1 Introduction

1.1 Background

Antibiotics are drugs that kill or inhibit the growth of microbes. Before they were discovered, many communicable diseases had a long course and often resulted in serious after-effects or death. Treatment with antibiotics revolutionized the treatment of disease and death caused by infectious agents. This situation is now being threatened. Many microbes have altered genetic material, which enables them to resist the action of antibiotics. They have become resistant. Through the process of natural selection these microbes will gradually become dominant in an environment where antibiotics are widely used. The increasing occurrence of resistant microbes is due to the increased use of antibiotics and the increased spread of such microbes, for example due to poor hospital hygiene.

The accelerating growth of resistant, pathological microbes in animals and humans is international. The trend also applies to Norway, but at present the problem is less serious here than in most other countries.

Antibiotics are administered to both humans and animals. In Norway humans account for about 80 per cent of their use, animals for about 18 per cent and farmed fish for less than 2 per cent. In 1997 an average of 17.2 doses of antibiotics per 1000 Norwegians per day were taken. This means that almost 2 per cent of the population took a normal dose of antibiotics every day, or that almost all Norwegians underwent one course of antibiotic treatment every year.

The use of antibiotics in Norway has shown a welcome decline in the last few years. The consumption of antibiotics by domestic animals has been reduced by 29 per cent from 1995 to 1997 as a result of specific efforts by the industry. Consumption by farmed fish has declined from 49 tons in 1987 to ^3 ton in 1997, owing to widespread vaccination and improved hygiene. In humans, consumption has been reduced from the highest level ever measured of 18.3 doses per day per 1000 Norwegians in 1993 to 17.2 doses in 1997.

If antibiotics are to continue to be effective, it is important to combat the development of resistance by continuing to reduce the unnecessary use of these drugs.

Consumers must be guaranteed food that does not endanger their health. With regard to antibiotics, there are two main health risks in connection with food. One is the presence of antibiotic-resistant bacteria in food. The other is the presence of traces of antibiotics in food.

In May 1998 the World Health Assembly adopted a resolution calling on the member countries to monitor the use of antibiotics and the extent of resistance, educate health professionals and the general public about resistance to antibiotics and strengthen measures to control communicable diseases. An EU conference hosted by Denmark made similar proposals in the Copenhagen Declaration, which also had a close focus on the use of antibiotics in food production.

1.2 Organization of the work

On 6 July 1998 the Ministry of Health and Social Affairs appointed a project group to draw up a plan for coordinating the efforts to combat resistance to antibiotics in Norway. A steering group at state secretary level coordinated the planning. The project group, which consisted of representatives of a range of public bodies and expert groups, presented its report on 29 January 1999. The report was then widely circulated for comment, with a deadline for comments of 1 July 1999. An interministerial steering group was also appointed, headed by the Ministry of Health and Social Affairs and consisting of representatives of the Ministry of Fisheries, the Ministry of Local Government and Regional Development, the Ministry of Agriculture and the Ministry of the Environment. The steering group was mandated to draw up a plan of action on the basis of the project group’s report and the comments on the report.

1.3 Contents

The main goal of the plan of action is to ensure that we can continue to use antibiotics as good and effective drugs for treating communicable diseases in the 21 ^st> century, by combating the development and spread of resistance. The goals for the period 1999-2003 emphasize cross-disciplinary action and a cross-sectoral approach. The measures for achieving the goals are divided into eight target areas, each with a subsidiary goal.

The factual part of the project group’s report is enclosed as an annex. The entire report may be obtained from the Norwegian Institute of Health (ISBN 82-7364-138-4).

1.4 Follow-up and evaluation of the work

The steering group responsible for drawing up the plan of action will be continued and will hold regular meetings during the period covered by the plan to evaluate the way the measures are being followed up. They will also present an annual status report.

An external evaluation of the plan of action will be carried out towards the end of the operational period.

1.5 Economic and administrative consequences

In 1999 the Ministry of Health and Social Affairs allocated NOK 4.5 million to the initiation of some of the ministry’s tasks under the terms of the plan, including the launching of a trial project for a national surveillance system for microbial resistance (NORM). For the year 2000 the allocation has been increased to NOK 10 million, 2 million of which is earmarked for strengthening research on resistance under the auspices of the Research Council of Norway. In addition, many of the measures will be followed up within the framework of the existing funds available to the Ministries of Agriculture, Fisheries, the Environment, and Health and Social Affairs, as indicated in the plan of action.

