Report to Sida on ReAct activities January - December 2012

List of abbreviations

ABR Antibiotic resistance

AMR Antimicrobial resistance

ASU Antibiotic Smart Use program

CSO Civil Society Organization

EFPIA European Federation of Pharmaceutical Industries and Associations

EU European Union

ICIUM International Conference for Improving the Use of Medicines

IMI Innovative Medicines Initiative

LMICs Low and Middle Income Countries

MDGs Millennium Development Goals

MoH Ministry of Health

MSF Médecins sans Frontières

OHE Office of Health Economics

PAHO WHO/Pan-American Health Organization

PHC Public Health Care Centers

RLA ReAct Latin America

RU Rational use

SEARO WHO South East Asian Regional Office

TATFAR Trans-Atlantic Task Force on Antimicrobial Resistance

WEF World Economic Forum

WHO World Health Organization

WPRO West Pacific Regional Office

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Table of contents 1. EXECUTIVE SUMMARY ..................................................................................................................... 3

2. ACHIEVEMENTS IN RELATION TO THEMES 2012 ................................................................................. 5

2.1 THEME 1: INCREASING THE VISIBILITY OF ANTIBIOTIC RESISTANCE IN THE GLOBAL HEALTH DIALOGUE ............................................................................................................................................ 5

2.1.1 Support to WHO ..................................................................................................................... 5

2.1.2 International meetings ........................................................................................................... 8

2.1.3 Other communication activities ........................................................................................... 10

2.1.4 Supporting the development and implementation of regional and national processes for the management of antibiotic resistance ..................................................................................... 11

2.2 THEME 2: EVIDENCE GENERATION .............................................................................................. 16

2.3 THEME 3: PROMOTING INNOVATION AND THE DEVELOPMENT OF HEALTH TECHNOLOGIES TO MEET GLOBAL NEEDS TO MANAGE ANTIBIOTIC RESISTANCE .......................................................... 19

2.3.1 The global need for new effective antibiotics ...................................................................... 19

2.3.2 Controlled distribution and use of new antibiotics .............................................................. 20

2.4 THEME 4: PROMOTING RATIONAL USE OF ANTIBIOTICS ............................................................ 22

2.4.1 Latin America ........................................................................................................................ 22

2.4.2 South East Asia ..................................................................................................................... 22

2.4.3 Africa..................................................................................................................................... 24

2.5 OVERALL COORDINATION ........................................................................................................... 24

2.5.1 Networking coordination ..................................................................................................... 27

2.6 TARGET FULFILMENT AND PERCEIVED IMPACT .......................................................................... 28

3. CSO PROJECT ENGAGING CIVIL SOCIETY ORGANIZATIONS FOR SOCIAL MOBILIZATION, HEALTH EDUCATION AND COMMUNICATION .................................................................................................... 36

4. CHALLENGES AND FUTURE PROSPECTS ............................................................................................ 41

Annex 1 - ReAct publications 2012 ................................................................................................ 43

Annex 2 - Meetings and events 2012 ............................................................................................ 44

Annex 3 - ReAct in the Media 2012 .............................................................................................. 47

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1. EXECUTIVE SUMMARY

During 2012 ReAct continued playing the role of a convening organization and a catalyst, facilitating important international and national processes. ReAct worked to deepen the understanding of the knowledge and perceptions of infections among different groups in order to create long-term behavioural changes in relation to the use of antibiotics. ReAct also further strengthened its work towards WHO and continued with activities within the policy development and debate on controlled distribution and use of new antibiotics.

International advocacy and collaboration

Throughout 2012, the issue of antibiotic resistance (ABR) became more widely recognized and ReAct supported and catalyzed many of the important global activities that took place. ReAct made significant contributions to The World Economic Forum (WEF) for the recognition of the seriousness of ABR. The WEF identified ABR as one of the ‘greatest risks to global health’ in their Global Risks report published in January 2013.

ReAct actively supported WHO in the process of forming a coordinating group and a task force on AMR which includes members from all WHO Regions.

ReAct contributed to the development of the call for “New Drugs for Bad Bugs” program intended to speed the development of new antibiotics. The program is within the Innovative Medicine's Initiative (IMI) - a 2 billion Euro PPP between the European Commission and the European pharmaceutical industry.

ReAct participated as an expert in the consultation work for the Joint Programming Initiative on Antimicrobial Resistance (JPIAMR), a EU undertaking of 18 member countries.

ReAct continued to push forward a process started in 2011 to explore innovative ways to preserve new effective antibiotics through several initiatives. One is the Treatment for Tomorrow (T4T) project, run by Duke university, which explores the realignment of incentives to balance affordable access with rational use of antibiotics. A stakeholder meeting was also hosted by Duke university in December 2012.

The ReAct Resource Centre, a publically accessible web-based database with currently over 500 high-quality reports, documents, tools, etc. concerning ABR and antibiotic use was launched in 2012. The main target groups are policy makers, health professionals and community-based organizations in low-income countries. The intention is to help these groups to take informed action on ABR.

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Extending the ReAct network

Sida provided an additional grant for the period 2012-2014 aimed at mobilizing Civil Society Organizations (CSOs) to address antibiotic resistance as part of their regular work. This CSO project was launched in connection with a planning-meeting in Penang, Malaysia, in February 2012. The CSOs participating are from Latin America, Ghana and South-East Asia. Most of them work in the areas of child and maternal health, women's issues, education and environment.

An ABR policy development process was initiated in Ghana under the leadership and coordination by the Ministry of Health in Ghana. They have initiated programs and stakeholder meetings at the policy/health-systems level and have included the community level through the CSO-project.

The ReAct South East Asia network of professionals and organizations working on ABR in the community, at hospital and on policy-level expanded during 2012. ReAct successfully facilitated the placing of AMR as a priority issue within the implementation of national medicines policies, with a strategy for action at the Asia Pacific Conference on National Medicines Policies in May 2012.

ReAct Latin America (RLA), based at the University of Cuenca, represented a strong force in educating healthcare workers and the community on ABR. RLA successfully combined research with advocacy in a study on ESBL in neonatals which was successfully used as a policy tool to advocate for improved infection control in hospitals.

RLA worked on new innovative solutions for communicating ABR and developed the novel concept envisaged in the FotoResisistencia project, where primary health care workers are trained in ABR and take photographs visualizing the causes and consequences of ABR.

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2. ACHIEVEMENTS IN RELATION TO THEMES 2012

2.1 THEME 1: INCREASING THE VISIBILITY OF ANTIBIOTIC RESISTANCE IN THE GLOBAL HEALTH DIALOGUE

2.1.1 Support to WHO ReAct has for many years been advocating for the need for WHO to increase its work and global leadership on antibiotic resistance, and has been instrumental in several processes to support WHO on both central and regional levels. ReAct played an important role in supporting the resolution improving the Containment of Antimicrobial Resistance (WHA 58.27) that was adopted in 2005 and the preparatory work to support the passing of the Rational Use of Medicines resolution (WHA 60:16) at the World Health Assembly 2007.

In 2008 ReAct hosted several activities at the 61st World Health Assembly, among them a session at the Third World Network NGO Briefing meeting and a ReAct reception attended by WHO, WHPA, FIP and 35 other well-renowned global organisations. At the 62th World Health Assembly in 2009 ReAct contributed to the campaign Fight AMR – Save medicines for our children was launched in a partnership between ReAct and the Ecumenical Pharmaceutical Network (EPN).

In 2011 ReAct played an important role in supporting the activities of the World Alliance for Patient Safety and the WHO interest in the issue and chaired two out of the five expert working groups contributing to the WHO monograph on “The Evolving Threat of Antimicrobial Resistance: Options for Action”1 launched in March 2012. ReAct facilitated the participation of groups in SEA, Latin America, Africa, and Europe in the World Health Day (WHD) 2011 campaign focused on ABR. Innovative communication materials were produced for this particular event, such as the information campaign “Save the pill for the really ill”. Following the renewed commitment by WHO to antimicrobial resistance, the WHO Headquarter has formed a small AMR secretarial team, placed within the Health Security and Environment (HSE) Cluster. This new structure was officially announced on Dec 1, 2011 and has been very active in creating an internal network on AMR within the HQ as well as forming a task force on AMR together with the regional offices. ReAct has been closely involved in the process as an expert advisor.

1 http://www.who.int/patientsafety/implementation/amr/en/index.html 5

Activities and accomplishments 2012

WHO Headquarters

ABR Stakeholder analysis WHO initiated the development a global roadmap for action on antimicrobial resistance (AMR), specifically addressing antibiotic resistance (ABR) to lay the ground for engaging stakeholders to work together. Whilst stakeholder analyses were available in the fields of malaria, TB and HIV/AIDS, there was a gap in the field of ABR.

ReAct conducted the analysis of stakeholders in the field of ABR for and with WHO, identifying key stakeholders of international relevance. The framework for the analysis included the 6-point policy package developed by WHO for the World Health Day 2011, and a broader set of issues related to engagement of new actors in ABR.

The main output of the analysis was a database of over 200 stakeholders. These stakeholders include for example governments, civil society organisations, surveillance networks, pharmaceutical trade associations, academic research and training organisations, health professional organisations, funding organisations and the key organisations working at global level to promote the issue of ABR in one aspect or another. In addition to those stakeholders working specifically in the area of ABR, important organisations working in relevant areas such as rational use of medicines, access, infection control etc. were included.

Additional outputs included a 15-page report describing the rationale behind the analysis and 5 additional annexes. In particular, one annex contained a shortlist of a selection of stakeholders categorised according to relevance.

Global surveillance of antibiotic resistance The AMR taskforce created at WHO HQ in Geneva in 2011 prioritized the creation of a global surveillance system on antibiotic resistance and appointed an AMR surveillance sub-working group. The taskforce asked ReAct to help draft a roadmap for development of a global ABR surveillance system. To this end, ReAct applied and received funding from the Swedish Ministry of Health and Social Affairs to enlist an expert in surveillance systems, (professor Hajo Grundmann) with whom ReAct has previously worked. As a follow up of this process, ReAct was invited to two expert consultations at WHO, the first one in July to discuss the roadmap. The outcomes of this meeting formed the basis of a strategy for Global antimicrobial drug resistance surveillance. The second meeting, in which ReAct also participated, was held at WHO HQ 18-19 December. This meeting was a wider consultation that brought international experts in surveillance together to take the first steps in creating a global surveillance system for ABR.

ReAct in a seminar on ABR at the World Health Assembly On May 22 2012, in conjunction with the 65th World Health Assembly in Geneva, Ghana and Sweden co-hosted a high-level ministerial seminar to share national experiences of combating antibiotic resistance. The seminar "Saving lives through cost-effective measures against antimicrobial

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resistance" addressed the growing health challenges the world is now facing due to the rapidly declining effectiveness of antibiotics.

