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Introduction Page 4 Objectives Page 5
The SWG Page 6 Background & AMR Page 7 Capacity Building Page 26 Logistics Page 34
Evaluation Page 37 Agenda Proposals Page 40 Dynamics Page 41 References Page 50
Conclusion Page 54
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Dear readers, Antimicrobial resistance (AMR) has been an issue that we have worked on in the IFMSA for several years both internally and externally. For years we have conducted informative sessions, held campaigns, done trainings and proceed with advocacy measures on both a local, national, regional and global level. AMR has played a major role in IFMSA for the past couple of years, and this is why we have had it as a regional priority for the past three years in the European region, and why it was selected as one of the IFMSA global priorities. But what impact does all our knowledge on AMR have, if we do not share it with each other and try to have a real impact in others with it? So by collecting information from several years of working experience within the field of AMR in IFMSA, we are now ready to present to you the first AMR training manual! The main goal of this training manual is for it to be a manual which can be used by all members in our organization, and not only for the members in the European region. By gathering a group of strong willed and motivated people, a long time idea of creating an AMR training manual for all members became a reality. The manual encompasses all the essential knowledge one needs to know when working with AMR, includes tips and tricks on how to do campaigns, trainings and how to be an effective advocate against AMR. As a closing statement, we would like to emphasize the famous words that define us in IFMSA “Think globally, act locally�. This manual will encourage you to think globally, while it will give you the necessary resources you need to act locally and make an impact.
We hope you will enjoy reading this training manual, and that you will find it inspiring and useful!
"If we fail to act, we are looking at an almost unthinkable scenario where antibiotics no longer work and we are cast back into the dark ages of medicine" David Cameron, former UK Prime Minister on AMR Best regards
The coordinators Abdulkarim Harakow (General Assistant for Europe) Blanca Paniello & Viktoria Kastner (SCOPH Regional Assistants for Europe)
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To increase the knowledge of students on AMR and its stakeholders; • • •
The general public Healthcare workers Policy makers (including European governmental structures)
To empower European members with the ideal background and tools to carry out activities (e.g. AMR workshops) on the topic of Antimicrobial Resistance.
To build capacity of medical students stakeholders of AMR within Europe.
To strengthen IFMSA Europe through the creation of an open forum to discuss the role of medical students within the field of Antimicrobial Resistance.
To establish interregional collaboration between European NMO’s on the topic of Antimicrobial Resistance.
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Background & AMR What is health? According to WHO, health is a “state of complete physical, mental and social well -being and not merely the absence of disease or infirmity.” It is a definition which implies that there is some intrinsic relationship between the good of the body and the good of the self. (1) Generally, the context in which individuals live is of great importance for both their health status and the quality of their life. It is increasingly recognized that health is maintained and improved not only through the advancement and application of health science, but also through the efforts and intelligent lifestyle choices of the individual and society. (1) Many factors combine together to affect the health of individuals and communities. Whether people are healthy or not is determined by their circumstances and environment. To a large extent, factors such as where we live, the state of our environment, genetics, our income and education level, as well as our relationships with friends and family - all have considerable impacts on health, whereas the more commonly considered factors such as access and use of health care services often have less of an impact. (1) The determinants of health include: the social and economic environment, the physical environment, and the person’s individual characteristics and behaviours.
What is Public Health? According to WHO, Public Health is defined as “the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society.” (2) The professionals in the public health field work to prevent problems from happening or recurring through the implementation of educational programs, recommendation policies, coordination of different services and research, differently to clinical professionals whose main focus is the treatment of individuals after they become sick. Many activities are targeted at populations such as health campaigns, but also include the personal services to individuals, such as vaccinations, behavioral counseling, or health advice. (2) Public health works to protect and improve the health and lives of individuals, families, communities, and populations. It is practiced at a local, national and global level with the main goal of promoting health and well-being of the population as a whole, not only the eradication of particular diseases. It also promotes healthcare equity, quality and accessibility in a sustainable way. (2) 7 7
What is AMR? In order to understand all the implications of raising levels of antimicrobial resistance, it is essential to understand how and why this process occurs. World Health Organization (WHO) defines antimicrobial resistance (AMR) as the ability of microorganisms to undergo change when they are exposed to antimicrobial drugs, causing them to become partially or fully resistant to these medications. This applies to bacteria, viruses, fungi, parasites and respective drugs that are used to treat them - antibiotics, antivirals, antifungals, antimalarials, and anthelmintics. Those microorganisms are sometimes referred to as „superbugs�, especially when they are resistant against multiple classes of drugs. (3,4,5)
While resistance of bacteria is most widespread and will be the main focus of this manual, it is significant to also remember about the other organisms. Over the past several years, there have been multiple reports about increasing resistance to drugs that are used as first-line treatments for HIV, malaria, candidiasis and other non-bacterial infections. These changes place medical advances we have achieved in the area of infectious diseases over the past decades in jeopardy. (3,4,5)
How does AMR happen? Antimicrobial resistance in itself is a natural occurrence that represents a principle of evolution. Microorganism compete against each other for limited resources and some of them develop an ability to secrete substances that are harmful or lethal to other species. Most of the antibiotics we use nowadays are either these natural chemicals or their synthetic derivatives. Due to random mutation in their genome, some portion of the bacteria become resistant to a specific type of drug. As a result of antibiotics killing off sensitive bacteria, resistant bacteria are allowed to proliferate further and therefore become predominant. This process occurs much quicker in antibiotic-rich environments, such as healthcare facilities. Reproduction and mutations are not the only way of gaining resistance - bacteria can also share specific genes responsible for development of resistance among themselves in the process called horizontal transfer. (3,4,5) There are many different kinds of resistance, that depend mostly on the mechanism of action of the antibiotic. Some bacteria produce enzymes that inactivate drugs, others change the structures of their organelle, alter their metabolic pathways or simply move the antibiotic out of the cell through efflux pumps. (3,4,5) Even though AMR is a natural phenomenon, it is linked to how often microbes are exposed to antimicrobial substances, so misuse and extensive overuse of antibiotics accelerates this process. Bacteria quickly gain resistance to multiple different types of drugs, limiting treatment options and spreading uncontrollably. The most common examples of misuse of antibiotics are: taking antibiotics for viral infections (such as common cold or flu) or without consulting a professional and not finishing the whole prescribed dosage. (3,4,5) 8 8
Antibiotics can be divided into two main groups: Broad-spectrum and narrow spectrum antibiotics. Broad-spectrum antibiotics are effective for a larger range of types of bacteria, both Gram(+) and Gram(-), which means that comparing with a narrow spectrum antibiotic, they are more likely to kill the bacteria. However, that also means that all the other bacteria that this broad spectrum antibiotic could affect, will also have a chance to become resistant to it. Doctors can also contribute to the misuse by needlessly prescribing antibiotics, as well as choosing wrong dosage or duration of treatment and using broad-spectrum drugs. Antibiotics are also frequently used in veterinary as a growth promoter and a cheaper alternative of preventing diseases. (3,4,5)
How does AMR spread? Since resistant bacteria can be transferred between different species, they have multiple ways of spreading. During antibiotic therapy, the drug kills not only the invasive bacteria, but also natural microbiome in the gastrointestinal tract, which leaves an open space and an opportunity for resistant bacteria to proliferate. People who carry those bacteria can easily spread them in general community, especially to those with weakened immune system. (3,4,5) Farm animals that are given antibiotics in massive doses also develop resistant bacteria in their gut. Those bacteria can remain inside the meat and spread to humans through poorly prepared food. This can also happen during close contact with animals without maintaining proper hygiene. From farms, resistant bacteria can spread to the environment (for example soil or air) and food through water contaminated with faeces, and from there to humans. (3,4,5) Since resistant bacteria can emerge anywhere and transmission is influenced by trade, travel and both human and animal migration, AMR must be treated as a global emergency that requires action across all regions, government and societies. (3,4,5)
Figure 1. Examples of mechanisms of resistance to specific types of antibiotics. Source: Gerard D Wright - http://www.biomedcentral.com/content/figures/1741-7007-8-123-1-
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Why do we need to tackle the problem?
ReAct—Risks for the Individual. https://www.reactgroup.org/toolbox/understand/why -should-i-care/
AMR is a global concern, from a health as well as from a socio-economic perspective, endangering the success of the Sustainable Development Goals. AMR is affecting the health of individual patients as they are less likely to recover from infection, require longer hospital stays and have an increased risk of premature deaths. [6] Some infections (e.g. gonorrhea, tuberculosis) are becoming more and more difficult or even impossible to treat, putting especially vulnerable groups, such as preterm babies or young children, at risk. There is an increasing risk in surgical procedures, cancer chemotherapy and organ transplants, as less effective antibiotics are available. [7,8] These days, AMR is already responsible for an estimated 33,000 deaths annually in the European Union, with a tendency to rise. [9] Globally, the number is estimated around 700,000 deaths per year. If current infection and resistance trends will not be reversed, these numbers could rise up to 10 million deaths per year in 2050. [8] It is projected that the majority of these deaths would occur in low-income countries in Africa and Asia [10] showing the global inequality of this problem.
