Managing Antimicrobial Resistance Through Behaviour Change

Pre-conference report

15–18th March 2021 Online from Uppsala

#UaHS2021 Uppsala Health Summit is an international arena Uppsala Health Summit is organized by partners for frank and challenging dialogue, exploring with long experience of developing health and possibilities and implementation challenges healthcare solutions through multi-disciplinary associated with advancement in medicine and efforts. public health. Uppsala Health Summit stimulates dialogue from various perspectives, such as The meeting is a collaborative effort between medical, economic and ethical. Uppsala University, the Swedish University of Agricultural Sciences, Uppsala County Council, We are an enabler for change, and an arena for the City of Uppsala, the Swedish Medical Prod- insights and collaborations that can help you ucts Agency, The National Veterinary Institute, improve health outcomes in your part of the Uppsala Monitoring Centre, and the network world. World Class Uppsala.

CONTENTS Can we manage the antimicrobial resistance crisis by changing our behaviours? 4

Workshops Why not practise knowledge? 8 Lots of talk but little action 12 Consumer behaviour and antibiotic resistance 16 Antibiotics and antibiotic resistant bacteria in the environment 20 Making sense of antibiotic resistance 26 When children relate to the ’wild’ 32 Where are our antibiotics? 36 Teaching antimicrobial resistance 42

Governance 46 Preface

Antimicrobial resistance is an ever-increasing ing the Uppsala Health Summit – have created a threat to human health. One by one, the medi- hub for multi-disciplinary research, practice and cations we rely on in modern medicine are los- advocacy regarding antimicrobial resistance. ing their power. The Uppsala Health Summit was created to Despite heightened awareness that cancer treat- bring medical, ethical and economic perspec- ments, childbirth or simple medical procedures tives together to address challenges and dilem- are becoming unsafe, antimicrobial resistance mas, with a view to improving health outcomes has failed to get the attention it deserves, par- all around the world. tially due to perverse economic incentives for overproduction and use of antibiotics. Another Due to Covid-19, the summit will be digital for reason is the complexity of the challenge: Where the first time. This has an advantage: We can do we begin, what actions matter, and how can engage more participants, provide greater out- individual behaviours change with respect to an reach and a stronger voice for change. issue that may not immediately affect each of us I welcome you to take part in this effort and individually? invite you to become engaged in the challenging and rewarding discussions taking place at the Complex issues demand multiple responses that Uppsala Health Summit! engage different actors. At the Uppsala Health Summit on Antimicrobial Resistance and Be- haviour Change, we will draft ideas for policy and actions. Together with researchers, practi- tioners, industry and policymakers, we aim to encourage new thinking to be put into action.

In Uppsala, we feel well-suited to host a discussion on this important theme. We have two leading academic institutions with scholars conducting internationally renound research in the field: Uppsala University and the Swedish University of Agricultural Sciences. The activi- Anders Malmberg, Professor ties of the two universities – along with our other Departing Chair of Uppsala Health Summit Uppsala-based, not-for-profit partners support- Steering Committee Can we manage the antimicrobial resistance crisis by changing our behaviours?

Ulf Magnusson, Professor, Swedish University of Agricultural Sciences, Chair of the Uppsala Health Summit Programme Committee

We are living in the midst of a severe pandemic Improved national policies and international that is taking its toll in many different ways all declarations and agreements are good support around the world. However, under the surface, instruments for curbing the emergence of AMR. there is another, less immediate health crisis that However, how well such regulatory means, is gaining more and more ground: The emer- which often imply restriction of antimicrobial gence of antimicrobial resistance (AMR). There use, are translated into change is very context are several reports predicting that, over time, specific. Different jurisdictions have different the AMR crisis will have an even more devastat- capacities to enforce regulations, depending on ing impact on health and countries’ economies their resources, political priorities or traditions than the current pandemic. related to compliance with regulations in general. Another, complimentary approach is to The theme of the current Uppsala Health Sum- introduce non-regulatory incentives along the mit – Managing Antimicrobial Resistance Through whole chain, starting from production of the an- Behaviour Change – was set several months before timicrobial until it ends up in a human, animal the start of the pandemic. Since then, the rel- or the environment. At this 7th Uppsala Health evance of, and need for, health-related behav- Summit, we will explore the opportunities and ioural changes has become well understood by limitations of behaviour change approaches tar- the public and policymakers around the world. geting individuals and organizations as a means The Covid-19 pandemic has also been a stark of managing the emergence of AMR. reminder that infectious diseases do not respect country borders and has highlighted the impor- Besides the high-quality plenary sessions, there tance of global collaborations. In addition, when will be eight interactive workshops where we trying to prevent and control pandemics and will discuss how different aspects of behaviour the emergence of AMR alike, the importance change can play a role in reducing the threats of of considering the health of humans, domestic AMR. animals and the environment concurrently is a realization that is gradually being taken up by Cross-sectorial exchange for better professionals as well as policymakers around the prevention world. Consequently, we have fully embraced On the whole, we know what to do to prevent the “One World, One Health” approach in the the spread of resistant bacteria. But it is clear programme committee of the Uppsala Health that we are simply not doing these things often Summit when addressing behaviour change as a enough. How can we get people to practise the means of managing the emergence of AMR. desired preventive behaviours? One approach is

4 PHOTO CREDITS: © ANNA P HABICH

In the One health approach for curbing the AMR emergence, it is important to consider the use of antibiotics in domestic animals. to bring together sectors with seemingly different per se that are dangerous, but the fact that they drivers and solutions. This may lead to new in- make bacteria resistant. Furthermore, using an sights that help us move forward. Putting expe- overly alarmistic tone in communication may riences from the health care sector, where health have unintended consequences and turn people workers have the ultimate responsibility for pa- away from facing the problem. tients, together with the livestock sector, where it is the farmer who has the ultimate responsibility Preventing risk of infection in animal- to protect his animals from disease, may allow human interactions us to identify successful commonalities concern- It is generally accepted that child-animal en- ing how to change behaviour. But how should counters are beneficial for children’s’ learning we ultimately work to move AMR-preventive and social development. These encounters may behaviours in the right direction? be in the form of children having pets in the family or living on or visiting farms with cows, Improving Communications pigs, and horses. However, close contact with Even if the severity of the emerging AMR is well animals also poses a risk to children from an known and understood among several groups of AMR perspective: Resistant bacteria may be stakeholders, there is reason to be disappointed transmitted from the animal to the child. So, by the seemingly poor response from society as a how great is this risk compared with the benefits whole. Is this due to a communication failure on for children of tending to and interacting with the part of the informed scientific community? animals? And how do we harness these benefits Obviously, there are some specific challenges in view of the risk of transmission of resistant associated with communicating about AMR: It bacteria? is a slow-moving crisis and thus not regarded as an urgent problem. Furthermore, it is a complex Children as change agents issue to communicate and misunderstandings The emergence of antimicrobial resistance puts abound. For instance, messages must communi- the children of today at risk of facing an adult- cate that it is the ‘bugs’ that become resistance, hood with very few pharmaceuticals that are not you, and that it is not the antimicrobials effective against infections. But children may

5 PHOTO CREDITS: © OLEG IVANOV

The tremendous progress made in the health sector are under threat from the emergence of AMR.

function as change agents regarding use of an- perhaps nudging with a view to slowly changing timicrobials if they have access to an adequate social norms would be effective. Or are financial education that allows them to feel competent, disincentives a better way to change consumers’ able and willing to contribute to a positive de- behaviour? velopment. To achieve this, it is not sufficient to teach the basic life science facts about AMR. It An environmental perspective – What are is also a matter of learning about social norms the opportunities for behaviour change? and political and economic priorities related to Antimicrobials often end up in the environment, antimicrobial use. However, exactly what such and how they get there, thrive and move on or instruction should specifically address is largely generate resistance in environmental microbes is unknown. Moreover, how can we instil in teach- obviously a very broad issue. For this reason, it is ers the confidence they need to teach such a necessary to identify key points where behaviour complex issue – one ranging from microbiology change could make a difference. Adding to this to political sciences – and to do so while also complexity, the contexts are, very different in taking up the conflicting interests? countries at varying income levels. When these key points for behaviour change are identified, a How can we influence consumer attitudes new set of questions arises. Who are the targets and behaviour? of behaviour change promotion? And in what Antimicrobial resistance generated by using forums should such efforts take place? Also, does antimicrobials in food production – mainly in the order of our attempts to change behaviour the livestock sector, but also when growing veg- matter for the outcome? etables – may occasionally be transferred to humans and become a health issue. The question Addressing supply shortages is: Is it possible to mitigate this risk by changing In parallel with the increase in AMR that causes consumers’ behaviour so they choose food that is antibiotics to lose their efficacy, there is also a produced using less antimicrobials, thereby forc- shortage in the supply of these drugs. This may ing producers to use less antimicrobials? In such accelerate antibiotic resistance, as suboptimal efforts there are several options. For instance, antibiotics have to be used instead of the most

6 efficient types. This is most likely to happen in The summit low-income countries. Why do these shortages We look forward to gathering stakeholders from occur and what can we do about them? Various different policy areas, academic disciplines and solutions to this problem have been discussed, geographies for a dialogue on the role of behav- one being more transparent supply chains with iour change in efforts to address the complex better profitability for suppliers. field of AMR.

New solutions to the R&D challenge? Organizing a meeting virtually is of course a There has been a dearth of new antibiotics since challenge, given that the hallmark of the summit the 1980s, with only a few new ones reaching has been collegial networking in the fabulous old the market during the past 30 years, despite the Uppsala Castle. However, thanks to our team’s fact that they are greatly needed. This has been efforts, we are reassured that this time, too, the due to the scientific challenges associated with workshops will be characterized by a dynamic developing new classes of antibiotics and because and productive atmosphere. And as mentioned, pharmaceutical companies don’t find it profit- the plenary sessions held by world-leading ex- able to invest in such development. Academics perts will now be available to a much wider and policymakers have identified incentives to audience! stimulate developers of new antimicrobials, but why haven’t these been fully implemented and why aren’t they functioning as expected?

Suggested readings Hall J, Jones L, Robertson G, Hiley R, Nathwani D, Perry Sands M, Aunger R. Determinants of hand hygiene compli- MR. ‘The Mould that Changed the World’: Quantitative ance among nurses in US hospitals: A formative research and qualitative evaluation of children’s knowledge and study. PLoS One. 2020 Apr 7;15(4):e0230573. doi: 10.1371/ motivation for behavioural change following participation journal.pone.0230573. in an antimicrobial resistance musical. PLoS One. 2020 Oct 29;15(10):e0240471. doi: 10.1371/journal.pone.0240471. Talkhan H, Stewart D, Mcintosh T, Ziglam H, Abdulrouf PV, Al-Hail M, Diab M, Cunningham S. The use of theory in the Raboisson D, Ferchiou A, Sans P, Lhermie G, Dervillé M. development and evaluation of behaviour change inter- The economics of antimicrobial resistance in veterinary ventions to improve antimicrobial prescribing: a systematic medicine: Optimizing societal benefits through mesoeco- review. J Antimicrob Chemother. 2020 Sep 1;75(9):2394- nomic approaches from public and private perspectives. 2410. doi: 10.1093/jac/dkaa154. One Health. 2020 Jun 5;10:100145. doi: 10.1016/j.one- hlt.2020.100145. Weldon I, Hoffman SJ. Bridging the commitment-compliance gap in global health politics: Lessons from interna- Roope LSJ, Tonkin-Crine S, Herd N, Michie S, Pouwels KB, tional relations for the global action plan on antimicro- Castro-Sanchez E, Sallis A, Hopkins S, Robotham JV, Crook bial resistance. Glob Public Health. 2020 Jul 4:1–15. doi: DW, Peto T, Peters M, Butler CC, Walker AS, Wordsworth 10.1080/17441692.2020.1788623. S. Reducing expectations for antibiotics in primary care: a randomised experiment to test the response to fear-based messages about antimicrobial resistance. BMC Med. 2020 Apr 23;18(1):110. doi: 10.1186/s12916-020-01553-6.

7 Workshop A Why not practise knowledge? The art of disease prevention

Christina Greko*, Strama VL, Department of Animal Health and Antimicrobial Strategies, National Veterinary Institute, Sweden Ulf Magnusson, Department of Clinical Sciences, Swedish University of Agricultural Sciences Birgitta Lytsy, Department of Clinical Microbiology and Infection Control, Uppsala University Hospital, Department of Infection Prevention and Control, Region Uppsala Leif Östman, Department of Education, Uppsala University

* [email protected]

Introduction forward. It has long been known that basic Preventing infections and the spread of anti- interventions like hand hygiene, appropriate biotic resistant bacteria is a key component clothing, etc., protect patients from becoming of the containment of antibiotic resistance. infected and from becoming carriers of re- Fewer infections in a population or sub-pop- sistant bacteria. Fewer infections in hospitals ulation mean a reduced need for antibiotics. mean lower antibiotic use and lower costs. This is true in health care, but also in livestock There is a great deal of knowledge not only production. about what should be done, but also about how to implement known measures. But hav- We know enough about what needs to be ing the science and guidance established does done to prevent infections and the spread of not necessarily mean that people will live up resistant bacteria, but these measures do not to the recommendations. occur often enough. Bringing sectors with seemingly different drivers and solutions to- At the farm level, the basic principle is also gether may lead to insights that can help to clear: “Keep infections out, and should you move things forward. get them in, try to limit the spread within the premises”. But biosecurity at farms can leave The health care sector was chosen because much to be desired, even in high-income it is ultimately responsible for delivering safe countries. The challenges are even greater care for patients. The livestock sector was in low- and middle-income countries where chosen because it is the farmer who is ulti- access to adequate advice may be limited. mately responsible for implementing biosecu- Farmers may then rely on professionals with rity to protect his/her animals. The veterinarian less interest in reducing the need for pharma- can give advice, but it is up to the farmer ceuticals. In addition, the resources needed to make the decision, including tackling the to invest in improvements may be limited, in potential economic consequences of improve- particular for small-scale farming. ments. Several parallels exist between the two sectors concerning the importance of a safety The focus areas of the workshop are: culture, appropriate behaviour and personal • What determines when measures to pre- motivation. vent infections are, or are not, translated into practice? Many measures taken to implement infection • How can we work to change behaviours in prevention and control (IPC) are straight- the right direction?

