Antibiotics Smart Use (ASU)
Food and Drug Administration

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Antimicrobial resistance (AMR), especially bacteria resistant to antibiotics, is a great health threat and undermines economics worldwide. AMR causes approximately 700,000 deaths globally per year. Failing to tackle AMR will cause 10 million deaths a year and cost up to 100 trillion USD by 2050. The highest impact will be found in Asia and Africa, accounting for 4.7 and 4.2 million deaths, respectively. In Thailand, a study estimates 88,000 AMR attributed morbidity and 38,000 mortalities in 2010; resulting in 1,200 million USD economic loss (1 USD = 35 Baht). There is a positive correlation between AMR and the antibiotic consumption. Evidence indicates that antibiotic consumption is on the rise worldwide during 2000-2010. Alarming evidence is the increase use of carbapenems and polymixins by 45% and 13%, respectively as they are two last-resort classes of antibiotics to combat highly resistant bacteria. While the rate of AMR is increasing, the pipeline of new antibiotics to combat AMR is running dry. Pharmaceutical companies slow down investments in new antibiotic research. Once bacteria become resistant to new antibiotics, the sale will drop and no profits gain. This situation is leading to “the post-antibiotic era,” a situation in which minor infections can kill, and to “the collapse of modern medicine,” a situation in which modern medical procedures e.g., surgeries, organ transplantation and chemotherapy cannot be performed because of the risk of untreatable infection due to AMR. Failure in curbing overuse of antibiotics is a key driver for AMR. In Thailand, a throat swab study in a teaching hospital revealed that only 7.9% of the upper respiratory infections (URI) were caused by bacteria infection. Taking diagnostic uncertainty into account, the rate of antibiotic use in URI should not exceed 20%. However, the high rates of antibiotic use for URI are commonly found in healthcare settings, clinics and pharmacies. In 2011, only 3% from 892 hospitals can contain the rate of antibiotic prescription for URI to be 20% or less. Three major factors contribute to overuse of antibiotics in Thailand are, first, a colloquial name for antibiotics is “ya-gae-ug-sep”, which more or less translates as ‘medicine for treating inflammation’. Not surprisingly, antibiotics are seen as a panacea for treating swelling, pain, fever and other conditions regardless of bacterial infection. Second, in the Thai healthcare system, there is no separation between prescription and dispensing: both physicians and pharmacists can prescribe and dispense antibiotics. Incentives to sell antibiotics are misaligned since physicians and pharmacists benefit from selling antibiotics whereas the consumer demand for antibiotics is high. Third, antibiotic overuse is social norms in Thailand. A normative behavior pattern is that if common cold with sore throats, then amoxicillin; if acute diarrhea, then norfloxacin; and if wound, then dicloxacillin. This normative behavioral pattern is rampant among health professionals, patients and consumers. Thus, it is important to break this normative behavioral pattern. Ironically, if we cannot even treat common, self-limited conditions e.g., URI, acute diarrhea and wound properly, then what will the situation be like for more complicated infectious conditions?

B. Strategic Approach

 2. What was the solution?
It is obviously that the rate of new antibiotic discovery cannot outrun the resistant rate of bacteria, and therefore the most important thing now is to stop overuse of antibiotics in order to prolong the effectiveness of existing antibiotics. Based on a primary concept “No antibiotics for non-bacterial infections,” the Antibiotics Smart Use (ASU) Program is introduced in 2007 as a solution to reduce unnecessary use of antibiotics in three common, self-limited conditions: URI especially common cold with sore throat, acute diarrhea especially food poisoning and simple wound. The program applies the multi-faceted, multi-level interventions to initiate prescribing behavioral change on antibiotic use and then scale up this behavioral change toward sustainability by creating new social norms.