From the left: Dr Phusit Prakongsai, Thailand, Dr Otto Cars, ReAct, Mrs Martha Gyansa-Lutterodt, Ghana Ministry of Health, Dr Keiji Fukuda, WHO, Dr Danilo Lo Fo Wong, WHO and Mr Göran Hägglund, Minister for Health and Social Affairs, Sweden.

The seminar was introduced by Mr Alban S.K. Bagbin, Minister of Health, Ghana and Mr. Göran Hägglund, Minister for Health and Social Affairs, Sweden. Prof. Otto Cars from ReAct and Dr Keiji Fukuda from the WHO gave introductory keynote presentations. Panelists from Ghana, Thailand, and the Republic of Korea shared valuable experiences in combating antibiotic resistance. The meeting was well attended by WHA delegates from many countries that also participated in the ensuing discussions.

WHO monograph on “The Evolving Threat of Antimicrobial Resistance: Options for Action” The book, "The evolving threat of antimicrobial resistance - Options for action"2, launched by WHO on March 8 2012, was the result of a collaboration between WHO and more than 50 international experts in the field of antimicrobial resistance. Members of ReAct chaired two of the working groups with international experts and were main authors of two of the chapters.

The book showcases examples of actions taken to slow down drug resistance and preserve the ability of medicine to effectively treat many infectious diseases, building on the recommendations in the 2001 WHO Global Strategy for Containment of Antimicrobial Resistance. ReAct participated in the launch event in Geneva on March 8 with a video presentation3.

WHO Regional Offices ReAct South East Asia (SEA), with co-funding from WHO-WPRO, developed a research proposal to study the costs of ABR. The study “South East Asia Antibiotic Resistance Costs in Hospitals” involves hospitals in Thailand, the Philippines, Malaysia, Indonesia, Singapore, Brunei and Vietnam. ReAct SEA

2 The evolving threat of antimicrobial resistance - Options for action http://whqlibdoc.who.int/publications/2012/9789241503181_eng.pdf 3 http://www.who.int/patientsafety/implementation/amr/en/

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also contributed to the WHO-WPRO Informal Consultative Meeting on Antimicrobial Resistance (AMR) Prevention and Control in Emergencies/Disasters

ReAct participated in the Scientific Planning Committee for the Asia Pacific Conference on National Medicines Policies co-hosted by WHO WPRO and SEARO and the Australian Government and hosted an AMR workshop which established AMR as a priority within the implementation strategy for National Medicines Policies. This also established a wider Asia Pacific network on AMR and linked it to the existing ReAct SEA network. ReAct contributed to PAHO’s online policy forum on the WHO Consultative Expert Working Group on R&D: Financing and Coordination (CEWG). The business model for new antibiotics put forward by ReAct was included as part of the actions suggested by CEWG. ReAct Latin America contributed to several key regional meetings of PAHO on AMR and continued its active collaboration with PAHO Ecuador on edu-communication and training models in ABR.

Inspired by Ghana’s work towards developing a national ABR policy and by ReAct’s support to the process, the WHO AFRO expressed interest in facilitating the sharing of Ghana’s national ABR policy process as a model for other countries in the region. ReAct organized a satellite meeting at the International Pharmaceutical Federation, FIP, meeting in October 2012 with representatives from WHO AFRO and the Ghana ABR National Policy team. It was decided that Ghana would document the process of the development of the ABR National Policy to facilitate its adoption, adaptation and deployment in other African countries. WHO AFRO will streamline activities with ongoing activities on the country level.

2.1.2 International meetings

Amsterdam ministerial summit

ReAct was represented at the Ministerial Summit on the responsible use of medicines hosted by the Dutch Minister of Health in Amsterdam on October 2. ReAct´s director was invited to make an intervention at the ministerial summit.

FIP stakeholder meeting

In conjunction with the ministerial summit, the International Pharmaceutical Federation (FIP) arranged its annual congress 3-8 October 2012 in Amsterdam. ReAct was invited to and attended a stakeholder roundtable with the main theme “improving health through responsible medicines use”.

World Economic Forum

World Economic Forum in Davos, Switzerland included an open discussion called ‘What if All Known Antibiotics Lost Their Effectiveness?’ on the future of antibiotics at their annual event 27 January 2012. The WEF Forum Blog in September 2012 contained an interview with Otto Cars from ReAct where the urgent need for research and development of new antibiotics was highlighted along with the comment that any new antibiotics must be made “globally accessible and affordable”.

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Otto Cars, ReAct, warns that the days of curing pneumonia and carrying out organ transplants will be over unless we tackle antibiotic resistance. The interview is part of the Risk Response Network’s “What if?” series.

Euroscience Open Forum, ESOF

ESOF, held in Dublin July 11-15, is Europe´s largest forum for science and research. The ESOF conference is open to academics, the public and the media. ReAct participated together with the Swedish Research Council, the Swedish Council for Working Life and Social Research, the Swedish Research Council Formas and the Swedish Governmental Agency for Innovation Systems at an interactive exhibition on antibiotic resistance entitled "The Good. The Bad. The Ugly".

The aim of the exhibition was to increase awareness and knowledge of antibiotic resistance. In conjunction with the exhibition a press meeting and a lunch seminar entitles “We are facing a world without antibiotics — Who takes responsibility?” was held on July 12 where ReAct’s director was one of the speakers.

Euroscience Open Forum, ESOF, held in Dublin July 11-15, is Europe´s largest forum for science and research.

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In conjunction with the exhibition a press meeting and a lunch seminar was held: “We are facing a world without antibiotics — Who takes responsibility?” on July 12 where professor Otto Cars from ReAct was one of the speakers

2.1.3 Other communication activities

The ReAct website ReAct’s present website www.reactgroup.org was launched in 2011. During the first year there were 915 visits/month with an increase of 25% to 1150 visits/month in 2012. The website hosts information about the ReAct network and the various projects carried out in the regional nodes, ReAct Latin America, ReAct South East Asia and ReAct Ghana. One of the major projects, the CSO (Civil Society Organizations) Project also has a dedicated sub-site, http://cso.reactgroup.org/ that showcases the work of CSO partners around the globe and provides regular updates on their activities, achievements and future plans. The ReAct web site also provides regular news updates on the antibiotic resistance situation globally together with reports on relevant meetings and events.

The news section is complemented by “Resistance in the News” that is published once a week is a selection of articles with relevance to antibiotic resistance and antibiotic use that have been published in various internet media and on-line scientific journals.

There is also a possibility to sign up for regular newsletters with updates on the activities of ReAct and other stakeholders working with public health and antibiotic resistance. The newsletter has around 1200 subscribers at present.

The ReAct Resource Center The ReAct Resource Center, http://www.reactgroup.org/rc.html, launched in 2012 and integrated with the ReAct website, is a publically accessible web-based database with a wide range of high-quality reports, policy documents, presentations, videos etcetera on antibiotic resistance and antibiotic use. The main focus is to provide policy makers with tools to take action on ABR but also students, CSOs, health professionals, journalists, community-based organizations and primary health workers can benefit from the Resource Center within their areas of interest. The Resource Center is

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also used as a source for background documents for courses on ABR. There are at present 500 different resources available.

In the next phase the Resource Center will be complemented with readymade “tool boxes” for more specialized needs. To better assist countries and/or regions in developing and introducing policies to manage ABR and to support other ongoing regional projects, the content in the “toolboxes” will not only describe results but also processes. What has been successful within our own and other´s areas of activities, highlighting success factors and benchmarks as well as critical points and but also critical factors and pitfalls.

The Resource Center will also be developed in a new version with advanced search functions, better navigation and resource presentation features together with better interactivity with the visitor.

Resistance in the News

Resistance in the News is a selection of articles with relevance to antibiotic resistance and antibiotic use published in various internet media and on-line scientific journals, gathered by ReAct and sent to around 125 health experts in co-operation with Swedish Institute for Communicable Disease Control, (SMI) and also published on the ReAct website.

IFMSA (International Federation of Medical Students' Associations)

Cecilia Kållberg, active in the medical student network IFMSA, did her Master’s thesis at ReAct. Cecilia has now set up the initiative “START” (Students Targeting Antibiotic Resistance) within IFSMA and discussions are currently ongoing regarding possibilities to collaborate on preparing a web platform with materials on ABR for students, including presentations and other tools.

2.1.4 Supporting the development and implementation of regional and national processes for the management of antibiotic resistance4

Establishing a national policy platform for work against ABR in Ghana

Much is known, primarily from European countries, about the necessary components required to manage antibiotic resistance (ABR), and how successful interventions can be coordinated and implemented. Although the basic components needed for a sustainable national process against ABR are no different, managing antibiotic resistance in LMICs poses significant challenges. There are no examples of coordinated national policies from the African region and Ghana is a country suitable for piloting such a project. This project focuses on and seeks to steward this process to gain experience on how countermeasures against ABR could be stepwise implemented in an African country. Through the engagement and leadership of Martha Gyansa-Lutterodt, Director of Pharmaceutical Services department at the Ghanaian Ministry of Health, a national policy platform for the work against ABR has been established. This process is also linked to the Ghana part of the CSO project (see page 31) and it could potentially be further linked to other networks and processes and countries in the

4 Some regional activities area los described under the themes 2, 4 and the CSO-project. 11

region, as well as to activities by the WHO AFRO.

Activities and accomplishments 2012

Activities on the development of a national policy on antimicrobial resistance in Ghana are in the advanced planning stages for roll out. In a recent meeting, a subcommittee led by the Director of Clinical Care, MoH, was tasked to come out with a Terms of Reference and guidelines for the development of the antimicrobial policy. The management team in collaboration with specific individuals and members of the Technical Working Group on AMR have been tasked to deliver on specific activities in order to achieve stated objectives.

Identification and mapping of major key stakeholders, an assessment of their interests and the ways in which their interests will affect the processes and overall policy development and subsequent implementation is another part of the process. These stakeholders are grouped to provide technical expertise that pertains to their interest, to develop the policy documents.

A website hosted by the Ghana National Drugs programme has been developed5 and will with time be made more interactive and accessible to all partners involved in the project.

ReAct in South East Asia (SEA)

ReAct in SEA have been organising successful annual meetings since 2007 and the partnerships developed are very promising. Since 2012, the Universiti Sains Malaysia is serving as the administrative host for the ReAct SEA network. Following upon four years of networking carried out by the ReAct coordinator, the achievement in 2011 was a visible and committed ReAct SEA network comprising physicians, pharmacists, CSO representatives, activists, academicians, policy makers, scientists and representatives of regional/global health-related networks and WHO regional bodies, numbering more than 50 professionals from six of the 10 ASEAN countries.

With support from ReAct and through voluntary work, the network members have initiated ABR-prevention interventions in their individual countries, including WHD 2011 campaigns; influenced policy making processes, to various extents at national and regional levels (for example, the Jaipur Declaration); come together to explore various ABR-related research; and facilitated cross-border learning of local community-level intervention programmes (Antibiotic Smart Use Thailand) as well as hospital level programmes (Antimicrobial Stewardship Program - Singapore). The process to roll these out as SEA-regional programs has begun in Indonesia and Malaysia with local adaptation and innovation.