8 PHOTO CREDITS: © STATENS VETERINÄRMEDICINSKA ANSTALT (SVA)

Wearing protective clothing and changing shoes before entering a stable can prevent introduction of infections. With a simple wooden barrier, visitors to the animals are reminded of these important measures.

Background of care. This includes simple things, such as It is possible to prevent infections from spread- always disinfecting one’s hands before and after ing between patients and health care workers, contact with a patient. If use of such practices and there is evidence for how to do this. Still, in is suboptimal, people will need to rethink and 2010, the WHO estimated that as many as one change the way they do things. patient in ten acquired an infection during care. This additional and often avoidable burden is It is equally possible to prevent many infections costly, both in terms of health and economy, but from spreading among livestock. Preventing it also contributes to increased use of antibiot- infections at the farm level leads to healthier ics. Thus, with improved IPC, antibiotic use in animals, which in turn leads to a reduced need hospitals is expected to decrease and the spread to use antibiotics. Presumably, production would of multiresistant bacteria to be slowed. An IPC also be better. As for health care, the key ele- programme should include not only guidance ments of change are known. Some changes may and training, but also mechanisms for assess- be structural, such as improving farm construc- ment and reassessment. The aim should be one tion. But there are also simpler things, like pay- of continuous improvement, and actions should ing attention to the health status of farms that be tailored to each specific setting. Some prob- supply animals, quarantining recently arrived lems that need to be tackled may be structural, animals, changing shoes when entering each but much of what needs to be done is at the point stable and wearing protective clothing specific

9 PHOTO CREDITS: © EYEEM / ALAMY STOCK PHOTO

The WHO has estimated that as many as one patient in ten acquire an infection during care. Many of these infections are avoidable.

to each stable. Washing and disinfecting the taken into account, there are no easy answers to stable before putting new animals in it is another be found, as these factors often are experienced example. Employment of these practices may as being in conflict with each other. In other be suboptimal, perhaps partly because the cost words, a decision requires some form of prior- of common production diseases has been poorly itization or trade-offs to be made. It is perhaps studied. In a short-term perspective, routine use for this reason we can observe the difficulty of of comparatively cheap antibiotics may seem changing habits and practices – it requires us to to be the best way to tackle disease problems. make new prioritizations. Again, this requires that the farmer rethink and change attitudes and behaviours, moving to- The need to change is often experienced when wards more sustainable use of antibiotics. old habits are disturbed. In such situations, the need for reflection and innovative thinking be- From knowledge to action comes visible to others and to ourselves. If peo- Research has shown that taking the step from ple are not experiencing disturbances, a change knowledge to action is complicated, and the ef- in habit is not likely to occur. On the other fect of new knowledge on changing habits is low. hand, such disturbances may not lead anywhere, Furthermore, in many situations, more than one because change requires innovative thinking factor must be considered, as human or animal and acting, which do not happen automatically. health factors as well as economic and cultural Thus, if we are to make changes, some form ones are highly relevant when deciding how to of support is often necessary. The question is act. When all of these three factors need to be what support would be fruitful? Could it be that

10 PHOTO CREDITS: © JIM HOLDEN / ALAMY STOCK PHOTO

Hand hygiene is crucial to prevent spread of infections in health care, animal production and food-processing.

support that involves collaborative learning pro- Suggested readings cesses might be a solution, i.e., when people get FAO website on antimicrobial resistance http://www.fao.org/antimicrobial-resistance/en/ together to learn from each other with a view to coming up with innovative solutions? Magnusson, U., Sternberg, S., Eklund, G., Rozstalnyy, A. 2019. Prudent and efficient use of antimicrobials in pigs and poultry. FAO Animal Production and Health Manual 23. Rome. FAO. http://www.fao.org/documents/card/en/c/ ca6729en/

WHO. Implementation manual to prevent and control the spread of carbapenem-resistant organisms at the national and health care facility level. World Health Or- ganization; 2019 (WHO/UHC/SDS/2019.6). Licence: CC BY- NC-SA 3.0 IGO. https://apps.who.int/iris/bitstream/handle/10665/312226/WHO-UHC-SDS-2019.6-eng.pdf?ua=1

WHO website on infection prevention and control https://www.who.int/teams/integrated-health-services/ infection-prevention-control

11 Workshop B Lots of talk but little action What’s hindering implementation of incentives to stimulate antibiotics R&D?

Enrico Baraldi*, Department of Civil and Industrial Engineering, Uppsala University Olof Lindahl, Department of Business Studies, Uppsala University Alexandra Waluszewski, Department of Economic History, Science and Technology Studies Centre, Uppsala University

* [email protected]

Why should we discuss incentives for introduced, and other incentives such as col- antibiotics R&D? laborative research and development (R&D) Because antimicrobial resistance (AMR) makes platforms have not been fully implemented. existing antibiotics ineffective, new antibiotics Why is it the case? What obstacles are cur- need to be developed and brought to market. rently blocking full implementation of these However, there has been a dearth of truly important incentives? innovative antibiotics since the 1980s due to both scientific challenges and lack of financial Aim of the workshop incentives for drug developers. Whereas the During this workshop, the discussion will focus incentives necessary to stimulate developers on the obstacles that are potentially hindering and their potential effects have been iden- implementation of three important incentives: tified by academics and policymakers, no Market Entry Rewards, Milestone-based major rewards for developers have yet been Payments, and Pipeline Coordinators.

12 PHOTO CREDITS: © FISHMAN64/SHUTTERSTOCK

There has been a dearth of truly innovative antibiotics since the 1980s, due to both scientific challenges and lack of financial incentives for drug developers.

Background which was supported by the UN General Assem- The Covid-19 pandemic and the risk of sec- bly. This plan also explicitly stressed the need ondary bacterial infections have cast light on to stimulate the development of new antibiotics. the importance of having efficacious antibiotics But why does development of drugs as obviously available. However, they have also increased the important as antibiotics need to be stimulated at consumption of antibiotics as prophylaxis and all? Isn’t their value in treating life-threatening without medical prescription. This implies that infections or enabling surgery and chemotherapy the pandemic has once again highlighted the enough to induce multitudes of drug developers triple challenge of AMR: the need for stewardship to engage and push these molecules through in use, for global access, and for new drugs that their R&D pipelines? Unfortunately, here there can combat resistant bacteria. In this critical is a strong disconnect between the societal and era, World Health Organization (WHO) Direc- public health value of antibiotics, on the one tor-General Dr Tedros Adhanom Ghebreyesus hand, and their economic value – that is, how stressed “…the importance both of protecting much profit developers can reap from launching the antimicrobials we have and developing new them to market – on the other. ones, to effectively treat infections, preserve health gains made in the last century and ensure The challenge a secure future”.1 The problem is basically that antibiotics as a business is financially unattractive, certainly less Already 20 years before the Covid-19 pandemic, attractive than other therapeutic areas such as the WHO recognized AMR as a global health cardiovascular diseases or cancer, which provide challenge and formulated a strategy to address developers with greater economic returns (Spell- it (WHO, 2001). However, the global response berg et al., 2015). This lower profitability de- was rather disappointing. In 2015 the WHO pends on scientific challenges – having already endorsed a “Global Action Plan on AMR”, picked the “low-hanging fruit”, developing new antibiotics has now become increasingly more 1 https://www.who.int/news-room/detail/ difficult, resulting in longer development times 01-06-2020-record-number-of-countries- and higher costs – as well as on higher risks of contribute-data-revealing-disturbing-rates-of- failure than previously experienced (Payne et al., antimicrobial-resistance

13 2015). Since 2000, only three new classes of an- (2018) and the AMR Review (2015) feature tibiotics have been launched to market, and they several “push” incentives that finance develop- had all been discovered in the 1980s or earlier. ers’ activities by covering their costs, as well as Moreover, even if a developer were able to even- “pull” incentives that reward developers when tually develop a new antibiotic, the revenue side they reach certain development goals. is still problematic: Sales are not only uncertain for a new product, especially one targeting a However, while the incentives and their possible new type of resistant bacteria, but they are most effects have been identified, researched, and an- likely going to be very modest thanks to impor- alysed over the past 5 years or so, most of them tant stewardship interventions to contain inap- are still far from being implemented. Neverthe- propriate use of new antibiotics. The financial less, public and private R&D actors, healthcare, paradox is that sales of the newest products will and industry have all clearly expressed their have to be kept low if we are to curb antibiotic need for incentives that will trigger behavioural resistance. changes on a systemic level – namely recreating a functioning antibiotics R&D infrastructure Accordingly, we are facing a market failure and even bringing private investors back into (Kesselheim & Outterson, 2011): Despite the this area. These actors have particularly ex- immense societal value of antibiotics, the risks pressed the need for “pull” incentives as well and costs involved are much higher than the as for improved coordination and continuity of revenues antibiotics developers can expect. This innovation support in the antibiotics pipeline. is why most of the large pharmaceutical companies have left the antibiotics field during the The workshop past 20 years. Out of 25 large pharmaceutical The aim of this workshop is to investigate why, labs focusing on antibiotics in the 1980s, only as the leader of the UK AMR Review Lord Jim a handful are left (Outterson et al., 2015). A O’Neil puts it, there have mostly been “empty key role in developing antibiotics has recently words” coming from global policymakers.2 been assumed by several SMEs (small and medium-sized enterprises), but these developers This workshop invites stakeholders from the are often underfinanced and may be unable to private, public and non-profit sectors to identify complete their R&D projects or even to survive and discuss what obstacles are currently blocking full if they do indeed bring products to market (Well- implementation or permanent establishment of come Trust, 2020). the three main incentives identified in academic and policy analyses: Market Entry Rewards, Even if the pipeline of antibiotics in clinical Milestone-based Prizes, and Pipeline Coordina- development in 2020 amounted to about 50 anti- tors. The aim of the workshop is not to evaluate biotics, many of them were not considered suffi- the strength and weaknesses of these incentives ciently innovative or relevant to address the most per se, but to identify the obstacles blocking their serious infections (Wellcome Trust, 2020). More- implementation. The contents of these incentives over, considering the high risk of failure before are as follows: reaching market approval, there is no guarantee that any truly innovative antibiotic will reach Market Entry Rewards: Financial payments to a the market in the next decade or so. This would developer or intellectual property holder after further extend the “discovery void”, i.e., the time the achievement of market authorization of an since the discovery and market launch of the last antibiotic that meets pre-defined product crite- new class of antibiotics (lipopeptides) in 1987 ria. The prize money is paid out incrementally, (ReAct, 2020). for example over the first five years after market launch. This prize, in turn, aims to either fully Actions taken, but more are needed or partially replace future revenues from sales of In order to address the dearth of innovation the new antibiotic in question in order to relieve in the antibiotics field, academic and policy pressures to maximize sales, as such pressures analyses have singled out several incentives to increase the risk of triggering premature resist- stimulate antibiotic R&D with the aim to result ance development. The size of this kind of inno- in new drugs that are effective against resistant bacteria. For instance, the DRIVE-AB Project 2 https://www.bbc.com/news/health-47719269

14 vation prize must be large enough to incentivize and that, using highly flexible tools and working developers to take on the very considerable costs methods, closely monitors the development of and risks associated with taking a new antibiotic antibiotics, identifies gaps in the pipeline, and all the way to market. actively supports (or directly conducts) R&D projects with a view to filling these gaps. As Milestone-based Prizes: Monetary outlays offered to Pipeline Coordinators may use several tools and developers after the achievement of clearly speci- are active along the whole development pipeline, fied R&D goals, including addressing particular the effectiveness and efficiency of such incentives diseases. Milestone prizes are “pull” incentives, are both more promising and more complicated. like Market Entry Rewards, but are considerably smaller (Baraldi et al., 2016; Mossialos et al., While these three incentives can provide ad- 2010). Rather than rewarding a developer for vantages by strengthening the global antibiotic taking a drug all the way to market, the Mile- R&D pipeline and eventually support bringing stone Prize is intended to take the development new antibiotics to market, they have neither of an important antibiotic successfully through been fully implemented nor made permanent. a certain development phase. The prize is paid This suggests that the incentives have been met out immediately following the phase in question with resistance, hesitation, or lack of interest and would involve sums considerably greater on the part of stakeholders. Possible obstacles than the cost of development for that phase. The include funding the incentives, their complex- milestone prize is, thus, an innovation prize that ity and difficulty of application, as well as the incentivizes short-term development goals. For various actors’ perceptions concerning potential this reason, it may be more suitable for small, or unexpected, potentially skewed, or crowding-out otherwise cash-strapped, developers. effects (Baraldi et al., 2016).

