Journal 8th Veterinary Public Health Journal by the International Veterinary Students Association, IVSA
One Health Day Antibiotic Awareness week
IN THIS EDITION
Medical, pharmacy and veterinary students 1 battling AMR together
ONE HEALTH CAREERS Aniek Lotterman VPH Journal 8th edition
Bryanna Andrews The impact of antibiotic resistance on livestock in the UK
Bryanna Andrews
Caroline Bulstra
Dear all, Antimicrobial resistance (AMR) is nothing new. Just after discovering penicillin in 1928, Alexander Fleming already warned us about the rising risk of antibiotic resistant pathogens. These days, AMR happens faster than ever before. Resistant microbes are found in humans, animals and the environment everywhere on our globe. If we don’t join forces and start fighting AMR now, there is a chance that we can no longer treat common infectious diseases in both humans and animals in times ahead of us. This week (14-16 November 2016) marks the second World Antibiotic Awareness Week, an initiative by the World Health Organization to raise awareness about one of the biggest health threats that is facing us today. This issue focusses on this global public health threat and covers the objectives of specialists, young graduates and students from multiple medical disciplines. Get inspired! Best, Caroline Bulstra Publication Team, Standing Committee on One Health (SCOH) 2016 – 2017 Final year Veterinary Student at Utrecht University, the Netherlands
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VPH Journal 8th edition
The VPH Journal is edited and published by the Standing Committee on One Health (SCOH), part of the International Veterinary Students Association (IVSA). 8th edition November 2016
SCOH 2016-2017 Chair Clara Buxbaum Secretary & Webmaster Katherina Turnbull Publications Team Bryanna Andrews Caroline Bulstra Regional Coordinator Zuzana Mojžišová Committee Liaison Officer Samuel Williams Project Managers Breanna Beberman Gavin Gan
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VPH Journal 8th edition
In this issue
6 10 14 17 23 4
IFMSA, IPSF, IVSA Medical, pharmacy and veterinary students battling AMR together What are their visions?
ONE HEALTH JOBS Aniek Lotterman - DVM, PhD candidate Working at the Dutch National Institute for Public Health and the Environment (RIVM)
UNITED NATIONS HIGH-LEVEL MEETING ON ANTIMICROBIAL RESISTANCE UN HQ, New York City Report by Samantha Morici
A FRIGHTENING FUTURE: A Look at the Impact of Antibiotic Resistance on Livestock in the UK Bryanna Andrews - Vet student at University of Edinburgh
REPORT ON THE NorWHO SIMULATION 2016 The elaboration of a resolution on Antimicrobial Resistance Denmark, 9-12 August
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26 30
HOW ARE YOU INVOLVED IN ONE HEALTH ACTIVITIES? Paulin Dettmann Students connecting through One Health - Fusion of human and veterinary medicine
MEET THE LoVPHOs! Fiona van Kaam and Tierney Mepham IVSA the Netherlands, Utrecht University
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ANTIBITIOCS IN VETERINARY PRACTICE
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STUDENTS IN THE FIGHT AGAINST
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The perioperative usage of antibiotics in the treatment of small animals Dyrka Magdalena & Rzezak Rafał, DVM
ANTIMICROBIAL RESISTANCE By the International Pharmaceutical Students´Federation (IPSF)
VPH Journal 8th edition
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VPH Journal 8th edition
IFMSA International Federation of Medical Students Associations
How does AMR occur and affect your discipline? Resistance has become a huge problem in recent years because the pace at which we are discovering novel antibiotics has slowed drastically, while antibiotic use is rising. Bacteria have always evolved so they can resist the new drugs that medicine has used to combat them. It is not just a problem confined to bacteria, but to all microbes that have the potential to mutate and render our drugs ineffective. Although antimicrobial resistance occurs naturally over time, the accelerated pace of development is attributable to human interference. Doctors are a contributing factor in the emergence of resistance, due to irrational prescription and drug misuse. And our role as medical students and future doctors of tomorrow is to spread awareness about this problem among our peers and the society. What can you do to prevent the increasing rate of AMR? As medical students: • Education: IFMSA targeting medical students • Campaigning: Students targeting medical (and other healthcare) students, doctors and the general population. • Advocacy: Students targeting decision-makers. • Research: IFMSA researching the knowledge, behaviors, and opinions of medical (and other healthcare) students. How does AMR spread? • Patients who consume antibiotics can develop drug-resistant bacteria in the gut. These bacteria can then spread to other people because of the poor hygiene or unclean facilities. • Animals that consume antibiotics can develop drug-resistant bacteria in the gut. These bacteria reach individuals through food, environment or direct contact. They can spread further to the general public afterwards. • Vegetables may be contaminated with antibiotic-resistant bacteria from animal manure used as a fertilizer. The bacteria then spreads through food to humans and can eventually reach the general public. • Individuals moving from one place to another (patient transfers, traveling, mass migration) can carry drug-resistant bacteria from places with higher antimicrobial resistance to their original country. We reiterate that the antimicrobial resistance does not recognize the geographical boundaries, making it a problem that can be tackled only with global efforts.
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IPSF International Pharmaceutical Students’ Federation
How does AMR occur and affect your discipline? Changes in the genes of bacteria over time lead to antimicrobial resistance. When exposed to antibiotics, susceptible bacteria are killed and resistant bacteria continues to grow and multiply. These resistant bacteria may spread and cause infections in other people who have not taken any antibiotics. Most antimicrobial prescribing occur in the community. As the most accessible healthcare providers, pharmacists must take initiative to prevent AMR. What can you do to prevent the increasing rate of AMR? As pharmacists, we should: • Assess the prescribed antimicrobial medicines, ensuring that the antimicrobial medicine is prescri bed with appropriate dose and duration with minimal side effects. • Educate patients regarding proper use of the prescribed medicine and stress the importance of completing the full treatment course therapy. • Encourage patients to bring any unused antimicrobials back to the pharmacy for proper disposal. • Advocate stricter guidelines for antimicrobial prescribing in the community, pharmacy, clinic, and hospital settings. • Guide and advise antimicrobial therapeutic drug monitoring. • Make anti-infective formulary decisions. • Maintain awareness of local resistance patterns. • Educate staff regardless of their levels of education or profession. How does AMR spread? Antimicrobial resistance occurs naturally over time, usually through genetic changes. However, the misuse and overuse of antimicrobials are accelerating this process. In many places, antibiotics are overused and misused in people and animals, and often given without professional oversight. Examples of misuse include: when people with viral infections like colds and flu take antibiotics, and when they are given as growth promoters for animals and fish. Antimicrobial resistant microbes are found in people, animals, food, and the environment (in water, soil, and air). They can spread between people and animals, and from person to person. Poor infection control, inadequate sanitary conditions, and inappropriate food-handling encourage the spread of antimicrobial resistance.
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IVSA International Veterinary Students’ Association
How does AMR occur and how does it affect your discipline? As we know, bacteria are capable of acquiring traits that allow them to become resistant to various antibiotics, especially those that are used frequently. Improper administration of antibiotics such as prescribing an antibiotic that is not effective against the current infection, ceasing the dose of the antibiotic prior to the determined date, or consistently prescribing the same, strong antibiotic for every infection, can increase the rate of acquisition of these resistant traits in bacterial strains. Occasionally, a trait that is unique to veterinary medicine, owners will give their own antibiotics to their animals. This practice adds an additional complication to the fight against AMR in veterinary medicine. In livestock, veterinarians also must verify that residues of an antibiotic will not remain in the meat from the animal. This requires an in-depth understanding of the metabolism of the drug. What can you do to prevent the increasing rate of AMR? We, as veterinarians, must ensure that we choose the best antibiotic for each patient. Furthermore, we need to explain any prescriptions to the owners and verify that they understand how the medication should be administered, as well as the withdrawal period. Additionally, culture and susceptibility testing prior to administration can prevent the prescription of drugs that are not effective against a given infection. We must also remember that some antimicrobials should never be administered to animals. In the United States, these include chloramphenicol, clenbuterol, metronidazole and nitrofurans. There are additional restrictions in food animals.
Perhaps the most important factor in combating AMR, however, is communication. Many of the
antibiotics used in veterinary medicine are also prescribed to humans, thus veterinarians should maintain an understanding of AMR in human medicine. We must also communicate within the veterinary profession and encourage all veterinary doctors to practice judicial use of antibiotics. How does AMR spread? The spread of AMR in veterinary medicine is very similar to that in human medicine. Non-judicial use of antibiotics is the main culprit for the development of antimicrobial resistance in many bacterial strains.
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ONE HEALTH JOBS: Working at the Dutch National Institute for Public Health and the Environment (RIVM) Aniek Lotterman, DVM Born and raised in a small village in the Netherlands,
wed veterinarians in the Netherlands and abroad,
I grew up surrounded by animals. I spent a lot of time
Sweden for example. The interaction between acade-
on my grandparents’ farm, which was right next door.
mics and practice was inspiring to me. For one thing,
He kept dairy cows and for hobby there were chic-
it taught me that there is not just one right way to do
kens, goats, horses, dogs and cats. Growing up in such
something. Depending on how you look at certain
an environment definitely laid down the foundations
situations and what you want to achieve, different
for becoming the person and professional that I am
methods might be needed.
today.
