Antimicrobial resistance: from global agenda to national strategic plan, Thailand

There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

Abstract

Problem

In Thailand, antimicrobial resistance has formed a small component of national drug policies and strategies on emerging infectious diseases. However, poor coordination and a lack of national goals and monitoring and evaluation platforms have reduced the effectiveness of the corresponding national actions.

Approach

On the basis of local evidence and with the strong participation of relevant stakeholders, the first national strategic plan on antimicrobial resistance has been developed in Thailand.

Local setting

Before the development of the plan, ineffective coordination meant that antimicrobial resistance profiles produced at sentinel hospitals were not used effectively for clinical decision-making. There was no integrated system for the surveillance of antimicrobial resistance, no system for monitoring consumption of antimicrobial drugs by humans, livestock and pets and little public awareness of antimicrobial resistance.

Relevant changes

In August 2016, the Thai government endorsed a national strategic plan on antimicrobial resistance that comprised six strategic actions and five targets. A national steering committee guides the plan’s implementation and a module to assess the prevalence of household antibiotic use and antimicrobial resistance awareness has been embedded into the biennial national health survey. A national system for the surveillance of antimicrobial consumption has also been initiated.

Lessons learnt

Strong political commitment, national ownership and adequate multisectoral institutional capacities will be essential for the effective implementation of the national plan. A robust monitoring and evaluation platform now contributes to evidence-based interventions. An integrated system for the surveillance of antimicrobial resistance still needs to be established.

Résumé

Problème

En Thaïlande, le problème de résistance aux antimicrobiens était partiellement pris en compte dans les stratégies et politiques nationales liées à la consommation de médicaments et destinées à lutter contre les maladies infectieuses émergentes. Mais des problèmes de coordination et l'absence d'objectifs nationaux et de plateformes de surveillance et d'évaluation limitaient l'efficacité de ces initiatives nationales.

Approche

À partir des données factuelles disponibles sur la situation locale et grâce à une importante participation des parties prenantes concernées, la Thaïlande a élaboré son premier plan stratégique national sur la résistance aux antimicrobiens.

Environnement local

Avant la conception de ce plan, une coordination inefficace faisait que les profils de résistance aux antimicrobiens produits dans les hôpitaux sentinelles n'étaient pas efficacement utilisés dans la prise de décisions cliniques. Il n'existait aucun système intégré de surveillance de la résistance aux antimicrobiens, aucun système de suivi de la consommation d’antimicrobiens par les humains, le bétail et les animaux domestiques, et la population était peu sensibilisée au problème de résistance aux antimicrobiens.

Changements significatifs

En août 2016, le gouvernement thaïlandais a validé un plan stratégique national sur la résistance aux antimicrobiens, comprenant six actions stratégiques et cinq objectifs. Un comité de pilotage national a été constitué pour guider la mise en œuvre du plan, et un module destiné à évaluer la prévalence de l'utilisation des antibiotiques dans les ménages et la sensibilisation à la résistance aux antimicrobiens a été intégré dans l'enquête nationale sur la santé réalisée tous les deux ans. Un système national pour la surveillance de la consommation d'antimicrobiens a également été lancé.

Leçons tirées

Un engagement politique fort, une mobilisation nationale et des capacités institutionnelles multisectorielles appropriées seront essentiels pour une mise en œuvre efficace du plan national. Une solide plateforme d'évaluation et de surveillance contribue désormais à fonder les interventions sur des données factuelles. Mais un système intégré pour la surveillance de la résistance aux antimicrobiens doit encore être créé.

Resumen

Situación

En Tailandia, la resistencia a los antimicrobianos ha formado un pequeño componente de las políticas y estrategias de medicamentos nacionales sobre las enfermedades infecciosas emergentes. No obstante, la escasa coordinación y la ausencia de objetivos nacionales y plataformas de control y evaluación han reducido la efectividad de las medidas nacionales correspondientes.

Enfoque

Sobre la base de las pruebas locales y con la gran participación de partes interesadas relevantes, se ha desarrollado en Tailandia el primer plan estratégico nacional sobre la resistencia a los antimicrobianos.

Marco regional

Antes de desarrollar el plan, la mala coordinación provocó que los perfiles de resistencia a los antimicrobianos producidos en los hospitales centinela no se utilizasen de forma adecuada para la toma de decisiones clínicas. No existía un sistema integrado para la vigilancia de la resistencia a los antimicrobianos, ni un sistema para el control del consumo de medicamentos antimicrobianos por parte de humanos, ganado y mascotas, ni apenas concienciación pública sobre la resistencia a los antimicrobianos.

