Evaluation of Antibiotic Awareness Campaigns

WHO Collaborating Centre on Patient Safety The University of Geneva Hospitals and Faculty of Medicine 4, Rue Gabrielle Perret-Gentil 1211 Geneva, Switzerland

Evaluation of antibiotic awareness campaigns

Report prepared by Mirko Saam, Benedikt Huttner and Stephan Harbarth1 for

World Health Organization Expert Committee on the Selection and Use of Essential Medicines Policy, Access and Use (PAU) Department of Essential Medicines and Health Products 20, Avenue Appia 1211 Geneva 27, Switzerland

1 [email protected]; [email protected]; [email protected] 1 SUMMARY 1

INTRODUCTION 2

KEY FINDINGS OF THE SURVEY 3

OUTLINE OF SURVEYED CAMPAIGNS 3 TARGET AUDIENCES 5 INFECTIONS TARGETED 7 KEY MESSAGES AND ESSENTIAL PUBLIC SLOGANS 8 GLOBAL VERSUS LOCAL KEY MESSAGES 11 “NEW” KEY MESSAGES IDENTIFIED 12 INTERVENTIONS USED IN THE CAMPAIGNS 13 EVALUATION OF THE CAMPAIGNS 14 OBSTACLES FACED WHILE IMPLEMENTING A PUBLIC AWARENESS CAMPAIGN 15

POTENTIAL FOR EXPANSION IN NEW DIRECTIONS 15

ACKNOWLEDGMENTS 17

APPENDIX I - METHODOLOGY I

APPENDIX II - SUMMARY TABLE I

APPENDIX III - QUESTIONNAIRE USED FOR THE SURVEY I

REFERENCES 18

SUMMARY

● Between September and November 2016, we conducted an online survey to review the characteristics of public awareness campaigns targeting antibiotic use conducted since 2010. We identified 60 campaigns implemented on a national (n=42, 70%), regional (14, 23%) or both levels simultaneously (2, 2%), across 16 low- and middle- income countries (LMICs), and 31 high-income countries. Respondents from another 8 countries (5 LMICs and 3 high-income countries) either stated they were not sure, or that there was no such campaign in their country. Among the 93 countries that were contacted, 38 (40%) did not respond at all.

● All but 12 (20%) campaigns targeted the general public and physicians simultaneously, with wide variations among the specifically targeted groups in the population (e.g. parents of young children, caregivers, etc.) and among the healthcare professionals (e.g. GPs, paediatricians, etc.).

● There were no major differences between middle-income and high-income countries in the type of key messages used in the campaigns. "Misuse/overuse of antibiotics causes resistance” (n=47, 78%) and "If we use antibiotics incorrectly we will lose them / they will become ineffective" (43, 72%) were the most commonly used key messages, followed by "Hand washing can reduce the spread of infection / Wash your hands", "Judicious / prudent / responsible / appropriate / adequate use of antibiotics is important" and "Antibiotics do not work against colds / flu" (used in 41 (68%) campaigns each).

● In the context of this survey we tried to identify and categorize messages which could be used by future campaigns. In general, it seems essential to base the campaigns messages more rigorously on scientific evidence and behavioral change concepts, while considering the particular context of each country. New key messages identified through this survey reveal, to a certain extent, the increasing prominence of the One Health approach in antibiotic awareness campaigns.

● The distribution or dissemination of education and communication material (either offline (87% of the campaigns) or online (77%)) was the intervention most frequently implemented. Other types of interventions included public relation activities, press conferences, training sessions for prescribers, and active promotion or distribution of guidelines.

● According to this survey, respondents reported that both human and financial constraints have posed significant barriers to implementing campaigns or to achieving a clinical or public health impact. Lack of political support, and an enduring

1 gap between common practices and suggested actions, are potential major obstacles to translating campaigns into concrete results.

● Evaluation of the impact of antibiotic awareness campaigns is still suboptimal, with 36 of 60 campaigns (60%) reporting no formal evaluation. Most of the campaigns that were formally evaluated (n=24, 40%) relied on the monitoring of antibiotic use to assess their impact (17, 28%), and/or surveillance of antibiotic resistance rates (13, 22%). The most effective messages and interventions remain unclear. The lack of thorough evaluation, the absence of prospectively determined control groups and the multifaceted nature of most campaigns makes any formal conclusions difficult. It seems, however, that some campaigns were associated with a reduction in overall antibiotic use.

● More research is required to better understand which key messages and which types of interventions work best in different setting. Nevertheless, based on the results of this survey, recommendations can already be made to enhance the deployment of communication activities related to antibiotics.

INTRODUCTION

Tackling the global spread of antibiotic resistance is a high priority for the World Health Organization (WHO). On the one hand, as part of the implementation of Objective 1 of the Global Action Plan on Antimicrobial Resistance, WHO is coordinating a global campaign to raise awareness and encourage best practices among the public, policymakers, as well as health and agriculture professionals.1 On the other hand, the list of “Critically Important Antimicrobials” has been established as a reference to help formulate and prioritise strategies for containing antibacterial resistance, and is intended for public health and animal health authorities, practicing physicians and veterinarians, and policymakers. The appropriate application of the “Critically Important Antimicrobials List” supports the implementation of the Global Action Plan’s Strategic Objective 1 -- to improve awareness and understanding of antimicrobial resistance -- as the list is an important component to assure the responsible use of antibiotics and for controlling the potential spread of resistant microbes through the food chain.

There is good evidence that public campaigns promoting responsible antibiotic use may be associated with reductions in overall antibiotic use. The individual impact of various public campaigns in Europe between 1997 and 2007 has been estimated to be equivalent to a 6.5– 28.3% drop in the mean level of overall antibiotic use.2 Factors leading to successful awareness campaigns include carefully designed and simple key messages; targeting a wide audience such as patients, their families and healthcare workers; engaging physicians and other healthcare professionals early in the campaign and designing the key messages with them; using mass media and social media; and continuously repeating key messages.3 4 The latter is of outmost importance, as experiences in Belgium and France have shown. In

2 these two countries national campaigns have reduced overall antibiotic consumption, but it has been difficult to sustain successes over time. Experience from other public health campaigns shows that repeated exposure of the targeted public over long periods of time is often necessary to exert a sustained effect.5 6

In its “Worldwide country situation analysis: response to antimicrobial resistance” report published in 2015, WHO stated that there are large variations across regions in the percentages of Member States that have conducted campaigns to educate the public about the appropriate use of antibiotics (e.g. 2% of countries in the WHO African Region vs. 42% in the WHO European Region). A multi-country public awareness survey on antibiotic resistance performed by WHO in 2015 highlighted that levels of knowledge around the appropriate use of antibiotics — including how and when to use antibiotics and what they should be used for — are mixed, but rather low in all regions. This is an alarming situation, particularly in countries where antimicrobial medicines are readily available over the counter without a prescription.

