Strengthening AMR Control: Japan’s Shift to a Targeted One Health Approach

Japan's AMR response from 2013 to 2025 focuses on surveillance, antimicrobial stewardship, infection prevention, and research, evolving from hospital-based measures in NAP1 (2016–2020) to a more targeted, One Health approach in NAP2 (2023–2027). Strengthened by COVID-19-driven IPC improvements, Japan continues to lead global AMR efforts through innovation, policy, and international collaboration.

Japan’s response to antimicrobial resistance (AMR) from 2013 to 2025 is a meticulously structured initiative involving the National Institute of Infectious Diseases (NIID), the National Center for Global Health and Medicine (NCGM), and the Ministry of Health, Labour and Welfare (MHLW), among others. Recognizing AMR as a major public health threat, Japan introduced strict antimicrobial usage policies within its universal health coverage (UHC) system, ensuring that antibiotics are only prescribed by licensed doctors and dispensed by pharmacists. Japan’s engagement with AMR intensified in the 1980s when methicillin-resistant Staphylococcus aureus (MRSA) infections surged, prompting infection prevention and control (IPC) measures. By 2015, Japan had formally aligned with the Global Action Plan on AMR (GAP) by the World Health Organization (WHO), setting the stage for comprehensive national strategies.

The First National Action Plan (NAP1): Strengthening Surveillance and Stewardship

Japan’s first National Action Plan on AMR (NAP1), launched for 2016–2020, focused on six priority areas: public awareness, surveillance, IPC, antimicrobial stewardship (AMS), research and development, and international cooperation. The plan aimed to minimize AMR emergence and prevent the spread of resistant infections through a multisectoral One Health approach, addressing AMR across human, animal, and environmental health sectors. Surveillance was reinforced through the National Epidemiological Surveillance of Infectious Diseases (NESID) and the Japan Nosocomial Infections Surveillance (JANIS), monitoring AMR trends in hospitals. The Japan Surveillance for Infection Prevention and Healthcare Epidemiology (J-SIPHE) system was introduced to track antimicrobial use (AMU).

Public awareness campaigns were initiated to reduce antibiotic misuse, but their effectiveness remained limited. Healthcare professionals were increasingly trained in AMS, leading to better prescribing habits, while IPC measures were incentivized through financial rewards for hospitals that complied with AMR guidelines. Research and development efforts were promoted, though pharmaceutical companies hesitated to invest in new antibiotics due to financial risks. Japan also became a global leader in AMR policy, hosting the Tokyo AMR One Health Conference and collaborating with WHO and other international organizations.

Despite significant progress, challenges emerged during NAP1 implementation. Surveillance was primarily hospital-focused, leaving outpatient and long-term care settings underrepresented in AMR data collection. While antimicrobial consumption fell by 32.7% from 2013 levels by 2021, resistance rates for some bacteria, such as fluoroquinolone-resistant Escherichia coli, remained high. The COVID-19 pandemic further delayed AMR initiatives as healthcare resources were diverted. However, the pandemic also strengthened IPC measures, increasing hand hygiene and infection control practices in both hospitals and communities.

The Second National Action Plan (NAP2): A More Targeted Approach

Learning from the challenges of NAP1, Japan introduced NAP2 (2023–2027) with a sharper focus on outpatient settings, long-term care facilities, and genomic surveillance. The plan retains its six-priority structure but sets clearer, more specific targets for AMR reduction. Surveillance systems now include genomic monitoring, improving early detection of resistant pathogens and enabling more targeted responses. The One Health approach has been expanded, integrating human, animal, and environmental AMR data for more comprehensive tracking.

Economic incentives were introduced to encourage antimicrobial research and development, with a revenue guarantee system to support pharmaceutical companies in producing new antibiotics. To address the vulnerabilities in antibiotic supply chains, Japan also launched policies to secure the domestic production of active pharmaceutical ingredients (APIs). The COVID-19 pandemic revealed weaknesses in global supply chains, prompting Japan to prioritize self-sufficiency in antimicrobial production.

Public awareness remains a challenge, with surveys showing that physicians have improved their prescribing practices, but the general public’s understanding of AMR has not significantly improved. To address this, NAP2 includes enhanced school curricula, community outreach programs, and digital campaigns. Healthcare professionals are being provided with additional AMS training, and AMS teams are being integrated into smaller hospitals. More robust monitoring of outpatient antibiotic prescriptions is being implemented to reduce unnecessary antibiotic use.

Impact of COVID-19 on AMR Efforts

The COVID-19 pandemic had a mixed impact on Japan’s AMR response. On one hand, respiratory infections declined due to social distancing and hygiene measures, leading to a natural reduction in antibiotic prescriptions. This demonstrated how infection control measures can reduce the need for antimicrobials. However, hospitalized COVID-19 patients were often treated with broad-spectrum antibiotics, increasing concerns about long-term AMR risks.

The pandemic also prompted a revision of Japan’s Infectious Disease Control Law, improving national preparedness for future public health threats, including AMR. Local governments and healthcare facilities have been mandated to strengthen AMR surveillance and preparedness, ensuring better outbreak response mechanisms in future pandemics. The medical reimbursement system was expanded to provide incentives for infection control, leading to improved IPC standards across healthcare facilities.

Japan’s AMR response benefited from increased awareness of IPC, but sustaining these improvements post-pandemic remains a challenge. While hand sanitizer usage spiked during COVID-19, compliance declined after restrictions were lifted, highlighting the need for ongoing education and reinforcement of hygiene practices.

Global Leadership and Future AMR Strategies

Japan continues to play a leading role in global AMR governance, strengthening collaborations with WHO, the G7, the Quadripartite organizations (WHO, FAO, WOAH, UNEP), and research institutions like the U.S. NIH and U.K. Medical Research Council. The AMR Research Center at NIID and the AMR Clinical Reference Center at NCGM have expanded their international training programs, assisting other countries in developing surveillance and outbreak response systems.

The One Health surveillance system in Japan has become a model for multisectoral AMR tracking, linking data from hospitals, veterinary medicine, agriculture, and environmental studies. Japan is also investing in regional AMR monitoring, particularly in Asia-Pacific nations, to prevent cross-border spread of resistant infections.

Looking ahead, Japan is focusing on sustainable research and development of antimicrobials, securing antimicrobial supply chains, and further integrating AMR policies into national health planning. The government is expanding financial incentives for AMS programs, encouraging the development of new antibiotics, and enhancing outpatient antibiotic stewardship to address gaps in primary care.

Japan’s transition from NAP1 to NAP2 marks a shift from broad surveillance to targeted, evidence-based interventions, ensuring a more resilient AMR response. By embedding AMR measures into health policies, strengthening surveillance, and fostering global cooperation, Japan remains at the forefront of the fight against antimicrobial resistance, setting a model for other countries to follow.