2 Goals and measures

The overriding goal of the plan of action is to ensure that antibiotics can continue to be used as good and effective drugs for the treatment of communicable diseases in the 21 ^st> century by combating the development and spread of resistance to antibiotics.

The main goals for the period 2000-2004 are to ensure that:

• we obtain better information on:

• the use of antibiotics,
• the occurrence of resistant microbes in humans and animals and in food and the environment,
• the causes of the development and spread of resistance to antibiotics;

• the use of antibiotics for treating humans and animals is improved; and
• control of communicable diseases is improved for humans and animals.

2.1 Target area 1 – surveillance of resistance

By surveillance of resistance to antibiotics is meant the continual, systematic collection, analysis and interpretation of data on the extent of microbial resistance and its impact on human and animal health, for use in the planning, implementing and evaluation of health measures for humans and animals. Surveillance can help to increase our understanding of the links between the use of antibiotics and measures to control communicable diseases on the one hand and the development of resistance on the other. It can also be used as a guideline in the choice of drugs for empirical treatment (i.e. treatment administered before the microbe and its resistance pattern are known).

Currently there is no national surveillance system for resistance to antibiotics in Norway, but such a system is very necessary. There are a number of local, regional and national elements on which it can be built.

Subsidiary goal

To monitor and survey the extent and development of resistance in microbes from humans, animals and food.

Measures

1. Establish in the course of 2000 a Norwegian surveillance system for microbial resistance (NORM), including zoonotic bacteria, on the basis of the trial project begun in 1999.
   Ministry responsible: Ministry of Health and Social Affairs
2. Establish a surveillance system for resistance in bacteria from animals and food that will be linked with NORM, which takes care of the human aspects.
   Ministry responsible: Ministry of Agriculture
3. Continue the surveillance of infections caused by certain resistant bacteria that is being carried out by the system for reporting communicable diseases (MSIS).
   Ministry responsible: Ministry of Health and Social Affairs
4. Continue to participate in official international systems for surveillance of resistance.
   Ministry responsible: Ministry of Health and Social Affairs
5. Establish surveillance of the development of resistance in individual hospital departments.
   Ministry responsible: Ministry of Health and Social Affairs
6. Further develop surveys of resistant bacteria in food originating in Norway and abroad.
   Ministries responsible: Ministry of Agriculture and Ministry of Health and Social Affairs
7. Survey the extent of resistance in the human immunodeficiency virus (HIV) in Norway.
   Ministry responsible: Ministry of Health and Social Affairs

2.2 Target area 2 – Surveillance of antibiotic use

The use of antibiotics is the major cause of the development of resistant microbes. The most important measure for combating resistance is therefore to optimalize the use of antibiotics, among other things by reducing unnecessary use. Monitoring both prescription patterns and the development of resistance will provide a useful guideline for antibiotics policy. It will enable us to monitor general trends in the use of these drugs and their use in connection with individual communicable diseases.

In order to optimalize the use of antibiotics we must monitor consumption. This means the continual systematic collection, analysis and interpretation of data on the use of antibiotics in humans and animals in order to use the findings for the planning, implementation and evaluation of measures for optimalizing this use. Monitoring may also increase our understanding of the connection between antibiotic consumption and measures to control communicable diseases on the one hand and the development of resistance on the other. Prescription-based statistics will provide a good basis for such monitoring.

The fisheries authorities monitor the use of antibiotics in aquaculture, which gives them a complete overview of consumption in the industry as a whole and for each individual fish farm. The information provided by this monitoring process determines further inspection and control.

Unfortunately the monitoring of antibiotic use in humans since 1995 has been inadequate, and considerably less efficient than in our neighbouring countries. This situation must be improved if our efforts to combat resistance are to bear fruit. The alarming development of resistance means that the need for effective monitoring of antibiotic use becomes greater every year. Prescription practices can change rapidly, among other things as a result of the marketing efforts of pharmaceutical companies, new scientific findings and the introduction of new drugs.

The total consumption of antibiotics by humans in Norway today is about the same as in the other Nordic countries (cf. 1.5.2 of the annex), and is considerably smaller than in the other European countries and most other industrial countries. However, the diagnosis-based prescription surveys from 1991 to 1996 have shown that there is considerable room for improvement. Antibiotics are still frequently administered unnecessarily.

Surveys of the use of antibiotics in veterinary medicine from 1990 to 1998 have shown that the measures implemented by the producer organizations and the veterinary authorities to reduce consumption have been effective.