In addition to that, AMR will have severe consequences for global trade and economy, as it is affecting labour supply, livestock productivity and health care costs. The latest World Bank Report modeled an annual global GDP loss between 1.1% and 3.8% by 2050, indicating an annual shortfall of between $1 and $3.4 trillion. [11] Therefore the annual reduction of global GDP caused by AMR could be comparable to the losses during the financial crisis 2008/2009, with the risk of prevailing longer. [11] By today, the European Union estimates a societal cost of 1.5 billion annually due to AMR. [12] 10 10
Antibiotic resistance has severe consequences for individuals as well as society as a whole, and the problem is expected to grow as resistance is spreading. Effective antibiotic treatment can be seen as a global public good [11] and therefore we should also see it as a global responsibility to protect it. There is an urgent need to tackle the problem now, in order to prevent medicine from falling back into a preantibiotic era.
What is “One Health”? (14) One Health is defined as a collaborative, multisectoral, and trans-disciplinary approach — working at the local, regional, national, and global levels — with the goal of achieving optimal health outcomes by recognizing the interconnection between people, animals, plants, and their shared environment. The areas of work in which a One Health approach is particularly relevant include food safety, the control of zoonoses and combating antibiotic resistance. Many of the same microbes infect animals and humans, as they share the ecosystems they live in. Efforts by just one sector cannot prevent or eliminate the problem. For instance, rabies in humans is effectively prevented only by targeting the animal source of the virus (for example, by vaccinating dogs). Information on influenza viruses circulating in animals is crucial to the selection of viruses used in human vaccines for potential influenza pandemics. Drug-resistant microbes can be transmitted between animals and humans through direct contact between them or through contaminated food, so to effectively contain it, a well-coordinated approach in both humans and animals is required.
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Vision of the One Health Initiative (13) The One Health Initiative is a movement to forge co-equal, all-inclusive collaborations between physicians, osteopathic physicians, veterinarians, dentists, nurses and other scientific-health and environmentally related disciplines, including numerous associations from the United States. One Health shall be achieved through: •
Joint educational efforts between human medical, veterinary medical schools, and schools of public health and the environment;
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Joint communication efforts in journals, at conferences, and via allied health networks;
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Joint efforts in clinical care through the assessment, treatment and prevention of cross-species disease transmission;
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Joint cross-species disease surveillance and control efforts in public health;
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Joint efforts in better understanding of cross-species disease transmission through comparative medicine and environmental research;
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Joint efforts in the development and evaluation of new diagnostic methods, medicines and vaccines for the prevention and control of diseases across species and;
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Joint efforts to inform and educate political leaders and the public sector through accurate media publications.
https://www.ucdavis.edu/one-health/collaborations/
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Veterinary medicine Since antibiotic resistance threatens both animal welfare and public health, the effort to combat it demands a One Health approach that recognizes the connections between animal and human health. In addition to treating and caring for animal patients, veterinarians play a wide range of roles in public health. The work and knowledge of veterinarians are critical to preserving the effectiveness of antibiotics and other disease-fighting antimicrobial drugs in both human and veterinary medicine, by an appropriate and responsible use of these drugs. For veterinarians, that means using antibiotics and other antimicrobial drugs only when they’re truly needed for an animal's medical condition, making sure the specific drug chosen is the most appropriate one and administering the correct dose over the correct amount of time. Due to concerns about the growing problem of antibiotic resistance, the rules of antibiotic use are evolving. Federal regulations are changing how antibiotics and other antimicrobials are used in veterinary medicine. Since the start of 2017, veterinarian's order or prescription is needed whenever food animals are to be given antibiotics that are important in human medicine. This is very significant, because antimicrobials should be used only when they are medically necessary to protect an animal's health. Previously, antibiotics were used for production purposes, such as growth promotion and feed efficiency. It was also very popular to use antibiotics as prevention measure in livestock kept in large farms and in inadequate spaces , therefore prone to infections. However, some antimicrobials which are not used in human medicine (such as ionophores, which help control coccidiosis and therefore help promote growth) can still be used.
Garbage disposal and environment Garbage disposal is important not only from the hazardous and infectious point of view. Different ways we dispose plants, tissues and medicines can affect soil, ecosystems and therefore humans, which leads to antimicrobial resistance. The environment is increasingly acknowledged as a contributor to the development and spread of AMR, particularly in high-risk areas due to human, animal and manufacturing waste streams. However, strong evidence is still required to better inform decision-making in this area.
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Development of new antibiotics With more and more antibiotics loosing effectiveness due to AMR, the development of new drugs is necessary to ensure the future treatment of infections. Unfortunately, we now see a severe discovery void, with the last discovery of an antibiotic class dating back to 1987. (15)
Figure 1. Time-line of the discovery of different antibiotic classes in clinical use. “The discovery void” refers to the period from 1987 until today, as the last antibiotic class that has been successfully introduced as treatment was discovered in 1987.(17)
Since then, there seemed to be a lack of innovation and even today there are only few new drugs in the pipeline. Most of the agents under development right now are only modifications of existing antibiotic classes, instead of new classes itself. They might therefore not be able to overcome multiple resistance mechanisms and are rather short-term solutions. (16) The reasons for this discovery void are various: •
Scientific difficulties: due to bacteria characteristics and challenges of proper target selection, less prone to rapid resistance (15)
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Financial and regulatory difficulties: the development of a new drug is very expensive and trials take a long time (often up to 10 years), but resistance develops faster. As a consequence, the usability of a drug can be decreased before it is even on the market. In order to avoid further resistance, new antibiotics should be used sparsely - making them not profitable for pharma companies. (18)
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Lack of know-how: Many pharmaceutical companies have given up their antibiotic development programs due to lack of financial incentives. This leads to a loss of skilled workforce, expertise and appropriate labs in this field. (19)
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There are two consequences arising from this situation, one the one hand concerning drug development and on the other hand the management of currently available antibiotics. In order to increase the efforts of drug development, innovation in the field of antibiotic development must be more incentivised and states, international organisations and the pharmaceutical industry must increase cooperation to tackle this problem. (16) Interdisciplinary antibiotic research centres, similar to the ones for cancer research, could be a first step to overcome the scientific bottleneck. (18) But only developing new drugs won't resolve the problem. Since pathogens will always keep evolving, a successful treatment will never be final. Therefore, more importantly, antibiotics which are on the market must be handled with care to maintain their effectiveness. (17) This requires a responsible handling of infectious diseases and antibiotics by pharmacists, medical professionals and patients, including social and cultural aspects of antibiotic management. It also has to be noticed, that AMR control is only one part of the whole process of infectious disease management. Sensible surveillance systems and action plans for infectious disease outbreaks are other key parts of tackling the problem. (19)
AMR Surveillance Surveillance of antimicrobial resistance tracks changes in microbial populations, permits the early detection of resistant strains of public health importance and supports the prompt notification and investigation of outbreaks. Surveillance findings are needed to inform clinical decision-making, to guide policy recommendations and to assess the impact of resistance containment interventions. (19) Bodies/Surveillance Systems 1) GLASS (Global Antimicrobial Resistance Surveillance System) Launched in October 2015, the Global Antimicrobial Resistance Surveillance System (GLASS) is being developed to support the global action plan on antimicrobial resistance. Its aim is to support global surveillance and research, in order to strengthen the evidence base on AMR, as well as to help informing decision-making and drive national, regional, and global actions. GLASS promotes and supports a standardized approach to the collection, analysis and sharing of AMR data at a global level by encouraging and facilitating the establishment of national AMR surveillance systems that are capable of monitoring AMR trends and producing reliable and comparable data. (20,21)
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Picture: Map of countries enrolled in GLASS, as of December 2018
By participating in GLASS countries commit to build or strengthen their national AMR surveillance system in order to generate quality AMR surveillance data to meet both local needs and GLASS requirements. (20,21) 2) EARS-Net (European Antimicrobial Resistance Surveillance Network) EARS-Net is the largest publicly funded system for AMR surveillance in Europe. Data from it plays an important role in raising awareness at the political level, among public health officials, in the scientific community and among the general public. Public access to descriptive data (maps, graphs and tables) are available through the ECDC Surveillance Atlas of Infectious Diseases. (22) 3) ESAC-Net (European Surveillance of Antimicrobial Consumption Network) ESAC-Net (formerly ESAC) is a Europe-wide network of national surveillance systems, providing European reference data on antimicrobial consumption. ESACNet collects and analyses data on antimicrobial consumption from EU and EEA/ EFTA countries, both in the community and in the hospital sector. The collected data are used to provide timely information and feedback to EU and EEA/EFTA countries on indicators of antimicrobial consumption. These indicators provide a basis for monitoring the progress of EU and EEA/EFTA countries towards prudent use of antimicrobials. (23)
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Global Health approach The increased prevalence of drug-resistant microorganisms worldwide is alarming. Antimicrobial resistance has been detected in all parts of the world; it is one of the greatest challenges to global public health today, and the problem is increasing. Although antimicrobial resistance is a natural phenomenon, its development and spread is being accelerated by misuse of antimicrobial medicines, inadequate or non -existent programmes for infection prevention and control, poor-quality medicines, weak laboratory capacity, inadequate surveillance and insufficient regulation of the use of antimicrobial medicines.