During the course of ReAct activities over the past 3-4 years ReAct SEA has also seen the participation and interest from national health promotion boards/foundations in Thailand, Malaysia, Indonesia and Philippines. These are important stakeholders and also potential local funders.

5 http://ghndp.org/antimicrobialresistance/ 12

Activities and accomplishments 2012

Malaysia ReAct´s partner, the Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences (DSAP), Universiti Sains Malaysia, participated in the launch of the national campaign to curb AMR by the Health Ministry of Malaysia. The DSAP described the implementation of the ReAct CSO project in Malaysia and called for the MoH AMR campaign to include community mobilisation and empowerment as an important and necessary strategy to address the problem of AMR.6 Asia Pacific Conference on National Medicines Policies, Sydney, Australia7 ReAct in SEA network partners participated in the planning and discussions of the workshop on ‘Antimicrobial resistance and rational use of antibiotics’, at the Asia Pacific Conference on National Medicines Policies (NMP), held in Sydney, May 2012.

The ReAct-organised workshop saw participants from the small island nations, such as Kiribati, American Samoa, Samoa, Vanuatu, Tonga, Cook Islands, Tuvalu, express keen interest to be part of the ReAct network in the region.

40 participants from Indonesia, Malaysia, Australia, India, Kiribati, American Samoa, Samoa, Vanuatu, Tonga, Cook Islands, Tuvalu, India, Netherlands, Nepal, New Zealand, Philippines, Bangladesh, Korea, China, Mongolia, Netherlands and WHO participated in the workshop, which aimed at identifying the main challenges/barriers/gaps to developing and implementing effective strategies to contain AMR, and integrate AMR into NMPs. A set of policy recommendations came out from the workshop including: education, awareness raising, national policy platforms, and research.

A spin off from the NMP conference was an invitation by the Chief Editor of the journal - Southern Med Review (SMR) – to ReAct to collaborate on a special issue of the journal, on antibiotic usage and resistance, to be published in April 2013. ReAct in SEA partners have been involved in the planning discussions in 2012.

Prince Mahidol Award Conference 2013 Planning towards the ReAct workshop on Controlling Antibiotic Resistance through the One Health Approach, to be convened at the Prince Mahidol Award Conference 2013 has been going on since June 2012.

6 http://thestar.com.my/news/story.asp?file=/2012/10/22/focus/12206549&sec=focus 7 http://www.apcnmp2012.com.au/

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ReAct in Latin America

ReAct in Latin America is coordinated by the Medical Faculty of the University of Cuenca and the Child to Child Centre. Since 2007 they have gradually built of a network of people, organizations and institutions that act against bacterial resistance to antibiotics in the fields of education, research and communication. Important items on the ReAct Latin American agenda have been the social determinants of health including poverty, inequity, environmental change and the conditions of indigenous peoples in the region.

Community based advocacy, knowledge, empowerment and practical initiatives have in parallel been initiated in Ecuador and neighbouring countries.

Activities and accomplishments 2012

Fotoresistencia The ReAct Latin America (RLA) so called edu-communication project, FotoResistencia (FR), a photodocumentary project, was launched for professionals and the public, and exhibited in twelve different places across Ecuador.

In the FR project, primary health care workers are trained in ABR and to take photographs visualizing the causes and consequences of ABR. Every participant develops a photo-ethnographic story, and later uses this material (photos and texts) to do edu-communicational activities in their communities, with their colleagues, and more widely. These activities represent a starting point to change knowledge and practices on the ABR and its underlying causes.

"FotoResistencia, Antibiotic Resistance in my Primary Health Center and my community". A ReAct Latin America documentation and edu-communication project based on photography.

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The project has been developed and implemented in four southern provinces of Ecuador with partners that include the Faculty of Medical Sciences of the University of Cuenca, the Pan-American Health Organization in Ecuador (PAHO), the Ministry of Public Health, the Ecuadorian Social Security Institute, and the city of Cuenca Health Council. The results of FR 2011 edition, i.e. the photos and the album, were disseminated during 2012 through an exhibition where the album was launched and, through various colloquia on ABR, oriented to several targets: health sector workers, students, artists, journalists, and the community.

The Global Health Program of the University of British Columbia’s interest in the FR project led to a collaboration initiated in Nov 2012 to look for arts based-methods to tackle the ABR issue from an ecosystem perspective. Now, RLA, its partners and the UBC group are developing a project to evaluate FR. A conference organized by RLA on Antimicrobial Resistance included a presentation of the “FotoResistencia” project in the Particular and Technical University of Loja, Ecuador, in June 2012.

Pedalling with consciousness In the “Pedalling with consciousness, using antibiotics wisely” project supported by RLA, three students of the Faculty of Medical Sciences of the University of Cuenca, travelled by bike along the coast of Ecuador (700 km) during 15 days. They visited elementary and high schools to raise consciousness on antibiotic resistance, the appropriate use of antibiotics and the use of bikes, in an ecology framework. A booklet documenting the activity with texts and pictures was produced and is available at the ReAct website. Moreover, there is a Facebook group of this project8.

Arts & Microbes Project An interdisciplinary cooperation between RLA and the Faculties of Medical Sciences and Arts of the University of Cuenca has been exploring new ways to understand ABR by generating artistic edu-communicational material and activities on the microbial world, the ABR and the use of antibiotics. The idea behind the project was to promote interchanges and actions between medical sciences students and arts students for better understanding of ABR. The outputs of this project were released in November 14th, 2012 in the Caravan for Life and Bacteria. A video is available9.

8 https://www.facebook.com/pedaleaconconciencia?fref=ts 9 http://www.youtube.com/watch?v=tKdFE4t3bnc&feature=youtu.be

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The Caravan for Life was part of an educational and mobilization process conducted by the Faculty of Medical Sciences and the Faculty of Arts of the University of Cuenca, ReAct Latin America and the Child to Child Foundation.

2.2 THEME 2: EVIDENCE GENERATION

Burden fact sheet

To better visualize both the health and economic burden of antibiotic resistance, ReAct produced a fact sheet on this topic in the spring of 2012. Scientific literature on the topic was gathered and translated into a more accessible format. The fact sheet was widely distributed at the Swedish/Ghanaian side event at the WHA, the Asia Pacific Conference on National Medicines Policies and at the Euroscience Open Forum. The fact sheet is available at the ReAct website together with the other ReAct produced fact sheets (one of which was referred to at the World Economic Forum blog in Jan 2012).

Master thesis on access, excess and ethics

ReAct in cooperation with the Institution for International Maternal and Child Health, IMCH, at Uppsala University supervised a master student, Gabriel Heyman, to conduct a study in 2012 to explore what properties a system of antibiotic distribution must possess to keep prescription and use rational while achieving access in areas where the coverage and quality of healthcare are poor. The MSc study “Access, excess and ethics-towards a model for rational use of new antibiotics” was presented in March 2013.

Knowledge, Attitude, Behaviour and Practices survey on health professional of ABR in Ghana

A Knowledge, Attitude, Behaviour and Practices (KAP) survey on ABR targeted to health professionals in Ghana helped collect data that will advice the training and building the capacity of core health care providers in public health institutions. This training will contribute to health professionals being better placed to influence and work with policy makers for more rational use of antibiotics in public sector institutions. The research subgroup of the Technical Working Group initially developed a protocol to carry out this activity within the demographic community at the four sentinel sites of the Ghana Health Service research institutions across the country. Due to the current direction and budgetary constraints this protocol is being redesigned to focus on health professionals within selected public health facilities in the three geographical zones of Ghana.

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Baseline study in Ghana on the level of resistance of five key antibiotics and the establishment of routine monitoring and surveillance of these antibiotics and resistance.

The baseline study in Ghana on the level of resistance of five key antibiotics is linked to the KAP study and form part of the assessment on antibiotic resistance in some selected hospitals in the country. These activities are directed towards providing additional evidence on resistance to commonly used antibiotics and also to determine the capacity of laboratories and personnel to handle resistant organisms.

A proposal to carry out needs assessment of the selected hospital laboratories and also determine the capacity of these laboratories to undertake surveillance on resistance has been developed. This proposal, “Monitoring Antibiotic Resistance in Hospital Laboratories” (Marhlab) is intended to be applied in four selected hospitals with different levels of laboratory capacity and facilities. Marhlab will achieve five objectives, which include a rapid assessment of the selected laboratories to determine capacity gaps; determine the prevalence of resistance strains; and then carry out routine monitoring and survey resistance pattern to five key antibiotics in the selected hospitals laboratories.

South East Asia Antibiotic Resistance Costs in Hospitals

The development of South East Asia Antibiotic Resistance Costs in Hospitals (SEARCH) proposal that had been initiated in 2011 was completed in 2012. The study protocol is aimed at documenting and analyzing the Costs and Consequences of Antibiotic Resistance in bacteraemic patients in South East Asian Hospitals. Hospitals from seven countries in the region have shown interest in participating in the research project and funds are being sought from regional organisations as well as from national health promotion boards.

ESBL-carriers in a neonatal intensive care unit at a tertiary hospital in Ecuador

In 2011, ReAct Latin America in cooperation with Karolinska Institutet, Stockholm, Sweden, finished a study on EBSL in neonates10, which was presented in the ICIUM conference11. The study showed that 55% of the admitted children were colonized by ESBL-producing isolates, and these data were used in 2012 to raise awareness with the authorities. This study is a first step in demonstrating the need for a national policy, the importance of national and regional programs as well as ongoing research to increase infection control in Ecuadorean hospitals.

Antibiotic use in children in indigenous communities in Ecuador

A study entitled “An ecosystem approach to promoting appropriate use of antibiotics for children in indigenous communities in Ecuador” was performed in 2012 and published in the Pan-American Journal of Public health12. The study was done in collaboration with University of British Colombia and showed that environmental, social, and cultural factors must be addressed to prevent antibiotic resistance in addition to training health personnel and that an ecosystem approach is well-suited to achieve this goal.

10 http://f1000.com/posters/browse/summary/1089935 11 Third International Conference for Improving Use of Medicines, http://www.inrud.org/ICIUM/ICIUM-2011.cfm 12 http://www.ncbi.nlm.nih.gov/pubmed/22358404

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Studies on the perception of infection and antibiotics by mothers and children in Ecuador.

In 2012, a study to analyze perceptions of ABR and use of antibiotics by 500 children, 10-12 years of age, and more than 1000 mothers in communities in urban and rural areas in different social strata was initiatied.

Evaluation of KAP of PHC doctors and community in the Amazonian region.

A new project to evaluate the knowledge, attitude and perception, (KAP) of public health center doctors and the community they serve in relation to antibiotic use was started in a region with 30,000 inhabitants encompassing one second-level hospital and eight primary health care units. Based on the results obtained, the goal is to develop a training program adapted to the identified needs.