The use of antibiotics in aquaculture has fallen steeply. This is mainly due to the development and use of vaccines, the implementation of rules to prevent the spread of infection and a general improvement in hygiene.

Traces of antibiotics are seldom demonstrated in food. This is monitored by means of programmes carried out by the Directorate of Fisheries and the Norwegian Food Control Authority.

Subsidiary goal

To monitor all use of antibiotics.

Measures

1. Implement the planned collection of prescription-based drug statistics and seek to include as soon as possible diagnostic codes and prescriptions made out by veterinarians.
   Ministries responsible: Ministry of Health and Social Affairs and Ministry of Agriculture
2. Continue monitoring the sale of antibiotics for use in animals on the basis of information from wholesalers as a supplement to prescription-based monitoring.
   Ministry responsible: Ministry of Agriculture
3. Continue and strengthen monitoring of the use of antibiotics in individual hospital departments.
   Ministry responsible: Ministry of Health and Social Affairs
4. Continue the prescription-based monitoring of the use of antibiotics in farmed fish.
   Ministry responsible: Ministry of Fisheries
5. Continue monitoring traces of antibiotics in food.
   Ministries responsible: Ministry of Fisheries, Ministry of Agriculture, Ministry of Health and Social Affairs.

2.3 Target area 3 – Prescription

As mentioned under section 2.2, antibiotics are used more freely than necessary in Norway as well as other countries. The indications may be wrong or the wrong antibiotic, dose or treatment duration may be chosen. The use of antibiotics is not good enough as regards either the individual patient or the development of resistance.

The most frequent reasons for the use of antibiotics in Norway are in the treatment of upper respiratory tract infections outside hospitals, and here there is considerable room for improvement.

There is also an improvement potential in hospitals and other medical institutions. The role of hospitals is absolutely crucial. They treat all patients with serious infections such as blood poisoning, serious infections of surgical wounds, serious pneumonia, meningitis, inflammation of cardiac valves, and not least infections in patients with reduced immunity (patients with organ transplants, leukaemia, HIV infections and so on). They also treat patients with less serious infections (infections of the skin, bones, joints and genitals, gastrointestinal infections, moderate pneumonia, and so on). Finally, antibiotics are often used to prevent surgical wounds from becoming infected.

All this means that hospitals are major users of antibiotics. Many departments spend half their drug-budgets on antibiotics, especially broad spectrum antibiotics, which are major contributors to the development of resistance. This applies especially to intensive care wards, but also to surgical, medical and paediatric departments.

There is also considerable room for improvement in veterinary medicine.

If this situation is to be altered, it will require among other things a change in the habits of the prescribers of antibiotics – physicians, dentists and veterinarians. Pharmacists, nurses and other health professionals also have important roles to play.

Subsidiary goal

To improve the prescription and use of antibiotics by physicians, dentists and veterinarians.

Measures

1. Make the veterinary centre for independent pharmaceutical information (VETLIS) a permanent institution.
   Ministry responsible: Ministry of Agriculture
2. Educate Norwegian and foreign physicians and veterinarians educated abroad and intending to practise in Norway in the correct use of antibiotics as early as possible and preferably before they start to practise.
   Ministries responsible: Ministry of Agriculture and Ministry of Health and Social Affairs
3. Create a balance between the pharmaceutical industry’s marketing of antibiotics and non-commercial alternatives, and encourage a critical attitude in the prescribers of drugs, other health personnel and the general public.
   Ministry responsible: Ministry of Health and Social Affairs
4. Consider introducing a system of free follow-up consultations when the physician is in doubt about whether the use of antibiotics is indicated. This could for example be tested out in larger accident and emergency wards.
   Ministry responsible: Ministry of Health and Social Affairs
5. Offer general practitioners information about antibiotics that is neutral and independent of marketing efforts by producers.
   Ministry responsible: Ministry of Health and Social Affairs
6. Include an analysis of whether antibiotic use has been affected in the evaluation of the list patient system.
   Ministry responsible: Ministry of Health and Social Affairs
7. Encourage the appointment of an individual or committee at each medical institution that is responsible for antibiotics issues. Such a committee should develop strategies for how to run the institution in accordance with guidelines for the use of antibiotics.
   Ministry responsible: Ministry of Health and Social Affairs
8. Promote an emphasis on the topic of resistance to antibiotics in the basic training of physicians, dentists, veterinarians and pharmacists.
   Ministries responsible: Ministry of Agriculture and Ministry of Health and Social Affairs
9. Continue annual therapy workshops on veterinary topics.
   Ministries responsible: Ministry of Agriculture and Ministry of Health and Social Affairs
10. Give priority to resistance in the continuing education of physicians, dentists, veterinarians, pharmacists and other relevant groups (especially nurses).
    Ministries responsible: Ministry of Agriculture and Ministry of Health and Social Affairs
11. Encourage general practitioners to participate in quality-oriented training schemes to improve their prescription practices, e.g. in small groups, visits to each other’s practices, and registration of prescription practices with feedback to the prescriber.
    Ministry responsible: Ministry of Health and Social Affairs
12. Monitor the need to train more medical microbiologists and specialists in infectious diseases.
    Ministry responsible: Ministry of Health and Social Affairs

