available at: Link. 
(62) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(63) Healthcare-Associated Infections in Long-Term Care Facilities (HALT) surveys. Available at: Link. 
(64) Regulation (EU) 2022/2371 of the European Parliament and of the Council of 23 November 2022 on serious cross-border 
threats to health and repealing Decision No 1082/2013/EU. Available at: Link 
(65) European Council recommendation (2023/C 220/01) on stepping up EU actions to combat antimicrobial resistance in a 
One Health approach. Available at: Link. 

10 

 
 
 
 
Directorate General for Health and Food Safety 

cephalosporins-resistant  E.  coli,  and  carbapenem  resistant  K.  pneumoniae  (66).  Belgium 
calculates the metrics using the same methodology as used for European benchmarking of 
ECDC calculation of the health burden of infections with antibiotic-resistant bacteria (67) - 
namely  the  number  of  cases  of  bloodstream  infections  reported  in  the  EARS-BE 
surveillance was divided by the population size (Eurostat data) multiplied by an estimate of 
the population coverage of participating hospitals each year. According to the interviewed 
stakeholders, this methodology has limitations and will therefore be validated at a national 
level against data from the mandatory blood stream infection surveillance during 2025. 

4.2.2 Antimicrobial consumption and use 

Belgium collects data on the WHO List of Medically important antimicrobials to monitor and 
regulate the use of critical antibiotics in both human and veterinary medicine (68). This data 
collection  aims  to  preserve  the  efficacy  of  essential  antimicrobials  by  identifying  usage 
patterns that could drive resistance. It includes information on the type, volume, and context 
of  antimicrobial  use  (e.g.,  species  treated,  dosage,  and  treatment  indications),  enabling 
policymakers  to  implement  targeted  stewardship  measures  and  align  with  international 
AMR  surveillance  efforts.  Sciensano  compiles  reimbursement  data  received  from  the 
National Institute for Health and Disability Insurance (NIHDI) and reports it  to ESAC-Net 
(69).  The  data  for  the  community  sector  include  all  antimicrobial  packages  dispensed  in 
community  pharmacies,  including  nursing  homes  that  receive  medication  from  these 
pharmacies,  which  applies  to  the  majority  in  Belgium  (70).  Hospital  data  include  all 
prescriptions delivered in hospital pharmacies. As reimbursement data only considers the 
insured population (99% of the total Belgian population in 2023), estimates for total AMC 
are extrapolated to cover the full Belgian population. To be noted, for reimbursement data 
from hospitals, reimbursement requests and corrections are legally allowed up to two years 
after the actual consumption, which leads to significant delays and to an underestimation of 
the  reimbursed  hospital  AMC  (71).  The  interviewed  stakeholders  highlighted  the  delay 
problematic, explaining that actions are in place to address it. 

Besides ESAC-Net, Belgium has a more detailed national surveillance system for AMC in 
hospitals: BeH-SAC (72). It relies on the National Institute for Health and Disability Insurance 
(NIHDI) reimbursement data and allows benchmarking between hospitals (73). Within BeH-
SAC  (74),  data  is  reported  by  hospital  type  (acute,  categorical  and  psychiatric).  When 
considering acute care hospitals, the presented data include inpatient wards only (excluding 
outpatient wards and day hospitalisations) and psychiatric wards are excluded. 

Both  ESAC-Net  and  BeH-SAC  only  consider  reimbursed  consumption,  excluding  non-
reimbursed,  off-label  use  or 
to  potential 
underestimations (75). Sales data obtained from IQVIA (Sciensano has a specific contract 
with IQVIA) are annually used to estimate the total consumption of fluoroquinolones in the 
community sector and a comment is added in Belgium’s national reporting.  

imported  antimicrobial  agents, 

leading 

(66) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(67)  ECDC,  Estimated  incidence  of  bloodstream  infections  with  three  key  pathogens  in  the  EU/EEA  in  2019,  April  2023. 
Available at: Link. 
(68) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(69) European (EU) Surveillance of Antimicrobial Consumption Network for Belgium (ESAC-Net). Available at: Link. 
(70) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(71) Ibid. 
(72) Belgian hospitals – Surveillance of Antimicrobial Consumption (BeH-SAC). Available at: Link. 
(73) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(74) Belgian hospitals – Surveillance of Antimicrobial Consumption (BeH-SAC). Available at: Link. 
(75) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 

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human health, animal health, plant health, food, wastewater and the environment 

In  addition  to  these  surveillance  systems,  point-prevalence  studies  (PPS)  of  healthcare 
associated infections and antimicrobial use are organised in hospitals (by both the ECDC 
and  Global-PPS)  and  long-term  care  facilities  at  regular  time  points.  In  all  these  PPS 
studies, data were collected from each hospital ward or facility on a single day by a local 
data collector (76).  

In  The  European  Council  Recommendations  outline  targets  for  reducing  the  incidence 
(number of resistant bloodstream infections per 100,000 inhabitants) of some key resistant 
pathogens by the year 2030. These target reductions are set per country (Belgian targets 
in parentheses, black lines in Figure 1), in order to achieve an EU-wide 15% reduction in 
MRSA (Belgian target -6%), 10% reduction in 3rd generation cephalosporins-resistant E. 
coli  (Belgian  target  -12%)  and  5%  reduction  in  carbapenem  resistant  K.  pneumoniae 
(Belgian target -2%) blood stream infections, considering 2019 as the reference year (77). 

Figure 1: Estimated incidence of resistant bloodstream infections per 100,000 inhabitants.  

Source: BELMAP report 2024(78).  

4.3  Surveillance  system  for  animal  health,  plant  health  and 

food safety  

4.3.1 Antimicrobial resistance 

Belgium  initiated  national  surveillance  of  AMR  in  animal  health  in  2011,  focusing  on 
monitoring resistance in Escherichia coli healthy animals (79). Belgium operates three main 
AMR surveillance programmes  in the animal sector:  European monitoring programme 

(76) Ibid.  
(77) Ibid. 
(78) Ibid. 
(79) Ibid. 

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Directorate General for Health and Food Safety 

(EARS-BE),  national  monitoring  programme,  and  passive  surveillance  system  (80). 
These programmes cover healthy and diseased animals (animals that have a diagnosed or 
detectable disease, whether or not they show symptoms), with data collected at farms and 
slaughterhouses, analysed by Sciensano, and reported to various stakeholders, including 
the European Food Safety Authority (EFSA). The abovementioned programmes expand on 
EU requirements (Directive 2003/99/EC(81), Decision 2020/1729(82)) by covering all food-
producing animal species annually and include additional pathogens such as surveillance 
of ESBL (extended-spectrum beta-lactamases) E. coli in fish and raw milk(83). 

Regarding AMR in food producing animals, BELMAP uses AMR data from commensal 
E.  coli  isolated  from  healthy  animals  as  a  general  indicator  for  resistance  among  food-
producing animals. For commensal E. coli monitoring, the Federal Agency for the Safety of 
the  Food  Chain  (FASFC)  collects  samples  of  caecal  content  at  the  slaughterhouse  and 
fresh faeces at farm annually since 2011 as part of a nationwide surveillance programme. 
The  following  categories  of  food-producing  animals  are  included:  beef  cattle  (meat 
production,  faeces  sampled  at  the  farm  level),  and  veal  calves,  broiler  chickens  and 
fattening pigs sampled at the slaughterhouse. The sampling and isolation of indicator E. coli 
strains are performed according to standardised technical instructions. The cultured E. coli 
bacteria are tested for susceptibility to ciprofloxacin, cefotaxime, colistin and twelve other 
antibiotics, as determined by European legislation (Decision 2020/1729(84)). Since 2014, all 
the isolates showing resistance to a third-generation cephalosporin are considered potential 
beta-lactamase producing E. coli and are analysed in detail for their beta-lactamase activity 
(85). 

Additionally, MRSA is monitored in different animal categories to map both the prevalence 
of this resistant zoonotic bacterium and its level of resistance to other antibiotics (86). The 
surveillance of MRSA follows a three-year cycle and includes farm samples (pooled nasal 
swabs) from the poultry, cattle, or pig sector, depending on the year. AMR testing of MRSA 
strains is detailed in the reports available on the Federal Agency for the Safety of the Food 
Chain (FASFC) website (87). After identification of Enterococcus faecalis or Enterococcus 
faecium species by Matrix-assisted laser desorption-ionization time of flight (MALDI-TOF), 
isolates  are  tested  for  susceptibility  to  linezolid,  vancomycin,  daptomycin  and  nine  other 
antibiotics, as determined by Decision 2020/1729 (88). In addition to the animals previously 
mentioned, e.faecalis and e.faecium are also monitored in veal calves, fattening turkeys, 
broiler chickens, breeding hens, laying hens and pigs (89). 

Regarding zoonotic pathogens in the food chain, in even years in Belgium, Salmonella 
spp. isolates are collected from poultry populations (broilers and fattening turkeys) before 
slaughter in the framework of the national control programme, using the isolates required 
by  the  mandatory  Regulation  2160/2003/EC(90),  but  does  not  test  specifically  for 

(80) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(81)Directive 2003/99/EC of the European Parliament and of the Council of 17 November 2003 on the monitoring of zoonoses 
and zoonotic agents, amending Council Decision 90/424/EEC and repealing Council Directive 92/117/EEC. Available at: Link. 
(82) Commission Implementing Decision (EU) 2020/1729 of 17 November 2020 on the monitoring and reporting of antimicrobial 
resistance in zoonotic and commensal bacteria and repealing Implementing Decision 2013/652/EU. Available at: Link 
(83) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(84) Commission Implementing Decision (EU) 2020/1729 of 17 November 2020 on the monitoring and reporting of antimicrobial 
resistance in zoonotic and commensal bacteria and repealing Implementing Decision 2013/652/EU. Available at: Link 
(85) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(86) Ibid. 
(87) FASC website. Available at: Link. 
(88) Commission Implementing Decision (EU) 2020/1729 of 17 November 2020 on the monitoring and reporting of antimicrobial 
resistance in zoonotic and commensal bacteria and repealing Implementing Decision 2013/652/EU. Available at: Link 
(89) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(90) Regulation (EC) No 2160/2003 of the European Parliament and of the Council of 17 November 2003 on the control of 
salmonella and other specified food-borne zoonotic agents. Available at: Link. 

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human health, animal health, plant health, food, wastewater and the environment 

susceptibility. In odd years, Salmonella spp. isolates are collected from caecal samples at 
the slaughterhouse from fattening pigs and veal calves (91). These isolates are tested for 
antimicrobial susceptibility following the method described in the Decision 2020/1729(92), 
and included in the AMR surveillance. In addition, isolates of Salmonella spp. collected in 
the framework of the official sampling of feed and the food chain are tested for the detection 
of  resistance  genes  via  whole  genome  sequencing  (WGS)  since  2023,  replacing 
antimicrobial susceptibility testing (93). 