During my studies at the school of Veterinary
between different fields of expertise, experience and
Medicine in Utrecht I loved putting newly acquired
discipline exist on a larger scale as well, often even
knowledge and skills into practice, so I often shado-
more compelling. Everything is interconnected, as
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It dawned on me that these types of interactions
VPH Journal 8th edition
Katinka de Balogh showed me during my internship
Infectious Diseases of the Harvard T.H. Chan School
at the FAO. For example, the health status of animals
of Public Health as a visiting researcher. It encou-
influences food safety, which is also influenced by the
raged me to continue in research, in particular that
resources available to ensure safe and sustainable
of highly resistant microorganisms. Currently, I am
food production. Safe and sufficient food production,
working at the National Institute for Public Health
or the lack thereof, in turn influences human health,
and the Environment (RIVM) in the Netherlands as
and so forth and so on. I then knew that would be
a PhD candidate, researching the attribution of hig-
how I wanted to put my skills and expertise to use;
hly resistant microorganisms in humans to sources
connecting dots in One Health issues (such as infec-
of animal origin. I hold a dual position between the
tious disease prevention and control). These issues
Centre for Zoonosis and Environmental Microbio-
do not exist in a void. They take place at the interface
logy and the Centre for Epidemiology and Surveillan-
of environmental health, human health and animal
ce. The research group that I am a part of is looking
health. Approaching One Health issues therefore re-
into characteristics of carriage of highly resistant
quires scientific, sociological, economic and political
microorganisms in humans. For example, we aim to
views to be taken into consideration. This makes One
elucidate transmission dynamics, quantify source
Health a very dynamic and exciting field to work in.
attribution, and investigate clinical relevance of
In my master’s program (Farm Animal Health and
carriage. With my research, I aim to provide new in-
Veterinary Public Health), I minored in Governance
sights that can inform policy to help ameliorate the
and Policy, which enabled me to draw out my own
current situation and hopefully change the direction
path and study the topics that I am passionate about
in which we are heading:, for if we do not, we will find
more in depth. After finishing my clinical rotations
ourselves unable to treat more and more (simple)
and my master thesis at Utrecht University’s Institute
infections that will then become lethal again.
for Risk Assessment Sciences on food safety I went to Spain for the ANTIGONE (ANTIcipating the Global
Antimicrobial Resistance
Onset of Novel Epidemics) One Health Course. For
Although it may sometimes seem so when you read
me, this was the cherry on top of the cake. Again, I
the news, antimicrobial resistance is nothing new.
felt at best in an environment where people have very
In fact the phenomenon is as old as bacteria them-
different backgrounds but, to move forward, connect
selves. As a mechanism to survive and thrive in a
dots between their respective fields of expertise.
competitive microbiological environment, bacteria
I worked as a clinical teacher at the School for Vete-
produce antibacterial substances to get ahead of
rinary Medicine for a while. With this opportunity, I
other bacteria. In response, some other bacteria may
pursued my passion for education and mentorship
adapt and develop resistance to this substance. Also
and gained valuable experience in didactics. Howe-
the risk of selecting for resistant bacteria by over-
ver, I still aspired a career at the interface of animal-,
using or misusing antibiotics had been clearly
human- and environmental health, but I had not
warned for by Sir Alexander Flemming. In his accep-
found my niche yet. The next year I moved to Boston
tance speech for the nobel prize he received for the
where I worked in the Department of Immunology and
discovery of our first know antibiotic, penicillin, he
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said: “The time may come when penicillin can be
ce. Their aim with this plan is to “ensure, for as long
bought by anyone in the shops. Then there is the
as possible, continuity of successful treatment and
danger that the ignorant man may easily underdose
prevention of infectious diseases with effective and
himself and by exposing his microbes to non-lethal
safe medicines that are quality-assured, used in a
quantities of the drug make them resistant”.
responsible way, and accessible to all who need
And yet we have done exactly that. For years
them”. One of the five strategic objectives to
new antibiotics were discovered and existing versi-
achieve this goal is reduction of incidence of infecti-
ons improved. They were considered a magic bullet
on. An import question that needs answering is what
and therefore enthusiastically prescribed by medi-
the sources of infection are and how much these
cal doctors and veterinarians, reaping great results
respective sources attribute to the incidence of
in the treatment of many patients. Even effects
infection. My work will be focused on attribution of the
beyond the scope of treating clinically ill patients
animal sources to prevalence of highly resistant micro-
were noticed and warmly welcomed in the general
organisms in humans. At the moment we are looking
practice. Antibiotics have been used extensively for
into the effect of meat consumption on carriage of
infection prevention and even as growth promoters,
ESBL-producing Enterobacteriaceae.
in livestock, adding to the selective pressure of clini-
cal antibiotic use.
bal action plan is to increase the awareness and
To slow down the clock the WHO has laun-
understanding of antimicrobial resistance. In the
ched a global action plan on antimicrobial resistan-
Netherlands this topic has been high on the agen-
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Another strategic objective of WHO’s glo-
VPH Journal 8th edition
da of ministries, public health and animal health
Further reading on this topic:
agencies for quite some time now and we, for one, managed to considerably reduce the amount of an-
RIVM:
tibiotics used in food producing animals over the last
http://www.rivm.nl/en/Topics/A/Antibiotic_resistan-
couple of years. A reduction of nearly 60% since 2009
ce
has been achieved. In the veterinary field we are not just more reserved in prescribing antibiotics, we are
WHO:
also very selective now as to what type of antibio-
http://www.who.int/antimicrobial-resistance/en/
tics to prescribe. More importantly, there are some antibiotics that are non-optional for treatment of
ECDC:
animals because they are last resort therapeutics in
http://ecdc.europa.eu/en/eaad/Pages/Home.aspx
human, such as carbapenems, glycopeptides, oxazolidones and daptomycin, mupirocin and tigecy-
ESCMID:
clin. These are some very positive developments
http://www.escmid.org/research_projects/fighting_
that are not just seen in the Netherlands, but also
resistance/
in other countries. However, we can do better and we need to do better. Bacteria do not respect country lines and they are often not all too picky when it comes to choosing a host to reside in or to infect.
Therefore, no matter how small the steps, more
countries around the world need to become aware of this critical situation that we are in and take action. As our Minister of public health, Edith Schippers, also emphasized in her statement at the High Level Meeting of the general assembly of the United Nations in New York this September, we should not hope for one sector, one region or one approach to win this battle on its own. In my opinion, we have to join forces in order to take big leaps forward, trying to slow down the clock on antimicrobial resistance. I hope and believe that with the research that we do in our group we can provide a piece of the puzzle and help slow down the spread of and selection for (highly) antimicrobial resistant microorganisms.
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United Nations High-Level Meeting on Antimicrobial Resistance UN Headquarters, New York, NY September 21, 2016 Samantha Morici Student American Veterinary Medical Association (SAVMA) International Veterinary Students’ Association (IVSA) Auburn University College of Veterinary Medicine
antimicrobials have historically been prescribed by veterinarians as growth promotants in food animals and in many other situations in which the drugs are not optimally effective. This flippant use of antimicrobials across health professions has allowed for the emergence of resistant pathogens that are crossing international barriers with ease, and pose a catastrophic threat to human and animal populations worldwide. In May 2015, the World Health Assembly adopted a global action plan on antimicrobial resistance – Antimicrobial resistance (AMR) is one of the
wherein the WHO, United Nations, FAO, and OIE
leading threats to modern medicine and global
agreed upon the need to establish multi-sectori-
health. Each year, millions of humans and animals
al, cross-discipline national action plans by the year
acquire serious infections with antibiotic-resistant
2017. In September 2016, the United Nations Gene-
bacteria. In the United States alone, it has been
ral Assembly held a High-Level Meeting on Antimi-
reported that over 23,000 people die annually as a direct
crobial Resistance at UN Headquarters in New York,
result of antibiotic-resistant infections.The single most
NY. Through IVSA’s developing partnership with the
important factor contributing to the development of
WHO, I had the opportunity to attend the High-Level
antimicrobial resistance is not misuse, not overu-
Meeting on behalf of IVSA and represent the global
se, but rather, use itself. Antimicrobials are among
veterinary student community in this important dis-
the most commonly prescribed drugs in human
cussion.