2.4 Target area 4 – Communication with and information to the public

As mentioned above, the consumption of antibiotics in Norway has shown a welcome decline in recent years. Humans account for a total of about 80 per cent of consumption, domestic animals for about 18 per cent and farmed fish for less than 2 per cent. Information to the public must take this into consideration while at the same time emphasizing the human and veterinary aspects.

Many patients expect to receive antibiotics when they consult a physician, for example for upper respiratory tract infections. It has been shown that such patients more often receive antibiotics.

Whether or not antibiotics are prescribed may affect the patient’s satisfaction with the consultation. However, in a recent qualitative study of consultations for sore throats in a Welsh general practice, it was found that a number of other factors played a role. The patients were primarily interested in being taken seriously and not dismissed with remarks such as, "This is only a virus infection and will go away by itself." They wanted to know how they had become infected, why antibiotics were not necessary, how to get rid of the infection and what to do to alleviate the symptoms.

On the other hand, many physicians are reporting that when they propose antibiotic treatment for children, the parents object. This may be due to a misunderstanding of the factors mentioned above, and it shows that information must be finely balanced. An exaggerated belief in antibiotics must not be replaced by an exaggerated fear.

The roles of physician and patient are changing, for several reasons:

• Medical information is more readily available. Anyone who wants to, can find the latest research results on any disease on the Internet.
• There is less fear of authority.
• There is a greater emphasis on consumer power and patients’ rights.

Information on the limited importance of antibiotics for curing most infections in the upper respiratory tract must be shared with patients. The same applies to the drawbacks, for the individual and for society, of the incorrect use of antibiotics. It must be made clear that there has been a substantial change in the medical view of antibiotics in recent years.

Subsidiary goal

To influence the knowledge, attitudes and behaviour of animal owners and the public at large vis-à-vis antibiotics, so that they will promote a sounder use of antibiotics while at the same time seeking medical help for possibly serious illness.

Measures

1.Put together general information on the issue of antibiotics.
Ministries responsible: Ministry of Fisheries, Ministry of Local Government and Regional Development, Ministry of Agriculture and Ministry of Health and Social Affairs

2.Put together specific information material for the various industries, at doctors’ surgeries, at accident and emergency departments and pharmacies and for pet-owners.
Ministries responsible: Ministry of Agriculture and Ministry of Health and Social Affairs

3. Launch an information campaign at well baby clinics targeted towards the parents of small children.
Ministry responsible: Ministry of Health and Social Affairs

4.Ensure that the efforts to reduce the use of antibiotics are included in the work of the health services for the various domestic animal associations and for Quality Systems in Agriculture (Kvalitetssystemer i landbruket, KSL).
Ministry responsible: Ministry of Agriculture

5.Encourage the inclusion of information on antibiotics in health and medical columns in magazines, newspapers and television.
Ministries responsible: Ministry of Fisheries, Ministry of Agriculture and Ministry of Health and Social Affairs

6.Encourage NGOs and organizations in business and industry to participate in the efforts to prevent resistance to antibiotics from becoming a public health problem.
Ministries responsible: Ministry of Fisheries, Ministry of Agriculture and Ministry of Health and Social Affairs

2.5 Target area 5 – Control of communicable diseases

All control of communicable diseases can help to prevent the development of resistance by reducing the number of infections and consequently the need for antibiotics, and by reducing infection by resistant bacteria. This applies to both humans and animals.

Measures for the control of communicable diseases are usually based on the chain of infection, which is a six-part model for describing the spread of infectious agents. Infectious agents are found in a source of infection. They are excreted through a port of exit and make their way via a route of infection to a port of entry in the recipient. Measures for the control of communicable diseases are adapted to the individual infection and are often directed at the source and route of infection and the recipient.

