Pre-conference report Managing Antimicrobial Resistance Through Behaviour Change 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 dis- cussion 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 gen- eral. 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