medicine, while only serving as the appropriate form of treatment in about 50% of cases. Similarly, 14
Others in attendance at the High-Level Meeting on
VPH Journal 8th edition
AMR were heads of state, ministers of health, stakeholders such as the World Bank, and members of private sector and academia. The meeting consisted of multiple compelling sessions beginning with an opening segment in which the President and Secre-
“I was honored to serve as the voice of veterinary students in this critical meeting.�
tary General of the United Nations, as well as other leading members of the UN, WHO, and OIE addressed
gaging session of the day included a facilitated panel
those in attendance and reaffirmed the WHA global
discussion between the Prime Minister of Norway,
action plan on AMR. The following segments were fil-
the Minister of Health of Argentina, the Secretary
led with statements made by each Member State on
of the Department of Health of the Philippines, the
how their nation was addressing the issue at hand. It
President of the World Bank, and others. This panel,
was fascinating to hear the varying lengths to which
more than any other session, helped me to appreciate
each nation was striving to combat the issue of anti-
the stark contrast among differing nation’s priorities
microbial resistance. While some are doing more than
and how these differences may present a hindrance
others, I found comfort in hearing the AMR recogni-
in achieving the objectives laid out in the WHA glo-
tion by each Member State and the swift action they
bal action plan. For example, Switzerland has recently
were each taking to address the issue. The most en-
developed a 20 million Swiss Franc national research
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VPH Journal 8th edition
program on AMR. Similarly, the use of antimicrobials
I was honored to serve as the voice of veterinary stu-
as growth promoting agents in food animals has been
dents in this critical meeting. Antimicrobial resistan-
banned in many countries. On the opposite side of the
ce is one of the most serious public health threats of
spectrum, Argentina is one of the leading producers
our time, which if left unalleviated, is projected to
of protein for entire human population and ponders
take the lives of 10 million people by the year 2050. If
how they will be able to feed an ever-growing hu-
we don’t take action against antimicrobial resistance
man population both domestically and worldwide if
right now, we face the risk of entering into a post-an-
they were to terminate the use of antimicrobials in
tibiotic era – where bacterial infection will once again
food animals. In a country that contains more bovines
be a major source of human mortality – at rates even
within its borders than humans, concerns also arise
higher than that of cancer. To quote Dr. Rosell-Ubial,
when considering financial stability, as beef serves as
the Secretary of the Department of Health of the Phi-
the major export product for Argentina.
lippines, “If we fail to plan, we plan to fail.” Veterinary students and veterinarians alike have an obligation to
While holding juxtaposing stances on certain aspects
contribute our skills and knowledge to national and
of the issue, I was shocked to hear the global consen-
international action plans to combat AMR. It’s time to
sus on veterinary responsibility for AMR emergence.
get involved!
While major contributors to the AMR crisis, evidence shows physicians are equally to blame. It is because of this public misinformation that I was especially proud to be at the UN High-Level Meeting on AMR, and that I recognized how crucial it will be to ensure we continue to send students and experienced veterinarians to the United Nations to share our unique perspective and ensure that our voice is heard in the global fight against AMR.
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VPH Journal 8th edition
A Frightening Future: A Look at the Impact of Antibiotic Resistance on Livestock in the UK Bryanna Mariel Andrews IVSA UK & Ireland Royal (Dick) School of Veterinary Studies, University of Edinburgh, GEP year 1 Since Alexander Fleming’s discovery of penicillin in 1928,
and welfare, and as such there are obvious concerns over
antibiotics have been seen as the ultimate weapon against
a reduction of their use in food production systems. An-
infectious disease. Their popularity only increased in 1950,
tibiotics treat a variety of common illnesses and infecti-
when a laboratory in New York discovered that sub-thera-
ons in livestock with a level of efficacy that existing ho-
peutic doses of antibiotics accelerated livestock growth
meopathic remedies cannot match, thus improving the
and were cheaper than available feed supplements (Ogle
quality of life of those animals inflicted. As they are no
2013). However, by 1966 the New England Journal of Me-
longer allowed as growth promoters as of 1999 or prop-
dicine was already warning livestock owners and medical
hylactically as of 2006, antibiotics in the United Kingdom
practitioners alike of the developed resistance that bac-
are currently used to treat acute infections (Casewell et
teria were demonstrating towards the very drugs meant
al., 2003). However, studies have shown that since the
to combat them (Ogle 2013). The European Commission
ban, countries participating have experienced increased
banned the use of antibiotics for non-medicinal purposes
morbidity and mortality, such as by enteric infections in
within the EU in 2006 in an attempt to slow the emer-
pigs (Wegener 2002), as well as deteriorated leg and skin
gence of multi-drug resistant strains and the spread of
health in poultry (Petersen 2002). These unexpected con-
that resistance from livestock to the environment and
sequences arising from the prohibition of use have led to
humans (European Commission 2005). Today more than
a substantial increase in the use of therapeutic antibiotics
ever, a crucial focus of scientific research is on the creati-
for food animals (Larsen 2002; Muirhead 2002; Veterinary
on of alternatives to antibiotics. Any reduction in the use
Medicines Directorate 2002). Were the United Kingdom,
of antibiotics on livestock in the UK could complicate the
or the EU as a whole, to place yet stricter regulations on
ability of farmers to meet food production demands and
the use of antibiotics, livestock health and welfare would
compromise animal welfare. As such, alternatives inclu-
suffer even further as farmers lack natural remedies strong
ding the improved biosecurity of farms, the education of
enough to alleviate symptoms and cure an infection.
farmers on appropriate use of antibiotics, and new medical therapies could prove promising solutions to the over-
use of antibiotics in the livestock sector.
as the most critical issue impacting dairy cattle health in
Antibiotics are a critical means of improving animal health
the Western world (Simoneit et al., 2012). It is common-
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An example of this is mastitis, which has been cited
VPH Journal 8th edition
ly treated with an intermammary infusion of antibiotics
and chronic diarrhea and infections (Callesen 2002 ; Ver-
to an afflicted cow, while in many places in the world dry
ner Wheelock and Foster 2002). The mechanisms for
cows will be provided with antibiotics to prevent mastitis
growth enhancement through use of antibiotics include
prophylactically (University of Illinois). Untreated or chro-
the prevention of sub-clinical infections, an increased
nic mastitis can lead to decreased lifetime milk yield; thus,
nutrient uptake through thinner intestinal walls, and a re-
quick and accurate treatment of mastitis is as much to re-
duced the number of microbes in body that also compete
duce the suffering a cow experiences as to ensure the live-
for nutrients (Gaskins et al., 2006). It therefore stands to
lihood of the owner. While one study found a “classical ho-
reason that any further reduction in the therapeutic use
meopathic remedy� to be equally effective as antibiotics
of antibiotics in the UK is likely to cause livestock to ex-
for mild cases of mastitis, the homeopathic remedy was
pend needless energy fighting treatable, sub-clinical in-
not strong enough to treat moderate to severe cases (Wer-
fections and competing with microbes in their own bo-
ner et al., 2010). This calls into question whether a further
dies for nutrients rather than producing greater yield,
reduction in the use of antibiotics for the sake of slowing
both in meat and milk. Consequently, in order to reduce
the development of antibiotic resistance is worth the loss
antibiotic use in livestock, alternative therapies that de-
of welfare and wellbeing for livestock (Werner et al., 2010).
monstrate equal efficacy must be developed to prevent loss of income for farmers and undue suffering for their
Failure to treat infections swiftly can lead not only
animals.
to an immediate decrease in food production by the ani-
mal, but can also have important long-term consequences
for lifetime output. In cattle, a major hindrance to lifetime
is the improved education of people working in the food
milk production is the aforementioned chronic or untrea-
production industry, especially farmers responsible for
ted mastitis. Additionally, since the antibiotic bans in the
the husbandry of the animals. One study found that 70%
EU, 11% of finisher pigs in Denmark have experienced in-
of cattle farmers polled believed it was important for them
creased frequency of diarrhea and a reduction in overall
to reduce the use of antibiotics, citing their veterinarians
weight gain (Callesen 2002). In both Spain and Denmark,
as the most influential source of information they acces-
weaning pigs have also experienced reduced weight gain
sed (Jones et al., 2015). However, the same study found
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The first step to reducing antibiotic use in livestock
VPH Journal 8th edition
there was little agreement among farmers as to whether
sistant genes. If the UK livestock sector were to reduce
the use of antibiotics in dairy cattle led to resistance and
the use of antibiotics, farmers must use the antibiotics to
that only 6% of farmers thought that antibiotic use in dairy
which they are granted access properly to ensure efficacy
cattle was a major cause of antibiotic resistance in humans
of the treatment, and they must also follow stricter biose-
(Jones et al., 2015). Finally, only 17% of farmers polled as-
curity and husbandry protocols to prevent the spread of
ked a veterinarian before starting a course of antibiotics on
resistance and disease within and beyond their farms.
their cows, using those remaining from previous, unfinished prescriptions to save money (Jones et al., 2015). This
It is crucial to mention that there are many places in the
study demonstrates the crucial need for those responsible
world where antibiotics are still regularly used to improve
for using antibiotics including farmers to have a much bet-
the growth and feed efficacy of meat-producing animals.
ter understanding of how antibiotics work, what role they
Although the European Union has banned the prophylac-
play in human and cross-species resistance, and the conse-
tic use of antibiotics in an effort to retard antimicrobial
quences they pose when not used correctly.
resistance, countries with vast food production systems such as the United States and some developing nations
On the other hand, the study demonstrates how cri-
still rely on antibiotics for enhanced growth. Growth-pro-
tical of a role the veterinarian plays in educating those in
moting antibiotics used elsewhere will cause resistant
the food production industry. Since veterinarians are seen
microbes to spread globally through the consumption of
as respected sources of information and advice, not only
antibiotic-treated meat (Rasheed et al., 2014; Ta et al.,
can they educate farmers about the proper use of antibio-
2014) and through livestock effluent that comes into con-
tics, but they can also demonstrate how to implement hus-
tact with and disseminates into the environment (Hsu et
bandry practices to reduce infections requiring antibiotics
al., 2014; Knapp et al., 2010). Antibiotics persisting in the
for treatment. Low stocking densities, correctly following
environment can accelerate the development of resistant
biohazard protocols, isolation of sick animals, and proper
bacteria and have been shown to move between species
containment and disposal of waste are all ways in which
using horizontal gene transfer of class 1 integrons, de-
farmers can reduce the spread of both transmissible disea-
monstrating that overuse of antibiotics in one species can
ses as well as the horizontal gene transfer of antibiotic re-
lead to unintended and undesirable resistances in many
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VPH Journal 8th edition
others (Hsu et al., 2014). Consequently, the use of sub-cli-
tics in the UK would most likely decrease animal welfare
nical antibiotics in one part of the world will not only de-
and production even further. Any such change should be
velop resistance in that locale, but instead has the poten-
supported by increased funding into alternative homeo-
tial spread globally through travel and trade.
