WHO Collaborating Centre on Patient Safety
The University of Geneva Hospitals and Faculty of Medicine
4, Rue Gabrielle Perret-Gentil
1211 Geneva, Switzerland
Evaluation of antibiotic awareness campaigns
Report prepared by Mirko Saam, Benedikt Huttner and Stephan Harbarth1 for
World Health Organization
Expert Committee on the Selection and Use of Essential Medicines
Policy, Access and Use (PAU)
Department of Essential Medicines and Health Products
20, Avenue Appia
1211 Geneva 27, Switzerland
1
[email protected]; [email protected]; [email protected]
1
SUMMARY
1
INTRODUCTION
2
KEY FINDINGS OF THE SURVEY
3
OUTLINE OF SURVEYED CAMPAIGNS
TARGET AUDIENCES
INFECTIONS TARGETED
KEY MESSAGES AND ESSENTIAL PUBLIC SLOGANS
GLOBAL VERSUS LOCAL KEY MESSAGES
“NEW” KEY MESSAGES IDENTIFIED
INTERVENTIONS USED IN THE CAMPAIGNS
EVALUATION OF THE CAMPAIGNS
OBSTACLES FACED WHILE IMPLEMENTING A PUBLIC AWARENESS CAMPAIGN
3
5
7
8
11
12
13
14
15
POTENTIAL FOR EXPANSION IN NEW DIRECTIONS
15
ACKNOWLEDGMENTS
17
APPENDIX I - METHODOLOGY
I
APPENDIX II - SUMMARY TABLE
I
APPENDIX III - QUESTIONNAIRE USED FOR THE SURVEY
I
REFERENCES
18
2
SUMMARY
●
Between September and November 2016, we conducted an online survey to review
the characteristics of public awareness campaigns targeting antibiotic use conducted
since 2010. We identified 60 campaigns implemented on a national (n=42, 70%),
regional (14, 23%) or both levels simultaneously (2, 2%), across 16 low- and middleincome countries (LMICs), and 31 high-income countries. Respondents from another
8 countries (5 LMICs and 3 high-income countries) either stated they were not sure,
or that there was no such campaign in their country. Among the 93 countries that
were contacted, 38 (40%) did not respond at all.
●
All but 12 (20%) campaigns targeted the general public and physicians
simultaneously, with wide variations among the specifically targeted groups in the
population (e.g. parents of young children, caregivers, etc.) and among the
healthcare professionals (e.g. GPs, paediatricians, etc.).
●
There were no major differences between middle-income and high-income countries
in the type of key messages used in the campaigns. "Misuse/overuse of antibiotics
causes resistance” (n=47, 78%) and "If we use antibiotics incorrectly we will lose
them / they will become ineffective" (43, 72%) were the most commonly used key
messages, followed by "Hand washing can reduce the spread of infection / Wash
your hands", "Judicious / prudent / responsible / appropriate / adequate use of
antibiotics is important" and "Antibiotics do not work against colds / flu" (used in 41
(68%) campaigns each).
●
In the context of this survey we tried to identify and categorize messages which could
be used by future campaigns. In general, it seems essential to base the campaigns
messages more rigorously on scientific evidence and behavioral change concepts,
while considering the particular context of each country. New key messages
identified through this survey reveal, to a certain extent, the increasing prominence of
the One Health approach in antibiotic awareness campaigns.
●
The distribution or dissemination of education and communication material (either
offline (87% of the campaigns) or online (77%)) was the intervention most frequently
implemented. Other types of interventions included public relation activities, press
conferences, training sessions for prescribers, and active promotion or distribution of
guidelines.
●
According to this survey, respondents reported that both human and financial
constraints have posed significant barriers to implementing campaigns or to
achieving a clinical or public health impact. Lack of political support, and an enduring
1
gap between common practices and suggested actions, are potential major obstacles
to translating campaigns into concrete results.
●
Evaluation of the impact of antibiotic awareness campaigns is still suboptimal, with
36 of 60 campaigns (60%) reporting no formal evaluation. Most of the campaigns that
were formally evaluated (n=24, 40%) relied on the monitoring of antibiotic use to
assess their impact (17, 28%), and/or surveillance of antibiotic resistance rates (13,
22%). The most effective messages and interventions remain unclear. The lack of
thorough evaluation, the absence of prospectively determined control groups and the
multifaceted nature of most campaigns makes any formal conclusions difficult. It
seems, however, that some campaigns were associated with a reduction in overall
antibiotic use.
●
More research is required to better understand which key messages and which types
of interventions work best in different setting. Nevertheless, based on the results of
this survey, recommendations can already be made to enhance the deployment of
communication activities related to antibiotics.
INTRODUCTION
Tackling the global spread of antibiotic resistance is a high priority for the World Health
Organization (WHO). On the one hand, as part of the implementation of Objective 1 of the
Global Action Plan on Antimicrobial Resistance, WHO is coordinating a global campaign to
raise awareness and encourage best practices among the public, policymakers, as well as
health and agriculture professionals.1 On the other hand, the list of “Critically Important
Antimicrobials” has been established as a reference to help formulate and prioritise
strategies for containing antibacterial resistance, and is intended for public health and animal
health authorities, practicing physicians and veterinarians, and policymakers. The
appropriate application of the “Critically Important Antimicrobials List” supports the
implementation of the Global Action Plan’s Strategic Objective 1 -- to improve awareness
and understanding of antimicrobial resistance -- as the list is an important component to
assure the responsible use of antibiotics and for controlling the potential spread of resistant
microbes through the food chain.
There is good evidence that public campaigns promoting responsible antibiotic use may be
associated with reductions in overall antibiotic use. The individual impact of various public
campaigns in Europe between 1997 and 2007 has been estimated to be equivalent to a 6.5–
28.3% drop in the mean level of overall antibiotic use.2 Factors leading to successful
awareness campaigns include carefully designed and simple key messages; targeting a
wide audience such as patients, their families and healthcare workers; engaging physicians
and other healthcare professionals early in the campaign and designing the key messages
with them; using mass media and social media; and continuously repeating key messages. 3
4
The latter is of outmost importance, as experiences in Belgium and France have shown. In
2
these two countries national campaigns have reduced overall antibiotic consumption, but it
has been difficult to sustain successes over time. Experience from other public health
campaigns shows that repeated exposure of the targeted public over long periods of time is
often necessary to exert a sustained effect.5 6
In its “Worldwide country situation analysis: response to antimicrobial resistance” report
published in 2015, WHO stated that there are large variations across regions in the
percentages of Member States that have conducted campaigns to educate the public about
the appropriate use of antibiotics (e.g. 2% of countries in the WHO African Region vs. 42%
in the WHO European Region). A multi-country public awareness survey on antibiotic
resistance performed by WHO in 2015 highlighted that levels of knowledge around the
appropriate use of antibiotics — including how and when to use antibiotics and what they
should be used for — are mixed, but rather low in all regions. This is an alarming situation,
particularly in countries where antimicrobial medicines are readily available over the counter
without a prescription.