In this context, WHO has mandated a team of researchers at the WHO collaborating center at the Geneva University Hospitals (Mirko Saam, Benedikt Huttner and Stephan Harbarth) to conduct an international survey of antibiotic awareness campaigns in order to fill some of the knowledge gaps and help the planning of future initiatives. The survey captured information on the design of campaigns in different contexts; this report compiles the data in an effort to facilitate information sharing and learning across countries.

KEY FINDINGS OF THE SURVEY

Outline of surveyed campaigns2

In mid-October 2016, invitations to participate in the survey were sent by email to a total of 93 countries, through WHO Regional offices and National Focal Points, and to persons in charge of antibiotic awareness campaigns; the countries to be contacted were identified through a preliminary review of the scientific literature and previously established contacts of the survey team.

Consolidated answers represent a total of 60 campaigns, implemented in 16 low- and middle-income countries, and 31 high-income countries (12 countries reported more than one campaign); 47 countries contacted (51%) provided positive answers, 8 (9%) stated there was no campaign implemented in their country and 38 (40%) did not provide any answer, despite several reminders.

2 The methodology is detailed in APPENDIX I and a summary table highlighting the main characteristics of the campaigns is provided in APPENDIX II. 3

Map of countries included in the survey. Blue: antibiotic campaign conducted since 2010 (LMICs = light blue / high-income countries = dark blue). Red: answered “no campaign” OR “not sure” to have had a campaign since 2010. Yellow: contacted, but no answer received, Grey: not contacted..

Classified by WHO regions, 3 campaigns took place in the African Region, 9 in the Region of the Americas, 6 in the South-East Asia Region, 35 in the European Region, 2 in the Eastern Mediterranean Region and 5 in the Western Pacific Region. Campaigns were reported even in some countries with a relatively low use of antibiotics, such as the Netherlands and Scandinavian countries. Most campaigns (45/60, 75%) were implemented on a national level and 15 of them (25%) on a regional level.

Three quarters of the countries (35/47) represented in this survey mentioned the existence of a national strategy to reduce antimicrobial resistance, which includes actions to disseminate information towards the public. Nevertheless, in most cases (47/60), campaigns were launched and supervised by health authorities, even in the absence of a national strategy.

The following stakeholders were involved in designing and/or conducting the campaign: infectious diseases specialists (48 campaigns, 80%), microbiologists (42, 70%), primary care physicians (34, 57%), professional societies (33, 55%), advertising companies or communication specialists (21, 35%), patients or patient interest groups (19, 32%) and international experts (18, 30%). Epidemiologists or public health experts (6, 10%) and pharmacists (5, 8%) were also associated in the implementation of some campaigns. The campaign implemented in Alberta (Canada) also involved school curriculum experts, early childhood educators, occupational health nurses, the well public (e.g. workers and employers, in contrast to patients) and even medical students.

Based on the responses only 4 of the 60 campaigns involved psychologists or medical sociologists in the design or conduct of the campaigns. These specialists should increasingly be associated in the definition and implementation of campaigns for achieving effective and sustainable behaviour change regarding antibiotics.7

Data on budgets and funding sources were provided by 32 (53%) campaigns and reflect widely varying volume and intensity, from simple campaigns with a budget of a few thousand US dollars, to expensive mass-media campaigns with budgets in the range of millions of USD per year. It should, however, be noted that these numbers are rough estimates including varying items (e.g. staff salaries, cost for producing and/or disseminating material, etc.). The majority of campaigns (47, 78%) were publicly funded by regional or national health authorities. Some campaigns also received complementary funding from foundations, charities or non-governmental organisations (12, 20%), United Nations agencies (11, 18%), professional societies (9, 15%), public (7, 12%) or private (1) health insurances, the pharmaceutical industry (5, 8%), universities (1), foreign embassies (1) and donations (1).

Only 25 (42%) campaigns were designed to run all year, 18 (30%) were seasonal and 17 (28%) temporary (e.g. for a few weeks during the year but independent of the season). Most campaigns (48, 80%) were “ongoing” at the time of the survey.

Most countries represented in this survey were participating in the World Antibiotic Awareness Week (38, 63%) and/or in the European Antibiotic Awareness Day (35, 58%). In fact, 6 campaigns directly referred to the local implementation of the European Antibiotic Awareness Day and highlighted the many forms of its local adaptation.

For information about countries which have not implemented campaigns, please refer to Appendix IV.

Target audiences

Since children are frequently (over-)prescribed antibiotics, 24 campaigns (40%) specifically targeted parents of young children, and 20 campaigns (33%) targeted personnel of day-care centres and teachers in schools. Interventions specifically aiming at school-age children and adolescents were also implemented, but only by 18 campaigns (30%). Other groups which have a higher than average exposure to antibiotics or are at increased risk of transmission of resistant pathogens, such as the elderly and travelers, were targeted by 8 and 1 campaigns, respectively. A third of the campaigns targeted journalists (20) or hospital patients (20), while just one aimed at politicians or policymakers (Antibiotic Guardian - UK). Interestingly, 6 campaigns (Armenia, Chile, France, Malta, the Republic of Macedonia and UK (Antibiotic Guardian)) also targeted pet owners or veterinarians, in line with the One Health approach.

Since the ultimate decision to use antibiotics lies with physicians in most cases, 43 campaigns (72%) directed their interventions towards general practitioners and family physicians, 29 (48%) to paediatricians and 29 to medical specialists. Pharmacists, nurses and dentists were respectively targeted by 32, 19 and 14 campaigns. Healthcare facility staff and administrators, caretakers at nursing homes, and pharmacy, nursing and medical students were also specifically targeted in some cases.

