Prevention of infectious diseases in school children Tereza Kopřivová Herotová Dagmar Schneidrová Dept. of Child and Youth Health

Infectious diseases in the Czech Republic in 2011 (Institute of Health Statistics and Information, CR 2012) Structure and incidence of infectious diseases by age groups (see p ÚZIS infnem2012.pdf)

Antibiotic use: evolution of penicillin resistance of Staphylococcus aureus

Ferech, M. et al. JAC : Total antibiotic use in European countries 2003

Antibiotic use: outpatient penicillin usage correlated with penicillin resistance, Europe, 2005 Source: Goossens et al. 2005

Prevalence of MRSA in Europe

Pneumococcus resistance to macrolides

Misunderstandings about antibiotics Antibiotics work on most coughs & colds Antibiotics can kill bacteria Antibiotics can kill viruses Antibiotics can kill bacteria that normally live on the skin and gut Bacteria that normally live on the skin and in the gut are good for you And year olds are less knowledgeable

ATB SELF MEDICATION (Europe)

Survey on ATB use in CR ( Dept. of Child Health, TH Bulovka, 2009) 18 % respondents used ATB without consulting a physician. 3 % parents gave ATB to the child without consulting a physician % resp. have ATB at home. 59 % of Prague resp. and 48 % of resp. outside Prague have no ATB leftovers at home. 55 % resp. expect ATB effect within 24 hours. 24 % resp. would prefer having medicaments in drugstores, 9 % resp. in shops. 10 % resp. would prefer PNC without prescription, 2 % resp. all ATB without prescripton % health profs. does not consider resistance a serious problem % resp. consider compulsory vaccination useful.

ATB are efficient against ? ( Dept. of Child Health, TH Bulovka, 2009)

The five key areas for prevention of antimicrobial resistance Rational drug use and regulation Research and development Animal husbandry, agriculture, aquaculture Surveillance Infection prevention

Rational drug use and regulation Reduce ATB use (↓ prescription) Reduce spread of resistent strains (isolation) Intervention (education) activities  focused on health profs in different fields  focused on public

e-Bug the EU initiative for school children Tereza Kopřivová Herotová National coordinator

What is an e-Bug project e-Bug is a European wide antibiotic and hygiene teaching resource for junior (9-11 y.) and senior (12-15 y.) school children Funded by DG Sanco (EU Commission) The project is lead by the Health Protection Agency (HPA) Primary Care Unit in Gloucester, UK and involves a consortium of 18 partner EU countries: 10 associate and 8 collaborating

10 Associate Partners Belgium Czech Republic Denmark France Greece Italy Poland Portugal Spain Great Britain

8 Collaborating Partners Croatia Finland Hungary Ireland Latvia Lithuania Slovakia Slovenia

e-BUG project 18 European countries → 62 % European population Great Britain Czech Republic France Poland Belgium Denmark Greece Portugal Italy Spain Lithuania Latvia Finland Croatia Hungary Slovakia Slovenia Ireland

E-Bug project Associate partners 46 % of European population 300 mil. people 62% of European Population Collaborative partners 15% of European population 90 mil. people

The aims of e-Bug project Increase awareness on benefits of compulsory and elective vaccination Increase awareness on microbial resistance Increase compliance of patients related to ATB use Improve personal hygiene of school children Teach: – Prevention better than cure – Benefits of antibiotics – Overuse of antibiotics may have adverse effect

DH SMAC Committee 1998: Teaching about antibiotics should be included as part of the National Curriculum

Reducing infection rates should reduce antibiotic use in children! Spread of infection is mainly via sneezing/coughing and contaminated hands Handwashing interventions reduce illnesses and absenteeism in schools

3 key topics 1. Microorganisms Useful and dangerous microbes Viruses vs. Bacteria vs. Fungi ATB have no effect against viral and fungal infections Compulsory and elective vaccination Natural microflora and its importance

3 key topics 2. Personal hygiene 80% common infections are spread via dirty hands Hand washing = effective prevention of infections of upper and lower respiratory tract and GIT (alimentary infections) Timing and technique of hand washing

3 key topics 3. Antibiotic resistance Misuse and overuse of ATB Mechanism of developing resistance Risks of resistance Prevention of resistance Negative effects of ATB on health

Developing e-Bug style & content Brainstorming sessions with teachers & partners: Suit range of teaching styles Have IT links Be student friendly MUST link closely to National Curriculums

Development of Junior and Senior Characters Clothing Hair styles ‘Girly look’ Amy and Harry

Development of bug characters Good BugsBad Bugs Junior bugsSenior bugs Bacteria Fungus Viruses

e-Bug Lesson Plan for Junior Schoolchildren 1. Introduction to microbes  They are found everywhere even though you can’t see them.  There are three types of micro-organisms. 2. Good Microbes  Good bacteria keep us healthy.  Bacteria can be put to good use. 3. Bad Microbes  Sometimes microbes can make us sick. 4. Prevention of Infection  Prevention when possible is better than cure.  Keep your bad microbes to yourself.  Our body helps defend against microbes. Hand hygiene How, When and Why to wash your hands Respiratory hygiene Cover your coughs and sneezes Vaccines Vaccines are important to prevent a range of infections (including the flu). There are not vaccines for ALL infections. 5. Treatment of Infection  Most common infections get better on their own through time, bed rest, liquid intake and healthy living.  Antibiotics : If you have antibiotics, finish the course!