Cambios importantes

En agosto de 2016, el gobierno tailandés aprobó un plan estratégico nacional sobre la resistencia a los antimicrobianos que estaba formado por seis medidas estratégicas y cinco objetivos. Un comité directivo nacional dirige la implementación del plan y un módulo para evaluar la prevalencia del uso doméstico de antibióticos y se ha integrado la concienciación sobre la resistencia a los antimicrobianos en la encuesta nacional bienal sobre salud. También se ha iniciado un sistema nacional para la vigilancia del consumo de antimicrobianos.

Lecciones aprendidas

Un fuerte compromiso político, una propiedad nacional y las capacidades institucionales multisectoriales adecuadas serán esenciales para la implementación eficaz del plan nacional. Ahora, una sólida plataforma de control y evaluación contribuye a las intervenciones basadas en pruebas. Sin embargo, aún debe establecerse un sistema integrado para la vigilancia de la resistencia a los antimicrobianos.

ملخص

المشكلة شكلت مقاومة الميكروبات في تايلند عنصرًا ضئيلاً من سياسات واستراتيجيات الأدوية الوطنية بشأن الأمراض المعدية الناشئة. ومع ذلك، فقد أدى ضعف التنسيق وغياب الأهداف الوطنية ومنصات الرصد والتقييم إلى تقليص فعالية الإجراءات الوطنية المقابلة.

الأسلوب استنادًا إلى الأدلة المحلية وبمشاركة قوية من أصحاب المصلحة المعنيين، فقد تم وضع أول خطة استراتيجية وطنية بشأن مقاومة الميكروبات في تايلند.

المواقع المحلية قبل وضع الخطة، كان التنسيق غير الفعال يعني أن أنماط مقاومة الميكروبات الناتجة في المستشفيات الخفرية لم تكن تُستخدم بشكل فعال لاتخاذ القرار السريري. ولم يكن هناك نظام متكامل لمراقبة مقاومة الميكروبات، ولا نظام لرصد استهلاك العقاقير المقاومة للميكروبات من قبل البشر والماشية والحيوانات الأليفة، بالإضافة إلى ضعف الوعي العام بمقاومة الميكروبات.

التغيّرات ذات الصلة أقرت الحكومة التايلندية خطة استراتيجية وطنية بشأن مقاومة الميكروبات والتي تضم ستة إجراءات استراتيجية وخمسة أهداف وذلك في شهر آب/أغسطس من عام 2016. وتوجد لجنة توجيهية وطنية معنية بتنفيذ الخطة، وقد تم تضمين وحدة لتقييم مدى انتشار استخدام المضادات الحيوية بين العائلات والوعي بمقاومة الميكروبات في المسح الصحي الوطني الذي يُجرى كل سنتين. كما بدأ العمل بنظام وطني لمراقبة استهلاك مقاومة الميكروبات.

الدروس المستفادة سيكون الالتزام السياسي القوي والمسؤولية الوطنية والقدرات المؤسسية الكافية متعددة القطاعات أمرًا أساسيًا للتنفيذ الفعال للخطة الوطنية. وتساهم الآن منصة قوية للرصد والتقييم في التدخلات القائمة على الأدلة. ولا يزال يتعين إنشاء نظام متكامل لمراقبة مقاومة الميكروبات.

摘要

问题

在泰国,抗菌素耐药性已成为针对新发现传染疾病的国家药物政策和策略的一小部分。然而,协调不力、缺乏国家目标以及监测和评估平台降低了相应国家行动的有效性。

方法

基于当地实情和在相关利益攸关方的大力参与下,首个国家抗菌素耐药性战略计划已于泰国制定。

当地状况

该计划制定之前,无效协调指在哨点医院生成的抗菌素耐药性资料未被有效地用于临床决策。没有用于监测抗菌素耐药性的综合系统,没有监测人类、家畜和宠物抗菌药物消耗的系统以及公众缺少对抗菌素耐药性的认识。

Резюме

Проблема

В Таиланде проблема устойчивости возбудителей к противомикробным препаратам стала одним из второстепенных направлений национальной политики и стратегии в отношении применения лекарственных препаратов при вновь возникающих инфекционных заболеваниях. Однако слабая координация и отсутствие национальных целей и платформ мониторинга и оценки снизили эффективность соответствующих национальных мероприятий.