 3. How did the initiative solve the problem and improve people’s lives?
To reduce unnecessary use of antibiotics, physicians are the primary target because they are key prescribers. Other health professionals and patients usually imitate physicians’ medication use behavior. District hospitals and their sub-district primary care units (sub-district PCUs, where nurses are prescribers) are the target sites because they are the most accessible healthcare outlets for people in rural areas, especially for the poor. According to World Bank, Thailand poverty is a rural phenomenon. Over 80% of the country's 7.3 million poor live in rural areas. Additionally, prescribers in district hospitals and sub-district PCUs are receptive to ASU, comparing to those in large hospitals (full of specialists) and pharmacies (gaining revenue from selling antibiotics). Key strategies used in reducing antibiotic prescriptions are (1) correcting prescribers’ understanding of antibiotic use e.g., training and giving treatment guidelines; (2) increasing prescribers’ confidence in managing targeted conditions without antibiotics, e.g., using alternative, herbal medicines to relieve patients’ symptoms and worrisome for not receiving antibiotics, asking nurses to make follow-up calls to some patients who were not prescribed antibiotics to assess their clinical outcome, and using the white light illuminator to improve diagnostic accuracy (Note: traditionally, orange-yellowish light illuminators were used for throat examination. Due to its light’s color, patients’ throats look redder. This stimulates prescribers to prescribe more antibiotics. ASU provides white light illuminators to all district hospitals and their sub-district PCUs); (3) reducing pressure due to patients’ expectation on antibiotics, e.g., priming patients with accurate information about diseases and antibiotics before seeing a doctor or giving them brochure to read before seeing a doctor and (4) providing feedback to physicians regarding their rate of antibiotic prescription, comparing to their peers’ and having discussion session among physicians to help them reduce antibiotic use. To empower the community and facilitate prescribing behavioral change, health volunteers and community members are the target. Key strategies aim at reducing consumer demand on antibiotics and educating/empowering them with the key messages: (1) Stop calling antibiotics as “ya-gae-ug-sep” because this colloquial name is misleading; (2) Antibiotics are dangerous because overuse or inappropriate use will lead to AMR; and (3) Three diseases: URI, acute diarrhea and simple wound can be cured without antibiotics. A strategy empowering community members in Muaklek District, Saraburi province is, for example, engaging health volunteers and community members to create their own “ASU personalized posters” conveying ASU key messages and using pictures of their individual families as presenters or ambassadors. These posters are put in front of their houses. This strategy is a simple device that transforms them from ‘information-receivers’ to ‘information-givers’ in promoting rational use of antibiotics in their communities. Apart from lack of knowledge on antibiotics, Thai people in rural areas especially the poor often purchase antibiotics from illegal outlets, i.e., grocery stores. It is because for them, “ya-gae-ug-sep” (antibiotics) is a panacea. A survey of 196 villages in 8 provinces in 2000 found that all villages (100%) had grocery stores selling antibiotics. Despite law enforcement, this situation still exists till today. A successful example in addressing this issue is Cha-lae District, Songkha Province the southern region of Thailand with a population of 2,800. They joined ASU in 2010. Instead of using a regulatory measure, they used a social measure by adding ASU key concepts into their own local “health constitution,” and signed memoranda of understanding with grocery store owners not to sell antibiotics while educated villagers about antibiotic use. In conclusion, antibiotic use behavior is interactions among individuals and their environment. Thus, multi-faceted, multi-level intervention is needed. Reducing unnecessary use of antibiotics leads to low risks of AMR and Adverse Drug Reactions (ADRs) to the patients.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The ASU program is innovative in three folds. First, instead of using a top-down approach by issuing a policy or regulation to curb antibiotic use, ASU uses a bottom-up approach to change prescribing behavior and then uses a top-down approach to sustain behavioral change. As action research, ASU initiates antibiotic prescribing behavioral change through collaborative actions between central partners and local partners. Second, for ASU, a behavioral change is a process, not a goal. The ultimate goal is to create new social norms, which is new to drug regulators and policy makers. Social norm is a soft law urging individuals to act congruently with societies. Discrepancies between social norms and the legislative laws lead to law violations and ineffective law enforcement. Third, it is the first time that the complex concept of rational use of medicines is simplified into two steps for action: (1) do not use medicine if not necessary and (2) if necessary to use, use it wisely. This new stance enables the complex problems to be solved in a clear and effective manner. Step 1 is a primary focus of ASU.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
Program organization: ASU organized on two levels: central partners and local partners. Local partners are a group of health professionals, community leaders and others. They are responsible for ASU implementation in their settings such as hospitals, schools and communities. Central partners are a group of national health authorities, research institutes, civil society organizations (CSO) and others. They are responsible for ASU implementation at national and sub-national levels. Program administration: The central and local partners are formed the ASU network, which is a decentralize network based on the starfish model, in which management has no hierarchical leadership. The ASU network emphasizes the importance of local ownership and mutual recognition, which have generated pride and commitment. To promote senses of local ownership, the local partners can name their own projects (no need to name it ASU) and design their own methods for improving the use of antibiotics among health profes¬sionals and the public. The central part¬ners play catalytic and supportive roles in two ways. First, they guide and harmonize activities across local partners and disseminate examples of good practice and success stories drawn from local partners (e.g. via newsletters). Second, they provide policy support as well as technical and financial support. The Food and Drug Administration (FDA) is in charge in coordinating across partners. Size of the population affected/benefited by ASU: The number of people affected and benefited by ASU has increased over time. In 2007, ASU was implemented in one province and then expanded to three provinces and two hospital networks in 2008. In 2010, ASU was expanded to 15 provinces. The first policy support is in 2009 when the National Health Security Office (NHSO), responsible for the Universal Health Coverage (UHC), adopted ASU in to the Pay-for-Performance (P4P) policy. This initial P4P policy was made to cover district hospitals across the country. Since 2011, the P4P policy covers all regional, provincial and district hospitals. As a result, ASU has become a nation-wide program. Additionally, the momentum to adopt ASU in other national policies has continued (see Item 14 for details).