The answers collected did not allow to discern the effects of targeting specific groups on the effectiveness of the campaigns. The scientific literature suggests that addressing specific subgroups of the public and healthcare professionals could increase the impact of campaigns; for instance targeting patients consulting general practitioners and their direct interactions during consultations.8 In the future, the EU Commission aims to target antibiotic campaigns more effectively at those who lack knowledge, and at prescribers (especially high prescribers) and pharmacists who have a key role to play in changing views and behaviour.9 Embedding knowledge within young people’s formal education could also be a successful approach.10 11 12 Larger investments are needed in this field, as not even a third of the campaigns surveyed focus on school-age children and adolescents. Additionally, medical and veterinary schools can also be important targets for awareness-raising activities.13

Infections targeted

A majority of campaigns (46, 77%) focused on respiratory tract infections (other than influenza) and 36 (60%) on influenza, since these are responsible for most of the inadequate prescriptions of antibiotics. Urinary tract infections and sexually transmitted diseases were addressed by 15 and 6 campaigns respectively, while 3 dealt with diarrhoea/gastro-intestinal infections, 2 with skin infections and one with viral diseases, such as dengue, which do not require antibiotic treatment.

Since the antibiotic resistance of bacteria causing sexually transmitted diseases and urinary tract infections is on the rise worldwide, and urinary tract infections represent an important proportion of outpatient antibiotic consumption, expanding the scope of future campaigns to cover these types of infections seems appropriate.

Key messages and essential public slogans

There were no major differences between middle- and high-income countries in the types of key messages used (see APPENDIX II for a summarised view). All but 3 campaigns (95%) conveyed messages related to antibiotic resistance, like “Misuse and overuse of antibiotics cause resistance” (47 campaigns, 78% ), “If we use antibiotics incorrectly we will lose them / they will become ineffective" (43, 72%) or “Antibiotic resistance is an important problem” (40, 67%).

Many campaigns (51, 85%) were also based on slogans relating to the prescription and consumption of antibiotics, mostly expressing that a “judicious / prudent / responsible / appropriate / adequate use of antibiotics is important” (41 campaigns, 68% ). Only 25 (42%) campaigns mentioned that antibiotics have side effects and/or adverse effects, although in the USA these are the most common cause of emergency department visits for adverse drug events in children under 18 years of age.14 15 No country reported using a slogan expressing the fact that antibiotics can interfere with the action of drugs that a patient may 8 be taking for another condition. Specific slogans were used in some cases, such as “Let’s preserve a valuable resource” (Cyprus), “Everyone has a role” (UK - Antibiotic Guardian), “Antibiotics - less is more” (Germany - Berlin), “Effective if necessary, harmful if abused” (Italy - Emilia-Romagna) “Antibiotics are not automatic” (France) or “If you are prescribed antibiotics, ask your doctor why” (Thailand).

More than half of the campaigns (31, 52%) stated “Follow / Finish the antibiotic prescription (in dosage and duration)” in their communication material. Whereas all other key messages identified through this survey seem scientifically valid, the validity of this particular message can been questioned, since antibiotic treatments are often prescribed for too long and unnecessarily, thereby favouring the the emergence and spread of antimicrobial resistance without benefit to the patient (see Box 1).

Box 1: Antibiotic resistance and the “complete your course” message

Awareness campaigns often include the message that it is important to finish the prescribed course of treatment to prevent the development of antibiotic resistance. However, this advice is not directly connected to the fight against antibiotic resistance. The objective of continuing the treatment beyond the resolution of symptoms is to prevent relapses rather than to prevent resistance. Because the rate of antibiotic resistance tends to increase with the total amount of antibiotics used,16 the general rule might be: the shorter the course, the lower the risk of resistance. Clinical studies have indeed shown that longer courses of therapy can result in a more likely emergence of antibiotic resistance.17 18 19 Shorter antibiotic treatment lower the opportunity for bacteria to become resistant, as well as reducing adverse side-effects. In otherwise healthy people, significantly reducing but not totally eliminating the bacteria causing the infection can allow the body’s natural defences to take over and destroy the remaining few.20 There are some circumstances when it is necessary to eliminate all the bacteria – when the patient’s natural defences are damaged for any reason, or when the infection is in an area less inaccessible to antibiotics and to white blood cells and when bacteria are slow-growing (such as tuberculosis). 9 But in many cases an argument can be made for stopping a course of antibiotics immediately after a bacterial infection has been ruled out or is unlikely (for instance in case of viral respiratory tract infections); or when the signs and symptoms of a mild infection have disappeared.21 Hence, in communication campaigns against antibiotic resistance, the “complete the course” message might be confusing, in comparison with other messages that are more directly connected to the objective of decreasing antibiotic resistance. No to skip antibiotic doses, might be a message that has a more direct link with antimicrobial resistance, although it is probably challenging to convey these subtle differences effectively to the greater public .

This survey did not identify messages that specifically support short courses of antibiotics, but 16 campaigns (27%) promoted the adoption of “watch and wait” strategies before starting a treatment.

More than three quarters of the campaigns (48, 80%) carried slogans relating to self- medication, as availability of antibiotics without a prescription is still a problem in many countries; either because antibiotics are legally available “over the counter”, or because laws mandating a prescription before dispensing antibiotics are not enforced. Additionally the Internet is now a potential way to obtain antibiotics without a prescription.22 Interestingly, the messages “Do not buy / use antibiotics without a prescription” (26) or “Do not save leftover antibiotics / Discard leftover antibiotics” (30) appeared equally in countries with or without problems related to antibiotic access without prescriptions. This last key message, used by half of the campaigns, also addressed the issue of stocking up on antibiotics, which is non- negligible; in a U.S. survey, 14% of respondents reported storing leftover antibiotics at home.23

Roughly the same proportion of campaigns (45, 75%) included a message about the role of infection prevention, and in particular of hand washing (41, 68%) to limit the spread of infectious diseases. Only 24 campaigns (40%) conveyed messages related to vaccination.

Messages related to vaccination could be used more frequently by campaigns for various reasons. First, because there are clear correlations between the flu season and the peak time of antibiotic consumption. Second, because the increased use of the pneumococcal conjugate vaccine effectively targets serotypes most frequently involved in pneumococcal disease and has decreased antibacterial resistance.24 Finally, there are various other vaccines available that have the potential to reduce the incidence of infectious diseases and related overuse of antibiotic therapies.

Messages used to communicate with physicians were mostly related to specific diagnoses. For instance, the US-CDC Get Smart for Healthcare campaign recommends to “Make sure you are diagnosing pneumonia correctly and reassess the diagnosis after 1-2 days”, whereas the Serbian campaign recommends: “Before antimicrobial treatment, take a sample for microbiological testing”. By contrast, the public education components related to infections often were unspecific, with 30 campaigns stating that "Most respiratory infections are of viral origin” and 22 recommending "In case of cold or flu, try treating symptoms first".

