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1 1 WHO Collaborating Centre on Pa
1 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 Harbarth 1 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, Swit zerland 1 m.saam@inscience.ch ; benedikt.huttner@hcuge.ch ; stephan.harbarth@hcuge.ch 2 SUMMARY 1 INTRODUCTION 2 KEY FINDINGS OF THE SURVEY 3 O UTLINE OF SURVEYED C AMPAIGNS 3 T ARGET AUDIENCES 5 I NFECTIONS TARGETED 7 K EY MESSAGES AND ESSE NTIAL PUBLIC SLOGANS 8 G LOBAL VERSUS LOCAL KEY MESSAGES 11 “N EW ” KEY MESSAGES IDENTIF IED 12 I NTERVENTIONS USED IN THE CAMPAIGNS 13 E VALUATION OF THE CAM PAIGNS 14 O BSTACLES FACED WHILE IMPLEMENTING A PUBLI C AWARENESS CAMPAIGN 15 POTENTIAL FOR EXPANS ION IN NEW DIRECTIONS 15 A CKNOWLEDGMENTS 17 APPENDIX I - METHODOLOGY I APPENDIX II - SUMMARY TABLE I APPENDIX III - QUESTIONNAIRE USED F OR THE SURVE Y I REFERENCES 18 1 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 middle - income countries (LMICs), and 31 high - income countries. Respondents from another 8 countries (5 LMICs and 3 high - income countries) ei ther 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. ● Al

2 l but 12 (20%) campaigns targeted the ge
l but 12 (20%) campaigns targeted the general public and physicians simultaneously, with wi de 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 hi gh - 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 u sed 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 (6 8%) 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 c hange 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, trainin g 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 o r public health impact. Lack of political support, and an enduring 2 gap between common practic

3 es and suggested actions, are potential
es 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 antibioti c 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 d ifficult. 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 Heal th 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 intende d 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 Ob jective 1 -- to improve awareness and under

4 standing of antimicrobial resistance --
standing 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. Th ere 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 equivale nt 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; en gaging 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 Belgi um and France have shown. In 3 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 tar geted 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 regio ns 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 regio

5 ns. This is an alarming situation, par
ns. 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 Universi ty 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 o n 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 campaigns 2 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 mo re 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. 4 Map of countries included in the survey . Blue: antibiotic campaign conducted since 2010 (LMICs = light blue / high - income countries = dark blue)N Red: answered “no campaign” OR “not sure” to have had a campaign since 2010. Yellow: contacted, but no answer received, Grey: not contacted..

6 Classi fied by WHO regions, 3 campaigns
Classi fied 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 report ed 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 launch ed 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%), prim ary 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, 1 0%) 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. wor kers 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 5 Data on budgets and funding sources were provided by 32 (53%) campaigns an

7 d reflect widely varying volume and i n
d reflect widely varying volume and i ntensity, 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, charit ies 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 donation s (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 surveyN Most cou ntries 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 A wareness 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 cam paigns (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

8 elderly and travelers, were targeted by
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. 6 Since the ultimate decision to use antibiotics lies with physicians in most cases, 43 campaigns (72%) directed their interventions towards general practitioners and fami ly 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, nursin g and medical students were also specifically targeted in some cases. 7 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 sp ecific 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 approachN 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%) focuse

9 d on respiratory tract infections (other
d 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 transmitt ed 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. 8 Since the anti biotic 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 ca mpaigns 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 / adequa te use of antibiotics is important” (41 campaigns, 68% )N 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 event s 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 9 be taking for another conditionN Specific slogans were used in

10 some cases, such as “ Let’s preser
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) o r “If you are prescribed antibiotics, ask your doctor why” (Thailand)N More than half of the campaigns (31, 52%) stated “Follow / Finish the antibiotic prescription (in dosage and duration)” in their communication materialN Whereas all other key messag es 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 an timicrobial 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 pr event 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 pre vent resistance. Because the rate of antibiotic resistance tends to increase with the total amount of antibiotics used, 16 the general rule might be: the shorter the course, the lower the risk of resistance. Clinical studies have indeed shown that longer co urses of therapy can result in a more likely emergence of antibiotic resistance. 17 18 19 Shorter antibiotic treatment lower the opportunity for bacteria to become resistant, as well as reducing adverse side - effects. In otherwise healthy people, significant ly reducing but not totally eliminating the bacteria causing the infection can allow the body’s natural defences to take over and destroy the remaining few. 20