pathic and medicinal therapies, and be reinforced by a directed focus on the education of farmers. With the global
The best hope for treating antimicrobial resistant
population expected to reach 9.7 billion people by 2050,
strains, improving the welfare of livestock, and increasing
the health of livestock is as much a concern for animal wel-
livestock growth to meet the mounting demand for food
fare as it is a concern for humans to meet ever-increasing
is through additional research. Such research should fo-
food requirements (United Nations 2015). As alternative
cus primarily on alternative medical treatments to antibi-
therapies are developed, it is vital to remember that anti-
otics including effective natural cures, feed supplements,
biotics were once seen as a miraculous cure for infectious
the use of probiotics, and alternative growth promoters
disease, and within a century have been exploited to the
to decrease the output of resistant strains from countries
point of inefficacy. Therefore, in order to balance animal
still relying on promoters to meet production needs. One
welfare and the demands of food production, no one fu-
therapy currently being developed is the application of
ture treatment should be relied upon solely.
“structurally nanoengineered antimicrobial peptide polymers� (SNAPPs) to fight drug-resistant gram-negative
References
bacteria (Lam et al., 2016). SNAPPs are star-shaped poly-
1. Animal Science Department, University of Illinois
mers that tear cell walls, allowing an unregulated influx of
(n.d.). Mastitis case studies; mastitis treatment and
ions and inducing cell death similar to apoptosis (Lam et
control. [Accessed 10 Oct. 2016]. Available from:
al., 2016). While still in the initial stages, this method has
http://ansci.illinois.edu/static/ansc438/Mastitis/con-
proved effective against six strains of drug resistant bac-
trol.html
teria in the lab, and against one superbug in mice (Lam et al., 2016).
2. Department of Economic and Social Affairs, United Nations. (2015). World population projected to reach 9.7 billion by 2050. [Accessed 10 Oct. 2016]. Available
Thus, a reduction in the use of therapeutic antibio20
from: http://www.un.org/en/development/desa/news/
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population/2015-report.html.
8. Jones, P. J., Marier, E. A., Tranter, R. B., Wu, G., Wats-
3. European Commission, (2005). Ban on antibiotics as
on, E., and Teale, C. J. (2015). Factors affecting dairy
growth promoters in animal feed enters into effect,
farmers’ attitudes towards antimicrobial medicine
cat. no. IP/05/1687, Brussels: Press Release Databa-
usage in England and Wales. Preventative Veterinary
se. [Accessed 10 Oct. 2016]. http://europa.eu/rapid/
Medicine, 121 30-40.
press-release_IP-05-1687_en.htm.
9. Knapp, C. W., Dolfing, J., Ehlert, P. A. I., and Gra-
4. Callesen, J. (2002). Effects of termination of AGP use
ham, D. W. (2010). Evidence of increasing antibiotic
on pig welfare and productivity. Abstracts of the Inter-
resistance gene abundances in archived soils since
national Invitational Symposium: Beyond Antibiotic
1940. Environmental Science and Technology, 44 (89)
Growth Promoters in Food Animal Production, 2002,
580-587.
Foulum, Denmark, 2002.
10. Lam, S. J., O’Brien-Simpson, N. M., Pantarat, N.,
5. Casewell, M., Friis, C., Marco, E., McMullin, P., and
Sulistio, A., Wong, E. H. H., Chen, Y., Lenzo, J. C., Hol-
Phillips, I. (2003). The European ban on growth-pro-
den, J. A., Blencowe, A., Reynolds, E. C., and Qiao, G.
moting antibiotics and emerging consequences for
G. (2016). Combating multidrug-resistant Gram-ne-
human and animal health. Journal of Antimicrobial
gative bacteria with structurally nanoengineered
Chemotherapy, 52 159-161.
antimicrobial peptide polymers. Nature Microbiology,
6. Gaskins, H. R., Collier, C. T., and Anderson, D. B. (2002). Antibiotics as growth promotants: mode of action. Animal Biotechnology, 13 (1) 29-42.
1 article number 16162. 11. Larsen, P. B. (2002). Consequences of terminating AGP use for pig health and usage of antimicrobials
7. Hsu, J. T., Chen, C. Y., Young, C. W., Chao, W. L., Li, M.
for therapy and prophylaxis. Abstracts of the Inter-
H., Liu, Y. H., Lin, C. M., and Ying, C. (2014). Prevalen-
national Invitational Symposium: Beyond Antibiotic
ce of sulfonamide-resistant bacteria, resistance ge-
Growth Promoters in Food Animal Production, 2002,
nes and integron-associated horizontal gene transfer
Foulum, Denmark.
in natural water bodies and soils adjacent to a swine feedlot in northern Taiwan. Journal of Hazardous Materials, 227 34-43. 21
12. Muirhead, S. (2002). Therapeutic use of antibiotics on rise in Denmark. Feedstuffs, 74 1–5. 13. Ogle, M. (2013). Riots, Rage, And Resistance: A Brief
VPH Journal 8th edition
History Of How Antibiotics Arrived On The Farm. [Ac-
18. Verner Wheelock, J. and Foster, C. (2002). Food Safe-
cessed 10 Oct. 2016]. Available from: https://blogs.
ty and Pig Production in Denmark. Report commissi-
scientificamerican.com
oned by the Danish Bacon and Meat Council. Verner
14. Petersen, J. S. (2002). Animal welfare and health as affected by management procedures in commercial
Wheelock Associates Ltd, Skipton, UK. 19. Veterinary Medicines Directorate (2002), Sales of
broiler flocks. The International Invitational Symposi-
antimicrobial products used as veterinary medici-
um: Beyond Growth Promoters in Food Animal Pro-
nes, growth promoters and coccidiostats in the UK in
duction, 2002, Foulum, Denmark.
2000. [Accessed 10 Oct. 2016]. http://www.vmd.gov.
15. Rasheed, M. U., Thajuddin, N., Ahamed, P., Tekle-
uk/general/publications.
mariam, Z., and Jamil, K. (2014). Antimicrobial drug
20. Wegener, H. C. (2002). Banning antimicrobial growth
resistance in strains of Escherichia coli isolated from
promoters in Europe: where does it make a differen-
food sources. Revista do Instituto de Medicina Tropi-
ce? 42nd Interscience Conference on Antimicrobial
cal de São Paulo, 56 (89) 341–346.
Agents and Chemotherapy, 2002, San Diego, CA.
16. Simoneit, C., Bender, S., and Koopmann, R. (2012).
21. Werner, C., Sobiraj, A., and Sundrum, A. (2010). Effi-
Quantitative and qualitative overview and assess-
cacy of homeopathic and antibiotic treatment stra-
ment of literature on animal health in organic farming
tegies in cases of mild and moderate bovine clinical
between 1991 and 2011 – Part I: general and cattle.
mastitis. Journal of Dairy Research, 77 460-467.
Landbauforschung vTI Agriculture and Forestry Research, 62 (3) 97-104. 17. Ta, Y. T., Nguyen, T. T., To, P. B., Pham, D. X., Le, H. T. H., Thi, G. N., Alali, W. Q., Walls, I., and Doyle, M. P. (2014). Quantification, serovars, and antibiotic resistance of Salmonella isolated from retail raw chicken meat in Vietnam. Journal of Food Protection, 77 (89) 57-66.
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IVSA REPRESENTED at the NorWHO simulation 2016 The elaboration of a resolution on Antimicrobial Resistance 9-12 August 2016 By Claudine Girardo, IVSA Lyon, France Project Manager on Antimicrobial Resistance for the Standing Committee on One Health 2015-2016
Between the 9th and the 12th of August 2016 took place the Nordic World Health Organization Simulation - shortened as the NorWHO Simulation. In the brand new buildings of the WHO Regional Office for Europe in Copenhagen, around fifty university students from different backgrounds –medical, veterinary, pharmaceutical, global health students- and young professionals came together to play a four-day lasting simulation game. The purpose of this game was to experience and live the functioning of the World Health Organization from the inside. Altogether, we had to reach an agreement and adopt a resolution on this year’s theme, Antimicrobial Resistance. All the participants were assigned a specific role, having to put themselves in the shoes of a member state or 23
VPH Journal 8th edition
of a non-governmental actor, including either non-governmental organizations (NGO’s), business representatives or journalists. Some more experienced students with this game acted as chairs for the regional meetings and plenary sessions. In that event, five students represented the IVSA. Four of them performed member states from different continents (Côte d’Ivoire, France, the Czech Republic and Honduras) and one of them acted as a NGO, representing the IVSA! How is a resolution adopted at the World Health Organization? Much work upstream has to be made prior to the plenary sessions. Hereafter is a simplified overview of how things work during the NorWHO Simulation. Member states and non-governmental actors start the work by putting down the ideas and interests they want to defend in a so-called position paper, which everyone can read. Then, the member states of a same block – from a same region of the world- meet during their regional meetings. Member states debate there on the ideas they would like to bring forward in the final resolution, and write them on a working paper. When all the ideas are collected, the next step is to draft the text properly, according to certain writing rules. Specific key terms have to be used to introduce two different types of clauses, which are the preambulatory clauses and the operational clauses. At the end of this work, you get a draft resolution that can be submitted to the plenary session. This plenary session corresponds to the World Health Assembly. The different draft resolutions are presented, amended and voted on. During the NorWHO Simulation, reality was simplified by merging all the draft resolutions into a single one. During that whole process, non-governmental actors are allowed to attend the regional meetings and the plenary sessions, and to approach the Member State during coffee breaks – a very strategic moment! NGO’s and pharmaceutical companies have to do their best to lobby the member states and to transmit their ideas. They can be allowed (or not) by the chair to make an oral statement during the regional meetings or to deliver written pronouncements to the member states. Another strategy can be to approach the journalists so as to get an article in the press or to be given an opportunity to speak during the daily press conference. To reflect the actual work of the World Health Organization, we got to experience an emergency breakout during the regional meetings. The debates got interrupted by a case that needed to be handled right away: the emergence of Zika virus. We got to leave our given roles as member states, NGO’s or pharmaceutical companies so as to become invited experts, here to decide on how to solve the presented emergency. What were the experiences of the delegates?