 6. How was the strategy implemented and what resources were mobilized?
ASU has evolved through three phases. Phase I (2007-2008) is to test the effectiveness of interventions in changing physicians’ behavior in three targeted conditions: URI, acute diarrhea and wound. Based on a quasi-experimental pre-post design with a control group, ASU was piloted in one province (Saraburi) covering 10 district hospitals and 87 sub-district PCUs. Ayutthaya, a matching, neighboring province was the control group. Effectiveness of intervention was as-sessed against the predetermined targeted, i.e., 10% reduction of antibiotic prescriptions, 10% increase in the number of patients who were not prescribed antibiotics; and 70% of the number of patients who were not prescribed antibiotics feel better or full recovery and satisfied with treatment outcome. It used multi-faceted interventions at the individual and organizational levels (see Item 3). The results showed antibiotic prescriptions reduced 18-46%. The number of patients who were not prescribed antibiotics increased 29%. Over 97% of 1,200 patients who were not prescribed antibiotics feel better or fully recovered and over 80% were satisfied with treatment outcome. Successes in Phase I led to Phase II. Phase II (2008-2009) is to examine feasibility of program scale-up. It was tested in three provinces (large, medium and small provinces) and two hospital networks (public and private hospital networks). It covered 44 hospitals and 627 sub-district PCUs. ASU orga¬nized on two levels: central partners and local partners. It used two strategies. The first strategy applies the interventions from Phase I for changing prescribing behavior. The second strategy aims at scaling-up ASU using the horizontal and vertical scaling-up measures. The horizontal scaling-up measure emphasizes creating a decentralize network (see Item 5) by (1) giving the local partners full autonomy in naming their own ASU projects and designing their own interven¬tions and media materials (see Item 3) and (2) establishing the ‘training for trainers’ program to build local network capacity that can provide technical support to their peers in neighboring areas. The vertical scaling-up measure emphasizes integrating ASU into policy. In 2009, ASU was included in the NHSO’s P4P policy. Key findings are all three provinces and two hospital networks can reduce the rates of antibiotic prescriptions and gain positive patients’ health outcome and satisfaction on treatment outcome as those found in Phase I, and the combination of horizontal and vertical scaling up measure is effective to scale up ASU program. Successes in Phase II led to Phase III. Phase III (2010-present) is to scale up ASU toward sustainability by creating new social norms. Key strategies include increasing the number of sites, transferring to different settings, and strengthening policy support. Key findings are ASU was expanded to 15 provinces in 2010, by Drug System Monitoring and Development Center (DSMDC), a CSO funded by Thai Health Promotion Foundation. It was adopted by Siriraj hospital (the largest, teaching hospital in Thailand) in 2012, by Queen Sirikit National Institute of Child Health (the largest, children hospital in Thailand) in 2013, by Community Pharmacist Association of Thailand (CPAT) in 2014, and by Antibiotic Awareness Campaign (a sub-national public campaign) in 2013. In 2016, ASU is included in Rational Drug Use (RDU) hospital policy of Ministry of Public Health (MOPH). We also conducted a survey to assess changes of knowledge, attitudes and social norms in various sites of ASU. Financial support are from WHO (Phase I), from Health Systems Research Institution (HSRI) and NHSO (Phase II) and from DSMDC and HSRI (Phase III) accounting for 33,000; 73,000 and 123,000 USD, respectively. FDA provides subsidiary budget and in-kind contribution of human resources in program management. Technical support for clinical training and program evaluation is from Chulalongkorn University and Srinakharinwirot University, respectively.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
