Nguyen Quynh Hoa Nguyen Thi Kim Chuc Ho Dang Phuc Mattias Larsson Bo Eriksson

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

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

3. Introduction 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 3

4. Introduction 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

5. 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 4

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

7. Methods 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 Mountainous area: 17 clusters 1048 children 6-60 months Highland area: 33 clusters 1998 children 6-60 months 4 clusters/3 communes 284 children/284 HHs 5 clusters/3 communes 282 children/282 HHs 4 clusters/3 communes 284 children/284 HHs Sample of the study 847 HHs - 847 children 6-60 months (13 clusters/9 communes) Sampling

8. Methods 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 8

9. Methods 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 Nguyen Quynh Hoa Nov 20, 2009 9

10. Methods 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.

11. Results Caregivers‘knowledge of AB use for ARIs • 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 Nguyen Quynh Hoa

12. Results 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% Nguyen Quynh Hoa

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

14. Results Illness and antibiotic use in 28-day follow up • 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. Results Duration of antibiotic course

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

17. Conclusions • 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 18

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 Nguyen Quynh Hoa