Подход

С учетом местных данных и при активном участии соответствующих заинтересованных сторон в Таиланде был разработан первый национальный стратегический план по решению проблемы с устойчивостью возбудителей к противомикробным препаратам.

Местные условия

До разработки плана неэффективная координация означала, что профили устойчивости возбудителей к противомикробным препаратам, составленные в дозорных больницах, неэффективно использовались при принятии клинических решений. Отсутствовала единая система для наблюдения за устойчивостью возбудителей к противомикробным препаратам, а также система мониторинга применения противомикробных препаратов у людей, сельскохозяйственных и домашних животных, и информированность общественности об устойчивости возбудителей к противомикробным препаратам была недостаточной.

Осуществленные перемены

В августе 2016 года Правительство Таиланда одобрило национальный стратегический план по решению проблемы устойчивости возбудителей к противомикробным препаратам, который включал шесть стратегических мероприятий и пять целей. Национальный управляющий комитет руководит реализацией плана, и в двухгодичный обзор общественного здравоохранения включен встроенный модуль оценки распространенности использования антибиотиков в домашних условиях и осведомленности общественности о микробной устойчивости. Также была введена национальная система наблюдения за применением антимикробных препаратов.

Выводы

Для эффективной реализации национального плана крайне важны решительная политическая приверженность, национальная ответственность и наличие соответствующего многосекторального институционального потенциала. Надежная платформа мониторинга и оценки в настоящее время вносит свой вклад в научно обоснованные вмешательства. Комплексную систему надзора за устойчивостью возбудителей к противомикробным препаратам все еще предстоит создать.

Related collections

Most cited references 4

Record: found
Abstract: found
Article: not found

Integrating animal health surveillance and food safety: the issue of antimicrobial resistance.

G Moulin, J F Acar (2013)

Surveillance of antimicrobial resistance in commensal, zoonotic and pathogenic bacteria from humans, animals and food is an essential source of information when formulating measures to improve food safety. International organisations (the World Health Organization, the World Organisation for Animal Health, the Food and Agriculture Organization of the United Nations, and the Codex Alimentarius Commission) have developed a complete set of standards related to resistance surveillance programmes and are calling for the establishment of integrated surveillance programmes. The most important task in establishing an integrated surveillance programme for antimicrobial resistance should be the harmonisation of laboratory testing methodology and antimicrobial-use reporting. Overthe last decade, the integration of surveillance of antimicrobial resistance has been an important step toward addressing the global concern with antimicrobial resistance. However, very few systems are in place and there is still a lot to do before harmonised surveillance systems become the norm.

0 comments Cited 14 times – based on 0 reviews      Review now

Bookmark

Record: found
Abstract: found
Article: found

Is Open Access

Surveillance of antimicrobial consumption: methodological review for systems development in Thailand

Viroj Tangcharoensathien, Angkana Sommanustweechai, Boonrat Chanthong … (2017)