10 Only 13 campaigns (22%) included the optimal use of antibiotics in animals in their key messages (also see “New” key messages identified here below). They mostly transmitted the idea that misuse and overuse of antibiotics (still in many cases used for growth promotion) in livestock and pisciculture causes resistance in microorganisms, which can be transmitted to consumers and ultimately impact human health. Only 9 campaigns (15%) made use of the message "Don't give antibiotics to your pet; consult a veterinarian first”.

Overall, about 20% of the campaigns represented in this survey embrace - at least partially - a One Health approach, which reflects its limited adoption across countries. Communication campaigns are generally tailored either to patients and healthcare personnel, or to farmers and veterinarians. Their implementation is often split across different government agencies, such as ministry of health, the ministry of agriculture, the ministry of environment, etc. Some countries, such as Australia since 2013, now include representatives from veterinary practice and agriculture in their communication working groups related to human medicine. Each of the involved parties plans resources and activities relevant to their individual objectives and target audience, with the messages across all groups remaining consistent.

Global versus local key messages

Most of the key messages identified in this survey may be used universally, but some make more sense in countries without access problems and where self-medication is common (e.g. “Do not buy / use antibiotics without a prescription” or “Do not save leftover antibiotics”). Other more local messages could include resistance patterns and trends associated with common syndromes, and changes in policies enforced by legislation (e.g. limits to the use of antibiotics for growth promotion or as prophylaxis in animals, enforcement of dispensing only by prescription, vaccinations, etc.). Campaigns should ideally constantly evolve to reflect the changes in legislation and in public misconceptions (see Box 2).

Box 2: Do campaigns match misconceptions?

Key messages used in campaigns are not always aligned with the most common myths about antibiotics. A comparison between misconceptions listed in the 2015 WHO report “Antibiotic resistance: Multi-country public awareness survey” and the data collected through this survey reveals that, in Russia, whereas only 56% of the population declare that they obtain their antibiotics (or a prescription for them) from a doctor or nurse, the message “Do not buy/use without prescription” was not used by the Smolensk regional campaign. In Russia, Serbia, China and India, where between 57% and 67% of the population believe that “it’s okay to use antibiotics that were given to a friend or family member, as long as they were used to treat the same illness”, none of the campaigns used the slogan “Do not share antibiotics” (or a variation of it). Although 61% of the Chinese population and 75% of the Indian population believe that cold or flu can be treated with antibiotics, the campaigns implemented in those countries did not state that antibiotics do not work against colds, flu, or viruses, or that they only work against bacteria. In Europe, while there was an increase between 2009 and 2013 in the proportion of people who responded that antibiotics do not kill viruses and are not effective against cold and flu, Eurobarometer surveys indicated little change during the same period in the proportion of people who answered correctly that the unnecessary use of 11 antibiotics is making them become ineffective or that taking antibiotics often has side effects. In fact, these differences could be explained by the specific key messages promoted by the ECDC for the European Antibiotic Awareness Day.25

“New” key messages identified

Several slogans rarely used by antibiotic awareness campaigns were identified through this survey.

● “Reduce the use of broad spectrum antibiotics” (Israel): this type of message is intended for physicians but highlights an important issue to be covered by public awareness campaigns, since “broad spectrum” antibiotics are increasingly prescribed worldwide, even in the outpatient setting. It seems worthwhile to target specific antibiotic classes (such as the fluoroquinolones) that are known to favour the emergence and spread of antibiotic resistance.

● “Unused antibiotics should be returned to the pharmacy” (Poland): this also applies to other types of medicines but in the case of antibiotics, as their residues are a potential driver of antibacterial resistance emergence in the environment,26 this slogan is appropriate. In addition, some classes of antibiotics quickly lose their therapeutical potential; in these cases, the use of leftover antibiotics make the emergence of resistance even more likely.27

● “Reduce and eventually phase out sub-therapeutic use in animals” (Kenya): the use of antibiotics by veterinarians was beyond the scope of the present survey, but this slogan highlights the existence of campaigns tackling antibiotic consumption through a One Health approach.

● “Get enough rest, eat healthily, do not use antibacterial cleaning products” (Indonesia - Smart Use of Antibiotics): the last part of this message indirectly exposes the fact that some cleaning products may have an impact on the emergence and spread of antibacterial resistance.28 This is supported by scientific evidence regarding certain types of cleaning products and antiseptics; this type of message may therefore be included in future campaigns related to antibiotic and biocide resistance, although legislation may be a more effective approach.

Box 3: Is there a single most effective key message?

There still is a lack of formal evaluations to determine the most effective messages for curbing antibiotic misuse and overuse. However, the most successful campaigns were based on slogans that were both simple and easy to remember, such as the one used in France - “Les antibiotiques, c’est pas automatique” (antibiotics are not automatic) - which is catchy thanks to its rhyme. However, this “catchiness” may be lost in translation and the 12 slogan may therefore not be easily adaptable to other languages.. Indeed, directly transposing communication material into other languages is often tricky and challenging. In the United States, when the CDC translated its “Get smart about antibiotics” campaign material for Spanish speakers, it changed the slogan to “informése” (get informed) with a special focus on self-medication since a literal translation may have been misunderstood as “get smart to self-medicate”. In fact, each country needs to select the most appropriate key messages according to local context and popular understanding, as no single message can be considered “universal”. The cultural framing and local adaptation of slogans are essential to achieve the best impact. Messages too complex to be assimilated by the public need to be avoided. It is also unclear if messages about factual knowledge, such as “antibiotics do not kill viruses”, are effective. Indeed, in an Italian study about the impact of a low-cost regional campaign, the percentage of the surveyed population in the intervention counties correctly identifying the statement “antibiotics are effective against viruses” actually decreased.29 Another issue that merits further research, is the framing of the campaign messages as “positive” or “negative”.30 These are problems faced also by other public health campaigns.

Interventions used in the campaigns

The distribution or dissemination of education and communication material was the intervention most frequently implemented (52 campaigns, 87%). This was mostly achieved through the following means, by order of occurrences in the campaigns: pamphlets, brochures or leaflets (44, 73%); posters (41, 68&); letters to stakeholders (28, 47%); advertisements in print media (16, 27%); billboards and public transport signs (14, 23%). These printed materials were mostly used in physicians’ or hospital waiting rooms, pharmacies, day care centers, and community hall forums. In most cases, people could order brochures and posters, or download pdf files and print them, to display wherever they liked.

The online dissemination of information also played a prominent role in 46 (77%) campaigns. Websites, social media channels, online documents and pdf and videos, were the tools most frequently used to that end.

Television and radio spots (on public or private channels) were used in 31 (52%) and 28 (47%) campaigns respectively; only 4 campaigns made use of spots broadcasted in cinemas. By order of importance, the following other types of interventions (beyond the promotion of communication material online and offline) were mentioned by respondents.