Junior Microbe activity

Respiratory Hygiene activity Best part: sneezing because you get to use the snot gun Holding a tissue in front of your nose spreads less germs

Junior antibiotic activity It really hurts and I think I’m getting a cough. Don’t you have any antibiotics at home you can take? Reading the comic Not to use someone elses antibiotics Best part: What we learnt: All antibiotics are different

e-Bug Lesson Plan for Senior Schoolchildren 1. Introduction to microbes  There are three different types of microorganisms (bacteria, viruses, fungi).  They are found everywhere even though you can’t see them.  They are found in your body. 2. Good Microbes  Good bacteria can help keep us healthy.  Most microbes are good for us. They can be put to good use.  We need bacterial colonisation to live a healthy life (normal flora). Protect your flora. 3. Spread and Prevention of Infection  Sometimes microbes can make us sick.  Prevention where possible is better than cure.  Don’t spread your bad microbes to others.  Our body helps defend against microbes.  Different routes of infection are hands, water, air, blood. 1.Hand hygiene - How, When and Why to wash your hands. 2.Respiratory hygiene - Cover your coughs and sneezes.How and why this is important. 3.Vaccines - Vaccines help prevent a range of bacterial and viral infections.Previously common infections are rare due to vaccines.There are not vaccines for all infections. Most common infections are not prevented by vaccines. 4.Sexually transmitted infections 4. Treatment of Infection  Most common infections get better on their own through time, bed rest, liquid intake and healthy living.  Antibiotics - If you have antibiotics, finish the course. Do not use leftover or other people antibiotics. Overuse of antibiotics can damage our normal / good bacteria. Bacteria are becoming resistant to antibiotics due to overuse.

Food hygiene activity Seeing the microbes was really cool It was a different type of lesson I never knew bacteria were alive It was really hard to keep the bacteria off the salad Germs can spread very easily Always wash hands when dealing with food

Hand hygiene activity There are loads of bacteria on your body I learnt how to stop microbes spreading I learnt to wash my hands all the time

Proper handwashing 10 teps 1.Water your hands in pouring warm water.

2. Soap all your hands.

3. Soap your palms.

4.Soap between fingers.

5.Soap back of your hands

6.Soap your nails and under nails.

7.Soap your wrists.

8.Water your hands and dry them with a paper towel.

9.Close the water tap with the towel.

10. Open the door with the paper towel and throw it to the basket!

Senior antibiotic activity That’s amazing – this bug’s killed by all of them

Development of Website – All pack content – Teacher presentations to aid lesson plans – Games for classroom or home play – Revision sections for students

e-Bug Time-lines 1-3m Jun 06 - Aug 06 appoint UK staff 3-12m Sep 06 - May 07 research across Europe 13-21m Jun 07 - Feb 08 pack and website in England 22-27m Mar 08 - Aug 08 translation in 9 AP countries 27-39m Aug 08 - Aug 09 dissemination in AP countries 22-39m Mar 08 - Aug 09 evaluation in 3 AP countries 36m May 09 presentation to collaborating countries 2010 final version translated to all European languages and distributed

Pack Evaluation France, Czech Republic and England Control and Intervention schools – 86 schools and 6290 students (52% senior) – Questionnaires pre and 2-4 weeks post activities Significant increase in knowledge in all activity areas

Where e-Bug fits into the Curriculum ScienceScienceSpain ScienceSciencePortugal Religion Perio ScienceSciencePoland ScienceScienceItaly ScienceScienceGreece PSHE BiologyScienceScience Great Britain ScienceScienceFrance ScienceScienceDenmark Homeland study Chemistry BiologyScience Science* Czech Republic ScienceScienceBelgium PrimarySecondary * And in Slovenia, Slovakia and Latvia science (natural and social) account for the largest portion of time in the curriculum.

e-Bug in the Czech Republic Implementation Review - adaptation to the CR school system Translation - pack and website (available Sept. 09) Promotion - Teachers fairs and science fairs ( ). − Links in packs to related websites and vice versa. − Information letter to all primary and secondary schools (August ’09). − Teachers magazines and websites − Science teachers networks Endorsement - Project supported by Ministries of Health and Education and Johnson&Johnson Printing – All Czech primary and secondary schools received a free printed copy (4,000 primary and 3,600 secondary schools)

Prevention of Infections Role of the Public Health Officer (CR – Hygiene of Children and Youth) Law No.258/2000 on public health protection Regular assessment of school environment according to hygienic standards and regulations (microclimate – temperature, ventilation, cleanliness of the facility, etc.) Consultant or coordinator of school health promotion programmes

Construction, technical and microclimatic conditions Law No.183/2006 on district planning and construction regulations Directive No.268/2009 on general technical requirements on buildings CSN – cloakrooms, washrooms and toilets

Hygiene of school facilities MoH Directives No. 410/2005, No. 343/2009 on hygienic requirements on facilities and regimen of educational facilities for children and youth: - incl. requirements on hygienic facilities (toilets, washrooms – e.g. 1 washbasin/20 children, soap container, hand dryer or paper towels)

Ambient temperature Direct. No. 343/2009 defines requirements on ventilation and parameters of microclimatic conditions (temperature, circulation velocity, relative moisture of air) defines measures in higher values (ventilation, heating regulation) and lower values in the classroom (3 days below 18 o C or 1 day below 16 o C – school attendance is stopped)

Air quality Directive No. 268/2009 max. concentration of CO2 acceptable for ambient environment – 1000 ppm. regular ventilation recommended