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2.3 THEME 3: PROMOTING INNOVATION AND THE DEVELOPMENT OF HEALTH TECHNOLOGIES TO MEET GLOBAL NEEDS TO MANAGE ANTIBIOTIC RESISTANCE

2.3.1 The global need for new effective antibiotics ReAct has since its inception in 2004 made strategic interventions to inform stakeholders about the need for development of new antibiotics. To influence the process of innovation of health products to manage ABR, ReAct has catalyzed and actively participated in processes to develop new funding mechanisms, and re-engineer the R&D pipeline to create an enabling environment for novel, reliable, and affordable antibiotics and diagnostics for all.

*Collaboration for Innovation”, ReAct high-level meeting with the European Commission, The European Medicines Agency, the World Health Organization, academia, the pharmaceutical industry as well as several civil society organizations

Activities and accomplishments 2012

Input to the process of the EU action plan against Antimicrobial Resistance This plan was launched in November 2011 and included research to speed the development of new antibiotics within the PPP between the European Commission and the European pharmaceutical industry -The Innovative Medicine's Initiative (IMI). ReAct was asked by IMI to suggest research areas to be considered and to write a background document on the topic “Controlled Distribution and Use of New Antibiotics”.

Lectures at meetings and conferences ReAct actively participated at several meetings including a meeting on ABR organized by the Joint Programming Initiative on Antimicrobial Resistance (JPIAMR), a session at Drug Information Association 24th Annual Euro Meeting 2012 (DIA 2012) in Copenhagen regarding the scientific and political challenges in antibiotic development (together with speakers from EFPIA and the EU

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Commission , DG Research) and a “meet the expert session“ on the urgent need for novel antibiotics at the International Conference on Antimicrobial Agents and Chemotherapy.

High level meetings on a new business model for R&D of new antibiotics On 20 April 2012 a meeting took place between ReAct and the Assistant Director General for the EU Commission Directorate on Health and Consumers. On November 26, a second meeting with WHO Assistant Director Keiji Fukuda and several representatives from WHO and the Director of EFPIA to discuss new business models for the development of new effective antibiotics took place. Leadership training in International health including policy innovation and access to medicines In November 2012, the ReAct strategic Policy unit at Duke University hosted a leadership training, co-organized with the American Medical Student Association, on several key issues for U.S. and international health including policy innovation and access to medicines, tackling antibiotic resistance, and ensuring open access to knowledge. Thirty students, selected from ninety applicants, came together for an intensive, two-and-a-half day training. The conference included three breakout session tracks, of which one focused on antibiotic resistance.

Treatment for Tomorrow (T4T): Finding Breakthrough Innovations for Tackling Antibiotic Resistance. The ReAct Strategic Policy Unit at Duke University explored the design of a co-opetition - that is, a prize competition with collaborative elements integrated into the event’s timeline - entitled, “Treatment for Tomorrow (T4T): Realigning Incentives to Balance Affordable Access with Rational Use of Antibiotics.” This ideation challenge was intended to call for innovative ideas on how to change the incentives throughout the value chain of antibiotics—from pharmaceutical company to consumer - in order to improve the use of antibiotics. In December 2012, a diverse group of global health stakeholders and topical experts were brought together to help develop a process by which breakthrough innovations to tackling the challenge of ABR in the healthcare delivery system might be supported within four related ABR challenges:

• Infection Control and Prevention • Metrics, Maps and Media (3M) • Delivery/Distribution Systems for Medicines • Incentives for Rational Use

The highly productive discussions generated many potential follow-up leads, but depending on funding and resources, ReAct will have to be strategic in selecting which to pursue.

2.3.2 Controlled distribution and use of new antibiotics As a logical step following the several ongoing EU and global initiatives to address the need for innovative R&D for new antibiotics and to push forward the process started in 2011 concerning the use of any future new antibiotics, ReAct initiated in the autumn 2012 a process to address and stir debate on how to ensure rational use of any future new antibiotics while securing the equitable access and affordability. To this end, ReAct procured the services of a consultant and appointed an

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academic team to write a debate paper to lay down exploratory ways to preserve new effective antibiotics.

3Rs for innovating novel antibiotics: sharing resources, risks, and rewards. Anthony So, ReAct Strategic Policy & Advocacy.

ReAct participated in the QUAMED (Quality Medicines for all) partner meeting held in December at the Institute of Tropical Medicine, in Antwerp, Belgium. The meeting gathered not only the 21 QUAMED partners but also organizations involved in the access to quality medicines in and towards developing countries. ReAct shared its views on controlled distribution and use of new antibiotics and what can be learned from other initiatives like those working to evaluate and control resistance to antimalarials

Addressing the importance of de-linkage of R&D investments for new antibiotics from marketing activities The ReAct strategic policy unit at Duke University worked to publicly address the importance of de-linkage R&D investments for new antibiotics from marketing activities in the United States. The activities relate to and address the passage of the Generating Antibiotic Incentives Now (GAIN) Act, a piece of U.S. legislation aimed to incentivize R&D of new antibiotics. The group at Duke debated and questioned the content of the GAIN Act that extends company monopoly rights to its new drug’s market. In light of the increased need to educate the public and policymakers on delinkage, ReAct worked with the head of Public Citizen, a major U.S. consumer rights group, to write a Huffington Post editorial against the use of data exclusivity as an incentive for antibiotic development. The article informed that there is little evidence that increased market monopoly rights address the scientific and business model challenges facing the antibiotic R&D space. Moreover, monopoly protections like exclusivity fail to delink R&D cost recuperation from high-volume sales of antibiotics - a contributing factor to the over-marketing and overuse of antibiotics, factors contributing to the public health threat of antibiotic resistance.

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2.4 THEME 4: PROMOTING RATIONAL USE OF ANTIBIOTICS

2.4.1 Latin America

Courses and Training activities

A seminar on the appropriate use of antibiotics in human health was organized in June 2012 and targeted 40 health workers of the Ecuadorian Ministry of Health, Morona Santiago province. ReAct in Latin America (RLA) participated in a conference about the global view of antibiotic resistance, appropriate use of antibiotics, water and healthy environments in a workshop for health promoters hosted by the Faculty of Medical Science of the University of Cuenca in April 2012 and have provided short training on rational use of antibiotics to community leaders (150 who are now “champions” in local communities).

In collaboration with academics from Brazil, Venezuela, Cuba and Ecuador React Latin America is developing a guideline for appropriate use of antibiotics aimed at Primary Health Care workers

Dr. Cristian Pacheco (research team) LCDA. Soledad Ortega (research team), Dr. Romulo Lima (medical director), DRA. Georgina Munöz (research team).

2.4.2 South East Asia

Baseline surveys and training of trainer’s workshops.

During 2012, ReAct partners in Indonesia, Malaysia and Thailand implemented activities related to the ReAct project - Engaging Civil Society Organizations as stakeholders in national/regional platforms to manage ABR. Baseline surveys and training of trainers workshops were held in project sites in the three countries since the launch of the project in 2012. The activities aimed at extending community-based health promotion and education networks to reach parents, children and youth to

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foster positive health behaviour including the themes of ABR management. The project will also engage relevant regional CSOs as active stakeholders in national/regional platforms to manage antibiotic resistance.

The CSOs participating in the new project are based in Latin America, West Africa and South-East Asia. Most of them are working in the areas of child and maternal health, women's issues, education and environment.

Antibiotics Smart Use: a workable model for promoting the rational use of medicines in Thailand.

Several ReAct partners in SEA are part of the Antibiotics Smart Use (ASU) program1 introduced in Thailand as a model to promote the rational use of medicines, starting with antibiotics. The programs first phase consisted of assessing interventions intended to change prescribing practices; the second phase examined the feasibility of program scale-up.

Currently the programme is in its third phase, which centers on sustainability. To change antibiotic prescription practices, multifaceted interventions at the individual and organizational levels were implemented; to maintain behaviour change and scale up the program, interventions at the network and policy levels were used.

The National Health Security Office has adopted ASU as a pay-for-performance criterion, a major achievement that has led to the program’s expansion nationwide. Despite limited resources, program scale-up and sustainability have been facilitated by the promotion of local ownership and mutual recognition, which has generated pride and commitment. ASU is clearly a workable entry point for efforts to rationalize the use of medicines in Thailand. Its long-term sustainability will require continued local commitment and political support, effective auditing and integration of ASU into routine systems with appropriate financial incentives.

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2.4.3 Africa

EPN Forum "Access to quality medicines: priority needs, priority actions for today and tomorrow".

ReAct actively participated in the 2012 EPN (Ecumenical Pharmaceutical Network) Forum and General Meeting held in Addis Ababa, Ethiopia in March that had the theme "Access to quality medicines: priority needs, priority actions for today and tomorrow".

EPN identified AMR as one of several priority issues it needs to address and expressed the desire to work with ReAct on this. Access to quality antibiotics, extending awareness of AMR in the community and development of tools to enable these were identified as issues.

The Forum brought together 62 representatives from member and non-member institutions.

About 20 high level speakers connected general approaches in fields of procurement, supply chain, quality of medicines, and non-communicable disease with practical results and successes within the network.

2.5 OVERALL COORDINATION

The overall coordinating functions of ReAct are managed by its office based at Uppsala University and its network coordinator. The tasks of the staff at the Uppsala office in the overall project management included: -planning and following up the progress of the projects including problem-solving and other decision-making in dialogue with ReAct staff, consultants and partners -providing infrastructure for documents, projects (platforms), teleconferences and meetings -contracting of partners, consultants and employees -financial management and reporting to funders

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-external communication with stakeholders through informal contacts and by representing ReAct at meetings and conferences -providing scientific knowledge and credibility -providing an updated website including the ReAct Resource Center The staffing of the office in Uppsala 2012 is described in the table below: Name Role ReAct 2012 % Sida funded % Comment Elisabeth Lindström

Project coord. & economy et. al

1 1

Christel Törnros

Website & comm. coord. et al.

1 1

Otto Cars Director 0,4 0 Director from 2012-03-01

Anna Zorzet Ass. Director researcher

1 0,17

Maria-Teresa Bejarano

Proj. manager CDU, Africa et.al.

0,5 0 100% 1 aug-31 dec

Anna Hedin Proj manager, strat. Policy

1 0,75 Left ReAct 2012-12-31

Liselotte Högberg-Diaz

Proj. manager researcher

0,08 0,08 Left ReAct 2012-01-31

Andreas Heddini

Director 0,16 0 Left ReAct 2012-02-28

Ingrid Trolin Scientific advisor 0,14 0,14 Left ReAct 2012-06-30

TOTAL: 5,28 3,14 Employees in the network and consultants: Name Role ReAct 2012% Sida funded% Comment Eva Ombaka Senior advisor 0,05 0,05 Tanzania Göran Tomson Senior advisor 0,05 0,05 Michael Chai SEA coordinator 0,8 0,8 Malaysia Mary Murray Network coord. 0,6 0,6 Australia/Uppsala Satya Sivaraman

Communication coordinator

0,4 0,4 India

Lars Blad Scientific advisor 0,15 0,15 2012-03-01 -

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2012-12-31 Ken Phillips Organisation

consultant 0,07 0,07 2012-09-19 -

2012-12-31 Yong Kwok Consultant CDU

project 0,12 0 2012-10-01 -

2012-12-31 Hajo Grundmann

Consultant Surveillance

0,16 0 2012-09-01 -2012-12-31

TOTAL: 2,4 2,12 Apart from the above listed personnel there are several people employed or working as volunteers through the funding provided as grants to the regions, see the presentation below.