Pipeline Coordinators: A governmental/non-profit During this workshop, we will begin by identi- organization that closely tracks the antibacterial fying which specific obstacles to implementation pipeline and actively supports R&D across all actually apply to each of the three incentives priority pathogens during the development pro- and, then, we will discuss how these obstacles cess, employing new financing tools. Specifically, can be tackled so as to enable implementation of a Pipeline Coordinator is an organization that the incentives. brings together public and private stakeholders

References AMR Review (2015). Securing new drugs for future gen- ReAct (2020). Few antibiotics under development. Avail- erations: the pipeline of antibiotics. Available at: https:// able at: https://www.reactgroup.org/wp-content/up- amr-review.org/sites/default/files/SECURING%20NEW%20 loads/2016/09/ab-discovery-timeline.png DRUGS%20FOR%20FUTURE%20GENERATIONS%20 FINAL%20WEB_0.pdf Wellcome Trust (2020). Why is it so hard to develop new antibiotics? Available at: https://wellcome.ac.uk/news/ Baraldi, E., Ciabuschi, F., Leach, R., Morel, C., & Walusze- why-is-it-so-hard-develop-new-antibiotics wski, A. (2016). Exploring the Obstacles to Implementing New Economic Mechanisms Addressing Antibiotic Resist- World Health Organization (2001). WHO Global Strategy ance: A Multi-actor and System-level Analysis, American for Containment of Antimicrobial Resistance. Available at: Journal of Law & Medicine, Vol. 42, No. 2–3, pp. 451–486. http://www.who.int/csr/resources/publications/drugresist/ EGlobal_Strat.pdf DRIVE-AB (2018). Revitalizing the antibiotic pipeline: Stim- ulating innovation while driving sustainable use and global access. Available at: http://drive-ab.eu/drive-ab-outputs/ Suggested readings drive-ab-reports/ Baraldi, E., Ciabuschi, F., Callegari, S., & Lindahl, O. (2019). Economic incentives for the development of new antibiot- Kesselheim, A. S., & Outterson, K. (2011). Improving anti- ics. Report commissioned by the Public Health Agency of biotic markets for long term sustainability. Yale J. Health Sweden. Pol’y L. & Ethics, 11, 101. Waluszewski, A., Baraldi, E., Ciabuschi, F., (2015). Work- Spellberg, B., Bartlett, J., Wunderink, R., & Gilbert, D. N. shop B: New economic models addressing antibiotic resist- (2015). Novel approaches are needed to develop tomor- ance, In: Post-conference report, Uppsala Health Summit row’s antibacterial therapies. American journal of respira- Uppsala: Uppsala universitet. tory and critical care medicine, 191(2), 135–140.

Payne, D. J., Miller, L. F., Findlay, D., Anderson, J., & Marks, L. (2015). Time for a change: addressing R&D and com- mercialization challenges for antibacterials. Philosophical Transactions of the Royal Society B: Biological Sciences, 370(1670), 20140086.

15 Workshop C Consumer behaviour and antibiotic resistance

Anna-Carin Nordvall*, Department of Business Studies, Uppsala University Mirko Ancillotti, Centre for Research Ethics and Bioethics, Department of Public Health and Caring Sciences, Uppsala University

* [email protected]

The food we consume contributes greatly Aim of the workshop to antibiotic resistance. Consumers can be a The aim of the workshop is to discuss the role driving force in the market because, through of consumers and strategies for influencing their choices, they can influence what food is consumer behaviour so it plays a lesser role in produced and how. While many may agree promoting antibiotic resistance. in principle with more sustainable consumer • Should we nudge consumers towards more behaviour, barriers of different kinds hinder sustainable purchasing behaviour? engagement in such behaviour. Several meas- • How can we use the benefits of social ures can be considered for bringing about the norms to overcome the mental barriers of desired changes, including the use of social consumer purchasing behaviour? pressure. • Could a system of financial incentives and disincentives be implemented to nudge consumers towards more sustainable antibiotic purchasing behaviour?

16 PHOTO CREDITS: © SORBIS/SHUTTERSTOCK

Consumers can play an important role through their choices on how foods are produced.

Background lines the important role that consumers can play. The use of antibiotics in veterinary medicine, Through their choices, consumers can act as a aquaculture and agriculture contributes to the driving force in the market and have a strong clinical problem of resistant disease in human influence on the way foods are produced (WHO, medicine. Globally, a large portion of antibiotics 2017). are employed for growth promotion and disease prevention, thus not to treat sick animals. Consumers’ behaviour The majority of consumers indicate that sus- Antibiotic resistance can be spread through the tainability is of high subjective importance. For environment and the food chain via direct or in- instance, people state that it is essential to reduce direct exposure. Direct exposure occurs during the use of antibiotics. At the same time, many human-animal contact, for instance in the pro- consumers also engage in unsustainable antibiot- cess of rearing pigs. Indirect contact occurs as a ic consumption behaviour. The question is: Why consequence of consuming contaminated food. do even consumers who are oriented towards This includes fruits and vegetables, which can “antibiotic responsibility” display unsustainable also be contaminated by bacteria on the farm or consumption behaviour? Under the umbrella of later through cross-contamination. the so-called attitude-behaviour gap, this question has been and still is a controversial topic The World Health Organization (WHO) recom- discussed in the area of consumer behaviour mends an overall reduction in use of antibiotics research (Eckhardt, Belk & Devinney, 2010). If in food production to preserve the effectiveness consumers are to make more informed decisions of these medications in human medicine. But about how they purchase and consume food, who is responsible for making the appropriate they need access to both relevant information changes? The WHO’s primary audience is pol- and decision support. However, it is more diffi- icymakers and regulatory officials overseeing cult than one might think to get consumers to food production. Nonetheless, the WHO under- act in an antibiotic-free manner. Previous studies

17 PHOTO CREDITS: © MOHAMED_HASSAN/PIXABAY

Choose the right product from a large variety of options. Easy or not?

have shown that consumers’ decision-making is behavioural change in consumers’ needs and driven by hedonism and emotions and that the conceptual world. cultural context base consumers experience is of great importance to their behaviour (Parker However, we speculate that there are also intra- & Tavassoli, 2000). Furthermore, consumers’ psychic consumer conflicts involved in the form behaviour patterns show almost no planned of behaviour rationalization. Consumers seem and structured consumption, which could push to be motivated to rationalize because they want consumers to buy products without regard to to reduce or avoid feelings of guilt (Murphy & antibiotic content. Studies have shown that Dacin, 2011) – first, because individuals are ea- consumers’ involvement in food issues is based ger to maintain their “sense of goodness” and on their desire to save money rather than to act avoid self-condemnation, as stipulated by self-af- more sustainably (Stancu, Haugaard & Lääht- firmation theory (Mazar, Amir et al., 2008), enmäki, 2016). In many respects, consumers can and second, because individuals are driven to therefore be said to be reluctant to move towards achieve harmony between their internalized more antibiotic-free consumption. Nonetheless, moral values and behaviour, as predicted by studies (Proschaska, Redding & Evers, 2008) cognitive dissonance theory (Festinger, 1957). show that forced behaviour change does not Recent research shows that laypeople can con- tend to lead to long-term change. To achieve ceive of the erosion of antibiotic effectiveness enduring change, it is necessary to anchor, in due to human activities as an ethical issue and, different ways and using different methods, any furthermore, that they can feel they have the

18 responsibility to act in a fashion that promotes Barriers and the need to overcome them the common good, even if some individual effort Mental barriers constitute another factor af- is involved (Dao, Douglas et al., 2019). fecting consumer behaviour. These barriers are either driven by emotions or based on effort lev- Bandura (2002) has developed different catego- el. The emotionally driven barriers are based on ries of rationalizations that individuals use to different behavioural factors, such as negative or morally disengage from shameful behaviour. positive attitudes and values, while the barriers Moral justification is used to depict the behaviour based on effort level rely on how willing the con- as morally and socially admirable. Individuals sumer is to make the necessary effort to change using this category often claim that their mis- his/her behaviour. conduct served a higher purpose. Advantageous comparison is often used to make misconduct Major efforts to try to change consumer be- look more benign. By comparing one’s own act haviour have been made, but it seems that of misreporting to a more egregious example consumers need to be approached from several of misreporting, one’s own act is reconstructed different directions. Punishments, rewards and as almost trifling and of little importance by regulations are the different methods that have comparison. Displacing responsibility is another been used to put pressure on consumers. Recent common rationalization that is used to reduce studies have looked at the possibility of socially agency in relation to the misconduct. By claim- encouraging consumers to display correct being that misreporting occurred under social haviours, which means putting social pressure pressure, individuals can deny responsibility for on them to act sustainably in their use of antibi- the act or project it onto someone else. Ration- otics. Behavioural studies have highlighted the alization implies that individuals search for rea- role of social norms in bringing about desirable sons and evidence to justify misreporting to the behaviour changes (Nyborg et al., 2016). Effec- self (Haidt, 2001). tive approaches to stewardship could include ap- propriately targeted awareness campaigns about food consumption and responsible consumption, which could have positive effects by educating citizens to be socially conscious.

References Bandura, A. (2002). Selective moral disengagement in the Nyborg, K., J. M. Anderies, A. Dannenberg, T. Lindahl, C. exercise of moral agency. Journal of Moral Education 31(2): Schill, M. Schlüter, W. N. Adger, K. J. Arrow, S. Barrett, S. 101–119. Carpenter, F. S. Chapin, A.-S. Crépin, G. Daily, P. Ehrlich, C. Folke, W. Jager, N. Kautsky, S. A. Levin, O. J. Madsen, S. Dao, B., T. Douglas, A. Giubilini, J. Savulescu, M. Selgelid Polasky, M. Scheffer, B. Walker, E. U. Weber, J. Wilen, A. and N. S. Faber (2019). Impartiality and infectious disease: Xepapadeas and A. de Zeeuw (2016). Social norms as solu- Prioritizing individuals versus the collective in antibiotic tions. Science 354(6308): 42. prescription. AJOB empirical bioethics 10(1): 63–69. Parker, P.M., and Tavassoli, N.T. (2000). Homeostasis and Eckhardt, Giana M., Russell Belk, and Timothy M. Devin- consumer behavior across cultures. International Journal of ney (2010), “Why Don’t Consumers Consume Ethically?” Research in Marketing, 17 (1), 33–35. Journal of Consumer Behaviour, 9 (November/December), 426–36. Prochaska, J. O., Redding, C. A., & Evers, K. E. (2008). The transtheoretical model and stages of change. In K. Glanz, Festinger, L. A. (1957). A theory of cognitive dissonance. B. K. Rimer, & K. Viswanath (Eds.), Health behavior and Evanston, IL, Row, Peterson. health education: Theory, research, and practice (4th ed., pp. 97–121). San Francisco: Jossey-Bass. Haidt, J. (2001). The emotional dog and its rational tail: A social intuitionist approach to moral judgment. Psychologi- Stancu, V., Haugaard, P., & Lähteenmäki, L. (2016). Deter- cal Review 108(4): 814–834. minants of consumer food waste behaviour: Two routes to food waste. Appetite, 96 (1), 7–17. Mazar, N., O. Amir and D. Ariely (2008). The Dishonesty of Honest People: A Theory of Self-Concept Maintenance. WHO (2017). WHO guidelines on use of medically impor- Journal of Marketing Research 45(6): 633–644. tant antimicrobials in food-producing animals.

Murphy, P. R. and M. T. Dacin (2011). Psychological Path- ways to Fraud: Understanding and Preventing Fraud in Organizations. Journal of Business Ethics 101(4): 601–618.

19 Workshop D Antibiotics and antibiotic resistant bacteria in the environment How can behaviour change become part of the solution?

Cecilia Stålsby Lundborg*, Department of Global Public Health, Karolinska Institutet Nada Hanna, Department of Global Public Health, Karolinska Institutet

* [email protected]

Introduction to the workshop and mortality. However, thus far, the problem The attention being paid to the issue of of antibiotic residues and antibiotic resistance pharmaceuticals, especially antibiotics, in the in the environment has mainly been described, environment is increasing, the focus being on and mitigation strategies or solutions – e.g., pharmaceuticals in water. Antibiotic residues take-back programmes and efficient waste- or antibiotic resistant bacteria may end up water treatment plants – are largely lacking in the environment after production, after globally. Besides the risk of resistance leading consumption, after disposal and even after to infections that are more difficult to treat, wastewater treatment. Human behaviour is there are also numerous other risks associated involved in all of these processes. It is known with having antibiotic residues and antibiotic that antibiotics, even in low concentrations, resistant bacteria and genes in the environ- can alter the micro-flora and stimulate the de- ment. Those risks can be both to the environ- velopment and spread of antibiotic resistance ment itself and to animal and human health. in bacteria. One of the main concerns with Increased efforts are thus needed to find solu- antibiotics in the environment is that antibiotic tions that focus on different aspects, not least resistance will be transferred to commensal behavioural aspects, with a view to reducing (normal flora) bacteria and/or to clinical path- antibiotic residues and antibiotic resistant ogens, e.g., through horizontal gene transfer. bacteria and genes in the environment glob- This could lead to bacterial infections that are ally. The workshop will focus on finding and difficult to treat or even untreatable, which in prioritizing effective and feasible behavioural turn would lead to increased morbidity, costs interventions.

