Addressing the threat of antibiotic resistance in Thailand: monitoring population knowledge and awareness.

The 2015 Global action plan on antimicrobial resistance (GAP-AMR) highlights the key importance of improving awareness and understanding of antimicrobial resistance among consumers. While low levels of awareness are not exclusive to consumers in low- and middle-income countries, the challenges to improving understanding are compounded in these settings, by factors such as higher rates of antibiotic self-medication and availability through informal suppliers. In 2016, Thailand set an ambitious target to increase, by 2021, public knowledge of antibiotic resistance and awareness of appropriate use of antibiotic by 20%. This involved first establishing baseline data by incorporating a module on antibiotic awareness into the 2017 national Health and Welfare Survey conducted by the National Statistical Office. The benefit of this approach is that the data from the antibiotic module are collected in parallel with data on socioeconomic, demographic and geospatial parameters that can inform targeted public communications. The module was developed by review of existing tools that have been used to measure public awareness of antibiotics, namely those of the Eurobarometer project of the European Union and a questionnaire developed by the World Health Organization. The Thai module was constructed in such a way that results could be benchmarked against those of the other survey tools, to allow international comparison. The Thai experience showed that close collaboration between the relevant national authorities allowed smooth integration of a module on antibiotic awareness into the national household survey. To date, evidence from the module has informed the content and strategy of public communications on antibiotic use and misuse. Work is under way to select the most robust indicators to use in monitoring progress. The other Member States of the World Health Organization South-East Asia Region can benefit from Thailand's experiences in improvement of monitoring population knowledge and awareness.

Surveillance of antimicrobial consumption in animal production sectors of low- and middle-income countries: Optimizing use and addressing antimicrobial resistance.

In a policy forum, Daniel Schar and colleagues discuss the need for surveillance of antimicrobial consumption in animals in low- and middle-income countries and propose the establishment of antimicrobial consumption monitoring systems.

Antibiotic distribution channels in Thailand: results of key-informant interviews, reviews of drug regulations and database searches.

OBJECTIVE: To analyse how antibiotics are imported, manufactured, distributed and regulated in Thailand. METHODS: We gathered information, on antibiotic distribution in Thailand, in in-depth interviews - with 43 key informants from farms, health facilities, pharmaceutical and animal feed industries, private pharmacies and regulators- and in database and literature searches. FINDINGS: In 2016-2017, licensed antibiotic distribution in Thailand involves over 700 importers and about 24 000 distributors - e.g. retail pharmacies and wholesalers. Thailand imports antibiotics and active pharmaceutical ingredients. There is no system for monitoring the distribution of active ingredients, some of which are used directly on farms, without being processed. Most antibiotics can be bought from pharmacies, for home or farm use, without a prescription. Although the 1987 Drug Act classified most antibiotics as "dangerous drugs", it only classified a few of them as prescription-only medicines and placed no restrictions on the quantities of antibiotics that could be sold to any individual. Pharmacists working in pharmacies are covered by some of the Act's regulations, but the quality of their dispensing and prescribing appears to be largely reliant on their competences. CONCLUSION: In Thailand, most antibiotics are easily and widely available from retail pharmacies, without a prescription. If the inappropriate use of active pharmaceutical ingredients and antibiotics is to be reduced, we need to reclassify and restrict access to certain antibiotics and to develop systems to audit the dispensing of antibiotics in the retail sector and track the movements of active ingredients.

Policy Choices for Progressive Realization of Universal Health Coverage Comment on "Ethical Perspective: Five Unacceptable Trade-offs on the Path to Universal Health Coverage".

In responses to Norheim's editorial, this commentary offers reflections from Thailand, how the five unacceptable trade-offs were applied to the universal health coverage (UHC) reforms between 1975 and 2002 when the whole 64 million people were covered by one of the three public health insurance systems. This commentary aims to generate global discussions on how best UHC can be gradually achieved. Not only the proposed five discrete trade-offs within each dimension, there are also trade-offs between the three dimensions of UHC such as population coverage, service coverage and cost coverage. Findings from Thai UHC show that equity is applied for the population coverage extension, when the low income households and the informal sector were the priority population groups for coverage extension by different prepayment schemes in 1975 and 1984, respectively. With an exception of public sector employees who were historically covered as part of fringe benefits were covered well before the poor. The private sector employees were covered last in 1990. Historically, Thailand applied a comprehensive benefit package where a few items are excluded using the negative list; until there was improved capacities on technology assessment that cost-effectiveness are used for the inclusion of new interventions into the benefit package. Not only cost-effectiveness, but long term budget impact, equity and ethical considerations are taken into account. Cost coverage is mostly determined by the fiscal capacities. Close ended budget with mix of provider payment methods are used as a tool for trade-off service coverage and financial risk protection. Introducing copayment in the context of fee-for-service can be harmful to beneficiaries due to supplier induced demands, inefficiency and unpredictable out of pocket payment by households. UHC achieves favorable outcomes as it was implemented when there was a full geographical coverage of primary healthcare coverage in all districts and sub-districts after three decade of health infrastructure investment and health workforce development since 1980s. The legacy of targeting population group by different prepayment mechanisms, leading to fragmentation, discrepancies and inequity across schemes, can be rectified by harmonization at the early phase when these schemes were introduced. Robust public accountability and participation mechanisms are recommended when deciding the UHC strategy.