11 There are some circumstances when it i
There are some circumstances when it is necessary to eliminate all the bacteria – when the patien t’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). 10 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 signs and symptoms of a mild infection have disappeared. 21 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 self - medication, as availability of antibiotics withou t 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 potentia l 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 wi thout problems related to antibiotic access without prescriptions. This last key message, used by hal

12 f of the campaigns, also addressed the i
f of the campaigns, also addressed the issue of stocking up on antibiotics, which is non - negligible; 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. Se cond, 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 hav e 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 campaig n 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”N By contrast, the public educ ation 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"N 11 Only 13 campaigns (22%) included the optimal use of antibiotics in animals in their key messages (also see “New” key messages identified here below)N They mostly transmitted the idea that misuse and overuse of antibiotics (still in many cases used for growth promotion) in livestock and pisci culture causes resistance in microorganisms, which

13 can be transmitted to consumers and ult
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”N 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 farmer s 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 representat ives 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 (eNgN “Do n ot buy / use antibiotics without a prescription” or “Do not save leftover antibiotics”)N Other more local messages could include resistance patterns and trends associated with common syndromes, and changes in policies enforced by legislation (e.g. limits t o 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

14 - co untry public awareness survey”
- co untry 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/us e without prescription” was not used by the Smolensk regional campaignN 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)N 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 12 antibiotics is ma king 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 classe

15 s (such as the fluoroquinolones) that ar
s (such as the fluoroquinolones) that are known to favour the emer gence 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 s pread 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, alt hough 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, th e 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 rhymeN However, this “ catchiness” may be lost in translation and the 13 slogan may therefore not be easily adaptabl

16 e to other languages.. Indeed, directly
e to other languages.. Indeed, directly transposing communication material into other languages is often tricky and challenging. In the United States, when the CDC tr anslated 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 - med icate”N 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”N 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 effectiveN Indeed, in an Italian study about the impac t 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 t he framing of the campaign messages as “positive” or “negative”N 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 coul d order brochures and posters,

17 or download pdf files and print them, t
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 importanc e, 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 ❏ pre ss conferences 14 ❏ 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 ❏ c omics or t - shirts ❏ pledge - based websites ❏ flashmobs Other innovative interventions (not covered by answers received for this survey) include a specific labelling on antibiotics’ packagingN 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 antibioti cs (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

18 to draw conclusions from the answers re
to draw conclusions from the answers received, for instance to determine if campaigns which were “multi - faceted” versus targeted at speci fic 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%). Conver sely, 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 c onsequences (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. 15 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: Europea n 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 high - income country wi

19 th no answer received. Potential for
th 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 aw areness campaigns in new directions and enhance their impact may include the following: 16  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 o f 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 fro m 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 res

20 istance: mult i - country public awaren
istance: mult i - country public awareness survey”N 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 accou nt 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 commu nication 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 healthN Such a “cross - fertilization” between global ca mpaigns 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 a nd 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

21 most statistically significant factors
most statistically significant factors for reducing unnecessary antib iotic use. 34 17 Acknowledgments We would like to thank the following individuals f or having provided comprehensive and detailed answers which form the basis of this report,: Perlat Kapisyzi, Albania; Karine Gabrielyan, Armenia; Stephanie Childs, Australia; R obert 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, Cy prus; 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 Erikse n, Norway; Waleria Hryniewicz, Poland; José - Artur 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 g

