Tracking progress on antimicrobial resistance by the quadripartite country self-assessment survey (TrACSS) in G7 countries, 2017-2023: opportunities and gaps.

Antimicrobial resistance (AMR) poses serious challenges to the healthcare systems worldwide. Multiple factors and activities contribute to the development and spread of antimicrobial-resistant microorganisms. Monitoring progress in combating AMR is fundamental at both global and national levels to drive multisectoral actions, identify priorities, and coordinate strategies. Since 2017, the World Health Organization (WHO) has collected data through the Tracking AMR Country Self-Assessment Survey (TrACSS). TrACSS data are published in a publicly-available database. In 2023, 71 (59.9%) out of 177 responding countries reported the existence of a monitoring and evaluation plan for their National Action Plan (NAP) on AMR, and just 20 countries (11.3%) the allocation of funding to support NAP implementation. Countries reported challenges including limited financial and human resources, lack of technical capacity, and variable political commitment. Even across the Group of Seven (G7) countries, which represent some of the world's most advanced economies, many areas still need improvement, such as full implementation of infection prevention and control measures, adoption of WHO access/watch/reserve (AWaRe) classification of antibiotics, effective integration of laboratories in AMR surveillance in the animal health and food safety sectors, training and education, good manufacturing and hygiene practices in food processing, optimising pesticides use and environmental residues of antimicrobial drugs. Continuous and coordinated efforts are needed to strengthen multisectoral engagement to fight AMR.

Associated deaths and disability-adjusted life-years caused by infections with antibiotic-resistant bacteria in Switzerland, 2010 to 2019.

BackgroundCassini et al. (2019) estimated that, in 2015, infections with 16 different antibiotic-resistant bacteria resulted in ca 170 disability-adjusted life-years (DALYs) per 100,000 population in the European Union and European Economic area (EU/EEA). The corresponding estimate for Switzerland was about half of this (87.8 DALYs per 100,000 population) but still higher than that of several EU/EEA countries (e.g. neighbouring Austria (77.2)).AimIn this study, the burden caused by the same infections due to antibiotic-resistant bacteria ('AMR burden') in Switzerland from 2010 to 2019 was estimated and the effect of the factors 'linguistic region' and 'hospital type' on this estimate was examined.MethodsNumber of infections, DALYs and deaths were estimated according to Cassini et al. (2019) whereas separate models were built for each linguistic region/hospital type combination.ResultsDALYs increased significantly from 3,995 (95% uncertainty interval (UI): 3;327-4,805) in 2010 to 6,805 (95% UI: 5,820-7,949) in 2019. Linguistic region and hospital type stratifications significantly affected the absolute values and the slope of the total AMR burden estimates. DALYs per population were higher in the Latin part of Switzerland (98 DALYs per 100,000 population; 95% UI: 83-115) compared with the German part (57 DALYs per 100,000 population; 95% UI: 49-66) and in university hospitals (165 DALYs per 100,000 hospitalisation days; 95% UI: 140-194) compared with non-university hospitals (62 DALYs per 100,000 hospitalisation days; 95% UI: 53-72).ConclusionsThe AMR burden estimate in Switzerland has increased significantly between 2010 and 2019. Considerable differences depending on the linguistic region and the hospital type were identified - a finding which affects the nationwide burden estimation.

Staphylococcus aureus bloodstream infections: diverging trends of meticillin-resistant and meticillin-susceptible isolates, EU/EEA, 2005 to 2018.

BackgroundInvasive infections caused by Staphylococcus aureus have high clinical and epidemiological relevance. It is therefore important to monitor the S. aureus trends using suitable methods.AimThe study aimed to describe the trends of bloodstream infections (BSI) caused by meticillin-resistant S. aureus (MRSA) and meticillin-susceptible S. aureus (MSSA) in the European Union (EU) and the European Economic Area (EEA).MethodsAnnual data on S. aureus BSI from 2005 to 2018 were obtained from the European Antimicrobial Resistance Surveillance Network (EARS-Net). Trends of BSI were assessed at the EU/EEA level by adjusting for blood culture set rate (number of blood culture sets per 1,000 days of hospitalisation) and stratification by patient characteristics.ResultsConsidering a fixed cohort of laboratories consistently reporting data over the entire study period, MRSA percentages among S. aureus BSI decreased from 30.2% in 2005 to 16.3% in 2018. Concurrently, the total number of BSI caused by S. aureus increased by 57%, MSSA BSI increased by 84% and MRSA BSI decreased by 31%. All these trends were statistically significant (p < 0.001).ConclusionsThe results indicate an increasing health burden of MSSA BSI in the EU/EEA despite a significant decrease in the MRSA percentage. These findings highlight the importance of monitoring antimicrobial resistance trends by assessing not only resistance percentages but also the incidence of infections. Further research is needed on the factors associated with the observed trends and on their attributable risk.