ASU is derived from collective efforts from partners, particularly, Central partners Food and Drug Administration is responsible for program planning, management and coordination, mobilizes resources, creates educational materials for patients and generates ASU reports. Medical professor, Chulalongkorn University trains health professionals, develops educational materials for health professionals and proposes to use white light illuminators. Pharmacy professors, Srinakharinwirot University conducts program evaluation and provides technical support for local partners for ASU research. National Health Security Office endorses ASU into P4P policy, supports funding and advances the E-tool program to monitor the rate of antibiotic prescription. Ministry of Public Health adopted ASU in the RDU hospital policy in 2016. Drug System Monitoring and Development Center, civil society organization, supports funding, expands ASU sites, initiates the Antibiotic Awareness Campaign by integrating ASU’s key messages in the campaign, and advocates ASU to policy. Health Systems Research Institute supports funding, advocates ASU to policy and provides a forum for ASU in its national research conference. Health Accreditation Institute, a public organization, provides a forum for ASU in its national HA forum. Siriraj Hospital generates evidence enabling NHSO to set the cut-off point at 20% for P4P policy, i.e., the rate of antibiotic prescription for URI and acute diarrhea should not exceed 20%. Queen Sirikit National Institute of Child Health initiates ASU-Kids project. Community Pharmacist Association of Thailand, a private sector, initiates ASU-pharmacy project and re-design the ‘Mirror-for-sore-throat-examination tool’ for pharmacies. Selected local partners Muaklek District, Saraburi Province is ASU best practice demonstrating sustainability. Choompae district hospital, Konkean Province develops prototype of E-tool program and then advanced by NHSO to monitor national antibiotic prescription. International supporter/partners WHO supports funding and promotes ASU in publication. ReAct-Action on Antibiotic Resistance, an international civil society organization, promotes ASU as a best practice to other countries and in website, www.reactgroup.org.

 8. What were the most successful outputs and why was the initiative effective?
These are four most successful outputs. First, the rate of antibiotic prescription in URI and acute diarrhea decrease from 50% to 40% and from 47% to 34%, respectively. Despite yet achieved the 20% target, the trend is promising. This successful reduction is because hospitals regularly receive the feedback data from NHSO regarding their rates of antibiotic prescription, comparing to other hospitals in the same health region. Technical support from FDA and academics to improve use of antibiotics is available for hospitals upon request. This success advances roles of SDG-3 as it reduces risks of AMR and ADRs due to overuse of antibiotics to patients and of SDG-12 as it prolongs the effectiveness of existing antibiotics and therefore promote sustainable consumption of antibiotics. Second, after 10-year implementation, there is no report that ASU practice jeopardizes patients’ health. In contrast, the follow-up phone calls within 7-10 days after the medical visits in public hospitals found that 97% of 1,200 patients who were affected with the targeted conditions and were not prescribed antibiotics felt better or fully recovered. The similar results were found in private hospitals and pharmacies, i.e., 99% of 917 patients and 92% of 998 patients, respectively. This success is due to the fact that the targeted condition is self-limited diseases and no need for antibiotics. This success advances roles of SDG-3 as this evidence ensures healthy lives and promotes well-being despite receiving antibiotics in these three targeted conditions. Third, hospitals can cut costs due to unnecessary antibiotic use. For example, Choompae district hospital, in Konkean province started ASU in 2010. They found that the costs of antibiotic use reduce from 25,000 to 6,300 USD during 2008-2014. Additionally, they can maintain the rate of antibiotic use in targeted conditions below 20% till today. The success results from the fact that they use the audit-feedback system to monitor antibiotic use in the hospital with dialogues among physicians. This success advances roles of SDG-1 as AMR negatively impacts on national economy, which could ultimately contribute to slowing down progress towards SDG-1. Fourth, there is a success in integrating ASU into policy so that it enhances the likelihood of sustainability of ASU implementation. Presently, ASU has been adopted and implemented under two national policies: NHSO’s P4P policy and MOPH’s RDU hospital policy. This success advances roles of SDG 1, 3 and 12 as the policy support is crucial to promote sustainable development.