The  BELMAP  indicates  that  at  both  national  and  European  level,  a  gap  in  AMR 
surveillance in veterinary medicine is evident. Current AMR surveillance efforts are of 
limited help to veterinary practitioners and policymakers seeking to improve antimicrobial 
stewardship in animal health, since the mandatory monitoring of AMR in bacteria sampled 
in healthy animals at slaughter is primarily not for animal health reasons but for public health 
- food safety reasons (94).  

regional 

to  national  AMR  surveillance, 

laboratories,  such  as 
In  addition 
Dierengezondheidszorg Vlaanderen (DGZ), the Regional Association of Animal Health and 
Identification (ARSIA) and Melkcontrolecentrum (MCC) Vlaanderen analyse samples from 
diseased animals to track infections (95). Farmers send data on healthy and diseased food-
producing  animals  to  DGZ,  ARSIA  and  MCC  Vlaaderen  every  three  months.  Testing 
guidelines exist for diseased  animals, but standardisation remains a challenge as not all 
bacteria are covered by these guidelines. Interviewed stakeholders agreed that while the 
data submitted to EFSA, regarding healthy and diseased animals, is of high quality, data 
outside  this  framework  is  lower  in  quality,  and  a  harmonised  approach  with  national 
reporting across actors is still lacking. 

To be noted, the surveillance of AMR for crop production is considered within the remit of 
the environmental sector in Belgium. A current, important gap in the veterinary sector is the 
absence of AMR surveillance in companion animals and aquatic food-producing animals 
(96). Projects researching this field are ongoing, according to interviewed stakeholders, the 
future  expansion  scheme  of  AMU  data-collection  to  new  animal  categories  should  be 
accompanied by a monitoring of AMR in the same animal species to evaluate the impact 
on  AMR  of  changes  in  AMU.  Moreover,  interviewed  stakeholders  expect  the  JAMRAI 
initiative on EARS-Vet (97) to contribute to filling this knowledge gap with the standardisation 
and organisation of external quality controls. 

4.3.2 Antimicrobial consumption and use 

Belgium initiated AMC surveillance in animal health in 2007, with the establishment of the 
BelVet-SAC (98) project. The first comprehensive BelVet-SAC report, covering data from 
2007 to 2009, was published in 2010. Data on AMC in veterinary medicine are based on 
both  sales  and  usage.  Commissioned  by  the  Federal  Agency  for  Medicines  and  Health 
Products (FAMHP), data on antimicrobial sales at the level of the wholesaler-distributors 

(91) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(92) Commission Implementing Decision (EU) 2020/1729 of 17 November 2020 on the monitoring and reporting of antimicrobial 
resistance in zoonotic and commensal bacteria and repealing Implementing Decision 2013/652/EU. Available at: Link 
(93) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(94) Ibid. 
(95) Ibid. 
(96) Ibid.  
(97)  JAMRAI,  Policy  Brief,  European  Antimicrobial  resistance  surveillance  network  in  veterinary  medicine  (EARS-Vet). 
Available at: Link. 
(98) Belgian hospitals – Surveillance of Antimicrobial Consumption (BeH-SAC). Available at: Link. 

14 

 
 
 
 
Directorate General for Health and Food Safety 

and  manufacturers  of  medicated  feed  licensed  to  produce  medicated  feed  have  been 
collected since 2007 in the BelVet-SAC. 

Since 2022, sales data for antimicrobial pharmaceutical products were collected at the level 
of  the  MAH  instead  of  the  wholesaler-distributors.  For  the  antibacterial  premixes  for 
medicated  feed,  the  data  of  the  manufacturers  of  medicated  feed  continued  to  be  used. 
These sales data comprise all animal species (food producing and non-food producing). 

The  use  data  originate  from  the  secured  online  data  collection  system  Sanitel-Med  (99), 
which has been developed and maintained by the FAMHP, and is linked to the Sanitel-Med 
data base of the Federal Agency for the Safety of the Food Chain (FASFC). Since February 
2017,  veterinarians  are  legally  obliged  (Royal  Decree  of  21.07.2016(100))  to  register  all 
antimicrobial products (pharmaceuticals as well as premixes) prescribed, administered, and 
delivered on Belgian farms that keep pigs, broilers, laying hens, or veal calves. Since August 
2023, this obligation is extended to all categories of food producing chickens and turkeys 
and  to  cattle  (EU  Regulation  2019/6  (101);  RD  of  21.07.2016(102)).  While  EU  Regulation 
2019/6 mandates the collection of antimicrobial usage data at the species level, the Belgian 
Royal Decree imposes stricter requirements, including: 

•  Veterinarian-level  registration:  Veterinarians  must  record  every  prescription, 

administration, and delivery of antimicrobials, not just aggregate data. 

• 

Individual  farm-level  data:  Belgium  requires  data  to  be  linked  to  specific  farms, 
enabling detailed monitoring and benchmarking. 

•  Broader  scope  earlier:  Belgium  introduced  these  obligations  well  before  the  EU 
regulation  took  effect  and  has  progressively  expanded  the  categories  of  animals 
included in the mandatory registration, demonstrating a proactive national policy to 
reduce antimicrobial use. 

Sanitel-Med is accessible as a web application or through automated data transfer using 
xml. Farmers and veterinarians can access Sanitel-Med with a login provided by DGZ and 
ARSIA,  so  they  can  verify  the  registration  of  the  use  data  and  consult  their  personal 
benchmark reports to evaluate their antibiotic use.  

Additionally,  every  quarter,  the  FAMHP  and  AMCRA  publish  the  'Antibiotic  Use 
Barometer' (103), based on the mandatory registration of antibiotic use in Sanitel-Med. This 
shows a number of trends with regard to antibiotic use per animal species (pigs, poultry, 
veal  calves,  dairy  and  beef  cattle):  the  evolution  of  the  total  annual  use  in  each  animal 
species. 

Interviewed stakeholders explained that the quality of antibiotic sales and use (Sanitel-Med) 
data  is  sufficient  for  year-to-year  comparisons  and  meeting  surveillance  and  policy 
objectives, though gaps remain, particularly in newly registered sectors. Sales data is strictly 
regulated, with only commercialised antibiotic reported, validation steps for data accuracy, 
and  built-in  monitoring  to  detect  anomalies.  Sanitel-Med  enforces  mandatory  data  entry 
controls,  ensuring  correct  prescription  formats,  veterinarian  and  facility  verification,  and 

(99) Sanitel-Med- Available at: Link. 
(100) Royal Decree of 21.07.2016 on the conditions governing the use of medicinal products by veterinary surgeons and those 
responsible for animals. Available at: Link. 
(101) Regulation (EU) 2019/6 of the European Parliament and of the Council of 11 December 2018 on veterinary medicinal 
products and repealing Directive 2001/82/EC- Available at: Link. 
(102) Royal Decree of 21.07.2016 on the conditions governing the use of medicinal products by veterinary surgeons and those 
responsible for animals. Available at: Link. 
(103) Barometer Antibiotic Use. Available at: Link. 

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human health, animal health, plant health, food, wastewater and the environment 

consistency  between  animal  species,  diagnosis,  and  drug  use,  with  additional  PowerBI-
based checks to flag abnormal entries. 

A  major  challenge  is  that  sales  data  does  not  directly  correlate  with  use  sometimes,  as 
stockpiling,  supply  chain  delays,  and  cross-border  purchases  can  create  discrepancies 
between  what  is  sold  and  what  is  actually  used  in  animal  treatment  (104).  The  BELMAP 
report shows how the gap between the sales and use data has been decreasing, meaning 
sales  and  use  data  are  getting  closer.  For  some  products  (e.g.  aminopenicillins, 
lincosamides  and  colistin)  greater  usage  within  the  Sanitel-Med  species  than  the  total 
volume  sold  has  been  observed.  The  BELMAP  report  partially  explains  this  evolution 
through the entering into force of Regulation EU 2019/6 (105) in January 2022, permitting 
purchasing of antimicrobials in other EU/EEA Member States. It is currently unclear how 
much  antimicrobials  are  bought  in  other  EU  Member  States  but  if  that amount  would  be 
increasing, the reported Belgian antimicrobials sales data may less accurately reflect the 
actual volume of antimicrobials purchased for use in Belgium. 

4.4  Surveillance system for AMR in the environment 

Environmental  AMR  surveillance  in  Belgium  is  limited,  according  to  the  interviewed 
stakeholders. Water monitoring is carried out following the European Water Framework 
Directive (106), which lead to the only surveillance system for the environment in place in 
Belgium.  All  Belgian  regions  adhere  to  the  European  Directive  2008/105/CE(107)  on 
environmental quality standards in the field of water policy. The monitoring of surface waters 
includes the antibiotics provided for by the EU Watchlist (108), as required by the European 
Water  Framework  Directive  (109).  The  Vlaamse  Milieumaatschappij  (VMM),  Brussels 
Environment and the Service Public de Wallonie (SPW) track the concentration of potential 
water pollutants of surface water listed in the EU Watchlist (110).  

One-off  projects  by  the  Regions  supplement  these  samplings,  in  particular  the 
AntiBIOBUG  pilot  project  by  the  Walloon  Region,  which  measures  E.  coli  resistance  in 
surface water downstream of farms and hospitals (Ourthe and Vesdre)(111). The Regions 
also  finance  one-off  projects  for  monitoring  antimicrobial  resistance  in  groundwater, 
including  the  IMHOTEP  (Inventaire  des  Matières  Hormonales  et  Organiques  en  Traces 
dans les Eaux Patrimoniales et Potabilisables) project by the Walloon Region, in which the 
Brussels-Capital Region is also participating (112). In the Flemish Region, several studies 
have also been conducted or are ongoing, including a preliminary analysis of antimicrobial 
resistance in surface waters near intensive livestock production, conducted in collaboration 
with the Flanders Research Institute for Agriculture, Fisheries and Food (ILVO)(113). 

(104) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(105) Regulation (EU) 2019/6 of the European Parliament and of the Council of 11 December 2018 on veterinary medicinal 
products and repealing Directive 2001/82/EC. Available at: Link. 
(106) Directive 2000/60/EC of the European Parliament and of the Council of 23 October 2000 establishing a framework for 
Community action in the field of water policy. Available at: Link. 
(107) Directive 2008/105/EC of the European Parliament and of the Council of 16 December 2008 on environmental quality 
standards in the field of water policy. Available at: Link. 
(108) Selection of substances for the 4th Watch List under the Water Framework Directive (2022). Available at: Link. 
(109)Directive 2000/60/EC of the European Parliament and of the Council of 23 October 2000 establishing a framework for 
Community action in the field of water policy. Available at: Link. 
(110) Selection of substances for the 4th Watch List under the Water Framework Directive (2022). Available at: Link. 
(111) Wallonie (n.d), Plan wallon environnement-santé 2019-2023. Available at: Link. 
(112)  Wallonie  environnement  SPW  (2018),  Recherche  des  substances  émergentes  dans  les  eaux  et  intéressant  la  santé 
publique et l’environnement, Programme de recherche IMHOTEP. Available at: Link. 
(113) ILVO  (n.d), Study of possible future pathways for livestock farming and fisheries in Flanders, based on dialogue  and 
science. Available at: Link. 

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Regarding  the  Urban  Wastewater  Treatment  Directive(114),  interviewed  stakeholders 
explained the directive is still under discussion to be decided how it will be implemented in 
Belgium.  

