France – Alpes maritimes
“Antibios Quand il Faut“
www.gepie.org
• ''Antibiotics only when necessary“
– 2000-2005
• Multidisciplinary group
– 90‟000 € in 2003
• Academic detailing
– 2000 + 2003
– 10 minutes/physician
– about 1„000 physicians
• Brochures and posters
• No use of mass media
Pradier et al. (2003). Med Mal Inf 33:9-14
Bruno-Bazureault et al. (2006). Presse Med 35:749-54
Blance et al. (2008). Presse Med Epub ahead of print
Population
1.0 million
New Zealand
Population
4.0 million
www.kickthatbug.co.nz
• “Wise Use of Antibiotics”
• Yearly campaign since 1999
• Organized by PHARMAC
– 47‟000-210‟000 €/campaign
• Interventions
– Pamphlets and posters
– Use of mass media (TV,
radio) only since 2007
– Videos in waiting rooms
http://kickthatbug.org.nz/downloads.html#
Sung et al. (2006). NZ Med J 119:U1956
Curry et al. (2006). NZ Med J 119:U1957
New Zealand
www.kickthatbug.co.nz
• Survey 2004
– posters in waiting rooms highest recall
– 30% aware of campaign
• Survey 2007 (after use of primetime TV)
– TV spots highest recall (71%)
– Overall recall similar
Australia
www.nps.org.au
Population
19.9 million
• Yearly campaign since 2000
– For prescribers since 1999
• National Prescribing Service
– 55‟000 -450‟000 €/campaign
• Interventions
– Information material
– TV and radio spots, billboard
and magazine advertising
– Guidelines, seminars and
some academic detailing
Harvey the wombat
Summary
Public campaigns to improve outpatient
antibiotic use
Summary
• Public campaigns are widely used in high-income
countries to raise public awareness about judicious
antibiotic use
Asia ?
Organization
• Mostly organized by official health authorities
– Type of health authority varies between countries
• In the United States often coalitions
• For development of campaign material often involvement
of advertising agencies
Funding
• Public funding
– National campaigns in Portugal and Canada entirely
funded by the pharmaceutical industry
• Funding varies widely
– Few thousand Euros to millions of Euros
– Mostly influenced by use of mass media
Infections targeted
• Focus on upper respiratory tract infections
– For the public: focus on the common cold and flu
– For physicians: otitis media, pharyngitis, sinusitis
– None targeted urinary tract infections specifically
– None targeted influenza in the physician education
component (rapid test?) Falsey et al. (2007). Arch Intern Med 167:354-60
Public targeted
• General population
• Children / Parents
• Other subgroups
– “Active” population and the elderly (France)
– Women 18-34 years (Australia)
– Employee groups and older people in group settings
(Canada – Alberta BC)
– Prison inmates (New Zealand)
– Lower socioeconomic class (UK – England)
Target population
General population
Parents / children
Both
Israel
Malta
Interventions for the public
•
•
•
•
Interventions multifaceted
Varying intensity
Pamphlets / posters most common
TV spots: variation
– Primetime TV (France, Belgium, Spain)
– Spots shown free of charge but at unattractive times
(USA, Greece)
• Radio spots
– Most campaigns that used radio also used TV and
vice versa
Use of TV
Primetime
Not primetime
No use
Israel
Malta
Approximate amount (x1’000 Euros) spent/
1 million inhabitants/campaign
Use of primetime TV
N
Z
B
EL
M
A
L
A
U
S
EN
G
U
SA
PO
R
N
I
FR
A
LU
X
C
A
N
ES
P
200
180
160
140
120
100
80
60
40
20
0
Limitation: Budget difficult to compare (with / without salaries)
Use of radio
Used
Not used
Israel
Malta
Use of Print Media
Used
Not used
Israel
Malta
Healthcare professionals targeted
• Interventions for the public AND physicians
• Primary care physicians
– General practitioners and family physicians
• Paediatricians
– One campaign focus only on paediatricians
• Other specialties rarely targeted
– ER physicians (USA), internists, ENT, pulmonologists
• Pharmacists
– Targeted in all but 6 campaigns in Europe
Websites
• Independent websites dedicated only to the campaign
– Belgium, France, Spain, Germany, CanadaBC/Alberta, Portugal, New Zealand
– Most other websites integrated into larger website
– Only one campaign no website at all
– Number of hits varying (few hundred to millions/year)
Evaluation
• Four campaigns in Europe not at all evaluated
• Recall (data available from 7 campaigns)
– 16% (Australia) to 71% (Northern Ireland)
– Depends on who you ask, when you ask and how
you ask
– TV probably highest recall
• Public knowledge / attitudes
– Data conflicting
– Knowledge regarding differences between viruses
and bacteria difficult to improve
– Knowledge not even high in the Netherlands
Cals et al. (2007). Br J Gen Pract 57:942-7.
Campaign Awareness
2005: 71% recall
2005: 34% recall
2003: 20% recall
2001: 46% recall
Israel
2006: 54% exposed
Malta
Cost / benefit
• Decreased costs of antibiotic prescriptions (and
resistance-related adverse outcomes) probably outweigh
costs of campaign by far
– Belgium: 70 million Euros (2000-2006)
– France: 500 million Euros (2002-2006)
• Example: Unites States, 1998
– Amount spent by pharmaceutical companies to
promote antibiotics: 1‟600‟000‟000 USD
Ma et al. (2005). Clin Ther 25:1503-17
– Amount spent by the CDC in the same year on its
“Campaign for Appropriate Antibiotic Use in the
Community”: 155‟000 USD
Outcome regarding antibiotic use
1992 -1997: 35% reduction
2003-2005: 10% reduction
2004-2005: 5.8% reduction
Self reported use
1999-2006: 32% reduction
2003-2004: 10% reduction broad-spectrum
Prescription data
2002-2007: 23.4% reduction
control population
1999-2002: 10 % reduction
Published in
scientific journals
Malta
Limitations
• Data rarely published
– Little information published in scientific journals
– Campaign identification and data retrieval
cumbersome and incomplete
• Information retrieval relies mostly on personal
contacts
– Sometimes difficult to establish
– Data less “reliable”
• Few campaigns formally evaluated or evaluation not
available
– Assessing outcomes difficult
Conclusions I
• Antibiotic campaigns probably have a beneficial effect on
antibiotic prescribing
– At least in countries with high antibiotic use
– Best evidence so far
– Quasi-experimental design makes it difficult to assess
true impact
Conclusions II
• Sustained effects ?
• Impact on antibiotic resistance ?
– Many confounding variables
• Adverse effects of reduced prescribing ?
– Not routinely monitored
• Most effective interventions ?
– Focus on the public vs physicians
– Might vary between different countries
Further research is needed...
Acknowledgements
CHAMP collaborators
Anastasia Antoniadou
Margaret Artist
Fatima Bragança
Edith Blondel-Hill
Pascale Bruno
José Campos
Mary Carson
Silke Christmann
John Dabrowski
Stijn De Corte
Alice Desprès
Brigitte Dunais
Nurit Friedman
Carlo Gagliotti
Hermann Goossens
Hilde Kløvstad
Michael Kresken
Karl Kristinsson
Janet Mackay
Margaret McCrory
Dominique Monnet
Alison Patti
Jesús Rodríguez-Marín
Don Sancton
Wayne Saray
Simone Steil
Sally Wellsteed
Peter Zarb
and many more…