“Being a part of an outstanding event such as NorWHO is a privilege. I got to learn so much within 4 days, but what I really enjoyed was feeling welcomed by all of the students and the OC. What worked so well was even though everyone was on different levels and studying programs, it was perfect for everyone. Being exposed to such knowledge is the best part of the event. Getting to discuss about the struggles and obstacles of One Health with students of different fields was enormously beneficiary. I believe in the future I will be applying to attend such events without thinking twice.” - Bajram Pirana
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“These days at the NorWHO simulation, representing a country that is not my own, provided me with an inestimable learning experience. While being able to bring something new to the discussions, due to my background in animal health, I could hear inputs from medical, pharmaceutical, human sciences and public health students.” - Mariana Marrana
“As for me, I was acting as an NGO - which I felt was a difficult task as you have to make the member states defend your ideas for you. I am really thankful for this position though, as I got the opportunity to learn through play some negotiation and communication skills that will be really useful in the future. And, of course, meeting people from all over the world, from different backgrounds, and sharing a social program with them made it even more special.” - Claudine Girardo
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How are you involved in One Health activities? Name: Paulin Dettmann Profession: Student of veterinary medicine (Freie Universität Berlin), volunteer and student assistant at VSF Germany Contact: paulindettmann@gmail.com
It is necessary to see the bigger picture; therefore, experts of different disciplines must sit down at one table.
One Health Event in Berlin - Fusion of human and veterinary medicine Until now the international One Health Day on 3rd November has not been as popular as Independence Day, Koningsdag or Fête Nationale. The topic of One Health goes beyond the borders of countries and its main goal is the close interlinking of several sections, for instance human and veterinary medicine. Given the opportunity, the vet students of Berlin organized an event which focused on this overlapping area. As members or volunteers for VSF- Germany¹, bvvd² and IVSA³, they are strongly interested in the impact of veterinary medicine on the bigger picture. What have animal doctors actually had to do with human health? To clarify this question, several speakers with several scientific backgrounds were invited. They introduced the listeners to the One Health concept seen from different points of views. PhD Antje Hoppenheit who works for the Institute of Parasitology at Freie Universität Berlin started the event with a short introduction into the One Health concept itself. As a broad member of VSF- Germany, she presented the implications VSF has in East Africa. 26
VPH Journal 8th edition
The expertise on the subject expanded with the first speaker, Cornelia Heine. As a Master of Science of Integrated Natural Resource Management, she outlined the importance of milk in pastoral societies. Pastoralism is a livelihood system related to Nomadism in which the people depend on the livestock and the natural resources in marginal areas. Just notice that 25% of the world wide surface is used by Pastoralists, which includes up to 400 million people!
Moreover, milk is an essential nutrition provider for Pastoralists. Compared with children in developed
countries, kids in pastoral communities consume ten times more milk. This fact punctuates the importance, but it should be even more alarming in consideration of hygiene and diseases - especially zoonosis. In the majority of cases and due to tradition, the milk is drunk raw. Do the lactogenic diseases and micro-organisms already pop up in your mind? - Brucellosis, Tuberculosis, Salmonellosis and Listeria, just to mention some of them. Cornelia Heine expanded on Brucellosis, which infects 500.000 people per year. In addition, the transportation of milk and even water bears the risk of infections due to the lack of hygiene. Plastic canisters worsen the danger, because they cannot be cleaned properly and preserve microorganisms and dirt. Battling with these problems given, VSF Germany implemented the milk project in Somalia in which, inter alia, milk cans made of aluminium were handed out. Aluminium is aseptic and the cans are easily cleaned. Furthermore, milk collection points were built so that the milk could be cooked. VSF organized several courses for further education about the diseases and how to prevent them. Thus Prof. Dr. Dr. Timo Ulrichs of Akkon University for Applied Sciences illustrated the significance of TB and the interfaces of his faculty and VSF’s attempts. Tuberculosis has already been a topic in the latest VPH journal, therefore let us summarize it shortly. As one of the three big killer diseases worldwide, including HIV and Malaria, this bacterial based illness causes 6 million deaths per year. During the same time period, 9 million people were newly infected. Contradictory to what many expected, Prof. Ulrichs outlined the primary airborne spread of the disease. Another common misconception is the evolution of Mycobacterium tuberculosis: M. bovis and M. tuberculosis are hardly genetically related.
Once exposed to the bacteria, the human patient can eliminate the pathogen without any infections. If it
invades the air ducts’ tissue, there is still the chance of a non-symptomatic clinical picture due to the macrophages which will partly cause encapsulation. An equilibrium between the immune system and the pathogen tends to establish until the patient will get immunosuppressed, e.g. due to HIV. Additionally, other suppressing factors can be malnutrition, oncological diseases and aging. The bacteria’s growth rate of one division per 24 hours is low compared to E. coli’s generation time of 20 minutes. Since it is already hard to diagnose TB properly, its lengths for doubling makes it even more challenging.
According to newest research there is no evidence to vaccinate against Tuberculosis with BCG- an acronym
for Bacillus Calmette- Guerin which is attenuated M. bovis, but it does not prevent the infection. A combination of four antibiotics is used to fight the disease and is for sure, related to the development of further resistances. Prof. Ulrichs added even the African neologism: TDR- totally drug resistant.
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Thus, which other treatments do we have up our sleeve? It is necessary to educate the people; TB positive patients need special treatment in private rooms to inhibit its spread. Additionally, milk can have a positive impact due to its high doses of vitamin D and calcium. Further research and capacity building is needed, especially improved diagnostics. The effects of malnutrition, lack of hygiene and poverty are continuing topics which connect the human and the veterinary part with each other.
The given example tends to be more international, but cooperation should already be a topic on the na-
tional level. Is veterinary medicine already a player in the topic of Public Health? Let’s get an update about VPH! Therefore, the audition got first impressions of the yet unpublished VPH position paper which was developed by several representatives of German veterinary universities. Prof. Dr. Marcus Doherr himself teaches at Freie Universität Berlin and his focus lies, amongst others, on Veterinary Public Health.