Moreover, interviewees highlighted that AMR surveillance in the environment is complex 
due to the federal structure and regional competencies. Sampling is conducted within 
regions: four sites in Flanders, one in Brussels, and six in Wallonia. Each region organises 
sampling  and  analysis  differently,  according  to  interviewed  stakeholders.  Many  activities 
are done by the regional  authorities; therefore, information is sometimes not available at 
federal  level.  The  interviews  highlighted  a  lack  of  communication  between  the  different 
regions. However, the launch of the BELMAP report allowed better communication between 
the stakeholders. Interviewed stakeholders emphasised the challenge of integrating data 
from different sectors due to differences in aims and methodologies. Moreover, interviewees 
highlighted there is still a limited understanding of the role of the environment in AMR, as 
well  as  a  lack  of  awareness  about  the  cost-efficiency  and  the  level  of  insights  that 
environmental surveillance could provide. 

According to the NAP-AMR (115), new environmental actions are planned, such as: 

•  Fungal agent resistance monitoring in the environment under Sciensano). 

•  Centralisation and consolidation of some environmental monitoring of antimicrobial 
residues and resistant bacteria in the environment (surface water, groundwater and 
wastewater)  to  be  able  to  monitor  the  state  of  the  environment  and  collate  this 
information with the resistance observed in human and animal health (at a regional 
level). 

•  The information collected will be shared with the water treatment organisations in 
order  to  strengthen  techniques  for  purification  and  the  removal  of  antimicrobial 
residues and resistant bacteria, where possible. 

Moreover,  Belgium’s  environmental  surveillance  is  actively  involved  in  the  European 
Environment Information and Observation Network (Eionet) (116), where it pledges in favour 
of a more integrated surveillance system, according to interviewed stakeholders. 

The  surveillance  of  AMR  for  crop  production  is  considered  within  the  remit  of  the 
environmental  sector  in Belgium.  Regarding  antifungal  pesticide  use in the  environment, 
Belgium  monitors  resistance  in  environmental  aspergillosis  samples  (117).  Additionally, 
Belgium is one of the only countries that have a reporting system for biocides and fungicides 
through a Federal Reduction plan for Biocides (118).  

4.5  Integration efforts and current state of interoperability 

4.5.1 Ongoing efforts 

Across  the  stakeholders  interviewed,  there  was  a  consensus  that  there  is  growing 
collaboration between the human, animal and environmental sectors in Belgium. However, 
this collaboration concerns more of  joint reporting, such as with the BELMAP report(119), 

(114)Directive  (EU)  2024/3019  of  the  European  Parliament  and  of  the  Council  of  27  November  2024  concerning  urban 
wastewater treatment. Available at: Link. 
(115) Belgian “One health” national action plan on the fight against AMR 2020-2024. Available at: Link. 
(116) European Environment Information and Observation Network (Eionet). Available at: Link. 
(117) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(118) Health Food Chain Safety Environment, Federal Reduction Plan for Biocides. Available at: Link. 
(119) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 

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human health, animal health, plant health, food, wastewater and the environment 

rather than an integrated surveillance system with a One Health approach. Several ongoing 
efforts are aimed at strengthening the functionality of individual systems.  

Stakeholders  described  several  ongoing  meetings  under  NAP-AMR  (120)  and  under  the 
BELMAP report that promote collaboration between different sectors. The FPS HFCSE and 
Sciensano  are  the  main  coordinators  of  those  meetings.  For  instance,  interviewed 
stakeholders  explained  that  a  second  NAP-AMR  is  currently  under  validation.  The 
coordination of the BELMAP report is overseen by an editorial board that convenes six times 
a year. Any proposed methodological changes are reviewed and put to a vote during these 
meetings.  Additionally,  the  editorial  board  collects  feedback  from  the  various  agencies 
involved, ensuring that the system functions effectively across different sectors. According 
to interviewed stakeholders, this process also plays a crucial role in keeping stakeholders 
engaged and encouraging them to submit data regularly. Importantly, stakeholders retain 
ownership  of  their  data,  and  Sciensano  does  not  claim  ownership  over  the  collected 
information, ensuring transparency and trust in the data-sharing process. 

In  the  human  sector,  the  Belgian  data  protection  legislation,  specifically  the  Act  on  the 
protection of natural persons with regards to processing of personal data (121), establishes 
provisions that complement and, in certain aspects, are more restrictive than the European 
Union's General Data Protection Regulation (GDPR)(122). This act leads to additional and 
specific  requirements  for  justifying  the  use  personal  data  in  surveillance  activities. 
Therefore, interviewed stakeholders explained that act can affect the quality and traceability 
of the data collected. Work is underway on how to overcome these legal obstacles to allow 
better use of personal data in the human surveillance. 

According to interviewed stakeholders, there are discussions on the future sharing of raw 
data  for  improved  analysis.  However,  concerns  remain  about  patient  confidentiality, 
particularly in hospitals, where questions arise about whether patient data should be publicly 
disclosed  and  if  patients  are  adequately  informed.  According  to  the  same  stakeholders, 
previous legal debate in Belgium determined that hospital-level AMR data should not be 
publicly disclosed to prevent unintended consequences, such as patient selection of specific 
hospitals.  

In human health, exchanges between national authorities and microbiological laboratories 
remain gradual due to  the fragmentation  of laboratory information systems  and the wide 
use of proprietary technologies, which present significant challenges for interoperability and 
seamless  data  exchange,  according  to  interviewed  stakeholders.  Belgium  is  actively 
working  on  the  standardisation  of  systems  and  the  harmonisation  of  coding  practices.  A 
central aspect of this strategy is the adoption of standardised clinical terminologies such as 
the  Systematised  Nomenclature  of  Medicine  Clinical  Terms  (SNOMED  CT)(123),  which 
supports  the  structured  coding  of  pathogens  and  resistance  mechanisms,  thereby 
facilitating future integration across diverse systems. To support healthcare professionals 
in  accessing  and  using  these  standardised  codes,  the  FPS  HFCSE  has  developed  a 
national  terminology  server.  This  centralised  digital  platform  offers  access 
to 
interoperable  terminologies,  enabling  consistent  data  entry  and  retrieval  across  health 
information systems.  

(120) Belgian “One health” national action plan on the fight against AMR 2020-2024. Available at: Link. 
(121) Act of 1 August 2018 on the protection of natural persons with regard to the processing of personal data in criminal and 
national security matters and amending. Available at: Link. 
(122) Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on the protection of natural 
persons with regard to the processing of personal data and on the free movement of such data. Available at: Link 
(123) The Federal Public Service Health, Food Chain Safety and Environment (n.d). SNOMED. Available at: Link. 

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Directorate General for Health and Food Safety 

In  parallel,  efforts  are  being  made  to  simplify  and  modernise  surveillance  protocols  to 
optimise data collection and reduce the burden on healthcare facilities. As AMC surveillance 
in  the  community  in  Belgium  is  currently  less  developed  than  that  in  hospital  settings, 
Belgium aims to develop more specific surveillance utilising datasets already available. A 
pilot  project  (AMC-Prim,  2022-2024)(124)  demonstrated  the  possibility  to  utilise  the 
Pharmanet  reimbursement  data  to  perform  more  nuanced  analyses  for  consumption 
specific to various populations and prescribers (e.g. in nursing homes, and dental or general 
actioners practices). According to interviewed stakeholders, developing an established data 
flow that supports such analyses is a vital first step for depicting more detailed patterns of 
AMU in community settings in Belgium, information needed for the development of detailed 
clinical guidelines and AMC targets. Such surveillance would also generate data needed to 
support  the  validation  of  future  surveillance  improvements.  The  development  of  a 
surveillance  that  collects  data  directly  from  community  pharmacies  or  medical  practices 
would  remove  the  two-year  delay  and  again  provide  the  possibility  to  include  other 
information such as the reason for prescription. 

In animal health, ongoing efforts from DGZ, ARSIA, AMCRA (described in section 4.3) allow 
to reshare the analysis from collected data with farmers and veterinarians, guarantying their 
commitment to provide surveillance data.  

In  the  area  of  environmental  surveillance,  a  wide  range  of  off-site  projects  to  develop 
systems  for  resistance  monitoring  exist.  As  described  in  section  4.4.,  current  efforts  are 
mostly focused on water surveillance. 

4.5.2 Planned actions 

The current NAP-AMR (125)sets a clear direction of actions that need to be undertaken to 
have a One Health approach. According to interviewed stakeholders, in the new NAP-AMR, 
it  is  planned  to  expand  integrated  surveillance,  especially  regarding  the  environmental 
sector. Furthermore, Belgium sees the developed of a whole genome sequencing (WGS) 
based,  early  detection  system  for  AMR  as  one  potential  option  for  developing  a  truly 
integrated One Health surveillance system, with data from diverse settings (human medical 
settings, veterinary pathogens, food samples, wastewater samples) centralised, analysed 
using standardised analytical pipelines and collectively reported (126). A pilot project for the 
construction  of  a  national,  integrated  disease  surveillance  system  is  currently  under 
development, funded by European HERA (2022-2024), and coordinated by Sciensano this 
project aims to create a digital architecture to integrate genomic and nominative data in a 
secure  environment  (127).  The  national  roll-out  of  this  platform  will  depend  upon  the 
integration  of  all  stakeholders  and  continued  funding  from  2025  onwards,  according  to 
interviewed stakeholders. In the long-term, such systems would ideally be integrated into 
data collection systems for national surveillances and mandatory declarations of infectious 
diseases to minimize the administrative burden and optimise dataflows (128). 

In  animal  health,  Belgium  plans  to  have  further  inter-sectoral  coordination  to  expand 
surveillance,  since  for  AMC  monitoring  in  the  veterinary  sector  there  are  notable  gaps, 
surveillance is based on sales fata and usage data (129). The usage data collection system 
is  currently  limited  to  certain  species  (chickens,  turkeys,  cattle  and  pigs),  and  disparities 

(124) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(125) Belgian “One health” national action plan on the fight against AMR 2020-2024. Available at: Link. 
(126) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(127) Sciensano (n.d.). HERA-Incubator-WGS – National Infrastructure for genomic epidemiologic surveillance of infectious 
diseases. Available at: Link. 
(128) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(129) Ibid. 

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human health, animal health, plant health, food, wastewater and the environment 

between  the  usage  and  sales  data  suggest  that  the  current  methodology  for  sales  data 
collection  may  not  cover  all  distribution  channels,  according  to  interviewed  stakeholders 
(130).  According  to  the  latest  BELMAP  report,  plans  to  expand  the  AMU  data-collection 
system to include the other food-producing animals (small ruminants, other poultry species, 
rabbits), aquaculture and horses in 2026 and companion animal species by 2029 exist, as 
required by EU Regulation 2019/6 (131).  

the  environmental  sector,  Belgium 

In 
implementation of the Urban Wastewater Treatment Directive (132).  

is  currently  analysing 

the  most  effective 

4.5.3 Necessary Conditions to Ensure Interoperability 

Interviewed  stakeholders  mentioned  several  necessary  conditions  for  achieving  more 
integrated system. The NAP-AMR (133) and the BELMAP report (134) brought together a wide 
range of stakeholders across sectors. However, some stakeholders highlight the need of a 
stronger  neutral  entity, empowered  to  further  develop  an  integrated  surveillance system, 
representing  all  stakeholders  and  not  having  individual  interests.  These  stakeholders 
estimate  Sciensano  is  currently  limited  to  do  joint  reporting,  rather  than  integrated 
surveillance acrosssectors. Additionally, they estimate the human health sector has most 
political power and the animal sector is less represented, or at least less powerful. 