❏ scientific/professional conferences ❏ publication of articles in medical journals ❏ public relation activities ❏ press conferences

13 ❏ training sessions for prescribers ❏ active promotion / distribution of guidelines ❏ activities targeting schools ❏ exhibitions ❏ gimmicks (a method or trick to get people's attention) ❏ short film competitions ❏ distribution of SMS ❏ campaign toolkits ❏ comics or t-shirts ❏ pledge-based websites ❏ flashmobs

Other innovative interventions (not covered by answers received for this survey) include a specific labelling on antibiotics’ packaging. For instance, in February 2016 the Indian Ministry of Health and Family Welfare launched a campaign called “Medicines with the Red Line”, with a clearly identifiable red line on the box of prescription drugs.31 In July 2016, the U.S. Food and Drug Administration approved safety labelling changes for a class of antibiotics (fluoroquinolones) to enhance warnings about their association with disabling and potentially permanent side effects and to limit their use in patients with less serious bacterial infections.32

Evaluation of the campaigns

Almost one in two campaigns (24, 40%) provided answers related to evaluation. As this topic was not the main focus of the survey, it is difficult to draw conclusions from the answers received, for instance to determine if campaigns which were “multi-faceted” versus targeted at specific populations or communication channels eventually achieved a better impact. The recent actions of many health leaders to raise public awareness on antibacterial resistance and their extensive media coverage have probably also interfered - in a positive way - with the campaigns.

The main indicators used for evaluation were antibiotic use (17, 71%), knowledge and attitudes of the public (15, 63%) and of healthcare professionals (11, 46%), and antimicrobial resistance rates or sensitivity (13, 54%). Conversely, the recall of the campaign (10, 42%) or consultation behaviour (2, 8%) were marginally used to assess the campaigns. Only 2 respondents mentioned an evaluation of the economic impact of the campaign, and none conducted an analysis of its unintended consequences (such as hospitalisations for complications). Capturing changes in those key indicators was beyond the scope of the present survey and should be subject of further public health research.

Obstacles faced while implementing a public awareness campaign

Both human and financial constraints posed significant barriers to implementing campaigns or achieving an impact (in 17 campaigns out of 24). Lack of political support (11/24) and an enduring gap between common practices and suggested actions (5/24) are major obstacles to translate campaigns into concrete results. Nevertheless, 20 out of the 24 (83%) respondents who had evaluation data would recommend a similar type of awareness campaign to a colleague in another country.

Light yellow: European high-income countries with antibiotic campaigns identified in a previous review in 2009 (REF Lancet ID), Red: Additional European high-income countries with antibiotic awareness identified in the current survey. Grey: no campaign (neither in the previous review nor the current survey). White: MLIC or high- income country with no answer received.

Potential for expansion in new directions

In addition to the sections highlighted in bold characters in this report, complementary actions to expand public awareness campaigns in new directions and enhance their impact may include the following:

15  Each year, WHO provides Member States with recommendations to improve messages in the framework of the World Antibiotic Awareness Week (WAAW). Several topics for which antibiotic resistance is of growing concern are currently not covered by these recommendations, such as urinary tract infections or the problem of multi-resistance among bacteria living in the gut. In the material provided for WAAW, there is a patchwork of diseases which could be confusing for the reader: TB and MDR-TB are listed next to the common cold, pneumonia and diarrhoea. From a policy perspective it might make sense to have an overview across diseases, although awareness campaigns would benefit from a more precise identity and focus.  Finding ways to drastically alter the perception of antibiotics in the general population seem of high-priority. Messages and interventions must convey the idea that these unique molecules are a “nonrenewable” resource for modern medicine – as they potentially lose some of their power every time we make use of them – implying long term consequences for the individual patient and the entire population.  To favor the exchange of experiences between countries in the field of public awareness, it would be appropriate to secure the required resources to create a public repository of campaign material, which would enable searches to be carried out by format (e.g. posters, brochures, etc.), target audience, content, language etc.  WHO could promote the use of consistent campaign monitoring and reporting, using a standardised approach. The first milestone could be a preliminary public awareness survey, based on the methodology used for the 2015 WHO report “Antibiotic resistance: multi-country public awareness survey”. This first step may help choose the most adequate key messages to address local misconceptions, whereas the active involvement of psychologists and advertising or communication specialists should allow to take into account behavioural and social aspects while planning the campaign. Securing funding not only to implement the campaign but also for its evaluation would be welcome in all cases. For the evaluation, WHO could approve an internationally accepted and standardised methodology; to that end, measuring the public knowledge before and after any intervention - even if it does not always translate into adapted behaviour - may be a good starting point.  WHO, CDC, ECDC and other international organizations should continue to support the deployment of public awareness campaigns related to antibiotics, because most countries covered in this survey have reported participating in such regional or global initiatives. To enhance the outreach and impact of antibiotic-related communication activities, WHO could compile best practices from its most effective and advanced campaigns - and financing models - developed for other health threats, such as HIV/AIDS, hepatitis or maternal health. Such a “cross-fertilization” between global campaigns could for instance include the local adaptation of messages (e.g. for the global Hand Hygiene campaign) or the expertise acquired in the use of social media.33  Finally, the most effective way to curb antibiotic consumption varies from one setting and continent to another. Other issues such as over-the-counter sale of antibiotics, drug advertisement or supplier induced use may dampen the effects of any public awareness activity. In this respect, a recent study revealed that having a national Ministry of Health unit specialized in promoting the rational use of medicines, a national drug information centre, as well as provincial and hospital drugs and therapeutics committees, were the most statistically significant factors for reducing unnecessary antibiotic use.34