In this context, WHO has mandated a team of researchers at the WHO collaborating center
at the Geneva University Hospitals (Mirko Saam, Benedikt Huttner and Stephan Harbarth) to
conduct an international survey of antibiotic awareness campaigns in order to fill some of the
knowledge gaps and help the planning of future initiatives. The survey captured information
on the design of campaigns in different contexts; this report compiles the data in an effort to
facilitate information sharing and learning across countries.
KEY FINDINGS OF THE SURVEY
Outline of surveyed campaigns2
In mid-October 2016, invitations to participate in the survey were sent by email to a total of
93 countries, through WHO Regional offices and National Focal Points, and to persons in
charge of antibiotic awareness campaigns; the countries to be contacted were identified
through a preliminary review of the scientific literature and previously established contacts of
the survey team.
Consolidated answers represent a total of 60 campaigns, implemented in 16 low- and
middle-income countries, and 31 high-income countries (12 countries reported more than
one campaign); 47 countries contacted (51%) provided positive answers, 8 (9%) stated there
was no campaign implemented in their country and 38 (40%) did not provide any answer,
despite several reminders.
2
The methodology is detailed in APPENDIX I and a summary table highlighting the main characteristics of the
campaigns is provided in APPENDIX II.
3
Map of countries included in the survey. Blue: antibiotic campaign conducted since 2010 (LMICs = light blue /
high-income countries = dark blue). Red: answered “no campaign” OR “not sure” to have had a campaign since
2010. Yellow: contacted, but no answer received, Grey: not contacted..
Classified by WHO regions, 3 campaigns took place in the African Region, 9 in the Region of
the Americas, 6 in the South-East Asia Region, 35 in the European Region, 2 in the Eastern
Mediterranean Region and 5 in the Western Pacific Region. Campaigns were reported even
in some countries with a relatively low use of antibiotics, such as the Netherlands and
Scandinavian countries. Most campaigns (45/60, 75%) were implemented on a national level
and 15 of them (25%) on a regional level.
Three quarters of the countries (35/47) represented in this survey mentioned the existence
of a national strategy to reduce antimicrobial resistance, which includes actions to
disseminate information towards the public. Nevertheless, in most cases (47/60), campaigns
were launched and supervised by health authorities, even in the absence of a national
strategy.
The following stakeholders were involved in designing and/or conducting the campaign:
infectious diseases specialists (48 campaigns, 80%), microbiologists (42, 70%), primary care
physicians (34, 57%), professional societies (33, 55%), advertising companies or
communication specialists (21, 35%), patients or patient interest groups (19, 32%) and
international experts (18, 30%). Epidemiologists or public health experts (6, 10%) and
pharmacists (5, 8%) were also associated in the implementation of some campaigns. The
campaign implemented in Alberta (Canada) also involved school curriculum experts, early
childhood educators, occupational health nurses, the well public (e.g. workers and
employers, in contrast to patients) and even medical students.
Based on the responses only 4 of the 60 campaigns involved psychologists or
medical sociologists in the design or conduct of the campaigns. These specialists
should increasingly be associated in the definition and implementation of campaigns
for achieving effective and sustainable behaviour change regarding antibiotics.7
4
Data on budgets and funding sources were provided by 32 (53%) campaigns and reflect
widely varying volume and intensity, from simple campaigns with a budget of a few thousand
US dollars, to expensive mass-media campaigns with budgets in the range of millions of
USD per year. It should, however, be noted that these numbers are rough estimates
including varying items (e.g. staff salaries, cost for producing and/or disseminating material,
etc.). The majority of campaigns (47, 78%) were publicly funded by regional or national
health authorities. Some campaigns also received complementary funding from foundations,
charities or non-governmental organisations (12, 20%), United Nations agencies (11, 18%),
professional societies (9, 15%), public (7, 12%) or private (1) health insurances, the
pharmaceutical industry (5, 8%), universities (1), foreign embassies (1) and donations (1).
Only 25 (42%) campaigns were designed to run all year, 18 (30%) were seasonal and 17
(28%) temporary (e.g. for a few weeks during the year but independent of the season). Most
campaigns (48, 80%) were “ongoing” at the time of the survey.
Most countries represented in this survey were participating in the World Antibiotic
Awareness Week (38, 63%) and/or in the European Antibiotic Awareness Day (35, 58%). In
fact, 6 campaigns directly referred to the local implementation of the European Antibiotic
Awareness Day and highlighted the many forms of its local adaptation.
For information about countries which have not implemented campaigns, please refer to
Appendix IV.
Target audiences
Since children are frequently (over-)prescribed antibiotics, 24 campaigns (40%) specifically
targeted parents of young children, and 20 campaigns (33%) targeted personnel of day-care
centres and teachers in schools. Interventions specifically aiming at school-age children and
adolescents were also implemented, but only by 18 campaigns (30%). Other groups which
have a higher than average exposure to antibiotics or are at increased risk of transmission of
resistant pathogens, such as the elderly and travelers, were targeted by 8 and 1 campaigns,
respectively. A third of the campaigns targeted journalists (20) or hospital patients (20), while
just one aimed at politicians or policymakers (Antibiotic Guardian - UK). Interestingly, 6
campaigns (Armenia, Chile, France, Malta, the Republic of Macedonia and UK (Antibiotic
Guardian)) also targeted pet owners or veterinarians, in line with the One Health approach.
5
Since the ultimate decision to use antibiotics lies with physicians in most cases, 43
campaigns (72%) directed their interventions towards general practitioners and family
physicians, 29 (48%) to paediatricians and 29 to medical specialists. Pharmacists, nurses
and dentists were respectively targeted by 32, 19 and 14 campaigns. Healthcare facility staff
and administrators, caretakers at nursing homes, and pharmacy, nursing and medical
students were also specifically targeted in some cases.
