Program Proposal: A Comprehensive Approach to Rationalize Antibiotics Use in Abu Dhabi

MPH Capstone Project: Program proposalNadia YounisInstructors:

Professor Alan lyles&

Professor Laura Morlock

Abu Dhabi –United Arab Emirates

•1.9m residents, 21% Nationals•Median age 19 for Nationals and 30 for Expatriates•Life expectancy 74.4 for men, 74.8 for women •11.5 million encounters –2% inpatient (179’948)–42% by Nationals–43% by hospitals•more insurance contracts (2.3m) than residents

HAAD Statistics, 2009

Abu Dhabi

Microbial resistance is a growing problem in UAE

base Latest Reference

Salmonella 0.3 % in 1998 to 17% in 2008 •(Jamal, Pal, Rotimi & Chugh, 1998)•(Rotimi, Jamal, Pal, Sovenned & Albert, 2008),

Campylobacter jejuni (resistance to nalidixic acid & ciprofloxacin)

50% in 2005 85.4 % in 2006 (highest reported world wide)

•(Jumaa & Neringer , 2005) •(Sonnevend et al., 2006).

Enterobacteriaceae (E. Coli, K. pneumoniae and K. oxytoca) ESBL phenotype (i.e. resistant to penicillin’s and cephalosporin),

Sweden: only 3%)

UAE: 41%(highest reported worldwide

•(Al-Zarouni, Senok, Rashid, Al-Jesmi & Panigrahi, 2008).

Community Acquired Pneumonia (CAP) admissions rate

250/100,000 admissions in 1997

710/100,000 admissions in 2002

•Al Muhairi et al., 2006

Microbial resistance to antibiotics : consequences

Four main long-term consequences: • 1) Increased Morbidity: – complications of treatment failures– longer time for resolving infections– emergence of new diseases caused by emergence of new

pathogen used to be harmless (Murray, 1991),• 2) Increased Mortality,• 3)increased costs of healthcare:– longer hospital stays – more expensive antibiotics (ReAct, 2008)

• 4) fewer options by time (WHO, 2011).

Ecological Model*Policy & Governmental Policies & Regulations

Community

Communities at large

Families and small groups

Organizational

InterpersonalPt pressureLimited counseling

Intrapersonal(Pt & HCP

beliefs )

1

5

4

3

2

*Glanz et al, (2005)Based on McLeroy et al.,( 1988)

Health Authority Abu Dhabi (HAAD):

• Enforced the prohibit of OTC antibiotics in October 2007 • partnership with Alliance For Prudent Use of Antibiotics (APUA-ABU

DHABI CHAPTER) in 2010 • Target to reduce the use of antibiotics in URTI by 25% at the end of

2012.• Newly an educational publication targeting parents was (impact not

evaluated yet)• Future projects:

– “Abu Dhabi –Antibiotic Resistance Surveillance Program (AD-ARSP), – Joint repository of guidelines, standards & relevant resource (Web-based),– Antibiotic utilization studies– Educational sessions and promotional material directing to physicians,

dispensers &public” (Abuelkhair, 2011).

(Ref: Abuelkheir, 2011).

No matter what the efforts are

• Engaging patients to rationalize Antibiotic use is a must.

perceived susceptibility

perceived severity)

perceived benefits

perceived barriers

cue to action

Self efficacy

actionHealth Belief Model

Ref: Hochbaum,(1958)Glanz et al,(2005)

Patient Value……•Immediate benefits•Benefits they can sense & perceive.•Their child health & welfare rather than microbial resistance

Don’t miss the chance of giving your child the only one right medication

Mothers need encouragement to raise their confidence and their self efficacy to share with doctors their worries and decision making (use role models).

The program• Target Area of Action: Upper Respiratory

Tract Infections (URTI):• 18.5% of all encounters, 15.2% of ER, 7.5% of total

inpatient encounters • 10.6% of expenditure on prescriptions (excluding over the

counter).• URTI make up 63.1% of the cases where antibiotics

purchased as OTC .• (86%) of cases: viral etiology**• 76% of common colds in PHC: sore throat***

Ref: *HAAD 2009 statistics**Fadil, Al Najjar & Udumann 2008*** Alawadi et al., 2010

Program elements

Speak up to your child

Program ElementsPolicy & Governmental Policies & Regulations

Community

Families and small groups

Organizational1- Guidelines (flexible, adapted … simple) & formularies:2-counseling time longer3- Involve Nurses and Pharmacists