Expansion of the 'Antibiotic Guardian' one health behavioural campaign across Europe to tackle antibiotic resistance: pilot phase and analysis of AMR knowledge.

Antimicrobial resistance (AMR) is a major public health threat. The UK Antibiotic Guardian (AG) behavioural change campaign developed to tackle AMR was expanded across Europe through translation into Russian, Dutch and French. Demographics and knowledge of AGs were analyzed between 01 November 2016 and 31 December 2016. A total of 367 pledges were received with the majority from the public and health care professionals. The pilot has significantly increased the proportion of pledges from Europe (excluding UK) (χ2 = 108.7, P < 0.001). AMR knowledge was greater in AGs (including the public) compared to the EU Eurobarometer survey. Further promotion across Europe is required to measure an impact on tackling AMR.

Hungarian general practice paediatricians' antibiotic prescribing behaviour for suspected respiratory tract infections: a qualitative study.

OBJECTIVES: Inappropriate antibiotic prescribing is a major cause of antimicrobial resistance (AMR). The aim of this study was to explore paediatric general practitioners' (GP Peds) antibiotic prescription practice in suspected respiratory tract infections (RTIs), using the capability-opportunity-motivation-behaviour framework. DESIGN: The design is a qualitative study based on individual, semistructured telephone or virtual interviews. SETTING: Paediatric general practice in Hungary. We applied stratified maximum variation sampling to cover the categories of age, sex and geographical location of participants. PARTICIPANTS: We interviewed 22 GP Peds. Nine were male and 13 were female: 2 of them were less than 40 years old, 14 were between 40 and 60 years, and 6 were above 60 years. 10 worked in low-antibiotic prescription areas, 5 in areas with medium levels of antibiotic prescription, 3 in high-antibiotic prescription areas, and 4 in and around the capital city. RESULTS: Study participants had varying antibiotic prescription preferences. Personal experience and physical examination play a central role in GP Peds' diagnostic and treatment practice. Participants emphasised the need to treat children in their entirety, taking their personal medical record, social background and sometimes parents' preferences into account, besides the acute clinical manifestation of RTI. Most respondents were confident they apply the most effective therapy even if, in some cases, this meant prescribing medicines with a higher chance of contributing to the development of AMR. Some participants felt antibiotic prescription frequency has decreased in recent years. CONCLUSIONS: Our findings suggest that a more prudent attitude toward antibiotic prescribing may have become more common but also highlight relevant gaps in both physicians' and public knowledge of antibiotics and AMR. To reinforce awareness and close remaining gaps, Hungary should adopt its national AMR National Action Plan and further increase its efforts towards active professional communication and feedback for primary care physicians.

Integrating genome-based informatics to modernize global disease monitoring, information sharing, and response.

The rapid advancement of genome technologies holds great promise for improving the quality and speed of clinical and public health laboratory investigations and for decreasing their cost. The latest generation of genome DNA sequencers can provide highly detailed and robust information on disease-causing microbes, and in the near future these technologies will be suitable for routine use in national, regional, and global public health laboratories. With additional improvements in instrumentation, these next- or third-generation sequencers are likely to replace conventional culture-based and molecular typing methods to provide point-of-care clinical diagnosis and other essential information for quicker and better treatment of patients. Provided there is free-sharing of information by all clinical and public health laboratories, these genomic tools could spawn a global system of linked databases of pathogen genomes that would ensure more efficient detection, prevention, and control of endemic, emerging, and other infectious disease outbreaks worldwide.

Global monitoring of Salmonella serovar distribution from the World Health Organization Global Foodborne Infections Network Country Data Bank: results of quality assured laboratories from 2001 to 2007.