• Measures directed at sources of infection: identification of sources, eradication of infection, isolation, sometimes containment and changes in behaviour.
• Measures directed at routes of infection: disinfection, hospital hygiene, food control.
• Measures directed at recipients: strengthening general immunity, vaccination, protection, changes in behaviour and, if infection has occurred, chemoprophylaxis or treatment.

All these measures may be useful in preventing resistance.

Subsidiary goal

To improve the control of communicable diseases for humans in and outside hospitals and for animals and thereby reduce the number of infections (including infections by resistant microbes) and the need for antibiotic treatment.

Measures

1. Review the capacity and need for sanitary installations in hospitals in order to implement sound isolation practices for patients with contagious and airborne infections.
   Ministry responsible: Ministry of Health and Social Affairs
2. Lay down guidelines for locally adapted control of communicable diseases at nursing homes and similar institutions and ensure that municipal medical officers are able to carry out their control functions in municipal medical institutions.
   Ministry responsible: Ministry of Health and Social Affairs
3. Motivate animal health professionals, animal producers and fish farmers to intensify their preventive activities, including vaccination, in animal production.
   Ministries responsible: Ministry of Fisheries and Ministry of Agriculture
4. Make active efforts to reduce overcrowding in hospitals so as to avoid having to place patients in the corridors.
   Ministry responsible: Ministry of Health and Social Affairs
5. Support international efforts to control communicable diseases under the auspices of the World Health Organization and other multinational organizations, and in particular efforts in areas adjacent to the Nordic countries.
   Ministry responsible: Ministry of Health and Social Affairs
6. Establish a system for developing appropriate hygienic procedures during operations, for example by ensuring that hospitals that implant prostheses, which are a source of infection, have operation rooms with air that satisfies microbiological standards.
   Ministry responsible: Ministry of Health and Social Affairs
7. Strengthen vaccination services for Norwegian travellers abroad and advice on how to protect themselves from communicable diseases.
   Ministry responsible: Ministry of Health and Social Affairs
8. Maintain a high level of support for the child vaccination programme.
   Ministry responsible: Ministry of Health and Social Affairs
9. Improve hand and kitchen hygiene among the general public.
   Ministry responsible: Ministry of Health and Social Affairs
10. Introduce measures for control of communicable diseases in child-care institutions as soon as the necessary knowledge base is available.
    Ministry responsible: Ministry of Health and Social Affairs
11. Replace disinfection by chemicals with disinfection by heat as far as possible.
    Ministries responsible: Ministry of Fisheries, Ministry of Agriculture and Ministry of Health and Social Affairs

2.6 Target area 6 – microbiological diagnosis and determination of resistance

The control of communicable diseases and the efforts to combat resistance depend on microbiological laboratories maintaining high standards. Microbiological diagnosis, i.e. the identification of infectious agents in clinical samples and if necessary the further characterization of the agent, is one of the cornerstones of effective control. New technology has in recent years allowed earlier and better identification of microbes. However, many microbiological laboratories need to invest in new equipment, recruit more qualified personnel and provide continuing education for the personnel they already have.

It is also probable that in the future many Norwegian hospital owners will choose to set out microbiological services for tender. Microbiological departments may be spun off from hospitals and be faced with the necessity of adapting to quite new demands from the market. Before these changes are implemented, it will be necessary to establish arrangements that ensure that activities not linked with the examination of patient samples are maintained. This applies especially to activities relating to the control of communicable diseases, such as the monitoring of communicable diseases and resistance, and research, advisory services and teaching.

Subsidiary goal

To take samples from humans and animals with communicable diseases correctly and in the right situations and improve the identification by laboratories of the pathological microbe and their determination of the extent of resistance.

Measures

1. Provide incentives for veterinarians to submit adequate samples from animals with communicable diseases in accordance with good veterinary practice.
   Ministry responsible: Ministry of Agriculture
2. Formalize the systems for specialized and reference functions in medical microbiology.
   Ministry responsible: Ministry of Health and Social Affairs
3. Strengthen the national reference laboratory for tuberculosis.
   Ministry responsible: Ministry of Health and Social Affairs
4. Retain the Norwegian centre for auditing of laboratory activities outside hospitals (NOKLUS) and its advisory functions on clinically relevant issues relating to infection.
   Ministry responsible: Ministry of Health and Social Affairs
5. Assist laboratories in maintaining the quality assurance of their resistance tests in accordance with the accreditation requirements.
   Ministry responsible: Ministry of Health and Social Affairs

2.7 Target area 7 – administration and supervision

As mentioned in section 2.2, there is still considerable room for improvement with regard to avoiding unnecessary use of antibiotics and limiting total consumption. In this connection it is therefore important to review the existing funding schemes, rules and supervisory arrangements to see what needs to be improved.

