Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA...
Transcript of Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA...
![Page 1: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/1.jpg)
Fotograf: Wilse, A. B. / Oslo byarkiv
![Page 2: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/2.jpg)
Is it possible to reverse antibiotic
resistance?
Dag Berild
Department of Infectious Diseases
Oslo University Hospital
UIO 200 år
![Page 3: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/3.jpg)
«Take home messages»
• All use of antibiotics (AB) leads to resistance
• All antibiotic changes the normal
bacteriological flora
• It is unethical to overuse AB
• We probably can reverse AB-resistance
UIO 200 år
![Page 4: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/4.jpg)
Mortality rate USA 1900-2000. Armstrong, JAMA
1999;281:61-6
UIO 200 år
![Page 5: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/5.jpg)
Antibiotic mediated reduction in mortality
![Page 6: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/6.jpg)
Antibiotics, from cradle to grave
![Page 7: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/7.jpg)
The correlation between antibiotic use and
resistance. Monnet DL et al. Emerg Inf Dis 2004
Monnet DL. Emerg Infect Dis 2004; 10 (8): 1432-41
UIO 200 år
![Page 8: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/8.jpg)
Mechanisms of resistance
UIO 200 år
![Page 9: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/9.jpg)
UIO 200 år
![Page 10: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/10.jpg)
UIO 200 år
![Page 11: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/11.jpg)
UIO 200 år
![Page 12: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/12.jpg)
UIO 200 år
![Page 13: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/13.jpg)
Solution to Killer Superbug Found in
Norway.
New York Times December 30, 2009 OSLO, Norway (AP) -- Aker University Hospital is a dingy place to heal.
The floors are streaked and scratched. A light layer of dust coats the
blood pressure monitors. A faint stench of urine and bleach wafts
from a pile of soiled bedsheets dropped in a corner.
Look closer, however, at a microscopic level, and this place is pristine.
There is no sign of a dangerous and contagious staph infection that
killed tens of thousands of patients in the most sophisticated
hospitals of Europe, North America and Asia this year, soaring
virtually unchecked.
The reason: Norwegians stopped taking so many drugs.
Twenty-five years ago, Norwegians were also losing their lives to this
bacteria. But Norway's public health system fought back with an
aggressive program that made it the most infection-free country in
the world. A key part of that program was cutting back severely on
the use of antibiotics.
UIO 200 år
![Page 14: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/14.jpg)
Total outpatient antibacterial use in the United States and 27 European countries in 2004
Goossens et al. (2007). Clin Infect Dis 44:1091-5.
Campaigns
Outpatient antibiotic use in European countries
UIO 200 år
![Page 15: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/15.jpg)
How can we preserve antibiotics?
• Stop (prophylactic) AB-use in agriculture
• Follow national guidelines for AB-use
• Use e-health and mobile health
• Public campaigns
• Campaigns and education of health personel
UIO 200 år
![Page 16: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/16.jpg)
Antibiotic use in fish farming
UIO 200 år
![Page 17: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/17.jpg)
Reduction of AB-resistant enterococci after the ban of
Avoparcin
UIO 200 år
![Page 18: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/18.jpg)
Overview over single campaigns
UIO 200 år
![Page 19: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/19.jpg)
Belgium www.antibiotics-info.be
Population
10.5 million
• Yearly campaign since 2000
– about 385’000 €/year
• Interventions
– Information material
– Treatment guidelines
– TV and radio spots
UIO 200 år
![Page 20: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/20.jpg)
Belgium
-36%
Goosens et al. (2008). Euro Surveill 13(46) UIO 200 år
![Page 21: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/21.jpg)
Belgium Evolution of bacterial resistance of pneumococci
0
5
10
15
20
25
30
35
40
1991
1993
1995
1997
1999
2001
2003
2005
2007
Year
% o
f is
ola
tes
PNSP
R Ery
Goosens et al. (2008). Euro Surveill 13 pii: 19036.
PCV-7 1st campaign
UIO 200 år
![Page 22: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/22.jpg)
Antibiotic Resistance of Throat Isolates of
Streptococcus pyogenes in Belgium (2002 – 2007)
0
2
4
6
8
10
12
14
16
18
2002 2003 2004 2005 2006 2007
year
per
cen
tage
erythromycin
National Reference Centre S. pyogenes (University of Antwerp) Courtesy: H. Goossens
UIO 200 år
![Page 23: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/23.jpg)
• “Antibiotics Are Not Automatic”
• Yearly campaign since 2002
– About 4 million €/year
• Interventions
– Ads on TV, radio, newspaper
– Information leaflets, internet campaign, exhibitions
– Academic detailing, promotion of streptococcal rapid
antigen test, treatment guidelines
France www.antibiotiquespasautomatiques.com
Population
64.5 million
UIO 200 år
![Page 24: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/24.jpg)
Evolution des prescriptions antibiotiques de ville
en France, en fonction de l’âge (1980 – 2009)
Chahwakilian P et al (2011). J Antimicrob Chemother 66: 2872-9 UIO 200 år
![Page 25: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/25.jpg)
Reduction in AB-use only in respiratory tract
infections…
0
10
20
30
40
50
60
70
0
100
200
300
400
500
600
700
800
2001 2002 2003 2004 2005 2006 2007 2008 2009
An
tib
ioti
c p
resc
rip
tio
ns
pe
r 1
00
0
inh
abit
ants
pe
r ye
ar (
UTI
)
An
tib
ioti
c p
resc
rip
tio
ns
pe
r 1
00
0
inh
abit
ants
pe
r ye
ar (
RTI
)
Respiratory tractinfections
Infections of the urinaryand female genital tract
Huttner B. & Harbarth S. (2009). PLoS Med 6:e1000080.
