Implementation of e-Bug in Denmark

Abstract

Bacterial resistance to antimicrobial agents in primary healthcare is low in Denmark compared with most other European countries. Denmark has a vaccination programme for children that recommends immunization against 10 infectious diseases, including a heptavalent pneumococcal conjugate vaccine (PCV7) and a vaccine against human papillomavirus (HPV). Outbreaks in schools due to other infectious illnesses are well recognized and have seasonal variations. A quarter of young people have had a sexually transmitted disease before the age of 25 years. Denmark had a considerable interest in joining the e-Bug project to keep a focus on the low prevalence of bacterial resistance and the prevention of infectious diseases, and to maintain the acceptance of the immunization programme. Furthermore, the Danish Folkeskole, which is the Danish municipal primary and lower secondary school, uses the principle of differentiated teaching, integrating information technology, and there are no recommended textbooks in the curriculum. The teaching is organized so that it both strengthens and develops an individual student's ability to act and care for themselves and for society in general. e-Bug, in its design, was seen as a tool that could be implemented well in the Danish Folkeskole, as it fulfils the goals on teaching methods and output. Two thousand e-Bug packs were printed, 100 local education authorities and 1507 school principals were contacted, and e-Bug was presented to important stakeholders in relevant scientific magazines and at meetings. It has been well accepted.

Introduction

In Denmark, bacterial resistance to antimicrobial agents in primary healthcare is low compared with most other European countries.¹ Nevertheless, both the consumption of antimicrobial agents and resistance have been increasing since the late 1990s, although prescribing is still characterized by the use of narrow-spectrum antibacterial agents in primary healthcare.²

The use of antimicrobial agents in primary healthcare [expressed as defined daily dose (DDD) per 1000 inhabitants per day] has increased by 31% from 1999 to 2008, but the number of treated patients per 1000 inhabitant-days has increased by only 14%, indicating that each treated patient has received more DDDs. However, data on the indications for antibacterial prescriptions in the Danish primary healthcare sector are incomplete, making it difficult to make assumptions about the nature of changes in trends.

In 2008, a reduction in the use of β-lactamase-sensitive penicillins of 0.37 DDD (7%) per 1000 inhabitants per day occurred. In most other groups of antimicrobial agents, consumption increased, e.g. tetracyclines, combinations of penicillins including β-lactamase inhibitors and fluoroquinolones.³

A heptavalent pneumococcal conjugate vaccine (PCV7) was introduced to the Danish Childhood Immunization Programme (DCIP) on 1 October 2007. The administration of PCV7 was followed by a marked decline in the incidence of invasive pneumococcal disease in both vaccinated and unvaccinated individuals.⁴

In 2008, 308 out of 1000 Danes received at least one prescription for antibacterial agents in primary healthcare.³ Among young school children (5–9 years old), the number of treated patients per 1000 inhabitants was almost as high as in the total population.⁵

Outbreaks in schools

Only sporadic outbreaks of hepatitis A, foodborne disease and meningococcal disease in schools have been reported within the last 15 years. Influenza, norovirus and upper respiratory tract infections are not reportable diseases, but the experience is that the absence of students from school varies according to the seasonal variation of these diseases.

Sexually transmitted diseases (STDs)

The age of consent for sexual intercourse is 16 years for both sexes in Denmark. The preferred contraceptives are contraceptive pills and condoms. Almost half of the young men and one-third of the young women aged 20–24 years do not use a condom on their first intercourse with a new partner.

Of young people, 20%–25% have had an STD before the age of 25 years. The numbers of induced abortions have grown during recent years among young girls in the age group 15–19 years.

Chlamydia is the most frequent STD: 7.5% of young men (20–24 years old) and 12.3% of young women (15–19 years old) have had it at least once. One out of 10 teachers is satisfied with the offered training in STDs in the Folkeskole. Of the 15–19 year olds, 75% refer to this training as the primary source of their knowledge on sexual matters.^6,7

Danish Childhood Immunization Programme

DCIP recommends vaccines against 10 infectious diseases. Vaccines are free and voluntary for all children. Today, the majority of the 10 childhood diseases either seldom occur or are not seen any more in Denmark.

The acceptance of DCIP is ∼90% for most of vaccines. The MFR vaccine (measles, mumps and rubella) has had the lowest acceptance (∼84%–88%). As a consequence of the low acceptance rate, the second MFR vaccine has been advanced to be given to children born after 1 April 2004, at the age of 4 years instead of at the age of 12 years.⁸

Human papillomavirus (HPV) vaccine

Vaccination against HPV was started in the DCIP on 1 January 2009. It is offered to girls born in 1996 or after. The free immunization covers girls aged 12–15 years. Until the end of 2010, the HPV vaccine is being offered also to girls born in 1993–95. The programme has an acceptance rate of ≥70%.⁸

Influenza vaccine

The free seasonal influenza vaccine is offered to persons >65 years old, to chronically ill citizens on recommendation from a doctor and to persons having taken early retirement. We hold no record on the number of children who are given the influenza vaccine.⁹

Recent intervention study

A 3 month pilot intervention study, randomized between two schools, was carried out on 652 pupils aged 5–15 years.¹⁰ The objective of this study was to determine the effect in elementary school pupils in Denmark of mandatory, scheduled handwashing on actual absenteeism due to infectious illness. The study suggests that handwashing could be an effective tool to reduce absences due to infectious illness in elementary school pupils. The study suggests that a school policy regarding hand hygiene and the teaching of hand hygiene is warranted.

The Danish Folkeskole

The Folkeskole is a municipal comprehensive school system covering both primary and lower secondary education, i.e. the first stage (grades 1–6) and second stage (grades 7–9/10) of basic education; it covers children aged 7–16/17 years.