20 Antibiotics and antibiotic resistant bacteria in the environment How can behaviour change become part of the solution?

PHOTO CREDITS: © COOPERFIELD/SHUTTERSTOCK

Main focus of the workshop sumer behaviour modification. Below are some The issue of antibiotics in the environment is examples of questions to be discussed during the very broad and cuts across all societal sectors workshop: and actors. Thus, we need to find and address ––Who are the key actors in promoting and the key points where interventions can be most facilitating behaviour change at the local, effective or most easily implemented and where national, regional and global/international behaviour change can truly become part of the level? solution and make a difference. Further, we need ––What behaviours are possible to change in to discuss the situation in countries at all income the short term and in the long term? What levels – high-income countries as well as low- are the ‘low-hanging’ fruits? and middle-income countries (LMICs) – and ––How and in what order should different with the potential need for different mitigation behaviours be addressed? Or can strategies. different behaviours be addressed jointly and simultaneously, through multi- or The main focus of the workshop is on discussing transdisciplinary collaborative efforts? possible behaviour modification interventions/ ––Where are the bottlenecks in changing the actions to reduce the spread of antibiotics in the different behaviours? environment; an additional focus is on produc- ––How can behavioural change be managed ing a ‘call to action’ or a prioritized list of rec- on the ground or in practice? ommendations for necessary behaviour changes. – This list could include behaviours related to –Who will pay for these efforts? everything from production of antibiotics use of antibiotics, disposal of antibiotics, discharge Background to the workshop topic of antibiotics from municipal, hospital, and Antibiotics are one of the more common classes industrial effluent, effective solutions for waste- of medications; they are used in human health, water treatment, and monitoring/surveillance animal health, agriculture and aquaculture as programmes. Actions are needed at all phases well as elsewhere in various types of produc- and in relation to all aspects and actors, from tion processes (WHO, 2010, 2018). Rational legislation to producers, professionals, and con- or appropriate use of antibiotics is commonly

21 addressed in relation to behaviour modification ly (van Boeckel et al., 2014), although in some in health systems. Less frequently addressed is countries like Sweden, it is decreasing.2 the appropriate disposal of unused antibiotics, the above-mentioned discharge of antibiotics in Let us assume that 20% of the population takes effluent or what is actually happening with the one course of antibiotics a year (it is lower in huge amounts of antibiotics that are excreted Sweden, but higher in many countries), and that into the environment after use by humans and each antibiotic course consists of 1500 mg a day. animals. As an example, in the South East Asia region (SEAR), that would amount to 380 million The Global Action Plan on antimicrobial re- people taking one antibiotic course a year. It is sistance (GAP)1 emphasizes the “One Health” estimated that about 50%–90% of consumed approach, i.e., seeing humans, animals, the food antibiotics are released unmetabolized or in bio- chain, the environment and the interconnected- logically active forms in excretion, which means ness between them as one entity. that only considering human consumption, about 500 tons/year or more than 1 ton/day of There is a range of key actors relevant to the antibiotics would be released into the environ- topic of this workshop. They are, e.g., legis- ment in the SEAR. Added to that is animal use, lators/policymakers/governmental agencies, which is estimated to result in roughly similar venture capitalists, industry (producers of sub- quantities. Thus, human and animal use togeth- stances, formulated medicines, diagnostics as er could be adding about 1000 tons of antibiotic well as producers of meat and water for sale, residues to the environment every year in the including bottled water), international organi- SEAR alone. zations, health care producers (health centres, hospitals, nursing homes, etc.) and professionals, Disposal of antibiotics or waste e.g., prescribers for humans as well as animals, containing antibiotics dispensers, pharmacy organizations, consumers, Consumers in many countries are accustomed persons responsible for wastewater treatment, to disposing of unwanted and expired antibiot- risk assessors, etc. – in sum, more or less every- ics through household waste and sewers. Such one in society. disposal practices release antibiotics into the environment, wastewater and water sources. In the following sections, some areas in which For this reason, there is a need to raise public behaviour modification will be needed to reduce awareness and encourage consumers to adopt antibiotic residues in the environment are briefly sustainable practices for disposing of unwanted discussed. This is by no means a comprehensive pharmaceuticals. In Australia, the RUM Project review, but just a presentation of examples relat- focuses on raising consumer awareness to inform ed to the different aspects, including some poten- consumers about the appropriate way to dispose tial behaviour modification recommendations. of medicines.

Production of antibiotics In Sweden, in addition to the regular collection Pharmaceutical plants can release large amounts of unused medicines that has long taken place at of antibiotics into the environment. One study all pharmacies as part of the national medicine estimated antibiotic release in kilograms every strategy, special campaigns have been conduct- day (several tons yearly) from only one cluster of ed during certain months to reach the goal of Indian pharmaceutical industries (Larsson et al., 80% return of unused medicines.3 Special cam- 2007). There are several such clusters in India paigns have also been used by various pharmacy and Bangladesh alone. chains, e.g., giving special bonus points to cus- tomers who return unsuded medications. This Antibiotic use Antibiotic use for humans is high, increasing or expected to increase in many countries global- 2 Swedres, 2019, https://www.folkhalsomyndigheten.se/ contentassets/fb80663bc7c94d678be785e 3360917d1/swedres-svarm-2019.pdf. 1 http://www.wpro.who.int/entity/drug_resistance/ 3 Medical Products Agency, resources/global_action_plan_eng.pdf. https://lakemedelsverket.se/english/

22 HUMAN USE ENVIRONMENT

Therapeutic Water Prophylactic EXCRETION, HOUSEHOLD WASTE, MEDICAL WASTE

Antibiotic residues

FOOD, DRINKING WATER antibiotic residues, resistance genes and bacteria

PHARMACEUTICAL INDUSTRIES Resistant bacteria

Land

NON-HUMAN USE

FOOD, DRINKING WATER Medical antibiotic residues, resistance genes and bacteria Therapeutic Resistance genes Prophylactic

Non-medical Growth promoter EXCRETION, HOUSEHOLD WASTE, MEDICAL WASTE Fishery Industry Agriculture

Potential routes of creation of antibiotic residues in the environment and transmission to and from the environment of antibiotic residues, antibiotic resistant bacteria, and antibiotic resistance genes.

kind of “take-back” programme exists in some resistance, and studies from Asia, e.g., India countries, but seldom or never in LMICs. (Diwan et al., 2013), have reported residues of several antibiotics in hospital wastewater: Moreover, health care facilities dispose of antibi- e.g., up to 240 μg/L of ciprofloxacin, 80 μg/L otics, and this might be done in general waste or of sulfametoxazole. The SEAR of the World in sinks if no facilities are available for collection Health Organization, to which India belongs, or return of unused antibiotics. has about 2,090,000 hospital beds, and each hospital bed is estimated to require 400 litres of Antibiotic residues and antibiotic resistance water a day; so, for only these two antibiotics, in wastewater the residues will be about 250 kg/day. Besides Antibiotics like fluoroquinolones and sulphona- the two above, many other antibiotics are used mides are chemically stable. Their residues are in hospitals. A conservative estimate of residues often detected in the environment, and resist- for all of the antibiotics used in all of the hospi- ance to them is commonly reported (Kummerer, tals in the region would be 500 kg or a half ton/ 2009). Beta-lactam antibiotics produce easily day, i.e., 183 tons of antibiotic residues a year. degradable residues that are not easily detected, However, it must also be remembered that about but that nonetheless contribute to resistance. 80% of antibiotics in human use are used by Identification of a complete sequence of antibiot- out-patients (European Union, 90%) (Stålsby ic resistance genes from soil bacteria and clinical Lundborg & Tamhankar, 2017). pathogens has demonstrated the potential for horizontal gene transfer between environmental Antibiotic residues and antibiotic resistance antibiotic resistant bacteria and pathogenic bac- in other waters teria. High concentrations of antibiotics including flouroquinolones in surface, ground, and drink- Hospital, municipal and industrial wastewa- ing water have been reported from Hyderabad, ter contains antibiotic residues and antibiotic India, and the study suggested that the area in

23 the vicinity of pharmaceutical plants was highly number and vulnerable to antibiotics could be prone to antibiotic contamination, especially lost, in contrast to the antibiotic resistant bacte- when wastewater treatment plants are inefficient ria that would survive. If the bacteria influenced (Fick et al., 2009). Detection of antibiotic resi- have special metabolic functions, the collateral dues in tap/drinking water impacted by waste- damage to the host might lead to human meta- water discharge has also been reported in Asian bolic perturbations and alteration of immuno- countries (Leung et al., 2013; Sharma et al., logic development, which may cause obesity and 2019; Hanna et al., 2018). For example, flouro- affect bone growth (Ashbolt et al., 2013; Ben et quinolones, including ciprofloxacin, were report- al., 2019) ed at high concentration in tap/drinking waters in China (Chen et al., 2018; Meng et al., 2019). Antibiotic resistance poses risks to human health, and there are concerns about the role an- Antibiotic residues have already entered the tibiotic residues in the environment may play in major sources of drinking water for most peo- the selection and spread of antibiotic resistance. ple, and the occurrence of such residues may Examining measured concentrations of antibi- be persistent for several months and may not be otics in aquatic environments where resistance completely removed through use of traditional could develop has recently been emphasized as a disinfection technologies. critical research need if we are to define risks to the environment and public health Wastewater treatment It must be noted that, even in Europe and Aus- Antibiotic residues and the sustainable tralia, significant levels of antibiotics have been development goals detected in effluents from treatment plants, Antibiotic residues and antibiotic resistance in indicating that the current technology does not the environment can threaten or have negative eliminate antibiotics completely. The situation is consequences for many of the sustainable devel- worse in many LMICs, e.g., in South East Asia, opment goals (Jasovský et al., 2016). Some ex- where up to 80% of wastewater is not treated amples are that antibiotic residues and antibiotic and contaminates ground water, surface waters, resistance in the environment directly influence soils and even crops. Innovations and imple- Goal 1 (no poverty) and indirectly influence mentation should target efficient and affordable Goal 2 (zero hunger), as infections with resistant technology to remove antibiotic residues and bacteria will result in high treatment costs and, resistant bacteria, preferably at the point of ori- thus, reduce the available funds. They directly gin. Wastewater treatment plants may also act as influence Goal 3 (good health and well-being). hotspots for antibiotic resistant bacteria (Rizzo Goal 6 (clean water and sanitation) is directly et al., 2013). influenced by antibiotic residues and antibiotic resistant bacteria in the environment. Innova- Photocatalysis (i.e., employing a substance to actions are needed in the area of antibiotic residues celerate a chemical reaction process in the pres- and antibiotic resistant bacteria in the environ- ence of light) using various types of light, such as ment, thus involving Goal 9. Goal 14 and 15 (life solar or UV or LED, is a promising method for below water and on land) are directly influenced disinfection of bacteria and decontamination of by antibiotic residues and antibiotic resistant antibiotics (Das et al., 2018). bacteria in the environment.

Antibiotics in the environment: Desired outcome of the workshop Risks and risk assessment To produce a ‘Call to action’ or a prioritized list Besides risks related to antibiotic resistance, of recommendations for behaviour change (be- antibiotic residues could lead to other risks. An- haviour modification) interventions that could tibiotic residues could interact with the human reduce antibiotic residues and antibiotic resistant microbiome. In this connection, one hypothesis bacteria and resistance genes in the environ- has been put forward suggesting that, during the ment. These behaviour modification interven- course of antibiotic treatment or through human tions could be directed towards various actors exposure to antibiotics via drinking water and and suitable to implement in different contexts. food, the groups of bacteria that were low in

