 Good morning to all. My name is Dr. Valayashara. I work as a medical doctor in the Asansol project MSF India, West Bengal. So today I am going to present a prescription audit that MSF staff did on the local doctors in Asansol. To tell you something about Asansol, it is 220 kilometers from Kolkata and second largest city of West Bengal. There are a lot of coal mines and steel plants in that region. This is one of the villages shown in that coal belt. You can see the location. From the data gathered, there is about 0.5 government doctors per 1000 residents. Right now MSF is based at two sites, District Hospital and one of the primary health center. I will tell you something more about the sites. Both are outpatient clinics and work from 9 a.m. to 1 p.m. apart from Sundays when they are closed. The patients who want to see the doctor are given clinical notes and they are allowed to keep it after the consultation is done. That is the only form of data that is there. The clinic in the District Hospital is outpatient pediatric clinic with one Ministry of Health pediatrician and one Ministry of Health pediatrician board trainee. They see about 110 patients per day. There is an X-ray site available. X-ray on site available. Something about the primary health center. There is one Ministry of Health general practitioner or medical officer who sees all age groups there. They see about 225 patients per day. There is no X-ray site available in the primary health center. Right now MSF is working to treat acute respiratory illnesses in the pediatric population. We are also learning about antibiotic resistance in the Asansore region alongside with the Ministry of Health. In December 2016 our project was concerned with fever in the pediatric group of populations but later it was decided we will open respiratory illness clinics. To understand more about antibiotic resistance in that area, we wanted to learn about baseline practices of doctors in that particular region. That is why we did this audit. We want to see the prescribing practices of pediatricians in the District Hospital and general practitioners in the primary health center. Diagnosis made prescription format and other medications prescribed were a few of the parameters that we studied. But today I will try to concentrate more on the antibiotic prescription patterns. How did we do it? So it was an exit survey over two weeks. So first of all all children who wants to see the doctor would come across MSF staff who if they meet the criteria. I will talk about criteria later. Later on the nurse will put a symbol on the prescription paper and the child is allowed to see the doctor. After the exit they again come across another MSF staff who actually takes a picture of the prescription and the data is extracted, entered into a spreadsheet and then the photo is destroyed. About the inclusion criteria like I mentioned, the age group that we decided was six months to 12 years. This is as per the agreement that we made with the local authorities. Plus any of cough, sore throat, runny or blocked nose, difficulty breathing, ear pain, discharge. Any patient with fever or history of fever was excluded from the study because like I said this was done in December 2016 where we were seeing fever in the pediatric population. So anyway any patient with fever saw MSF doctors so they were not part of the study. To tell you something more about the photo that we took, parameters like age, assessment, diagnosis, medication, duration were taken and later on like I said the photo was destroyed and this was after taking proper permission from the authorities. So these are the results that we came up to. We saw about 268 patients, 201 in district hospital and 67 in the primary health center. The mean age of the patients was 45 months in the district hospital while it was 40 months in the primary health center. So 61% of patients were prescribed antibiotics in the district hospital and 67% in primary health center. Mind you these are the patients that were without fever. One of the very striking difference between the two clinics was that 75% of patients were recorded diagnosis in district hospital and in the primary health center there was no diagnosis recorded in the prescription paper. It was only the medication that was given. Indicators of severity of the patient was not documented in any of the clinics. These are few more things that we concluded. The mean antibiotic duration at the district hospital was 5 days and 3 days in the primary health center. Non-pharma advice like steam inhalation, hot fermentation, hydration was about 20% in district hospital while only 4% in primary health center. Generic antibiotic prescriptions were about 83% in district hospital and only 13% in primary health center. Doctors followed a standard prescription format in 95% in district hospital while it was very less about 13% in primary health center. The most commonly prescribed antibiotic was amoxicillin and clavulanic acid in the district hospital and in the primary health center it was amoxicillin. This was the graph that we plotted. That's the antibiotic given against diagnosis made. So there are a few important things seen from this graph. As you can see, anyone who were given diagnosis of common cold were not given antibiotics. On the other hand, any patients who were given diagnosis of low respiratory tract infection were given antibiotics, all of them. As you can also see that many patients who were not given any diagnosis and a large portion of such patients were given antibiotics. When they made a diagnosis, it was something like RTI which is respiratory tract infection which in itself is a very non-specific diagnosis again. As you can see, a very large portion of patients received antibiotics for that. This is the desk of one of the doctors in the government hospital. We can see a lot of medical literature from the medical representative and we all know that this is forbidden but it still happens. We shared our findings with the local health authorities and the head of department of pediatrics at the district hospital was happy with the first step that MSF took for antibiotics stewardship. But he was not sure how he can help further. The chief medical officer at the primary health center was surprised that the diagnosis was missing from the notes but was on the other hand happy with the antibiotic prescription rate. What did we learn? It was easy to do this study. The patients and the local doctors accepted the technique. The limitations of this study are that it is actually difficult to comment on the appropriateness of antibiotics as very limited information is given on the assessment of the patient and the clinical diagnosis made. It was a point prevalence audit within a very short time frame, only two weeks. There are ongoing discussions with the local health authorities there on how we can take this course further, how we can decrease the antibiotic prescription rates. There are some talks that we make treatment guidelines and offer it to the doctors after the local consensus but how it will actually help the local authorities and doctors is yet to be determined. So, since last few months we have opened a respiratory clinic and this is one of the problems that we came across and it was that the patient themselves they actually expect a longer list of medications in their prescription papers and we are trying to find a way around it. In summary in this prescription survey