6
The answers collected did not allow to discern the effects of targeting specific groups
on the effectiveness of the campaigns. The scientific literature suggests that
addressing specific subgroups of the public and healthcare professionals could
increase the impact of campaigns; for instance targeting patients consulting general
practitioners and their direct interactions during consultations.8 In the future, the EU
Commission aims to target antibiotic campaigns more effectively at those who lack
knowledge, and at prescribers (especially high prescribers) and pharmacists who
have a key role to play in changing views and behaviour. 9 Embedding knowledge
within young people’s formal education could also be a successful approach. 10 11 12
Larger investments are needed in this field, as not even a third of the campaigns
surveyed focus on school-age children and adolescents. Additionally, medical and
veterinary schools can also be important targets for awareness-raising activities.13
Infections targeted
A majority of campaigns (46, 77%) focused on respiratory tract infections (other than
influenza) and 36 (60%) on influenza, since these are responsible for most of the inadequate
prescriptions of antibiotics. Urinary tract infections and sexually transmitted diseases were
addressed by 15 and 6 campaigns respectively, while 3 dealt with diarrhoea/gastro-intestinal
infections, 2 with skin infections and one with viral diseases, such as dengue, which do not
require antibiotic treatment.
7
Since the antibiotic resistance of bacteria causing sexually transmitted diseases and
urinary tract infections is on the rise worldwide, and urinary tract infections represent
an important proportion of outpatient antibiotic consumption, expanding the scope of
future campaigns to cover these types of infections seems appropriate.
Key messages and essential public slogans
There were no major differences between middle- and high-income countries in the types of
key messages used (see APPENDIX II for a summarised view). All but 3 campaigns (95%)
conveyed messages related to antibiotic resistance, like “Misuse and overuse of antibiotics
cause resistance” (47 campaigns, 78% ), “If we use antibiotics incorrectly we will lose them /
they will become ineffective" (43, 72%) or “Antibiotic resistance is an important problem” (40,
67%).
Many campaigns (51, 85%) were also based on slogans relating to the prescription and
consumption of antibiotics, mostly expressing that a “judicious / prudent / responsible /
appropriate / adequate use of antibiotics is important” (41 campaigns, 68% ). Only 25 (42%)
campaigns mentioned that antibiotics have side effects and/or adverse effects, although in
the USA these are the most common cause of emergency department visits for adverse
drug events in children under 18 years of age.14 15 No country reported using a slogan
expressing the fact that antibiotics can interfere with the action of drugs that a patient may
8
be taking for another condition. Specific slogans were used in some cases, such as “Let’s
preserve a valuable resource” (Cyprus), “Everyone has a role” (UK - Antibiotic Guardian),
“Antibiotics - less is more” (Germany - Berlin), “Effective if necessary, harmful if abused”
(Italy - Emilia-Romagna) “Antibiotics are not automatic” (France) or “If you are prescribed
antibiotics, ask your doctor why” (Thailand).
More than half of the campaigns (31, 52%) stated “Follow / Finish the antibiotic prescription
(in dosage and duration)” in their communication material. Whereas all other key messages
identified through this survey seem scientifically valid, the validity of this particular message
can been questioned, since antibiotic treatments are often prescribed for too long and
unnecessarily, thereby favouring the the emergence and spread of antimicrobial resistance
without benefit to the patient (see Box 1).
Box 1: Antibiotic resistance and the “complete your course” message
Awareness campaigns often include the message that it is important to finish the prescribed course of treatment
to prevent the development of antibiotic resistance. However, this advice is not directly connected to the fight
against antibiotic resistance. The objective of continuing the treatment beyond the resolution of symptoms is to
prevent relapses rather than to prevent resistance. Because the rate of antibiotic resistance tends to increase
16
with the total amount of antibiotics used, the general rule might be: the shorter the course, the lower the risk of
resistance. Clinical studies have indeed shown that longer courses of therapy can result in a more likely
17 18 19
emergence of antibiotic resistance.
Shorter antibiotic treatment lower the opportunity for bacteria to
become resistant, as well as reducing adverse side-effects. In otherwise healthy people, significantly reducing but
not totally eliminating the bacteria causing the infection can allow the body’s natural defences to take over and
20
destroy the remaining few. There are some circumstances when it is necessary to eliminate all the bacteria –
when the patient’s natural defences are damaged for any reason, or when the infection is in an area less
inaccessible to antibiotics and to white blood cells and when bacteria are slow-growing (such as tuberculosis).
9
But in many cases an argument can be made for stopping a course of antibiotics immediately after a bacterial
infection has been ruled out or is unlikely (for instance in case of viral respiratory tract infections); or when the
21
signs and symptoms of a mild infection have disappeared.
Hence, in communication campaigns against antibiotic resistance, the “complete the course” message might be
confusing, in comparison with other messages that are more directly connected to the objective of decreasing
antibiotic resistance. No to skip antibiotic doses, might be a message that has a more direct link with
antimicrobial resistance, although it is probably challenging to convey these subtle differences effectively to the
greater public .
This survey did not identify messages that specifically support short courses of antibiotics,
but 16 campaigns (27%) promoted the adoption of “watch and wait” strategies before
starting a treatment.
More than three quarters of the campaigns (48, 80%) carried slogans relating to selfmedication, as availability of antibiotics without a prescription is still a problem in many
countries; either because antibiotics are legally available “over the counter”, or because laws
mandating a prescription before dispensing antibiotics are not enforced. Additionally the
Internet is now a potential way to obtain antibiotics without a prescription.22 Interestingly, the
messages “Do not buy / use antibiotics without a prescription” (26) or “Do not save leftover
antibiotics / Discard leftover antibiotics” (30) appeared equally in countries with or without
problems related to antibiotic access without prescriptions. This last key message, used by
half of the campaigns, also addressed the issue of stocking up on antibiotics, which is nonnegligible; in a U.S. survey, 14% of respondents reported storing leftover antibiotics at
home.23
Roughly the same proportion of campaigns (45, 75%) included a message about the role of
infection prevention, and in particular of hand washing (41, 68%) to limit the spread of
infectious diseases. Only 24 campaigns (40%) conveyed messages related to vaccination.
Messages related to vaccination could be used more frequently by campaigns for
various reasons. First, because there are clear correlations between the flu season
and the peak time of antibiotic consumption. Second, because the increased use of
the pneumococcal conjugate vaccine effectively targets serotypes most frequently
involved in pneumococcal disease and has decreased antibacterial resistance.24
Finally, there are various other vaccines available that have the potential to reduce the
incidence of infectious diseases and related overuse of antibiotic therapies.