Referring to the Public Health paper, One Health is correlated to Global Health and includes zoonosis as
well as education and training. Nevertheless, the paper left out the impact of VPH itself, which was one of the main motivators for the VPH position paper. That is quite surprising as you realize that 60-80% of new emerging infectious diseases are zoonosis. Prof. Doherr outlines six concrete recommendations for the realisation and inclusion of VPH in the aspect of
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VPH Journal 8th edition
ONE HEALTH: 1. Veterinary medicine needs to participate more in the debate about Public Health in Germany 2. Strengthening the education about multi-sectoral cooperation, especially between human and veterinary medicine 3. Implementing an international competitive cross-sectoral training within VPH in Germany 4. Greater public relation for the presentation of the impacts VPH has on One Health 5. Expanding current platforms and panels of intersectoral collaborations of the Public Health- community in Germany 6. Strategic development of a cross-sectoral cooperation in the aspect of official permits and scientific work, as well as observing its practical feasibility through specific research funding and other local and international measurements The VPH Position Paper will be soon published and openly accessible. We will see if the veterinary sectors widen its influence as soon as we wish. All in all, One Health is more than combining human and veterinary medicine, it also involves environmental and economic aspects, as well as politics, pharmacy and social parts. It is necessary to see the bigger picture; therefore, experts of different disciplines must sit down at one table. We need to share our specific knowledge and to get used to collaboration between various fields. Events like the one in Berlin are essential. Remember 3rd of November- the international One Health Day. And yes, we are planning more events. Feel free to join us! References 1. Vétérinaires Sans Frontières- Germany http://www.vsfg.org/ 2. Bundesverband der Veterinärmedizinstudierenden Deutschland http://www.bvvd.de/ 3. International Veterinary Student Association http://www.ivsa.org/
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MEET THE LoVPHOs Blogpost from the Dutch IVSA Local Veterinary Public Health Officers Dear reader, Nice to meet you! We are Tierney Mepham and Fiona van Kaam and we’re pleased to represent ourselves to you as the Local Veterinary Public Health Officers of IVSA the Netherlands. As you might know, in 2014 the Standing Committee on One Health was established as a new committee within IVSA global. The SCOH acts according to the IVSA principle ‘Think globally, act locally,’ and therefore a LoVPHO was added to every IVSA chapter. In 2014 Anne-Fleur Brand, a master’s student, was nominated to be the first LoVPHO of the Netherlands. She started her function by establishing important contacts with students from other disciplines such as pharmacology, human medicine and toxicology. Half a year later, Fiona van Kaam got in close contact with Anne-Fleur and they decided to share the function of LoVPHO. After one year Anne-Fleur left the Netherlands to do research on the interface of veterinary medicine and toxicology. Tierney Mepham has since replaced Anne-Fleur’s function and today Tierney and Fiona are the LoVPHOs of the Netherlands. Our mission is to build bridges between students of different disciplines with relation to the One Health concept. This mission may sound great, but implementing it can be challenging. This may be an issue familiar to other LoVoPHOs around the world. Our advice is avoid expending too much time and effort to work with people who are uninterested in a project, and to instead cherish the people who do understand the importance of your work and connect with them. To give you an impression of what initiatives have been taken in the Netherlands, we have selected a few things to tell you about: Dr. House evening This lecture was a local collaboration between IVSA and IFMSA Utrecht. The purpose of this evening was to connect students of human and veterinary medicine by teaching them about a zoonotic, parasitic infection of animals and humans in the Netherlands. The evening started with an episode of the famous Dr. House in which he has to solve the medical case of a patient with an Echinococcus multilocularis infection. At some points the episode was paused and both a human and veterinary parasitologist commented on the case and taught the medical students about it. It was both a very informative and interactive evening. One Health Students’ Congress The OHSC was a local collaboration, initiated by the LoVPHOs of IVSA, between students of Pharmacology, Medicine, Veterinary Medicine and Biomedical Sciences at the University of Utrecht. The congress took place at the Faculty of Veterinary Medicine. In the morning programme there were plenary lectures about cross-study issues like antibiotic resistance, vaccination and zoonotic diseases. In the afternoon programme a game called the One Health Game was played. The game gives a virtual reality about the national outbreak of a zoonotic disease. The game was played in mixed teams with students of different studies. At the end of the game a ‘press conference’ was held in the lecture hall, were all the teams had to formally inform the ‘Dutch citizens’ about the disease and 30
VPH Journal 8th edition
crisis management. To achieve a good communication at the ‘press conference’ all students had to share their knowledge and work together in making a plan for crisis management. The collaboration worked out well and therefore it was a successful congress. The organization of this congress is being continued at the moment and it will be held once every two years from now. One Health Event After the success of the OHSC the LoVPHOs together with IFMSA initiated the organization of a national One Health Students’ Event. The purpose of this event was to connect students from medical, but also from environmental and biomedical sciences from all over the Netherlands. The organizing committee consisted of enthusiastic students from different studies at the University of Utrecht. The LoVPHOs promoted this upcoming event at the launch of the Netherlands Centre for One Health and received financial contributions from four different Universities in the Netherlands. The morning programme of the event consisted of lectures about zoonotic diseases, public health, food security for the expanding world population and genetic modification of plants and crops. The afternoon programme consisted of two rounds of workshops with six workshops in total: two human medicine workshops, two veterinary medicine workshops and two environmental sciences workshops. The intention of the workshops was to teach students about different disciplines by sending them to a different workshop than their own study. Evaluation of the event showed that students very much liked our concept of the workshops. Human medicine students for instance went to the workshop at the farm, to learn about food safety and diseases humans can get from animals. At the end of the day Tierney and Fiona performed a quiz to check if all students payed attention during the lectures and the workshops. Afterwards we arranged free drinks for everyone, to talk and get in touch with students from other studies.
This is us, at the launch of the Netherlands Centre for One
One Health is an important subject during the IVSA Euro-
Health in February 2016
pean Veterinary Students’ Seminar in October 2016
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How are you involved in One Health activities? Name: Fiona van Kaam Profession: Veterinary Master’s student Farm Animal Health and Public Health at Utrecht University (the Netherlands)
“The challenges we face including antibiotic resistance, zoonotic diseases, climate change and sustainable food production are not someone else’s problems, they are OUR problems.” One Health Approach For me the most important thing to achieve as LoVPHO (this acronym should be written out for readers like me who don’t know what it is) is to connect students from different studies and disciplines. The challenges we face including antibiotic resistance, zoonotic diseases, climate change and sustainable food production are not someone else’s problems, they are OUR problems. In my opinion, students are the future and I hope I can contribute to a better future by building bridges between students on a local level. I hope our contribution to the IVSA magazine inspires other people to start organizing lectures and events to spread the One Health concept to students in their countries. How are you staying involved In 2014 I went to the IVSA congress in Indonesia. The congress was eye-opening to me and I learned a lot about veterinary medicine in other countries. At this time, the SCOH was launched and it directly got my attention. When I returned home to Utrecht I came in contact with Anne-Fleur, who just started her function as LVPHO (this can stay an acronym as long as we have it written out completely the first time), and she asked me to join her by becoming a second LoVPHO. When Anne-Fleur went to Australia for her master thesis, Tierney took over her function. Because there are already many students associations at the Faculty of Veterinary Medicine in Utrecht, we collaborate with them and thus created our international network. This is how I stay involved!
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How are you involved in One Health activities? Name: Tierney Mepham Profession: Veterinary Master’s student Companion Animals at Utrecht University (the Netherlands)
“How can we optimize food production to feed 9 billion people without causing massive deforestation and thereby destroying whole ecosystems? “ One Health Approach I believe the One Health principle is an essential concept, not only for healthcare, but also to ensure a healthy future for animals, humans, and the planet. One-Health thinking can help professionals in different fields achieve more; by combining knowledge and tackling problems together instead of only from one perspective, we will be able to approach these problems far more efficiently and effectively.
An excellent example of this is food security in the future. How can we optimize food production to feed 9 billi-
on people without causing massive deforestation and thereby destroying whole ecosystems? Or how can we ensure optimal animal welfare when keeping increasing numbers of animals in close contact? How can we ensure public health in areas regarding zoonosis and food safety when eating from new food sources such as insects? How are you staying involved During my time as a Vet Med student, I have been active in various committees and was a member of the board of Hygieia, the Dutch One Health Students’ Association. I organised multiple events for students focusing on One Health-related topics. Now as Local Veterinary Public Health Officer, I try to connect students from different fields and universities with each other, as well as connecting different students’ associations. For example, this year I helped organise the first One Health Event 2016, a multidisciplinary congress for 100 students from the whole country, with lectures and workshops about different One Health topics.
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VPH Journal 8th edition
ANTIBITIOCS IN VETERINARY PRACTICE The perioperative usage of antibiotics in the treatment of small animals Authors Dyrka Magdalena, 5th year student of Veterinary Medicine, University of Life Sciences in Lublin, Poland; the Official Member of SCoVE 2016/2017 Rzezak Rafał DVM, Veterinary Clinic for Small Animals Chiron – Wet in Lublin, Poland; specialist in veterinary surgery & internal medicine of dogs and cats; Editor Gierska Jagoda, 3rd year student of Dutch Philology, Catholic University of Lublin, Poland Nowadays great attention is paid to rules of
minated, contaminated and dirty wounds.
non-contamination and sterility during veterinary
A surgical wound is a clean wound, which is created
surgeries. It begins with preparing the operating the-
in sterile conditions. It does not penetrate into the
atre, getting the surgeons ready, using sterile surgical
digestive system, respiratory system, urogenital sys-
tools and working in a sterile surgical site. It ends with
tem or the oral cavity and throat space. Clean - con-
proper disinfection of the incision with adequate anti-
taminated wound are operative wounds in which
bacterial cleaning supplies. Thanks to those rules, the
non-infected any tracts are entered under controlled
postoperative wound is clean and the risk of infection
conditions. Comparing to clean wounds in this kind of
is avoided. However some surgeries require the use
wounds there are procedures in which a minor break
of antibiotics, of which overuse and mismanagement
in asepsis occurs. Contaminated wounds have more
can cause resistance.
than 105 bacteria. They are during operations on
traumatic wounds without purulent discharge, but
As a consequence the treatment of bacterial in-
fections is less effective.
when purulent occurs it is a dirty wound.
The most effective way of administering anti-
Classification of contaminated wounds
biotics is in intramuscular or intravenous injections,
Wounds are classified based on the level of contamina-
contrary to the subcutaneous usage of long lasting
tion. According to National Research Council wound
drugs.
classification system consists of: clean, clean-conta34
VPH Journal 8th edition
The selection of antibiotics in accordance with the
ratories. These labs select specific culture substrates,
type of surgery
microclimates and aerobic or anaerobic conditions.