A strong, collaborative approach will be required to combat antimicrobial resistance, involving countries from all regions and actors in different sectors. Although widely recognized as an immense problem, not all countries have a response plan to tackle antimicrobial resistance. Some regions face other, more pressing, problems and many low- to middle-income countries do not have the resources to implement adequate response mechanisms.That is why WHO invites all international, regional and national partners, to implement the necessary actions in order to contribute to the global action plan tackling this problem. The goal of the global action plan is to ensure, for as long as possible, continuity of successful treatment and prevention of infectious diseases with effective and safe medicines that are quality-assured, used in a responsible way, and accessible to all who need them. To achieve this goal, the global action plan sets out five strategic objectives: • to improve awareness and understanding of antimicrobial resistance; •
to strengthen knowledge through surveillance and research;
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to reduce the incidence of infection;
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to optimize the use of antimicrobial agents; and
• develop the economic case for sustainable investment that takes account of the needs of all countries, and increase investment in new medicines, diagnostic tools, vaccines and other interventions.
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Role of General Practitioners General Practitioners (GPs) / Family doctors have the potential to be the most influential health care professionals to address this problem as the majority of antibiotics are prescribed in the family medicine setting. Continued improvements in prescribing practice and a positive influence on individual and community beliefs about antibiotic consumption are essential to limit the spread of antibiotic resistance. There are a lot of opportunities in primary care that combined are likely to enable clinicians and health care systems to implement the strategies that will reduce antimicrobial resistance in the future. General measures: The health professional in the exercise of his duties should ensure the safety of his patients, especially in regards to treatment and transmission of infections concerns. To do this, he or she must comply with the rules of infection control (such as those described below), as well as with local antibiotic prescription policies. It is necessary to raise awareness among health professionals about the direct contact with patients, a vehicle with a large spread of infections. 1. 2.
3. 4.
Hand washing or alcohol-based rinses by staff between each patient and before undertaking any procedures; Use of barrier precautions, e.g. wearing gloves and gowns for certain procedures; Adequate sterilization and disinfection of supplies and equipment; Use of sterile techniques, in compliance with protocols, for medical and nursing procedures.
Prescription Policy There are a number of interventions that have shown promise at improving antibiotic prescribing in primary care: delayed prescribing, patient decision aids, communication training etc. Prescribers are well placed to convey the importance of informing patients, that they are twice as likely to carry resistant bacteria after a course of antibiotics compared to someone who didn’t take them. Evidence from general practice demonstrates that patient satisfaction is linked more to good communication than a prescription for an antibiotic. Several studies have demonstrated that GPs trained in communication skills and specifically in Shared Decision Making prescribed antibiotics significantly less than GPs without training. (24)The benefits of patients managed by a GP trained in enhanced communication skills can persist for at least 3 years and do not appear to compromise repeat consultation rate, patient recovery or patient satisfaction.
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Patient Education People should have the skills and knowledge to make informed decisions about how to prevent infection and reduce transmission of infectious diseases through simple, cheap and effective measures. Such measures include prevention of: • • • •
Diarrhoeal disease through hand washing, using safe water sources and containers, boiling unsafe water and using latrines; Malaria through the use of bed nets impregnated with insecticide; Sexually transmitted infections through the use of condoms; Certain infectious diseases through routine childhood vaccination (diphtheria, measles, pertussis, Haemophilus influenzae, Streptococcus pneumoniae) and
epidemic vaccination (meningitis, typhoid); •
HIV/AIDS and hepatitis B and C through the avoidance of injections (unless oral medicines cannot be used, in which case, a sterile needle and syringe must be used). (25)
GP can also counsel patients with viral infections about the ineffectiveness of antibacterials and can recommend appropriate medication for supportive care. Above all and most importantly, by addressing patient concerns related to antimicrobial and understanding of the appropriate use of these agents, GP can be an essential arm in preventing AMR. (26) Discussing Antibiotics Therapy Example:
“Mr. Smith, you have sinusitis caused by a virus. You don’t need antibiotics. Antibiotics will not resolve your infection and can cause you harm, for example diarrhea, future infections due to resistant bacteria and other, even life-threatening side effects. If you develop worsening symptoms, such as fever or continue to experience persistent severe symptoms after 10-14 days, I will consider additional medications. For now, use OTC medications or no medications at all and call us with any concerns.”
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EU action plan on AMR Facing regional and global AMR challenges, the EU stands at the forefront for addressing the issue. However, no single action will, in isolation, provide an adequate solution. Resistant bacteria and infectious diseases do not respect borders. No individual Member State or the EU can tackle the problem on its own. The European One Health action plan against AMR (2017) will support the EU and its Member States in delivering innovative, effective and sustainable responses to AMR; strategically reinforce the research agenda on AMR and enable the EU to actively promote global action and play a leading role in the fight against AMR. Its overarching goal is to preserve the possibility of effective treatment of infections in humans and animals. It provides a framework for continued, more extensive action to reduce the emergence and spread of AMR and to increase the development and availability of new effective antimicrobials inside and outside the EU. The key objectives of this new plan are built on three main pillars: (27, 28) 1.
2. 3.
Making the EU a best practice region - better evidence, better coordination and surveillance, and better control measures. EU action will focus on key areas and help Member States in establishing, implementing and monitoring their own national One Health action plans on AMR; Boosting research, development and innovation by closing current knowledge gaps, providing novel solutions and tools to prevent and treat infectious diseases, and improving diagnosis in order to control the spread of AMR; Shaping the global agenda
This Communication provides a framework for future actions against AMR and aims to make the best possible use of the EU legal framework and policy instruments, focusing on the real added value the EU can bring to the fight against AMR. Most of the actions can be done by adapting and reinforcing existing actions for a more integrated, comprehensive and effective approach to combating AMR. Other actions focus on identified gaps in the EU response so far that requires new activities, the discovery of new knowledge and the creation of new partnerships. (27, 28) Additional global and regional strategies and plans to address antimicrobial resistance (29) •
Global Antibiotic Resistance Partnership (GARP): GARP was started in 2009 to create a platform for developing actionable policy proposals on antibiotic resistance in low and middle income countries. National GARP working groups are established in: India, Kenya, South Africa, Vietnam, Mozambique, Nepal, Tanzania and Uganda. GARP is a Center for Disease Dynamics, Economics & Policy (CDDEP) project. (30)
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Global Health Security Agenda (GHSA): The GHSA was launched in February 2014. One of its identified Global Health Security Risks is ‘Rise of drug resistance’ (31). 20 20
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Jaipur Declaration on Antimicrobial Resistance: The Declaration was signed in September 2011, at the 29th South East Asia Health Ministers Meeting, by all Member States of the WHO South-East Asia Region. The signatories agreed to 18 broad commitments for action on preserving the efficacy of antimicrobial drugs (32, 33).
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Strategic action plan to control antimicrobial resistance in the Asia-Pacific region: The Health Working Group (HWG) of the Asia-Pacific Economic Cooperation (APEC) has been working since 2010 to establish future strategies to control and prevent AMR in the Asia Pacific region: The ‘Strategic action plan to control antimicrobial resistance in the Asia-Pacific region’ was developed by the Strategic Focus Group, which consisted of the experts on infectious diseases, health science, veterinary medicine, healthcare officials from APEC economies, and external APEC stakeholders. (34, 35)
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Transatlantic Task Force on Antimicrobial resistance (TATFAR) TATFAR was created in 2009 with the goal of improving cooperation between the U.S. and the EU in three key areas: (36, 37) (1) appropriate therapeutic use of antimicrobial drugs in medical and veteri nary communities; (2) prevention of healthcare and community-associated drug-resistant in fections; (3) strategies for improving the pipeline of new antimicrobial drugs.