Messages used to communicate with physicians were mostly related to specific diagnoses.
For instance, the US-CDC Get Smart for Healthcare campaign recommends to “Make sure
you are diagnosing pneumonia correctly and reassess the diagnosis after 1-2 days”,
whereas the Serbian campaign recommends: “Before antimicrobial treatment, take a sample
for microbiological testing”. By contrast, the public education components related to
infections often were unspecific, with 30 campaigns stating that "Most respiratory infections
are of viral origin” and 22 recommending "In case of cold or flu, try treating symptoms first".
10
Only 13 campaigns (22%) included the optimal use of antibiotics in animals in their key
messages (also see “New” key messages identified here below). They mostly transmitted
the idea that misuse and overuse of antibiotics (still in many cases used for growth
promotion) in livestock and pisciculture causes resistance in microorganisms, which can be
transmitted to consumers and ultimately impact human health. Only 9 campaigns (15%)
made use of the message "Don't give antibiotics to your pet; consult a veterinarian first”.
Overall, about 20% of the campaigns represented in this survey embrace - at least
partially - a One Health approach, which reflects its limited adoption across countries.
Communication campaigns are generally tailored either to patients and healthcare
personnel, or to farmers and veterinarians. Their implementation is often split across
different government agencies, such as ministry of health, the ministry of agriculture,
the ministry of environment, etc. Some countries, such as Australia since 2013, now
include representatives from veterinary practice and agriculture in their
communication working groups related to human medicine. Each of the involved
parties plans resources and activities relevant to their individual objectives and target
audience, with the messages across all groups remaining consistent.
Global versus local key messages
Most of the key messages identified in this survey may be used universally, but some make
more sense in countries without access problems and where self-medication is common
(e.g. “Do not buy / use antibiotics without a prescription” or “Do not save leftover antibiotics”).
Other more local messages could include resistance patterns and trends associated with
common syndromes, and changes in policies enforced by legislation (e.g. limits to the use of
antibiotics for growth promotion or as prophylaxis in animals, enforcement of dispensing only
by prescription, vaccinations, etc.). Campaigns should ideally constantly evolve to reflect the
changes in legislation and in public misconceptions (see Box 2).
Box 2: Do campaigns match misconceptions?
Key messages used in campaigns are not always aligned with the most common myths about antibiotics. A
comparison between misconceptions listed in the 2015 WHO report “Antibiotic resistance: Multi-country public
awareness survey” and the data collected through this survey reveals that, in Russia, whereas only 56% of the
population declare that they obtain their antibiotics (or a prescription for them) from a doctor or nurse, the
message “Do not buy/use without prescription” was not used by the Smolensk regional campaign. In Russia,
Serbia, China and India, where between 57% and 67% of the population believe that “it’s okay to use antibiotics
that were given to a friend or family member, as long as they were used to treat the same illness”, none of the
campaigns used the slogan “Do not share antibiotics” (or a variation of it). Although 61% of the Chinese
population and 75% of the Indian population believe that cold or flu can be treated with antibiotics, the campaigns
implemented in those countries did not state that antibiotics do not work against colds, flu, or viruses, or that they
only work against bacteria.
In Europe, while there was an increase between 2009 and 2013 in the proportion of people who responded that
antibiotics do not kill viruses and are not effective against cold and flu, Eurobarometer surveys indicated little
change during the same period in the proportion of people who answered correctly that the unnecessary use of
11
antibiotics is making them become ineffective or that taking antibiotics often has side effects. In fact, these
differences could be explained by the specific key messages promoted by the ECDC for the European Antibiotic
Awareness Day.
25
“New” key messages identified
Several slogans rarely used by antibiotic awareness campaigns were identified through this
survey.
●
“Reduce the use of broad spectrum antibiotics” (Israel): this type of message is
intended for physicians but highlights an important issue to be covered by public
awareness campaigns, since “broad spectrum” antibiotics are increasingly prescribed
worldwide, even in the outpatient setting. It seems worthwhile to target specific
antibiotic classes (such as the fluoroquinolones) that are known to favour the
emergence and spread of antibiotic resistance.
●
“Unused antibiotics should be returned to the pharmacy” (Poland): this also
applies to other types of medicines but in the case of antibiotics, as their residues are
a potential driver of antibacterial resistance emergence in the environment,26 this
slogan is appropriate. In addition, some classes of antibiotics quickly lose their
therapeutical potential; in these cases, the use of leftover antibiotics make the
emergence of resistance even more likely.27
●
“Reduce and eventually phase out sub-therapeutic use in animals” (Kenya): the
use of antibiotics by veterinarians was beyond the scope of the present survey, but
this slogan highlights the existence of campaigns tackling antibiotic consumption
through a One Health approach.
●
“Get enough rest, eat healthily, do not use antibacterial cleaning products”
(Indonesia - Smart Use of Antibiotics): the last part of this message indirectly
exposes the fact that some cleaning products may have an impact on the emergence
and spread of antibacterial resistance.28 This is supported by scientific evidence
regarding certain types of cleaning products and antiseptics; this type of message
may therefore be included in future campaigns related to antibiotic and biocide
resistance, although legislation may be a more effective approach.
Box 3: Is there a single most effective key message?
There still is a lack of formal evaluations to determine the most effective messages for curbing antibiotic misuse
and overuse. However, the most successful campaigns were based on slogans that were both simple and easy
to remember, such as the one used in France - “Les antibiotiques, c’est pas automatique” (antibiotics are not
automatic) - which is catchy thanks to its rhyme. However, this “catchiness” may be lost in translation and the
12
slogan may therefore not be easily adaptable to other languages.. Indeed, directly transposing communication
material into other languages is often tricky and challenging. In the United States, when the CDC translated its
“Get smart about antibiotics” campaign material for Spanish speakers, it changed the slogan to “informése” (get
informed) with a special focus on self-medication since a literal translation may have been misunderstood as “get
smart to self-medicate”. In fact, each country needs to select the most appropriate key messages according to
local context and popular understanding, as no single message can be considered “universal”. The cultural
framing and local adaptation of slogans are essential to achieve the best impact. Messages too complex to be
assimilated by the public need to be avoided.
It is also unclear if messages about factual knowledge, such as “antibiotics do not kill viruses”, are effective.
Indeed, in an Italian study about the impact of a low-cost regional campaign, the percentage of the surveyed
population in the intervention counties correctly identifying the statement “antibiotics are effective against viruses”
actually decreased.
