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1 1 st Global Forum on Bacterial Infections New Delhi, 3-5 October 2011 Interventions and innovations at community level to improve antibiotic access and use: global overview Kathleen Holloway Regional Advisor Essential Drugs and Other Medicines WHO South East Asia Regional Office

Dr kathy holloway 2

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Page 1: Dr kathy holloway 2

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1st Global Forum on Bacterial Infections

New Delhi, 3-5 October 2011

Interventions and innovations at community level to improve antibiotic

access and use: global overview

Kathleen Holloway Regional Advisor Essential Drugs and Other Medicines

WHO South East Asia Regional Office

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1st Global Forum on Bacterial Infections

New Delhi, 3-5 October 2011

Database on medicines use ! Database of all medicines use

surveys using standard indicators in primary care in developing and transitional countries

! Studies identified from INRUD bibliog, PUBMED, WHO archives

! Data on study setting, interventions, methods and drug use extracted & entered

! All data extraction and entry checked by 2 persons

! Now > 900 studies entered ! Systematic quantitative review ! Evidence from analysis used for

WHA60.16 in 2007

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1st Global Forum on Bacterial Infections

New Delhi, 3-5 October 2011

Treatment of ARI by prescriber type: WHO 2009

01020304050607080

% viral URTI casesprescribed antibiotic

% pneumonia casesprescribed antibiotic

% ARI cases treatedwith cough syrup

Doctor (n=26-62) Nurse/paramedic (n=12-86) Pharmacy staff (n=9-17)

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1st Global Forum on Bacterial Infections

New Delhi, 3-5 October 2011

Public / private treatment of acute diarrhoea by doctors, nurses, paramedical staff: WHO 2009

01020304050607080

% diarrhoea casesprescribed antibiotic

% diarrhoea casesprescribed anti-

diarrhoeals

% diarrhoea casesprescribed ORS

Public (n=54-90) Private-for-profit (n=5-10)

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1st Global Forum on Bacterial Infections

New Delhi, 3-5 October 2011

Treatment Choices

Prior Knowledge

Habits Scientific Information

Relationships With Peers

Influence of Drug Industry

Workload & Staffing

Infra- structure

Authority & Supervision

Societal

Information

Intrinsic

Workplace

Workgroup

Social & Cultural Factors

Economic & Legal Factors

Many Factors Influence Use of Medicines

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1st Global Forum on Bacterial Infections

New Delhi, 3-5 October 2011

Community surveillance of AMR and use (1) ! Developing & piloting method for

integrated surveillance of AMR & AB use & collection of baseline data in 2 resource-constrained settings

! 3 sites in India & 2 in S. Africa ! AMR & AB use data collected

monthly for 1-2 years from same communities

! 4 sites measured AMR in E.Coli & 1 in S.pneum & H.influenzae

! AB use by private GPs, retailers, public & priv hospitals & PHCs by exiting patient interview or prescribing & dispensing records

! Qualitative study (FGDs) into provider & consumer behaviour

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1st Global Forum on Bacterial Infections

New Delhi, 3-5 October 2011

Community surveillance of AMR and use (2): results

! Antimicrobial resistance ! pathogenic E.Coli in pregnant women's urine in India

! Cotrim 46-65%; Ampi 52-85%; Cipro 32-59%; Cefalex 16-50% ! S.Pneumoniae & H.influenzae in sputa in S. Africa

! Cotrim > 50% (both organisms); Ampi >70% (H.influenzae) ! Antibiotic use

! About ½ patients in India & ¼ or less of patients in S.Africa get ABs ! Much inappropriate AB use especially in India e.g. use of

fluoroquinolones for coughs and colds in private sector ! Motivation of providers & consumers

! Patient demand – looking for quick cure ! Lack of CME & unwillingness to attend for fear of losing custom ! Uncontrolled pharmaceutical promotion, involving financial gain

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1st Global Forum on Bacterial Infections

New Delhi, 3-5 October 2011

% school children treated with antibiotics for cough & cold in the previous winter in Moldova Cebotarenco & Bush, Health Ed. Res, 2008

0

10

20

30

40

50

60

70

Pre-intervention Post-intervention

Control group Intervention group

Intervention: volunteer students train fellow students & parents on ABs, using video, newsletter, meetings, booklets, contests

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1st Global Forum on Bacterial Infections

New Delhi, 3-5 October 2011

Impact of user fees on prescribing quality in Nepal Source: Holloway et al: HPP 2001 & SSM 2002

User Fees (complete drug courses)

control fee / Px N=12

1-band item fee N=10

2-band item fee N=11

Av. no. drugs per prescription (Px)

2.9 2.9 (+/- 0)

2.9 2.0 (-0.9 drugs)

2.8 2.2 (-0.6 drugs)

% prescriptions containing ABs

66.7 67.5 (+0.8%)

63.5 54.8 (-8.7%)

60.7 54.3 (-6.4%)

% prescriptions according to STGs

23.5 26.3 (+2.7%)

31.5 45.0 (+13.5%)

31.2 47.7 (+16.5%)

Average cost per prescription (Rs)

24.3 33.0 (+8.7 Rs)

27.7 28.0 (+0.3 Rs)

25.6 24.0 (-1.6 Rs)