World Bank Report (38) In 2017, the World Bank Group published a report titled “Drug-Resistant Infections: A threat to our economic future”, highlighting the effect of AMR on global trade and economy. This report not only presents the costs of inaction, but also calls for for action at national and international level. The threats of AMR on the global economy are described in the early chapter (“why we need to tackle the problem”) in more detail. However, the World Bank Report suggests, that the financial impact of AMR could be comparable to the financial crisis 2008/2009 and highlights the special vulnerability of low-income countries (LICs) to these losses. While policy makers may be concerned that costs of tackling AMR will be considerable, the World Bank Group actually suggests that it could be one of the highest-yield development investments. Especially LICs could see remarkable pay-offs relatively to the size of their economies, even though the highest absolute gains will be achieved in high-income countries (HICs). The Report calls for strong leadership on the country level and gives recommendations on how to best tackle the problem. These are summarized in the following:
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The Report calls for strong leadership on the country level and gives recommendations on how to best tackle the problem. These are summarized in the following: From the healthcare sector: • Establishing Universal health coverage (UHC) as an enabling framework to tackle AMR through better oversight & quality of care, improved stewardship and smarter financing; • Implementation of the International Health Regulations to focus global support and cooperation; • Building of laboratory capacities for AMR surveillance and development of synergistic laboratory networks. From the agricultural sector: • Reduction of the use of antibiotics in animal production; • Strengthening of national surveillance systems for the use of antibiotics and the spread of AMR in animals; • Establishing new partnerships for AMR control across agriculture, environmental science and health. From the water and sanitation sector: • Universal access to sanitation and clear water to prevent infections; • Establishing basic hygiene measures to decrease incidence of AMR infections. Eventually, the World Bank Group describes its own plans to take on responsibility in AMR action.The following steps are planned: 1. 2. 3. 4. 5.
Creation of a global investment framework for AMR action; Putting an AMR lens on development finance by reviewing its on investment lending policies and instruments; Mobilizing finance for AMR Innovation across Agriculture and Health; Increasing the involvement of the private sector; Supporting countries UHC reforms.
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WHO role (39, 40) World Health Organisation plays a major role in the fight with a global threat that is AMR. In compliance with One Health approach, it works in collaboration with Food and Agriculture Organization of the United Nations (FAO) and the World Organisation for Animal Health (OIE) while preparing all its policies. In May 2015 68th World Health Assembly adopted the “Global Action Plan on Antimicrobial Resistance�, which goal is to ensure, for as long as possible, continuity of successful treatment and prevention of infectious diseases with effective and safe medicines that are quality-assured, used in a responsible way, and accessible to all who need them. All the efforts of WHO to tackle AMR revolve around 5 strategic objectives set out in the global plan: 1. Improve awareness and understanding of antimicrobial resistance through effective communication, education and training. WHO is leading several education campaigns, including World Antibiotic Awareness Week, a global initiative to encourage best practices among the general public, health workers and policy makers to avoid the further emergence and spread of antibiotic resistance. 2. Strengthen the knowledge and evidence base through surveillance and research. WHO launched Global Antimicrobial Resistance Surveillance System (GLASS), world-wide network which aims to estimate the extent and burden of AMR globally by selected indicators, analyse and report global data on AMR on a regular basis, as well as detect emerging resistance and its international spread. Call for country participation in GLASS is open and all the data collected is used to create annual reports. 3. Reduce the incidence of infection through effective sanitation, hygiene and infection prevention measures. Infection prevention measures such as sanitation, hand washing, food and water safety, and vaccination can decrease the spread of microorganisms resistant to antimicrobial medicines, therefore increase the longevity of these drugs. WHO encourages all such measures and creates supporting documents on antibiotic stewardship programmes to be implemented in health care facilities. 4. Optimize the use of antimicrobial medicines in human and animal health. In order to promote prudent use of antibiotics, WHO is constantly launching up-to-date guidelines on medical treatments of specific diseases, as well as on use of antibiotics within agriculture and animal production. It advocates on legislation regarding distribution, quality and efficacy of antibiotics in clinical, pharmacy, and veterinary practices. 5. Develop the economic case for sustainable investment that takes account of the needs of all countries, and increase investment in new medicines, diagnostic tools, vaccines and other interventions. WHO co-founded Global Antibiotic Research & Development Partnership (GARDP), a not-for-profit initiative, that works with all stakeholders in public and private sectors to target priority pathogens and then develop and deliver new treatments methods. In order to properly assess current advances, WHO creates annual analysis of antimicrobial agents in the clinical development pipeline. Moreover, it runs and supports multiple programmes that focus on finding and improving alternative methods of preventing diseases (e.g. protective vaccinations) and novel diagnostic tools. 23 23
EARS-Net (41) The European Antimicrobial Resistance Surveillance Network (EARS-Net) is the biggest system for antimicrobial resistance surveillance in Europe. Data from this network plays an important role in raising awareness at the political level, among public health officials, in the scientific community and among the general public. This network is administered and coordinated by the European Centre for Disease Prevention and Control (ECDC). The objectives of EARS-Net are to: • collect comparable, representative and accurate AMR data;
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analyze the temporal and spatial trends of AMR in Europe;
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provide timely AMR data for policy decisions;
• encourage the implementation, maintenance, and improvement of national AMR surveillance programmes; • support national systems in their efforts to improve diagnostic accuracy by offering annual external quality assessments (EQA). EARS-Net is based on routine clinical antimicrobial susceptibility data from invasive isolates (blood and cerebrospinal fluid), from local and clinical laboratories who report to ECDC by appointed representatives from the Member States. EARS-Net performs surveillance of antimicrobial susceptibility of bacterial pathogens commonly causing infections in humans such as Escherichia coli, Klebsiella
pneumoniae, Pseudomonas aeruginosa, Acinetobacter species, Streptococcus pneumoniae, Staphylococcus aureus, Enterococcus faecalis and Enterococcus faecium. The reporting protocol defines antimicrobial agent combinations under surveillance for each species, presents guidelines for the detection of resistance mechanisms, describes specific types of resistance of clinical or epidemiological importance and explains the mechanisms of resistance. The information on current and historical trends in the occurrence of antimicrobial resistance across Europe can be consulted on The ECDC Surveillance Atlas of Infectious Diseases and also in various annual reports and related publications.
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Antibiotic Stewardship “Antibiotic stewardship refers to a set of coordinated strategies to improve the use of antimicrobial medications with the goal of enhancing patient health outcomes, reducing resistance to antibiotics, and decreasing unnecessary costs.” (42) “Antimicrobial stewardship is a collective set of strategies to improve the appropriateness and minimise the adverse effects of antibiotic use including resistance, toxicity and costs. Stewardship is achieved by promoting the selection of the optimal antibiotic regimen, dose, duration and route of administration.” (43) Antimicrobial Stewardship Programs (44) According to the CDC, the Hospital Antibiotic Stewardship Program should include the following Core Elements: •
Leadership Commitment: Dedicating necessary human, financial and information technology resources. This can include: A. formal, written statement from leadership that it supports efforts to improve antibiotic use (antibiotic stewardship); B. budgeted financial support for antibiotic stewardship Activities.
•
Accountability: Appointing a single leader responsible for program outcomes. Experience with successful programs show that a physician leader is effective.
•
Drug Expertise: Appointing a single pharmacist leader responsible for working to improve antibiotic use. Additional staff members such as Clinicians Infection Prevention and Healthcare Epidemiology, Quality Improvement Microbiology (Laboratory), Information Technology and Nurses can also work with the stewardship leaders to improve antibiotic use.
•
Action: Implementing at least one recommended action, such as: A. systemic evaluation of ongoing treatment need after a set period of initial tre atment (i.e. “antibiotic time out” after 48 hours); B. a policy that requires prescribers to document in the medical record or during order entry a dose, duration, and indication for all antibiotic prescriptions; C. facility-specific treatment recommendations, based on national guidelines and local susceptibility, to assist with antibiotic selection for common clinical conditions.
•
Tracking: Monitoring antibiotic prescribing and resistance patterns.
•
Reporting: Regular reporting information on antibiotic use and resistance to doctors, nurses and relevant staff.
•
Education: Educating clinicians about resistance and optimal prescribing.
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Capacity Building An Activity is a unique set of planned interventions designed and implemented to achieve certain specific objectives – within a given budget and a specified period of time. Normally an activity starts with a planning-phase progressing to a monitoringphase when the activity is or has been implemented. An activity ends by an evaluation aiming to provide learning-points and recommendations, which can be used to plan a new activity and set a new vision and goals. ACT
PLAN
- What change are to be done?
- Objective
- Next cycle?