Chahwakilian P et al (2011). J Antimicrob Chemother 66: 2872-9
UIO 200 år
![Page 26: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/26.jpg)
http://www.sante-jeunesse-sports.gouv.fr/dossiers/antibiotiques/Pres_Varon.pdf UIO 200 år
![Page 27: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/27.jpg)
Germany Informationskampagne Antibiotika-Resistenz
www.viamedica-stiftung.de
• Campaign since 2007
• Private Foundation to promote: “Equilibrium between medicine, man and nature"
• Few interventions, no evaluation
• "Use herbal remedies first "
• "Patients should always ask
their doctor if a herbal remedy
can be prescribed instead of
antibiotics"
![Page 28: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/28.jpg)
Even the Netherlands…
UIO 200 år
![Page 29: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/29.jpg)
Spain www.antibioticos.msc.es
• “Campaign for the responsible use
of antibiotics”
• Yearly campaign since 2006
– 6.5 million € (2006)
• Target population
– General population, parents
– GPs, paediatricians,
pharmacists
• Interventions
– Mass mailing to physicians
– Ads on TV, radio, print-media
Population
43 million
UIO 200 år
![Page 30: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/30.jpg)
UIO 200 år
![Page 31: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/31.jpg)
Campaign Awareness
Malta
2006: 54% exposed
Israel
2005: 71% recall 2005: 34% recall
2001: 46% recall 2003: 20% recall
2003: 14% recall
UIO 200 år
![Page 32: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/32.jpg)
Outcome regarding antibiotic use
Malta
1999-2006: 32% reduction
1992 -1997: 35% reduction (children)
2002-2007: 23.4% reduction
1999-2002: 15 % reduction
2003-2005: 10% reduction
2004-2005: 5.8% reduction over
winter months compared to control
UIO 200 år
![Page 33: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/33.jpg)
Italy
France
Trends in antibiotic consumption
France and Italy (1999-2006)
DDD/1000 inhabitants/day
UIO 200 år
![Page 34: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/34.jpg)
Er det farlig å redusere antibiotikabruken?
Neppe
UIO 200 år
![Page 35: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/35.jpg)
Potential adverse effects of reduced
prescribing
Not routinely
monitored
UIO 200 år
![Page 36: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/36.jpg)
• England
– 1992-2002: admissions for peritonsillar abscesses,
mastoiditis and rheumatic fever in children stable Sharland et al. (2005). BMJ 331:328-9
• Sweden
– 1987-2003: no increase in admissions for acute
sinusitis, peritonsillar abscess and acute mastoiditis
– 1995-2004: outpatient antibiotic use ↓20%
Potential adverse effects of reduced prescribing?
Mölstad et al. (2008). Lancet Infect Dis 8:125-32.
• Alpes-Maritimes
– 1998-2003: stables rates of invasive infections:
S. pneumoniae, S. pyogenes, N. meningitidis
– 1999-2002: AB use in children (self reported) 15% ↓
Blanc et al. (2008). Presse Med 37:1739-45. UIO 200 år
![Page 37: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/37.jpg)
To eksempler på at resistens begrenser
våre behandlingsmuligheter
Følg med
UIO 200 år
![Page 38: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/38.jpg)
Only two treatment options in urinary tract infections. Nitrofurantoin OR Fosfomycin
UIO 200 år
![Page 39: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/39.jpg)
Treat UTI in 2012 with antibiotics of the 1960s!
Super-heros never die!! UIO 200 år
![Page 40: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/40.jpg)
Gonorrhea is not a serious disease, but…
UIO 200 år
![Page 41: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/41.jpg)
Conclusion: It is possible to improve AB-use and
preserve ABs as useful drugs in Norway
• Reduce total and broad spectrum AB by
– Using official guidelines for AB use
– Implement e-health and mobil health
– Education
• This will reduce resistance, costs and side
effects
• Improve hospital hygiene
UIO 200 år
![Page 42: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/42.jpg)
Number of molecular entity for systemic antibiotics
![Page 43: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/43.jpg)
Thank you
UIO 200 år
![Page 44: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/44.jpg)
![Page 45: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/45.jpg)
But, we can face an apocalypse because of:
• Political neglect
• Ignorant, unethical and poor educated
doctors
• Greed (false drugs, legalislation)
• Agriculture, live stock, fruits
• Lack of basic resources in dev. countries
• Inadeqate infection control
• No new antibiotics
UIO 200 år
![Page 46: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/46.jpg)
Perspectives
• Average age increased from 50 to 80 years
from y1900 to y2000
• 20 y because of better standard of living
• 10 y due to modern medicin
• 7/10 y due to antibiotics and vaccines
• Resistance is a threat to modern medicine
• There is no new AB in the pipelines
UIO 200 år
![Page 47: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/47.jpg)
Use of macrolide antibiotics in Finland
UIO 200 år
![Page 48: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/48.jpg)
Reduction of macrolide resistance after
reduction of macrolide use
UIO 200 år
![Page 49: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/49.jpg)
UIO 200 år
The change of the normal flora Price & Sligh, Lancet 1970, Des 12;2 (7685):1213-5
![Page 50: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/50.jpg)
Reduction of antibiotics
UIO 200 år
![Page 51: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/51.jpg)
UIO 200 år
![Page 52: Fotograf: Wilse, A. B. / Oslo byarkiv · Mortality rate USA 1900-2000. Armstrong, JAMA 1999;281:61-6 UIO 200 år](https://reader034.fdocuments.net/reader034/viewer/2022052022/6037998e8fb70a14450fcc00/html5/thumbnails/52.jpg)