Report- ReAct-DMDC-SPC Southeast Asia Regional Conference, 3-4 May 2011

CONFERENCE REPORT

ReAct-DMDC-SPR Southeast Asia Regional Conference:
Dealing with Antimicrobial Resistance
and Strategic Plan for Drug System Monitoring & Development

2-4 May 2011
Twin Towers Hotel, Bangkok, Thailand

Summary

1.    The ReAct-DMDC-SPR Southeast Asia Regional Conference: Dealing with Antimicrobial Resistance and Strategic Plan for Drug System Monitoring & Development, was held from 3 to 4 May 2011 at the Twin Towers Hotel, Bangkok, Thailand. The conference was jointly organized and sponsored by ReAct and the Drug System Monitoring and Development Program, Social Pharmacy Research Unit, Chulalongkorn University, Bangkok, Thailand (see APPENDIX I for Programme).

2.    The goal of the conference was to sustain the dialogue, among key stakeholders, towards a regional agenda for action, including especially national and regional policy platforms on ABR. The objectives were to share and learn from country activities, projects and programs, with a focus on successful initiatives that can be further developed into cross-country or regional programmes.

3.    Some 200 Thai and 25 participants from the region (Indonesia, Malaysia, Philippines, Thailand, and Vietnam) attended the conference (see Appendix II for Participants List).

4.    The conference kicked off as a common plenary meeting of all participants in the morning of Day 1. The rest of the conference was organized into two parallel meetings, one of the Thai participants and the second of the regional participants. Both meetings focused on similar themes of sharing experience, knowledge and initiatives undertaken, with the aim of developing an action plan for the year.

5.    The conference was preceded by two related ReAct-sponsored study visits. The first was that of participants from four hospitals in Thailand, engaged in setting up Antimicrobial Stewardship Program (ASP) activities in the country, visiting three public hospitals in Singapore, which have established the ASP (27-28 April 2011). The second was a study visit of nine participants from Indonesia, Malaysia and Philippines (including Mary Murray from ReAct and an IPS journalist covering the story) to the Antibiotic Smart Use Project site at Lungkoa Primary Health Center, Muaklek District, Saraburi Province, Thailand on 2 May 2011.

6.    After two days of presentations and deliberations, participants of the regional meeting put together a ReAct-SEA Regional Plan of Action, which called for the development of projects in the following areas:

•    A regional community-level Antibiotic Smart Use Pogramme
•    A regional hospital-based Antimicrobial Stewardship Programme
•    A model generic curriculum related to AMR for healthcare professionals
•    Research in the region on: 1) Differences in health outcomes and costs of hospital and community acquired bacterial infections in relation to ABR; 2) Community dispensing of AB; 3) Country ABR Index; 4) AB use in farm food production
•    A network of cities around the world/region to champion and collaborate on the smart use of antibiotics

7.    Participants agreed to work with ReAct and its partner institutions in the region to further discuss and develop these action-plan ideas towards project development, fund raising and implementation.

8.    Participants also agreed that another positive outcome of the meeting was an expanded and strengthened network, which should continue with information-communication sharing, collaboration in regional programmes and projects and other forms of support to local initiatives.

Conference Report

Introduction

9.    ReAct and DMDC-SPR representatives (Dr. Niyada Kiatying-Angsulee, Dr. Mary Murray and Dr. Michael Chai) introduced the themes and objectives of the conference. Both the Thai and regional meetings focused on similar themes of sharing experience, knowledge and initiatives undertaken over the years, with the objective of developing an action plan for the year.

10.    Dr. Niyada explained that the meeting of the Thai stakeholders was an important part of an advocacy campaign to include ABR as an agenda item in the Thai National Health Assembly. The Thai stakeholders’ meeting was organized around the following themes:
•    Addressing the issue of irrational drug use at the community level.
•    Addressing the problems of advertising and promotion of health products.
•    Promoting the rational use of drugs through art media.
•    Rational use of drugs campaign and safety in using drugs in hospitals: sharing.

11.    Dr. Michael explained that ReAct and its partners in Southeast Asia have been engaged in a series of initiatives to build partnerships, raise awareness and strengthen collaboration among stakeholders to address the growing challenge of antibiotic resistance in the region. A first regional meeting was held in March 2008, with partners in Malaysia and Thailand, to identify the issues and initiatives for collaboration. This was followed by a second meeting in March 2010, with representatives from five countries in the SEA region coming together to share knowledge on the country situation, initiatives undertaken and ways ahead with regard to a “Cooperative Campaign for Antibiotic Resistance Control”. This, the third regional meeting, was focused on local initiatives, projects and programmes, which have contributed to the understanding and addressing of AB use and ABR, and which can serve as good practices to be replicated elsewhere in the region.

12.    Dr. Mary Murray presented an overview of the global ABR problem and the role of ReAct, as a global organization, in addressing ABR challenges. ReAct’s role is that of a catalyst, facilitating access to expertise and tools that strengthens local voices and work on ABR. The work covers a variety of areas from awareness raising and mobilisation to multidisciplinary policy processes. Importantly, ReAct serves to link stakeholders, ideas, projects, sharing of experience and cross-learning between communities, countries, regions and globally.

Panel on ABR-RUD initiatives

13.    The first panel, moderated by Dr. Nithima Sumpradit, consisted of Dr. Purnamawati S. Pujiarto, Dr. Jaya Balan and Prof. Dr. Isidro Sia, part of the group which had participated in the study visit to the ASU project site in Saraburi Province, Thailand. Nithima, who is a Senior Pharmacist with the Food and Drug Administration and Assistant Director of the International Health Policy Program, Ministry of Public Health, Thailand, presented an overview of the ASU program in Thailand. The program, began in 2007, is currently in its third phase and covers 50 provinces across the country and involving community hospitals, primary health centers, village organizations, provincial/district health authorities, as well as MoPH agencies such as the FDA, IHPP, HSRI, the National Health Security Office, Thai Health Promotion Foundation, and faculties of medicine and pharmacy at local universities. The objective of the ASU program is to reduce the unnecessary use of antibiotics through learning, understanding and behaviour change. Additionally, in working and building a country-wide collaborative network of all stakeholders, the long term goal of the ASU program is to make the smart use of antibiotics an institutionalized social norm.

14.    Dr. Purnamawati is Project Director on Empowering Community through promoting RUM and patient safety and Health Education Program for Parents, presented her community work on RUM and prudent use of AB.  They have documented the common practice in Indonesia to prescribe multiple drugs (often 6- 10) combinations of antibiotics, anti-inflammatories, appetite stimulants etc for children – and all are ground into a powder.  It is risky and costs families a lot of rupiah as well. Through the use of online media, radio talk shows, community publications, workshops and her clinical practice, her organization has, since 2003, focused on patient empowerment by sharing, learning and practicing RUM and prudent use of AB. Dr. Wati also focuses her campaign on physicians and patients of private practice as this is a neglected sector in terms of RUM and ASU. The organisation finances the education face to face work through providing services to companies in model clinics and education. This way they slowly spread to other places and build relationships and understanding of the issue and increase the interactive web-based work. Their approach promotes better knowledge of common illnesses and how to diagnose them, rational use of medicine through guidelines and information, therapy as more than a medicine – but also information, non-drug therapy and advice and second opinion and detailed drug information.

15.    On the ASU, Dr. Wati commented that the program in Thailand has been developed and implemented in the public health system and now spreading in the community through links with the health centre activities and personnel. Her program works much more in the private health system which is stronger in Indonesia than the public health system. There would be good cross-fertilisation between the two as ASU works towards the players in the private health system.

16.    Other panelists also shared their experiences of the ASU study visit to Muak Lek Primary Health Centre and Don Pud Community Hospital, Saraburi Province. The success of the ASU interventions at the community level, it was observed, was the result of several strategic approaches (Dr. Jayabalan). These included sensitivity to local context, personalized messages, real interactive collaboration with local stakeholders, use of local champions and use of tried and tested traditional treatments. The program is now in phase three and has become a dynamic peoples project – decentralized and networked. The reflections of the Buddhist monk – his ideas and efforts to interact with the people on the issue, softly understanding why people do what they do was very impressive – and also that this is part of the process of ASU. He is a convert and converting his colleagues also. The community brochures and process were also impressive.

