ECDC/EC/EFSA country visit to Kosovo* to advance One Health responses against antimicrobial resistance

Assessment

The European Centre for Disease Prevention and Control (ECDC), the European Commission’s Directorate-General for Health and Food Safety (DG SANTE) and the European Food Safety Authority (EFSA), supported by a consortium composed of Epiconcept and Integrated Quality Laboratory Services (IQLS), jointly carried out a country visit to Kosovo* from 9 to 13 October 2023. The visit is part of ECDC’s accession support activities to contribute to the advancement of a One Health approach against antimicrobial resistance (AMR) in the Western Balkans funded by the Directorate General for Neighbourhood and Enlargement Negotiations (DG NEAR) of the European Commission.

Executive Summary

The report concludes that Kosovo has initiated several key activities to address AMR issues, mostly in the human health sector. The previous National Action Plan (NAP) on AMR for Kosovo ended in 2021 and the management of the COVID-19 pandemic delayed its implementation. Activities addressing AMR in the human health sector are now included in a comprehensive plan of actions for communicable disease prevention and control 2023–2025 following the recommendations of the EC/ECDC Technical Assessment Report in 2018. However, the identification of priorities as well as the allocation of resources on AMR surveillance and the reduced and prudent use of antimicrobials for animal health, food production and environment are still to be developed to allow an effective and coordinated One Health approach on AMR involving all sectors.

In the human health sector, a national AMR surveillance system, organised and led by the National Institute of Public Health in Kosovo (NIPHK), is currently collecting data from a network of regional public health laboratories. A Laboratory Information Management System recently installed at NIPHK will be deployed to participating laboratories to facilitate the sharing and analysis of data and the reporting of AMR trends at the central level. However, AMR data are only collected for surveillance purposes and are not used for guided treatment in hospitals, and the timely reporting of critical results to clinicians has not yet been implemented.

Antimicrobial consumption (AMC) is being intermittently monitored in the country using data from imports, sales and, on some occasions, prescriptions from primary care. Establishing AMC monitoring using electronic data collection from hospital pharmacies will allow more regular and timely surveillance on the consumption. Regarding the prudent and appropriate use of antimicrobials, the legislation on prescriptions and sales of antibiotics should be enforced in order to stop the common practice of over-the-counter sales in pharmacies. The establishment of antimicrobial stewardship (AMS) committees needs to continue to cover all hospitals throughout the country. National guidelines for the treatment of common infectious diseases as well as prophylaxis in healthcare settings are required to ensure more appropriate use of antibiotics.

Strengthening hand hygiene practices in healthcare facilities, providing regular infection prevention and control (IPC) training for healthcare staff in all facilities, increasing dedicated IPC staff in hospitals, and establishing national surveillance of healthcare-associated infections (HAI) would be key measures to improve IPC in the country. Finally, it is essential to improve collaboration between the different levels and specialities in the healthcare system and to plan long-term behaviour change interventions and awareness-raising campaigns on AMR.

In the animal health and food safety sectors, there is no system in place to generate data to monitor AMR and Antimicrobial Sales and Use (ASU). Consequently, there are no baseline data to assess the burden of AMR in these sectors, allow outbreak detection and evaluate the efficacy of future actions to encourage reduced and prudent of antimicrobials. National legislation on AMR/ASU surveillance needs to be developed, implemented and subsequently enforced to address these issues.

Laboratory capacity to monitor AMR in livestock and the food production sector is available at the Food and Veterinary Agency (FVA) although developing antimicrobial susceptibility testing (AST) capacity to EU standards would be required. Allocating resources to reinstall a Salmonella control plan that existed previously in Kosovo could be a first step in developing an AMR surveillance system in the animal health/food sector.

So far, the competent authority has not introduced any measures to encourage reduced and prudent use of antimicrobials in animals. The veterinarians and animal keepers had limited awareness of the risks associated with AMR and the use of broad-spectrum antimicrobials in animals, including some of critical importance for the treatment of humas, as the first line treatment. Some of the antimicrobial Veterinary Medicinal Products (VMPs) authorised in Kosovo, such as growth and yield promoters (including colistin in combination with other antimicrobials) are banned in the European Union.

For the moment, collecting data on the use of antimicrobials in different species is likely to be challenging due to the absence of a regulatory framework for the prescription of VMPs, over-the-counter sales, and the absence of farm records for VMPs. However, collecting data on sales of antimicrobials from wholesalers could be a starting point considering the relatively low number of companies selling VMPs in Kosovo.

The commitment of relevant actors in the human health, food production and veterinary sectors in Kosovo is a good starting point for improving AMR control and promoting the reduced and prudent use of antimicrobials. Many EC/ECDC recommendations to control AMR and HAIs are under implementation. However, many challenges for monitoring AMR in a One Health approach and establishing efficient prevention and control measures against AMR remain in all sectors, and especially in the food production, veterinary and environment sectors. Continued efforts and renewed commitment of the ministries, agencies and stakeholders in all sectors are required to move forward on the control of AMR in Kosovo. This involves further development and implementation of the AMR activities outlined in the comprehensive action plan for communicable disease prevention and control 2023–2025 and developing a comprehensive plan in the food production sector and environment. In this report, several initial recommendations are provided that could serve as a starting point to develop a more specific roadmap for a One Health approach to prevent AMR.

* This designation is without prejudice to positions on status, and is in line with UNSCR 1244/1999 and the ICJ opinion on the Kosovo declaration of independence