22 raphics and editorial revision, to Frede
raphics and editorial revision, to Frederic Pont and Derek Christie ( Communication in Science ). 18 REFERENCES 1 http://www.who.int/campaigns/world - antibiotic - awareness - week/en/ (accessed January 10, 2017) 2 Filippini M, Ortiz LG, Masiero G. Assessing the impact of national antibiotic campaigns in Europe. Eur. J. Health Econ. 2013;14 :587 – 599. doi: 10.1007/s10198 - 012 - 0404 - 9 3 Huttner B, Goossens H, Verheij T et al. CHAMP consortium. Characteristics and outcomes of public campaigns aimed at improving the use of antibiotics in outpatients in high - income countries. Lancet Infect Dis. 2010;10:17 – 31. doi: 10.1016/S1473 - 3099(09)70305 - 6 4 LOcal Campaign on Antibiotics ALliance (LOCAAL) study group. Doctors and local media: a synergy for public health information? A controlled trial to evaluate the effects of a multifaceted campaign o n antibiotic prescribing (protocol). BMC Public Health 2011;11:816. doi: 10.1186/1471 - 2458 - 11 - 816 5 Hornik R, Kelly B. Communication and diet: an overview of experience and principles. J. Nutr. Educ. Behav. 2007;39:5 – 12. 6 Bala M, Strzeszynski L, Cahill K. Mass media interventions for smoking cessation in adults. Cochrane Database Syst. Rev. 2008;1:CD004704. 7 Harbarth S, Balkhy HH, Goossens H et al. Antimicrobial resistance: one world, one fight! Antimicrobial Resistance and Infection Contro l 2015;4:49. doi: 10.1186/s13756 - 015 - 0091 - 2 8 McNulty AMC, Nichols T, Boyle PJ et al. The English antibiotic awareness campaigns: did they change the public's knowledge of and attitudes to antibiotic use? J. Antimicrob. Chemother. 2010;65:1526 - 1533. doi: 10.1093/jac/dkq126 9 European Commission. Progress report on the Action plan against the rising threats from Antimicrobial Resistance. Commission Staff Working Document. 26.2.2015 10 Lecky DM, Hawking MKD, Verlander NQ et al. Using Interactive Family Science Shows to Improve Public Knowledge on Antibiotic Re

23 sistance: Does It Work? PLoS One 2014
sistance: Does It Work? PLoS One 2014;9:e104556. doi: 10.1371/journal.pone.0104556 11 http://www.listentoyourgut.org.uk/ ( accessed January 10, 2017) 12 World BankN 2016N “Drug - Resistant Infections: A Threat to Our Economic Future (Discussion Draft)N” Washington, DC: World BankN 19 13 Wellcome Trust. Evidence for action on antimicrobial resistance. Proceedings of the m eeting ‘Integrating Science and Policy for Decisive Action on Antimicrobial Resistance’, London, UK, 26 – 27 April 2016. 14 Centers for Disease Control and Prevention. Antimicrobial Resistance Threat Report. 2013. http://www.cdc.gov/drugresistance/threat - report - 2013/ (accessed January 10, 2017) 15 Shehab N, Lovegrove MC, Geller AI et al. US Emergency Department Visits for Outpatient Adverse Drug Events, 2013 - 2014. JAMA 2016;316:2115 – 2125 . doi: 10.1001/jama.2016.16201 16 Turnidge J and Christiansen K. Antibiotic use and resistance — proving the obvious. Lancet 2015;365:548 – 549. 17 Spellberg B. The new antibiotic mantra - Shorter is better, 2016, JAMA Intern. Med. 2016;176:1254 – 12 55. 18 Kouyos RD, Metcalf CJ, Birger R et al. The path of least resistance: aggressive or moderate treatment. Proc. Royal Soc. B. 2014;281:1794. 19 Gulliford MC, Moore MV, Little P et al. Safety of reduced antibiotic prescribing for self limiting respiratory tract infections in primary care: cohort study using electronic health records. British Medical Journal 2016;354:3410 20 Gilbert GLN No you don’t have to finish all your antibioticsN theconversation.com 17 April 2015. 21 Gilbert GL. Knowing when to stop antibiotic therapy. Medical Journal of Australia 2015;202:121. 22 Mainous AG, Everett CJ, Post RE et al. Availability of Antibiotics for Purchase Without a Prescription on the Internet. Ann Fam Med. 2009;7:431 – 435. 23 Zooroba R, Grigoryan L, Nash S et al. Nonprescription Antimicrobial Use in a Pr