From the human sector, stakeholders identify the need for efforts to develop an integrated 
national epidemiological surveillance of antimicrobial resistance in Belgian hospitals with an 
acceptable delay in time, incorporating the collection of data on a wider range of pathogen-
antibiotic combinations at Aspartate transaminase (AST) level. Stakeholders see a need for 
improvement in the standardisation of data collection, including crucial information related 
to  ASTs,  isolates,  and  patient  characteristics,  and  for  validation  or  further  follow-up  of 
suspected alert cases, ideally with a methodology developed to support comparison with 
historical  surveillance  results.  Therefore,  they  also  identified  a  need  for  more  financial 
support for IT improvements to facilitate harmonised reporting of results. According to them, 
ideally, participation within this harmonised, national surveillance would be mandatory  as 
for MRSA. 

Regarding  the  animal  sector,  interviewed  stakeholders  explained  to  be  able  to  maintain 
current  AMR  monitoring  of  zoonotic  MRSA  and  indicator  enterococci,  and  follow  the 
Directive  2003/99/EC  (135),  Decision  2020/1729  (136),  it  is  crucial  to  ensure  a  structural 
budget  for  these  fundamental  surveillances.  They  think  an  objective  evaluation  of  the 
current Belgian monitoring systems on national level in animal species is urgently needed 
to be able to most effectively provide recommendations to improve the existing schemes 
(livestock) or set up new ones for companion animals, horses, for example. 

(130) Ibid. 
(131) Regulation (EU) 2019/6 of the European Parliament and of the Council of 11 December 2018 on veterinary medicinal 
products and repealing Directive 2001/82/EC- Available at: Link. 
(132)Directive  (EU)  2024/3019  of  the  European  Parliament  and  of  the  Council  of  27  November  2024  concerning  urban 
wastewater treatment. Available at: Link. 
(133) Belgian “One health” national action plan on the fight against AMR 2020-2024. Available at: Link. 
(134) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(135)Directive 2003/99/EC of the European Parliament and of the Council of 17 November 2003 on the monitoring of zoonoses 
and zoonotic agents, amending Council Decision 90/424/EEC and repealing Council Directive 92/117/EEC. Available at: Link. 
(136)  Commission  Implementing  Decision  (EU)  2020/1729  of  17  November  2020  on  the  monitoring  and  reporting  of 
antimicrobial resistance in zoonotic and commensal bacteria and repealing Implementing Decision 2013/652/EU. Available 
at: Link 

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Directorate General for Health and Food Safety 

Stakeholders  in  the  environment  sector,  argued,  before  an  effective  surveillance 
programme can be established, key information should be established, with pilot studies 
needed to determine:  

•  Which  environments  should  be  prioritised  (effluents  of  hospitals/nursing  homes, 
wastewater,  surface/recreational  waters,  agricultural  fertilisers,  agricultural  soils, 
agricultural products, manufacturing surfaces, compost heaps etc.). 

•  Which  micro-organisms,  antimicrobial  resistance  genes  (ARGs)  and  resistance 

mechanisms to monitor. 

•  What indicators to use for this monitoring (isolates, genes, genetic elements).  The 
development of standardised methodologies (sampling as well as testing methods) 
for  detecting  AMR  patterns  in  a  way  that  is  reliable  and  comparable  between 
sites/over time. 

4.5.4 Expected impact of a further integrated system 

The implementation of a further integrated surveillance system in Belgium is expected to be 
a long-term process, potentially taking several years, according to interviewed stakeholders. 
At this stage, there is still uncertainty among interviewed stakeholders regarding how the 
integration of surveillance systems should look like in the end. However, moving forward, 
greater  interoperability  between  systems  is  set  as  a  key  objective  for  all  interviewed 
stakeholders.  Stakeholders  identify  a  need  for  more  evidence-based  decision-making, 
when  it  comes  to  address  AMR  and  AMC  across  the  different  sectors,  expecting  better 
detection  of  emerging  resistance  trends,  better  evidence-based  policy  making  and 
regulation and targeted stewardship. 

5  Challenges and barriers 

This  section  identifies  the  primary  challenges  and  barriers  to  establishing  an  integrated 
surveillance system for AMR and AMC in Belgium. It highlights sector-specific issues, cross-
sectoral coordination challenges, and resource constraints, along with strategies used (or 
needed) to overcome these barriers. 

According  to  all  interviewees,  the  biggest  obstacle  to  develop  an  integrated  surveillance 
system is Belgium’s  fragmented and decentralised surveillance structure. Despite the 
progress  evidenced  by  the  BELMAP  report,  stakeholders  perceive  that  surveillance  in 
Belgium  remains  sector-specific,  with  data  collected  separately  for  human  health, 
veterinary, and environmental sectors and consists currently of joint reporting, rather than 
a  fully  integrated  surveillance  system.  Regarding  AMC  in  human  and  animal  sectors, 
stakeholders  reported  that  Belgium  provides  a  relatively  integrated  surveillance  system 
through the BELMAP report. However, with respect to AMR in humans, animals and the 
environment, the stakeholders remarked that surveillance systems could not be considered 
as being integrated and rather should be considered as joint reporting. 

This fragmented surveillance structure leads to data coverage gaps between the health, 
animal, food, and environmental sectors, according to the interviewed stakeholders(137). It 
was emphasised that surveillance systems are not designed for integrated analysis, as 
these are elaborated on a sector specific base. Belgium struggles putting in place common 
indicators and standardised data protocols across the different sectors. Regular meetings 
are organised to overcome the silo structure. Nevertheless, certain interview participants 
highlighted  the  fact  that  the  human  sector  is  seen  as  the  main  driver  of  integrated 

(137) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 

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human health, animal health, plant health, food, wastewater and the environment 

surveillance. In that sense, a further integrated surveillance system could only be achieved 
if specific benefits for the human sector are identified. Stakeholders from animal and food 
sectors  are  calling  for  a  hierarchy  shift  and  a  more  neutral  stakeholder  representing  all 
sector’s  interests.  The  ongoing  actions  trying  to  improve  the  surveillance  remain  sector 
specific. 

Moreover, interviewed stakeholders have indicated that the BELMAP report is not widely 
recognised within the veterinary sector and lacks detailed, sector-specific insights, limiting 
its  usefulness  for  veterinary  policy.  Stakeholders  explained  that,  while  it  functions  as  a 
public  report  summarising  key  findings,  its  relevance  depends  on  appropriate  framing, 
including a clear explanation of its benefits and limitations.  

Belgium’s  administrative  structure  can  complicate  data  integration,  as  human  health 
surveillance is managed at the national level, while environmental surveillance falls under 
regional competence, making it challenging to incorporate environmental data into broader 
public health analyses. The lack of a centralised institution for environmental surveillance 
further fragments data-sharing efforts, as multiple regional authorities must be included in 
surveillance activities. 

Additionally, interviewees stressed that the integration of data from different sectors poses 
a risk of reducing its granularity. Even though all stakeholders see the value in having a 
more integrated surveillance system, certain  stakeholders emphasised it is dangerous to 
go  too  far  into  integration,  fearing  losing  surveillance  relevance  within  each  sector. 
Therefore, they highlighted the need to foster sector specific surveillance reporting, beyond 
an integrated surveillance approach. 

According to interviewed stakeholders, limited financial resources hinder the deployment 
of  larger  and  more  efficient  systems  in  each  sector,  as  mentioned  in  section  4.5, 
stakeholders  pledged  for  more  financial  support  for  IT  improvements  to  facilitate 
harmonised reporting of results, more structural budget for fundamental surveillances. This 
financial limitation prevents the eventual integration across sectors, restricting progress and 
the ability to create a unified approach, according to interviewed stakeholders. Additionally, 
there is not always a clear mandate or funding for doing integrated surveillance, which, for 
most of the actors, is done on the top of their normal duties. Participation in initiatives such 
as EU-JAMRAI(138) is seeing as a key enabler but remains time-consuming and resource 
intensive for most of the stakeholders interviewed. 

Additionally, according to the interviewed stakeholders,  surveillance systems in place do 
not allow to demonstrate the benefits of collecting the data. The interviewed stakeholders 
explained various stakeholders are asked to collect data, without necessarily retrieving the 
outcomes of the analyses. Data collection can remain time-consuming, because of the lack 
standardised of data collection, IT-tools and discourage actors providing the data, especially 
if they do not understand the benefit of collecting such data. Actors like the DGZ or ARSIA 
play a key role in overcoming these challenges, since they share  the analysed data with 
farmers through dashboards, explaining the benefits of the surveillance systems and putting 
in place coaching with veterinarians and farmers for better AMU.  

Moreover,  even  if,  as  previously  mentioned,  the  NAP-AMR  2020-2024  (139)  sets  clear 
objectives,  establishing  quantified  and  measurable  targets  for  reducing  AMR  and  AMC, 

(138) European Union Joint Action on Antimicrobial Resistance (AMR) and Healthcare-Associated Infections (HCAI). Available 
at: Link. 
(139) Belgian “One health” national action plan on the fight against AMR 2020-2024. Available at: Link. 

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stakeholders  highlight  the  lack  of  clear  objectives  regarding  an  integrated  surveillance 
system. Sector-specific objectives are in place for both AMR and AMC in the human and 
animal sectors, but stakeholders see is a need for shared goals. The second NAP-AMR, 
which is currently under review for validation by different stakeholders, aims to set up such 
common objectives regarding integrated surveillance. Concrete actions with cross-sectoral 
goals, such as tracing the origin of outbreaks or conducting cross-sectoral tracing of origins 
of outbreaks were mentioned during the interviews to improve outbreak related actions and 
outbreak prevention strategies. 

Stakeholders highlighted Belgium lacks a centralised data platform and formalised data 
sharing  between  sectors,  which  limits  cross-analysis.  Data  collection  remains  time-
consuming as there is no user-friendly IT tool to easily collect data. Ongoing discussions 
exist to eventually have Sciensano putting in place a centralised platform, as described in 
section 4.5. 

Data ownership remains a key challenge in Belgium. Certain stakeholders, especially from 
research  institutes  or  laboratories,  are  reluctant  to  share  their  data,  access  is  irregularly 
provided  through  specific  funding.  GDPR  (140)  and  the  Act  on  the  protection  of  natural 
persons  with  regards  to  processing  of  personal  data  (141)  were  a  constraint  in  collecting 
data, as described in section 4.5.  

In both the human and in the animal and food sectors, mandatory surveillance systems are 
in  place,  however,  the  interviews  highlighted  the  lack  of  penalties  for  non-compliance. 
Stakeholders emphasised the need for stronger regulations.  

Challenges specific to the human sector 

In the human sector, a major challenge is the fragmentation of hospital IT systems, with 
over 100 hospitals using more than 80 different computing platforms. The situation is even 
more complex in nursing homes, where IT infrastructure is less developed, making system 
integration  difficult.  As  described  in  section  4.5,  exchanges  between  national  authorities 
and  microbiological  laboratories  remain  gradual  due  to  the  fragmentation  of  laboratory 
information systems and the wide use of proprietary technologies, which present significant 
challenges for interoperability and seamless data exchange. Belgium is actively working on 
the  standardisation  of  systems  and  the  harmonisation  of  coding  practices,  through 
SNOMED CT.  