16 Acknowledgments We would like to thank the following individuals for having provided comprehensive and detailed answers which form the basis of this report,: Perlat Kapisyzi, Albania; Karine Gabrielyan, Armenia; Stephanie Childs, Australia; Robert Muchl, Austria; Samuel Coenen, Belgium; Tiago Reis, Brazil; Mary Carson, Canada; Jorge Valdebenito, Chile; Yu Fang, China; Yonghong Xiao, China; Maria Virginia Villegas, Colombia; Vera Vlahović-Palčevski, Croatia; Sven Pal, Croatia; Niki Paphitou, Cyprus; Ute Wolff Sönksen, Denmark; Martin Kadai, Estonia; Jari Jalava, Finland; Jean-Michel Azanowsky, France; Florian Salm, Germany; Janine Zweigner, Germany; Edith Andrews, Ghana; Sotirios Tsiodras, Greece; Thorolfur Gudnason, Iceland; N. K Ganguly, India; Naveen Chharang, India; Vida Parady, Indonesia; K. Kuntaman, Indonesia; Maurice Kelly, Ireland; Marcelo Low, Israel; Giulio Formoso, Italy; Carlo Gagliotti, Italy; Yumi Kawata, Japan; Yoshiaki Gu, Japan; Yvon de Jong, Kenya; Evelyn Wesangula, Kenya; Lul Raka, Kosovo; Anete Jansone, Latvia; Ziad Daoud, Lebanon; Natalja Samp, Lithuania; Silke Gansen, Luxembourg; Peter Zarb, Malta; Anahí Dreser, Mexico; Mussaret Bano Zaidi, Mexico; Arjen Elsemulder, Netherlands; Janet Mackay, New Zealand; Hanne-Merete Eriksen, Norway; Waleria Hryniewicz, Poland; José- Artur Paiva, Portugal; Bosevska Golubinka, Macedonia; Claudia Dima, Romania; Roman Kozlov, Russian Federation; Frederic Muhoza, Rwanda; Gorana Dragovac, Serbia; Eva Schreterova, Slovakia; Milan Cizman, Slovenia; Marc Mendelson, South Africa; Ester Dejuan, Spain; Beatriz Perez Gorricho, Spain; Olov Aspevall, Sweden; Homa Attar Cohen, Switzerland; Siana Gideon Mapunjo, Tanzania; Niyada Kiatying-Angsulee, Thailand; Suzana Soares Hendriques, Timor Leste; Diane Ashiru-Oredope, United Kingdom; Laura Piddock, United Kingdom; Becky Roberts, USA; Ann Thomas, USA; Arjun Srinivasan, USA. And for their help in producing graphics and editorial revision, to Frederic Pont and Derek Christie (Communication in Science).

17 REFERENCES

1 http://www.who.int/campaigns/world-antibiotic-awareness-week/en/ (accessed January 10, 2017)

2 Filippini M, Ortiz LG, Masiero G. Assessing the impact of national antibiotic campaigns in Europe. Eur. J. Health Econ. 2013;14:587–599. doi: 10.1007/s10198-012-0404-9

3 Huttner B, Goossens H, Verheij T et al. CHAMP consortium. Characteristics and outcomes of public campaigns aimed at improving the use of antibiotics in outpatients in high-income countries. Lancet Infect Dis. 2010;10:17–31. doi: 10.1016/S1473-3099(09)70305-6

4 LOcal Campaign on Antibiotics ALliance (LOCAAL) study group. Doctors and local media: a synergy for public health information? A controlled trial to evaluate the effects of a multifaceted campaign on antibiotic prescribing (protocol). BMC Public Health 2011;11:816. doi: 10.1186/1471-2458-11-816

5 Hornik R, Kelly B. Communication and diet: an overview of experience and principles. J. Nutr. Educ. Behav. 2007;39:5–12.

6 Bala M, Strzeszynski L, Cahill K. Mass media interventions for smoking cessation in adults. Cochrane Database Syst. Rev. 2008;1:CD004704.

7 Harbarth S, Balkhy HH, Goossens H et al. Antimicrobial resistance: one world, one fight! Antimicrobial Resistance and Infection Control 2015;4:49. doi: 10.1186/s13756-015-0091-2

8 McNulty AMC, Nichols T, Boyle PJ et al. The English antibiotic awareness campaigns: did they change the public's knowledge of and attitudes to antibiotic use? J. Antimicrob. Chemother. 2010;65:1526-1533. doi: 10.1093/jac/dkq126

9 European Commission. Progress report on the Action plan against the rising threats from Antimicrobial Resistance. Commission Staff Working Document. 26.2.2015

10 Lecky DM, Hawking MKD, Verlander NQ et al. Using Interactive Family Science Shows to Improve Public Knowledge on Antibiotic Resistance: Does It Work? PLoS One 2014;9:e104556. doi: 10.1371/journal.pone.0104556

11 http://www.listentoyourgut.org.uk/ (accessed January 10, 2017)

12 World Bank. 2016. “Drug-Resistant Infections: A Threat to Our Economic Future (Discussion Draft).” Washington, DC: World Bank.

18 13 Wellcome Trust. Evidence for action on antimicrobial resistance. Proceedings of the meeting ‘Integrating Science and Policy for Decisive Action on Antimicrobial Resistance’, London, UK, 26–27 April 2016.

14 Centers for Disease Control and Prevention. Antimicrobial Resistance Threat Report. 2013. http://www.cdc.gov/drugresistance/threat-report-2013/ (accessed January 10, 2017)

15 Shehab N, Lovegrove MC, Geller AI et al. US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014. JAMA 2016;316:2115–2125. doi: 10.1001/jama.2016.16201

16 Turnidge J and Christiansen K. Antibiotic use and resistance — proving the obvious. Lancet 2015;365:548–549.

17 Spellberg B. The new antibiotic mantra - Shorter is better, 2016, JAMA Intern. Med. 2016;176:1254–1255.

18 Kouyos RD, Metcalf CJ, Birger R et al. The path of least resistance: aggressive or moderate treatment. Proc. Royal Soc. B. 2014;281:1794.

19 Gulliford MC, Moore MV, Little P et al. Safety of reduced antibiotic prescribing for self limiting respiratory tract infections in primary care: cohort study using electronic health records. British Medical Journal 2016;354:3410

20 Gilbert GL. No you don’t have to finish all your antibiotics. theconversation.com 17 April 2015.

21 Gilbert GL. Knowing when to stop antibiotic therapy. Medical Journal of Australia 2015;202:121.

22 Mainous AG, Everett CJ, Post RE et al. Availability of Antibiotics for Purchase Without a Prescription on the Internet. Ann Fam Med. 2009;7:431–435.

23 Zooroba R, Grigoryan L, Nash S et al. Nonprescription Antimicrobial Use in a Primary Care Population in the United States. Antimicrob Agents Chemother. 2016;60:5527–5532. doi: 10.1128/AAC.00528-16

24 European Centre for Disease Prevention and Control. Antimicrobial resistance surveillance in Europe 2014. Annual Report of the European Antimicrobial Resistance Surveillance Network (EARS-Net). Stockholm: ECDC; 2015.