Subsidiary goal

To review and improve rules, make decisions and implement supervision that will contribute to a stringent antibiotics policy and the sound use of antibiotics.

Measures

1. Investigate how national insurance refunds for antibiotics function and if necessary make the system more stringent if it is found to encourage the unnecessary use of antibiotics or the use of undesirable drugs.
   Ministry responsible: Ministry of Health and Social Affairs
2. Maintain the current restrictive line concerning marketing licences for new antibiotics, for example by continuing to give weight to the risk of the development of resistance when assessing the safety of new products.
   Ministry responsible: Ministry of Health and Social Affairs
3. Continue the use of prescription limitations and delivery conditions in order to limit the use of certain important antibiotics to special situations.
   Ministry responsible: Ministry of Health and Social Affairs
4. Continue to make prescription mandatory for antibiotics.
   Ministry responsible: Ministry of Health and Social Affairs
5. Cooperate with other countries with a view to influencing the pharmaceutical authorities in the EU to adopt a more restrictive attitude to the approval of antibiotics.
   Ministry responsible: Ministry of Health and Social Affairs
6. Closely monitor advertisements for antibiotics and take action against violations.
   Ministry responsible: Ministry of Health and Social Affairs
7. Supervise the efforts of hospitals to control communicable diseases, including their antibiotics strategy and where necessary their containment measures.
   Ministry responsible: Ministry of Health and Social Affairs
8. Amend legislation so as to enable further supervision, control and monitoring of the use of drugs in animals, including fish.
   Ministries responsible: Ministry of Fisheries and Ministry of Agriculture
9. Continue supervising the use of antibiotics in the feed given to warm-blooded animals.
   Ministry responsible: Ministry of Agriculture
10. Further develop the rules relating to preventive measures against infection in domestic animal production and aquaculture.
    Ministries responsible: Ministry of Fisheries and Ministry of Agriculture
11. Maintain a strict policy concerning genetically modified organisms (GMO) with added genes that code for antibiotics resistance in both human and animal food.
    Ministries responsible: Ministry of Fisheries, Ministry of the Environment, Ministry of Agriculture, and Ministry of Health and Social Affairs
12. Encourage more limited marketing of "bactericidal detergents".
    Ministry responsible: Ministry of the Environment

2.8 Target area 8 – research and development

Although we know about many different resistance mechanisms and are beginning to understand how microbial resistance develops and spreads, we still lack a good deal of knowledge that we need in order to choose the right measures for controlling the threatening problem of resistance. There are also few measures where the effects have been properly assessed. There is thus an urgent need to strengthen research in this field, in Norway as well as abroad. Research will give us better tools for preventing and combating resistance. There are a number of reasons why we must undertake studies in Norway and not merely exploit other countries’ research findings:

• Norway must have front-line researchers so that we can be aware of, interpret and make use of international research findings.
• Resistance in Norway has certain unique characteristics that can only be studied in this country. Results from other countries cannot be automatically extrapolated to Norwegian conditions.
• Research will help to make teaching and clinical practice more knowledge-based.
• Norway has an obligation to contribute to the international knowledge base.

Subsidiary goal

To strengthen our knowledge of the causes of the development and spread of resistance and improve the knowledge base necessary for an informed choice of methods to combat resistance.

Measures

1. Establish a five-year programme under the auspices of the Research Council of Norway to strengthen research on resistance, starting in 2000.
   Ministry responsible: Ministry of Health and Social Affairs
2. Encourage research in a number of different fields and achieve a better understanding of the application of antibiotics through cooperation between disciplines such as bacteriology, clinical medicine, veterinary medicine, health services research and epidemiology.
   Ministries responsible: Ministry of Agriculture and Ministry of Health and Social Affairs
3. Assess the necessity of studies to investigate the stability and possible influence on the environment of antibacterial agents.
   Ministries responsible: Ministry of Agriculture, Ministry of Fisheries, Ministry of the Environment and Ministry of Health and Social Affairs
4. Study alternative methods of treatment and preventive measures.
   Ministries responsible: Ministry of Agriculture, Ministry of Fisheries and Ministry of Health and Social Affairs