Salmonella enterica is commonly acquired from contaminated food and is an important cause of illness worldwide. Interventions are needed to control Salmonella; subtyping Salmonella by serotyping is useful for targeting such interventions. We, therefore, analyzed the global distribution of the 15 most frequently identified serovars of Salmonella isolated from humans from 2001 to 2007 in laboratories from 37 countries that participated in World Health Organization Global Foodborne Infections Network and demonstrated serotyping proficiency in the Global Foodborne Infections Network External Quality Assurance System. In all regions throughout the study period, with the exception of the Oceania and North American regions, Salmonella serovars Enteritidis and Typhimurium ranked as the most common and second most common serovar, respectively. In the North American and Oceania (Australia and New Zealand) regions, Salmonella serovar Typhimurium was the most common serovar reported, and Salmonella serovar Enteritidis was the second most common serovar. During the study period, the proportion of Salmonella isolates reported from humans that were Salmonella serovar Enteritidis was 43.5% (range: 40.6% [2007] to 44.9% [2003]), and Salmonella serovar Typhimurium was 17.1% (range: 15% [2007] to 18.9% [2001]). Salmonella serovars Newport (mainly observed in Latin and North American and European countries), Infantis (dominating in all regions), Virchow (mainly observed in Asian, European, and Oceanic countries), Hadar (profound in European countries), and Agona (intense in Latin and North American and European countries) were also frequently isolated with an overall proportion of 3.5%, 1.8%, 1.5%, 1.5%, and 0.8%, respectively. There were large differences in the most commonly isolated serovars between regions, but lesser differences between countries within the same region. The results also highlight the complexity of the global epidemiology of Salmonella and the need and importance for improving monitoring data of those serovars of highest epidemiologic importance.

Laboratory-based surveillance of nontyphoidal Salmonella infections in China.

Foodborne infections are an important public health problem in China. In 2008, we conducted surveillance for laboratory-confirmed nontyphoidal Salmonella to monitor trends for this infection in China and to build capacity for rapid detection and response to foodborne outbreaks. Salmonella isolates from patients with diarrhea were sent from hospitals to local public health laboratories for confirmation, serotyping, and antimicrobial susceptibility testing. A total of 126 hospitals in 44 cities and counties from 8 provinces provided isolates and epidemiologic data for analysis. Of 23,140 stool specimens submitted to clinical laboratories, 662 (3%) grew Salmonella enterica. Salmonella were most commonly detected between April and October. The median age of infected patients was 27 years; 34% of infections occurred in patients <5 years old. Of the 662 isolates, we found 73 serotypes, of which serotype Enteritidis (31%) and serotype Typhimurium (26%) were the most common. The prevalence of resistance was high for clinically important antimicrobial agents, including ampicillin (41%) and ciprofloxacin (6%). More than 60% of isolates, including 35% of all Typhimurium, were resistant to three or more antimicrobial agents. In this first multiprovince surveillance report of laboratory-confirmed Salmonella infections in China, we found that Enteritidis and Typhimurium are the most common serotypes and that efforts to reduce antimicrobial resistance among Salmonella in China are needed. Although no outbreaks were detected using this system, efforts to improve this system's capacity to do so are underway.

WHO Global Salm-Surv external quality assurance system for serotyping of Salmonella isolates from 2000 to 2007.

An international external quality assurance system (EQAS) for the serotyping of Salmonella species was initiated in 2000 by WHO Global Salm-Surv to enhance the capacity of national reference laboratories to obtain reliable data for surveillance purposes worldwide. Seven EQAS iterations were conducted between 2000 and 2007. In each iteration, participating laboratories submitted serotyping results for eight Salmonella isolates. A total of 249 laboratories in 96 countries participated in at least one EQAS iteration. A total of 756 reports were received from the participating laboratories during the seven EQAS iterations. Cumulatively, 76% of participating laboratories submitted data for all eight strains, and 82% of strains were correctly serotyped. In each iteration, 84% to 96% of the laboratories correctly serotyped the Salmonella enterica serovar Enteritidis isolate that was included as an internal quality control strain. Regional differences in performance were observed, with laboratories in Central Asia and the Middle East performing less well overall than those in other regions. Errors that resulted in incorrect serovar identification were typically caused by difficulties in the detection of the phase two flagellar antigen or in differentiation within antigen complexes; some of these errors are likely related to the quality of the antisera available. The results from the WHO Global Salm-Surv EQAS, the largest of its kind in the world, show that most laboratories worldwide are capable of correctly serotyping Salmonella species. However, this study also indicates a continuing need for improvement. Future training efforts should be aimed at enhancing the ability to detect the phase two flagellar antigen and at disseminating information on where to purchase high-quality antisera.

Results of use of WHO Global Salm-Surv external quality assurance system for antimicrobial susceptibility testing of Salmonella isolates from 2000 to 2007.