ACT
PLAN
CHECK - Complete analysis - Compare data and predictions
CHECK
DO
- Plan to carry out
- Who, what, where, when, how - Questions and predictors
DO - Carry out the plan - Document unexpected observations
- Summarize what was learned
- Begin analysis of the data PDCA Cycle
How to get started In the very beginning of an activity-making-process, it is essential to allow a broad range of ideas to be discussed. This is the time where creativity should be encouraged. Two easy tools to start with are the “Problem Tree and Objective Tree” followed by a “stakeholder analysis”. After making these three exercises, it should be easier for you to formulate and write a great activity or campaign. It is essential for the whole activity period and outcome that as many people/members of your activity team are involved in the planning phase. This is to ensure the best possible engagement to the activity as well as obtaining as many inputs and ideas as possible. We recommend that you set a plan for how to monitor and evaluate your activity before you start your activity, in order to ensure the success. The Problem Tree (45) The problem tree is a central method to use in the planning of an activity, but can also be used in later stages of the project cycle. The problem tree allows you to discover the underlying causes of the problem you are trying to solve, thereby enabling you to create objectives that tackle the true cause(s) of the problem, instead of simply planning your activity to target the immediately apparent causes. The method should be used as a group exercise in your activity group, but it can also be beneficial to create a problem tree with your target group or key stakeholders – this gives you the broadest insight into the problem you wish to tackle, so you can plan for the activity that will have the highest possible impact. 26 26
The first step in creating a problem tree is to discuss and agree the problem or issue to be analysed. Do not worry if it seems like a broad topic, because the problem tree will help to break it down and make it more concrete. During this first stage, it is important that as many possible options are examined. Here, the aim is to establish an overview of the situation (e.g. Cholera in Kingstown). Later in the process, the perspective will be narrowed and deepened in order to prepare an activity design. Step 1 – Formulate problems Brainstorm suggestions to identify a focal problem that the your activity will focus on (e.g. Cholera in Kingstown). Each identified problem is written down on a separate card or Post-It. The wording of your suggestions does not need to be exact as the roots and branches will further define it, but it should describe an actual issue that everyone feels passionately about to change it. What is a ‘problem’? A problem is not the absence of a solution but an existing negative state: ‘High prevalence of bacterial infections’ is a problem; ‘No antibiotics are available’ is not.
Step 2 – Identify the central problem Discuss your suggested problems – are they related, and if so, in what way? Through your discussions, identify the central problem. If agreement cannot be reached, then: • Arrange the proposed problems in a problem tree according to the causal relationships between them; • Try again to agree on the focal problem on the basis of the overview achieved in this way. If no consensus can be achieved: • Try further brainstorming; • Select the best decision, e.g. by awarding points; or decide temporarily on one, continue your work but return at a later stage to discuss the other options. • Decide whether this really is the problem you want to tackle. One of the most important things in teamwork is to all be passionate and motivated to work on it. Step 3 – Develop your problem tree Once you have identified your central problem, the cards or post-its can be moved so that the immediate and direct causes of the focal problem are placed in parallel (see example above), and draw connecting lines to indicate the means-ends relationships. • Beneath it; the immediate and direct effects of the focal problem are placed in parallel • Above it: causes and effects are further developed along the same principle to form the problem tree. The problem analysis can be concluded when your group agrees that all essential information has been included that explains the main cause and effect relationships characterizing the problem. The heart of the exercise is the discussion; debate and dialogue that is generated as factors are arranged and rearranged, often forming sub-dividing roots and branches (like a Mind map). Take time to allow people to explain their feelings and reasoning, and record related ideas and points that come up on separate flip chart papers under titles such as solutions, concerns and decisions. 27 27
Problems tree from the IFMSA manual “From Idea to Impact” (45)
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Objectives Tree (45) Creating an objective tree will help you find best solutions to the problems you want to focus on in your activity. Once completed, the objective tree provides a summary picture of the desired future situation, including the means by which ends can be achieved. While developing, a problem tree will provide your activity group with great insight into the issue at hand. The real strength of the method is to use your problem tree to develop an objective tree. Having broken down your issue into separate problems (a central problem and its causes and effects) in the problem tree, you can now reformulate each of the problems in your tree to a solution, or a desired scenario. Step 1 Reformulate all the elements in your problem tree into positive desirable conditions. Step 2 Review the resulting means-ends relationships to assure the validity and completeness of the objective tree. Step 3 If required, revise statements; delete objectives that appear unrealistic or unnecessary; add new objectives where required. Select one or more conditions that you want to change with your activity. Choose realistic goals; goals that are set too high, are meant to fail and knock down all the motivation.
Objectives tree from the IFMSA manual “From Idea to Impact� (45)
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Long-term goal and immediate objectives (45) At the end of the activity-planning-phase you have insight into the issue at hand, and you are ready to decide what the long-term goal for your activity should be. Your long-term goal (or overall objective) describes why your activity is being done – it is a vision based on insight into context and society. It should characterize the future and overall situation that the activity is expected to contribute to achieving – often in the long term. As students volunteering, with often limited time or access to funding, we can never achieve our long-term goals by ourselves. However, our activity will contribute to achieving this goal. Your immediate objective(s) describe the change you are looking for within your activity group – a change that you are able to influence. Your immediate objectives will often feed directly into the outputs/outcome of your activity. Outputs or results (45) The outputs are defined as the results that can be guaranteed by the activity as a consequence of its actions.The outputs are the concrete results that you plan your actions to produce or deliver to achieve the immediate objective. The outputs are meant to be produced during different stages in the activity. The outcomes should be what “comes out” of the actions and something that is within your control of your activity. It is recommended to keep the amount of outputs limited to 2-5, in order to ensure the overview of the activity design and to keep realistic goals. However, be aware of including all necessary outputs required to achieve the immediate objective. Finally remember to keep your outputs precise and verifiable. Indicators or success criteria (45) Indicators or success criteria are important as they provide a basis for monitoring and evaluation. They are intended to indicate the extent to which objectives and results have been achieved. They should indicate a concrete ambition level – i.e. a “certain percentage of” or number – not just “more” or “increased”; they should be SMART. SMART Criteria SMART is an acronym representing five points that your indicators should follow: Specific – target a specific area for improvement. Measurable – quantify -or at least suggest- an indicator of progress. Achievable– is this attainable? Relevant – state what results can realistically be achieved, given available resources. Time-bound – specify when the result(s) can/will be achieved.
Means of verifications (45) Tells us where and how we will find our answers/data, tells us who will do it and for most of us, must be reasonable in terms of costs and other resources required.
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Peer Education Methods (46, 47) Tell me…I forget. Show me…I remember. Involve me…I understand. - Ancient Proverb
Peer education is the process whereby well-trained and motivated young people undertake informal or organized educational activities with their peers (those similar to themselves in age, background, or interests). These activities, occurring over an extended period of time, are aimed at developing young people’s knowledge, attitudes, beliefs, and skills and at enabling them to be responsible for and to protect their own health. When undertaking a peer education programme, the objectives are often to reinforce positive behaviours, to develop new recommended behaviours, or to change risky behaviours in a target group. The following theories and models of
behaviour change are of particular relevance for peer education: 1.
2. 3.
4.
5.
Theory of reasoned action - In the context of peer education, this concept is relevant because young people’s attitudes are highly influenced by their
perception of what their peers do and think. Also, young people may be motivated by the expectations of respected peer educators. Social learning theory - In the context of peer education, this means that the inclusion of interactive experimental learning activities are extremely
important, and peer educators can be influential teachers and role models.
Diffusion of innovations theory - In the context of peer education, this means that the selected peer educators should be trustworthy and credible opinion
leaders within the target group. The opinion leader’s role as educator is especially important in informal peer education, where the target audience is not reached through formally planned activities but through everyday social contacts. Theory of participatory education - In the context of peer education, this means that many advocates of peer education believe that the process of peers talking among themselves and determining a course of action is key to
the success of a peer education project.
Health belief model - In the context of peer education, this means that the health belief model’s most relevant concept is that of perceived barriers, or a
person’s opinion of the tangible and psychological costs of the advised action. In this regard, a peer educator could reduce perceived barriers through reassurance, correction of misinformation, incentives, and assistance. For example, when telling a high school class about superbugs, AMR and ways to prevent it, some students of the class might not believe that superbugs affect their health, because their parents told them so and it is now their belief, which builds a barrier to the educator. In order to reduce this barrier, slowly explain to them the mechanisms of resistance with solid information they also believe in, e.g. the WHO or a recommended science book.
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6.
7.
Social ecological model for health promotion - In the context of peer education, this means that it is important to recognize that peer education is just one piece
of the puzzle. While peer education can be an important intervention to affect intrapersonal and interpersonal change, in order to be successful, peer education activities must be coordinated with other efforts designed to influence institutions, communities, and public policy.
IMBR model: information, motivation, behavioural skills, and resources - It focuses largely on the information (the ‘what’), the motivation (the ‘why’ - e.g.
because it is about their future and the change starts with yourself), the behavioural skills (the ‘how’ - e.g. paying attention not to take too many antibiotics, hygienic standards), and the resources (the ‘where’) that can be used to target at-risk behaviours. In the context of peer education, this means that a programme that does not have a comprehensive approach including all four IMBR concepts probably lacks essential components for reducing risk behaviour and promoting healthier lifestyles. Translating theory into practice
Use of role plays and other theatre-based techniques: Realistic theatre pieces and role plays can help achieve several major objectives of a health education programme. They can: Provide information. Role plays and other theatre techniques provide an attractive way to deliver information through humour and true-to-life drama. It permits educators to dramatize the myths that people spread and show how to break them down. In a role play, people can explore problems that they might feel uncomfortable about discussing in real life. Create motivation. Theatre techniques can effectively dramatize external situational pressures and difficult psychosocial situations that sometimes result from poor decision-making and risk behaviour. Strong theatre engages the hearts and minds of the audience and can motivate them to change their attitudes. Build skills. Role playing and other theatre techniques have the potential to shape behaviour by demonstrating various skills, such as negotiation, refusal, decision-making, and practical expertise. Make a link to resources. Learning by experiences Participation Reflection on the experience Generalization (lessons learned) Application of lessons learned.