According  to  interviewed  stakeholders,  since  Belgium  has  not  an  IT  structure  in  place, 
allowing  standardised  data  collection,  this  leads  to  time-consuming  data  collection.  As 
described in section 4.5, Belgium has established templates, trying to give guidelines for 
standardised data collection, but misses a dedicated IT tool.  

Additionally, funding disparities mean that hospitals with greater financial resources tend 
to  have  more  advanced  IT  solutions,  further  widening  the  gap  in  data  management 
capabilities,  according  to  interviewed  stakeholders.  Time  constraints  can  also  hinder 
implementation,  as  healthcare  professionals  struggle  to  manage  separate  IT  systems 
alongside their clinical responsibilities. 

As described in section 4.5, ongoing discussions exist to decide whether patient data should 
be  publicly  disclosed  and  if  patients  are  adequately  informed,  which  causes  patient 

(140) Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on the protection of natural 
persons with regard to the processing of personal data and on the free movement of such data. Available at: Link 
(141) Act of 1 August 2018 on the protection of natural persons with regard to the processing of personal data in criminal and 
national security matters and amending. Available at: Link. 

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Feasibility study on integrated surveillance systems on AMR and AMC encompassing 
human health, animal health, plant health, food, wastewater and the environment 

confidentially barriers. Interviewed stakeholders expect the European Health Data Space 
(EHDS) regulation (142) to further guide on the legislative framework to adopt. 

Moreover,  human  heath  AMC  data  is  primarily  obtained  through  reimbursement  records 
and reliance on these data presents limitations, including time delays and the exclusion of 
non-reimbursed  antimicrobial  sales  (143).  For  reimbursement  data  from  hospitals, 
reimbursement requests and corrections are legally allowed up to two years after the actual 
consumption, which leads to significant delays and to an underestimation of the reimbursed 
hospital AMC (144).  

Reimbursement  data  from  hospitals  and  corrections  are  legally  allowed  up  to  two  years 
after the actual consumption, which leads to significant delays and to an underestimation of 
the reimbursed hospital AMC (145). To address this challenge, a pilot project (AMC-Prim, 
2022-2024)(146) was put in place and demonstrated the possibility to utilise the Pharmanet 
reimbursement data to perform more nuanced analyses for consumption specific to various 
populations  and  prescribers  (e.g.  in  nursing  homes,  and  dental  or  general  actioners 
practices). 

Challenges specific to the animal and food sector 

Regarding  the  animal  and  food  sector,  testing guidelines  exist  for  diseased  animals,  but 
standardisation  remains  a  challenge  as  not  all  pathogens  are  covered  by  these 
guidelines,  according  to  interviewed  stakeholders.  This  creates  inconsistencies  in 
surveillance data and makes  comparing results across  different regions and  laboratories 
harder. Interviewed participants agreed  that while the data submitted to  EFSA is of  high 
quality, data outside this framework is lower in quality, and a harmonised approach is still 
lacking. Plus, there is no data collected for companion or aquatic animals (147). 

Another major challenge is that sales data does not directly correlate with use sometimes, 
as stockpiling, supply chain delays, and cross-border purchases can create discrepancies 
between what is sold and what is actually used in animal treatment (148). One response to 
this challenge is the 'Antibiotic Use Barometer' (149), published every quarter by the FAMHP 
and AMCRA (described in section 4.2.2). 

Challenges specific to the environment 

AMR surveillance in the environment is complex due to the federal structure and regional 
competencies,  according  to  interviewed  stakeholders.  Sampling  is  conducted  within 
regions; each region organises sampling and analysis differently. Moreover, there is still a 
limited understanding of the role of the environment in AMR, as well as a lack of awareness 
about the cost-efficiency and population-level insights that environmental surveillance could 
provide,  according  to  interviewed  stakeholders.  Many  activities  are  done  by  the  regional 
authorities; therefore, information is sometimes not available at federal level. The BELMAP 
report allowed better communication between stakeholders.  

(142) Regulation (EU) 2025/327 of the European Parliament and of the Council of 11 February 2025 on the European Health 
Data Space. Available at: Link. 
(143) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(144) Ibid. 
(145) Ibid. 
(146) Ibid. 
(147) Ibid. 
(148) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(149) Barometer Antibiotic Use. Available at: Link. 

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Directorate General for Health and Food Safety 

Only certain regions participate to specific working groups, such as the Eionet on AMR or 
the EU-JAMRAI (150) initiative is limited to certain regions. The FPS HFCSE aims to have a 
more  centralised  approach  and  therefore  dominated  an  AMR  coordinator  for  the 
environment. 

6  Enablers and drivers 

This  section  highlights  the  factors  that  have  facilitated  integrated  surveillance  efforts  in 
Belgium.  It  identifies  key  enablers,  drivers,  successful  strategies,  and  stakeholder 
recommendations  for  further  development  and  implementation  of  integrated  surveillance 
systems. 

All  stakeholders  agree  there  is  a  will  and  a  need  for  further  developing  an  integrated 
surveillance  system.  Interviewees  emphasised  that  the  successful  implementation  of 
BELPMAP  relies  on  a  key  factor,  which  is  having  a  neutral  entity  –  independent  of  any 
specific  sector  –  responsible  for  overseeing  integration  efforts  from  the  different  sectors, 
even though they see like joint reporting, rather than an integrated surveillance system. The 
presence of the NAP-AMR was also seen as a facilitator, proving the political commitment 
for a One Health approach, allowing a strong collaboration between federal, community and 
regional  partner  administrations,  experts  and  organisations.  The  action  plan  promoted  a 
common vision to ensure continuity in the prevention and treatment of infectious diseases 
in humans and animals. Ten strategic directions for combatting AMR have been elaborated, 
which helped defining clear objectives, even these objectives remain often sector specific. 

Moreover, interviewed stakeholders identified specific funding for the last BELMAP report 
and the NAP-AMR as a key enabler, since it allowed a further development of the different 
surveillance systems toward an integrated surveillance system. It gave a clear mandate to 
stakeholders to do the surveillance in a one health approach.  

Furthermore,  all  stakeholders  mentioned  national  and  EU  regulations  on  mandatory 
surveillance  systems  as  playing  a  key  role  in  developing  AMR  and  AMC  surveillance 
systems across sectors. Stakeholders explained EU regulations imposes surveillance to the 
national  agenda,  regardless  of  the  national  political  will  to  combat  AMR.  Having  the 
mandatory surveillance in place, encouraged certain stakeholders to go beyond regulation 
and to develop the systems on a voluntary base. 

Beyond regulations, public awareness significantly raised the need for concrete actions 
towards  a  more  integrated  surveillance  system,  according  to  interviewed  stakeholders. 
Different  campaigns,  as  well  as  outbreaks,  allowed  a  stronger  cross-sectoral  political 
collaboration. Interviewed stakeholders explained the rising public awareness about AMR 
and  AMC  and  the  links  between  the  different  sector,  emphasised  the  need  of  stronger 
collaborations.   

The  existing  strong  national  dialogue  between  the  different  sectors  to  enhance  an 
integrated  surveillance  system  was  highlighted  during  the  interviews.  Regular  meetings 
across  the  different  stakeholders  allowed  to  identify  new  needs  for  data  collection  in  an 
integrated way. 

Beyond  regulations,  public  awareness  and  national  dialogue,  Belgium’s  involvement  in 
different  European  initiatives  allowed  to  gain  a  better  overview  of  what  other  Member 
States  are  doing  and  how  this  could  be  relevant  for  Belgium,  according  to  interviewed 
stakeholders. Based on the data submitted by Belgium under mandatory EU surveillance 

(150) European Union Joint Action on Antimicrobial Resistance (AMR) and Healthcare-Associated Infections (HCAI). Available 
at: Link. 

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Feasibility study on integrated surveillance systems on AMR and AMC encompassing 
human health, animal health, plant health, food, wastewater and the environment 

schemes, Belgium appears in the third joint inter-agency report on integrated analysis of 
antimicrobial agent consumption and occurrence of antimicrobial resistance in bacteria from 
humans and food-producing animals in the EU/EEA (JIACRA III)(151). Belgium led a study 
on  One-Health  approach  to  monitoring  antimicrobial  consumption  in  Belgium  2012-2021 
(152) used the JIACRA methodology (153) adapted to the Belgian context. It is also actively 
participating  in  the  Joint  Programming  Initiative  on  Antimicrobial  Resistance  (JPIAMR), 
represented by the FPS HFCSE is responsible for antimicrobial policy and sanitary risks 
and the Department of Economy, Science and Innovation from the Flemish Government. 

Additionally,  stakeholders  mentioned  user-friendly  IT  solutions  have  the  potential  to 
significantly improve the collection, analysis, and integration of data, particularly in outbreak 
situations  where  speed  and  interconnectivity  are  crucial.  Increased  automation  would 
enhance  efficiency,  ensuring  that  if  two  phenotypes  are  identified  in  a  specific  region, 
notifications reach relevant stakeholders automatically rather than passing through multiple 
layers of reporting. Ongoing efforts from DGZ, ARSIA, AMCRA (described in section 4.3) 
allowed to reshare the analysis from collected data with farmers and veterinarians, through 
interactive dashboards, allowing them to monitor AMC and AMR. 

Moreover, WGS was identified as a powerful tool for better understanding AMR, as it can 
provide  insights  into  reservoirs  and  transmission  pathways  of  resistance  genes  (154),  as 
described in section 4.5.2. Currently Belgium considers WGS-based early detection system 
for AMR as an option for developing a truly integrated One Health surveillance system, with 
data from diverse settings (human medical settings, veterinary pathogens, food samples, 
wastewater  samples)  centralised,  analysed  using  standardised  analytical  pipelines  and 
collectively reported (155). 

7  Conclusions and lessons learnt 

Bringing together the insights from the previous sections, this part describes to what extent 
systems are ready for the future, and to what extent they are flexible to accommodate future 
European action in the topics. Moreover, it describes the key lessons learnt from developing 
an integrated surveillance system.  

Belgium’s  surveillance  systems  in  human  and  animal  health  are  well-established, 
according to interviewed stakeholders, with mandatory AMR surveillance for key pathogens 
and mandatory AMC data collection via health insurance records and veterinary monitoring 
systems. However, environmental surveillance is still limited to the EU Water Framework 
Directive  Watch  List  (156)    and  one-off  initiatives  (rather  than  systematic  monitoring)  and 
region-specific sampling. 

Stakeholders from the various sectors interviewed expressed confidence in the resilience 
of  Belgium’s  surveillance  system  and  its  capacity  to  adapt  to  changes  in  EU  legislation. 
They noted that the system is reasonably flexible and designed to be scalable—capable of 
providing  minimum  required  data  initially,  with  the  potential  to  expand  data  reporting  as 
needed.  This  adaptability  was  for  example  demonstrated  in  the  implementation  of  the 

(151)  ECDC,  EFSA,  EMA,  Third  joint  inter-agency  report  on  integrated  analysis  of  antimicrobial  agent  consumption  and 
occurrence  of  antimicrobial  resistance  in  bacteria  from  humans  and  food-producing  animals  in  the  EU/EEA,  2016-2018. 
Available at: Link. 
(152)Sciensano, A One-Health approach to monitoring antimicrobial consumption in Belgium 2012-2021. Available at: Link. 
(153) JIACRA III - Antimicrobial Consumption and Resistance in Bacteria from Humans and Animals. Available at: Link. 
(154) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(155) Ibid. 
(156) EU surface water Watch List Available at: Link. 