17.    The ASU study visit was interesting and helpful in thinking about strengthening the community level work on antibiotics and resistance in the Philippines. Champions are very important such as the Director of Donpud Hospital. But culutral issues strongly affect the use of medicines (Sid Sia). People expect a prescription at the end of the doctor’s consultation and expect to have antibiotics if they have inflammation. Similar to the ASU programme, there is a program in the Philippines for flu-like symptoms, diarrhea, cough and simple wound. They started small and targeted the sources of the drugs. But every home has antibiotics and paracetamol. They developed a household formulary. People need a symbol that they are being treated. They use village stores to buy drugs. They have documented the cultural beliefs behind the people’s actions and behind the store owners. Paracetamol is seen as the wife and antibiotics as the husband – therefore taken together. It has been possible to improve the knowledge and actions of pharmacists and storekeepers but not prescribers. Therefore, it is important to provide consistent information for all stakeholders and they have been developing and doing that through the Drug Information Centre in the Philippines. The Medical Curriculum also needs to be improved. The National Drug policy is an important frameworks and the Guide to Good Prescribing of WHO is useful. At UP they provide electives on community pharmacology. Here they teach students to work in the community, identify a problem, research it and come up with a solution. IDSP has also developed clinical practice guidelines.

Panel on Antimicrobial Stewardship Program

18.    The panel of speakers (Dr. Roungtiva Muenpa, Dr. Sripetcharat Mekviwattanawong, Dr.Niyada Kiatying-Angsulee, Dr.Patcharasarn Linasmita) presented their learnings from the study visit to the ASP in three hospitals in Singapore (Singapore General Hospital, Tan Tock Seng Hospital and National University Hospital), as well as their own ASP activities in Thai hospitals (Ramathibodi Hospital and Chiang Mai Hospital).

19.    Since June 2006, ID Pharmacists have been actively running the Antibiotic Stewardship Program at Singapore General Hospital, auditing the use of vancomycin and carbapenems throughout the hospital. Following decreased consumption of these antibiotics and more appropriate prescribing behaviour, the program expanded in 2008 to include eight more broad-spectrum antibiotics. Clinical microbiologists, infection control officers and ID physicians joined the ASP to provide a more holistic service. Tan Tock Seng Hospital launched their ASP in 2009, which includes guidelines on AB use for patients and a computer system that provides advice on antibiotic prescriptions. This has resulted in a 13 per cent fall in the use of five powerful antibiotics, without any compromise to patient safety. Together with a hand-hygiene programme introduced in 2009, it led to the incidence of drug-resistant bacteria dropping by 36 per cent between January 2009 and December 2010. Another benefit is in terms of savings. The increase in antibiotic costs from 2008 to 2009 was $1.3 million; from 2009 to 2010, it was $400,000. ASPs, the participants concurred, have the potential to reduce antimicrobial resistance, health care costs, and drug-related adverse events while improving clinical outcomes. The efforts and expense required to implement and maintain ASPs are more than justified given their potential benefits to both the hospital and the patient.

20.    Panelists agreed that implementation of an ASP requires a multidisciplinary approach with an infectious diseases physician and a clinical pharmacist with infectious diseases training as its core team members. Proactive strategies for promoting antimicrobial stewardship include: (1) formulary restriction and pre-authorization, and (2) prospective audit with intervention and feedback. Other supplemental strategies involve education, guidelines and clinical pathways, antimicrobial order forms, de-escalation of therapy, intravenous-to-oral switch therapy, and dose optimization. But there are several barriers to successful implementation of ASPs. These include obtaining adequate administrative support and compensation for team members. Gaining physician acceptance can also be challenging if there is a perceived loss of autonomy in clinical decision making.

Competition awards on ABR Campaign in Thailand and Press Conference

21.    Dr Siriwat Tiptaradol (Deputy Permanent Secretary, Ministry of Health, Thailand), Dr. Maureen Birmingham (WHO Representative to Thailand), Dr. Sirikiat Liangkobkit (Thai Health Promotion Foundation), Dr. Mary Murray (ReAct) and Dr. Niyada Kiatying-Angsulee (Drug System Monitoring and Development Program, Chulalongkorn University) held a press conference and fielded questions from the media. Several newspapers, local television stations, online news agencies were represented in the press conference.

22.    The speakers emphasized that the growing antimicrobial resistance from indiscriminate use of existing antibiotics and a lack of new ones in development could mean a return to the pre-antibiotic era of medicine with disastrous consequences. Currently, antibiotic resistance mechanisms have been reported for virtually all known antibacterial drugs available for clinical use.

23.    The crisis is so alarming that the World Health Organization has made antibiotic resistance the central focus of this year’s World Health Day, the goal of which is to highlight a global public health issue of critical concern. Necessary and collective action to combating drug resistance is necessary, said Dr. Maureen Birmingham. She added that more than half of all medicines are prescribed, dispensed or sold inappropriately and half of patients fail to take them correctly. According to WHO reviews, between 1990 and 2009, worldwide there is less than 50 per cent of compliance to clinical guidelines in all regions and only 15 per cent compliance in the Southeast Asia region.

24.    Dr. Mary Murray echoed the concerns of the other speakers and emphasized the need for concerted and collaborative efforts. Thailand sets a good example with its strong primary healthcare foundation and a network of committed policy makers and health professionals, pioneering in many ways to tackle antibiotic resistance. The Antibiotic Smart Use (ASU) project of the Thai Ministry of Public Health together with other innovations in Thailand are of special interest as they offer models of action that can be replicated throughout the region and indeed the entire world. Use of new communication methods and creative techniques of public outreach are special features of the Thai campaign on antibiotic resistance and hold lessons for the entire region. At a global level networks such as ReAct has acted as a catalyst to develop international and national policies, mobilise doctors, pharmacists, health workers and patients to tackle antibiotic resistance. From the WHO to national governments in Latin America, Asia, Africa and from patient safety groups to health communicators ReAct has interacted with a wide variety of institutions to generate specific action on antibiotic resistance issues. In South East Asia too ReAct’s focus has been to develop a regional platform of institutions and individuals concerned about antibiotic resistance and promote cross-border sharing of expertise and experiences. ReAct believes, that in the short term, it is crucial to undertake global surveillance of resistance and antibiotic use, radically improve the appropriate use of antibiotics and infection control and overcome the blocks to developing new antibiotics. But, in the long run the issue of antibiotic resistance can be tackled only by ensuring overall ecological health of the globe together with new understanding of interaction between microbes, human being and medicine.

25.    The press conference also witnessed the awards ceremony for the winners of the Antibiotic Smart Media Competition. Organised by the Drug System Monitoring and Development Program and Thai Health Promotion Foundation, the competition was opened to primary, secondary and tertiary schools as part of the campaign to promote the smart use of antibiotics. Contestants had submitted posters, writings and videos on the message of “Antibiotic Smart Media: Do not use antibiotics without necessity”. The student contestants were also invited to a “Meet and Greet” event with Thai health experts, with a view to encourage the rational use of antibiotics, exchange experiences as well as to develop thinking skills by sharing through media.

Panel on Antimicrobial Resistance Control Program (ARCP), Indonesia

26.    This panel was moderated by Dr. Erie Gusnellyanti and consisted of Dr. Hari Parathon, Dr. Hidayati Mas’ud and Dr. Zorni Fadia. The main presentation was made by Dr. Hari Parathon who is Chair of the ARCP, Indonesia.

27.    Dr. Parathon presented the findings of the AMRIN Study – Antimicrobial Resistance in Indonesia: Prevalence and Prevention, which was carried out between 2000 and 2005.  One of the aims of the AMRIN study was to develop an efficient, standardized programme for the assessment of antimicrobial resistance, the quantity and quality of antibiotic usage, and infection control measures in Indonesian hospitals. The AMRIN study showed that antimicrobial resistance has become a public health threat in Indonesia. It reviewed the use of AB in two hospitals using three reviewers. There was a high incidence of use for non-indicated conditions. The hospital is the source of resistant infection in E.coli which is resistant to gentamicin and cefataxime.  The documentation was done by assessing resistance upon discharge of patients compared to on admission.