24 References and suggested readings Ashbolt NJ, Amézquita A, Backhaus T, Borriello P, Brandt Kummerer K, 2009. Antibiotics in the aquatic envi- KK, Collignon P, Coors A, Finley R, Gaze WH, Heberer T, ronment–a review–part I. Chemosphere;75: 417–434. Lawrence JR, Larsson DG, McEwen SA, Ryan JJ, Schönfeld doi:10.1016/j.chemosphere.2008.11.086 J, Silley P, Snape JR, Van den Eede C, Topp E, 2013. Human health risk assessment (HHRA) for environmental develop- Larsson DGJ, de Pedro C, Paxeus N, 2007. Effluent from ment and transfer of antibiotic resistance. Environ Health drug manufactures contains extremely high levels of Perspect ;121:993–1001.doi: 10.1289/ehp.1206316 pharmaceuticals. J Hazard Mater ;148:751–5. doi:10.1016/j. jhazmat.2007.07.008 Ben Y, Fu C, Hu M, Liu L, Wong MH, Zheng CM,2019. Hu- man health risk assessment of antibiotic resistance associ- Leung, H. W. et al, 2013. Pharmaceuticals in tap water: ated with antibiotic residues in the environment: A review human health risk assessment and proposed monitoring Environmental Research Volume 169, February , Pages framework in China. Environ. Health Perspect. 121, 839–46 483–493 Meng, T. et al, 2019. Occurrence of antibiotics in rural Chen, Y. H. et al, 2018.Occurrence, Distribution, and Risk drinking water and related human health risk assessment. Assessment of Antibiotics in a Subtropical River-Reservoir Environ. Technol. 23, 1–11 . System. Water 10, 104 . Rizzo, L. et al, 2013. Urban wastewater treatment plants as Das S, Ghosh S, Misra AJ, Tamhankar AJ, Mishra A, Stålsby hotspots for antibiotic resistant bacteria and genes spread Lundborg C, Tripathy SK, 2018. Sunlight Assisted Photo- into the environment: A review. Sci. Total Environ. 447, catalytic Degradation of Ciprofloxacin in Water Using Fe 345–360 . Doped ZnO Nanoparticles for Potential Public Health Ap- plications. Int J Environ Res Public Health. Nov 1;15(11). pii: Sharma, B. M. et al, 2019. Health and ecological risk assess- E2440. doi: 10.3390/ijerph15112440 ment of emerging contaminants (pharmaceuticals, personal care products, and artificial sweeteners) in surface and Diwan V, Stålsby Lundborg C, Tamhankar AJ, 2013. Sea- groundwater (drinking water) in the Ganges River Basin, sonal and temporal variation in release of antibiotics in India. Sci. Total Environ. 646, 1459–1467 . hospital wastewater: estimation using continuous and grab sampling Stålsby Lundborg C, Tamhankar AJ, 2017.Antibiotic res- PLOS ONE Jul 8;8(7):e68715. idues in the environment of South East Asia. BMJ. Sep 5;358:j2440. doi: 10.1136/bmj.j2440. Fick J, Soderstrom H, Lindberg RH, Phan C, Tysklind M, Larsson DGJ,2009. Contamination of surface, ground, and Stålsby Lundborg C, Tamhankar AJ, 2014. Understanding drinking water from pharmaceutical production. Environ and changing human behavior - Antibiotic mainstreaming Toxicol Chem ;28:2522–7.doi:10.1897/09-073.1 as an approach to facilitate modification of provider and consumer behavior. Ups J Med Sci. May;119(2):125–33. Hanna N, Sun P, Sun Q, Li X, Yang X, Ji X, Zou H, Ottoson doi: 10.3109/03009734.2014.905664. J, Nilsson LE, Berglund B, Dyar O, Tamhankar AJ, Stålsby Lundborg C, 2018. Presence of antibiotic residues in vari- Watkinson AJ, Murby EJ, Kolpin DW, Costanzo SD, 2009. ous environmental compartments of Shandong province in The occurrence of antibiotics in an urban watershed: from eastern China and its potential for resistance development wastewater to drinking water. Sci Total Environ ;407:2711- and ecological and human risk. Environ Int. Mar 1;114:131- 23.doi: 10.1016/j.scitotenv.2008.11.059. 142. doi: 10.1016/j.envint.2018.02.003 Wernli D, Jørgensen PS, Parmley EJ, Troell M, Majowicz Hanna N, Purohit M, Diwan V et al, 2020. Monitoring of S, Harbarth S, Léger A, Lambraki I, Graells T, Henriksson Water Quality, Antibiotic Residues, and Antibiotic-Re- PJG, Carson C, Cousins M, Skoog Ståhlgren G, Mohan CV, sistant Escherichia coli in the Kshipra River in India over Simpson AJH, Wieland B, Pedersen K, Schneider A, Chandy a 3-Year Period. Int. J. Environ. Res. Public Health, 17(21), SJ, Wijayathilaka TP, Deboutteville DJ, Vila J, Stålsby Lund- 7706; https://doi.org/10.3390/ijerph17217706 borg C, Pittet D, 2020. Evidence for action: A One Health learning platform on interventions to tackle antimicrobial Jasovský D, Littmann J, Zorzet A, Cars O,2016. Antimicrobi- resistance. www.thelancet.com/infection Published online al resistance—a threat to the world’s sustainable develop- August 24. ment, Upsala Journal of Medical Sciences, 121:3, 159-164, DOI: 10.1080/03009734.2016.1195900 WHO, 2018. Report on Surveillance of Antibiotic Con- sumption. WHO https://apps.who.int/iris/bitstream/hand le/10665/277359/9789241514880-eng.pdf?ua=1

25 Workshop E Making sense of antibiotic resistance Communicate for behaviour change

Linus Sandegren*, Uppsala Antibiotic Center, Uppsala University Eva Garmendia, Uppsala Antibiotic Center, Uppsala University Maria Pränting, ReAct, Uppsala University Alexandra Hoegberg, Uppsala Monitoring Centre

* [email protected]

Aim of the Workshop nication can support changes in habits and Although the looming crisis of antibiotic re- attitudes. Drawing on principles of behaviour sistance is well understood scientifically, the change communication, we will explore ways response thus far has not been proportional to create narratives as well as to tailor and to the scale of the problem. This is partly due deliver messages to different target groups. to a failure in communication. The slow-moving nature of the problem poses a challenge After an inspirational introduction, the work- in communicating its urgency, and the mul- shop participants will discuss and work col- tifactorial nature of the issue necessitates lectively to develop communication messages a complex communications response. The and/or tactics for a set of predefined scenarios shortcomings of antibiotic resistance com- related to antibiotic use and resistance. munication are to some extent caused by a tendency to rely on technical and often ag- Expected outcomes of the workshop gressive language as well as by not sufficiently • Development of a more comprehensive tailoring messages to all relevant contexts and understanding of the concepts of behaviour stakeholders. change communication among the participants as well as the organizations and The aim of this workshop is both to encour- countries they represent. age interaction between different disciplines • Advancement of the discussion on effective and professional groups and to advance communication tactics and messaging re- the discussion on effective communication garding antibiotic resistance. tactics and messaging concerning antibiotic • Development of a set of communication resistance. The workshop will bring together messages or tactics for specific scenarios of experts on communication, social science and relevance to antibiotic resistance. antibiotic resistance to explore how commu-

26 PHOTO CREDITS: © JASON ROSEWELL/UNSPLASH

Slow moving but urgent – the challenge of to resistance. This is no longer the case, which communicating antibiotic resistance means that although the ramifications of antibi- Several factors affect the way we think about a otic resistance are more severe and more urgent problem, and therefore, also how we act. In the than ever before, it is still seen as a problem for case of antibiotic resistance, several things stand the future that does not need to be dealt with out as particularly challenging from a communi- right now. cation perspective. Second, managing antibiotic resistance requires First, antibiotic resistance is perceived to be a that we make a lasting change in our behav- slowly growing threat. We know that pathogens iour, both as individuals and as communities are developing resistance to existing antibiot- – something that is intrinsically difficult. It is a ics and that people are dying as a result right large, multifaceted and global problem that will now, but the rate of this development is slower require larger systemic changes that go beyond than that of a faster moving pandemic, such as individual action. This makes it impossible to Covid-19, and the extent of it is not completely devise a single solution. It also makes it difficult known. Moreover, we have yet to adjust to that for individuals to feel their actions can lead to the current situation is more vulnerable than meaningful change, making it easier to block before. In the past, new types of antibiotics used it out rather than to take action – “what does it to emerge on the market, thus replacing the loss matter if I do something small?” of antibiotics that were no longer effective due

27 Third, given the complexity of the problem and the right knowledge, becoming motivated, ena- the many different levels at which change has bled to act, and conforming to social norms. The to occur, it is imperative that communication same is true of the peer network level and soci- efforts target the relevant stakeholders. This re- etal level – each of which requires an adjustment quires specifically addressing the motivation and to how the factors are applied. possibilities for action of each respective target group. One size does not fit all. At an individual level, knowledge is a powerful factor to change behaviour: I limit my use of an- Even though there are and have been many tibiotics because I know that using them can be directly awareness-raising campaigns on antibiotic re- harmful to my health, and there is a real risk that an- sistance, their impact is not completely known. tibiotics will not work for me in the future. But at a It is difficult to evaluate the effect of a specific societal level, it is challenging to motivate people campaign for several reasons. For example, it is to do what is best for complete strangers, or for hard to define solid metrics with which to meas- unknown future generations. In some instances, ure change. Even a successful campaign might establishing new norms might be the most pow- not show results until later on as a situation that erful way forward: The excessive use of antibiotics requires a changed behaviour may only emerge is frowned upon in my community, so I limit my use of long after the campaign itself, making it difficult antibiotics because I want to conform with the norm. to define in which time frame the success of a campaign should be measured. Additionally, Moreover, it’s crucial to remember that merely these campaigns are often part of bigger efforts conveying information from one party to anoth- and/or are simultaneously ongoing with other er is not the same as successful communication. interventions, making it difficult to attribute a The latter implies that the information has also noticeable effect to one specific communication been received and understood by the audience, campaign or specific target group. which can only be gauged by following up with the audience to check how much of the infor- Communication for behaviour change mation they retained. Messages normally have Behaviour change communication is based on to be repeated several times and from different the idea that human behaviour is influenced sources before an idea really sticks with the audi- at the levels of the individual, the family and ence. Different tactics are routinely employed to peer network as well as the level of society. The get the target audience to pay attention, such as factors that drive change include knowledge, using humour or nostalgia to invoke an emotion- motivation, ability to act, and social norms. For al response, or embedding a message in a sto- a communication campaign to succeed, you first ry-driven narrative that provides the audience need to understand how each factor impacts with an easy-to-remember context. each level. For example, how you educate an individual is not the same way you educate a Given that in many cases, particularly in re- group of people, and how you motivate a society source-limited settings, it may not be possible to change is not dictated by the same drivers to act on the recommendations provided, it is that would motivate a family unit. not feasible to place all of the responsibility for change on the individual. Thus, for communi- Individuals may consider their personal gain, cation campaigns on antibiotic resistance to be and a small network what is best for the people successful, it is important to consider cultural they care about who are closest to them. At the contexts, what types of knowledge, expertise and societal level, you are asking people to take ac- channels are trusted to reach different target tion that may have little direct impact on them groups, as well as to test the messages among the and their peers, but is beneficial to society as a intended target populations. And as emphasized whole. by the WHO World Antibiotic Awareness Week campaign: “although raising individuals’ aware- To create change, each change-inducing factor ness of antibiotics and resistance is important, needs to be applied to each level. The individual the campaign recognizes that real and actiona- will be impacted by a combination of acquiring ble change happens when communities every- where become engaged.”

28 PHOTO CREDITS: © MARK FLETCHER-BROWN, UNSPLASH

Managing antibiotic resistance require that we make a lasting change in our behaviours, both as individuals and as communities.

Creating paths for change behaviours one wishes to change with a cam- Communication and awareness-raising are cru- paign and whether the structures are in place to cial to bringing about large-scale change and enable that change, as well as to deal with any the will to change. But equally important is the potential unintended consequences. Continu- creation of structures that support the desired ously reviewing the results of a communication behaviour and clear the path for new habits, be- campaign is crucial, as it identifies unintended cause without the necessary logistics and options consequences and obstacles, and allows for in place to make the “right” choice, it matters adjustments that could result in more effective little how well-informed an individual is. In hu- campaigns. To give a more specific example, an man health, such a structure could be to make antibiotic-related communication intervention diagnostics available to allow the right treatment based on awareness-raising materials from the choice, and in animal health it might involve World Health Organization in three villages offering support for improving hygiene and in Thailand found that, although participants husbandry practices in farms that can replace aligned with the recommendations provided, the routine use of antibiotics in livestock. fragmented availability of healthcare to some extent limited their ability to act on these rec- This will require political action to: invest fund- ommendations – the structures for change were ing in actions such as educating stakeholders in simply not available (Charoenboon et al., 2019). the healthcare sector and in farming, offer finan- The intervention also brought with it a negative cial compensation to those who have to establish unintended result: One participant started to sell new practices to replace excessive use of antibi- antibiotics because she felt educated enough to otics as well as make alternative treatments or take on the task. methods readily available. Another potential unintended result is the possi- Increased knowledge or awareness does not ble stigmatization of certain groups, as demon- automatically translate to desired actions or be- strated by a case in Denmark. Although the haviours. It is thus important to consider what country is internationally known for fairly low

29 usage of antibiotics in pig farming, a heightened resistance causes the public to feel powerless to awareness of the risks associated with antibiotics take action and unable to be part of the solution in farming linked to overrepresentation of pig (Davis et al., 2020). farmers as carriers of MRSA has resulted in pig farmers being publicly exposed as irresponsible Recent research (Wellcome, 2019) points out users of antibiotics, with stigmatization as a re- that, in order to increase public comprehension sult (Fynbo et al., 2018). and persuade the public and policymakers to make behaviour changes and take action, five How should we improve communication main principles can be applied that lead to bet- about antibiotic resistance? ter communication about antibiotic resistance. Communications, messaging and media cover- These five principles focus on: age on antibiotic resistance today commonly rely on the use of scare tactics and war metaphors. 1. Framing resistance as undermining modern This attracts attention, but is known to be inef- medicine. ficient from a behavioural change perspective, 2. Explaining the fundamentals in a simple and as it easily wears out the recipient and causes straightforward manner. “deflection of the problem”. Moreover, it is prob- 3. Emphasizing that it is a problem that affects lematic from the perspective of creating an often everyone. misplaced fear of microbes. Other problems with 4. Focusing the messages on the here and now. how antibiotic resistance is currently communi- 5. Encouraging immediate action that is within cated extend to: the number of different terms the intended audience’s means. used, for example, “drug resistance”, “antibiotic resistance”, “antimicrobial resistance” and “superbugs”; the multiple frames presented, such These principles highlight the need to frame the as different impact frames on death, economy, problem as a current, relevant and actionable or healthcare; the uneven media coverage; and issue for the target audience. It is of special im- the lack of a mainstream conversation about portance to communicate what actions can be the topic (Capurro, 2020; Krockow, 2020; Well- taken now to stimulate behaviour change. For come, 2019). Additionally, it has been proposed this reason, broad global campaigns without a that the current scientific discourse on antibiotic narrow targeted audience may not work as well for this purpose (Huttner, 2019).