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Illustration of Direct Experience (46)
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Logistics The key to a successful workshop is good coordination. While planning the event, define all the goals beforehand, so you can tackle them one by one. Venue: When choosing the location, think about practical details of your workshop. The venue should be easily accessible for everyone, not too far away from the lodging. Consider the number of participants and if they will be separated into groups that require multiple rooms. You have to make sure there will be enough space for everyone to feel comfortable, including facilitators. During trainings, people have to move around in different smaller groups or do activities, so it is important that the rooms provide enough space for this. Remember, that everyone must be able to sit and see visual aids. If you need a certain technology, like projector, check beforehand if the location supports it and if everything is working. Also, make sure it is possible to hang up the flipcharts on the walls and that the chairs can be moved. Lodging: Depending on what kind of workshop/event you are hosting and how big it is, the lodging necessities may vary. Is this something that will be provided by the organizing committee? Or the participants need to find a place on their own? Either way, communication is key so if you are providing the lodging don’t forget to let the participants know what type of lodging they’ll be staying in, the address, if there will be showers, WiFi, and so on. Food: Providing food on site during breaks will keep participants from getting hungry and distracted. Tea and coffee may also keep people awake and increase their mental capacities. Remember about free access to water, so that everyone stays properly hydrated. While preparing food or ordering catering, try to choose things that are nutritious and tasty. You also have to make sure beforehand about all allergies or dietary restrictions among participants. Logistics considerations for the session: Discuss early with the facilitators of the workshop about the order of events, and what they will need to deliver their sessions. Take time to list exactly which group discussions and activities you'll have at which point in the workshop. How much time will you allow for each exercise? Make sure your activities are appropriate for the size of the group and ensure that your venue has the resources (for example, seminar rooms) needed to run sessions. Check if all necessary visual aids are prepared and all materials are provided. If they are not, at least keep the facilitators posted so they can restructure their session in some way.
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Fundraising: Create a case for support A powerful, engaging argument as to why a donor or an organization should support your work. Explain what the problem is, what is your solution to the problem, the difference you will make if you succeed, the difference you will make if you fail and why you are the one tackling this problem. The case should be simple to understand, emotionally engaging and convincing. Research Look around for new possible supporters and establish how to reach each one Ask for help within your team, we all know someone that knows someone. Some suggestions for donors are: trusts and foundations, private companies, individuals and local organizations, grants provided by local or national governments. Analyse and plan Decide which sources or which funds your will focus on. Consider and compare how much time and effort it will take to deliver results. Think about individual characteristics of different sources, e.g. find out if the donor has supported similar cases in the past and use that as one of your arguments. Always remember to check if the fund has any limitations and if you are applicable. Structure Once you decided which sources to approach, it is time to structure the fundraising. According to your needs, you can even develop a fundraising team or even employ a fundraiser consultant. Don’t forget to build capacity among your team in terms of fundraising as early as possible. Create a proposal and ask for money You will probably have to write down a written proposal in the case of charities and big organizations.There are many ways in which one can ask for support; writing to then, asking them face to face, the important thing here is to do it in a more tailored and personal way. Shape your needs and match the donor interests. If you write your proposal, make sure everything is correct and clear. Build relationships for the long term Don’t forget to thank the donor and mention their contribution. Or even those who didn’t ended up supporting you financially, they can always be a potential donor in the future. Always try continuously involving the donor in your organization and always report back on the difference their contribution made.
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Strategy When talking about Strategy for your event, it is important to highlight the following steps: Set your Goals
In order to have a successful workshop, you must set the goals that will guide you through all the planning and also will help you to do the overall evaluation. An easy way to create goals is the SMART way: Specific, Measurable, Achievable, Realistic and Time – related. Gather your Team The success of any job is due to the people who are responsible for it. For everything to run around the best surround yourself with committed and passionate people, who have a special interest in the subject and who have the taste and aptitude to work as a team. Develop your team according to your main event necessities and overall goals. Some of the members that you should have on your team are the general coordinator (that will be probably you), logistics manager, finances manager, and publicity manager. Each of them can have their own teams, but remember that you must take care of your core team. Create your strategy Develop a strategy together with your team that clearly states your goals and objectives. A strategy is a well-elaborated plan set in order to achieve goals and objectives. Ask input from more experienced people in your entourage. Ask feedback on your ideas. Identify your budget Make sure you do this since the beginning and establish the fundraising necessities (if any) along with the plan to keep up proper accountability of the expenses and incomes. If possible, design one specific member of your team to deal with this. Be Organized Establish right from the start a strong communication between your team and you. Establish a work plan, setting a realistic timeline along with the tasks and make it understandable to everyone. Revisit your Team Needs Try to always be aware of what is happening with and within your team. Be there ready to help and solve problems. Using the proper communication channels, asses your team needs and constantly review the progress of the work getting done comparing it with the timeline you designed before. Remember that in order to improve something, we always need to assess it.
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Evaluation Evaluation is a key part of any activity. It is through this process that you will be able to see if the objectives you have set for the work have been achieved, if the message you wanted to pass reached the recipients, what the participants' opinions were, the strengths and weaknesses of the workshop and what is there to improve on an upcoming occasion . For this reason, it is very important that evaluation grids related to the objectives that you set out to achieve with workshop are established. The following is an example of a questionnaire that you can give participants to understand the level of impact you were able to have with them. You should give them this survey before and after the workshop so you will be able to see the improvement that the group has achieved during the training, through the increase of their capacities and their motivation for the topic. The goal is for the group to complete the questionnaire in these two moments and the difference between the two answers will constitute a score. This is a more objective way than only evaluating the level of knowledge in the end because you can compare with their initial status. Questions/Answers: How do you rate your knowledge about antimicrobials? How do you rate your knowledge about antimicrobial resistance and its impact to health? Do you feel motivated to start activities in that area? Do you feel you can create an impact and raise your voice to your policymakers? Here are some examples of ways to perform an evaluation: • Feedback This type of evaluation should be considered as a matter of perception and opinion regarding the session. Take advantage of several moments of the workshop when the lines are to do it. Feedback is one that is a guy and a more private environment. • Check out (5 fingers, swot): Before the end of the session, everyone is asked about what they thought about the session, what they liked the most, what they liked least and the suggestions for improvement. This can be done in a free or structured way. Two examples of structured ways of doing this are the 5-finger method or SWOT analysis: 5 Fingers • Thumb: What was OK. • Index: What I learned. • Middle finger: What was not OK or can be improved. • Ring finger: What friendships I made. • Little finger: What was too short.
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SWOT analysis: SWOT stands for Strengths, Weaknesses, Opportunities, and Threats. This analysis leads to a richer understanding of what the project can offer, the key weaknesses that need to be worked upon in order to succeed, the opportunities you have to improve and the things that might be a threat to the goal. Helpful
Harmful
(for your objective) (for your objective) Internal (inside your organisati on) External (outside your organisati on)
STRENGTHS
WEAKNESSES
(skills, motivated volunteers, interdisciplinarity...)
(sponsors not identified, no communication plan...)
OPPORTUNITIES
THREATS
(networking, industry exposure...)
(No external funding, sickness...)
•
Post it evaluation: Ask everyone to write on 2 post-its good things and Post-it things that can be improved. Get a flipchart paper, draw a line in the middle and put “-” on one side and “+” on the other and ask the participants to stick on it.
•
Pizza chart: Draw a circle and split it into 4 slices and write on each slice an aspect of the meeting (format of the session, content, dynamics, and trainer). Ask the participants to take a marker and draw a line on each slice of the pizza, the longer the line, the more satisfied they would have been with that aspect of the session
•
Suggestion box: You can also give the participants a box of shoes where they can leave opinions and suggestions so you can read later.
•
Evaluation form: This can be on paper or online. You design it easily by putting the topics in the agenda and making a 1 to 5 scale for each of them and a clear question.
It will also be important to get follow up from the participants. Take the opportunity of the training moment to create a communication channel that all have easy access and that allows you to maintain contact with them in a way that encourages them to organize their own activities and to make the transition to real action, as well as assisting them if necessary.
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Advocacy & Campaigning (48) Advocacy describes actions, which are aiming for an improvement of the current situation through speaking up and influencing decision-making processes on a local, national and international level. It therefore includes strategies as lobbying, networking, as well as information, education & communication. Advocacy come in various form, but there some central points to consider when drafting successful advocacy campaigns: 1. Research & problem analysis Inform yourself, break complex problems down into smaller components and define what needs to be changed. 2. Finding a influencing strategy Analyse the political and cultural context of change and define your stakeholders. Note that for a complex topic as AMR, stakeholders come from different sectors (health, research, agriculture, pharmaceutical industry, media, etc.) and from different levels (institutional, local, national, international). Define your target audience and strategy based on your specific problem.