Depending on the type of surgery, the referring doc-
Before receiving the results from the lab, a process
tor of veterinary medicine or surgeon decides if an-
that approximately 5 – 7 days the administration of a
tibiotic therapy is needed before or after surgery. If
wide range of spectrum antibiotics is needed to con-
necessary, he or she decides for how long antibiotics
tain the anaerobic culture.
should be and chooses the first-choice antibiotic tre-
atment.
ventive measure, known as “prophylactic�. This me-
The reason for the use of antibiotics in the periope-
ans that the wound (for example a wound on the
rative period - that is, around the time of surgery, is
paws) will be safe from repeated environmental con-
to get an appropriate concentration of antibiotics in
tamination. There are many more cases in which we
animal tissue both during surgery and for about three
might administrate antibiotics as a preventive measu-
hours post surgery, while the fibrin integrates the
re such as: operations over 90 minutes, prosthesis
wound. It is recommended to administrate antibiotics
implantation, operations on patients with prosthesis,
intravenously, prior to the induction of anaesthesia to
oral cavity surgery, treatment and dressing of trau-
prevent the development of an imminent but limited
matic wound, operations on rectal area or attenuated
bacterial contamination. Antibiotics are used until the
patients. These patients have a weakened immunolo-
end of surgery. Thanks to this procedure, the necessi-
gic system and are at a high risk of related complica-
ty of its usage is eliminated in the postoperative pe-
tions.
It is possible to administer antibiotics as a pre-
riod. After surgeries that require further antibiotical treatment, as well as when dealing with abscesses or
Antibiotics vs. surgeries
dressing contaminated wounds, the selection of anti-
Ovariohysterectomy and castration are the most
biotics is based on the results of bacteriological tests
common surgeries in veterinary medicine. It is not
from a sample taken from such a wound. Those tests
considered logical to use antibiotic prophylactically in
are carried out by professional microbacterial labo-
those cases, especially when the sterility prior to sur-
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VPH Journal 8th edition
gery is maintained and also when there is no damage
antibiograms. Antibiograms are usually carried out to
to other organs that could cause contamination.
determine which antibiotic will be most successful in
Problem occurs with organ disorders, such as:
treating a bacterial infection in vivo. The use of ami-
pyometra, other uterine infections or prostatitis.
noglycosides, tetracycline (with the exception of doxy-
Pyometra is a uterine infection, which can happen in
cycline) and sulfonamides is not allowed. Penicillin and
non-spayed dogs or cats. Prostatitis is inflammation
cephalosporin are the best choice, as they have great
of the prostate gland. The most commonly occuring
concentration in urine. Great concentrations means
bacteria is Escherichia coli in case of pyometra. In
that the antibiotic will be effective for this bacterial in-
complications caused by pyometra it is advised to
fection. Fluoroquinolones are good choice as well, but
avoid the use of aminoglycosides, because aminogly-
only Gram - bacterias are sensitive. However, if a bac-
cosides are nephrotoxic, meaning there is a possibili-
teriological culture sample taken via urinary bladder
ty of causing damage to the kidneys. Most common-
has negative results, another sample must be biopsied
ly chosen antibiotics are: erythromycin, clindamycin,
and a bacteriological culture in aerobic and anaerobic
enrofloxacin. In case of prostatitis, fat-soluble antibi-
conditions from the barrier lining of the urinary blad-
otics are selected based on the ability to exceed the
der must be done. The most commonly occurring bac-
blood - prostate gland barrier.
teria is Escherichia coli after kidney surgery.
Kidney surgeries like operative removal of
stones, ectopic ureters and urinary obstructions are
Most patients undergoing liver operations, with the
the indicators to use antibiotics. The choice of anti-
exception of liver biopsy patients, are expected to use
biotics is determined by bacteriological cultures and
antibiotics. Liver diseases can cause the decrease of li-
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VPH Journal 8th edition
ver metabolism, disturbed blood flow in the arteries
of expected pathogens. Following the aforementio-
and hepatic portal vein, hypoalbuminemia and de-
ned treatment plans can decrease the resistance of
creased production of bile. These factors can incre-
bacteria to antibiotics and will help successfully
ase the pharmacokinetics of antibiotics, thus making
to eliminate further difficult bacterial infections.
them more toxic. It is advisable to use antibiotics in liver encephalopathy, hepatitis and hepatic absces-
References
ses. In the case of gallbladder diseases the whole gal-
1. Fossum W. Theresa, Small Animal Surgery Volume
lbladder is cut out and the use of antibiotics is iden-
I, Elsevier Urban & Partner, Wrocław, 2014 (2nd Po-
tical to use in liver diseases. Antibiotics are selected
lish edition)
in bacteriological platings and antibiograms from
2. O’ Dwyer L., Tatton B. Wound management in small
material taken from liver tissue and/or gall. Bacteria
animals, Elsevier Urban & Partner, Wrocław 2008 (1st
such as Escherichia coli., Klebsiella spp., Enterobac-
Polish edition)
ter, Proteus, Pseudomonas can cause contamination.
3.
The most common antibiotics in these instances are
tics-surgical-patients (4/11/2016)
http://www.cliniciansbrief.com/article/antibio-
amoxicillin, cefazolin, enrofloxacin.
There is no need for the use of antibiotics in ca-
ses of uncomplicated pancreatitis in dogs and cats. It is common however, to use them in pancreatic abscesses, partial pancreatic resection and neoplasms to avoid secondary contamination of the necrotic and perivascular tissue. Imipenem and ciprofloxacin decrease septic complications.
Antibiotics are used prior to surgeries on the
upper respiratory tract that are not connected to bacterial contaminations such as palatoplasty. All surgeries on the lower respiratory tract and thoracic surgery can require prolonged antibiotic therapy due to the length of surgery. Conclusions Doctors of veterinary medicine are responsible for the reasonable choice of antibiotics. Thus, antibiotics are chosen on the basis of microorganism identification (gram staining, smear tests, bacteriological tests) and by their sensitivity. Preventive usage of antibiotics and wound healing should be effective in at least 80%
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STUDENTS IN THE FIGHT AGAINST ANTIMICROBIAL RESISTANCE International Pharmaceutical Students’ Federation (IPSF): Ms. Leah Osae (USA); Ms. Estelle Yau (France); Ms. Raluca-Mihaela Șișu (Romania); Mr. Farooq Ali Khan (India); edited by Whitley Yi (USA)
A rising concern Penicillin ushered us in the age of antimicrobials. Since then, there was an expansive growth of antibiotics, antifungals, and antiparasitics, both for human and veterinary use. However, as the development of antimicrobials continued, so did the evolution of the microbes and they acquired resistance to these agents. The growing resistance of microorganisms has emerged as a serious issue termed “Antimicrobial Resistance (AMR)” that needs immediate attention. It has been referred to as the “silent tsunami,” while the 2014 WHO’s AMR Global Report on Surveillance states that the issue has gone from being an “apocalyptic fantasy” to a very real possibility (WHO AMR). Currently, it is estimated that bacteria resistant to antibiotics claim 700,000 lives annually and this will only get worse if left unsolved (Cox 2016). Governments around the world are starting to pay attention and are addressing this issue, but more action is needed. The present article will focus on factors contributing to this problem and current efforts to fight AMR, with an emphasis on the role of IPSF and pharmacy students. Evaluating the contributing factors The rapid and critical rise of AMR worldwide is sustained by multiple interconnected factors, endangering the efficacy of antibiotics and becoming a tremendous public health challenge of today’s society that calls for a global response (Castro-Sánchez, Moore, Husson, Holmes, 2016; Ventola, 2015; WHO, 2001). Some of the key determinants of this phenomenon include use and misuse of antibiotics, inappropriate prescribing and underdevelopment of new antibiotic molecules and vaccines (Castro-Sánchez et al., 2016; Ventola, 2015; WHO, 2001). Overuse of antibiotics has a large impact on the evolution of AMR and it had a great influence on the current situation. Misperceptions among patients, self-medication and minor infections that are unnecessarily and incorrectly treated are all contributing factors (Castro-Sánchez et al., 2016; WHO, 2001; Knobler et al., 2003). Lack of health and pharmaceutical regulations that allow over-the-counter access, online sales and direct advertising create an image of easily accessible and affordable remedies and endorse their usage (Michael, Dominey-Howes, Labbate, 2014; WHO, 2001). Another contributor to the problem is represented by the underuse of antibiotics caused mainly by non-adherence as the patients do not receive enough information 38
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or do not understand the importance of taking their treatment and possible implications (Castro-Sánchez et al., 2016; Ventola, 2015; WHO, 2001). Depending on the societal development, lack of financial support, inappropriate access to treatment or lack of the availability of necessary drugs due to inadequate drug supply infrastructure can have an impact on the adherence and hence the underuse (WHO, 2001). The promotion of resistant bacteria can also be sustained by inappropriate prescriptions caused by errors in the mode of use (dosage, duration, route of administration) as well as lack of access to appropriate diagnostic facilities, inability to perform culture and sensitivity tests, and a lack of capacity for therapeutic drug monitoring (WHO, 2001). Studies have shown that, in up to 50% of the cases, there is an incorrect implementation of antibiotic therapy that may lead to low therapeutical effect, potential complications and an increased susceptibility to AMR (Ventola, 2015). As a result, subinhibitory and subtherapeutic antibiotic concentration can contribute to genetic alterations and ulterior changes in virulence, resistance and spread of bacteria (Ventola, 2015). As new antibiotic agents are used as last-line drugs in therapy and important restraints are applied in prescribing, the availability of new antibiotic molecules has become another contributor to the AMR issue (Ventola, 2015). Even though the development of new molecules has been used as a strategy to fight bacterial resistance, economic and regulatory obstacles are significant elements that are affecting both pharmaceutical industry and academia in conducting antibiotic research (Ventola, 2015). Bacterial populations have a great ability to adapt rapidly and effectively that is provided by genetic variability (through mutations) and “reservoirs” of adaptive genes that spread within and between microbial species (Michael et al., 2014). Antimicrobial use creates a selective pressure upon microbial communities; the higher the pressure, the faster the development of antimicrobial resistance, as bacteria with a natural “advantage” or resistance to the antimicrobial will survive, while others do not (Michael et al., 2014). This alters the composition of the whole community, as only resistance microbes are left (Michael et al., 2014). Therefore, using current and forthcoming antimicrobial agents requires caution and careful selection to try to minimize the use of an antimicrobial on a bacterial population with pre-existing resistance (Michael et al., 2014). AMR, a complex and multifactorial problem, is also influenced by other aspects such as extensive agricultural use in livestock and crops that leads to environmental contamination, healthcare transmission – a rising occurrence in some regions (Ventola, 2015; Knobler et al., 2003).