The increased trend of antimicrobial resistance has become a global threat to human security, causing serious negative impacts on human, animal and environment. Inappropriate uses of antimicrobial are main drivers of the emergence of resistant bacteria [1].Combating AMR requires in–country multi–sectoral actions and global collective efforts using “One Health” approach. The Thai National Strategic Plan on AMR (2017–2021) was developed through a full engagement of stakeholders and National Health Assembly processes [2]. The Thailand Cabinet endorsed it in August 2016. Two out of the five targets are 20% and 30% reduction in antimicrobial consumption in human and animal by 2021, respectively (see Box 1 ). Box 1 Goals of the National Strategic Plan for AMR By 2021: 50% reduction in AMR morbidity 20% reduction in antimicrobial consumption in humans 30% reduction in antimicrobial consumption in animals 20% increase of public knowledge on AMR and awareness of appropriate use of antimicrobials Capacity of the national AMR management system is improved to level 4 (measured by the 2016 WHO’s Joint External Evaluation for International Health Regulation 2005) To optimize use of antimicrobial agents in human and animal, as recommended by the WHO Global Action Plan [3], countries need to develop a sustainable system which monitors their consumption and disseminate the information for policy decision. For example, France had a high human antibiotic use in the EU, and implemented a national campaign which resulted in a significant reduction in consumption [4]. This paper reviews international approaches on surveillance of antimicrobial consumption in human and animal, analyzes antimicrobial sales reporting systems and assesses how the surveillance system can be developed and sustained in Thailand. ANTIMICROBIAL CONSUMPTION IN HUMAN AND ANIMAL: REVIEW OF INTERNATIONAL APPROACHES Human consumption Since 2011, European countries have been developing a surveillance system for human. The European Surveillance of Antimicrobial Consumption Network (ESAC–Net) [5], covers 30 European Union and European Economic Area (EU/EEA) countries. It provides cross–country analysis and information is fed back to member countries to inform policy, as well as making publicly assessable information through the interactive database. Data sources are either national sales of antimicrobials or reimbursement data available from health insurance systems. These data disaggregate consumption by community (ambulatory care) and hospital care ( Table 1 ). Table 1 Two data sources used by ESAC–Net and ESVAC: reimbursement vs sales data Country Reimbursement data Antimicrobial sales data Human, community uses Human, hospital uses Human, combined community and hospital uses Human, community uses Human, hospital uses Human, combined community and hospital uses Animal uses Austria X X Belgium X X X Bulgaria X X X Croatia* X X Cyprus X X Czech Republic X X Denmark X X X Estonia X X X Finland X X X France X X X Germany X X Greece* X X Hungary X X Iceland X X Ireland X X X X Italy X X X Latvia X X X Lithuania X X X Luxembourg X X X Malta* X X Netherlands X X X Norway X X X X X Poland X X Portugal X X X X Romania* X Slovakia X X X Slovenia X X X X X Spain X X Sweden X X X United Kingdom X X *No data in animals. The surveillance system may cover hospital or community levels [6]. Monitoring consumption in hospital settings is useful for impact assessment of AMR leading to attribution of morbidity and mortality on health care cost and for micro–policy decision on rational use. Monitoring consumption in community is more complex than a hospital setting, where national sales data to communities are used for estimation. A majority of developing countries do not compile national sales data to communities. Alternative ways of capturing antimicrobial use are surveys of pharmacies, sentinel in specific sites or prospective household survey. Animal consumption The European Surveillance of Veterinary Antimicrobial Consumption (ESVAC) project was established in 2009 [7]. It reports antimicrobial consumption in animal by collecting sales data of veterinary antimicrobials in 26 countries, which covers 95% of total food–producing animal populations. The data sources came from wholesalers (17 countries), marketing–authorization holders (4 countries), both wholesalers and marketing–authorization holders (2 countries). Some countries provide feed mill data ( Table 1 ) [7]. In all countries, it is mandatory by Law for pharmaceutical operators to report their sales data to the national authority, except in France, Hungary, Netherlands and Spain. Analysis of data sources: reimbursement vs sales data As seen in Table 1 , antimicrobial sales data for human use is the main source in a majority of the 30 EU/EEA countries. These data are able to be disaggregated by community and hospital uses; while all countries are reliant on sales data for antimicrobial agents used in animals. Most European countries had achieved universal health coverage; still there are limitations in capturing antimicrobial consumption from reimbursement databases. In developing countries with limited population coverage by insurance schemes, more limitation of reimbursement data for estimate of antimicrobial consumption is expected. This indicates that development of the surveillance system requires strengthening of antimicrobial sales data for both humans and animals. Reviews found that approaches used by EU/EAA countries can be applied to developing countries given there is a good antimicrobial sales data systems in both sectors. UNDERSTANDING THE LANDSCAPE OF DRUG AUTHORIZATION IN THAILAND Legal frameworks and actors Two laws govern the distribution of antimicrobials for human and animals: the 1967 Drug Act responsible by Thai Food and Drug Authority (Thai–FDA); and the 2015 Animal Feed Quality Control Act, responsible by Department of Livestock Development. It is noted that a majority of antimicrobials used in livestock are consumed through medicated feeds, and much less on finished products mostly applied to pets. Key actors are importers, local manufacturers and pharmacies which are authorized to sell antimicrobials by Thai–FDA. Antimicrobials can be used upon prescription, but in practice the requests from customers and farmers could influence dispensing in private pharmacies. A major loop–hole in enforcing the Drug Act is the lack of effective measures and monitoring systems for antibiotic distribution especially active pharmaceutical ingredients (API). Reporting sales data by operators There are two mandatory sales reporting systems by the importers and manufacturers. First is the four–monthly report of sales and distribution of potentially abused medicines by consumers, such as steroids, tramadol and dextromethorphan. This system is designed for tight control of distribution of these medicines to prevent drug abuse. Second an annual report of production and importation of all pharmaceutical products where historically Thai–FDA did not request to provide distribution details. To facilitate development of surveillance system, the existing two reports needs to revise in order to track the distribution of antimicrobials from productions/importation to users. However, the Thai–FDA has to issue regulations to add highly potentially antibiotics to the four–monthly report. Moreover, a greater reliance on the annual report on production and importation with volumes and values of product and it requires them to report data on distribution channel. There is a gap which is the lack