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Directorate General for Health and Food Safety 

BelVet-SAC  database,  which  tracks  veterinary  antimicrobial  consumption  in  compliance 
with evolving EU regulations. The integration of BelVet-SAC into the existing surveillance 
infrastructure illustrates Belgium’s ability to respond effectively to legislative developments, 
providing a concrete example that supports claims of resilience. Moreover, the mandatory 
participation  in  MRSA  by  Royal  Decree  (157)  in  2006  for  acute  care  hospitals  or  the 
surveillance’s expansion in 2000 to include MRGN, with mandatory participation starting in 
2014 show the system’s resilience.  

However,  the  surveillance  system  is  still  sector-based,  and  complete  One  Health 
integration  has  not  yet  been  achieved,  according  to  interviewed  stakeholders.  Having  a 
more One Health integrated surveillance systems approach, encompassing human, animal 
health and the environment, including real-time digital data are next frontiers that require 
additional actions, according to interviewed stakeholders.  

According to interviewed stakeholders, at the national level, Belgium must take further steps 
to harmonise governance and policies across human, animal, and environmental sectors. 
Currently,  different  sectors  operate  under  their  own  legal  mandates  and  institutional 
responsibilities, leading to fragmentation and limited coordination. To move toward a fully 
integrated system, Belgium requires a cohesive national framework that clearly defines 
the  roles  of  each  institution,  enables  intersectoral  collaboration,  and  aligns  surveillance 
indicators and reporting requirements. Additionally, while recent progress has been made 
through temporary or project-based funding, a stable, long-term funding mechanism is 
needed to maintain and expand surveillance activities.  

At the EU level, policy harmonisation plays a central role in supporting Belgium’s efforts. 
EU-wide  frameworks,  offering  standardised  indicators  and  reporting  mechanisms  helped 
harmonising  data  collection.  Interviewed  stakeholders  were  in  favour  of  a  further 
development  of  a  legally  binding  EU  framework  for  One  Health  surveillance,  which 
could  provide  Belgium  with  stronger  guidance  and  expectations,  particularly  regarding 
environmental monitoring, which is limited in Belgium. However, all stakeholders insisted 
on  the  need  to  maintain  and  further  develop  national  surveillance,  also  at  a  sector 
specific level, as each country and even region has its own specificities. 

EU financial and technical support is also critical. Continued access to funding mechanisms 
such as EU-JAMRAI (158), allows Belgium to pilot new tools, scale up integration efforts, and 
build capacity in areas like data science, epidemiology, and IT development. For example, 
European  HERA  (2022-2024)  funds  the  pilot  project  in  Belgium  to  create  a  digital 
architecture  to  integrate  genomic  and  nominative  data  in  a  secure  environment. 
Furthermore,  the  EU’s  role  in  facilitating  cross-border  collaboration  and  knowledge 
exchange helps Belgium align its surveillance with best practices and emerging standards, 
while also addressing shared risks. 

•  Regarding  lessons  learnt  from  the  case  study  from  Belgium  on  how  to  further 
develop an integrated AMR surveillance system: National and EU actions have been 
key in developing AMR and AMC surveillance systems in Belgium.  Both national 
and  EU-level  actions  remain  essential  to  further  develop  these  surveillance 
systems, considering also the One Health approach objective. While progress has 
been made, particularly through initiatives like the BELMAP report and the NAP-
AMR 2020–2024, Moreover, certain stakeholders have indicated that the BELMAP 

(157) 10th September 2020 - Arrêté royal modifiant l'arrêté royal du 25 avril 2002 relatif à la fixation et à la liquidation du budget 
des moyens financiers des hôpitaux. Available at: Link. 
(158) European Union Joint Action on Antimicrobial Resistance (AMR) and Healthcare-Associated Infections (HCAI). Available 
at: Link. 

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human health, animal health, plant health, food, wastewater and the environment 

report  is  not  widely  recognised  within  the  veterinary  sector  and  lacks  detailed, 
sector-specific  insights,  limiting  its  usefulness  for  veterinary  policy.  Stakeholders 
explained  that,  while  it  functions  as  a  public  report  summarising  key  findings,  its 
relevance  depends  on  appropriate  framing,  including  a  clear  explanation  of  its 
benefits and limitations. 

•  Belgium  also  learnt,  especially  through  the  BELPMAP  report  (159),  that  effective 
integrated  surveillance  relies  on  a  key  factor,  which  is  having  a  neutral  entity  - 
independent of any specific sector - who is responsible for overseeing integration 
efforts from the different sectors. Additionally, actions such as NAP-AMR allowed a 
better  cross-sector  alignment,  which  is  essential  for  developing  an  integrated 
surveillance  system.  A  neutral  entity  is  vital  to  align  regional  and  federal  efforts, 
mitigating Belgium’s decentralised governance challenges. 

•  The  need  for  digital  infrastructure,  working  to  enhance  data  interoperability 
between systems. This includes strengthening IT systems, ensuring compatibility of 
data formats, and addressing challenges related to data privacy under the  GDPR 
(160). A pilot project for the construction of a national, integrated disease surveillance 
system  is  currently  under  development,  funded  by  European  HERA  (2022-2024), 
and coordinated  by Sciensano this  project aims to create a digital architecture to 
integrate genomic and nominative data in a secure environment. 

•  Moreover,  interviewed  stakeholders  highlight  that  Belgium's  progress  toward 
integrated AMR and AMC surveillance depends on a strong national commitment 
to  harmonise  governance  and  secure  structural  funding,  as  well  as  EU-level 
support to align policies, share expertise, and co-finance innovation. Both levels of 
action  are  not  only  complementary  but  also  necessary  to build  a  resilient,  future-
proof One Health surveillance system. 

(159) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(160) Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on the protection of natural 
persons with regard to the processing of personal data and on the free movement of such data. Available at: Link 

28 

 
 
 
 
 
 
 
 
Directorate General for Health and Food Safety 

8  Annexes 

8.1  Annex A: Case study interview questions 

N° 

Question 

Core Questions 

Introduction to the study 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

How  would  you  define  an  integrated  One  Health 
AMR/AMC  surveillance  system?  (161)  Consider  the 
difference  between 
integrated 
surveillance systems. 

joint-reporting  and 

To what extent do you believe AMR/AMC surveillance 
system(s)  in  your  country  are  integrated  in  terms  of 
One Health? 

How  much  future  proof  is  your  country’s  integrated 
surveillance system? 

How much agile it is in view of changes in the EU legal 
requirements? 

the 

Beyond the regulation at EU level, can you elaborate 
regulatory 
on 
international  and  national 
considerations  and 
for  AMR/AMC 
integrated  One  Health  surveillance  systems  that  you 
have adopted?    

requirements 

Please  describe  some  of  the  key  benefits/ways  you 
have  utilised  your  integrated  One  Health  AMR/AMC 
(nudge:  what  degree  of 
Surveillance  System? 
integration will your country mostly benefit from?) 

the 

the 

impacts  of 

Are 
integrated  One  Health 
AMR/AMC system so far in line with the objectives that 
have been set? How do you measure and monitor the 
impact of this system? 

What  were  the  key  accelerators/enablers  to  the 
integration of your AMR and AMC surveillance across 
sectors? 

Has  the  integration  of  the  surveillance  systems 
increased or decreased the  administrative burden for 
the stakeholders involved? And in what extent? 

What are the key barriers you faced in the integration 
of your One Health AMR and AMC Surveillance? How 
did you overcome them? 

What  would  you  recommend  other  Member  States 
starting the development of an integrated One Health 
surveillance system for AMR/AMC? 

Stakeholders experts in: 

Animal 
Health 
(including 
food sector, 
plant) 

Environment 
(including soil 
and 
wastewater) 

Human 
Health 

x 

x 

x 

x 

x 

x 

x 

x 

 x 

x 

x 

x 

x 

x 

x 

x 

x 

x 

x 

x 

x 

x 

x 

 x 

x 

x 

x 

x 

x 

x 

x 

x 

x 

x 

x  

x  

(161) For this question, it is important for the interviewer to clarify that this includes environment for people in human and animal 
health as they most likely will not automatically include it.  

29 

 
 
 
 
Feasibility study on integrated surveillance systems on AMR and AMC encompassing 
human health, animal health, plant health, food, wastewater and the environment 

12 

Do you think there is a need for stronger EU action to 
integrated  surveillance  of  AMR/AMC?  Do  you  think 
there is a need to develop a common EU template for 
AMR/AMC  One  Health  reports?  What  are  your 
thoughts on developing common AMR/AMC indicators 
on EU-level on EU-level beyond legislation? 

Questions specific for human sector 

What year did you begin AMR and AMC surveillance 
for  human  health?  What  is  the  aim  of  human  health 
surveillance?  How  often  is  the  data  collected  and 
reported?  What  stakeholders  are 
involved  (e.g. 
hospitals, laboratories etc.)?  

Do  you  consider  the  surveillance  system  in  place  for 
human health as being efficient?  

What  data  do  you 
consumption/use)? 

report 

(prescription 

rates, 

Please  describe  some  of  the  key  benefits  with  ways 
you  have  utilised  your  Human  Health  AMR/AMC 
Surveillance System?  

13 

14 

15 

16 

Questions specific for animal sector (including food sector) 

The EU has established specific requirements for AMR 
and AMC surveillance in animals through several key 
regulations and directives, such as: 

•  EU Zoonoses Directive (2003/99/EC). 
•  European Surveillance of Veterinary 

Antimicrobial Consumption (ESVAC). 

The  mandatory  monitoring  in  food  producing  animals 
and in meat is for food safety purposes. The animals in 
slaughter are healthy. 

Beyond  that  some  countries  monitor  AMR  in  sick 
animals - for the sake of animal health. 

What year did you begin AMR and AMC surveillance in 
animals  and  food?  What  aspects  do  you  consider  in 
scope  of  this  surveillance?  Does  it  include  plant 
health? How often is the data collected and reported? 
What stakeholders are involved? Do you monitor AMR 
in sick animals - for the sake of animal health? 

Do  you  consider  the  surveillance  system  in  place  for 
animals and food as being efficient?  

Which  animals  and 
food  are  covered  by  your 
surveillance  system?  (i.e.  Farm  animals,  terrestrial 
animals, farmed aquatic species, companion animals, 
retail sampling?) 

17 

18 

19 

Questions specific for environmental sector 

20 

What is the status of surveillance systems for AMR in 
the environment in your country (e.g. water, soil)?  

21 

[If Question 20 has started developing systems] What 
year did you begin the development of surveillance of 
AMR  in  the  environment?  Do  you  consider  crop 
production included in the scope of this surveillance? 
How often is the data collected and reported? 