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

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.

Adoption of One Health in Thailand's National strategic plan for emerging infectious diseases.

This study illustrates how Thailand adopted the One Health concept. Massive socio-economic and health consequences of emerging infectious diseases, especially Avian Influenza in 2004, led to recognition of the importance of and need for One Health. Based on collaboration and consultative meetings between the national actors and international development partners, Thailand adopted One Health to drive more effective containment of Emerging Infectious Diseases. This concept gained support from the non-governmental and civil society organizations through processes of the National Health Assembly. In 2012, a Cabinet resolution endorsed a National Strategic Plan for Emerging Infectious Diseases (2013-2016), in which One Health appeared as a core principle. Collaboration among multi-disciplinary groups of professionals, particularly epidemiologists trained in Field Epidemiology Training Programs (FETP), including FETP, FETP-veterinarian, and FETP-wildlife veterinarians, promoted implementation of One Health.

Making Fair Choices on the Path to Universal Health Coverage: Applying Principles to Difficult Cases.

Abstract-Progress toward universal health coverage (UHC) requires making difficult trade-offs. In this journal, Dr. Margaret Chan, the World Health Organization (WHO) Director-General, has endorsed the principles for making such decisions put forward by the WHO Consultative Group on Equity and UHC. These principles include maximizing population health, priority for the worse off, and shielding people from health-related financial risks. But how should one apply these principles in particular cases, and how should one adjudicate between them when their demands conflict? This article by some members of the Consultative Group and a diverse group of health policy professionals addresses these questions. It considers three stylized versions of actual policy dilemmas. Each of these cases pertains to one of the three key dimensions of progress toward UHC: which services to cover first, which populations to prioritize for coverage, and how to move from out-of-pocket expenditures to prepayment with pooling of funds. Our cases are simplified to highlight common trade-offs. Though we make specific recommendations, our primary aim is to demonstrate both the form and substance of the reasoning involved in striking a fair balance between competing interests on the road to UHC.

Community health worker in hard-to-reach rural areas of Myanmar: filling primary health care service gaps.

BACKGROUND: Myanmar is classified as critical shortage of health workforce. In responses to limited number of trained health workforce in the hard-to-reach and remote areas, the MOH trained the Community Health Worker (CHW) as health volunteers serving these communities on a pro bono basis. This study aimed to assess the socio-economic profiles, contributions of CHW to primary health care services and their needs for supports to maintain their quality contributions in rural hard to reach areas in Myanmar. METHODS: In 2013, cross-sectional census survey was conducted on all three groups of CHW classified by their training dates: (1) prior to 2000, (2) between 2000 and 2011, and (3) more recently trained in 2012, who are still working in 21 townships of 17 states and regions in Myanmar, using a self-administered questionnaire survey in the Burmese language. FINDINGS: The total 715 CHWs from 21 townships had completely responded to the questionnaire. CHWs were trained to support the work of midwives in the sub-centres and health assistant and midwives in rural health centres (RHCs) such as community mobilization for immunization, advocates of safe water and sanitation, and general health education and health awareness for the citizens. CHWs were able to provide some of the services by themselves, such as treatment of simple illnesses, and they provided services to 62 patients in the last 6 months. Their contributions to primary health care services were well accepted by the communities as they are geographically and culturally accessible. However, supports from the RHC were inadequate in particular technical supervision, as well as replenishment of CHW kits and financial support for their work and transportation. In practice, 6 % of service provided by CHWs was funded by the community and 22 % by the patients. The CHW's confidence in providing health services was positively associated with their age, education, and more recent training. A majority of them intended to serve as a CHW for more than the next 5 years which was determined by their ages, confidence, and training batch. CONCLUSIONS: CHWs are the health volunteers in the community supporting the midwives in hard-to-reach areas; given their contributions and easy access, policies to strengthen support to sustain their contributions and ensure the quality of services are recommended.

Three Case Studies in Making Fair Choices on the Path to Universal Health Coverage.

The goal of achieving Universal Health Coverage (UHC) can generally be realized only in stages. Moreover, resource, capacity, and political constraints mean governments often face difficult trade-offs on the path to UHC. In a 2014 report, Making fair choices on the path to UHC, the WHO Consultative Group on Equity and Universal Health Coverage articulated principles for making such trade-offs in an equitable manner. We present three case studies which illustrate how these principles can guide practical decision-making. These case studies show how progressive realization of the right to health can be effectively guided by priority-setting principles, including generating the greatest total health gain, priority for those who are worse off in a number of dimensions (including health, access to health services, and social and economic status), and financial risk protection. They also demonstrate the value of a fair and accountable process of priority setting.

HIV/AIDS health care challenges for cross-country migrants in low- and middle-income countries: a scoping review.