References Suggested readings Capurro G. “Superbugs” in the Risk Society: Assessing the Health Communication Capacity Collaborative HC3. So- Reflexive Function of North American Newspaper Cover- cial and Behavior Change Communication for Emergency age of Antimicrobial Resistance. SAGE Open. 2020;10. Preparedness Implementation Kit. 2016.

Charoenboon N, Haenssgen MJ, Warapikuptanun P, Ledingham K, Steve Hinchliffe S, Jackson M, Thomas F, Xayavong T and Zaw YK. Translating antimicrobial resist- Tomson G. Antibiotic resistance: using a cultural context ance: a case study of context and consequences of antibi- of health approach to address a global health challenge. otic-related communication in three northern Thai villages. WHO Regional Office for Europe. 2019. Policy brief, No. 2. Palgrave Commun. 2019;5:1–24. The ReAct Toolbox - How do people change? Wellcome. Davis M. D. M., Lohm, D. B., Whittaker, A. & Flowers, P. Reframing resistance - How to communicate about antimi- ‘Willy nilly’ doctors, bad patients, and resistant bodies in crobial resistance effectively. 2019. general public explanations of antimicrobial resistance. Sociology of Health & Illness Vol. 42 No. 6 2020. World Health Organization. Communication for behavioural impact (COMBI) - A toolkit for behavioural and social Fynbo L, Jensen CS. Antimicrobial stigmatization: Public communication in outbreak response. 2012. health concerns about conventional pig farming and pig farmers’ experiences with stigmatization. Soc Sci Med. 2018;201:1–8.

Huttner B, Saam M, Moja L, Mah K, Sprenger M, Harbarth S, Magrini B. How to improve antibiotic awareness campaigns: findings of a WHO global survey. BMJ Glob Health. 2019;9:4(3):e001239.

Krockow EM. Nomen est omen: why we need to rename ‘antimicrobial resistance’. JAC-AMR. 2020;2.

30 Interactions between patients and health-care workers are important for proper antibiotic use. Efforts to change social norms and to increase patient--doctor trust can be efficient pathways to change.

31 Workshop F When children relate to the ’wild’ Potentials benefits and perils in human-animal learning encounters

Martin Mickelsson*, Department of Education, Swedish International Center of Education for Sustainable Development, Uppsala University Tanja Strand, National Veterinary Institute, Sweden

* [email protected]

Aim of the workshop The workshop aims to draw on participants’ Practices involving encounters between experiences to explore how we can address humans and animals can be manifested in both the potential benefits and the perils various ways. From the everyday practices of of human-animal encounters, especially for children living with and tending to animals children. in their homes to planned educational activities in which children visit animals at farms, The workshop offers participants an opportu- research has indicated that human-animal nity to: encounters can promote learning among both 1. Reflect on their past experiences of animal adult and children. Meanwhile, such encoun- proximal practices from the perspective of ters also involve the perils of exposure to in- potential benefits and perils and fection and the transmission of resistant genes 2. Develop a vision and action plan concern- between humans and animals. These perils ing how we can facilitate children’s hu- represent the ‘wild’ of zoonosis and antimicro- man-animal encounters, harnessing their bial resistance (AMR), highlighting our limited learning potential while addressing the ability to control all aspects of human-animal ‘wild’ of zoonosis and AMR. encounters. To realize the learning benefits of human-animal encounters, there is a need to account for ongoing microbial processes.

32 PHOTO CREDITS: © ABDELRAHMAN H. HASSANEIN/ISTOCK

People and their livestock in a village near Ngorongoro Crater, Tanzania

The focus of the workshop children who visit animals, whether in the global The workshop aim, as outlined above, can be south or the global north. understood in relation to the body of research that has primarily focused on the perils of hu- As such, the workshop involves two focus areas man-animal encounters. As such, guidelines of investigation: have often been outlined to mitigate these risks ––What are the potentially beneficial and without fully considering the learning potential. perilous conditions for encounters between Meanwhile, the question remains of how we children and animals as part of animal can make this information relevant over time to proximal practices? the specific animal proximal practices and the ––How can the planning and organization of children, regardless of whether they occasionally human-animal encounters be contextually visit or live with animals in their everyday lives. adapted so as to enable children to learn, while mitigating the risk of resistant Furthermore, what opportunities do we have to microbes through zoonosis? ‘inform’ about the perils, while not undermining potentials for learning and promotion of well-be- In line with the purpose and focus areas of the ing in human-animal encounters? workshop, we will enable participants to develop their ability to create understandings (mean- We argue that there is a need to involve practi- ing-making) of health-related information, to tioners as well as would-be visitors and learners critically evaluate health-related information in organizing human-animal encounters. Such and to take conscious health-related decisions efforts would help us find ways to harness the and actions. potential benefits of human-animal encounters while addressing the possible risks. Naturally, The workshop will take its starting point in which children will be involved depends on participants’ past experiences and progress, whether the practices discussed are children’s ranging from developing contextually relevant on-going everyday practices or the practices of understandings of health-related information,

33 PHOTO CREDITS: © FILINECEK/PIXABAY.

Children’s interactions with animals provide many important benefits. How to effectively communicate about infectious disease risk in these encounters without undermining their potential, is an important area for discussion and learning.

through developing criteria for critically evalu- pathogens and AMR were clearly present within ating health-related information, to formulating the studied animals and their environment. The visions and action plans for taking conscious identified pathogens could potentially cause both health-related decisions and actions. mild and severe illnesses.

The resulting action plan(s) can help practition- The workshop ers, teachers, educators in informal education, The workshop will take the form of learning policymakers, politicians, and others to bridge encounters between the participants, health- the implementation gap between health-related related information (specifically AMR), and ‘information’ and health-promoting practices. participants’ experiences. The workshop will As such, the workshop offers participants op- progress from participants developing contex- portunities to explore the potential of children’s tually relevant understandings of health-related learning encounters with animals, while con- information and criteria for critically evaluat- sciously addressing the perils that such encoun- ing health-related information, to formulating ters involve in relation to the ‘wild’, i.e. not fully visions and action plans for taking conscious controllable, aspects of zoonotic diseases and health-related decisions. AMR. The workshop will include three parts, includ- As highlighted by Conrad et al. (2018), signif- ing short lectures/presentations and workshop icant educational opportunities are provided sessions. Part I of the workshop focuses on ‘in- by petting zoos and agricultural fairs – places formation’ regarding the potential benefits and where children and adults can interact with and perils of children’s human-animal encounters. learn about farm animals. Meanwhile, these Part II centres on how the ‘information’ has encounters present significant human exposure been used in various practical implementations to zoonotic pathogens and AMR. In their study, and examples. The workshop session addresses Conrad et al. (2018) concluded that zoonotic Aspect II, how the ‘information’ can be critically

34 evaluated, using a number of example scenarios. M. et al., 2019). Health literacy presents a con- Finally, Part III addresses Aspect III (health ceptual avenue for exploring the relationship literacy), emphasizing learning encounters be- between education and health and offers a way tween humans and animals. Additionally, efforts to bridge the ‘implementation gap’ between to create conditions for learning that emphasize knowledge about health and health-promoting the potential benefits and perils of such encoun- practices (Van der Heide et al., 2013). ters are considered. As part of the workshop session, participants will envision their own im- As concerns educational research on AMR as a plementation and adaptation of the ‘information’ sustainability challenge, the emphasis on health presented during the workshop. Resulting from literacy suggests exciting parallels to the work our workshop, participants will have co-created that has been done in and on science literacy, knowledge regarding the potential benefits and especially related to climate change as a sustain- perils of human-animal encounters as well as ability challenge. how this knowledge can be related to their past, present and future practices. Moreover, health literacy is not limited to developing knowledge, but also concerns facilitat- While the research has offered a range of defi- ing the development of people’s capacities and nitions, health literacy can be described as the improved empowerment with regard to health ability to understand as well as critically evalu- issues, whether these issues affect them person- ate health-related information, further enabling ally or their social and natural environments, conscious health-related decisions to be taken including both animals in food production and (Nutbeam D, 2008; Sørensen et al., 2012; Ward animals in the wild.

References and suggested readings Conrad, C., Stanford, K., Narvaez-Bravo, C., Neumann, N., Munns, K., Tymensen, L., McAllister, T. (2018). Zoonotic fecal pathogens and antimicrobial resistance in Canadian petting zoos. Microorganisms (Basel), 6(3), 70. doi: 10.3390/microorganisms6030070

Nutbeam, D. (2008). The evolving concept of health literacy. Social Science & Medicine (1982), 67(12), 2072-2078. doi:10.1016/j.socscimed.2008.09.050

Sørensen, K., Van den Broucke, S., Fullam, J., Doyle, G., Pelikan, J., Slonska, Z. (2012). Health literacy and public health: A systematic review and integration of defi- nitions and models. BMC Public Health, 12(1), 80-80. doi:10.1186/1471-2458-12-80

Ward, M., Kristiansen, M., & Sørensen, K. (2019). Migrant health literacy in the European Union: A systematic literature review. Health Education Jour- nal. DOI:10.1177/0017896918792700

35 Workshop G Where are our antibiotics? Three possible solutions to addressing antibiotics shortages and improving antibiotics supply globally

Enrico Baraldi*, Department of Civil and Industrial Engineering, Uppsala University, PLATINEA Anna Franzén, Uppsala University Innovation Sofia Wagrell, Department of Civil and Industrial Engineering, Uppsala University

* [email protected]

Antibiotics are a cornerstone of modern med- Aim of the workshop icine, and yet access to established antibiotics Why do antibiotics shortages occur? And is a major problem across the globe. There what solutions can be introduced to avoid are both occasional shortages of old generic these shortages? These questions are dis- products either locally or globally, as occurred cussed in this workshop, with a specific focus in 2017 with piperacillin-tazobactam, and sud- on three potential solutions: (1) more trans- den withdrawals from markets, as occurred in parent supply chains, (2) improved profitability 2016 with ceftibuten. Moreover, many other for antibiotics suppliers and (3) upgraded antibiotics are not registered and supplied at production systems. The workshop will also all in markets considered economically unat- address the need for greater collaboration tractive, such as low-income countries. When among the various stakeholders involved in these antibiotics are not available, patients are the antibiotics field, relying on the experience exposed to unnecessary suffering, healthcare of, for instance, the Swedish collaboration costs surge and antibiotic resistance acceler- platform PLATINEA (www.platinea.se). ates because suboptimal antibiotics have to be used in the place of better options.

The phenomenon of drug and antibiotics shortages is not new, it has been slowly increasing over the past 10 years, and antimicrobials are among the drugs most often in shortage across Europe.