InterpersonalHCP: communication/

tactics-Pts: ask and speak for

your child

IntrapersonalPts: Believes, perceptions, confidence

1

5

4

3

2

1- Community

mobilizing

2- Socia

l M

arketing:

Media

Campaign

Policies:1- Resistance monitoring and surveillance 2-Institutionalize curbing AB resistance

Regulations:1-Insurance coverage

2-Facility Licensing

3-Medical Liability law

HCP Patient

Involve Nurses and

Pharmacists in the

process and incentives

Facilitate quality

counseling time

Education & training on best

tactics to deal with Patients

Guidelines on flash cards

in checklist format per sub

diagnosis

Social marketing:

Media Campaign

Testing for tonsillitis

and Pharyngitis

Delayed Antibiotic

Program

The Proposed Program Elements

Delayed Antibiotic Program: patient level

– Delayed Antibiotic Program:

The patient (PT) will get a prescription but with delayed dispensing status

In the Pharmacy Pt will be provided by coupon exchangeable for AB

The coupon has a check list for conditions ands symptoms the patient have to experience to decide the administration of the AB

The Unused coupons could be returned to HCP for next visit and will be used as indicator for saved Abs

– Testing for tonsillitis and Pharyngitis:

In clinic testing kits to be available for private sector(available in public)

Insurance coverage could be linked for the test

HCP level & organizational level:

– Guidelines (pocket size cards with simplified checklists, each sub diagnosis on a card).

– Educational Campaign and awareness about best tactics to manage pt expectations(ensure that pt satisfaction is more influenced by quality of counseling).

– Facilitate quality counseling by adequate counseling time per pt.

– Involve Nurses and Pharmacists (incentives could be by reflecting the returned coupons for all)

The program …….continued

• Target Audience: Mothers (phase one), adults (Phase two).• Target behaviors:

– Mothers & Pts to share with doctors an informed decision making process.

– HCP to comply with guidelines– Pt to delay AB administration

• Target Messages: – HCP: your patient satisfaction is led by counseling quality not AB

prescribing.– Mothers:

– Speak for your child ask for testing– You can give your child many medications but one is right.

• ”

• The target behavior:

• to ask for testing prior to antibiotics use

• , to delay the antibiotic use until necessary.

• To give up the security the mother feels after using the antibiotic for her child vs. waiting for nature course taking place to heal her child

• Pediatric clinics, pharmacies, children apparel and toys shops, kinder-gardens, Nurseries, school.

Place

PromotionProduct

Price

Posters, mass media, websites, TV ads, fridge magnets,Baby T shirts that has the slogan “Mama: you speak for me ask for testing before I get an antibiotic

Marketing MiX

Outcomes

Conceptual model structure build up process based on : Earp & Ennett. 1991. Bertrand , 2009 course: Program planning

outcomes1. Short term (initial ):

• Awareness,• acceptance • willingness

2. Medium term: • behaviors (HCP compliance, Patients use of AB over the counter, … )• service utilization

3. Long term: health problem level (% of complications due to failure, % of resistant pathogens per species….)

4. Ultimate outcomes: Quality of life

Barriers and challenges

• Community mobilizing• Feasibility issues • Administrative issues (coupons management)• Pharma companies (may become aggressive)• Private sector• Patient satisfaction out of AB delay

Chile name:Doctor: telPharmacist tel

Otitis Media (ear infection)

Try to delay the Antibiotic, your child has to have more than three of the below before you decide giving himdon't hesitate to call your doctor.Fever get worse, no matter fever goes down with medicines still my child don’t feel good. greenish sputum, mucousWet cough

Serial No: 0009999

Give your child the one medicine he needs

Antibiotics don’t do any good for common cold of viral origin 86% of common cold are viral

Ask your doctor for testing of your child throat

SPEAK FOR YOUR CHILD

Thank You

• References:• Abuelkhair, M.(2011), Pharmacoeconomics HAAD Initiatives. March 2011, retrieved from:

http://themccgroup.com/Presentation/Day%201%20Pharmaeco%20pres/Pharmacoeconomics%20%20march%202011%20final.pdf

• Al-Muhairi, S., Zoubeidi, T., Ellis, M., Nicholls, M.G., Safa, W. & Joseph, J., (2006). Demographics and microbiological profile of Pneumonia in United Arab Emirates. Monaldi Arch Chest Di, 65: 1, 13-18