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Current efforts Pharmacists and pharmacy students have made strides in fighting AMR via both local and global initiatives and partnerships. In 2015, the International Pharmaceutical Federation [FIP] released “Fighting antimicrobial resistance: The contribution of pharmacists” to highlight the role of pharmacists in preventing AMR. In that same year, the World Health Organization developed a Global Action Plan on Antimicrobial Resistance and stated that industry leaders in the pharmaceutical sector “are important partners in combating antimicrobial resistance, both by supporting the responsible use of medicines in order to prolong their effectiveness and through research and development of innovative medicines and other tools to combat resistance (WHO 2015).” The action plan highlighted the relevance of antimicrobial stewardship [AMS] programs, in which pharmacy students may play an integral part. AMS programs are coordinated programs, commonly implemented within hospital and health systems, that aim to reduce microbial resistance and promote appropriate use of antimicrobials and antibiotics. AMS programs accomplish these goals by implementing policies supporting appropriate antibiotic use, primarily by documenting dose, duration, and indication and by developing and implementing facility specific treatment recommendations for common indications, such as community-acquired pneumonia or urinary tract infections (CDC 2014). A 2015 review study of successful AMS programs from 6 different countries (U.S., U.K., South Africa, Singapore, Australia, and Italy) found that pharmacists with key roles in AMS programs were able to improve “hangtime” compliance, reduce duration of therapy, decrease length of hospital stay, and increase institutional cost savings (Goff & Rybak 2015). Pharmacy students may participate in AMS programs in various ways as well. For example, a three-year hospital study found that an AMS program integrating pharmacy students, whose primary role was to monitor infection-related patient problems and meet daily with infectious disease and clinical pharmacists to develop recommendations for optimizing antimicrobial use, decreased antimicrobial costs over a twoyear period (Benson 2014). Outside of clinical settings, student pharmacists have also made strides within professional organizations. Within the past years, the International Pharmaceutical Students’ Federation [IPSF],the International Veterinary Students’ Association [IVSA], and International Federation of Medical Students’ Associations [IFMSA] have joined forces to advocate for the responsible use of antimicrobials in animals and humans. In fact, IPSF developed an AMR campaign kit outlining the ways in which pharmacy students can run a successful Medicine Awareness Campaign [MAC], and over the years, IPSF member or40
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ganizations have developed campaigns to inform the public about antimicrobial resistance. For example, the fifth issue of the IPSF Public Health Spot newsletter highlighted two student pharmacist campaigns addressing AMR. First, members of the Rwanda Pharmaceutical Students Association [RPSA] collaborated with the Rwanda Correctional Services Huye Prison to offer teaching sessions on multidrug-resistant tuberculosis [MDR-TB] to inmate health advisors. Their campaign to decreases misuse of TB medications led to the initiation of a long-term health education project named “PIHEP – Prison Inmates Health Education Project” (Mandela 2015). Additionally, FPSA-Sudan [University of Khartoum] initiated a three-day medication awareness campaign on AMR, consisting of scientific exhibitions on antibiotic resistance, lectures on the rational use of antibiotics, and street campaigns to boost awareness (Jamal 2015). With these two past initiatives as proof of the impact that students can have in fighting the progression of AMR around the globe, it is even more important that in the years ahead, students are equipped with more tools to continue the fight against AMR, no matter the setting will be. A continued commitment Looking to the future, IPSF continues to be committed in the fight against AMR. Once again this year in November, IPSF will join efforts and actions with IVSA and IFMSA for the World Antimicrobial Awareness Week. The three organizations are working together on informational materials for the campaign and are assisting member associations to execute their campaigns through providing promotional materials and a manual kit. IPSF believes that interprofessional collaboration between pharmacists, veterinarians and medical doctors is essential for spreading awareness to communities, and having an impactful intervention is optimized by sharing different views on possible ways of fighting AMR. In addition to this major campaign, IPSF will be organizing its Anti-Counterfeit Drugs Campaign, Tuberculosis Awareness Campaign and Medicine Awareness Campaign in February and March. These various campaigns contribute to fighting AMR by informing student pharmacists, health professionals, and patients about the dangers of fake antimicrobial drugs, the importance of medication adherence to antibiotic therapy, and the prevention of drug-resistant tuberculosis, amongst others. Furthermore, as a non-governmental organization in official relations with the WHO, IPSF has the privilege of representing the voice of future pharmacists at the World Health Assembly [WHA] and contributing to the improvement of global health. At the 138th Executive Board Meeting of WHO, IPSF reinforced statements made previously in collaboration with IFMSA and IVSA, stressing the importance of improving awareness and understanding of AMR, especially through the education and trai41
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ning of future healthcare professionals and encouraged Member States to adopt the Global Action Plan on AMR. Future efforts to fight AMR In conclusion, the multi-factorial nature of AMR, coupled with its alarming growth rate, places it as a top priority for both human and veterinary health. Rational and regulated use of antibiotics in both humans and animals is essential in order to prevent this growing threat and will require effective education, training and improved access to knowledge. Therefore, the current interprofessional collaboration of student associations must be sustained and grown, while also incorporating more regional and local student association involvement. Coordinated and harmonized efforts are vital in combating the global crisis of AMR, as it is a sinuous problem that does not discriminate against regions and borders. References 1. Cox, David. "Antibiotic Resistance: The Race to Stop the 'silent Tsunami' Facing Modern Medicine." The Guardian. Guardian News and Media, 21 Aug. 2015. Web. 10 Nov. 2016. 2. World Health Organization Antimicrobial Resistance Global Report on Surveillance http://apps.who.int/ iris/bitstream/10665/112642/1/9789241564748_eng.pdf. 3. Castro-Sånchez, E., Moore, L. S. P., Husson, F., & Holmes, A. H. (2016). What are the factors driving antimicrobial resistance? Perspectives from a public event in London, England. BMC Infectious Diseases, 16(1), 465. http://doi.org/10.1186/s12879-016-1810-x 4. Ventola, C. L. (2015). The Antibiotic Resistance Crisis: Part 1: Causes and Threats. Pharmacy and Therapeutics, 40(4), 277–283. 5. Michael, C. A., Dominey-Howes, D., & Labbate, M. (2014). The Antimicrobial Resistance Crisis: Causes, Consequences, and Management. Frontiers in Public Health, 2, 145. http://doi.org/10.3389/ fpubh.2014.00145 6. World Health Organization. (2001). WHO Global Strategy for Containment of Antimicrobial Resistance. Available from: http://www.who.int/drugresistance/WHO_Global_Strategy_English.pdf 7. Institute of Medicine (US) Forum on Emerging Infections; Knobler SL, Lemon SM, Najafi M, et al., editors. The Resistance Phenomenon in Microbes and Infectious Disease Vectors: Implications for Human Health and Strategies for Containment: Workshop Summary. Washington (DC): National Academies 42
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Press (US); 2003. 5, Factors Contributing to the Emergence of Resistance. Available from: https://www. ncbi.nlm.nih.gov/books/NBK97126 8. Benson JM. Incorporating pharmacy student activities into an antimicrobial stewardship program in a long-term acute care hospital. American Journal of Health-System Pharmacy. 2014;71(3):227-230. doi:10.2146/ajhp130321. 9. CDC. Core Elements of Hospital Antibiotic Stewardship Programs. Atlanta, GA: US Department of Health and Human Services, CDC; 2014. Available at http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html 10. Goff DA, Rybak MJ. Global Antimicrobial Stewardship: Challenges and Successes from Frontline Stewards. Infect Dis Ther Infectious Diseases and Therapy. 2015;4(S1):1-3. doi:10.1007/s40121-015-0088-4. 11. Jamal A. Medicine Awareness Campaign. IPSF Public Health Spot 5th issue. 2015. https://issuu.com/ipsf. org/docs/public_health_spot_5_final. 12. Mandela EM. Tuberculosis awareness campaign at Huye prison. IPSF Public Health Spot 5th issue. 2015. https://issuu.com/ipsf.org/docs/public_health_spot_5_final. 13. World Health Organization. Global action plan on antimicrobial resistance. 2015. http://apps.who.int/ iris/bitstream/10665/193736/1/9789241509763_eng.pdf?ua=1
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IVSA. Information Office DSR KU LIFE DyrlĂŚgevej 9, Kopenhag 1870 Fredriksberg C Website: www.ivsa.org Email: publichealth@ivsa.org 44
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