 9. What were the main obstacles encountered and how were they overcome?
Four obstacles are worth mentioning as follows. First, although ASU is a well-planned project, it must inevitably be adapted to the local context. For example, physicians in district hospitals have tight schedules as they need to handle hospital and community services. Leaving a hospital to join the training is difficult for them. Thus, an individual training program was delivered on-site in every district hospital to adapt to the tight schedule of district hospital physicians. It took 1.5 months to complete the ‘on-site training’ program for all 10 district hospitals. Second, physicians fear that patients may get worse without antibiotics. Couple tactics are used to overcome this fear. For example, they may prescribe alternative, herbal medicines listed in Thailand’s National List of Essential Medicines, such as Andrographis paniculata capsules, for patients to relieve symptoms of fever and sore throat from viral infection. Alternatively, they may experiment by cutting down antibiotic use then have nurses/pharmacies to make follow-up calls to monitor clinical outcome of patients who did not receive antibiotics. In one district hospital, the hospital director had physicians, nurses and pharmacists collectively observe his practice of not prescribing antibiotics and co-monitor patients’ clinical outcomes. This can enhance prescribers’ confidence in non-antibiotic therapy. Third, in district hospitals physicians trained in ASU are often rotated to other settings. Thus, self-governance by hospital’s medical board or pharmacy therapeutic committee to ensure training for incoming physicians is important. Fourth, resource limitation is a major challenge. Many effective devices, e.g., ‘Mirror-for-sore-throat-examination’ (see Item 10) cannot be reproduced sufficiently due to lack of financial support. In overcoming this difficulty, apart from solving problem on a case basis, we expected multiple, long-term policy commitment to provide sufficient resources so that ASU can achieve creating new social norms on antibiotic use for Thailand.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
ASU has direct benefits of ASU as follows. ASU implementation can protect patients from antibiotic-related ADRs. Evidence indicates that antibiotics are the most common drug classes causing ADRs in Thailand. In 2009, Ubonratchathani province joined ASU. After 4-month implementation, the rate of antibiotic prescriptions in URI in 20 district hospitals reduced by 13% (from 50.4% to 37.5%). The reduction by 13% means that 6,747 patients of URI are safe from unnecessary use of antibiotics, in which some of them may develop ADRs either minor or fatal ones. In Thailand, purchasing antibiotics without prescription is common. Refusing to sell antibiotics creates tension between pharmacists and consumers. Thus, an important goal was to lower consumer demand for antibiotics. In 2010, a community pharmacist pioneered ASU in her own pharmacy. She put a dressing table mirror on a pharmacy counter beside an ASU pamphlet describing differences between viral and bacterial infections of the throat. She asked consumers to use the mirror to examine their own tonsils along with a tongue depressor and white-light illuminator while explained to them differences between viral and bacterial infections, using the Centor criteria, the criteria to identify the likelihood of bacterial infection in adult patients with sore throat. She found that many consumers decided not to buy antibiotics and were willing to purchase alternative treatments to relieve their symptoms. Thus, a pharmacy did not lost incomes. Inspired by her story, the CPAT initiated the ASU-Pharmacy project in 2012 and re-designed the ‘Mirror-for-sore-throat-examination’ device. They tested this device in nearly 100 pharmacies and found that over 90% of the 998 patients fully recovered. More than 80% were satisfied with treatment outcomes. Presently, countless consumers are educated about sore throats via this device. This device was re-produced and distributed to sub-district PCUs. It was also modified by FDA to be a portable version and distribute to health volunteers to use for educating villagers during door-to-door visits. A founder of GABFAI Community Theater located in Chaingmai province joined ASU in 2013 by producing street plays on antibiotics and engaging children to take parts in the plays. His daughter got sore through and was prescribed antibiotics. He asked a doctor if it was viral or bacterial infection. Running a diagnostic test, the result confirmed viral infection. His daughter was safe from unnecessary use of antibiotics. This is just one of many parents whose children being exposed to antibiotics. Equipped with knowledge, they can protect their children from overuse of antibiotics. ASU was integrated in school-based activities. For example, Thairath Witthaya School-68, kindergarten-middle school, has students to learn about antibiotics from direct experiences, e.g., composing a song, conducting the plays, producing multimedia and storytelling about antibiotics. Students with a teacher visit grocery stores in their villages to educate shop owners about antibiotics. This learning style enables young generations to be cultivated about antibiotics properly and use antibiotic responsibly. There are lots more about public awareness activities. Although these activities are fragmented, the key messages are similar, adapted from ASU’s key messages.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