The Folkeskole statistics in 2008 were that 98 municipalities had 1605 municipal schools. These covered 595 573 students (59 869 bilingual students) divided into 28 591 classes. The average number of students per class was 19.6 and there were 50 972 teachers, which gives a teacher:student ratio of 1:10.7.¹¹

Common Objectives (Fælles Mål)

The Danish Parliament lays down the overall aims of the teaching curriculum, the Ministry of Education sets the targets for individual subjects and the local school authorities decide on how to attain these targets.

On the national level, the Danish Folkeskole is regulated by the Folkeskole Act, which provides the overall framework for the schools’ activities. The Folkeskole Act gives the Minister the authority to establish the regulations and aims regarding education and the central knowledge and skill areas (end objectives) in subjects and compulsory topics. Moreover, the Minister of Education determines the regulations and objectives for specific form levels (form-level objectives) for the specific subjects/topics. The end and form-level objectives establish a national objective for the direction and goals of the teaching. This ensures that students acquire the knowledge and skills in the subject/topic at the end of their programme of education and at the conclusion of specific form levels, respectively. This is named Common Objectives (Fælles Mål) and covers the two most important sets of academic texts regarding a school's subjects and topics.

There are no recommended textbooks in the curriculum. The curriculum comprises three subject blocks: the humanities; practical/art subjects; and science. Science consists of mathematics (all), science/technology (grades 1–6), geography (grades 7–9), biology (grades 7–9) and physics/chemistry (grades 7–9).

It is the responsibility of the individual municipal board to determine and to describe in an annual report how the municipality's schools are to be organized in practice, within the framework established by law. The municipal boards themselves determine the municipal level of service for the Folkeskole within this overriding framework and can set their own additional objectives for the schools, and thereby incorporate their own local characteristics.¹¹

Teaching in the Folkeskole

In order to give all students the best possibilities for all-round development and for learning as much as possible, the Folkeskole builds on the principle of differentiated teaching. The teaching is organized so that it both strengthens and develops the individual student's interests, qualifications and needs, and also contains common experiences and situations to provide the students with experience and prepare them for cooperation in the performance of tasks.

Information technology (IT) must be integrated into the teaching of all subjects, at all form levels.¹¹

Partnership/stakeholders

As a consequence of the fact that there are no recommended textbooks in the curriculum, the main focus has been on promoting e-Bug for all relevant partners within Public Health, Infection Prevention and Science who could use e-Bug as a complementary tool in their existing educational material.

e-Bug has been presented to and is endorsed by the National Board of Health and by The Danish Committee for Health Education; both have the prevention of infectious diseases and STDs on their agenda. Spokespersons on healthcare topics in all the political parties have been informed as well.

Implementing the resource

Two thousand e-Bug packs were printed. An information folder on the educational resource was created together with an informative and more formal letter. All local education authorities (100 in total) received three packs by mail, an information folder and a formal letter.

All school principals (in total 1507) received the informative folder and the formal letter on the resource, with information on how to order additional copies.

After this first shipment, school libraries ordered an additional 84 packs and schools ordered another 180 packs. After an article was published in the magazine for science teachers, additional orders were received. Other groups, such as healthcare workers and teachers in other professions, have ordered another 80 packs. Partnerships received books, folders and letters.

Those who received packs were logged and the schools that had not ordered packs by the beginning of 2010 received an additional letter that encouraged them to order the packs.

Marketing and presentation

Marketing has been carried out in the form of a press release to all national newspapers and relevant national professional magazines, articles in professional science magazines, and general information to the infection control society. e-Bug has been presented at the Nordic Diploma Education in Infection Control and at numerous professional meetings.

e-Bug has been promoted in relevant teachers' forums, such as the Educational Meeting Universe (EMU), which is the common portal for the educational world in Denmark. EMU gathers all relevant educational material, services and resources available on the Internet. Furthermore, e-Bug has been introduced to teachers through articles in magazines for teachers, such as Folkeskolen and Kaskelotten. The latter is a magazine specifically for Science teachers.

e-Bug has been presented at the Antibiotic Awareness Day 2009 and at the National Hygiene Week in October 2009, at a handwashing event in the Copenhagen town square.

Endorsements and future of e-Bug in Denmark

As previously described, there are no mandatory textbooks for the curriculum of the Danish Folkeskole. The main focus has been on spreading information on e-Bug.

Thus, e-Bug more than fulfils the current and future principles for differentiated teaching in the Folkeskole. With e-Bug it is possible to work with different learning styles, and different languages, to integrate IT in the training, to work both on your own and in groups, and to work in an interdisciplinary manner with Science. This strengthens students' ability to act and to take responsibility for themselves and the outside world. The existing educational materials on the topics are few, and e-Bug is therefore a valuable tool in teaching on infection prevention, and antimicrobial agents and resistance issues.

At the time of the launch, lesson plans were already in place for 2009–10, so just a few schools were able to use it this year. Web log statistics show an increasing interest in the materials. Teachers from whom we have heard expressed satisfaction with the materials and will use them as a supplementary educational resource.

Arrangements on future presentations have been made with the Centre for Information about Natural Science and Modern Technology (Foundation) (the Experimentarium). Parents and their children meet here to explore the scientific world and this is an optimal place to introduce public health matters, such as infection prevention and knowledge on antimicrobials.

Publishing of textbooks on this topic is usually done on a private basis. However, it is our hope that e-Bug is maintained as a valuable tool in the Danish Folkeskole in the years to come. The Statens Serum Institute sees this as an important goal.

Funding

This work was supported by DG SANCO of the European Commission (2005211).

Transparency declarations

This article is part of a Supplement sponsored by the European Commission Health and Consumer Protection Directorate-General DG SANCO (grant number 2005211).

References