1. Unnecessary antibiotic use for mild ARI in 28-day follow-up of 823 children under five in rural Vietnam 1 Nguyen Quynh Hoa Nguyen Thi Kim Chuc Ho Dang Phuc Mattias Larsson Bo Eriksson Cecilia Stalsby Lundborg

2.  Introduction  Aim of the study  Study method  Results and discussion  Conclusions  Recommendations Outline

3. 3 Acute respiratory infections (ARI)  Leading cause of mortality and morbidity  Antibiotic treatment  IMCI guidelines: don’t need antibiotic for mild ARI  Irrational antibiotic use  resistance  Role of caregivers  Primary diagnosis, assess the severity  Make the decisions to treat the sick child Introduction

4. Antibiotic use and AB resistance in Vietnam  A dramatic increase of private health facilities  Availability of antibiotics: easily obtain  increase the Irrational Use of Antibiotics : self- medication, incorrect dose  High resistance and multidrug resistance  Weak regulatory implementation and enforcement 4 Introduction

5. 4 Aim of the study To assess knowledge and practice among caregivers about antibiotic use for mild ARIs in children and the association with demographic, social and economic characteristics

6. Study setting Bavi district 410 km2; 476 person/km2 262,000 persons Methods

7. BAVI DISTRICT: 32 communes 50.000 HHs; 232.400 persons FILABAVI: 69 clusters, 12.000 HHs 51.000 persons; 4.000 children under 5 Lowland area: 19 clusters 899 children 6-60 months Highland area: 33 clusters 1998 children 6-60 months Mountainous area: 17 clusters 1048 children 6-60 months 4 clusters/3 communes 284 children/284 HHs 4 clusters/3 communes 284 children/284 HHs 5 clusters/3 communes 282 children/282 HHs Sample of the study 847 HHs - 847 children 6-60 months (13 clusters/9 communes) Sampling Methods

8. 8 Interview using questionnaire  Knowledge, reported practice: 828 Antibiotic use Symptoms in the most recent illness Health seeking behavior  Antibiotic use survey: 823 children Symptoms, health-care, drug use 28 days follow-up: daily self- report, prescription, drug container Methods

9. Nov 20, 2009Nguyen Quynh Hoa9 Data management and data analysis  Illness classification: IMCI guidelines Mild ARI: cough, runny nose, sore throat, without fast breathing Severe ARI: fast breathing, chest in-drawing, stridor Others: watery feces, vomit, ear ache, injury, pain, skin rash…  28-day follow up period: Episode of illness: period of having continuous symptoms Course of antibiotic: period of using continuous antibiotic  Multiple logistic regression: knowledge and reported practice Methods

10. Data management and quality control  Instruments: developed in consultancy with relevant professionals  Pre-tested and piloted before conducting each sub-study.  Training of interviewers: theory and field practice.  One week recall period of drug use based on households’ daily self- reported forms: reduce recall bias.  Re-interviewed 5% of study population, checked 5% entered data against questionnaires. 10 Methods

11. Nguyen Quynh Hoa Caregivers‘knowledge of AB use for ARIs 11 Results 85% would not require for non-febrile cough 45% would require for febrile cough 47% would need antibiotics for pneumonia symptoms 42% would not need antibiotics in any case 37% would need in all the cases 13% caregivers had correct overall knowledge

12. Nguyen Quynh Hoa Child illness & caregivers’ health-care seeking behaviour  The most recent child illness: 79% mild ARIs Health seeking behavior: Drugstores 38%; public clinics 34%, private clinics 27%, self-treatment 19% Higher-educated caregivers more likely to self-treat  In the 28-day followed-up period: Mild ARIs: 623 children (73%), in 1,048 episodes 286 children (35%) had ≥ 2 mild ARI episodes Health seeking behavior: Drugstores 34%, public clinic 27%, self treatment 25%, private clinics 21% 12 Results

13. Antibiotic use for children in the most recent illness 13 71 % Seeking care at health facilities: higher antibiotic use Nguyen Quynh Hoa Results

14. Illness and antibiotic use in 28-day follow up Results  Antibiotic use: inappropriate use 62% children (513/823), 843 courses, in 1,790 days 63% AB courses for mild ARI  Mild ARIs: most common 73% children (623/823), 1048 episodes, in 4,077 days Half of episodes were treated with antibiotics

15. Duration of antibiotic course Results

16. Pattern of antibiotics use for 823 children in 28 days 16 Results 82% of antibiotics for mild ARI were recommended by HCPs

17. 18  Most of children had unnecessarily used antibiotics putting a constant selective pressure on bacterial resistance.  It’s likely health facilities used more unnecessary antibiotic use for mild ARI Conclusions

18. Policy implications  Need to improve caregivers’ knowledge about cause of cold and appropriate AB indications  Need to have regular training and monitoring for Health Care Providers in both public and private sectors  Controlling and enforcing the regulations of prescribed-drugs, GPP and registering of antibiotics 18 Nguyen Quynh Hoa