ASU improves integrity and accountability in public service by confirming that antibiotic use in URI, acute diarrhea and simple wound, should not exceed 20% regardless sizes of hospitals. Previously, opponents argued that ASU is inappropriate for large hospitals because patients who are affected with these conditions and visit large hospitals are sicker than those who visit district hospitals and sub-district PCUs. Thus, the rate of antibiotic prescription for these conditions in large hospitals should be higher than 20%. In 2012, Siriraj hospital (the largest, teaching hospital in Thailand) conducted an ASU study and found that less than 10% of URI and acute diarrhea are bacterial infection. It also can reduce the rates of antibiotic prescription from 74% to 13% in URI and 78% to 19.1% in acute diarrhea without observing any harmful effects to the patients who did not receive antibiotics, comparing with those who received antibiotics. Evidence from Siriraj hospital overrules the previous argument. Taking evidence from Siriraj hospital into account and adjusting for diagnostic uncertainty, the cut-off point at 20% for antibiotic prescription rates for URI and acute diarrhea is proposed to use in the P4P policy. The NHSO’s P4P policy relies on a step-wise approach. Healthcare settings will receive financial incentives if their antibiotic prescription rates of URI and acute diarrhea were 20% or less, partial incentives if its antibiotic prescription rates of these conditions were 21-40%, and no incentives if its antibiotic prescription rates of these conditions were more than 40%. In 2016, the MOPH adopted the step-wise criteria of NHSO’s P4P policy to its RDU hospital policy. Instead of using financial incentive, the MOPH applies its administrative power to have all regional, provincial, district hospitals and sub-district PCUs under MOPH to curb down the antibiotic prescription rates in URI and acute diarrhea to be 20% or less. Based on these two policies of NHSO and MOPH, people are entitled to understand about their diseases, treatment options and reasons if antibiotics are prescribed. They can hold the government accountable on the delivery of proper medical services for these three targeted conditions. Finally, ASU takes the conflict of interest (COI) issue seriously. It has a strong policy for not receiving support from any entities relating to COI, including pharmaceutical companies in order to maintain the program integrity and credibility, to hold accountability to all of partners, and to prevent potential corruption in the future.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
In April 2016, scoop news reported a case of 7-year old boy in a middle-high-income family being affected with life-threatening AMR due to frequently being prescribed with antibiotics for his sore throat since the age of three. This case confirms that children, regardless of their gender and socioeconomic status, are the vulnerable group, especially children less than 5-years-old as they have frequent URI due to their immature immune system especially among those attending childcare services or kindergartens. Thus, they are more likely to be exposed to antibiotics compared to other age groups. In 2013, the Queen Sirikit National Institute of Child Health (QSNICH), the 450-bed tertiary care hospital under the MOPH, launched the ASU-Kids project to improve antibiotic prescribing behaviors of their medical staff and to empower the parents, especially mothers by training them to do the nasal irrigation for their children to relief cold symptom and educating them about URI and dangers of antibiotic overuse in children. The QSNICH also expands their roles by joining outreach programs with DSMDC to educate parents via citizen forums, scoop news and the annual Antibiotic Awareness Day Campaign. Engaging in these programs made them realize that lots more need to be done.

Contact Information

Institution Name:   Food and Drug Administration
Institution Type:   Government Department  
Contact Person:   Nithima Sumpradit
Title:   Dr.  
Telephone/ Fax:   +66840046469
Institution's / Project's Website:  
E-mail:   nithima@fda.moph.go.th  
Address:   Food and Drug Administration, Ministry of Public Health, 88/24 Tiwanon Rd.
Postal Code:   11000
City:   Meuang
State/Province:   Nonthaburi
Country:  

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