of reporting on the production of medicated feeds. Figure 1 presents the distribution channels. Figure 1 Distributional channels by antimicrobial agents. This study covers solid line which includes antibiotic sales data from importers and manufactures. The dotted line distributions are outside the scope of this study. With reference to reviewed information from ESAC and ESVAC, the planned Thailand systems where data sources on total sales for human are the combine of community and hospital levels and sales data for animal happens to be similar to Iceland ( Table 1 ) where antimicrobials sales data are available on combined community and hospital care in humans; and totals are available for animal use. The breakdown by community and hospital use will be discussed further in the subsequent section. Key parameters in the electronic reporting will include: the operator’s unique ID; pharmaceutical product unique ID with reference to the License ID assigned by Thai–FDA; Anatomical Therapeutic Chemical (ATC) classification); quantity and value including package size; doses; and forms. The objectives are to estimate human consumption as measured by Defined Daily Dose (DDD) and animal consumption as measured by milligram of antibiotic. DEVELOPMENT OF SURVEILLANCE OF ANTIMICROBIAL CONSUMPTION: METHODOLOGICAL APPROACHES FOR THAILAND Currently, there is no system to monitor consumption of antimicrobial in Thailand. The Thai Surveillance of Antimicrobial Consumption (Thai SAC) is developed to fill the gap, which provides a 2017 baseline consumption and a long term monitoring process. In 2017, grants from USAID, WHO and FAO had been approved for research and development of the Thai surveillance system. Research team comprises of Thai–FDA, Department of Livestock Development, universities and International Health Policy Program of the Ministry of Public Health. Systems analysis was conducted to understand the distributional channel, legal framework and sales reporting systems; all forms the basis of the surveillance system development. All medicines in the Thai–FDA registration database are assigned with ATC classification code for human drugs and ATCvet for veterinary medicinal products. The scope of surveillance system will cover antimicrobials at least for systemic use, J01 in human and QJ01 in animal. The design of Thai Surveillance of Antimicrobial Consumption is based on national sales data, which is a mandatory report by importers and manufacturers to the Thai–FDA; as use data by clinical conditions, age and gender are not readily available. The antimicrobial sales data will be verified for their adequacy, accuracy and completeness before analysis. In human, antimicrobial consumption is measured by DDD per 1000 inhabitants–day [8]. The consumption of antimicrobials in animal is measured by milligrams of API per population correction unit (PCU). The PCU is the estimated weight for each animal species at treatment of livestock and of slaughtered animals at import and export for fattening and slaughter [7]. As there is no PCU in Thailand, we will use PCU following the ESVAC to facilitate international comparison. Photo: from the International Health Policy Program, Ministry of Public Health, Thailand, taken by Phanit Phacharaphimansakul (used with permission) CHALLENGES AND SOLUTIONS A few challenges are identified for improvement of methodological approaches. Development of Surveillance of Antimicrobial Consumption relies on two sets of parameters: the numerators are total antimicrobial sales for human and animal consumption; the denominators are the total human and animal population. The numerators The completeness and accuracy of reporting by operators, though mandatory, is an initial challenge. However, electronic submission with reference to the unique identification number of each ATC code would facilitate accuracy of reporting. There are total 774 importers and 184 manufactures; for which representative samples of operators selected for on–site verification. This will gradually improve the quality of reports. Command and control, though a mandatory requirement by Thai–FDA, may not work well. Rather, effective communication between Thai–FDA and the operators and social recognition of their contributions to surveillance data are essential for adherence to quality report. We assume that the total antimicrobial production and importation (though certain unknown size of reported illegal importation and production) minus total exports is the total consumption in both sectors. Although there is variation in annual stock, in an efficient pharmaceutical market, the stock level should be constant. The annual report by operators does not disaggregate by community, hospital and animal species. For human antimicrobials, we plan to disaggregate by using national insurance reimbursement data set or surveys of organisations. Antimicrobial consumption by key species of food animals is important for specific policy intervention, efforts are planned to disaggregate data by special surveys, including the estimate of total consumption in the aquaculture. The off–label use of human antibiotics in pets and plants in particular citrus trees for the treatment of Greening Diseases [9] is commonly observed in Thailand; efforts are under way to investigate sources and magnitude of antibiotic use in pets and plants with supports from FAO by this research program. The denominators The Department of Livestock Development has yet to strengthen the data systems for accurate statistics on the total number of livestock by species. Not all livestock are raised through commercial standard farming systems, estimate size of local backyard farming contributes to accurate consumption per PCU. Estimate total national number of pets, most common are dogs and cats, and total PCU in aquaculture are the future research agenda. The sustainability of the surveillance system Sustainability of the surveillance system not only depends on the mandatory reporting system, other enabling factors are for example effective communication with the operators, user friendly electronic submission, systems which facilitate e–submission and safeguard confidentiality of sales data. Relevant authorities had fully involved in the surveillance system design and development; this ensures long term sustainability in particular the IT systems. Policy decision based on evidences and publicly accessible report foster political support for a sustainable Thai Surveillance of Antimicrobial Consumption. CONCLUSION In responses to AMR, the Thai national surveillance system is critical for monitoring total consumption for which effective policies can be introduced to curb down excessive consumption. The current design disaggregates human consumption by level of care such as hospital and pharmacies; however point prevalence surveys are needed to estimate consumption by clinical conditions, age and gender. The current design does not differentiate consumption by animal species; further monitoring of veterinary prescription support consumption by animal species. Reviews of international experiences and the analysis of how to design a Thai Surveillance of Antimicrobial Consumption are useful to developing countries to apply to suit the national data systems. The Political Declaration of the High–Level Meeting of the UNGA on AMR in September 2016 which calls for “Improve surveillance and monitoring of AMR and the use of antimicrobials to inform policies” [10] puts pressure on countries to develop surveillance system and ensure its use for policy decision.