Background Recently, there have also been cases of global The Covid-19 epidemic has brought to the fore antibiotics shortages: Ceftibuten was withdrawn the key problem of drug shortages, as demand from most markets in 2016 due to difficulties for such medicines as painkillers, anaesthetics in transferring production to a new facility; in and some classes of antibiotics peaked while 2017, there was a long-term shortage of pipera- supply was disrupted globally; there were even cillin-tazobactam due to repeated accidents in countries that introduced export restrictions on the core API production facility in China; ben- active pharmaceutical ingredients (API) and zathine penicillin, one of the most common and final products (Chatterjee, 2020). However, the inexpensive antibiotics, was unavailable in 2015 phenomenon of drug and especially antibiotics in almost 40 countries (Nurse-Findlay et al., shortages is not new. Rather it has been slowly 2017) due to insufficient production capacity at increasing over the past 10 years or so (OECD, too few API producers (Cogan et al., 2018). 2020), and antimicrobials are among the drugs most often in shortage across Europe (Miljković Costs and other negative consequences et al., 2019). Other high-income countries, in- of antibiotics shortages cluding the US, are also regularly and increas- Drug shortages entail costs and negative con- ingly being hit by antibiotics shortages (Quadri sequences, which are particularly serious in et al., 2015; US FDA, 2019), not to mention the case of antibiotics due to indirect effects on the notoriously poor access to essential antibi- antimicrobial resistance (AMR) (ReAct, 2020). otics experienced in low- and medium-income While in modern healthcare systems an antibi- countries, as these products have never been otics shortage typically causes additional costs registered in these markets (Pulcini et al., 2018; for replacements in modern healthcare systems, Tängdén et al., 2019). in places where there are no alternatives, like in low-income countries, the extreme consequence

37 is increased mortality. Assessing the costs of rate? What are the reasons for these shortages? shortages is extremely complex, but estimates It is possible to trace a particular shortage event made by some countries indicate USD 20–30 to, for instance, a sudden surge in demand that million per antibiotics shortage (WHO, 2019). could not be met with timely orders, to disas- These costs include the direct fixed administra- ters or accidents, discontinued production or tive cost of identifying, deciding on and procur- quality problems in production, with the latter ing alternative antibiotics, as well as the variable accounting for over 60% of shortage events (US cost of purchasing possibly more expensive an- FDA, 2019; OECD, 2020). However, behind the tibiotics, depending on the country and patient reasons for a single antibiotics shortage event, population size (cf. Miljković et al., 2019). To there is a set of complex root causes at play, most these direct costs one should also add indirect of which concern economic and profitability costs related to longer hospitalization, increased issues (WHO, 2019; US FDA, 2019) related to morbidity and even mortality in situations where the entire antibiotics field, from supply sectors alternative therapies are not available. Unfortu- such as API all the way to end markets. One nately, it is estimated that between 450,000 and overarching problem is that most antibiotics are 800,000 children under the age of five die of “generics” (Cogan et al., 2018), that is, have lost pneumonia annually owing to lack of access to exclusivity and are open to intense competition, antibiotics (ReAct, 2020; Stoppneumonia, 2020), which makes their price fall to the direct advan- and here we are talking about a standard, simple tage of consumers, but which also reduces their antibiotic treatment that would cost only 40–50 profit margins to a point where suppliers may US cents. eventually lose the economic motivation to make them available. Moreover, antibiotics shortages cause a series of other negative consequences that impact on The general problem of low profitability in this AMR. Not receiving the right antibiotic means field can be further broken down into several that patients get a suboptimal antibiotic with specific causes, which in turn generate numer- potentially poorer effect and greater risk of side ous effects that further aggravate the problem of effects, possibly leading to development of more antibiotics shortages. For instance, the Swedish resistance (ReAct, 2020). These outcomes are multi-sectorial collaboration platform PLATIN- particularly likely when a narrower spectrum EA has identified no fewer than 60 such specific antibiotic is in shortage and must be replaced causes. Some of these causes concern the buyer with a broader spectrum one, causing not only side, such as procurement models causing price resistance development among more bacteria, races “to the bottom” (US FDA, 2019; WHO, but also negative effects on the patient’s mi- 2019), the absence of volume commitment crobiome. Further, when the antibiotic of first through long-term contracts or strong fluctua- choice is unavailable, it may be replaced with tions in local demand (Cogan et al., 2018), which “reserve” antibiotics, which should preferably be result in both low profit per unit and uncertainty about used more sparingly to maintain their efficacy volumes – two factors that, if they occur simulta- against more aggressive or resistant bacteria. neously, have a strong negative effect on antibi- This means that the power of antibiotics that otics providers. This problem is aggravated by constitute our last lines of defence, such as colis- manufacturing side causes: The antibiotics produc- tin and meropenem, is unnecessarily reduced. tion system is rigid, that is, not flexible enough to Finally, antibiotics shortages open a door to dis- cope with the aforementioned uncertainty, due honest players who sell expired products without to both regulatory constraints (e.g., moving old authorizations or entirely counterfeit products, products from one plant to another) and techni- which can again cause adverse reactions or be of cal constraints, with plants operating close to full such low concentration that they obstruct treat- capacity, but facing costs of building a new plant ment or accelerate resistance (ReAct, 2020). that exceed USD 100 million (US FDA, 2019). This is a much-needed investment, as many fa- The causes of antibiotics shortages cilities need modernization and upgrading when Considering the immense therapeutic value confronted by, among other things, stricter envi- of antibiotics, how is it possible that shortages ronmental requirements, but it is also a problem- occur, and are even occurring at an increasing atic investment when profitability is so low.

Rewarding suppliers that offer high manufacturing quality and delivery precision, or increasing transparency across supply chains are among the possible solutions for antibiotic shortages.

As a reaction to these challenges on both the Moreover, these global supply chains, stretching buyer and manufacturing side, as well as to across several countries, are longer and ultimate- the pressure to constantly reduce prices, many ly more fragile (US FDA, 2019; Cogan et al., antibiotics providers have opted to offshore the 2018): Their fragmentation causes difficulties production of API to remote locations, which in communication and coordination of physi- in turn results in shortages caused by the supply cal flows, which increase the risk of shortages. sector side: The number of API suppliers has de- This problem is aggravated by yet another root creased, and they are concentrated geograph- cause, namely the lack of transparency concerning ically in a few locations in China and India antibiotics supply chains (US FDA, 2019; WHO, (WHO, 2019; Huq et al., 2016), which exposes 2019), because industrial players consider this in- the supply of antibiotics to disaster risk as well as formation to be strictly confidential and sensitive to geopolitical and global trade risks. Pollution owing to the impact it may have on competition. and discharge of wastewater accelerating AMR This approach reflects, in turn, a broader prob- locally are other risks associated with this geo- lem regarding the norms of the antibiotics field, graphic pattern (Bengtsson-Palme et al., 2014). namely weak collaboration between the various

39 involved stakeholders, such as authorities, aca- gle actors is “multiple sourcing” in various steps demia, industry and healthcare, who typically of the supply chain (Cogan et al., 2018), starting lack forums in which they can meet and discuss from public tenders that, instead of the current solutions to problems such as shortages. “winner-takes-all” approach, split allocations among several suppliers (WHO, 2019). One pos- Possible solutions to antibiotics shortages itive side effect of multiple-winner tenders would Given the many causes mentioned above, several be motivating more suppliers to remain on the solutions have been proposed to address antibi- market, as a way to preserve supply alternatives. otics shortages (OECD, 2020; US FDA, 2019; WHO, 2019; Cogan et al., 2018). Clearly, when Looking even more specifically at the pur- a shortage occurs, it has to be handled immedi- chasing side, another relevant solution is joint ately through, for instance, identification of al- procurement by the governments representing ternative antibiotics or parallel imports (OECD, smaller or unattractive markets (OECD, 2020; 2020). But it is even more important to prevent Tängdén et al., 2018). Finally, an extreme shortages from happening in the first place. measure to ensure supply is to stimulate local Most of the preventive solutions involve innova- production of critically important antibiotics tive economic models and changed behaviours (WHO, 2019), even by relying on not-for-profit on the part of several actors in the entire antibi- producers (OECD, 2020). All in all, there seems otics field. Some of these solutions operate in the to be no scarcity of possible solutions to antibiot- short term, such as introducing early warning ics shortages, but this workshop will focus on the systems, improving stocks (acting as buffers following three solutions: (1) increased transparency against demand fluctuations) and improving of antibiotics supply chains; (2) improved profita- demand forecasts as well as suppliers introduc- bility throughout the supply chain, starting from ing risk management programmes (WHO, 2019; better reimbursement and certainty for suppliers Cogan et al., 2018). (e.g., long-term contracts); two solutions that, in turn, are expected to (3) enable investments in However, to justify major long-term efforts, it is new and upgraded factories, as a way to counteract pivotal to start by clearly quantifying the harms the risks of adverse events such as production caused by antibiotics shortages, something that failures and environmental pollution. The dis- is currently lacking (US FDA, 2019) but that cussion will focus on the pros and cons of these would show the benefits of such efforts. In par- three solutions, as well as the possibilities and ticular, the proposed long-term solutions include obstacles associated with introducing them. the following: providing better financial incentives through additional rewards or alternative International collaboration involving all stake- reimbursement models de-linked from sales holders is another overarching solution to ad- volumes, such as those currently being piloted by dressing drug shortages that has been proposed Sweden and the UK (WHO, 2019); rewarding by, among others, the OECD (2020). Therefore, suppliers that offer high manufacturing quality we will also take the opportunity to discuss the and delivery precision (US FDA, 2019); capac- possibility of creating such collaboration by ity building and investments to strengthen key looking at the experience of the Swedish mul- nodes in supply chains (Cogan et al., 2018); and ti-sectorial collaboration platform PLATINEA, increasing transparency across supply chains which involves academia, industry, healthcare to allow all stakeholders to identify supply risks and public authorities working together to de- related to specific locations and plants (US FDA, velop solutions against antibiotics shortages 2019; WHO, 2019; Tängdén, 2018). Another (www.platinea.se). important solution to avoid dependence on sin-

40 References Bengtsson-Palme, J., Boulund, F., Fick, J., Kristiansson, E., ReAct (2020). Shortages and AMR – why should we care? 4 Larsson, D.G.J., (2014). Shotgun metagenomics reveals a consequences of antibiotic shortages. Available at: wide array of antibiotic resistance genes and mobile ele- https://www.reactgroup.org/news-and-views/news-and- ments in a polluted lake in India, Frontiers in Microbiology, opinions/year-2020/shortages-and-amr-why-should-we- 5, 648. care-4-consequences-of-antibiotic-shortages/

Chatterjee P., (2020). Indian pharma threatened by COV- Stoppneumonia (2020), Tackling pneumonia could avert ID-19 shutdowns in China. The Lancet; 395(10225): 675. almost 9 million child deaths this decade. Available at: https://stoppneumonia.org/wp-content/uploads/2020/01/ Cogan D, Karrar K, & Iyer J., (2018). Shortages, stockouts JHU_List_Briefing_24012020_final2.pdf and scarcity: the issues facing the security of antibiotic supply and the role for pharmaceutical companies. Access Tängden, T., Pulcini, C., Aagaard, H., Balasegaram, M., Levy to Medicine Foundation. Hara, G., Nathwani, D., Sharland, M., Theuretzbacher, U., & Cars, O. (2018). Unavailability of old antibiotics threat- Huq, F., Pawar K.S., & Rogers, H., (2016), Supply chain ens effective treatment for common bacterial infections, configuration conundrum: how does the pharmaceutical Lancet Infectious Diseases, 2018;18:242–244. industry mitigate disturbance factors?, Production Plan- ning & Control, DOI: 10.1080 / 09537287.2016.1193911 US FDA (2019), Drug shortages: root causes and potential solutions. Miljkovi, N., Gibbons, N., Batista. A., et al., (2019). Results of EAHP’s 2018 Survey on Medicines Shortages European Vyas, M., de Vries, E.G., Casali, P.G., & Tabernero, J. (2019). Journal of Hospital Pharmacy 2019; 26:60–65. Shortages of inexpensive essential medicines. The Lancet Oncology, 20(5): e224-e5 Nurse-Findlay, S., Taylor, M.M., Savage, M., Mello, M.B., Saliyou, S., Lavayen, M., et al. (2017). Shortages of benza- WHO (2019). Meeting Report Antibiotic Shortages: thine penicillin for prevention of mother-to-child transmis- Magnitude, Causes and Possible Solutions. Norwegian sion of syphilis: An evaluation from multi-country surveys Directorate of Health, Oslo, Norway 10–11 December and stakeholder interviews. PLoS Med 14(12): e1002473. 2018. Available at: https://apps.who.int/iris/bitstream/ handle/10665/311288/WHO-MVP-EMP-IAU-2019.02-eng. OECD (2020). Shortage of medicines in OECD countries, pdf?ua=1 Directorate for Employment, Labour and Social Affairs. Health Committee. Suggested readings Pulcini, C., Beovic, B., Béraud, G., Carlet, J., Cars, O., How- Cedervall, I, Molin, L., Faghihi, L., Ali Mohsen, L., & Yek- ard, P., ... & Sharland, M., (2017). Ensuring universal access erusta, R., (2020). An Investigation of Aspects Affecting to old antibiotics: a critical but neglected priority. Clinical Availability and the Health-economical Consequences of Microbiology and Infection, 23(9), 590–592. Shortages of Vancomycin and Piperacillin/Tazobactam, Bachelor Thesis –Pharmaceutical Chemistry Program, Quadri F., Mazer-Amirshahi, M., Fox, E.R., Hawley, K.L., Uppsala University. Pines, J.M., Zocchi, M.S., et al. (2015). Antibacterial drug shortages from 2001 to 2013: implications for clinical prac- PGEU (2019), PGEU Survey on medicines shortages 2019, tice, Clinical Infectious Diseases, 2015;60:1737e42. https://www.pgeu.eu/wp-content/uploads/2019/03/ PGEU-Medicine-Shortages-Survey-Results-2019.pdf

41 Workshop H Teaching antimicrobial resistance Educating young people to be change agents

Eva Lundqvist*, Department of Education, Uppsala University Malena Lidar, Department of Education, Uppsala University

* [email protected]

We want our children to have the benefit of is a need for teaching that helps students pay growing up in a world where it is possible to attention to, and see connections between, cure common diseases, such as pneumonia or the many concurrent perspectives of rele- meningitis, successfully treat complex diseases vance: medical, ecological, technical, ethical, such as cancer and to do surgery without im- social and economic perspectives. With this in minent risk of incurable infection. Therefore, mind, we would like the workshop to address, we need our children – the next generation of in particular, what education should include citizens – to feel competent, able and willing if it is to produce students who can act com- to contribute to the work of preserving the petently in relation to AMR issues, and how power of antibiotics as effective medicine for this competence is best taught in the context bacterial infections in humans and animals. If of a formal education system. The workshop we are to give children the competence they discussion will be guided by the following need to take action to preserve antibiotics, it questions: is not enough to teach them the medical or • What does teaching need to address, in- epidemiological facts; they also need to learn cluding both facts and values, to educate values and priorities associated with the emer- students and ensure their competence and gence and spread of antimicrobial resistance willingness to act in relation to AMR issues? (AMR) as well as to transform their knowledge • How can we work to enable teachers to and values into practical actions. feel confident about teaching issues of high complexity, including multiple perspectives Aim of the workshop and, at times, conflicting interests and In this workshop, we want to bring together needs? a group of educators, curriculum experts, pol- • How is it possible to teach about a topic icymakers and health experts to discuss the that may have very severe consequences role schools can play in giving young people without students becoming scared or disil- the competence they need to act responsibly lusioned about the future? and preventively as well as to, when antibiot- • How do we work to accumulate, sustain ics are necessary, use them wisely. In address- and disseminate experiences of and build ing the multi-sectorial nature of AMR, there a knowledge base around teaching about AMR?