Interviews with patients & providers

Both wanted the most drugs for least cost so the item fee resulted in many people opting for fewer drugs

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New Delhi, 3-5 October 2011

Impact of Patient-Provider Discussion Groups on % patients receiving injections in Indonesian PHC Facilities Hadiyono et al, SSM, 1996, 42:1185

0

10

20

30

40

50

60

70

80

Pre-intervention Post-intervention

Control group Intervention group

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1st Global Forum on Bacterial Infections

New Delhi, 3-5 October 2011

Impact of multiple interventions on injection use in Indonesia

Source: Long-term impact of small group interventions, Santoso et al., 1996

0%20%40%60%80%

100%

1 3 5 7 9 11 13 15 17 19 21 23 25

Months

Pro

port

ion o

f vi

sits

with

inje

ctio

n

Comparison group Interactive group discussion

Interactive group discussion (IGC group only)

Seminar (both groups)

District-wide monitoring (both groups)

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1st Global Forum on Bacterial Infections

New Delhi, 3-5 October 2011

Review: Public education campaigns in industrialised nations Huttner et al 2009, Lancet Infectious Diseases, 2009,10(1):17-31.

Country Period Campaign Type Antibiotic (AB) reduction

France 2002 - Yearly mass media

targeting Providers & Consumers

27% AB prescriptions

Belgium 2000 - 36% reimbursed packages UK Yearly Stable use

Australia 2000-8 14% AB consumption (DDDs)

USA 1995 - 18-36% in ABs for ARI

Canada* 1996-2005 Limited Seasonal

mass media campaign targeting

consumers

9% AB Prescriptions

Spain Portugal

2006-8 2004-7

High use / No change

Germany Norway

2000 - 2004

Low use / No change

* Providers also targeted

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1st Global Forum on Bacterial Infections

New Delhi, 3-5 October 2011

Intervention impact: largest % change in any outcome measured: Source - WHO database on medicines use 2009

Intervention type No. studies Med. impact 25,75th centiles Printed materials only 5 8% 7%, 18% National medicines policy 6 15% 14%, 24% Economic strategies 7 15% 14%, 31% Provider education 25 18% 11%, 24% Consumer education 3 26% 13%, 27% Provider+consumer education 12 18% 7%, 21% Provider supervision 25 22% 16%, 40% Provider group process 8 37% 21%, 59% Essential drug program 5 28% 26%, 50% Community case management 5 28% 28%, 37% Provider+consumer ed & supervis 7 40% 23%, 54%

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New Delhi, 3-5 October 2011

Intervention impact: median % change in all outcomes measured (av. 4/study): Source - WHO database on medicines use 2009

Intervention type No. studies Med. impact 25,75th centiles Printed materials only 5 5% -2%, 7% National medicines policy 6 5% 0%, 15% Economic strategies 7 6% -1%, 8% Provider education 25 7% 4%, 15% Consumer education 3 2% 1%, 14% Provider+consumer education 12 9% -1%, 18% Provider supervision 25 13% 5%, 17% Provider group process 8 13% 9%, 28% Essential drug program 5 15% 1%, 45% Community case management 5 29% 24%, 36% Provider+consumer ed & supervis 7 24% 18%, 28%

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1st Global Forum on Bacterial Infections

New Delhi, 3-5 October 2011

What national policies do countries have to promote rational use? Source: MOH Pharmaceutical policy surveys 2003 and 2007

0 20 40 60 80 100

EML updated in last 2 years

STGs updated in last 2 years

UG doctors trained on EML/STGs

Obligatory CME for doctors

Drug Info Centre for prescribers

DTCs in >half general hospitals

Public education on antibiotic use

Antibiotic OTC non-availability

National strategy to contain AMR

Drug use audit in last 2 years

% countries implementing policies2007 (n>85) 2003 (n>90)

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1st Global Forum on Bacterial Infections

New Delhi, 3-5 October 2011

2nd International Conference for Improving Use of Medicines, Chiang Mai, Thailand, 2004 472 participants from 70 countries

Recommendations for countries to: ! Implement national medicines programmes to improve

medicines use ! Scale up successful interventions ! Implement interventions to address community medicines use

3rd ICIUM to be held 14-18 November 2011

http://www.icium.org

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1st Global Forum on Bacterial Infections

New Delhi, 3-5 October 2011

What are we spending to promote rational use of medicines ?

! Global sales of medicines 2002-3 (IMS): US$ 867 billion

! Drug promotion costs in USA 2002-3: US$ >30 billion

! Global WHO expenditure in 2002-3: US$ 2.3 billion

! Essential Medicines expenditure 2% (of 2.3 billion)

! Essential Medicines expenditure on promoting rational use of medicines 10% (of 2%)

! WHO expenditure on promoting rational use of medicines 0.2% (of 2.3 billion)

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New Delhi, 3-5 October 2011

Conclusions ! Irrational use of medicines is a very serious global public

health problem

! Much is known about how to improve rational use of medicines but much more needs to be done ! policy implementation at the national level ! implementation and evaluation of more interventions,

particularly managerial, economic and regulatory interventions aimed at prescribers and the community

! Rational use of medicines could be greatly improved if a fraction of the resources spent on medicines and their promotion were spent on improving use.