28.    One outcome of the AMRIN Study was the development of a self-assessment tool, which was published under the auspices of the Directorate General of Medical Care of the Ministry of Health, Indonesia and has become a national programme to control AMR in Indonesia.

29.    20 teaching hospitals implemented the program on AMR as a pilot project. The implementation involved: setting up an ARCP team of nine clinical pharmacists, clinical microbiologist, infection control and physician. Application of the AMRIN self-assessment programme in more hospitals offers new possibilities to stimulate the fight against antimicrobial resistance by improvement of quality of care in health care institutions. The AMRIN self-assessment program can be developed into a benchmark system for Indonesian hospitals regarding antimicrobial resistance, antibiotic use, and infection control. Amounts of antibiotics used, levels of antimicrobial resistance, and prevalence rates of health care-associated infection as measured by the AMRIN self-assessment program, can be used as performance indicators to compare hospitals or wards within hospitals. For this purpose these indicators should be validated and corrected for variables that significantly influence the indicators but cannot be influenced by the health care workers. Future research is needed to support this development.

Panel on Research and Studies

30.    Dr.Kumthorn Malathum moderated the panel consisting of Dr. Mohamed Azmi Ahmad Hassali, Ms. Do Thi Thuy Nga, Dr. Yoel Lubell and Dr. Heiman Wertheim.

31.    Dr. Yoel Lubbel discussed the importance for inclusion of AMR costs in economic evaluations (EE) of infectious disease diagnostics and treatments. Given the rising and alarming rates of resistance, adequate diagnostic and treatment interventions are increasingly necessary to mitigate the potential negative consequences of antibiotics use, or the ‘harm of treatment’. Including the costs of resistance, in terms of health outcomes, as well as the costs of necessary diagnostic and treatment interventions will also be useful and influential to affect policy. It is important, therefore, that EE be done in a comprehensive way to include critical factors such as AMR.

32.    One misconception in EE is that its aim is to cut costs and do things in the cheapest possible way. The main objective, however, is to compare the cost and consequences of of healthcare interventions to determine whether the incremental benefits of one intervention are worth any additional costs. This involves drawing in epidemiology, intervention effectiveness, costs and other factors into a single analysis. Ideally EEs would include all costs and consequences of interventions to society; in practice focus is on costs to health care providers and immediate health benefits to individual patients.

33.    While some EE studies have been done on the costs of AMR, the focus has been on the incremental costs of AMR on the patient and the health system. There is a need to go further and include the long terms costs of both resistance and interventions. Methods to include AMR in evaluations are, however, lacking. Better data on both AM consumption and AMR is critical but will still require extensive modelling of emergence and spread of resistance. The task ahead therefore is for those working on improving the methodology of EEs work with those engaged in data collection on Am consumtion and AMR levels.

34.    Dr. Azmi Hassali presented the preliminary findings of the USM survey on current curriculum contents vis-à-vis rational use of antibiotics in South East Asian medical and pharmacy schools. Given the increasing incidence of ABR worldwide, there is limited knowledge if the issue is included as part of the training of in medical and pharmacy schools.

35.    The survey sample consisted of faculty members of medical and pharmacy schools involved in teaching antibiotic curricula in 10 countries in SEA (Malaysia, Thailand, Cambodia, Laos, Singapore, Vietnam, Brunei, Indonesia, Philippines and Myanmar). A cross sectional web based survey was employed for data collection. Given the limitations of the study and that only preliminary analysis has been done so far, the results do suggest that, although ABR-related topics are covered to certain extent in the pharmacy and medical school curriculum, several gaps exist, especially in course delivery. In terms of differences among disciplines, pharmacy and medical schools placed different emphasis on ABR in their curriculum. ABR was focused as a compulsory subject in medical schools while pharmacy curriculum emphasized the criteria of selecting antibiotics. The medical curriculum was more directed at teaching students topics related to treatment response and infection control compared to pharmacy schools. Topics related to cost of ABR, resistance mechanisms and patterns were given more consideration in medical schools as compared to pharmacy schools. The findings suggest a need to work towards a comprehensive core curriculum specifically on the issues of ABR for both pharmacy and medical schools in SEA.

36.    Ms. Do Thi Thuy Nga, presented the findings of her study on Antibiotic Dispensing in Rural and Urban Pharmacies in Hanoi, Vietnam. Given the many factors related to ABR, not least the whole chains of supply and demand, the study aimed at comparing business buying and sales practices/behaviours of retailers and customers at drug outlets in rural and urban areas of Hanoi; to gauge the  importance of AB  sales and profitability.

37.    The survey included both qualitative and quantitative methods of information collection. Findings showed that there were many commonalities in both rural and urban behaviour: the private pharmacy is the first place of choice in seeking help for mild ailments; the overuse of ABs; ABs purchased without prescription and often for acute upper respiratory infections; the importance for drug sellers to satisfy clients; customers resorting to other drug outlets if unable to purchase; weak knowledge of sellers and buyers on consequences of  irrational drug use in the community; and absence of regulatory enforcement regarding sales and purchases of ABs.

38.    Survey findings showed that 20 per cent of customers buy AB in urban settings, 10 per cent in rural areas. ABs are, in fact, the most sold medicine in the pharmacy. Some 24 per cent of the transactions in the pharmacy are AB, 10 per cent with prescription. In urban areas, consumers buy imported and expensive AB three times as often as domestically produced AB. Thus, compared to their average income, people pay a high proportion for AB. The main reasons for selling inappropriate AB are that pharmaceutical companies strongly promote them and the pharmacy does not want to lose customers.

39.    The survey findings also show that profits of antibiotic sales are considerable and there are no sanctions for non-compliance with regulations on sales of prescription-only drugs without a prescription. One recommendation is to encourage sales of symptom relieving drugs or vitamins as a strategy to compensate pharmacies and motivate them to comply with government regulations. But, importantly, public awareness campaigns should be part of behaviour changing campaigns regarding the sales and consumption of Abs.

40.    Dr. Heiman Wertheim presented the findings of the study on “Situational Analysis: Antibiotic Use and Resistance in Vietnam”, undertaken by the Centre for Disease Dynamics, Economy and Policy in collaboration with the GARP-Vietnam national Working Group.

41.    Vietnam has high levels of ABR. Clearly a key driver of ABR is the inappropriate use of Abs and the evidence shows that they are over used both in the community and the hospital. Out of pocket health expenses, purchases without prescription and lack of knowledge regarding inappropriate use of Abs are related factors for the community behaviour. In hospitals, added factors for ABR are inadequate infection control and overcrowding; inadequate microbiology services and lack of effective drugs and therapeutic committees. AB sales study must be repeated in hospitals. They make up 45 per cent of the cost in general hospitals and up to 90 per cent in provincial hospitals.

42.    Additionally, there are signs also of excessive use of antibiotics in agriculture resulting in farm foods containing multidrug resistant microbes. Some 50% of drug use in AB is in agriculture. Resistance is high in gram positive and gram negative organisms. In pork and chicken resistance genes are transferred to humans.

43.    There are several policy options and opportunities for controlling ABR. Among them are: national action plans for ABR, enforcement of existing regulation, establishing effective infection control committees in hospitals, track national ABR, monitor AB use in hospitals, teach and train professionals on AB use and ABR, develop treatment guidelines, establish pharmacovigilance centres, conduct public education campaigns, enhance laboratory capabilities and curb AB use in agriculture.

44.    A major challenge remains communicating information on resistance to policymakers and the public in general. One proposal is a “New Tool for Gauging Antibiotic Resistance: The “Resistance Index”. Its similar to indices used to measure cost-of-living, stock market value, airport congestion, sports performance scores, vehicle reliability etc. The Index, weighing resistance by proportion of antibiotic used to treat the pathogen, in a specified country or population, can be extremely useful in cross country comparisons at affect policy.

45.    Developing the Index will, of course, require necessary data, including on resistance of pathogens to all ABs commonly used to treat them and the proportion of ABs used for treatment , ideally at level of the pathogen. The goal of establishing the Index can, moreover, provide the necessary impetus to collect data for many other uses.