24 imary Care Population in the United Sta
imary Care Population in the United States. Antimicrob Agents Chemother. 2016;60:5527 – 5532. doi: 10.1128/AAC.00528 - 16 24 European Centre for Disease Prevention and Control. Antimicrobial resistance surveillance in Europe 2014. Annual Report of the European Antimicrobial Resistance Surveillance Network ( EARS - Net ). Stockholm: ECDC; 2015. 25 Monnet DL, Safrany N, Heine N et alN Comment on: A systematic review of the public’ s knowledge and beliefs about antibiotic resistance. J Antimicrob Chemother. 2016;71:2364 – 2365. doi: 10.1093/jac/dkw141 26 Hai - Feng et al. Nanomedicine and Biotherapeutics for Antibiotic Resistance Bacteria. J. Nanomedicine Biotherapeutic Discov. 2015;5:3 . doi: 10.4172/2155 - 983X.1000e138 20 27 Verma P, Samanta SK. Comparative assessment of antibiotic potency loss with time and its impact on antibiotic resistance. Comp Clin Pathol. 2016;25:1163. doi: 10.1007/s00580 - 016 - 2321 - 2 28 Di Cesare A, Fontaneto D, Dop pelbauer J et al. Fitness and Recovery of Bacterial Communities and Antibiotic Resistance Genes in Urban Wastewaters Exposed to Classical Disinfection Treatments. Environmental Science & Technology 2016;50:10153 – 10161. doi: 10.1021/acs.est.6b02268 2 9 Formoso G, Paltrinieri B, Marata AM et al. Feasibility and effectiveness of a low cost campaign on antibiotic prescribing in Italy: community level, controlled, non - randomised trial. BMJ 2013;347:5391. doi: 10.1136/bmj.f5391 30 Apollonio DE and Malone R E. Turning negative into positive: public health mass media campaigns and negative advertising. Health Educ Res. 2009;24:483 – 495. doi: 10.1093/her/cyn046 31 http://www.mohfw.nic.in/ (accessed January 10, 2017) 32 http://www.fda.gov/newsevents/newsroom/pressannouncements/ucm513183.htm 33 Zowawi HM, Abedalthagafi M, Charles FA et al. The potential role of social media platforms in community awareness of antibiotic use in the Gulf Cooperation Council States. Luxury or necessity?

25 J Med Internet Res 2015;17:e233.
J Med Internet Res 2015;17:e233. 34 Holloway KA, Rosella L, Henry D. The Impact of WHO Essential Medicines P olicies on Inappropriate Use of Antibiotics. PLoS ONE 2016;11:e0152020. doi: 10.1371/journal.pone.0152020 Appendix I 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”N Fo r 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 ac tivities 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 Points 3 , and to persons in charge of an tibiotic 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); e ventually, 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 comprehen sive) were taken into account (number: 6). Conflicts in answers emerged in 8 countries (Brazi

26 l, Chile, Colombia, Germany, Israel, Le
l, 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 cou ntries that were taken into account for the analysis. Results were summarised according to WHO Regions and the high, medium and low - income 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. Appendix I II Limitations Answ ers received by each country cannot be assumed to be comprehensive. In some cases, when respondents stated that there was no antibiotic aware ness campaign in their country, there may have been one that they did not know about. As most campaigns were descri bed 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 W HO Regions, th e 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 que stions that respondents may feel have a ‘correct’ response, a bias may come from respondents giving the answer they feel is ‘expected’ (social desirability bias)N Appendix II I