30 

x 

x 

x 

x 

x 

 x 

x 

x 

x 

x 

x 

x 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
Directorate General for Health and Food Safety 

Have you considered whether your system related to 
include  pharmaceutical 
the  environment  should 
manufacturing,  healthcare  delivery  (hospitals  and 
healthcare facilities) and food production? 

Do you monitor AMR in soil, plants or water bodies ? If 
yes, please describe? 

[If  Question  20  has  started  developing  systems]  To 
what extent do you use EU Directives (watchlist water 
framework, soil and plants) to inform data collection? 
(e.g. to inform the pathogens in scope of surveillance). 

Do you have protocols in place for the management of 
AMR in any environmental location or source? 

What do you think should be included in environmental 
surveillance of AMR? 

22 

23 

24 

25 

26 

Closing Remarks 

27 

Is there anything else you would like to add that may 
be relevant to this study? 

x 

x 

8.2  Annex B: Interview summary  

8.2.1 Overview 

x 

x 

x 

x 

x 

x 

A total of four stakeholders relevant to the surveillance of AMR and AMC in Belgium were 
interviewed.  The  Regional  Association  of  Animal  Health  and  Identification  (ARSIA)  is 
responsible for collecting and analysing veterinary health data in Wallonia, including data 
related to AMU, animal treatments, disease occurrences. It works in close collaboration with 
AMCRA  (the  national  center  for  antimicrobial  consumption  and  resistance  in  animals  in 
Belgium), the Federal Agency for the Safety of the Food Chain (FASFC), and the Walloon 
regional  authorities.  ARSIA  supports  and  promotes  the  use  of  the  Sanitel-Med  (162) 
database, a national platform that collects detailed data on veterinary antibiotic prescriptions 
and  usage. Additionally,  ARSIA  coordinates  with  laboratories  and  veterinary  services  for 
bacteriological testing and resistance profiling. Dierengezondheidszorg Vlaanderen (DGZ) 
is the primary  organisation responsible for animal health and disease surveillance in the 
Flemish  region  of  Belgium.  It  collaborates  closely  with  farmers,  veterinarians,  and 
governmental bodies to monitor and enhance animal health, ensuring food safety and public 
health. The Federal Public Service for Health Food Chain Safety and Environment (FPS 
HFCSE) acts as the national authority on health and food safety, FPS HFCSE is responsible 
for  coordinating  policies  and  surveillance  activities  that  span  the  human,  animal,  and 
environmental  sectors,  in  line  with  Belgium’s  One  Health  approach  to  tackling  AMR. 
Sciensano is Belgium’s national public health institute, operating under the authority of the 
federal ministers of Public Health and Agriculture. It plays a central role in the surveillance 
of  AMR  and  AMC  across  both  human  and  animal  health  sectors,  aligning  with  the  One 
Health  approach.  Sciensano,  analyses  and  report  AMR/AMC  surveillance  data.  It  is  the 
main coordinator of the BELMAP report (163). 

Table 2. List of Belgian stakeholders who participated in the interviews 

Belgian stakeholders 

Regional Association of Animal Health and Identification (ARSIA) 

(162) Sanitel-Med- Available at: Link. 
(163) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 

31 

 
 
 
 
 
 
 
 
 
 
 
 
 
Feasibility study on integrated surveillance systems on AMR and AMC encompassing 
human health, animal health, plant health, food, wastewater and the environment 

Belgian stakeholders 

Dierengezondheidszorg Vlaanderen (DGZ) 

Federal Public Service for Health Food Chain Safety and Environment (FPS HFCSE) 

Sciensano 

8.2.2 Discussion of responses 

Views on integration 

All  interviewed  stakeholders  were  aligned  on  the  definition  of  an  integrated  One  Health 
AMR/AMC surveillance system, describing it as a programme producing comparable data 
and therefore able to perform intersectoral analyses and comparison  for the One Health 
approach. ARSIA, DGZ, FPS HFCSE explained there is growing collaboration between the 
human, animal and environmental sectors in Belgium. However, this collaboration concerns 
more  of  joint  reporting,  such  as  with  the  BELMAP  report(164),  rather  than  an  integrated 
surveillance  system  with  a  One  Health  approach.  Several  ongoing  efforts  are  aimed  at 
strengthening  the  functionality  of  individual  systems,  which  will,  in  turn,  enhance 
interoperability and integration across these systems.  

Whereas  Sciensano  insisted  even  more  on  the  potential  of  the  current  AMR/AMC 
surveillance  systems,  mentioning  ongoing  meetings  under  NAP-AMR(165)  and  under  the 
BELMAP  report(166)  that  promote  collaboration  between  different  sectors.  Sciensano 
explained the coordination of the BELMAP report(167)  is overseen by an editorial board that 
convenes six times a year. Any proposed methodological changes are reviewed and put to 
a vote during these meetings. Additionally, the editorial board collects feedback from the 
various agencies involved, ensuring that the system functions effectively across different 
sectors.  According  to  Sciensano,  this  process  also  plays  a  crucial  role  in  keeping 
stakeholders  engaged  and  encouraging  them  to  submit  data  regularly.  Importantly, 
stakeholders retain ownership of their data, and Sciensano does not claim ownership over 
the collected information, ensuring transparency and trust in the data-sharing process. 

Regarding  AMC,  Sciensano  and  FPS  HFCSE  highlighted  that  consumption  in  Belgium 
remains high, with little significant improvement in the last ten years in the human health 
sector.  In  contrast,  ARSIA,  DGZ,  did  highlight  that  AMC  in  the  veterinary  sector  was 
decreasing.  

Human sector surveillance 

Sciensano  explained  there  was  a  sufficient  legal  basis  for  health  surveillance,  since 
Belgium has national regulations and since the European regulation 2022/2371 on cross-
border threats(168) is directly applicable legislation in the Member States, without the need 
for transposition. Nevertheless, some actors continued to argue  that there was a lack  of 
sanctions  for  not  collecting  the  data.  Sciensano  explained  even  though  participation  in 

(164) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(165) Belgian “One health” national action plan on the fight against AMR 2020-2024. Available at: Link. 
(166) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(167) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(168) Regulation (EU) 2022/2371 of the European Parliament and of the Council of 23 November 2022 on serious cross-border 
threats to health and repealing Decision No 1082/2013/EU. Available at: Link 

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Directorate General for Health and Food Safety 

MRSA  and  MRGN  surveillance  is  mandatory,  there  are  no  existing  penalties  for  not 
reporting data.  

Following  the  European  Council  recommendation  2023/C  220/01  on  stepping  up  EU 
actions  to  combat  antimicrobial  resistance  in  a  One  Health  approach(169),  Belgium  set 
targets  for  the  incidence  of  resistant  bloodstream  infections  for  MRSA,  3rd  generation 
cephalosporins-resistant  E.  coli,  and  carbapenem  resistant  K.  pneumoniae.  Belgium 
calculates the metrics using the same methodology as used for European benchmarking of 
ECDC calculation of the health burden of infections with antibiotic-resistant bacteria(170) - 
namely  the  number  of  cases  of  bloodstream  infections  reported  in  the  EARS-BE 
surveillance was divided by the population size (Eurostat data) multiplied by an estimate of 
the population coverage of participating hospitals each year. According to Sciensano, this 
methodology has limitations and will therefore be validated at a national level against data 
from the mandatory blood stream infection surveillance during 2025. 

Belgium  collects  data  on  the  WHO  List  of  Medically  important  antimicrobials(171). 
Sciensano  compiles  reimbursement  data  received  from  the  National  Institute  for  Health 
and  Disability  Insurance  (NIHDI)  and  reports  it  to  ESAC-Net(172).  The  data  for  the 
community sector include all antimicrobial packages dispensed in community pharmacies, 
including nursing homes that receive medication from these pharmacies, which applies to 
the  majority  in  Belgium.  Hospital  data  include  all  prescriptions  delivered  in  hospital 
pharmacies. As reimbursement data only considers the insured population (99% of the total 
Belgian population in 2023)(173), estimates for total AMC are extrapolated to cover the full 
Belgian  population.  To  be  noted,  for  reimbursement  data  from  hospitals,  reimbursement 
requests and corrections are legally allowed up to two years after the actual consumption, 
which leads to significant delays and to an underestimation of the reimbursed hospital AMC. 
Sciensano highlighted the delay problematic, explaining that actions are in place to address 
it. 

Animal sector surveillance  

In addition to national AMR surveillance, regional laboratories, such as DGZ and ARSIA 
analyse samples from diseased animals to track infections. Farmers sent data on healthy 
and  diseased  food-producing  animals  to  DGZ,  ARSIA  every  three  months.  Testing 
guidelines exist for diseased animals, but standardisation remains a challenge as not all 
bacteria  are  covered  by  these  guidelines.  DGZ  and  ARSIA  agreed  that  while  the  data 
submitted to EFSA, regarding health and diseased animals, is of high quality, data outside 
this framework is lower in quality, and a harmonised approach with national reporting across 
actors is still lacking. 

A  current,  important  gap  in  the  veterinary  sector  is  the  absence  of  AMR  surveillance  in 
companion animals and aquatic food-producing animals. Projects researching this field are 
ongoing, according to Sciensano, the future expansion scheme of AMU data-collection to 
new animal categories should be accompanied by a monitoring of AMR in the same animal 
species to evaluate the impact on AMR of changes in AMU. Moreover, Sciensano expects 

(169) European Council recommendation (2023/C 220/01) on stepping up EU actions to combat antimicrobial resistance in a 
One Health approach. Available at: Link. 
(170)  ECDC,  Estimated  incidence  of  bloodstream  infections  with  three  key  pathogens  in  the  EU/EEA  in  2019,  April  2023. 
Available at: Link. 
(171) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(172) European (EU) Surveillance of Antimicrobial Consumption Network for Belgium (ESAC-Net). Available at: Link. 
(173) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 

33 

 
 
 
Feasibility study on integrated surveillance systems on AMR and AMC encompassing 
human health, animal health, plant health, food, wastewater and the environment 

the JAMRAI initiative on EARS-Vet (174) to contribute to filling this knowledge gap with the 
standardisation and organisation of external quality controls. 

Sciensano,  ARSIA, DGZ, FPS HFCSE explained that the quality of antibiotic sales  and 
use (Sanitel-Med) data is sufficient for year-to-year comparisons and meeting surveillance 
and policy objectives, though gaps remain, particularly in newly registered sectors. Sales 
data is strictly regulated, with only commercialised antibiotic reported, validation steps for 
data accuracy, and built-in monitoring to detect anomalies. Sanitel-Med enforces mandatory 
data  entry  controls,  ensuring  correct  prescription  formats,  veterinarian  and  facility 
verification,  and  consistency  between  animal  species,  diagnosis,  and  drug  use,  with 
additional PowerBI-based checks to flag abnormal entries. 

Sciensano, ARSIA, DGZ explained in animal health, Belgium plans to have further inter-
sectoral  coordination  to  expand  surveillance,  since  for  AMC  monitoring  in  the  veterinary 
sector  there  are  notable  gaps,  surveillance  is  based  on  sales  fata  and  usage  data.  The 
usage data collection system is currently limited to certain species (chickens, turkeys, cattle 
and  pigs),  and  disparities  between  the  usage  and  sales  data  suggest  that  the  current 
methodology for sales data collection may not cover all distribution channels. 