25 Monnet DL, Safrany N, Heine N et al. Comment on: A systematic review of the public’s knowledge and beliefs about antibiotic resistance. J Antimicrob Chemother. 2016;71:2364–2365. doi: 10.1093/jac/dkw141

26 Hai-Feng et al. Nanomedicine and Biotherapeutics for Antibiotic Resistance Bacteria. J. Nanomedicine Biotherapeutic Discov. 2015;5:3. doi: 10.4172/2155-983X.1000e138 19

27 Verma P, Samanta SK. Comparative assessment of antibiotic potency loss with time and its impact on antibiotic resistance. Comp Clin Pathol. 2016;25:1163. doi: 10.1007/s00580-016-2321- 2

28 Di Cesare A, Fontaneto D, Doppelbauer J et al. Fitness and Recovery of Bacterial Communities and Antibiotic Resistance Genes in Urban Wastewaters Exposed to Classical Disinfection Treatments. Environmental Science & Technology 2016;50:10153–10161. doi: 10.1021/acs.est.6b02268

29 Formoso G, Paltrinieri B, Marata AM et al. Feasibility and effectiveness of a low cost campaign on antibiotic prescribing in Italy: community level, controlled, non-randomised trial. BMJ 2013;347:5391. doi: 10.1136/bmj.f5391

30 Apollonio DE and Malone RE. Turning negative into positive: public health mass media campaigns and negative advertising. Health Educ Res. 2009;24:483–495. doi: 10.1093/her/cyn046

31 http://www.mohfw.nic.in/ (accessed January 10, 2017)

32 http://www.fda.gov/newsevents/newsroom/pressannouncements/ucm513183.htm

33 Zowawi HM, Abedalthagafi M, Charles FA et al. The potential role of social media platforms in community awareness of antibiotic use in the Gulf Cooperation Council States. Luxury or necessity? J Med Internet Res 2015;17:e233.

34 Holloway KA, Rosella L, Henry D. The Impact of WHO Essential Medicines Policies on Inappropriate Use of Antibiotics. PLoS ONE 2016;11:e0152020. doi: 10.1371/journal.pone.0152020

20 Appendix I

APPENDIX I - Methodology

We developed a survey (APPENDIX III) about the characteristics of antibiotic awareness campaigns, with a special focus on key messages. For the purpose of this survey, the term "antibiotic awareness campaign" was defined as “a comprehensive effort to disseminate information about responsible use of antibiotics and the risks of antibiotic misuse to the lay public”. For this purpose, it was assumed that an antibiotic awareness campaign typically uses posters, pamphlets, billboards, radio and television advertisements, social media, etc. Healthcare professionals may also be targeted as part of these interventions, but activities focusing mainly on healthcare professionals were beyond the scope of this survey.

In mid-October 2016, invitations to participate in the survey were sent by e-mail to WHO Regional offices and National Focal Points3, and to persons in charge of antibiotic awareness campaigns (identified through a preliminary review of the scientific literature and known contacts of the survey team). This way, more than a hundred people in 93 countries were invited to answer the survey. Reminders to participate were also sent on 25 October and 4 November.

A total of 105 persons from 56 countries answered the online questionnaire between October 12 and December 2, 2016. Two follow-up emails were sent to respondents who initially provided incomplete answers (n: 44); eventually, 30 incomplete answers had to be removed from the data analysis. When several answers were received for the same campaign, only the answers provided by the official coordinators of the campaigns (which seemed to be the most reliable and comprehensive) were taken into account (number: 6). Conflicts in answers emerged in 8 countries (Brazil, Chile, Colombia, Germany, Israel, Lebanon, Norway and Slovakia), from which we received answers referring to the fact that no campaign took place in the country, and answers stating the opposite. In those cases, we kept the answers from the respondent mentioning an awareness campaign in the country (except for Lebanon, for lack of comprehensive answers). This consolidation led to a total of 60 campaigns in 47 countries that were taken into account for the analysis.

Results were summarised according to WHO Regions and the high, medium and low- income country classification of the World Bank (July 2016 list of gross national income per capita).

3 In Albania, Armenia, Austria, Azerbaijan, Bosnia Herzegovina, Belarus, Brazil, Bulgaria, Chile, Colombia, Cyprus, Denmark, Estonia, Finland, Germany, Greece, Italy, Kuwait, Kyrgyzstan, Montenegro, Nigeria, Romania, Slovakia, Tajikistan, Tanzania, Thailand, Timor-Leste and Vietnam.

I Appendix I

Limitations Answers received by each country cannot be assumed to be comprehensive. In some cases, when respondents stated that there was no antibiotic awareness campaign in their country, there may have been one that they did not know about. As most campaigns were described by a single respondent, who was not always the person in charge of the campaign, some answers may contain errors or be incomplete. Other limitations include the following: - Because of the limited number of countries taking part in the survey in some WHO Regions, the findings cannot be considered representative of each Region, nor of the global situation. - Online research methodologies may lead to less considered responses than face-to-face methodologies. - In all surveys, and especially those with questions that respondents may feel have a ‘correct’ response, a bias may come from respondents giving the answer they feel is ‘expected’ (social desirability bias).

II Appendix II

APPENDIX II - Summary table

Country Campaign name Campaign URL Contains One Targeted Targeted Targeted Involved Involved Impact of the Respondent Health school age urinary tract sexually psychologists advertisement campaign recommends components children and infections transmitted in the companies in formally a similar type adolescents diseases design/condu the evaluated of awareness ct of the design/condu campaign campaign ct of the campaign Armenia AMR Awareness raising X campaign Australia Reducing Antibiotic www.nps.org.au/antibiotics X X X X Yes Resistance Belgium National antibiotic www.gebruikantibioticacorrec X X X X Yes awareness campaign t.be (version in Dutch, French, German and English) Brazil Rational use of http://www.anvisa.gov.br/serv antimicrobials icosaude/controle/rede_rm/cu rsos/atm_racional/modulo1/pr e_uso.htm Canada Do Bugs Need Drugs? www.dobugsneeddrugs.org X X X X Yes and www.francais.dobugsneeddru gs.org Chile Rational use of X antimicrobials China National drug safety: use antibiotics carefully China Special campaign for X X Yes antibiotic rational use Colombia Bacterial resistance and X X Yes Nosocomial Infections network led by CIDEIM Croatia Public awareness X X X X Yes campaign on prudent antibiotic use Croatia Cold or flu - say no to https://www.facebook.com/re X X antibiotics ciNEantibioticima/