Snapshot of the staffing situation of ReAct (total all funds) in March 2013 One major focus for the coordinating function 2012 has been the organization of a Strategic Planning Workshop for ReAct staff and external advisory key stakeholders in Noordwijk, the Netherlands March 2013. Working closely with an organizational consultant, background material was prepared

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during 2012 and a number of activities to facilitate organization and analysis of material to help ReAct to plan and make decisions on four inter-related areas:

• Resource mobilization and financial sustainability • Strategic and operational planning • Organization culture, development and change management • Team, management and leadership development

In 2012 ReAct has seen an increased level of engagement and coordination across themes and regional affiliation that has created good synergy and strength when managing the cross-cutting activities within controlled distribution and use and innovation of new antibiotics and the planning of a course concept.

2.5.1 Networking coordination The work of the Global Network Coordinator has been important in 2012 as a major contribution to the active unification of ReAct’s work under themes and between themes, the integration of ReAct’s previous work, links and network relationships into the conceptualising and development of new projects such as CDU; supporting and mentoring every person in the ReAct organization through 2012 - a period of challenge in ReAct’s growth and reorganization thereby keeping the ReAct spirit alive.

One of the main efforts was to actively facilitate understanding and collaboration between the regions, themes, projects and people that as a whole make up ReAct as a catalyst organization. The global network coordinator was actively involved in the preparations for the abovementioned Strategic Planning Workshop together with an external consultant. A major task in 2012 was initiating the first step of a harvesting process which involved interviewing each member of the ReAct international secretariat and drafting a paper on the experiences and influence of the ReAct network. This work contributed significantly to developing links and inducting new people and organisations into the issue of ABR and ReAct’s approach to it.

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2.6 TARGET FULFILMENT AND PERCEIVED IMPACT

Target- fulfilment of ReAct Log frame for 2012

Activities Achieved results Indicators Fulfilment of LFA Increased visibility of antibiotic resistance in the global health dialogue

1.To work with national and regional partners to promote the establishment of national platforms on antibiotic resistance;

Regional and/or national policies on ABR established in one or several countries where ReAct is active;

1.1Management of ABR featured in national health plans; Measures to manage ABR being featured in national health plans

(Chapter 2.1.4) 1.1.1 In Ghana an AMR policy is ready for roll out. 1.1.2 In South East Asia the policy network has expanded as seen by the MoH Malaysia AMR campaign and Asia Pacific conference13 1.1.3 In Latin America mainly the “bottom-up” approach is used ex. ESBL-study lifted to policy makers to improve infection control14 1.1.4 Pre-policy paper developed and signed by University of Cuenca, MoH Ecuador, Social Security, Municipality of Cuenca, PAHO, and ReAct15

2. To engage communities, health professionals, international organisations and academic centres in antibiotic resistance and its management;

Antibiotic resistance being recognised as a major problem by organisations and networks working with health, access to medicines and drug quality in LMICs;

2.1 ReAct’s work being brought up in meetings, media and publications

2.1.1-2.2.1 RLA campaigns to engage different groups: - Expansion of the Fotoresistencia campaign; - Pedalling with conscience 8. - Arts & microbes project 9, see also launch of the CSO-project (chapt. 3) 2.1.2 ReAct’s work being brought up in publications, meetings and media (annexes 1, 2 and 3)

13 http://thestar.com.my/news/story.asp?file=/2012/10/22/focus/12206549&sec=focus 13 http://www.apcnmp2012.com.au/ 14 http://f1000.com/posters/browse/summary/1089935 15http://ia600606.us.archive.org/34/items/EsTiempoDeSensibilizarnosAnteLaResistenciaALosAntibioticos/Declaracion_diaMundialDeLaSalud_7abril2011.pdf

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Additional network partners in SSA.

2.2 New organisations taking on antibiotic resistance as a result of ReAct collaboration esp in SSA;

2.3 Relevant information on the root causes of poor access, its consequences and options to improve access to antibiotics in different contexts published by React and/or partners (no. of publications);

2.2.1 ReAct SEA have been organising successful annual meetings and the partnerships developed are promising. Network members have initiated ABR-prevention interventions locally (chapt.2.1.4) 2.2.2 Collaboration with WHO-AMR-team (chapt 2.1.1) and regional offices such as WHO-AFRO and other actors. 2.3.1 Publication of root causes to access not complied to sufficiently but is an element in most ReAct communication, see annex 1,2,3

3. To publish articles, newsletters and other communication materials

3.1.1 Well updated ReAct website www.reactgroup.org 3.1.2 Publication of articles, newsletters and other communication-material, see annex 1

Evidence on antibiotic resistance, its causes and consequences generated

1. To work with organisations, NGOs, networks and other actors to increase the generation of data on antibiotic resistance and use;

First steps towards a global network for surveillance of antibiotic use and resistance taken where ReAct has contributed by catalysing action with multiple regional partners;

Data is being used to underpin new policies and guides decision making.

1.1 Continuous surveillance being carried out in resource constrained settings;

1.1.1 This is a huge task but as a first step a ReAct roadmap on global ABR surveillance has been developed and fed to WHO (chapt 2.1). The next step is ongoing; WHO is mapping what data that exist globally. 1.1.2 Studies on ESBL, MRSA etc conducted by ReAct Latin America in cooperation with other Universities and fed to stakeholders in different ways (chapt. 2.2) 1.1.3 Baseline study on the level of resistance of 5 key antibiotics and establishment of surveillance of these

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1.2 Funding leveraged for work on surveillance

antibiotics initiated in Ghana by the Ghana MoH. 1.2.1 Catalysation and uptake of ABR on the INDEPTH agenda including a funding proposal to Wellcome Trust.

2. To promote better assessment of the social and economic burden of antibiotic resistance.

Data is being used to underpin new policies and guides decision making.

2.1 Increase in the number of organizations involved in this area 2.2 Reports and publications on burden where ReAct has contributed (no. of publications);

2.3 Policy statements and documented decision processes of governments and position papers of relevant health organisations (no. of publications).

2.1.1 ABR costing study developed by ReAct South East Asia, this proposal was funded by SEARO (chapt. 2.2) 2.2.1 Fact-sheet about health and economic burden of ABR produced and widely disseminated,(chapt.2.2) 2.2.2 Publication of articles, newsletters and other communication-material (annex 1) 2.3.1 Policy-documents exists, but it is difficult to quantify.

3. To increase the visibility and knowledge of restricted access to effective antibiotics and its consequences in global, regional and local dialogues on health and related areas;

3. To make data available through dissemination and communication;

3. To promote the uptake and use of growing evidence base.

Data is being used to underpin new policies and guides decision making.

3.1 Increase in the number of organizations involved in this area

3.1.1 Restricted access lifted in multiple local, regional and global dialogues. 3.1.2 Master-thesis conducted on access, excess and ethics (chapt.2.2) 3.1.3 KAP survey initiated by MoH Ghana to influence health professionals and policymakers on rational use. (chapt.2.2) 3.1.4 Study on antibiotic use for children in indigenious communities in Ecuador published. (chapt.2.2) 3.1.5 Study on perception of antibiotic use targeted to mother and children initiated

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in Ecuador. (chapt.2.2) 3.1.6 KAP study of PHC personnel in Amazonas initiated. (chapt.2.2) 3.1.7 Publication of articles, newsletters and other communication-material, (annex 1)

Innovation and development of health technologies to meet global needs to manage antibiotic resistance

1. To engage in and drive a process to stimulate the development of new antibiotics;

A new initiative for the development of new antibiotics and associated health technologies established.

1.1 No. of policy convenings and international meetings;

1.2 New efforts arising from this process, e.g. the establishment of PDPs, funding of basic research etc; 1.3 Other actions taken by boundary partners; 1.4 Amount of funding that goes into this area

1.1.1 ReAct has contributed to the outcome of several conferences: JPIAMR, DIA, ICAAC and high level meetings with EU and WHO (annex 2) 1.2.1 Mainly delivered 2011. Actions now taken by boundary partners eg. IMI-process (chapt. 2.3.1) 1.3.1 Antibiotic Action, British initiative to stimulate development of new antibiotics and EU AMR strategy, see outcome-mapping table. 1.4.1 In May 2012, IMI launched The ‘New Drugs for Bad Bugs’ programme (ND4BB) with the first topics having a budget of EUR 224 million. The next call, in December 2012, included projects with a budget of EUR 137 million.

2. To link innovation to global access to forthcoming products;

2.1 No. of policy convenings and international meetings;

2.1.1 Organisation of international leadership training in health for students including access issue see chapt. 2.3.1. Active participation at the QUAMED-meeting in Antwerpen, December (chapt. 2.3.2 and annex 2)

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2.2.3 Master thesis conducted on access vs, excess problematic on antibiotic distribution (chapt. 2.3)

3. To stimulate re-engineering of the value chain of R&D to make drugs, vaccines and diagnostics affordable;

3.1 No. of policy convenings and international meetings; 3.2 Framework for prioritizing amongst health technologies developed;

3.1.1 Treatment for Tomorrow (T4T) meeting in December that generated many potential follow up leads, see also annex 2. 3.2.1 The T4T process may deliver results here during 2013 and 2014. 3.2.2 Importance of delinking R&D investments from sales has been addressed, e.g. by debating the GAIN-act (chapt. 2.3.2)

Promoting rational use of antibiotics

1. To work with other networks and organisations to promote rational use of antibiotics;

1.1 No. of processes where ReAct is involved to promote rational use of antibiotics

1.1.1 ReAct has been involved to promote rational use of antibiotics in: -partnership with ASU-program in SEA -WHO consultations -community initiatives -public awareness raising through websites and social media (chapt 2.1) - education of PHC workers in Latin America and SEA (chapt. 2.4) - conferences and workshops for various audiences about rational use (chapt 2.1 & 2.4) 1.1.2 Process initiated to debate a new system for CDU of antibiotics (chapt. 2.3) 1.1.3 Debate article under production, will be published 2013.