If you need help with finding stakeholders within this area, you can contact your NMO president, as they will have access to a stakeholders map created and developed by the EuroTeam from 2016-2019 in the NMO folder on google drive.
3. Defining a core message Plan your message on how to deliver it, tailored to your audience and and the contextual factors. 4. Implementing of advocacy strategy Raise awareness for your issue, form networks, get in contact with central stakeholder directly and indirectly and have an eye on key opportunities for advocacy (conferences, etc.). 5. Measuring the impact Evaluate your activities and monitor the progress. Make sure to start thinking about the evaluation on the initial planning phase. Thinking strategically from the beginning helps you to develop more successful advocacy, tailor activities to your audience and see the impact of your actions. Campaigning, also called mobilising the public, aims for raising awareness for an issue amongst the wider public and engaging people to take action. It can therefore be seen as an engine for social change. Various activities can be used for campaigning, especially: • Workshops, lectures and other direct forms of education • Organisation of public meetings and events • Petitions • Using different media channels to inform about your issue (poster, radio, newspaper articles, TV, etc.) • Social media campaigns To make you campaign a success, start by defining an end goal, your target audience and setting SMART (specific- measurable-achievable-realistic- timebound) objectives. As with advocacy, it is important to define indicators of success and monitor progress.
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Agenda Proposals An activity on AMR can varies between different methodologies and target groups. Depending on the objectives of the activity, an educational workshop may be the appropriate method in order to fulfill them. Here you can find 3 different Agenda templates each one to a different approach of the topic. A. Healthcare approach 1. Introduction to Health - What is Health (definition) - What is Public Health (definition) 2. Introduction to AMR - What is AMR - How does AMR happen 3. AMR in Healthcare Sector - Hospital Acquired Infections - Antimicrobial Resistance in Hospital Environment - Antibiotic Stewardship - Surveillance on AMR and Surveillance Systems 4. Doctor-Patient Communication
B. One Health Approach 1. Introduction to Health - What is Health (definition) - What is Public Health (definition) 2. Introduction to AMR - What is AMR - How does AMR happen 3. One Health Approach - One Health in general - One Health | Vet & Pharma 4. Global Health Approach & AMR C. AMR & Governance Approach 1. Introduction to Health - What is Health (definition) - What is Public Health (definition) 2. Introduction to AMR - What is AMR - How does AMR happen 3. AMR in Healthcare Sector - Hospital Acquired Infections - Antimicrobial Resistance in Hospital Environment - Antibiotic Stewardship - Surveillance on AMR and Surveillance Systems 4. One Health Approach - One Health in general - One Health | Vet & Pharma 5. Global Health Approach & AMR 6. Financial & Policy - EU plan for action - World Bank Report - WHO and AMR 7. AMR Advocacy
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Dynamics Social Media Campaign Level: Basic A Social Media Campaign is the easiest way for an NMO to start working on AMR but doesn’t have previous experience on the topic. Furthermore, it is a clever way to spot some light on the issue and raise awareness in case AMR is not a widely discussed matter in your country or your domain. The first step is to identify the direction your campaign is supposed to lead to. As already mentioned AMR is a very broad topic, so the agenda of your campaign should be adapted to your target group as well as the message you want to share. You should first decide the topics you want to include and then start working on the methods etc.
Internal Part Besides the external part, you can also take advantage of that opportunity in order to raise awareness around the topic within your NMO. It is important to involve all the members in order to get them inspired by the campaign and therefore effort contribution to the promotion of it. HelMSIC’s Antimicrobial Resistance Campaign Target Groups: Medical students, Healthcare Professionals, students from other specialties (pharmacy, biology, veterinary) Beneficiaries: Patients and the general public will be benefited as future doctors will be sensibilized on AMR. Objectives and indicators of success: The main objectives are: • To educate medical students, health care professionals and the general public on antimicrobial resistance • Show emphasis on the harmful effects of antibiotic misuse in Greece as well as globally • To equip medical students with strategies to reduce the excessive antibiotic use • To show the importance of prevention of nosocomial infections for AMR • To raise awareness between medical students and healthcare professionals and stimulate them to act against AMR The success indicators were: • The project is a campaign and thus it is launched mostly on social media. We evaluated the outreach of our campaign based on how many students read the posts on our facebook page and on how many visitors we had on our website and read the informative articles there. • The most important indicator is that we had a quiz that was testing the students’ knowledge on AMR and at the end of it there were the correct answers and some useful links. The amount of answered questionnaires were more than 500. Another benefit of the quiz was that we gained insight in their lack of knowledge and thus the specific needs we need to cover in the future. • The willingness of healthcare professionals to distribute our booklets to their departments 41 41
Methodology The methods we used on the campaign were: • Social Media Campaign • Informative articles on our website • Med school action – to educate medical students • Informative posters for medical students (medical school) • Informative posters for the general public (hospital) • Informative booklet for the healthcare professionals about AMR and the practices they need to follow from the National Center for Disease Control Post Timeplan:
Day 1: afternoon: Quiz Day 2: noon: “Introduction to AMR” Article & Quiz & Gif Day 2: night: Video & Quiz Day 3: “The problem in Greece” Article & Quiz & Gif Day 4: noon: Hospital’s top vies & Quiz Day 4: night: Quiz Day 5: CPME’s President interview Day 6: “One Health approach” article & Quiz Day 7: noon: Photos from the Med-School actions & Quiz Day 7: night: Quiz results
You can read more about the campaign, projects and activities in the IFMSA’s program & activities database in https://ifmsa.org/activities/
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Simulations Educating future clinicians in the art of communication is essential for conducting effective conversations with patients. In fact, improving patient/clinician communication has been shown to reduce antibiotic prescriptions. Below we give you several examples of simulations that can be used as an educational activity during workshops. During each scenario one person takes a role of a doctor and another a role of patient. Although in every situation the goal is a little bit different, in the end you want to make sure that your patient understands the importance of AMR and will avoid similar mistakes in the future. Simulation 1 A patient is presenting with symptoms that indicate bacterial infection and asks for a specific antibiotic. The goal of this simulation is for a patient to understand that different kinds of drugs are indicated in infections caused by different species of bacteria. Doctors should stick to up-to-date guidelines and always consider the possibility of resistance.
Situation A – patient asks for a drug because it is convenient
“Can I get the one that only takes 3 days, azithromycin?”
Situation B – patient wants a drug that he/she is used to
“I always take this one when I’m sick.”
Simulation 2 Patient is insisting on receiving a prescription for antibiotics while presenting with symptoms that indicate viral etiology. The goal is to understand why sometimes antibiotics are not necessary and how to properly explain it to the patients.
Situation A – patient has started therapy with medications he had already possessed
Situation B – patient is self-diagnosing
Situation C – patient is directly demanding medications
Situation D – patient says an antibiotic has been successful in the past
I had some pills from previous time I was sick and didn't want to wait until my apoint ment.” “It must be strep throat, I’ve read about it on the internet.” “I need this antibiotic, because I had several infections in the last year.” “I had similar symptoms last year and it really helped me.” Situation E – patient says an antibiotic has helped his family member/friend “My mother was taking it when she had similar cough.”
Situation F – patient says he/she had similar symptoms in the past and it required the use of an antibiotic
“I know that every time I cough like this, I get antibiotic. It’s always like this.”
Situation G – patient puts emphasis on the severity of symptoms
“My throat hurts so much.”
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Simulation 3 Patient has been diagnosed with bacterial infection and treated with antibiotics, but is not responding correctly. The goal is to learn what to do in case of antimicrobial resistance and how to explain the situation to the patient.
Situation A – you suspect resistant bacteria, so you want to order an antibiogram and change the course of treatment Situation B – more severe situation, the patient is infected with a superbug resistant to multiple types of antibiotics
Simulation 4 A patient has been treated for a viral infection, but now developed a secondary bacterial infection which requires antibiotics. The goal is to explain to the patient why the course of treatment may change depending on the clinical condition and once again why antibiotics are not used against viruses. Simulation 5 A patient is taking medications incorrectly. The goal is to understand why antibiotics must be used accordingly in order to avoid not only prolonged recovery, but also the development of resistance.
Situation A – patient’s condition improved, so he/she stopped taking the antibiotic
Situation B – patient is not sticking to medication schedule
“I feel much better now, so I guess I don’t need to keep taking it?”
“I had forgotten to take it in the morning, so I just took 2 pills in the evening.”
Simulation 6 Patient presents with symptoms that indicate bacterial etiology, but doesn’t want to take antibiotics. The goal is to make him understand why these medications are sometimes necessary to successfully treat infections. We also encourage you to try the simulation linked below. It offers clinicians the ability to engage in role-play conversations about antibiotics with virtual patients as a way to build competency to effectively lead them in real-life. https://www.conversationsforhealth.com/antibiotics/
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Debating (49, 50, 51) Debate refers to a discussion in which two or more people advocate for opposing positions on a topic or question attempting to convince the audience (or the other advocates) of their point of view. A reasoned debate allows people to explore and gain understanding of alternative viewpoints and, for the participants, develops communication, critical thinking and argumentation skills. A debate that serves effective teaching and learning is encouraged to incorporate four conceptual components: a) b) c) d)
development of ideas with description, explanation, and demonstration, clash of opinions supported by reasons and evidence, extension or arguments against criticisms, which again are refused by the opponent, perspective, the process of weighing ideas and issues to conclude with a logical decision is made, either about the issue or about the presentation of arguments .