46.    An outline of next steps will include:

•    Research on treatment trials of severe resistant infections, rapid diagnostics, multi-targetted interventions and burden of resistance (morbidity, mortality,costs)
•    Surveillance, which will involve improving quality microbiology labs; of AB use in humans and agriculture; and of resistance in humans and animals
•    Policies to enforce existing regulations, while safeguarding access to antibiotics and changing the incentive structure for physicians and pharmacists in prescribing and dispensing.

Panel on further initiatives

47.    Dr. Mary Murray moderated this session with panelists Mr. Satya Sivaraman, Mr. Panya Chayakam, Dr. Asrul Akmal Shafie, Dr. Purnamawati S. Pujiarto, Prof. Dr. Isidro Sia and Dr Madeleine de Rosas-Valera, presenting other initiatives around the region.

48.    Satya spoke of the Chiang Mai – Uppsala Twin ABR City Project, which has been in discussion over the past year. The idea is for two cities around the world, its municipality authorities and stakeholders from different levels of society to share ideas, join efforts, and mobilise city-level activities around ABR as a public health issue. The approach also includes linking this public health concern with related issues such as environmental and urban-social concerns. Importantly, the aim of the twin-city project is to move the discussions on ABR concerns out of the narrow confines of experts and scientists to the larger social milieu where social mobilization and behaviour change matters most. Of course, the long term goal is for as many cities as possible to link up and work towards an ABR-free environment.

49.    Chiangmai and Uppsala were chosen as a pilot effort, given their unique characteristics favourable to a twin city venture. The process is ongoing and many discussions underway, both among stakeholders in CM and between CM and Uppsala interested parties. In CM, discussions are ongoing not only with municipal an health authorities but representatives in civil society, media representatives, artists and others, all of who are key actors especially in getting the message to a wider audience.  The next step is to work towards a formal arrangement between the two cities, something which will involve a lot more discussions and meetings. Part of the understanding will be a list of various activities and events, involving the range of city groups, to be organized as an ongoing process.

50.    The twin city project represents the linking of constituencies in each city; linking the issues around healthy cities, sustainable cities, environment, ecology, art, lifestyle, etc. It is also about linking different ways to mobilize both human and financial resources. Socio-cultural differences need to be considered as well, how different cities work towards solutions.

51.    In the discussions towards the twin city project, interest has been expressed from ReAct partners in Cuenca and Penang to be part of the network of cities. Like CM and Uppsala, they come with their own models of a twin city process. In the case of Penang, the proposal was to have a twinning between smaller locales such as a district or local council. An example would be a twinning of a local district/council in Penang with a counterpart such as Muang Lek/Saraburi District in Thailand.

Artists and new communication approaches for health promotion on ABR

52.    Panya Chayakam is a veteran Thai artist, working on ecological and wildlife themes in the medium of painting and sculpture. He shared his experiences of working as an artist with scientists (a group of Thai pharmacists) in an exercise to express the dynamics of drugs and microbes in art. It was an exercise in imagination and communication. During a period of four days over two weeks Panya and the pharmacists took a journey to the woods both literally and metaphorically. It was a struggle of sorts, not precluding humour and excitement. The results were works of art, but more than that, expressions of self and work as scientists. The work of the artist-pharmacists were exhibited at various places and generated discussions among the public and professional viewers on the issues of microbes and resistance.

53.    Mary Murray shared of a WHD 2011 activity in Equador whence an artist-photographer worked with a group of 25 medical doctors from remote, primary health centres around the country to photograph life situations of the people they provide health services to. The photos they took – in homes, in the clinics, in the places of livelihoods and homes – captured in pictorial form the social determinants of health The exercise was also a competition, with selected photographs being exhibited in a public park in Cuenca as well as in the capital city Quito. The project activity engaged local health authorities, school teachers, community leaders. The physicians took on the activity with enthusiasm capturing in their photos the context of their patients – the social surroundings, natural environment, quality of sanitation and water supply, home spaces, home-grown food, use of traditional medicines, as well as reactions on faces to adverse health situations. The exercise had, as a result captured the interest of local health authorities, community leaders as well as federal health authorities.

54.    The physicians in Ecuador, upon seeing the art work of the Thai pharmacists expressed keen interest in doing something similar for medical doctors, to further explore art and photography as new tools in medicine and pharmacy.

World Health Day 2011 – continuing the campaign

55.    Participants shared activities and events organized around World Health Day 2011, which carried the theme of Antimicrobial resistance: no action today, no cure tomorrow.

56.    Dr. Azmi Hassali spoke of the activities organized with staff and students at University Science Malaysia in Penang. In collaboration between the Department of Social and Administrative Pharmacy and the Wellness Centre of the University, a one week long program was organized around the theme of sustainable health. Talks, exhibitions and discussions were organized on various health themes including the use of Abs and ABR. Staff and students across faculties and departments participated in the activities. Much discussion was generated in the context of empowering consumers in health issues. Added activities included involving pharmacy students in a local community health centre.Azmi also share his recent experience in Pakistan where, for WHD, doctors and pharmacists used the medium of drama to communicate issues related to AB use and ABR.

57.    Dr Madeleine de Rosas-Valera shared her experience in papua New Guinea of community drama to communicate issues related to AB use and ABR.

58.    Prof. Dr. Isidro Sia shared of the WHD activities in the Philippines, which included a multisectoral gathering organized by the Department of Health on the WHO 6-point Agenda. More activities are scheduled in June 2011 to include the participants from the fisheries and animal-food industries.

59.    Dr Wati shared on WHD activities in Indonesia, which were part of an ongoing campaign to raise public awareness on Abs and ABR. Medical professionals and lay persons formed the team of resource persons to engage in discussions with the community on ABR. The team also organized a seminar for journalists to discuss the issues of resistance. Additionally, an online seminar was organized on “Smart patients”, a virtual meeting of mailing list network members from various cities who came together to share their views on health issues, including use of Abs and ABR. Another gathering organized was a family day of activities around health issues, with music, singing, drama, art, postcard making and story telling by parents and children.

60.    Dr. Niyada shared on WHD activities in Thailand, which were jointly organized by the Thai network, MoPH, WHO Thailand and WHO-SEARO. Activities included the competition among students on ABR and Smart Media, art exhibition of the pharmacist-artists, production of a Kit on AMR and a press conference

What next? – Discussions on future projects, local and regional

61.    Following upon presentations and discussions on Day One, the participants reflected on what should be some useful approaches, strategies and guidelines in identifying and developing future projects.

62.    Questions were put to the meeting if partners can translate local initiatives such the ASU project or the ASP into a regional program? Similarly are there useful local research projects that can be developed into a research programme across a few centres and then extend to more regional centres to show the regional situation in a powerful way? Can we take the next step on the educational curriculum survey and develop and agenda for change in education? What other ideas for projects and what other effective strategies to incorporate for successful outcomes?

63.    Dr. Wati started off the session with some pointers for a comprehensive approach or context for identifying specific projects, which is can allow for more efficient and cost effective interventions. Importantly, there is a need to acknowledge, award, and support initiatives and projects underway. Attention has to be given to the private sector practice and patients. The HEPP is a campaign, which includes involvement with the private health sector. She also emphasized the need for training the trainer components, focused on the prevention and curative aspects. Is IT based. ASU – modify for priate sector.

64.    The problem is obviously complex. We are seeing only the tip of the iceberg in inpatients and in outpatients with regard to high AB use. The use is also irrational. But is it sufficient to just promote the rational use of AB and to regulate? Is public sector intervention enough?

65.    AMR is part of the Patient Safety agenda for 2011. What is needed, therefore, is engagement with the patients, information for patients and public awareness.

66.    There are four strategies to use: Educational (inform and persuade consumers and HP), Regulatory (restrict choices), Managerial (guide clinical practice) and Economic (incentives).

67.    Education:  For health providers – when something goes wrong – if they know what to do – something gets lost in translation.  They are also disconnected with the community.  Stronger pharmacy education may be priority. For consumers, patient-oriented education is vital. The approach has to be bottom up, engaging the community, multi-faceted and repeated. Programmes should also the young. Additionally, coalition and networking are important. Using different media should include the use of the online resources as well as conventional PSAs, public campaigns with media, t-shirts, stickers, etc. There is also need for research in and with the community, not only the bio-medical but social, behavioural and economic.