INTRODUCTION: HIV/AIDS has been one of the world's most important health challenges in recent history. The global solidarity in responding to HIV/AIDS through the provision of antiretroviral therapy (ART) and encouraging early screening has been proved successful in saving lives of infected populations in past decades. However, there remain several challenges, one of which is how HIV/AIDS policies keep pace with the growing speed and diversity of migration flows. This study therefore aimed to examine the nature and the extent of HIV/AIDS health services, barriers to care, and epidemic burdens among cross-country migrants in low-and middle-income countries. METHODS: A scoping review was undertaken by gathering evidence from electronic databases and gray literature from the websites of relevant international initiatives. The articles were reviewed according to the defined themes: epidemic burdens of HIV/AIDS, barriers to health services and HIV/AIDS risks, and the operational management of the current health systems for HIV/AIDS. RESULTS: Of the 437 articles selected for an initial screening, 35 were read in full and mapped with the defined research questions. A high HIV/AIDS infection rate was a major concern among cross-country migrants in many regions, in particular sub-Saharan Africa. Despite a large number of studies reported in Africa, fewer studies were found in Asia and Latin America. Barriers of access to HIV/AIDS services comprised inadequate management of guidelines and referral systems, discriminatory attitudes, language differences, unstable legal status, and financial hardship. Though health systems management varied across countries, international partners consistently played a critical role in providing support for HIV/AIDS services to uninsured migrants and refugees. CONCLUSION: It was evident that HIV/AIDS health care problems for migrants were a major concern in many developing nations. However, there was little evidence suggesting if the current health systems effectively addressed those problems or if such management would sustainably function if support from global partners was withdrawn. More in-depth studies were recommended to further explore those knowledge gaps.

Environmental management procedures following fatal melioidosis in a captive chimpanzee (Pan troglodytes).

A 40-yr-old male captive chimpanzee (Pan troglodytes) presented with depression and anorexia for 7 days. The tentative diagnosis, following a physical examination under anesthesia, was pneumonia with sepsis. Despite antibiotic treatment and supportive care the chimpanzee died a week following presentation. Gross pathology confirmed severe purulent pneumonia and diffuse hepatosplenic abscesses. Detected in serum at the time of the initial examination, the melioidosis serum antibody titer was elevated (> 1:512). Soil samples were collected from three sites in the exhibit at three depths of 5, 15, and 30 cm. By direct and enrichment culture, positive cultures for Burkholderia pseudomallei were found at 5 and 15 cm in one site. The other two sites were positive by enrichment culture at the depth of 5 cm. To prevent disease in the remaining seven troop members, they were relocated to permit a soil treatment with calcium oxide. The exhibit remained empty for approximately 1 yr before the chimpanzees were returned. During that period, the soil in the exhibit area was again cultured as before and all samples were negative for B. pseudomallei. Following the soil treatment in the exhibit, all chimpanzees have remained free of clinical signs consistent with melioidosis.

A case report concerning male gametes rescued from a Siamese Eld's deer (Rucervus eldii siamensis): post-thawed testicular and epididymal sperm quality and heterologous zona pellucida binding ability.

In the present study, the quality of frozen-thawed epididymal and testicular sperm recovered from a Siamese Eld's deer was examined. The epididymal sperm quality was assessed in fresh, cold-stored at 4°C and frozen-thawed samples. Zona binding ability of the frozen-thawed epididymal samples with Burmese Eld's deer oocytes was also evaluated. Testicular sperm extracted from tissues frozen at -80 or -196°C for one month were examined for membrane and DNA integrity. Epididymal sperm retained their quality for up to 24 hr of cold storage at 4°C. The percentages of sperm motility, intact membrane, intact acrosome and intact DNA were 30, 46.5, 27 and 89.5% in the frozen and thawed epididymal sperm, and the average ability to bind with oocytes was 92.5 ± 64 sperm/oocytes. Around 70% of the sperm extracted from testicular tissues cryopreserved at -196 and -80°C for one month showed an intact membrane. In conclusion, epididymal and testicular sperm survived for more than 13 hr post-mortem. Furthermore, cold storage at 4°C and cryopreservation at -196 and -80°C maintain the quality of epididymal and testicular sperm. This study represents a model for male gamete rescue in endangered Eld's deer.

Cross-species transmission of gibbon and orangutan hepatitis B virus to uPA/SCID mice with human hepatocytes.

To investigate the potential of cross-species transmission of non-human primate HBV to humans, severe combined immunodeficiency mice transgenic for urokinase-type plasminogen activator, in which the mouse liver has been engrafted with human hepatocytes, were inoculated with non-human primate HBV. HBV-DNA positive serum samples from a gibbon or orangutan were inoculated into 6 chimeric mice. HBV-DNA, hepatitis B surface antigen (HBsAg), and HB core-related antigen in sera and HBV cccDNA in liver were detectable in 2 of 3 mice each from the gibbon and orangutan. Likewise, applying immunofluorescence HBV core protein was only found in human hepatocytes expressing human albumin. The HBV sequences from mouse sera were identical to those from orangutan and gibbon sera determined prior to inoculation. In conclusion, human hepatocytes have been infected with gibbon/orangutan HBV.