2.To develop more powerful tools and processes for training of

New participatory action-oriented education model for primary health care

2.1 Established training course on the management of ABR in primary health care established

2.1.1. In SEA baseline surveys and train the trainer workshops has been arranged

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health workers and engaging the community;

workers developed, tested and implemented in several countries in South America;

in at least one Latin American country

in Indonesia, Malaysia, Thailand in synergy with the CSO project see chapt.3. Training of health workers and community done in partnership with ASU-program in SEA (chapt. 2.4.2) 2.1.2 Education of PHC workers in Latin America e.g.: seminar on appropriate use of antibiotics for health workers of the Ecuadorian ministry of health and training of rational use of abs to community leaders (chapt. 2.4.1) 2.1.3 In a collaboration with Brazil, Venezuela and Cuba RLA is developing guidelines for appropriate use of antibiotics aimed at PHC workers.

3. To stimulate interdisciplinary work to re-conceptualise ABR issues to uncover new aspects of the human-microbe-ecology relation.

Broader understanding of ABR as a complex phenomenon beyond the health care sector.

3.1 Broader understanding of ABR as a complex phenomenon beyond the health care sector 3.2 No. references to paradigm shift or need for holistic approach to ABR in scientific literature;

3.3 No. of messages with changed image of ABR as expressed by language, images, etc

3.1.1 Interdisciplinary work to re-conceptualise ABR: pedalling with consciousness & art projects in Latin America (chapt. 2.1) 3.2.1 References made about the need for a holistic approach; example16 3.3.1 Messages with changed image of ABR, example 17 18 19 3.3.2 ReAct’s work being brought up in meetings, media and publications, see annexes 1,2 and 3 (applies to all activities in this theme)

16 http://www.onehealthglobal.net/?page_id=1132 17 http://www.economist.com/node/21560523 18 http://www.spiegel.de/wissenschaft/medizin/mikrobiom-ueber-10-000-bakterien-am-menschen-gezaehlt-a-838739.htm 19 http://www.newyorker.com/reporting/2012/10/22/121022fa_fact_specter#ixzz2HUd6j4Wt

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Overall coordination

1. Optimise synergies between the ReAct components to harness the collective potential of ReAct; Improve internal and external communication;

ReAct continues to grow and consolidate its role as a catalyst that can leverage action to manage antibiotic resistance. ReAct engages in and leads several different international projects and processes

1.1 Network coordination and management as assessed by ReAct core members (qualitative); 1.2 Overall funding level; No. of funders;

1.1.1. Process initiated for: -Strategic and operational planning, -Organization culture, development and change management and -Team, management and leadership development 1.2.1 Process initiated for: -Resource mobilization and financial sustainability -Funders contacted (chapt. 4)

2. Develop a method for prioritising amongst projects; Focus on a limited number of larger projects;

ReAct continues to grow and consolidate its role as a catalyst that can leverage action to manage antibiotic resistance. ReAct engages in and leads several different international projects and processes

2.1.1. Process initiated for: -Improved strategic and operational planning

3. Global surveillance of news and activities relating to antibiotic resistance;

3.1 Quality and contents of website (external reviews); No. of visitors to website;

3.2 No. of media briefs; No. of media interviews and publications. No. of media interviews and publications.

3.1.1 Regularly updated high quality website, www.reactgroup.org with 1150 visits/month 2012 (chapt. 2.1.3) 3.1.2 Launch of the ReAct resource center with over 500 documents available (chapt.2.1.3) 3.1.3 Global surveillance of news relating to antibiotic resistance, compiled into the “resistance in the news” collection that is distributed weekly by email & published at the ReAct website (chapt.2.1.3) 3.2.1 ReAct’s work being brought up in meetings, media and publications (annexes 1,2 and 3)

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Elements of outcome-mapping During 2012 contacts and collaborations have been established with an increasing number of actors/organisations, some of which are described in the table below. We wish in this way to capture changes in behaviour in actors with whom we do not have direct contact with but where ReAct has influenced or given impetus to change processes.

Organization Type of contact/relation with ReAct

Outcome

Antibiotic Smart Use (ASU) programme, Thailand

Part of the extended ReAct network, joint meetings, ad-hoc contacts. ReAct facilitated cross-country study visits to introduce champions for ABR to the ASU project.

Since 2006, ASU has evolved from a small pilot project to a national programme to improve rational use of antibiotics, which is now much appreciated internationally. Organisations in Indonesia and Malaysia have adapted ASU and implemented it in pilot locations.

Australian working group on ABR Personal contacts through one of ReAct’s Sec members, participation in meeting

National programme on ABR launched in Australia

Antibiotic Action A British initiative aiming to stimulate the development of new antibiotics launched autumn 2011

Part of the extended ReAct network, joint meetings, joint-debate articles, ad-hoc contacts

Increased global awareness raised through debate articles and workshops

EU Meetings and workshops for EU representatives 2009-2011

EU AMR strategy to contain AMR launched 2011 IMI initiative launched 211

IFMSA (International Federation of Medical Students Associations)

Master thesis student from IFMSA.

Initiation of START (Students targeting antibiotic resistance) project

IMI Engagement in a process stemming from meetings in Sweden in 2009, 2010 and 2011 and involvement in call process 2012

New initiatives to stimulate development of new antibiotics

INDEPTH International Network for the Demographic Evaluation of Populations and Their Health. INDEPTH currently consists of 37 demographic surveillance field

One ReAct member was previously chair of INDEPTH and managed to catalyse an uptake of ABR on their agenda and initiate a funding proposal to Wellcome Trust

Improved surveillance of ABR through INDEPTH sites

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sites (DSS) in 19 developing countries KI /ICHAR Part of the extended ReAct

network, joint meetings, joint courses and research projects, ad-hoc contacts

Increased knowledge of the root causes of ABR and methods for managing ABR better among international health students & authorities in Latin America

Numerous partners in SEA and RLA extended network

Interactions through the ReAct SEA group and RLA group through WHO regional offices, governments, CSO organisations, workshops, training, meetings, joint publications..

ABR included on other actors agendas locally, nationally and regionally (Jaipur declaration, Chennai declaration, Malaysian campaign to curb ABR, …)

WHO Long standing advocacy contacts. Frequent participation in WHO meetings and WHO projects. Preparation of a number of reports for WHO. Support to the Swedish governments WHO delegation

Initiation of global coordination of ABR through the WHO AMR group

3. CSO PROJECT ENGAGING CIVIL SOCIETY ORGANIZATIONS FOR SOCIAL MOBILIZATION, HEALTH EDUCATION AND COMMUNICATION

Background information

2012 saw the start of ReAct’s CSO Project: Towards national/regional policy platforms to manage antibiotic resistance - engaging civil society organizations for social mobilization, health education and communication. The project was launched at a meeting in Penang, Malaysia, on 17-18 February 2012. The CSOs participating in the project based in Latin America (Ecuador and Nicaragua), West Africa (Ghana) and South-East Asia (Indonesia, Malaysia and Thailand) and work in, among other things, the areas of child and maternal health, women's issues, education and environment.

In Latin America, the lead CSOs involved are the Child to Child Foundation, Ecuador (CCF), and Information Center & Advisory Services in Health, Nicaragua (CISAS). In West Africa (Ghana), the lead CSOs involved are Centre for Science and Health Communication, Alert Foundation, and LAPAG- Lady Pharmacist association of Ghana. In Southeast Asia, the lead CSOs involved are Yayasan Orangtua Peduli (Foundation of Concerned Parents) (YOP) (Indonesia); Yayasan Bina Ilmu Foundation for Building Knowledge) (YBI) and Discipline of Social and Administrative Pharmacy, USM (DSAP) (Malaysia); and Family Network Foundation (FNF), AIDS Access Foundation (AAF) and Drugs System Monitoring Development, Chulalongkorn University (DMD) (Thailand).

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The administration of project funds are managed by CCF (Latin America); Ministry of Health (Ghana); and USAINS Holdings (Southeast Asia).

The General Manager of the global project is Michael Chai (ReAct Southeast Asia), who also manages the SEA component of the project. The Regional Managers of the Latin America and West Africa component of the project are Klever Calle (Ecuador) and Martha Gyansa-Lutterodt (Ghana) respectively.

ReAct Uppsala coordinates the overall CSO global project and funds administration. Professor Otto Cars, the PI of the global project also managers the global component of the CSO project, which is aimed at linking international CSOs in the work of this project.

Project results

Year One saw a slow start, to implementation of project activities, in most countries, due to planning processes, capacity of partners, local challenges and paperwork related to contracts, LoAs and disbursements of funds. In SEA, Indonesia began their activities the earliest, in March 2012, using their own funds first. Malaysia began activities in mid-June 2012, Thailand in August. In Latin America, Ecuador began project activities in March, Nicaragua in April. In Ghana, project activities began in August 2012.

The first main activity of all project partners was a baseline survey (knowledge, attitudes, behaviour and practice - KABP), to indicate the KABP of the CSOs, and when possible the KABPs of the communities they worked in, vis-à-vis use of antibiotics and understanding of ABR. All countries completed their baseline surveys in 2012, with the exception of Ghana.

The results of the project site surveys were mixed. Against the completed baseline surveys, KABPs indicate that the CSO members are generally familiar with the basics of AB use and ABR. The community knowledge, however, varies from a significant lack to mis-informed knowledge about AB use and ABR. Examples include use of AB without prescription, use of others’ AB, use of AB for viral infections, lack of awareness of ABR, not completing the AB course, and expecting AB prescription in visits to physicians, despite the nature of the ailments.

Results achieved against outputs and outcomes planned

As Ghana was the latest among the country project partners to implement the activities, having started the KABP survey in November 2012, there were no outcomes of note to report. The outputs of 2012 consisted of several preparatory meetings and preparations of the KABP survey, the results of which is expected to be reported in 2013.

As for the other country partners, the Training of Trainers (ToT) workshops, aimed at equiping the project CSOs with, knowledge, skills and tools for health promotion including AB use and ABR, proved successful. From reports of the ToT workshops, the participants indicated an improved knowledge and understanding of the issues and challenges related to AB use and ABR, and ways to communicate these messages to the communities they worked with. The development of materials for use in the

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information-communication-education activities were, additionally, innovative, context-relevant and effective. Examples include the use of the Fotoresistencia materials, exhibitions, visuals, etc.in Ecuador and Nicaragua; drama, art and music in Thailand; brochures, posters and easy-to-use manuals in Malaysia; social media formats (twitter, facebook, mobile messaging etc) in Indonesia.

Participants of the ToT workshops also indicated a greater commitment and cooperation towards addressing the challenges of ABR in their health promotion work. Examples include the time, effort and voluntarism given to communicating the ABR messages to the communities. CSOs in Ecuador, Thailand, Malaysia and Indonesia also used their own organisational funds and human resources to co-fund the CSO project activities.

Of particular note is the ‘Life in Plenitude and Health’ approach taken by the Ecuador project partners in learning and communicating the ABR problem. The ‘Life in Plenitude and Health’ approach is a holistic one, considering and linking health to ecology as well as cultural, social and economic drivers and contexts.