68.    Managerial: There is a need to sing the same song to health professionals and consumers by way of managerial procedures. For example, guidelines for clinical practice on the common three or four ailments, which should be promoted among consumers as well; evaluate use through research on compliance; and perhaps develop a policy of indirect audit by the patient. The role of the insurer is important in this regard, whether in systems of universal or partial coverage or private insurance.

69.    Other measures to take are the promotion and monitoring of compliance of EDL among the community and make this child friendly and research on dispensing of AB in drug outlets. Pharmacists may be hesitant to participate so need to develop collaboration with them and acknowledge their involvement and give rewards for achievement and effort. Strengthening capacity to increase efficiency in surveillance of drugs and bugs are is important. Importantly surveillance results should be made public.

70.    Economic: Incentives are necessary, for institutions: health care facilities, medical faculties and professional bodies; for providers, NGOs and patients. For example if one is providing a model clinic within a company, awards can be given to the company adopting a policy on RUAB. Similarly, poor practices can be disclosed, together with access to necessary drug information. Many organizations and individual practitioners in the field, especially NGOs need acknowledgement, support, possibly funding and networking opportunities through international/regional meetings. This psychological support is important for many feel alone in their efforts in preventing and controlling ABR.

71.    Regulatory: Whether the market or the medical practice, control is needed and for this a formulary and restricted drug list is important. Additional measures can include the setting up of a patient safety body and EBM guidelines to insurance bodies. In all this, however, enforcement is needed, allowing for civil society consultation, audit measures and legal protection for those who speak up on wrong or poor practices.

72.    On the ASU programme, participants agreed that, as implemented in Thailand, it is a very good, useful and successful initiative, involving the range of stakeholders, not least the community themselves, healthcare professionals and policy makers. And that it could be contextualized and extended to other localities in the region.

73.    Dr. Wati supported the ASU programme and suggested some guidelines to consider. Health workers or volunteers need training and strong basic knowledge to engage confidently.  There is a need for robust, smart facilitators to conduct training of trainers programmes. With regard to ADR, for instance, doctors say that AB is one of the safest medicines.  In the case of Stephens Johnsons syndrome, for instance, it may be argued that, because it is such a rare occurrence, it is not a result of doctor’s error or poor prescribing. She also proposed for the ASU programme going to the big hospitals and to the private sector. Incorporating an IT strategy can help make the ASU a stronger programme with the benefit of sharing knowledge to a wider audience.

74.    There can be collaboration between ASU and HEPP program. The HEPP is a form of school for lay people, which addresses the preventative and the curative part and RUM. It address the six key problems in irrational use of AB: use in common cold, acute GE, fever; multiple antibiotics in outpatient setting; inappropriate use of IV antibiotics; inappropriate broad-spectrum AB; high rate of use of non-generic AB;  and self-medication.

75.    Dr Jayabalan also proposed the occupational health and safety approach to be included in the ASU programme. He observed the practice in Donpud Hospital during the ASU study visit to Saraburi Province. There should be a written commitment to an ABR policy in the workplace. This means a commitment form management to support a workplace policy with a timeframe, resources and procedures for monitoring and evaluation.

76.    On the ASP, Dr Claire Italiano shared what she saw as two main obstacles to extending ASP programs effectively, viz. resources and attitudes. There is also the possibility to take an ethical approach to the problem, i.e. it is unethical for pharmacists to dispense AB, Therefore, perhaps look to the level of the Pharmaceutical Society and the government to act on the basis of ethics. At the education level, health professionals coming out of educational programmes should have the knowledge and respect for limited resources or money. This should be an incentive in itself to not use AB wrongly. But dispensing medicines is a conflict of interest in a doctor’s practice and it is a challenge in many countries to drive this message home. Having said that, the task of putting in place a ASP in a hospital can be a logistically simple process, involving a half-time pharmacist and a physician committed to the ASP, and of course the hospital administration supporting the scheme.

77.    On the curriculum survey project, a proposed next step is to develop a core curriculum for undergraduate medical/pharmacy students. In this regard, Dr. Asrul proposed that such a curriculum should be aimed at bridging the gap between what is taught and what is practiced. The educationist must consider that there is currently a mismatch between education and practice with regard to the issue of ABR. Specific recommendations include: a core component within the curriculum on ABR, for different health care professions, test the competency in AMR between final year students and present practitioners to show the gap in knowledge on AMR, facilitate curriculum integration and availability of knowledge resources. One idea is to develop an online vault of teaching resources, perhaps on the ReAct website, that will address the present inflexibility of the curriculum and the lack of materials.

78.    On research, given that resistance patterns are time dependent and changing, one proposal is to establish a working committee on methodology or technical guides (sample selection, co-morbidity index, resistance susceptibility index, and existing requirement attributing AMR cost) so that technical methodology can be advanced while data quality can be improved.

79.    There were other strategies proposed, with which to accompany programmes and projects. Ms. Kalyhani shared of her experience in the Green Lung Initiative by pharmacy students in collaboration with the National Poison Centre at USM. Although it was a tobacco use and anti-smoking campaign, the methodology used can be applied to dealing with ABR use. One method was the training of champions or future leaders, through peer education on aspects of leadership and life skills on important matters of concern. The Green Lung project was not limited to the pharmacy students at USM. Students from other faculties and departments were invited to participate and the campaign was then taken to communities and schools, and presented in different languages. The Green Lung project is continuing and adapting with new and creative ways of addressing the issues among peers.

ReAct-SEA Regional Action Plan

80.    The meeting then discussed how to develop a regional agenda that would move forward action on ABR: best practices to learn from; research/evidence that will convince policy makers, useful for advocacy at all levels; educational change; and communication for empowerment.

81.    The participants first outlined some parameters in considering the action ideas.

82.    Isidro suggested that the change we aim for will happen at country and national level. Each country stakeholders are familiar with the local needs and interventions which are culturally sensitive. The regional network can play a supportive role especially in terms of resources, exchange of information on best practices, and coordination of inter-country work where applicable. A concrete next step is having a regional team to put together best practices, such as ASU, ASP, HEPP, etc. in the region and make them available through the internet. Stakeholders in individual countries can then decide on projects best suited to each country and which projects to work on as an inter-country venture.

83.    Heiman pointed to the availability of practical tips and resources on some 30 antimicrobial stewardship projects in 20 countries around the world hosted by the International Society for Chemotherapy website (http://inventory.infectionnet.org/). The site serves as an important resource so not to reproduce too many similar websites.

84.    Mattias raised the question of the competitive advantage of the network we are building. It appears that we do have tools such as ASU, ASP and HEPP, as well as some evidence base from a number of studies and surveillance sites. Can we pool these into a bigger group and perhaps do some comparative analysis? And perhaps conduct some community studies to compile data in order to have a good international impact?

85.    Mary summarized the points raised by the participants towards an action agenda for the region. Several successful initiatives are already underway in different localities in the region. The initiatives represent engagement of stakeholders at different levels, with strong participation on the ground, that have a degree of evidence and tools developed. Given therefore all these resources of tools, best practices, evidence, etc., of network members in the region, how do we put them together in practical ways to serve all members in the network? How do we facilitate the learning process for others to best benefit from the experiences around the region? How then also to more effectively advocate, identifying new ways of communication for advocacy and change at different levels? How do we generate more evidence for advocacy and change?

86.    Magdalene concurred that much work in the area has been piecemeal and rarely sustained, and not strong enough to affect change on a larger scale or convince policy makers and funders to support the cause. But successful initiatives are happening at local levels. Therefore the need to pool together what evidence, tools, initiatives, resources, etc., link them up, share the experiences  and identify/develop some action plans to fill the gaps.

87.    With regards to a research action that can influence policy change, Yoel proposed two types of costing studies. The first to examine the total costs of resistance for a specific disease, in a specific setting, but in different countries across the region. Of course, this will require a lot of good data, so it does not have to be a one-off study but an ongoing research and a growing database, with which to flag the issues to policy makers. The second costing study to do is to focus on the costs of AB use and compare the health outcomes and costs of diagnostic and treatments.