29
Another issue that merits further research, is the framing of the campaign messages as
“positive” or “negative”.
30
These are problems faced also by other public health campaigns.
Interventions used in the campaigns
The distribution or dissemination of education and communication material was the
intervention most frequently implemented (52 campaigns, 87%). This was mostly achieved
through the following means, by order of occurrences in the campaigns: pamphlets,
brochures or leaflets (44, 73%); posters (41, 68&); letters to stakeholders (28, 47%);
advertisements in print media (16, 27%); billboards and public transport signs (14, 23%).
These printed materials were mostly used in physicians’ or hospital waiting rooms,
pharmacies, day care centers, and community hall forums. In most cases, people could
order brochures and posters, or download pdf files and print them, to display wherever they
liked.
The online dissemination of information also played a prominent role in 46 (77%) campaigns.
Websites, social media channels, online documents and pdf and videos, were the tools most
frequently used to that end.
Television and radio spots (on public or private channels) were used in 31 (52%) and 28
(47%) campaigns respectively; only 4 campaigns made use of spots broadcasted in
cinemas.
By order of importance, the following other types of interventions (beyond the promotion of
communication material online and offline) were mentioned by respondents.
❏
❏
❏
❏
scientific/professional conferences
publication of articles in medical journals
public relation activities
press conferences
13
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
training sessions for prescribers
active promotion / distribution of guidelines
activities targeting schools
exhibitions
gimmicks (a method or trick to get people's attention)
short film competitions
distribution of SMS
campaign toolkits
comics or t-shirts
pledge-based websites
flashmobs
Other innovative interventions (not covered by answers received for this survey) include a
specific labelling on antibiotics’ packaging. For instance, in February 2016 the Indian Ministry
of Health and Family Welfare launched a campaign called “Medicines with the Red Line”,
with a clearly identifiable red line on the box of prescription drugs.31 In July 2016, the U.S.
Food and Drug Administration approved safety labelling changes for a class of antibiotics
(fluoroquinolones) to enhance warnings about their association with disabling and potentially
permanent side effects and to limit their use in patients with less serious bacterial
infections.32
Evaluation of the campaigns
Almost one in two campaigns (24, 40%) provided answers related to evaluation. As this topic
was not the main focus of the survey, it is difficult to draw conclusions from the answers
received, for instance to determine if campaigns which were “multi-faceted” versus targeted
at specific populations or communication channels eventually achieved a better impact. The
recent actions of many health leaders to raise public awareness on antibacterial resistance
and their extensive media coverage have probably also interfered - in a positive way - with
the campaigns.
The main indicators used for evaluation were antibiotic use (17, 71%), knowledge and
attitudes of the public (15, 63%) and of healthcare professionals (11, 46%), and antimicrobial
resistance rates or sensitivity (13, 54%). Conversely, the recall of the campaign (10, 42%) or
consultation behaviour (2, 8%) were marginally used to assess the campaigns. Only 2
respondents mentioned an evaluation of the economic impact of the campaign, and none
conducted an analysis of its unintended consequences (such as hospitalisations for
complications). Capturing changes in those key indicators was beyond the scope of the
present survey and should be subject of further public health research.
14
Obstacles faced while implementing a public awareness campaign
Both human and financial constraints posed significant barriers to implementing campaigns
or achieving an impact (in 17 campaigns out of 24). Lack of political support (11/24) and an
enduring gap between common practices and suggested actions (5/24) are major obstacles
to translate campaigns into concrete results. Nevertheless, 20 out of the 24 (83%)
respondents who had evaluation data would recommend a similar type of awareness
campaign to a colleague in another country.
Light yellow: European high-income countries with antibiotic campaigns identified in a previous review in 2009
(REF Lancet ID), Red: Additional European high-income countries with antibiotic awareness identified in the
current survey. Grey: no campaign (neither in the previous review nor the current survey). White: MLIC or highincome country with no answer received.
Potential for expansion in new directions
In addition to the sections highlighted in bold characters in this report, complementary
actions to expand public awareness campaigns in new directions and enhance their impact
may include the following:
15






Each year, WHO provides Member States with recommendations to improve messages
in the framework of the World Antibiotic Awareness Week (WAAW). Several topics for
which antibiotic resistance is of growing concern are currently not covered by these
recommendations, such as urinary tract infections or the problem of multi-resistance
among bacteria living in the gut. In the material provided for WAAW, there is a patchwork
of diseases which could be confusing for the reader: TB and MDR-TB are listed next to
the common cold, pneumonia and diarrhoea. From a policy perspective it might make
sense to have an overview across diseases, although awareness campaigns would
benefit from a more precise identity and focus.
Finding ways to drastically alter the perception of antibiotics in the general population
seem of high-priority. Messages and interventions must convey the idea that these
unique molecules are a “nonrenewable” resource for modern medicine – as they
potentially lose some of their power every time we make use of them – implying long
term consequences for the individual patient and the entire population.
To favor the exchange of experiences between countries in the field of public awareness,
it would be appropriate to secure the required resources to create a public repository of
campaign material, which would enable searches to be carried out by format (e.g.
posters, brochures, etc.), target audience, content, language etc.
WHO could promote the use of consistent campaign monitoring and reporting, using a
standardised approach. The first milestone could be a preliminary public awareness
survey, based on the methodology used for the 2015 WHO report “Antibiotic resistance:
multi-country public awareness survey”. This first step may help choose the most
adequate key messages to address local misconceptions, whereas the active
involvement of psychologists and advertising or communication specialists should allow
to take into account behavioural and social aspects while planning the campaign.
Securing funding not only to implement the campaign but also for its evaluation would be
welcome in all cases. For the evaluation, WHO could approve an internationally
accepted and standardised methodology; to that end, measuring the public knowledge
before and after any intervention - even if it does not always translate into adapted
behaviour - may be a good starting point.