I Appendix II

Country Campaign name Campaign URL Contains One Targeted Targeted Targeted Involved Involved Impact of the Respondent Health school age urinary tract sexually psychologists advertisement campaign recommends components children and infections transmitted in the companies in formally a similar type adolescents diseases design/condu the evaluated of awareness ct of the design/condu campaign campaign ct of the campaign Cyprus Antibiotic Awareness http://www.moh.gov.cy/moh/ X Yes Campaign moh.nsf/All/6B4121829D850 2A5C2257C210026E74C Denmark "piss annoying!" X X National antibiotic campaign on urinary tract infections in younger and elderly women Estonia European Antibiotic X Awareness Day Finland European Antibiotic https://www.thl.fi/fi/web/infekti X Awareness Day otaudit/ajankohtaista/teemap aivat/euroopan- antibioottipaiva France Antibiotics, if you use http://www.ameli.fr/assures/pr X X X Not sure them wrong, they will evention-sante/les- become less strong antibiotiques.php For the veterinary side: http://agriculture.gouv.fr/camp "Immunization, health agne-vaccinacteurs-vacciner- investment for your les-animaux-pour-reduire- flock" / "Nourished lutilisation-des-antibiotiques housed, vaccinated" http://agriculture.gouv.fr/les- "Antibiotics for us either antibiotiques-pour-les-chiens- are not automatic" et-les-chats-cest-pas- automatique Germany Rational antibiotic use www.rai-projekt.de X X Yes through Information and communication Germany Antibiotic-Therapy- X X Yes Optimisationsstudy Ghana Ghana Anti-Microbial http://ghndp.org/antimicrobialr X X X X Resistance Platform esistance/ : Ghndp.org/reactcso

II Appendix II

Country Campaign name Campaign URL Contains One Targeted Targeted Targeted Involved Involved Impact of the Respondent Health school age urinary tract sexually psychologists advertisement campaign recommends components children and infections transmitted in the companies in formally a similar type adolescents diseases design/condu the evaluated of awareness ct of the design/condu campaign campaign ct of the campaign Greece Educational campaign http://www.kedke.gr/?p=1547 X X on the appropriate use 8 of Antbiotics and Vaccines organized in common by the Greek Intermunicipal network for healthy cities, the Infectious diseases society of Greece, the Greek Society of Chemptherapy and the Athens Medical Association under the auspices of the Central Union of Municipalities of Greece Iceland European Antibiotic http://www.landlaeknir.is/um- Awareness Day embaettid/frettir/frett/item281 05/Evropudagur- vitundarvakningar-um-syklalyf India ReAct http://www.bmj.com/content/3 X 52/bmj.i1202 India Antimicrobial resistance stop Indonesia Smart Use of Antibiotics http://bijak-antibiotik.com/ X X Yes Indonesia Antimicrobial X X X X Not sure Resistance Control Program ireland under the weather www.undertheweather.ie X X X Yes Israel Reducing Antibiotic use X X Yes in the Community Italy Antibiotics: solution or http://assr.regione.emilia- X X Yes problem? romagna.it/it/aree_attivita/val utazione-del-farmaco/ricerca- III Appendix II

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

IV Appendix II

Serbia "Prudent use of antibiotics in primary care settings: awearness, knowledge and attitude"

V Appendix II

Country Campaign name Campaign URL Contains One Targeted Targeted Targeted Involved Involved Impact of the Respondent Health school age urinary tract sexually psychologists advertisement campaign recommends components children and infections transmitted in the companies in formally a similar type adolescents diseases design/condu the evaluated of awareness ct of the design/condu campaign campaign ct of the campaign Slovakia Life without antibiotics.- www.zivotbezantibiotik.sk National campaign. Antibiotics. Use them wisely! - tagline of campaign EAAD 2016 Slovenia Flyer Get well without Furst J,Cizman M et al.Expert X X X Not sure antibiotics Flyer Rev Anti Infect Ther 2015 Interactions of drugs Spain What do parents know about antibiotics Spain Prudent Use of http://www.msssi.gob.es/cam Antibiotics Antibiotics pannas/campanas13/antibioti Day in Europe cos.htm and http://www.msssi.gob.es/cam pannas/campanas06/Antibioti cos.htm Sweden Protect the antibiotics https://www.folkhalsomyndigh X X eten.se/skyddaantibiotikan/ Thailand Thai Antibiotic http://atb- X Awareness Week 2016 aware.thaidrugwatch.org/ (FB Antibiotic Awareness Thailand) Timor Leste Stop Antibiotic X Yes Resistances Now United Antibiotic Guardian www.antibioticguardian.com X X X X Yes Kingdom United Antibiotic Action http://antibiotic-action.com/ X X X Yes Kingdom USA Get Smart: Know When www.cdc.gov/getsmart X X Antibiotics Work

VI Appendix II

Summary table of campaigns: by country, name of campaign, URL and characteristics of interest (One Health approach, targeting school-age children, having used psychologists or advertising companies for their design and conduct, targeting under-represented infections, recommended for replication by respondents).

VII Appendix III

APPENDIX III - Questionnaire used for the survey

See pdf file attached.

Temporary link: https://drive.google.com/file/d/0B_Mj9qCOE5veS1I5V2lJMlhwQ1E/view?usp=sharing

CAVEAT: A branching logic was applied to this questionnaire on the Survey Monkey platform, meaning that respondents did not have to reply to all questions.

I Appendix IV

APPENDIX IV - Answers from countries which have not implemented campaigns

Respondents from Austria, Lebanon, New Zealand, Rwanda, South Africa and Switzerland stated that, to their knowledge, no large-scale public antibiotic awareness campaign had been deployed in their country since 2010. Respondents from Albania and Tanzania were “not sure” about it.

These respondents were directed to a special set of questions and were asked to rate the importance of issues related to antibiotic use in their country. The median and range of their ratings from 1 (not at all important) to 5 (very important) were: - Limited access to antibiotics: 2 [1-5] - Inappropriate prescribing of antibiotics by physicians: 4 [2-5] - Antibiotic resistance: 4 [2-5] - Self-medication with antibiotics: 3 [1-5]

Only 4 respondents stated that the problem of widespread antibiotic use or antibiotic resistance was addressed by policy actions in their country, citing the following: - In one instance each: “Provide education and training sessions for healthcare professionals”, “Restrict use of antimicrobials in animal husbandry and agriculture” and “Mandate antimicrobial stewardship programs in hospitals”. - In two instances: “Restrict sale of antibiotics without a prescription”. - In three instances: “Establish surveillance of antibiotic use and resistance”

Only one respondent judged that the implemented policies failed, mainly for lack of political support, scarce recognition of the problem or competing priorities.

Except for Austria, all the respondents from the above-mentioned countries confirmed that they were considering launching an antibiotic awareness campaign for the public.