Another event of note, in Ecuador, was the Creando conciencia sobre la resistencia… en bicicleta. Students of the Faculty of Medical Sciences, University of Cuenca, carried out a bicycle tour to promote the smart use of antibiotics among students. The Sun Route is a coastal road which crosses three provinces of Ecuador. During 14 days, along 700 kilometters, the group visited elementary schools and high schools in each town they reached. They sent periodically messages on the travel and the educational activities via their Facebook page, texts and images. The aim was to disseminate project messages among the schools teachers who are participating in the CSO training program. The teachers and schools showed great interest in the creative campaign.

The CSO in Ecuador have also entered into an agreement with PAHO to support the development of materials for the CSO project.

In Thailand, CSOs not involved in the ReAct project have expressed interest in participating. The lead CSO - DMD - has used its own funds to include the new CSOs in the project activities.

In Indonesia, YOP has received air time with two national television stations to broadcast their work in the project.

Changes in workplan

There were changes in the workplans of all the project countries due to due to planning processes, arrangements with CSOs, management capacity of partners, local challenges and paperwork related to contracts, LoAs and disbursements of funds.

A combination of the aforementioned problems in Ghana resulted in only one Year One scheduled project activity initiated, in November 2012, but not completed by end of Year One, i.e. the baseline survey. In November 2012, the General Manager of the project worked with the Coordinator of the Ghana component of the CSO project to re-work the Year One activities and plan for the Year Two activities, bringing forward all of the unfinished Year One activities into the Year Two schedule.

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In LA, differences in approach, in the baseline survey, development of materials and training activities, between the lead CSO in Ecuador (CCF) and the partner CSO in Nicaragua (CISAS), led to several delays and changes in the workplan. Local problems with governmental changes to policy with regard to teachers being involved in extra-curricula activities, such as those of the project, led to further delays in scheduled activities. Despite these challenges, however, both Ecuador and Nicaragua managed to complete most of their scheduled Year One activities successfully. The few remaining unfinsihed Year One activities have been brought forward to Year Two.

In SEA, similar problems as mentioned above saw a delay in implementation of activities in Malaysia (mid-June 2012) and Thailand (August 2012). Malaysia, however, successfully managed to complete all scheduled Year One activities by December 2012. Thailand successfully managed to complete most of its scheduled Year One activities, bringing forward to Year Two unfinished ToT workshops and development of materials. Indonesia, which saw an early start of their project activities (January 2012) was able to successfully complete all its scheduled Year One activities.

The global component of the CSO project (aimed at linking the project objectives with international CSOs) was also delayed somewhat in Year One. But discussions at sidelines of various global meetings, especially related to ReAct’s CDU activities, have set the stage for further meetings to link up with a view to clearer and specific collaboration with international CSOs in 2013.

Successful strategies

Successful strategies that bore results were partnerships with key stakeholders, inculcating a sense of ownership in the project, consultation in decision-making projects regarding approaches to activities, building on existing health promotion projects of the CSOs, and use of creative and innovative media in training and communication.

Examples include

Indonesia

• Recruitment of dedicated volunteers (medical doctors and parents) from YOP’s programs to participate in the project

• Utilization of existing health promotion interventions to reach wider audience in locations outside Jakarta

• Collaboration with existing partners to disseminate information on AB and ABR through various events and channels

• Improvement of the volunteers’ capacity as AB/ABR campaigners among foster families and wider target communities.

Malaysia

• The aspects of the project that were particularly successful are the planning and implementation of activities, which showed great enthusiasm and commitment of the project team and community members.

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• The training module and booklet on AB use and ABR, developed by the project team were very useful and they are being considered for use in the MoH programme on ABR.

Thailand

Thailand has the advantage of the established Antibiotic Smart Use (ASU) programme in several communities across the country. The CSO project is, therefore, benefitting from a pool of expert trainers, leaders and volunteers from the DMD, and the Family Network Foundation has the members of parents and guardians in each school in many areas. The ASU programme also has rich resources of effective info-communication tools and media materials.

Nicaragua

The project implementation in Nicaragua has the strategic advantage that it is integrated into a CISAS health programme involving five schools in Managua and six in Chinandega, working on health promotion among teachers, students, and parents. There already a good network of local authorities, school principals, school counselors and school children exists.

Challenges/constraints

Project team in the participating countries faced challenges and constraints of different sorts. All project team members have other work commitments in their organisations apart from their responsibilities in the project. In Indonesia, for example, project team members are practising physicians, medical students and parents, whose time need to be balanced between project work, family commitments and professional duties. Additionally, the time and skills in project process documentation is demanding. Nonetheless, the project implementation organisation has taken measures to overcome the challenges with extra training, engaging more volunteers and identifying opportunities to distribute and share the work commitments.

In Malaysia, the delay in starting project activities, from March to June, meant that project activities for Year One had to be implemented within six months. The project team members are also full time professionals who need to balance their time between project and professional work commitments. The Project Team, however, with the cooperation of the community leaders, stepped up to the challenge and was able to carry out all of the scheduled Year One activities.

In Thailand, project staff had to be trained in conducting the baseline survey and its analysis. Developing new training materials in the context of the project goals required more research, meetings and consultations, which took more time and human resources.

In Ecuador, a major challenge was recent changes in education policy restricting the activities of teachers in extra-school related projects. Many meetings and much negotiation with the authorities

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were necessary to resolve the issue, which meant delays in implementing the project activities. The project team in Nicaragua faced similar challenges because of constraints in national policy

Ghana faced the most challenges and constraints. Lack of capacity, delays in preparing the paperwork on work plans, budgets, contracts and Log frame analysis, which resulted in delays in funds disbursements, saw the project team being able to only initiate one project activity in 2012. A revised work plan for 2013 has been developed for Ghana to meet its delivery of project outputs and outcomes in 2013.

4. CHALLENGES AND FUTURE PROSPECTS

Although 2012 has been a highly productive year for ReAct it has not been free from challenges. First, the unexpected departure of ReAct´s director Andreas Heddini in March 2012, implied a significant loss of capacity.

Second, the growing network of ReAct has generated increased demands on support and internal communication and created challenges on how to maintain an overview of all ongoing processes in the regions where we work.

ReAct’s major funding comes from Sida, but intense work to expand the funding base has been undertaken and is planned to be expanded further. A science journalist, covering health and pharmaceuticals in a major Swedish business journal worked with ReAct one month to identify and approach potential funders. So far, these contacts have not generated interest in supporting ReAct.

In 2012, ReAct received continued co- funding from Uppsala University and component funding for specific projects from the Swedish Ministry of Social Affairs and the Beijer foundation.

ReAct funders 2012:

Funder Total amount ( 1000 SEK)

Sida core-funding 7 000 000

Sida CSO-project funding 2 540 600

Uppsala University 1 000 000

Ministry of Social Affairs 2 000 000

Beijer foundation 500 000

Substantial co-funding and voluntary work is also contributed by the regional partners, see the separate ReAct financial report for 2012.

Meetings are planned during 2013 with several of the larger, international donors. The regional partners of ReAct have engaged several boundary partners in co-founding and in-kind contributions to ReAct activities.

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The first year of the CSO project saw a slow start in most countries due to planning processes, capacity of partners, local challenges and paperwork related to contracts. However ReAct believes that the implementation of project activities will start to take shape during 2013 and give some good results.

The development of a national policy on antimicrobial resistance in Ghana is in an advanced planning stage for roll out. ReAct sees great potential in Ghana serving as a pilot country for the African region and WHO AFRO has expressed interest in facilitating the sharing of Ghana’s national ABR policy process as a model for other countries in the region WHO AFRO. There are mature plans to further strengthening the ReAct African network by recruiting a well renowned experienced coordinator based in Africa.

Continued development and evaluation of innovative solutions that help changing the perception and attitudes regarding antibiotics to stimulate change in practice at the hospital, clinical and community levels as well as policy is another focus for 2013. ReAct's civil society components can help test and disseminate the results to wider audiences and help bring about behaviour change. Good results have already been accomplished in projects such as the Fotoresistencia that has a potential in scaling and replicating in other countries and is now being evaluated by the University of British Colombia.

Development of training courses on ABR will be explored by ReAct by during 2013. In January 2013, ReAct organized an introductory pilot course on ABR for students from mainly Iraq and Pakistan. ReAct sees a potential in tailoring and expanding the course concept for an international audience. However it will require additional resources to actually launch a full-scale course program and we are currently investigating potential funding.

ReAct initiated in the autumn 2012 a process to address and stir debate on how to ensure controlled and rational use of any future new antibiotics while securing the equitable access and affordability. To this end, ReAct in cooperation with a consultant has developed a debate paper to lay down exploratory ways to preserve new effective antibiotics. The plans for 2013 are to publish the debate article in an international journal and to convene meetings that will lead up to a high-level workshop in 2014. ReAct's role and perspective is unique on this landscape. Its voice is independent of pharmaceutical company support and the international experience and many contacts at the global policy level have rendered ReAct significant credibility.

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Annex 1 - ReAct publications 2012 Lack of action on antibiotics a threat (pdf) Joint debate article on ABR in The Financial Times, November 13, by Carlet J (World Alliance), Cars O (ReAct), Piddock L (BSAC Antibiotic Action), Laxminarayan R (GARP) and Levy S (APUA ).

3Rs for innovating novel antibiotics: sharing resources, risks, and rewards, Analysis report published in British Medical Journal, BMJ, on April 3 by So A, Ruiz-Esparza Q., Gupta N, Cars O.

International Program for Training and Research on Comprehensive Primary Health Care, with emphasis in Infectious Diseases and Containment of Antimicrobial Resistance Quizhpe A, Murray M, Peralta J, Calle K, and Encalada L. Published February 2012.

PAHO magazine ReAct Latin America study on MRSA in children in indigenious communities.

Recovering Comprehensive Health and the Harmony of the Ecosystems to Contain Bacterial Resistance to Antibiotics. Quizhpe A, Murray M, Muñoz G, Peralta J, Calle K

WHO monograph on “The Evolving Threat of Antimicrobial Resistance: Options for Action” The book, "The evolving threat of antimicrobial resistance - Options for action”, launched by WHO on March 8 2012, is the result of a collaboration between WHO and more than 50 international experts in the field of antimicrobial resistance. ReAct contributed with working group leaders and main authors of two of the chapters.

Other products 2012 Burden of Antibiotic Resistance. ReAct Fact Sheet produced for the Swedish/Ghanaian ministerial side-event at the WHA.

Medical students’ views on the current and future antibiotic resistance situation. MSc examination work by Cecilia Kållberg, supervised by Liselotte Diaz Högberg, ReAct.

Perceptions of acute respiratory infections, severity and treatment of the care givers of children under 5 years. Printed in the journal of Faculty of medical Science in the University of Cuenca.