Sciensano,  ARSIA,  DGZ,  FPS  HFCSE  explained  to  be  able  to  maintain  current  AMR 
monitoring of zoonotic MRSA and indicator enterococci, and follow to European monitoring 
recommendations,  it  is  crucial  to  ensure  a  structural  budget  for  these  fundamental 
surveillances. They think an objective evaluation of the current Belgian monitoring systems 
on national level in animal species is urgently needed to be able to most effectively provide 
recommendations  to  improve  the  existing  schemes  (livestock)  or  set  up  new  ones  for 
companion animals, horses, for example. 

Environmental sector surveillance  

Regarding the Urban Wastewater Treatment Directive(175), The FPS HFCSE explained 
the  directive  is  still  under  discussion  to  decided  how  it  will  be  implemented  in  Belgium. 
Moreover,  The  FPS  HFCSE  and  Sciensano  highlighted  that  AMR  surveillance  in  the 
environment  is  complex  due  to  the  federal  structure  and  regional  competencies. 
Sampling  is  conducted  within  regions:  four  sites  in  Flanders,  one  in  Brussels,  and  six  in 
Wallonia. Each region organises sampling and analysis differently. Many activities are done 
by the regional authorities; therefore, information is sometimes not available at federal level.  

The  FPS  HFCSE  highlighted  a  lack  of  communication  between  the  different  regions. 
However,  the  launch  of  the  BELMAP  report  allowed  better  communication  between  the 
stakeholders. Interviewed stakeholders emphasised the challenge of integrating data from 
different sectors due to differences in aims and methodologies. Moreover, the FPS HFCSE 
highlighted there is still a limited understanding of the role of the environment in AMR, as 
well  as  a  lack  of  awareness  about  the  cost-efficiency  and  the  level  of  insights  that 
environmental surveillance could provide. 

The  FPS  HFCSE  explained  Belgium  is  actively  involved  in  the  European  Environment 
Information and Observation Network (Eionet) (176), where it pledges in favour of a more 
integrated surveillance system, according to interviewed stakeholders. 

(174)  JAMRAI,  Policy  Brief,  European  Antimicrobial  resistance  surveillance  network  in  veterinary  medicine  (EARS-Vet). 
Available at: Link. 
(175)  Directive  (EU)  2024/3019  of  the  European  Parliament  and  of  the  Council  of  27  November  2024  concerning  urban 
wastewater treatment. Available at: Link. 
(176) European Environment Information and Observation Network (Eionet). Available at: Link. 

34 

 
 
 
 
Directorate General for Health and Food Safety 

Regarding  antifungal  pesticide  use  in  the  environment,  Belgium  monitors  resistance  in 
environmental aspergillosis samples (177). Additionally, Belgium is one of the only countries 
that have a reporting system for biocides and fungicides through a Federal Reduction plan 
for Biocides (178). 

The FPS HFCSE argued, before an effective surveillance programme can be established, 
key information should be established, with pilot studies needed to determine:  

•  Which  environments  should  be  prioritised  (effluents  of  hospitals/nursing  homes, 
wastewater,  surface/recreational  waters,  agricultural  fertilisers,  agricultural  soils, 
agricultural products, manufacturing surfaces, compost heaps etc.). 

•  Which  micro-organisms,  antimicrobial  resistance  genes  (ARGs)  and  resistance 

mechanisms to monitor. 

•  What indicators to use for this monitoring (isolates, genes, genetic elements). d) The 
development of standardised methodologies (sampling as well as testing methods) 
for  detecting  AMR  patterns  in  a  way  that  is  reliable  and  comparable  between 
sites/over time. 

Challenges and barriers  

According to Sciensano ARSIA, DGZ, there are discussions on the future sharing of raw 
data  for  improved  analysis.  However,  concerns  remain  about  patient  confidentiality, 
particularly in hospitals, where questions arise about whether patient data should be publicly 
disclosed  and  if  patients  are  adequately  informed.  According  to  the  same  stakeholders, 
previous legal debate in Belgium determined that hospital-level AMR data should not be 
publicly disclosed to prevent unintended consequences, such as patient selection of specific 
hospitals.  

For  all  interviewed  stakeholders,  the  biggest  obstacle  to  develop  an  integrated 
surveillance system is Belgium’s fragmented and decentralised surveillance structure. 
Despite  the  progress  evidenced  by  the  BELMAP  report  (179),  stakeholders  perceive  that 
surveillance in Belgium remains sector-specific, with data collected separately for human 
health, veterinary, and environmental sectors and consists currently of joint reporting, rather 
than a fully integrated surveillance system. Regarding AMC in human and animal sectors, 
stakeholders  reported  that  Belgium  provides  a  relatively  integrated  surveillance  system 
through the BELMAP report (180). However, with respect to AMR in humans, animals and 
the  environment,  the  stakeholders  remarked  that  surveillance  systems  could  not  be 
considered  as  being  integrated  and  rather  should  be  considered  as  joint  reporting. 
According  to  ARISA  and  Sciensano  surveillance  systems  are  not  designed  for 
integrated analysis, as these are elaborated on a sector specific base. 

Moreover, FPS HFCSE and ARISA have indicated that the BELMAP report (181) is not 
widely recognised within the veterinary sector and lacks detailed, sector-specific insights, 
limiting its usefulness for veterinary policy. They explained that, while it functions as a public 
report summarising key findings, its relevance depends on appropriate framing, including a 
clear explanation of its benefits and limitations.  

FPS HFCSE and ARISA stressed that the integration of data from different sectors poses 
a risk of reducing its granularity. Even though all stakeholders see the value in having a 

(177) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(178) Health Food Chain Safety Environment, Federal Reduction Plan for Biocides. Available at: Link. 
(179) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(180) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(181) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 

35 

 
 
 
Feasibility study on integrated surveillance systems on AMR and AMC encompassing 
human health, animal health, plant health, food, wastewater and the environment 

more integrated surveillance system, certain stakeholders strength it is dangerous to go too 
far into integration, fearing losing surveillance relevance within each sector. Therefore, they 
highlighted the need to foster sector specific surveillance reporting, beyond an integrated 
surveillance approach. 

According  to  all  interviewed  stakeholders,  limited  financial  resources  hinder  the 
deployment of larger and more efficient systems in each sector, stakeholders pledged for 
more  financial  support  for  IT  improvements  to  facilitate  harmonised  reporting  of  results, 
more structural budget for fundamental surveillances. This financial limitation prevents the 
eventual integration across sectors, restricting progress and the ability to create a unified 
approach,  according  to  interviewed  stakeholders.  Additionally,  they  argued  there  is  not 
always a clear mandate or funding for doing integrated surveillance, which, for most of the 
actors,  is  done  on  the  top  of  their  normal  duties.  Participation  in  initiatives  such  as  EU-
JAMRAI(182) is seeing as a key enabler, but remains time-consuming and resource intensive 
for most of the stakeholders interviewed. 

Additionally, according to the FPS HFCSE, surveillance systems in place do not allow to 
demonstrate the benefits of collecting the data. The interviewed stakeholders explained 
various stakeholders are asked to collect data, without necessarily retrieving the outcomes 
of  the  analyses.  Data  collection  can  remain  time-consuming,  because  of  the  lack 
standardised of data collection, IT-tools and discourage actors providing the data, especially 
if they do not understand the benefit of collecting such data.  

Enablers and drivers  

According to FPS HFCSE, Sciensano and DGZ, developing an established data flow that 
supports such analyses is a vital first step for depicting more detailed patterns of AMU in 
community settings in Belgium, information needed for the development of detailed clinical 
guidelines and AMC targets. Such surveillance would also generate data needed to support 
the validation of future surveillance improvements. The development of a surveillance that 
collects data directly from community pharmacies or medical practices would remove the 
two-year delay and again provide the possibility to include other information such as the 
reason for prescription. 

All  interviewed  stakeholders  see  the  potential  for  Belgium  to  have  a  whole  genome 
sequencing  (WGS)  based,  early  detection  system  for  AMR  as  one  potential  option  for 
developing  a  truly  integrated  One  Health  surveillance  system,  with  data  from  diverse 
settings  (human  medical  settings,  veterinary  pathogens,  food  samples,  wastewater 
samples)  centralised,  analysed  using  standardised  analytical  pipelines  and  collectively 
reported(183). 

All interviewed stakeholders identified specific funding for the last BELMAP report (184) 
and the NAP-AMR(185) as key enabler, since it allowed a further development of the different 
surveillance systems toward an integrated surveillance system. It gave a clear mandate to 
stakeholders to do the surveillance in a one health approach.  

Furthermore, all interviewed stakeholders national and EU regulations on mandatory 
surveillance  systems  as  playing  a  key  role  in  developing  AMR  and  AMC  surveillance 
systems across sectors. Stakeholders explained EU regulations imposes surveillance to the 

(182) European Union Joint Action on Antimicrobial Resistance (AMR) and Healthcare-Associated Infections (HCAI). Available 
at: Link. 
(183) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(184) BELMAP One Health report on antimicrobial use and resistance in Belgium. Available at: Link. 
(185) Belgian “One health” national action plan on the fight against AMR 2020-2024. Available at: Link. 

36 

 
 
 
 
Directorate General for Health and Food Safety 

national  agenda,  regardless  of  the  national  political  will  to  combat  AMR.  Having  the 
mandatory surveillance in place, encouraged certain stakeholders to go beyond regulation 
and to develop the systems on a voluntary base. 

Beyond  regulations,  DGZ  and  Sciensano  insisted  on  public  awareness,  which 
significantly raised  the  need  for  concrete  actions  towards  a  more  integrated  surveillance 
system.  Different  campaigns,  as  well  as  outbreaks,  allowed  a  stronger  cross-sectoral 
political collaboration.  

All interviewed stakeholders mentioned existing strong national dialogue between the 
different sectors to enhance an integrated surveillance system was highlighted during the 
interviews.  Regular  meetings  across  the  different  stakeholders  allowed  to  identify  new 
needs for data collection in an integrated way. 

Additionally, all stakeholders smentioned user-friendly IT solutions have the potential to 
significantly improve the collection, analysis, and integration of data, particularly in outbreak 
situations where speed and interconnectivity are crucial.  

Next steps  

All  stakeholders  agreed  that  adopting  a  more  integrated  approach  would  enable  more 
targeted and efficient analyses of AMR. Moreover, an integrated analysis would allow for a 
better  understanding  of  the  relationship  between  antibiotic  use  and  the  emergence  of 
resistance across sectors. They all mentioned that a second NAP-AMR is currently under 
validation.  ARSIA  and  FPS  HFCSE  estimate  Sciensano  is  currently  limited  to  do  joint 
reporting, rather than integrated surveillance across sectors. Additionally, they estimate the 
human health sector has most political power and the animal sector is less represented, or 
at least less powerful. 

The FPS HFCSE explained, Belgium plans to analyse the potential implementation of the 
Urban Wastewater Treatment Directive (186).  

(186)  Directive  (EU)  2024/3019  of  the  European  Parliament  and  of  the  Council  of  27  November  2024  concerning  urban 
wastewater treatment. Available at: Link. 

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Feasibility study on integrated surveillance systems on AMR and AMC encompassing 
human health, animal health, plant health, food, wastewater and the environment 

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