• Al-Zarouni, M., Senok, A., Rashid, F., Al-Jesmi, S.M., Panigrahi, D.,(2008). Prevalence and Antimicrobial Susceptibility Pattern of Extended-Spectrum Beta-Lactamase-Producing Enterobacteriaceae in the United Arab Emirates. Med Princ Pract, 17:32–36

• Fadil Y.A., Al-Najjar, and Uduman S.A., (2008) “Clinical utility of a new rapid test for the detection of group A Streptococcus and discriminate use of antibiotics for bacterial pharyngitis in an outpatient setting” International Journal of Infectious Diseases, May 2008;12( 3);308-311

• Glanz, K., Rimer, B.K. & Su M.S. (2005). Theory at a Glance: A Guide for Health Promotion Practice. published by United States National Cancer Institute/ U.S. Department of Health and Human Services -National Institutes of Health –Second Edition. A monograph based on the original work Glanz, K., Rimer, B.K. & Su M.S., with the same title NCI, NIH (1995; reprinted 1997), http://www.cancer.gov/cancertopics/cancerlibrary/theory.pdf Retrieved on 15th April 2011.

• HAAD. (2009). HAAD Statistics 2009. Retrieved from: http://www.haad.ae/HAAD/LinkClick.aspx?fileticket=SFBJ8BXGkHM%3d&tabid=349 last retrieved on 15th April 2011.

• HAAD. (2011). Parents guide for rational use of antibiotics”,Brochure, HAAD website, retrieved from: http://www.haad.ae/HAAD/Portals/0/Health%20Authority%20Parents%20Guide%20Eng.indd.pdf retrieved on 2nd April 2010

• Jamal, W. Y., Pal, T., Rotimi, V. O. & Chugh, T. D. (1998). Serogroups and Antimicrobial Susceptibility of Clinical Isolates of Salmonella Species from a Teaching Hospital in Kuwait. J Diarrhoeal Dis Res 16, 180–186.

• Jamal, W., Rotimi, V.O., Khodakhast, F., Saleem, R., Pazhoor, A. & Al Hashim, G. (2005). Prevalence of extended-spectrum beta-lactamases in Enterobacteriaceae, Pseudomonas and tenotrophomonas as determined by the VITEK 2 and E test systems in a Kuwait teaching hospital. Med Princ Pract, 14:325–331

• Jumaa, P. A. & Neringer, R. (2005). A Survey of Antimicrobial Resistance in a Tertiary Referral Hospital in The United Arab Emirates. J Chemother 17, 376–379.

• Murray, BE.(1991). New aspects of antimicrobial resistance and the resulting therapeutic dilemmas. J Infect Dis; 163: 1185-1194.

• McLeroy, K. R., Bibeau, D., Steckler, A., & Glanz, K. (1988). An ecological perspective on health promotion programs. Health Education Quarterly, 15, 351-377.

• ReAct. (2007- Updated 2008). “Economic Aspects of Antibiotic Resistance”, A fact sheet from ReAct – Action on Antibiotic Resistance”, http://www.reactgroup.org/uploads/publications/react-publications/economic-aspects-of-antibiotic-resistance.pdf retrieved on 15th April 2011.

• Rotimi V.O., Jamal W., PalW., SovennedA. and AlbertM.J. (2008), “Emergence of CTX-M-15 type extended-spectrum β-lactamase-producing Salmonella spp. in Kuwait and the United Arab EmiratesMed” Microbiol 57, 881-886.

• Senok, A.C., Ismaeel, A.Y., Al-Qashar, F.A. & Agab, W.A.( 2009). Pattern of upper respiratory tract infections and physicians' antibiotic prescribing practices in Bahrain, Med Princ Pract, 18(3):170-4.

• Sonnevend, A., Rotimi, V.O. , Kolodziejek, J., Usmani, A., Nowotny, N. & Pál T. (2006). High Level of Ciprofloxacin Resistance and its Molecular Background Among Campylobacter jejuni Strains Isolated in the United Arab Emirates”, J Med Microbiol, 55, 1533-1538.

• WHO, (2011). Antimicrobial resistance, Fact sheet N°194 updated on February 2011, http://www.who.int/mediacentre/factsheets/fs194/en/ retrieved on 15th April 2011