WHO, CDC, ECDC and other international organizations should continue to support the
deployment of public awareness campaigns related to antibiotics, because most
countries covered in this survey have reported participating in such regional or global
initiatives. To enhance the outreach and impact of antibiotic-related communication
activities, WHO could compile best practices from its most effective and advanced
campaigns - and financing models - developed for other health threats, such as
HIV/AIDS, hepatitis or maternal health. Such a “cross-fertilization” between global
campaigns could for instance include the local adaptation of messages (e.g. for the
global Hand Hygiene campaign) or the expertise acquired in the use of social media.33
Finally, the most effective way to curb antibiotic consumption varies from one setting and
continent to another. Other issues such as over-the-counter sale of antibiotics, drug
advertisement or supplier induced use may dampen the effects of any public awareness
activity. In this respect, a recent study revealed that having a national Ministry of Health
unit specialized in promoting the rational use of medicines, a national drug information
centre, as well as provincial and hospital drugs and therapeutics committees, were the
most statistically significant factors for reducing unnecessary antibiotic use.34
16
Acknowledgments
We would like to thank the following individuals for having provided comprehensive and
detailed answers which form the basis of this report,: Perlat Kapisyzi, Albania; Karine
Gabrielyan, Armenia; Stephanie Childs, Australia; Robert Muchl, Austria; Samuel Coenen,
Belgium; Tiago Reis, Brazil; Mary Carson, Canada; Jorge Valdebenito, Chile; Yu Fang,
China; Yonghong Xiao, China; Maria Virginia Villegas, Colombia; Vera Vlahović-Palčevski,
Croatia; Sven Pal, Croatia; Niki Paphitou, Cyprus; Ute Wolff Sönksen, Denmark; Martin
Kadai, Estonia; Jari Jalava, Finland; Jean-Michel Azanowsky, France; Florian Salm,
Germany; Janine Zweigner, Germany; Edith Andrews, Ghana; Sotirios Tsiodras, Greece;
Thorolfur Gudnason, Iceland; N. K Ganguly, India; Naveen Chharang, India; Vida Parady,
Indonesia; K. Kuntaman, Indonesia; Maurice Kelly, Ireland; Marcelo Low, Israel; Giulio
Formoso, Italy; Carlo Gagliotti, Italy; Yumi Kawata, Japan; Yoshiaki Gu, Japan; Yvon de
Jong, Kenya; Evelyn Wesangula, Kenya; Lul Raka, Kosovo; Anete Jansone, Latvia; Ziad
Daoud, Lebanon; Natalja Samp, Lithuania; Silke Gansen, Luxembourg; Peter Zarb, Malta;
Anahí Dreser, Mexico; Mussaret Bano Zaidi, Mexico; Arjen Elsemulder, Netherlands; Janet
Mackay, New Zealand; Hanne-Merete Eriksen, Norway; Waleria Hryniewicz, Poland; JoséArtur Paiva, Portugal; Bosevska Golubinka, Macedonia; Claudia Dima, Romania; Roman
Kozlov, Russian Federation; Frederic Muhoza, Rwanda; Gorana Dragovac, Serbia; Eva
Schreterova, Slovakia; Milan Cizman, Slovenia; Marc Mendelson, South Africa; Ester
Dejuan, Spain; Beatriz Perez Gorricho, Spain; Olov Aspevall, Sweden; Homa Attar Cohen,
Switzerland; Siana Gideon Mapunjo, Tanzania; Niyada Kiatying-Angsulee, Thailand; Suzana
Soares Hendriques, Timor Leste; Diane Ashiru-Oredope, United Kingdom; Laura Piddock,
United Kingdom; Becky Roberts, USA; Ann Thomas, USA; Arjun Srinivasan, USA. And for
their help in producing graphics and editorial revision, to Frederic Pont and Derek Christie
(Communication in Science).
17
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20
Appendix I
APPENDIX I - Methodology
We developed a survey (APPENDIX III) about the characteristics of antibiotic awareness
campaigns, with a special focus on key messages. For the purpose of this survey, the term
"antibiotic awareness campaign" was defined as “a comprehensive effort to disseminate
information about responsible use of antibiotics and the risks of antibiotic misuse to the lay
public”. For this purpose, it was assumed that an antibiotic awareness campaign typically
uses posters, pamphlets, billboards, radio and television advertisements, social media, etc.
Healthcare professionals may also be targeted as part of these interventions, but activities
focusing mainly on healthcare professionals were beyond the scope of this survey.
In mid-October 2016, invitations to participate in the survey were sent by e-mail to WHO
Regional offices and National Focal Points3, and to persons in charge of antibiotic
awareness campaigns (identified through a preliminary review of the scientific literature and
known contacts of the survey team). This way, more than a hundred people in 93 countries
were invited to answer the survey. Reminders to participate were also sent on 25 October
and 4 November.
A total of 105 persons from 56 countries answered the online questionnaire between
October 12 and December 2, 2016. Two follow-up emails were sent to respondents who
initially provided incomplete answers (n: 44); eventually, 30 incomplete answers had to be
removed from the data analysis. When several answers were received for the same
campaign, only the answers provided by the official coordinators of the campaigns (which
seemed to be the most reliable and comprehensive) were taken into account (number: 6).
Conflicts in answers emerged in 8 countries (Brazil, Chile, Colombia, Germany, Israel,
Lebanon, Norway and Slovakia), from which we received answers referring to the fact that
no campaign took place in the country, and answers stating the opposite. In those cases, we
kept the answers from the respondent mentioning an awareness campaign in the country
(except for Lebanon, for lack of comprehensive answers). This consolidation led to a total of
60 campaigns in 47 countries that were taken into account for the analysis.
Results were summarised according to WHO Regions and the high, medium and lowincome country classification of the World Bank (July 2016 list of gross national income per
capita).
3
In Albania, Armenia, Austria, Azerbaijan, Bosnia Herzegovina, Belarus, Brazil, Bulgaria, Chile, Colombia,
Cyprus, Denmark, Estonia, Finland, Germany, Greece, Italy, Kuwait, Kyrgyzstan, Montenegro, Nigeria, Romania,
Slovakia, Tajikistan, Tanzania, Thailand, Timor-Leste and Vietnam.
I
Appendix I
Limitations
Answers received by each country cannot be assumed to be comprehensive. In some
cases, when respondents stated that there was no antibiotic awareness campaign in their
country, there may have been one that they did not know about. As most campaigns were
described by a single respondent, who was not always the person in charge of the
campaign, some answers may contain errors or be incomplete. Other limitations include the
following:
- Because of the limited number of countries taking part in the survey in some WHO
Regions, the findings cannot be considered representative of each Region, nor of the global
situation.
- Online research methodologies may lead to less considered responses than face-to-face
methodologies.
- In all surveys, and especially those with questions that respondents may feel have a
‘correct’ response, a bias may come from respondents giving the answer they feel is
‘expected’ (social desirability bias).
II
Appendix II
APPENDIX II - Summary table
Country
Campaign name
Armenia
AMR Awareness raising
campaign
Reducing Antibiotic
Resistance
National antibiotic
awareness campaign
Australia
Belgium
Brazil
Rational use of
antimicrobials
Canada
Do Bugs Need Drugs?