88.    Claire added that data from ASPs in different hospital, in terms of change in resistance patterns, can also be usefully analysed in costing studies.

89.    Wati added that the monetary cost of unnecessary AB consumption, in the community, is useful data in itself and can be easily carried out as a study. For example, a regional study prescribing, dispensing and procuring of ABs for viral infections. Such studies have been done in Vietnam and compared to resistance levels, according to Mattias.

90.    While the focus has been on the human use of ABs, its use in animal and other food farming industries is much larger in volumes and also a largely neglected issue in the region. Satya reminded the meeting on the need to address this problem as well when identifying research projects on ABR.

91.    The meeting then proceeded to a discussion on Best Practices – how to share and learn from them in order to initiate similar interventions in other locales in the region or develop as a regional programme.

Discussion on Best Practice/ Successful Initiatives – how to share and learn

92.    The participants agreed that the ASU programme is certainly an example of best practice, a successful initiative, as it has been implemented in Thailand. It also serves as a good model to be contextualized and extended to other countries in the region. Jayabalan proposed that the ASU programme in Thailand be written out with details on its process and procedures so as to assist partners in other countries in the region who wish to initiate a similar programme. He sees Malaysia and neighbouring countries sharing many socio-economic similarities and structures with Thailand, therefore suitable contexts for replicating a useful programme as the ASU. Examples include the village administrative structure, role of religious leaders, district health administrative structures, etc. Moreover, as in Thailand, the involvement of other stakeholders such as health professionals from the academy as well as MoH agencies in Malaysia can be mobilized to support the ASU programme.

93.    Isidro emphasized the need, in cross-learning and replicating models such as the ASU programme, to identify the different players and their roles in the issue as they vary in country and settings. Given that a key goal of the interventions is to change behaviour of all possible stakeholders, we need to identify who they are and what roles they play. For example, while in the case of the ASU programme in Thailand, the stakeholders in the consuming, prescribing, dispensing and procuring of Abs are centred around the public health sector, the same may not be the case in other locales within Thailand or neighbouring countries. In many locales, the private sector plays a much bigger role as players in the cycle of AB use, in which case, a programme such as the HEPP in Indonesia may offer a better model of intervention as it is designed in a context where private health care practitioners play a stronger role in the community.

94.    Nga also echoed the strong roles of the private sector prescribers, dispensers and retailers of drugs in the many communities in Vietnam. As such, community level interventions to change behavior must consider including incentives into the programme in order to achieve success in outcomes. Regulation alone, in these cases, will not ensure compliance.

95.    Ernie echoed the need to give attention to changing behaviour of private prescribers. There are many programmes on EDL/RUD in Indonesia but given the pressure of the industry on private practitioners, coupled with the latter’s lack of confidence and knowledge regulation alone is insufficient to change behaviour. Therefore, a comprehensive programme is required – networking with pharmacists, doctors and public health centers (nurses) and including EDL/RUD as well as incentives to guide prescribing and dispensing.

96.    The discussions on the ASU programme ended on the note that the programme has its limitations when applied to situations where the private sector played a stronger role in the prescribing and dispensing of ABs. However, it has proven successful in many locales in Thailand – it has engaged the community, volunteers, local champions;  mobilized stakeholders at different levels; and built a living, sustainable network, which is producing positive results. And, with some modification, it can be applied to other settings where the private sector plays a stronger role in the prescribing, dispensing and use of ABs.

97.    The next topic of discussion was the project idea to follow the curriculum survey. Azmi proposed the development of a model curriculum. Online discussions can be organized to discuss the survey results and from there, refine a curriculum, aimed at being as generic as possible for the SEA region and one that combines fundamental science and social science.

98.    Comments from the floor suggested that the academia, having a stake in the community, must consider their situation and perspectives in producing the curriculum (Isidro). They can, for instance, translate the three common conditions into understandable materials for physicians and pharmacists in district hospitals, nurses in subdistricts, village health workers in community, family care providers, and drug sellers. Similar provisions in the curriculum should address the roles and responsibilities of the private market prescribers and dispensers both in rural and urban settings in different countries.

99.    Medical and Pharmacy Curriculum will include local as well as international partnerships such as accreditation bodies for public and private hospitals, nursing boards, the Malaysia Medical Council, licensing authorities, etc. (Jayabalan, Magdalene), ReAct, WHO, etc. are important to achieve change (Azmi).

100.    It may be useful to link up with work done currently in ReAct Latin America network on curriculum development for physicians and pharmacist in primary health care (Mary). It is focused on skills to work with the community, addressing infectious diseases and resistance.

101.    Competencies in health/pharmacology skills as well as understanding of social and economic determinants behind prescribing, dispensing and use of ABs, should also be included in the curriculum (Isidro).

102.    The discussions then moved on to the topic of ASP as a best practice and it can be implemented in other countries, based on the experience of Singapore and elsewhere. The Thai pharmacist who participated in Study tour, explained that ASP is not new to Thailand as it has been practiced in different forms in the country. However, the ASP in Singapore is a good system and part of hospital policy. Moreover, Thai hospitals engaged in ASP practices do not have not ID physicians and pharmacists as they do as part of the ASP in Singapore. Physicians and pharmacists who are interested in ASP are guided by the EDL categories as a general rule. Thailand should have an ASP policy for hospitals, which includes a full time ID pharmacist and physician. Perhaps, pharmacists and physicians who are to be involved in the ASP can undergo one-year training in ASP hospitals in Singapore.

103.    One big obstacle in implementing the ASP in countries such as Malaysia is the lack of pharmacists (Claire). But apart from the personnel required, it’s the pre-education  of the available physicians and pharmacists, even if on a part time basis, on the need and importance of the ASP for good health outcomes. The Malaysian ID Pharmacists Society does conduct relevant trainings for pharmacists, including for ASP needs, and we need to take advantage of this resource (Azmi). Moreover, hospitals are required by the Private Facilities Act of Malaysia to put in place appropriate infection control procedures (Jayabalan).

104.    In summary, the discussions on the ASP need to consider the adaptation to local hospital situations and personnel resources issues.

105.    The next discussion focused on initiatives and projects taking on innovative ways of communicating, involving champions and the youth, using rt, music and drama, and mobilizing and organizing for change vis-à-vis health promotion, including ABR concerns, in the wider ecological context. Satya began with a showing of trailers of ReAct’s animation and cartoon productions capturing and communicating the ABR messages for WHD. The animations are cartoon are currently available in English, Thai and Spanish but future translations in other languages are planned. They are aimed at airing on television. Funding is also being sought to complete the series. Work is also ongoing on producing children’s story books on ABR and artwork on microbes and metaphors. The messages are varied and wholistic, not merely narrow biomedical representations of microbes and life and health in positive ways of interaction.

106.    Panya suggested using the conventional forms as well, for example producing stickers for everyday communication. He emphasized the need for connecting for communication among the artists, the scientists, the students and other stakeholders. He was also keen to work with people in Penang and elsewhere.

107.    Other comments pointed to the importance of using the web as a place to meet to discuss these issues and showcase the communication strategies as well as make it accessible to different age groups and languages (Kalyhani). Another consideration is to engage well-suitable known personalities to act as ambassadors for the cause, as is done in other important issues.

108.    The participants then proceeded to break-up groups to further discuss the outlines of the various project ideas of the Action Plan. The ideas were presented by each group, discussed and agreed upon (see Appendix III for ReAct-SEA Action Plan).