Debate at its simplest form requires a question, statement or an idea with at least two opposing positions, from which each is defended against the others by an advocate, often with an impartial moderator ensuring that the discussion remains focused. It is important that the moderator ensures that the discussion does not become personal and that the participants remain focused and composed, and a set of ground rules is useful to reduce the possibility and impact of any problems. Also, ensure the participants know there is no right or wrong answer. Be observant of those who want to speak and are not getting a chance. Encourage participants to give a reason for their opinions.
An exemplary technique for organizing a debate can be the Fishbowl. In a Fishbowl discussion, participants seated inside the “fishbowl� actively participate in a discussion by asking questions and sharing their opinions, while students standing outside listen carefully to the ideas presented. Participants swap these roles, so that they practice being both, contributors and listeners in a group discussion. This strategy is especially useful when you want to make sure everyone participates in a discussion, as well as helping people to reflect on what a good debate looks like and presenting the need of a structure for discussing controversial or difficult topics.
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Procedure 1- Select a Topic 2- Set Up the Room: A Fishbowl discussion requires a circle of chairs (“the fishbowl”) and enough room around the circle for the remaining participants to observe what is happening in the “fishbowl.” 3- Prepare for the Discussion: Fishbowl discussions are most effective when participants have had a few minutes in advance to prepare their ideas and questions. Another approach would be distributing role-playing cards to each participant, containing relevant information regarding their character´s perspective. For example: their character´s history, possible issues it might encounter and possible questions to ask. This is especially useful if you want the participants to explore other points of view which might be different than their own and learn to stand up for them. 4- Discuss Norms and Rules: Discuss when it is time to exchange the listeners and the speakers. The moderator can: let them sit in the fishbowl for as long as they have ideas to share and they will be the ones to decide when it is time to become a “listener” announce “switch” after a certain amount of time so the listeners and speakers will swap use the “tap” method: the listeners can join the fishbowl by gently tapping on a speaker’s shoulders if they feel they have something to add to the discussion and they will switch roles Regardless of the particular rules you establish, make sure they are explained to the participants beforehand. Do not forget to provide instructions for the participants in the audience:
What should they be listening for? Should they be taking notes? Before beginning the Fishbowl activity, you may wish to review guidelines for having a respectful conversation. 5- Debrief: After the discussion, you can ask the students to reflect on how they think the discussion developed and what they learned from its outcome. Apart from that suggestions on how to improve the quality of future discussions are welcome.
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Variation: A Fishbowl for opposing positions: This is a type of group discussion which can be utilized when there are two distinct positions or arguments. Each group has the opportunity to discuss the issue while the other group observes. The goal of this technique is for one group to gain insight about the other perspective by listening and thereby formulating questions. After both sides have shared and listened, students are often given the chance to discuss their questions and ideas with students who are representing the opposing argument. Examples of debates: Debates on AMR and on Vaccination: http://www.e-bug.eu/ young_teacher_pack.aspx?cc=eng&ss=12&t=Young%20teacher%20debate% 20kits Debate on the Medicinal Use of Marijuana: http://sciencecases.lib.buffalo.edu/ cs/pdfs/Intimate%20Debate%20Technique-Pot-XXXVI-4.pdf Video of a discussion on Pro/Con Vaccination which brings people to a middle ground: https://www.youtube.com/watch?v=WQptarOLSBU Glitter on Candies Goal: To simulate the spread of microbes. Where to do it: In a big room (preferably with low light) with many participants like an NGA session or a seminar on AMR. Description: Take a big bowl (colored and covered) so that nobody can see its content and fill it with chocolate or candies. Then, sprinkle it with glitter and give it a smooth shake in order to spread the glitter on all candies, without letting the participants know. Then, in case of a reward for something you distribute some candies to them. Instead of giving the bowl directly to someone, you can also hand some candies to one person in order to let the candies get passed around the room to reach a certain person. As a reason, you could state that you can not reach him/her. After finishing, you can unravel the true purpose of this simulation. The participants will realize having glitter not only on their hands but also among their notebooks, desks, clothes etc. You will explain the fast spreading of microbes which is comparable to the glitter and therefore the importance of good hand hygiene.
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Small Working Groups A small working group (SWG) is a set of a maximum of 15 people solving a problematic issue. They work on pointing out and implementing strategies to provide solutions. During the development of a theme such as AMR, the use of this dynamic allows broadening the range of ideas and initiatives from the activity. This has the effect to keep all the participants more involved, since they are directly connected with a small group of people focused in completing a given task. A common challenge when having people work in small groups is to keep them focused on the task. Here are some strategies: • Announce a time limit • Give them a realistic amount of time to complete all or a segment of an assignment, but short enough to keep them focused • Tell them that they should produce a certain number of items • Give them specific tasks • Follow the working process and be available to provide solutions to problems that may arise
Here are some examples you can use: Development of a campaign in social networks: You can give the group the task of developing a campaign on social media including the selection of a theme, the entire timeline and the graphic material.
Creation of awareness materials: You can try to create a group whose task it will be to create intellectual material which is used to sensitize a particular population (which may be medical students, health professionals or the community at large) to the problem of AMR. The group should make abundant bibliographical research and select key messages. Development of a workshop: A small working group may be responsible for the development of a workshop whose purpose is to enable participants in becoming active in AMR. They should plan the activity including the expected date, the addressed topics, the speakers to be contacted, as well as the logistical issues of rooms and food among others.
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Development of a study: A small working group may be responsible for ascertaining the knowledge of a particular population about antimicrobial resistance. The tasks could be: • develop a questionnaire • apply it to target population • evaluate the answers below The objective may be to draw some conclusions, which may serve as a basis for the development of initiatives aiming to solve the severest difficulties encountered.
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ReAct Group—https://www.reactgroup.org/toolbox/understand/
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The health and econòmic costs of AMR | WHO. https://www.who.int/trade/ distance_learning/gpgh/gpgh4/en/index2.html
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EU Action on Antimicrobial Resistance | European Commission. https://ec.europa.eu/ health/amr/antimicrobial-resistance_en
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Potential burden of antibiotic resistance on surgery and cancer chemotherapy antibiotic prophylaxis in the USA: a literature review and modelling study. Lancet Infectious Diseases—https://www.ncbi.nlm.nih.gov/pubmed/26482597
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About AMR from the Norwegian Cancer Society. https://kreftforeningen.no/ antimicrobial-resistance/
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Antimicrobial Resistance factsheet, from European Commission, https://ec.europa.eu/ health/amr/sites/amr/files/amr_factsheet_en.pdf
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Drug-Resistant Infections: A threat to Our Economic Future | World Bank Group https://www.researchgate.net/publication/317235080_DrugResistant_Infections_A_Threat_to_Our_Economic_Future
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Few antibiotis under development | ReAct Group https://www.reactgroup.org/tool box/understand/how-did-we-end-up-here/few-antibiotics-under-development/
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EU action plan on AMR https://ec.europa.eu/health/amr/sites/amr/files amr_action_plan_2017_en.pdf
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As discussed in this training manual, AMR is a topic of utmost importance. It is a complex issue, which has to be tackled urgently thus taking into consideration different approaches to inhibit further worsening.
This Training Manual will provide you with a profound insight into the basics of AMR and the One Health approach, deepen the understanding of the mechanisms for developing resistance and equip you with guiding tools and skills on how to advocate for fighting against antimicrobial resistance. We have discussed the crucial factors regarding AMR development as well as its prevention and some plans for the future. Furthermore,some of the most influential stakeholders for AMR have been presented and we strongly encourage you to take initiative and advocate with them using their impact capacity. Now, it is our responsibility to act! We need to use our abilities and skills as young future healthcare professionals to engage and advocate for AMR, together as a unified taskforce. Therefore, a concrete purpose of this training manual was to provide different activities and dynamics to provide our members with all this skills and capacities mentioned. However, our suggestion is to look at this manual as information and idea resource and to shape your activities according to the target group and NMO needs.
Our job as healthcare professionals is not only to treat patients for illness, but also to promote educational tools and, last but not least, to advocate for permanent changes in our society thus contributing to the enhancement of preventive measures and an improved well-being status. We strongly believe that it is never early to start and that we can, even as students, have a real impact in this world. Are you in? However, the manual didn’t create itself, it was created by an extraordinary SWG on AMR that have spent countless hours collecting resources and writing this manual. We would therefore like to give a special thank you to all the members in the SWG, for their efforts and contributions. Without them this would not have been feasible and would still only exist in our imagination. Best regards, The whole team.
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