Chile
Rational use of
antimicrobials
National drug safety:
use antibiotics carefully
Special campaign for
antibiotic rational use
Bacterial resistance and
Nosocomial Infections
network led by CIDEIM
Public awareness
campaign on prudent
antibiotic use
Cold or flu - say no to
antibiotics
China
China
Colombia
Croatia
Croatia
Campaign URL
Contains One
Health
components
Targeted
school age
children and
adolescents
Targeted
urinary tract
infections
www.nps.org.au/antibiotics
X
X
www.gebruikantibioticacorrec
t.be (version in Dutch,
French, German and English)
http://www.anvisa.gov.br/serv
icosaude/controle/rede_rm/cu
rsos/atm_racional/modulo1/pr
e_uso.htm
www.dobugsneeddrugs.org
and
www.francais.dobugsneeddru
gs.org
X
Targeted
sexually
transmitted
diseases
Involved
psychologists
in the
design/condu
ct of the
campaign
Involved
advertisement
companies in
the
design/condu
ct of the
campaign
Impact of the
campaign
formally
evaluated
Respondent
recommends
a similar type
of awareness
campaign
X
X
Yes
X
X
Yes
X
X
Yes
X
X
Yes
X
X
Yes
X
Yes
X
X
X
X
X
X
https://www.facebook.com/re
ciNEantibioticima/
X
X
X
X
I
Appendix II
Country
Campaign name
Campaign URL
Cyprus
Antibiotic Awareness
Campaign
http://www.moh.gov.cy/moh/
moh.nsf/All/6B4121829D850
2A5C2257C210026E74C
Denmark
"piss annoying!"
National antibiotic
campaign on urinary
tract infections in
younger and elderly
women
European Antibiotic
Awareness Day
European Antibiotic
Awareness Day
Estonia
Finland
France
Antibiotics, if you use
them wrong, they will
become less strong
For the veterinary side:
"Immunization, health
investment for your
flock" / "Nourished
housed, vaccinated"
"Antibiotics for us either
are not automatic"
Germany
Rational antibiotic use
through Information and
communication
Antibiotic-TherapyOptimisationsstudy
Ghana Anti-Microbial
Resistance Platform
Germany
Ghana
Contains One
Health
components
Targeted
school age
children and
adolescents
Targeted
urinary tract
infections
Targeted
sexually
transmitted
diseases
X
Involved
psychologists
in the
design/condu
ct of the
campaign
Involved
advertisement
companies in
the
design/condu
ct of the
campaign
Impact of the
campaign
formally
evaluated
Respondent
recommends
a similar type
of awareness
campaign
X
Yes
X
X
Not sure
X
X
Yes
X
X
Yes
X
X
https://www.thl.fi/fi/web/infekti
otaudit/ajankohtaista/teemap
aivat/euroopanantibioottipaiva
http://www.ameli.fr/assures/pr
evention-sante/lesantibiotiques.php
http://agriculture.gouv.fr/camp
agne-vaccinacteurs-vaccinerles-animaux-pour-reduirelutilisation-des-antibiotiques
http://agriculture.gouv.fr/lesantibiotiques-pour-les-chienset-les-chats-cest-pasautomatique
www.rai-projekt.de
http://ghndp.org/antimicrobialr
esistance/ :
Ghndp.org/reactcso
X
X
X
X
X
X
II
Appendix II
Country
Campaign name
Campaign URL
Greece
Educational campaign
on the appropriate use
of Antbiotics and
Vaccines organized in
common by the Greek
Intermunicipal network
for healthy cities, the
Infectious diseases
society of Greece, the
Greek Society of
Chemptherapy and the
Athens Medical
Association under the
auspices of the Central
Union of Municipalities
of Greece
European Antibiotic
Awareness Day
http://www.kedke.gr/?p=1547
8
Iceland
India
ReAct
India
Antimicrobial resistance
stop
Smart Use of Antibiotics
Antimicrobial
Resistance Control
Program
under the weather
Reducing Antibiotic use
in the Community
Antibiotics: solution or
problem?
Indonesia
Indonesia
ireland
Israel
Italy
Contains One
Health
components
Targeted
school age
children and
adolescents
Targeted
urinary tract
infections
Targeted
sexually
transmitted
diseases
X
X
http://www.landlaeknir.is/umembaettid/frettir/frett/item281
05/Evropudagurvitundarvakningar-um-syklalyf
http://www.bmj.com/content/3
52/bmj.i1202
Involved
advertisement
companies in
the
design/condu
ct of the
campaign
Impact of the
campaign
formally
evaluated
Respondent
recommends
a similar type
of awareness
campaign
X
X
Yes
Not sure
X
X
Yes
Yes
X
Yes
X
http://bijak-antibiotik.com/
X
X
www.undertheweather.ie
Involved
psychologists
in the
design/condu
ct of the
campaign
X
X
X
X
X
http://assr.regione.emiliaromagna.it/it/aree_attivita/val
utazione-del-farmaco/ricerca-
X
III
Appendix II
Country
Campaign name
Campaign URL
Contains One
Health
components
Targeted
school age
children and
adolescents
Targeted
urinary tract
infections
Targeted
sexually
transmitted
diseases
Involved
psychologists
in the
design/condu
ct of the
campaign
Involved
advertisement
companies in
the
design/condu
ct of the
campaign
Impact of the
campaign
formally
evaluated
Respondent
recommends
a similar type
of awareness
campaign
X
X
Yes
X
X
Not sure
X
Yes
innovazione/uso-di-antibiotici
Italy
Japan
Japan
Kenya
Kenya
KOSOVO
Latvia
Lithuania
Antibiotics. It's a sin to
use them bad.
We set up Awareness
Month in November, not
only the WHO
Awareness Week.
Understand your risk,
take proper antibiotics
AMR Awareness Week
Handle antibiotics with
Care
Let's keep antibiotics
working!
No specific name
European Antibiotic
Awareness Day
Luxembour
g
Antibiotics are not
candy.