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Annex 2 - Meetings and events 2012 Meetings organised by ReAct

Feb 17–18, ReAct’s Launch Meeting of CSO Project, network meeting in Penang, Malaysia Feb 23, Launch of ReAct South East Asia/Thailand CSO Project, Bangkok, Thailand May 5, A conference organized by ReAct Latin America, Faculty of Medical Sciences and Pediatriacs Scientific Association on “Antimicrobial Resistance” including a presentation of the “FotoResistencia” project . Venue: Universidad Técnica Particular de Loja.

May 26–29, ReAct organized workshop at the Asia Pacific Conference on National Medicines Policies in Sydney, Australia.

June 19, Seminar on the appropriate use of antibiotics in human health, aimed to 40 health workers of the Ecuadorian Ministry of Health Limón, Morona Santiago, June 19, 2012 Arturo Quizhpe, Lorena Encalada, Diana Andrade.

Nov 15-17, ReAct’s Global Workshop on CSO Project - Towards Policy Platforms to Manage Antibiotic Resistance, Cuenca, Ecuador

Meetings attended by ReAct

Feb 3, Tapestry Networks, London

Mar 8, Participation in the WHO launch event in Geneva of the book "The evolving threat of antimicrobial resistance - Options for action" which was a result of a collaboration between WHO and more than 50 international experts in the field of antimicrobial resistance. ReAct contributed with working group leaders and main authors for two of the chapters. Mar 12-13, the Joint Programming Initiative on Antimicrobial Resistance (JPIAMR) held an invite-only meeting for stakeholders in ABR within the EU in Copenhagen, Denmark. ReAct were invited to hold a presentation at the meeting. Mar 14-15, Expert conference on AMR in Copenhagen during the Denmark´s EU presidency “The impact of antimicrobial resistance in the human health sector and in the veterinary sector – a “One Health” perspective”.

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Mar 26 – 28, Drug Information Association 24th Annual Euro Meeting 2012 (DIA 2012), in Copenhagen. ReAct participated in a session regarding the scientific and political challenges in antibiotic development together with Richard Bergström, EFPIA, Line Mattiesen (EU Commisson, DG Research).

Mar 21-23, ReAct hosted sessions at the 2012 EPN (Ecumenical Pharmaceutical Network) Forum and General Meeting held in Addis Ababa, Ethiopia in March that had the theme "Access to quality medicines: priority needs, priority actions for today and tomorrow".

Mar 31-Apr 3, ECCMID, European Congress of Clinical Microbiology and Infectious Diseases, London.

April 25-27, 2nd. International Congress in Advances on Clinic Laboratory, Hematology, Microbiology, Genetics, Molecular Biology, Cuenca, Ecuador A lecture on the ReAct Latin American research project “High proportion of ESBL – carriers among neonates in a tertiary hospital in Ecuador” by Lorena Encalada.

May 10, Meeting of the Ghana Policy Development Task Force, Accra, Ghana

May 22, A high-level ministerial seminar entitled "Saving lives through cost-effective measures against antimicrobial resistance"was co-hosted by Sweden and Ghana in connection with the World Health Assembly. ReAct helped shape the agenda and held an introductory keynote presentation.

May 27-30, Conveners and rapporteurs for a workshop on AMR and Rational Use of Antibiotics at the Asia Pacific Conference on National Medicin Policies, Sydney, Australia

Jul 2, ReAct was invited to WHO Global HQ in Geneva, Switzerland to collaborate on a global Surveillance strategy for AMR.

Jul 6-11, The Third People´s Health Assembly, Cape Town, South Africa

Jul 11-15, Euroscience Open Forum (ESOF) in Dublin, Europe´s largest forum for science and research. ReAct participated together with the Swedish Research Council, the Swedish Council for Working Life and Social Research, the Swedish Research Council Formas and the Swedish Governmental Agency for Innovation Systems at an interactive exhibition on antibiotic resistance entitled "The Good.The Bad.The Ugly". Sep 9-12, 52nd ICCAC, International Conference on Antimicrobial Agents and Infectious Diseases, US. ReAct through Otto Cars participated at the large International Conference on Antimicrobial Agents and Chemotherapy in a “meet the expert session “, on ABR.

Sep 28, ReAct made a presentation on ABR at the ‘Truth is Concrete’ arts festival in Graz, Austria

Oct 2–4, The International Pharmaceutical Federation (FIP) World Centennial Congress of Pharmacy and Pharmaceutical Sciences.ReAct was also invited to the high-level ministerial meeting held in conjunction with the conference.

Nov 16 - 18, Knowledge for Global Health (K4GH) Leadership Institute. The ReAct strategic Policy unit at Duke University hosted a leadership training, with an antibiotic resistance breakout session

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component, co-organized with the American Medical Student Association, on several key issues for U.S. and international health including policy innovation and access to medicines, tackling antibiotic resistance, and ensuring open access to knowledge.

Nov 23, SciLifeLab Uppsala meeting “One health - In Joint Battle Against Infectious Disease and Antibiotic Resistance”. ReAct organized the session, “Bridging the gap between science and policy” by ReAct at the SciLifeLab Uppsala meeting held on November 23.

Nov 26, Meeting with WHO Assistant Director-General of Health, Security and Environment, Keiji Fukuda, in Geneva( Otto Cars, ReAct) and Richard Bergström, EFPIA, to frame the issue of a “new business model” for the development of new effective antibiotics.

Dec 11-13, Participation in The QUAMED (Quality Medicines for all) partner meeting held in Antwerp, Belgium. ReAct was invited as speaker to share its views on controlled distribution and use of new antibiotics and what can be learned from other initiatives like those working to evaluate and control resistance to antimalarials.

Dec 18, Participation in technical expert session at WHO HQ in Geneva to draft a roadmap for global surveillance of antimicrobial resistance.

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Annex 3 - ReAct in the Media 2012

Datum Namn på media och artikel + länk

2012-01-18 SVT Aktuellt kl 21.00. Inslag om resistens i Antarktis, spår efter forskare. Andreas blir intervjuad. http://svtplay.se/v/2680621/aktuellt/18_1_21_00?sb,p102536,2,f,-1

2012-01-27 World Economic Forum. On the WEF blog presenting one of the Global Risks 2012: What if antibiotics stopped working?", The Risk Response Network within World Economic Forum invited to a discussion about a world without antibiotics. Referrals were made to several facts and figures from ReAct.

2012-02-19 Hindustan Times. Super laws can squash superbugs; http://www.hindustantimes.com/Entertainment/Wellness/Super-laws-can-squash-superbugs/Article1-813584.aspx

2012-02-22 SR, Vetandets värld. Industrin ska lockas till att satsa på nya antibiotika. Intervju med Anna H. http://sverigesradio.se/sida/gruppsida.aspx?programid=412&grupp=16348&artikel=4976543

2012-02-15 SR, Vetandets värld. Vetenskaplig utmaning få fram nya antibiotika. Intervju med Otto. http://sverigesradio.se/sida/gruppsida.aspx?programid=412&grupp=16348&artikel=4958608

2012-03-13 Expressen. Dödsbakterien är här för att stanna. http://www.expressen.se/nyheter/dokument/dodsbakterien-ar-har-for-att-stanna/

2012-03-19 The Star Online. An end to modern medicine? http://thestar.com.my/news/story.asp?file=/2012/3/19/focus/10942727&sec=focus

2012-05-10 SR, Bakterier överlistade forskare, studie stoppad: http://sverigesradio.se/sida/artikel.aspx?programid=83&artikel=5101104

2012-05-25 UNT. Satsning ska hitta nya antibiotika. http://www.unt.se/sverige/satsning-ska-hitta-nya-antibiotika-1756024.aspx

2012-05-27 Financial Times. Public Health: Raised Resistance. http://www.ft.com/intl/cms/s/0/a796ecc0-a644-11e1-9453-00144feabdc0.html#axzz274yvri9k

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2012-05-28 DN, SvD, Aftonbladet. Satsning på nya antibiotika. http://www.dn.se/ekonomi/satsning-ska-hitta-nya-antibiotika

http://www.svd.se/nyheter/inrikes/satsning-ska-hitta-nya-antibiotika_7230233.svd

http://www.aftonbladet.se/senastenytt/ttnyheter/inrikes/article14881617.ab

2012-06-06 Huffington Post. Generating Antibiotic Incentives Now: GAIN -- Or Just Greed. Debate article by Anthony So, ReAct and Robert Weissman. http://www.huffingtonpost.com/anthony-so/antibiotic-resistance-_b_1572284.html

2012-06-17 SvD, Resistens hot mot fattiga. http://www.svd.se/nyheter/utrikes/antibiotikaresistens-hotar-fns-millenniemal_7283481.svd (även som pdf-bilaga)

2012-06-28 Vetenskapsrådet. Stort intresse för antibiotikaresistens under ESOF 2012 i Dublin. http://www.vr.se/franvetenskapsradet/nyheter/nyhetsarkiv/nyheter2012/nyheter2012/svensktfokuspaantibiotikaresistensunderesof2012idublin.5.405c4f3813823f65fee580.html

2012-07-12 UNT. Viktig antibiotika försvinner. http://www.unt.se/uppsala/viktig-antibiotika-forsvinner-1793431.aspx

2012-07-14 Forskning.no, Antibiotika er for billig. http://www.forskning.no/artikler/2012/juli/328028 (även som pdf-bilaga)

2012-07-19 Videnskabdk, Antibiotika skal ikkevaere en menneskeret. http://videnskab.dk/krop-sundhed/antibiotika-skal-ikke-vaere-en-menneskeret (även som pdf-bilaga)

2012-07-21 UNT. Gammal medicin tillbaka. http://www.unt.se/uppsala/gammal-medicin-tillbaka-1799466.aspx

2012-09-10 SR Nyheter/Ekot. Framsteg i forskningen om resistenta bakterier. http://sverigesradio.se/sida/gruppsida.aspx?programid=83&grupp=10974&artikel=5263651

2012-09-10 SR Nyheter/Ekot. Antibiotika testas i nya kombinationer i Grekland.http://sverigesradio.se/sida/gruppsida.aspx?programid=3304&grupp=6240&artikel=5264504

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2012-09 Miljöforskning (Formas). Stora prövningar att vänta för sjukvården. http://miljoforskning.formas.se/sv/Nummer/September-2012/Innehall/Temaartiklar/Stora-provningar-att-vanta-for-sjukvarden/

2012-09-25 What if we lost the use of antibiotics? Intervju med Otto för The World Economic Forum.

http://forumblog.org/2012/09/what-if-we-lost-the-use-of-antibiotics/

2012-09-28 DN Debatt. ”Stärkt infektionsforskning möjlighet för Sverige. http://www.dn.se/debatt/starkt-infektionsforskning-mojlighet-for-sverige

2012-10-16 Life Science Sweden. Plåster nytt vapen mot resistens. http://lifescience.idg.se/2.1763/1.471546/plaster-nytt-vapen-mot-resistens

2012-12-09 SVT Agenda, Intervju med Otto Cars. http://www.svt.se/agenda/varsta-hotet-mot-den-moderna-sjukvarden

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