27 APPENDIX II - Summary table Coun
APPENDIX II - Summary table 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 de sign/condu ct of the campaign Impact of the campaign formally evaluated Respondent recommends a similar type of awareness campaign Armenia AMR Awareness raising campaign X Australia Reducing Antibiotic Resistance www.nps.org.au/antibiotics X X X X Yes Belgium National antibiotic awareness campaign www.gebruikantibioticacorrec t.be (version in Dutch, French, German and English) X X X X Yes Brazil Rational use of antimicrobials http://www.anvisa.gov.br/serv icosaude/controle/rede_rm/cu rsos/atm_racional/modulo1/pr e_uso.htm Canada Do Bugs Need Drugs? www.dobugsneeddrugs.org and www.francais.dobugsneeddru gs.org X X X X Yes C hile Rational use of antimicrobials X China National drug safety: use antibiotics carefully China Special campaign for antibiotic rational use X X Yes Colombia Bacterial resistance and Nosocomial Infections network led by CIDEIM X X Yes Croatia Public awareness campaign on prudent antibiotic use X X X X Yes Croatia Cold or flu - say no to antibiotics https://www.facebook.com/re ciNEantibioticima/ X X Appendix II 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 des

28 ign/condu ct of the campaign Involved
ign/condu ct of the campaign Involved advertisement companies in the de sign/condu ct of the campaign Impact of the campaign formally evaluated Respondent recommends a similar type of awareness campaign Cyprus Antibiotic Awareness Campaign http://www.moh.gov.cy/moh/ moh.nsf/All/6B4121829D850 2A5C2257C210026E74C X Yes Denmark "piss annoying!" National antibiotic campaign on urinary tract infections in younger and elderly women X X Estonia European Antibiotic Awareness Day X Finland European Antibiotic Awareness Day https://www.thl.fi/fi/web/infekti otaudit/ajankohtaista/teemap aivat/euroopan - antibioottipaiva X 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" http://www.ameli.fr/assures/pr evention - sante/les - antibiotiques.php http://agriculture.gouv.fr/camp agne - vaccinacteurs - vacciner - les - animaux - pour - reduire - lutilisation - des - antibiotiques http://agriculture.gouv.fr/les - antibiotiques - pour - les - chiens - et - les - chats - cest - pas - automatique X X X Not sure Germany Rational antibiotic use through Information and communication www.rai - projekt.de X X Yes Germany Antibiotic - Therapy - Optimisationsstudy X X Yes Ghana Ghana Anti - Microbial Resistance Platform http://ghndp.org/antimicrobialr esistance/ : Ghndp.org/reactcso X X X X Appendix II III 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

29 the campaign Involved advertisement
the campaign Involved advertisement companies in the de sign/condu ct of the campaign Impact of the campaign formally evaluated Respondent recommends a similar type of awareness campaign 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 http://www.kedke.gr/?p=1547 8 X X Iceland European Antibiotic Awareness Day http://www.landlaeknir.is/um - embaettid/frettir/frett/item281 05/Evropudagur - vitundarvakningar - um - syklalyf India ReAct http://www.bmj.com/content/3 52/bmj.i1202 X India Antimicrobial resistance stop Indonesia Smart Use of Antibiotics http://bijak - antibiotik.com/ X X Yes Indonesia Antimicrobial Resistance Control Program X X X X Not sure ireland under the weather www.undertheweather.ie X X X Yes Israel Reducing Antibiotic use in the Community X X Yes Italy Antibiotics: solution or problem? http://assr.regione.emilia - romagna.it/it/aree_attivita/val utazione - del - farmaco/ricerca - X X Yes Appendix II IV 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 de sign/condu ct of the campaign Impact of the campaign formally evaluated Respondent recommends a similar type of awareness campaign innovazione/uso - di - a