0 comments Cited 8 times – based on 0 reviews      Review now

Bookmark

Record: found
Abstract: not found
Article: not found

Health and economic impacts of antimicrobial resistance in Thailand.

P Pumart, T Phodha, V Thamlikitkul … (2012)

0 comments Cited 3 times – based on 0 reviews      Review now

Bookmark

All references

Author and article information

Journal

Journal ID (nlm-ta): Bull World Health Organ

Journal ID (iso-abbrev): Bull. World Health Organ

Journal ID (publisher-id): BLT

Title: Bulletin of the World Health Organization

Publisher: World Health Organization

ISSN (Print): 0042-9686

ISSN (Electronic): 1564-0604

Publication date (Print): 01 August 2017

Publication date (Electronic): 11 May 2017

Volume: 95

Issue: 8

Pages: 599-603

Affiliations

[a ]International Health Policy Program, Ministry of Public Health, Soi Satharanasook 6, Tiwanon Road, Nonthaburi 11000, Thailand.

[b ]Food and Drug Administration, Ministry of Public Health, Nonthaburi, Thailand.

[c ]Department of Medical Science, Ministry of Public Health, Nonthaburi, Thailand.

[d ]Food and Agriculture Organization Regional Office for Asia and the Pacific, Bangkok, Thailand.

[e ]World Health Organization Country Office, Ministry of Public Health, Nonthaburi, Thailand.

Author notes

Correspondence to Viroj Tangcharoensathien (email: viroj@ 123456ihpp.thaigov.net ).

Article

Publisher ID: BLT.16.179648

DOI: 10.2471/BLT.16.179648

PMC ID: 5537745

PubMed ID: 28804172

SO-VID: 3fc5c245-2d57-437c-bc9e-c05248ba1bde

License:

This is an open access article distributed under the terms of the Creative Commons Attribution IGO License ( http://creativecommons.org/licenses/by/3.0/igo/legalcode), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In any reproduction of this article there should not be any suggestion that WHO or this article endorse any specific organization or products. The use of the WHO logo is not permitted. This notice should be preserved along with the article's original URL.

History

Date received : 02 June 2016

Date revision received : 12 November 2016

Date accepted : 06 April 2017

Comments

Comment on this article

scite_

Cited by 25

See all cited by

Most referenced authors 76

See all reference authors

- Version 1

Read this article at

Abstract

Problem

Approach

Local setting

Relevant changes

Lessons learnt

Résumé

Resumen

ملخص

摘要

Резюме

Related collections

Special issue: Negotiating the Nation: Young people, national narratives and history education

Most cited references 4

Integrating animal health surveillance and food safety: the issue of antimicrobial resistance.

Surveillance of antimicrobial consumption: methodological review for systems development in Thailand

Health and economic impacts of antimicrobial resistance in Thailand.

Author and article information

Journal

Affiliations

Author notes

Article

History

Categories

Comments

Comment on this article

Similar content 111

Cited by 25

Most referenced authors 76