Malta
European Antibiotic
Awareness Day
Day for the appropriate
use of antibiotics, Week
for the appropriate use
of antibiotics
Mexico
http://salute.regione.emiliaromagna.it/antibiotici
http://www.cas.go.jp/jp/houdo
u/161004amr.html
http://sam.lrv.lt/lt/veiklossritys/visuomenes-sveikatosprieziura/uzkreciamuju-liguvaldymas/antimikrobinisatsparumas
http://www.sante.public.lu/fr/c
ampagnes/2013/campagneantibiotiques/index.html
http://www.nac.gov.mt
X
X
X
X
X
X
X
X
https://www.insp.mx/lineasdeinvestigacion/medicamentosen-saludpublica/eventos.html
X
IV
Appendix II
Country
Campaign name
Mexico
Regulation and
Promotion of
Appropriate Antibiotic
Use in Mexico. A
Proposal of Guidelines
for Action
Be careful with
antibiotics
Antibiotic awareness
campaign
European Antibiotic
Awareness Day/World
Antibiotic Awareness
Week
Awareness Campaign
for the Rational Use of
Antibiotics
Antibiotics are not food
European Antibiotic
Awareness Day
(because the campaign
is occasioned by
EAAD)
Antibiotic is a strong
weapon if the target is
bacterial infection
Netherland
s
Norway
Poland
Portugal
Macedonia
Romania
Russia
Serbia
Campaign URL
Contains One
Health
components
Targeted
school age
children and
adolescents
Targeted
urinary tract
infections
Targeted
sexually
transmitted
diseases
www.daarwordtiedereenbeter
van.nl
www.antybiotyki.edu.pl
X
http://insp.gov.ro/sites/cnepss
/antibioticorezistenta/ and
http://www.ms.gov.ro/?pag=1
99
Involved
psychologists
in the
design/condu
ct of the
campaign
Involved
advertisement
companies in
the
design/condu
ct of the
campaign
Impact of the
campaign
formally
evaluated
Respondent
recommends
a similar type
of awareness
campaign
X
X
X
Yes
X
Yes
X
X
X
X
X
X
www.antibiotic-save.ru
"Prudent use of
antibiotics in primary
care settings:
awearness, knowledge
and attitude"
V
Appendix II
Country
Campaign name
Slovakia
Life without antibiotics.National campaign.
Antibiotics. Use them
wisely! - tagline of
campaign EAAD 2016
Flyer Get well without
antibiotics Flyer
Interactions of drugs
What do parents know
about antibiotics
Prudent Use of
Antibiotics Antibiotics
Day in Europe
Slovenia
Spain
Spain
Sweden
Protect the antibiotics
Thailand
Thai Antibiotic
Awareness Week 2016
(FB Antibiotic
Awareness Thailand)
Stop Antibiotic
Resistances Now
Antibiotic Guardian
Timor Leste
United
Kingdom
United
Kingdom
USA
Antibiotic Action
Get Smart: Know When
Antibiotics Work
Campaign URL
Contains One
Health
components
Targeted
school age
children and
adolescents
Targeted
urinary tract
infections
Targeted
sexually
transmitted
diseases
X
X
Involved
psychologists
in the
design/condu
ct of the
campaign
Involved
advertisement
companies in
the
design/condu
ct of the
campaign
Impact of the
campaign
formally
evaluated
Respondent
recommends
a similar type
of awareness
campaign
X
Not sure
X
Yes
X
Yes
X
Yes
www.zivotbezantibiotik.sk
Furst J,Cizman M et al.Expert
Rev Anti Infect Ther 2015
http://www.msssi.gob.es/cam
pannas/campanas13/antibioti
cos.htm and
http://www.msssi.gob.es/cam
pannas/campanas06/Antibioti
cos.htm
https://www.folkhalsomyndigh
eten.se/skyddaantibiotikan/
http://atbaware.thaidrugwatch.org/
www.antibioticguardian.com
http://antibiotic-action.com/
www.cdc.gov/getsmart
X
X
X
X
X
X
X
X
X
X
VI
Appendix II
Country
Campaign name
Campaign URL
USA
Alliance Working for
Antibiotic Resistance
Education (AWARE)
USA
Get Smart for
Healthcare
https://public.health.oregon.g
ov/DiseasesConditions/Com
municableDisease/AntibioticR
esistance/Pages/index.aspx
http://www.cdc.gov/getsmart/
healthcare/
Contains One
Health
components
Targeted
school age
children and
adolescents
Targeted
urinary tract
infections
Targeted
sexually
transmitted
diseases
Involved
psychologists
in the
design/condu
ct of the
campaign
Involved
advertisement
companies in
the
design/condu
ct of the
campaign
Impact of the
campaign
formally
evaluated
Respondent
recommends
a similar type
of awareness
campaign
X
X
Summary table of campaigns: by country, name of campaign, URL and characteristics of interest (One Health approach, targeting school-age children, having used
psychologists or advertising companies for their design and conduct, targeting under-represented infections, recommended for replication by respondents).
VII
Appendix III
APPENDIX III - Questionnaire used for the survey
See pdf file attached.
Temporary link:
https://drive.google.com/file/d/0B_Mj9qCOE5veS1I5V2lJMlhwQ1E/view?usp=sharing
CAVEAT: A branching logic was applied to this questionnaire on the Survey Monkey
platform, meaning that respondents did not have to reply to all questions.
I
Appendix IV
APPENDIX IV - Answers from countries which
have not implemented campaigns
Respondents from Austria, Lebanon, New Zealand, Rwanda, South Africa and Switzerland
stated that, to their knowledge, no large-scale public antibiotic awareness campaign had
been deployed in their country since 2010. Respondents from Albania and Tanzania were
“not sure” about it.
These respondents were directed to a special set of questions and were asked to rate the
importance of issues related to antibiotic use in their country. The median and range of their
ratings from 1 (not at all important) to 5 (very important) were:
- Limited access to antibiotics: 2 [1-5]
- Inappropriate prescribing of antibiotics by physicians: 4 [2-5]
- Antibiotic resistance: 4 [2-5]
- Self-medication with antibiotics: 3 [1-5]
Only 4 respondents stated that the problem of widespread antibiotic use or antibiotic
resistance was addressed by policy actions in their country, citing the following:
- In one instance each: “Provide education and training sessions for healthcare
professionals”, “Restrict use of antimicrobials in animal husbandry and agriculture”
and “Mandate antimicrobial stewardship programs in hospitals”.
- In two instances: “Restrict sale of antibiotics without a prescription”.
- In three instances: “Establish surveillance of antibiotic use and resistance”
Only one respondent judged that the implemented policies failed, mainly for lack of political
support, scarce recognition of the problem or competing priorities.
Except for Austria, all the respondents from the above-mentioned countries confirmed that
they were considering launching an antibiotic awareness campaign for the public.
I