Habits are something we learn early. Formal education provides a potential to influence them in a positive direction.

Situating education and priorities regarding the use and overuse of Establishing effective education in AMR has antibiotics. been highlighted as a high priority area, both in the UN Sustainable Development Goals (UN, Designing lesson plans always involves selecting 2015, §26) and in the WHO Global Action Plan what content to include and what methods to use for Antimicrobial Resistance (WHO, 2015). Ed- in conveying this content. These choices must be ucation is seen as crucial to creating awareness made with regard both to students’ prior knowl- of AMR and increasing people’s opportunities to edge and to their experiences, also considering develop responsible habits. the school system’s regulations. This situation poses a challenge to schools and teachers, es- Children spend much of their day at school, and pecially because the schools must educate both given that good habits are established early in students who are considering a career in science life, schools could have an important role to play and students who will use their scientific knowl- in promoting better understanding, awareness edge in everyday life. and action competencies in relation to AMR. Schools in most countries reach all children Challenges for education regardless of their socio-economic situation, The responsibility for addressing the content of gender and ethnicity, and if parents and relatives AMR, if it is addressed at all, frequently falls also get involved, a large proportion of the popu- on the science teacher. Previous research has lation will be reached. shown that teachers often find it difficult to teach about issues that concern questions for which a Getting people to change their behaviour in- scientific answer is not sufficient (Zeidler et al., volves learning new habits, including knowledge 2005). Teachers tend to hesitate to include con- and values, as well as acquiring the skills needed tent from different disciplines in their teaching. to transform their knowledge and values into Apart from the difficulty of teaching subjects making new priorities and creating new behav- one does not fully master, teachers fear that their iour patterns. In teaching, there are opportuni- “own” subject content may suffer and that it will ties to introduce and discuss the issues of values be hard to find relevant teaching material that

43 integrate different subject areas in a productive knowledge about both the issue and the deci- way (e.g., Tytler, 2012). sion-making processes involved. Moreover, he/ she is able to consider different perspectives, take The disciplinary components of AMR have a critical but positive stance on the issue at stake also proven to be difficult to learn and master. and has confidence in his/her ability to make Studies investigating AMR have shown that the a change for the better. This way of thinking majority of university-level students have mis- about teaching AMR places great demands on conceptions about AMR and often rather use the ability to weigh different considerations and intuitive reasoning to explain the evolutionary critical thinking skills. processes about AMR (e.g., Richard et al., 2017). At the lower secondary school level, reports on Action and innovations to support teaching scores from national tests in Sweden have shown Regarding the educational research on AMR that items testing knowledge about AMR were as a challenge to sustainability, there is a need very difficult for both high- and low-achieving for more knowledge about AMR in relation to students (Lind Pantzare et al., 2015). Thus, more teaching and learning in formal education, yet research and development are needed concern- some studies have made important contribu- ing teaching and learning about AMR. tions. For example, Fridrichsen et al. (2016) presented a design case for teaching AMR in upper Perspectives from science education secondary school biology as well as the key chal- On a general level, selecting what content should lenges they have encountered in this work. Their be included in science education has been de- ambition was to situate the content of AMR in a scribed as a struggle between two approaches: societal context, thereby engaging the students Vision I and Vision II (Roberts, 2007). Simply in examining the social aspects of the issue from put, Vision I is based on the belief that if one multiple perspectives. learns scientific facts and methods, one can automatically apply this knowledge when the situ- Additionally, there have been several national ation requires. In Vision II, the argument is that and international educational efforts to influence the ability to apply scientific knowledge requires and support public knowledge about AMR. special knowledge, skills and values concerning Such initiatives have typically been taken by au- how to apply this knowledge, and that acquir- thorities or organizations, aiming to inform and ing them also requires a learning process. For educate citizens. Some of the projects have been example, involving students in decision-making directly related to the curricula in a specific con- also includes their learning competences, such as text and are, thereby, available for teachers to argumentation skills. In such situations, students use. There has been a tendency in these efforts must be able both to cope with disagreements to assume there is a link between public aware- and to put forward their own arguments in re- ness of, knowledge about or certain attitudes sponse to others’ opinions. towards AMR and the propensity to act in what is often described as a ‘rational’ way. Still, the In Vision II education, it is not enough for stu- question remains as to whether and how more dents to learn facts about AMR; teaching must knowledge can lead to changes in behaviour. also include practising how to apply scientific knowledge in authentic situations where evalu- The question of teaching and learning AMR ation of different options is necessary, enabling in relation to behaviour change has not been students to use this knowledge and act upon the addressed to a great extent, and we maintain issues at hand. that there is a need to further develop knowledge about how this can be done fruitfully in teach- If students are to become “action competent”, ing. One major problem in education is that the they must be given opportunities to practise teaching profession does not have established multiple kinds of skills (e.g., Jensen & Schnack, methods for professional knowledge exchange. 2006). Sass et al. (2020) discuss what character- If we could enable teachers around the world to izes an action-competent person. In their view, share their lesson plans, teaching material, etc., this person is devoted to and passionate about with each other, time and money could be saved, solving societal issues; he/she also has relevant while at the same time increasing the quality of teaching.

44 Students’ interest in and engagement How can we help schools and teachers with the subject plan AMR education that promotes One of the reasons for encouraging use of au- action competence? thentic problems and students’ genuine partic- We live in a time with great local and global ipation in education is that this is one way to sustainability challenges – challenges for which create engagement with an issue. Engagement there are no clear-cut solutions. In this text, we with a subject can be achieved when participants have highlighted the need to re-think traditional feel an emotional connection to what is being modes of teaching, which are often character- discussed (Östman, van Poeck & Öhman, 2019). ized by transferring an established set of facts However, it may be challenging to encourage about an issue. We argue that there is a need emotional attachment to a subject students have for citizens to have knowledge about AMR, but limited experience with. Research in the area also the competence needed to act and change of climate change education has shown that stu- behaviour in relation to AMR issues, thus, to dents experience feelings of anxiety, worry and make a change. The question is: What can for- helplessness, but also hope, when presented with mal education do so that students will be able future prospects (e.g., Ojala, 2016). Many times, to contribute to preserving the effectiveness of worry is seen as wholly negative, as it distracts antibiotics? people from the essential question, makes them unreceptive to new information, and causes In this workshop, we wish to discuss how we can them to focus on their own self-interest, all of work to ensure that a diverse future generation which prevent change. But Ojala argued, on the has relevant knowledge about both the emer- contrary, that recognizing and addressing these gence and spread of AMR as well as about the feelings may also be a driver of engagement. decision-making processes involved. How can Such engagement can motivate students to ac- we see to it that this generation is committed to quire subject knowledge as well as to think criti- and passionate about solving the problem? How cally, deliberate, engage in problem-solving and can we promote students’ confidence in their discover more sustainable habits. own ability to make a change in the conditions that will shape the future? This challenge involves operationalizing and concretizing a form of teaching about AMR that enables this kind of learning.

References Fridrichsen, P., Sadler, T. D., Graham, K. & Brown, P. (2016). Tytler R. (2012). Socio-Scientific Issues, Sustainability and Design of a socioscientific issue curriculum unit: Antibiotic Science Education. Research in Science Education, 42(1), resistance, natural selection and modelling. International 155–163. Journal of Designs for Learning, 7(1), 1–18. United Nations (2015). Transforming our World: The 2030 Jensen, B. B. & Schnack, K. (2006). The Action Competence Agenda for Sustainable Development. New York: UN. Approach in Environmental Education. Environmental Education Research 12(2), 471–486. WHO (2015). World Health Organization. Global Action Plan on Antimicrobial Resistance. Retrieved from: Lind Pantzare, A., Abrahamsson M., Almarlind, P. & Lund- http://www.who.int/antimicrobial-resistance/publications/ gren C. (2015). Ämnesproven i grundskolans årskurs 9 och global-action-plan/en/ specialskolans årskurs 10: Vårterminen 2015. Umeå: Umeå University. Zeidler, D. L., Sadler, T. D., Simmons, M. L., & Howes, E. V. (2005). Beyond STS: A research-based framework for Ojala, M. (2016). Facing anxiety in climate change educa- socioscientific issues education. Science Education, 89(3), tion: From therapeutic practice to hopeful transgressive 357–377. learning. Canadian Journal of Environmental Education, 21, 41–56. Östman, L., van Poeck, K. & Öhman, J. (2019). A transac- tional theory on sustainability learning. In K. van Poeck, Roberts, D. A. (2007). Scientific literacy/Science literacy. In L. Östman & J. Öhman Eds.), Sustainability development S. K. Abell & N. G. Lederman (Eds.), Handbook of Research teaching. Ethical and political challenges. New York: on Science Education (pp. 729–780). Mahwah, NJ: Law- Routledge. rence Erlbaum.

Sass, W., Boeve-de Pauw, J., Olsson, D., Gericke, N., De Maeyer, S., & Van Petegem, P. (2020). Redefining action competence: the case of sustainable development. The Journal of Environmental Education, 51(4), 292–305.

45 Governance Steering Committee Project management Chair: Professor Anders Malmberg Anna Ledin Uppsala University Project Manager Uppsala Health Summit and Senior Advisor, Uppsala University Joakim Brandberg Acting Director General, Swedish Medical Kerstin Stewart Products Agency Program Coordinator, Uppsala Health Summit, Uppsala University Maria Knutson Wedel Vice Chancellor, Swedish University of Agricultural Hang Nguyen Sciences Administrator, Uppsala Health Summit, Uppsala University Marie Lindquist Senior Advisor, Uppsala Monitoring Centre Monika Gutestam Hustus Communicator, Uppsala Health Summit, Ann Lindberg Uppsala University Director General, National Veterinary Institute, SVA Charlotte Skott Program Committee Director Business and Economic Development, Chair: Ulf Magnusson City of Uppsala Professor of Animal Reproduction, Department Christer Svensson of Clinical Sciences, Swedish University of President, World Class Uppsala Agricultural Sciences

Emilie Orring Mirko Ancilotti Chair: Uppsala County Council Executive Committee PhD student, Department of Public Health and Caring Sciences, Centre for Research Ethics & Bioethics (CRB), Advisory Board Uppsala University Chair: Anders Milton Enrico Baraldi Former chairman of the Council of the World Medical Professor, Department of Civil and Industrial Association; former CEO and Secretary General of Engineering, Project Manager PLATINEA, the Swedish Medical Association, of the Swedish Red Uppsala University Cross and of the Swedish Confederation of Professional Eva Garmendia Associations Project Coordinator, Uppsala Antibiotic Center, Elisabeth Björk Uppsala University VP, Head of Cardiovascular and Metabolic Development Christina Greko Unit (CVMD), AstraZeneca Associate Professor, Strama VL, Department of Professor Florence Haseltine Animal Health and Antimicrobial Strategies, Founder, Society for Women’s Health Research; National Veterinary Institute, Sweden Former Director, NIH Center for Population Research Alexandra Hoegberg Bernadette Klapper Head of Global Communications, Uppsala Director of Health, Robert Bosch Foundation Monitoring Centre

Ingrid Wünning Tschol Malena Lidar Senior Vice President, Strategy, Robert Bosch Senior Lecturer, Department of Education, Foundation Uppsala University

Maria Stella de Sabata Olof Lindahl International Diabetes Federation European Region, Associate Senior Lecturer, Department of and Advisor, Fondo Elena Moroni per l’Oncologia. Business Studies, Uppsala University 46 Eva Lundqvist Senior Lecturer, Department of Education, Uppsala University

Birgitta Lytsy Medical Specialist in Infection and Control, Department of Clinical Microbiology and Infection Control, Uppsala University Hospital

Martin Mickelsson PhD Candidate, Department of Education, Uppsala University

Cecilia Nilsson Collaboration manager at UU Innovation, Deputy Project-manager PLATINEA, Uppsala University

Anna-Carin Nordvall Senior Lecturer, Department of Business Studies, Uppsala University

Maria Pränting Scientific Coordinator, ReAct, Uppsala University

Linus Sandegren Senior Lecturer, Department of Medical Biochemistry and Microbiology, Project Coordinator at Uppsala Antibiotic Center, Uppsala University

Tanja Strand Coordinator of One Health Sweden, Scientific Administrator at National Veterinary Institute, Sweden

Cecilia Stålsby Lundborg Professor, Health Systems and Policy (HSP): Medicines, focusing on Antibiotics, Department of Global Public Health, Karolinska Institutet

Sofia Wagrell Lecturer, Department of Civil and Industrial Engineering, Uppsala University

Alexandra Waluszewski Professor, Department of Economic History, Science and Technology Studies Centre, Uppsala University

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