30 ntibiotici Italy Antibiotics. It's a
ntibiotici Italy Antibiotics. It's a sin to use them bad. http://salute.regione.emilia - romagna.it/antibiotici X X X Yes Japan We set up Awareness Month in November, not only the WHO Awareness Week. http://www.cas.go.jp/jp/houdo u/161004amr.html X X Not sure Japan Understand your risk, take proper antibiotics Kenya AMR Awareness Week Kenya Handle antibiotics with Care X X KOSOVO Let's keep antibiotics working! Latvia No specific name Lithuania European Antibiotic Awareness Day http://sam.lrv.lt/lt/veiklos - sritys/visuomenes - sveikatos - prieziura/uzkreciamuju - ligu - valdymas/antimikrobinis - atsparumas X X X X Yes Luxembour g Antibiotics are not candy. http://www.sante.public.lu/fr/c ampagnes/2013/campagne - antibiotiques/index.html X Malta European Antibiotic Awareness Day http://www.nac.gov.mt X Mexico Day for the appropriate use of antibiotics, Week for the appropriate use of antibiotics https://www.insp.mx/lineas - de - investigacion/medicamentos - en - salud - publica/eventos.html X Appendix II V 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 de sign/condu ct of the campaign Impact of the campaign formally evaluated Respondent recommends a similar type of awareness campaign Mexico Regulation and Promotion of Appropriate Antibiotic Use in Mexico. A Proposal of Guidelines for Action Ne

31 therland s Be careful with antibiotic
therland s Be careful with antibiotics www.daarwordtiedereenbeter van.nl X X X Yes Norway Antibiotic awareness campaign X X Poland European Antibiotic Awareness Day/World Antibiotic Awareness Week www.antybiotyki.edu.pl X X X Yes Portugal Awareness Campaign for the Rational Use of Antibiotics Macedonia Antibiotics are not food X X Romania European Antibiotic Awareness Day (because the campaign is occasioned by EAAD) http://insp.gov.ro/sites/cnepss /antibioticorezistenta/ and http://www.ms.gov.ro/?pag=1 99 X Russia Antibiotic is a strong weapon if the target is bacterial infection www.antibiotic - save.ru Serbia "Prudent use of antibiotics in primary care settings: awearness, knowledge and attitude" Appendix II VI 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 de sign/condu ct of the campaign Impact of the campaign formally evaluated Respondent recommends a similar type of awareness campaign Slovakia Life without antibiotics. - National campaign. Antibiotics. Use them wisely! - tagline of campaign EAAD 2016 www.zivotbezantibiotik.sk Slovenia Flyer Get well without antibiotics Flyer Interactions of drugs Furst J,Cizman M et al.Expert Rev Anti Infect Ther 2015 X X X Not sure Spain What do parents know about antibiotics S pain Prudent Use of Antibiotics Antibiotics Day in Europe http://www.msssi.gob.es/cam panna

32 s/campanas13/antibioti cos.htm and http
s/campanas13/antibioti cos.htm and http://www.msssi.gob.es/cam pannas/campanas06/Antibioti cos.htm Sweden Protect the antibiotics https://www.folkhalsomyndigh eten.se/skyddaantibiotikan/ X X Thailand Thai Antibiotic Awareness Week 2016 (FB Antibiotic Awareness Thailand) http://atb - aware.thaidrugwatch.org/ X Timor Leste Stop Antibiotic Resistances Now X Yes United Kingdom Antibiotic Guardian www.antibioticguardian.com X X X X Yes United Kingdom Antibiotic Action http://antibiotic - action.com/ X X X Yes USA Get Smart: Know When Antibiotics Work www.cdc.gov/getsmart X X Appendix II VII 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 de sign/condu ct of the campaign Impact of the campaign formally evaluated Respondent recommends a similar type of awareness campaign USA Alliance Working for Antibiotic Resistance Education (AWARE) https://public.health.oregon.g ov/DiseasesConditions/Com municableDisease/AntibioticR esistance/Pages/index.aspx X USA Get Smart for Healthcare http://www.cdc.gov/getsmart/ healthcare/ 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). Appendix III I APPENDIX III - Questionnaire used for the survey See pdf file

33 attached. Temporary link: https://d
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. Appendix IV I APPENDIX IV - Answers from countries which have not implemente d 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 a nd Tanzania were “not sure” about itN 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 impor tant) 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 ani mal husbandry and agriculture” and “Mandate antimicrobial stewardship programs in hospitals”N - In two instances: “Restrict sale of antibiotics without a prescription”N - 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 wer e considering launching an antibiotic awar