APPENDIX I:
Programme

Day 1 (3 May 2011)
8.00am        Registration

8.30am        Introduction of conference and participants
Niyada Kiatying-Angsulee, Mary Murray, Michael Chai

9.15am        Panel on ABR-RUD initiatives
Moderator: Dr. Nithima Sumpradit
Panelists: Dr. Purnamawati S. Pujiarto, Dr. Jaya Balan and Prof. Dr. Isidro Sia

10.15am    Panel on Antimicrobial Stewardship Program (ASP)
Moderator: Dr.Kumthorn Malathum
Panelists: Dr. Roungtiva Muenpa, Dr. Sripetcharat Mekviwattanawong, Dr.Niyada Kiatying-Angsulee, Dr.Patcharasarn Linasmita

11.30am    Competition awards on Thai ABR Campaign and press conference
Panelists: Dr Siriwat Tiptaradol, Dr. Maureen Birmingham, Dr. Sirikiat Liangkobkit, Dr. Mary Murray, Dr. Niyada Kiatying-Angsulee

12.30pm    Lunch & Thai Poster Exhibition

2.00pm        Panel on Indonesia
Moderator: Dr. Erie Gusnellyanti
Panelists: Dr. Hari Parathon, Dr. Hidayati Mas’ud, Apt., Ms. Zorni Fadia

2.30pm        Panel on Research and Studies
Moderator: Dr.Kumthorn Malathum
Panelists: Dr. Mohamed Azmi Ahmad Hassali, Ms. Do Thi Thuy Nga, Dr. Yoel Lubell, Dr. Heiman Wertheim

4.00pm        Tea/coffee break

4.15pm        Panel on further initiatives
Moderator: Dr. Mary Murray
Panelists: Mr. Satya Sivaraman, Mr. Panya Chayakam, Dr. Asrul Akmal Shafie, Dr. Purnamawati S. Pujiarto, Prof. Dr. Isidro Sia, Dr Madeleine de Rosas-Valera

1.    Chiang Mai – Uppsala Twin ABR City Project
2.    Artists and new communication approaches for health promotion on ABR
3.    World Health Day 2011 – continuing the campaign
4.    Research, fund raising and other initiatives.

6.00pm        End of Day 1 Panel Discussions

7.00pm        Dinner, cultural shows for rational use of medicines

Day 1 (3 May 2011)

9.00am        What next? – Discussions on future projects, local and regional
Moderator:
1.    A regional ASU project
2.    A regional ASP project
3.    What next for the curriculum survey project?
4.    Developing a regional project to document the cost of treating a specified resistant infection
5.    SEA Regional conference 2012
6.    Regional Action Plan

10.30am    Coffee/Tea Break

11.00am    What next? – Discussions on future projects, local and regional – contd.

12.30pm    Lunch

2.00pm        Agreement of Action Plans and Recommendations of Meeting
Moderators: Dr. Niyada Kiatying-Angsulee & Dr. Mary Murray
1.    Presentation of Thai Plan followed by discussions
2.    Presentation of Regional Plan followed by discussions
3.    Agreement of recommendations and plans.

3.30pm        Tea/Coffee Break

4.00pm    Agreement of Action Plans and closing of meeting
Moderators: Dr. Niyada Kiatying-Angsulee & Dr. Mary Murray

5.00pm        Scientific Committee Meeting on the 2012 SEA Conference on ABR
Niyada Kiatying-Angsulee, Mary Murray, Heiman Wertheim, Isidro Sia, Hari Parathon, Kadir Alam, Mattias Larson, Michael Chai

APPENDIX II
PARTICIPANT LIST
Thailand
Dr. Niyada Kiatying-Angsulee, Chair, Social Pharmacy Research Unit, Faculty of Pharmaceutical Sciences; Director, Social Research Institute; Manager, Drug System Monitoring and Development Program, Chulalongkorn University, Thailand.

Dr.Kumthorn Malathum, Ramathibodi Hospital, Mahidol University, Secretary General, Infectious Disease Association, Secretary General, Infectious Disease Association of Thailand; Chair,  Antibiotics Working Team, Faculty of Medicine Ramathibodi Hospital
Thailand.

Dr. Nithima Soompradith, Senior Pharmacist, Food and Drug Administration; Assistant Director, International Health Policy Program, Ministry of Public Health, Thailand
Ms. Pornpit Silkavute, Health Systems Research Institute, Ministry of Public Health, Thailand
Dr.Pisonthi Chongtrakul, Faculty of Medicine, Chulalongkorn University, Director of the Antibiotic Smart Use Project, Thailand
Dr. Roungtiva Muenpa, Head of Acute Care Unit, Head of Human Resource System and research Development Unit , Pharmacy Department, Lampang Hospital, Thailand.
Yaowapha Shaijarernwana, Head, Drug Information Unit, Department of Pharmacy, Maharat Nakorn Chiang Mai  Hospital, Thailand
Dr. Sripetcharat Mekviwattanawong, Department of Medicine, Phra Nang Klao Hospital, Nonthaburi, Thailand
Dr. Patcharasarn Linasmita, Department of Medicine, Faculty of Medicine, Srinakharinwirot University, HRH Princess Maha Chakri Sirindhorn Medical Center, Thailand
Dr.Somying Poomtong, Faculty of Pharmacy, Srinakharinwirot University, THAILAND.
Dr. Sirikiat Liangkobkit, Thai Health Promotion Foundation.

Mr. Panya Chayakam, Veteran Thai artist, working on ecological and wildlife themes in the medium of painting and sculpture.

Dr. Yoel Lubell, MSc Public Health, PhD Health Economics, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand.
Mr. Marwaan Macan-Markar, IPS Journalist, Thailand.
Dr Siriwat Tiptaradol, Secretary General, Thai Food and Drug Administration. Ministry of Public Health, Thailand.

Indonesia

Dr. Purnamawati S. Pujiarto, Clinical Pediatrician, Project Director on Empowering community through promoting RUM and patient safety; World Alliance for Patient Safety; Advisory board, Foundation for Older Persons Care, Indonesia.

Dr. Hari Parathon, SpOG (K), Chaiman of PPRA (AMR Containment Programme), Sutomo Hospital, Surabaya, Indonesia.

Dr. Hidayati Mas’ud, Apt., Head, Sub-directorate of Rational Use of Drug

Ms. Zorni Fadia, Chief, Sub-Directorate of Standardization, Directorate of Pharmaceutical Services, Ministry of Health, Indonesia

Dr. Erie Gusnellyanti, SSi., Apt, Head of Section of Standardization of Pharmaceutical Services, Ministry of Health, Indonesia.

Malaysia
Dr. Jaya Balan, Health Advisor, Consumers Association of Penang; Senior Lecturer, Discipline Of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia.
Dr. Mohamed Azmi Ahmad Hassali, Senior Lecturer, Discipline Of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia.
Dr. Asrul Akmal Shafie, Lecturer, Discipline Of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia.
Dr. Claire Italiano, Senior Lecturer, Infectious Diseases, University of Malaya Medical Centre, Malaysia
Ms. Kalyhani Nagappa, USM Pharmacy Student, Community Health Worker, Penang, Malaysia
Ms. Nor Izreen Fazlinda Binti Idris, USM Pharmacy Student and Community Health Worker, Penang, Malaysia
Ms. Vilasini, Registered Nurse, Community Health Worker, Penang, Malaysia.

Nepal
Drs. Kadir Alam, Manipal College of Medical Sciences, Department of Clinical Pharmacy, Nepal.

Philippines
Prof. Dr. Isidro Sia, Department of Pharmacology and Toxicology, College of Medicine, University of the Philippines, Manila, Philippines.

Vietnam
Ms. Nguyen Thi Thuy Nguyen, Epidemiological Field Laboratory of Bavi, Project, on “Antibiotic resistance a global challenge” – contextualized interventions to improve infection control and antibiotic management in Vietnam and India, Vietnam.
Ms. Do Thi Thuy Nga Coordinator-GARP, Oxford University Clinical Research Unit, NHTD-Bach Mai Hospital, Vietnam
Dr. Heiman Wertheim, Oxford University Clinical Research Unit; GARP Coordinator Vietnam, National Institute of Infectious and Tropical Diseases, Bach Mai Hospital, Vietnam.
Dr. Mattias Erik Larsson, Hanoi Medical University (as representative for Karolinska Institutet, Department of Public Health Science, Division of International Health and Dept. of Infectious Diseases), Vietnam.

WHO
Dr Madeleine de Rosas-Valera, Technical Officer for Patient Safety, WHO-WPRO

Dr. Maureen Birmingham, WHO Representative, Thailand.