it can be said that 61% and 66% of children with acute respiratory illness were given antibiotics and these were the patients who were without fever. Limited documentation on outpatient clinical notes was very common like I discussed and carrying out the survey was acceptable to doctors, patients and caretakers. So this study was not possible without help from my team back in Asansore. Thank you very much for listening. Okay, thank you Dr. Asher. Prescription analysis is a simple but very important tool to understand the prescription habits of doctors but also this is a very worrying study. It gives you a sense of what is not being done right. Questions? Hi, thank you. I am Jyoti from CDEP. Thank you for that study. It was a very small but very informative study. I think it also points like you have said about two important areas. In clinical practice, viral infections that happen quite a lot tend to be given antibiotics which is irrational use. So that is where stewardship with the medical college and the clinical practitioners will help. But also a fact that comes out very clearly from your study is the demand for antibiotics from the community or not knowing the need for the antibiotic in case of anything they suffer. So besides I think doing stewardship programs with clinical facilities, it is also important to do advocacy with the public and the common man who is entering clinic that you know trust the doctor or do not ask for antibiotics unless you have been prescribed and do not insist on it or if you have been prescribed an antibiotic double check because there are long term implications like we are discussing today for livestock, for human health and with the binding pipeline it is not needed. So I think we are doing a lot of work with the health facilities and that is really good but at the same time there is a lot of need to educate the common masses on the nature of this epidemic which is impending. Very true. So did you do anything of this sort? Actually yes we try to educate the people during consultation all the time and we have our communications team who is working very hard against this. We give a lot of advice, non-pharma advice that can help them with the disease when it is acute and then the symptoms will eventually subside. So yes we are actually trying a lot to make the people understand the importance of not taking an antibiotic when it is not required. Thank you doctor. I am Jyoth Snapuri. I am with the Green Climate Fund. So I am a non-medical doctor. For me what came out really interestingly was that there was such a stark contrast between the practice at the district hospital and the primary healthcare centre. And I was wondering whether you had seen it in other cases and systematically as well because I noticed that in one of your list of next steps I didn't see you thinking about perhaps investigating this divergence across other sites and then trying to see as to whether this was also, well first of course explaining the difference between the district hospital and the primary healthcare centre. But then also seeing whether this was systematic and whether if you could find a systematic difference then what conclusions you could get for policy there. And don't forget the private healthcare providers. They haven't even talked about them in the district. Yeah sure. I mean like I said there is a very big difference between the district health and the primary health centre. And we have talked about the authorities who are in the primary health centre why such difference is there. One of their concern is the less number of doctors that are there at one time. So they see like there actually excuses like they see about 225 patients in four hours and with only one doctor there at one time. So that was their excuse that it's really not possible to assess all the patients and write all the clinical notes for each and every patient. They have to see a lot of patients. I'm Ankur from a university research company. So I have a small question. Was there any difference in terms of the profile of the doctor or doctors in two facilities in terms of their specialty or experience? Like I said in the district hospital there's one consultant pediatrician and there's his pediatrician board trainee at one time while in the BHCs it was one medical officer who is a general practitioner and sees all age groups at once. So that was how it happened. Sir Ani is a doctor, MBBS doctor. I'm Dr Santosh from Sara Gold. This one question is like 61% of the 67% of the both groups were prescribed antibiotics. That's only finding. But how would we arrive at a conclusion that these were, are we going for a conclusion that these prescriptions were irrational? Because actually we don't have any tools of knowing that even the 61% or 67% had a bacterial load. So how are we actually going to direct this to a conclusion that if there is a rational practice or not? That's our question. I understand. And actually that is one of the, like I mentioned when I was giving the presentation, this is one of the limitations of the study. Because from whatever information we have from the clinical notes, not enough data is actually there to say that this is or not an appropriate antibiotic prescription. All, but it is safe to say that there's a lot of clinical data that is missing from the clinical notes. We'll take one last question and then we move on to the panel discussion, Suman. Yeah. I'm from DNDI. I'm Dr Suman Rijal. Thanks for your presentation. I just wanted to share with you that there are multiple factors that can play a role in these prescribing habits. And some of them are very obvious. As you mentioned, you've got the load of the patient, number of patients they have to see. And then I think recently we have been hearing a lot, especially from West Bengal, of defensive medicine because of the, you know, hyper-sensitivity of the population to incidents where, you know, sometimes you have more morbidity, mortality, which are quite obvious in some instances. So doctors are doing defensive medicine. And there's another issue I would like to also bring to, you know, the thoughts for some thoughts is we have to see how we are training our graduates. What I can see are medical graduates. Because most of the times as you see, we are, they're exposing them to tertiary care hospitals. We are exposing them to, you know, inpatients and very little exposure to working in the PhDs. So I think there's also a fundamental lack of experience on, you know, especially in the PhDs. When you see, when you send doctors after they, you know, recruited and they do have very little exposure in managing patients at such limits. Because the type of patients which will present to you, PhD and hospitals are quite different. So this is from my experience from my previous job that we, you know, we see that there is a difference when you train them in the different ways. This is just some comments. I mean, it's really a valid point from your side. And the doctors have actually also said, and we have experienced quite sometimes aggression from the patient side if something happens to the patient. So sometimes the doctor actually replies by saying that we can't take chance if the patient is really far from the primary health center or district hospital. And if it's very difficult for him to come when the situation rises, it can be very difficult for the patient in general. And so they prescribe the antibiotics that they do sometimes. Okay.