ReAct

Dr. Mary Murray, Global Network Coordinator, ReAct, Australia.
Mr. Satya Sivaraman, Information and Communications Coordinator, ReAct, India.
Dr. Michael Chai – ReAct SEA Coordinator, Malaysia/Thailand

APPENDIX III: ReAct-SEA Action Plan

A.    Proposed Research Projects
1.    Estimating the differences in health outcomes and costs of hospital and community acquired bacterial infections in relation to antibiotic resistance
Objectives:
•    Assess the cost and health burden due to resistance in bacterial infections as measured in hospitalized patients
•    Using hospital surveillance data on AMR and AMU, estimate the resistance cost per antibiotic provided
Methods:
•    Enrol patients with a culture confirmed infection
•    Collect data on length of stay, underlying diseases, morbidity and mortality and resources used (treatments, diagnostics etc.) during admission
•    Compare these data in groups of patients with susceptible infections as opposed to patients with resistant infections (stratified by resistance type)
•    Debating prospective vs. retrospective analysis
•    Create database on AMR and AMU in the sites
•    Regression analysis to identify the degree to which AMU can explain higher AMR
•    Using the cost estimates and the estimated effect of consumption on levels of resistance, calculate the cost per AB provided
Next Steps:
•    Finalize methodology
•    Identify sites (hospitals with good culture facilities; AMR surveillance; AMU)
•    Write proposal and start chasing donors
Notes:
•    Stratify by type of hospital (teaching, etc.) – will implement this on secondary and tertiary centre. Stratification would depend on the sample size.

2.    Community dispensing of antibiotics
Objective:
•    To assess dispensing of AB from private and public drug dispensaries
Method:
•    Exit interviews with customers from private and public drug dispensaries using structured questionnaires
•    Stratify according to symptoms and assess rationality of AB
Notes:
•    Feasibility? – exit interview is most feasible compared to household visit, phone interview, simulated client (more expensive, difficulty from retailer’s consent)
•    Possibility of including cost of the pharmaceuticals
•    Possibility of using online interview – very interesting idea provided we could get representative sample of population.

3.    Country AB Resistance Index
Objective:
•    To calculate resistance index by South East Asian country (and Europe, USA) for benchmarking
Data needs:
•    antibiotic use pattern
•    resistance pattern
•    Index – resistance weighted by proportion of antibiotic used to treat the pathogen.
Notes:
•    Is the data easy to get particularly with some SEA countries? – will begin with countries that already have existing data e.g. Philippines, Vietnam, Malaysia, Indonesia and refocus on South East Asia.
4.    Antibiotic use in farm food production
Objective:
•    To assess the amount and type of AB used in food production as well resistance in bacteria isolated from animals and food products.

Methods:
•    To assess sources of information about AB in farming
•    To describe AB use among food producers e.g. poultry, pig, seafood
•    To describe AB resistance in farm animals and food products e.g poultry, pig, seafood, vegetables
Notes:
•    Maybe can use available data from pharmaceutical regulatory authority as practiced in Malaysia.

GENERAL Notes
•    What will be the order of feasibility? – Hospital resistance and community dispensing of antibiotics are the most feasible.

B.  Learning from best practices in the region:
Rational use of antibiotics in the community

First steps:
1.    Identify specific location for intervention e.g. district, village
2.    Needs assessments
•    extent of AB use in the community
•    identification of the three common diseases in which antibiotics are used (e.g in Thailand – upper respiratory infection (URI), diarrheal disease and skin wounds)

3.    Approaches
•    Collecting the local data of the cost
–    Community level – (in Thailand: Questionnaire is available; village, primary healthcare level; subdistrict, District hospital level)
–    Type of data: AB usage among the community and annual budget of the cost

•    Identify CHAMPIONS
–    In the community level (e.g religious leaders because they are influential, village headman)
–    In the hospital level (e.g nurses, doctors)

4.    Strategies*
•    Educational:
–    Key messages
–    Educational materials for trainers and for community (e.g banners, brochures)

•    Managerial
–    From community for the community
–    Supported by international & national bodies incl funding & acknowledgement
–    Designed based on local needs
–    Public & private sectors

•    Motivational: bottom up
•    Regulatory: periodic evaluation (funding!)

*Based from best practices of Thailand (ASU), Indonesia (HEPP), Malaysia, Philippines, Vietnam

•    Implementation
–    Draw up a program e.g regular meetings among the participants and the community
–    Mainly to sensitize the community

•    Periodic evaluation of the program
–    whether the program is successful or not

•    Expand the project to larger settings
–    ultimate aim is to influence policy makers

•    ASU in Thailand is willing to be the learning site
–     As a model to other countries
–    Introduction of inter-regional exchange program
–    Translation of reading or knowledge materials into other languages

1. Community
2. Student
3. Healthcare workers
4. Healthcare professionals

C. Antimicrobial Stewardship Program
(ASP)

1.    Resources required:

•    Physician (infectious diseases or clinical microbiologist if available) – minimum 5-7 hours/ week)
•    Pharmacist (~10 hours/week)
•    Microbiology laboratory and microbiologists capable of close clinical liaison
•    Education resources prior to roll-out of program
•    Sticker/ stamp/ sheet representative of ASP
•    Basic database
•    Ongoing training

2.    Initial training required
•    Variable dependent upon background experience
•    Options
–    Pharmacist – ‘shadowing of Singapore APS program’, attendance at specific ID pharmacist conference, training program (1 year SGH or create a regional training program)
–    Physician-if no ID/microbiology background will need opportunity to train/shadow
–    ASP workflow-modifications to Singapore model*

3.    Proposal for initiation
–    Major costs – personnel (pharmacists) and initial training
–    Initiation in larger centres with further training done within own countries
–    Start with a focus on 3-5 antibiotics
–    Need to liaise with Singapore + potential other sites regarding possibility of training and requirements for implementation of ASP

D. AMR curriculum for health care professionals

1.    Action Plan

–    The need to include issues related to AMR in current health professional education is well mandated by ReAct and its partners (WHO)
–    The recent survey conducted in SEA to evaluate the current teaching on issues related to ABR among pharmacy and medical students had identified barriers and disparity in existing curriculum.

2.    Objectives
–    To develop a model generic curriculum related to AMR for healthcare professional
–    To evaluate the suitability and applicability of such model curriculum across countries and profession

3.    Proposed plan
•    Content development
–    Structure of the program (Input from stakeholders on the topic)
–    Teaching methods (Didactic lecture, Role-play, Community engagement)
–    Assessment method (Evaluative and summative evaluation)
–    Pilot testing
–    Finalization

•    Partnerships

4.    Suggested title of course and contents
•    Title: Introduction to Antimicrobial Resistance

•    Proposed Content:
–    Concept of RUA
–    Overview of AMR
–    Mechanism of AMR
–    Antibiotic use and patient safety
–    Introduction to infection control
–    Introduction to antibiotic stewardship program
–    Role of health care professional in preventing AMR

E. Twin City: Creating a network of cities around the world/region that are champions of smart use of antibiotics

1.    Twin City Efforts
•    First phase
–    To strengthen the various local processes on ABR before moving on to exchange by inviting others
–    Eg Chiang Mai : local campaigns, bringing together various stakeholders etc.
–    Public participation important. Not just medical professionals but also civil society and also politicians, public opinion builders etc.

2.    Promoting Exchange
•    Second phase :
–    Facilitate exchanges between cities identified as part of the twin/multiple city process
–    Eg., Artists, students, pharmacists, political leaders can visit each other in different cities to learn from each other
–    Develop campaigns like ‘Antibiotic Free Food’ in cities, get public involvement
–    Students can form ‘Love Your Microbes’ groups for better understanding of microbial ecology and its role in public health.

F . Public education/communication and creative health promotion

1.Extending, sharing the creative health promotion processes devleping in  Thailand (and other places)
–    Extending initaitves between artists, scientists, students and staekholders in Chiang Mai and Penang ( for example)
–    Develop these ideas and other for conventional communication media such as stickers
–    Develop the Green Lung student campaign approach developed in Malaysia to a ‘Love your microbes- don’t misuse them – don’t mistreat them’ theme.

G. Facilitate processes of linkage, cross-learning. Research and analysis, and education within the region

1.    Expand the network
2.    Facilitate collaborative project
3.    Describe the work and network and make it visible more widely
4.    Work toward a regional platform for change in ABR

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