An international External Quality Assurance System (EQAS) for antimicrobial susceptibility testing of Salmonella was initiated in 2000 by the World Health Organization (WHO) Global Salm-Surv in order to enhance the capacities of national reference laboratories to obtain reliable data for surveillance purposes worldwide. Seven EQAS iterations have been conducted from 2000 to 2007. In each iteration, participating laboratories submitted susceptibility results from 10 to 15 antimicrobial agents for eight Salmonella isolates and an Escherichia coli reference strain (ATCC 25922). A total of 287 laboratories in 102 countries participated in at least one EQAS iteration. A large number of laboratories reported results for the E. coli ATCC 25922 reference strain which were outside the quality control ranges. Critical deviations for susceptibility testing of the Salmonella isolates varied from 4% in 2000 to 3% in 2007. Consistent difficulties were observed in susceptibility testing of amoxicillin-clavulanic acid, cefotaxime, ceftazidime, streptomycin, sulfonamides, and tetracycline. Regional variations in performance were observed, with laboratories in central Asia, Africa, and the Middle East not performing as well as those in other regions. Results from the WHO Global Salm-Surv EQAS show that most laboratories worldwide are capable of correctly performing antimicrobial susceptibility testing of Salmonella isolates, but they also indicate that further improvement for some laboratories is needed. In particular, further training and dissemination of information on quality control, appropriate interpretive criteria (breakpoints), and harmonization of the methodology worldwide through WHO Global Salm-Surv and other programs will contribute to the generation of comparable and reliable antimicrobial susceptibility data.

Impact of antimicrobial usage on the transmission dynamics of antimicrobial resistant bacteria among pigs.

There is increasing evidence showing that antimicrobial consumption provides a powerful selective force that promotes the emergence of resistance in pathogenic, commensal as well as zoonotic bacteria in animals. The main aim of this study was to develop a modeling framework that can be used to assess the impact of antimicrobial usage in pigs on the emergence and transmission of resistant bacteria within a finisher pig farm. The transmission dynamics of drug-sensitive and drug-resistant bacteria among pigs in the herd were characterized by studying the local and global stability properties of steady state solutions of the system. Numerical simulations demonstrating the influence of factors such as initial prevalence of infection, presence of pre-existing antimicrobial resistant mutants, and frequency of treatment on predicted prevalence were performed. Sensitivity analysis revealed that two parameters had a huge influence on the predicted proportion of pigs carrying resistant bacteria: (a) the transmission coefficient between uninfected pigs and those infected with drug-resistant bacteria during treatment (beta(2)) and after treatment stops (beta(3)), and (b) the spontaneous clear-out rate of drug-resistant bacteria during treatment (gamma(2)) and immediately after treatment stops (gamma(3)). Control measures should therefore be geared towards reducing the magnitudes of beta(2) and beta(3) or increasing those of gamma(2) and gamma(3).

Association between tetracycline consumption and tetracycline resistance in Escherichia coli from healthy Danish slaughter pigs.

It has been recognized that exposure to antimicrobial agents can exert a selective pressure for the emergence of antimicrobial resistance. The objective of this study was to investigate an association between the probability of isolating a tetracycline-resistant Escherichia coli isolate from the intestinal tract of healthy pigs and patterns of tetracycline consumption in the herds of origin, together with other risk factors. Data on antimicrobial resistance, antimicrobial consumption, and pig herd demographics were obtained from different Danish surveillance programs. Descriptive statistics were performed for the risk factors in relation to the susceptibility status. Logistic regression analysis was performed to identify risk factors with significant effect on the log odds of tetracycline resistance of E. coli isolates. The model showed that an increase in the interval between last prescription and sampling date would decrease the probability of isolating a resistant E. coli isolate (p-value = 0.01). Also, a direct association between treatment incidence rate in a herd and probability of resistance was detected (p-value = 0.03). Other risk factors found to have a significant effect in the isolate susceptibility status were number of produced animals in the year and year of sampling. Other antimicrobial consumption risk factors, such as number of prescriptions and amount prescribed, although not included in the final model, presented indirect impact in the tetracycline resistance probability. From this study, we can infer that tetracycline usage, the time span between last treatment and sampling date, together with herd size and the proportion of animals being treated in a herd, increase the probability of obtaining a resistant isolate.

Cross-programmatic consultation on the role of primary care in the responsible use of medicines and the reduction of antimicrobial resistance.

This meeting was held from the 30 October to the 1 November 2018 in Almaty, Kazakhstan. The meeting brought together participants from 16 countries of central Asia, Caucasus, eastern Europe and expert speakers from western Europe and India. Participants discussed the analysis and use of data on antimicrobial medicines consumption, country experiences in enforcing legislation for prescription-only access to antibiotics, the role of primary health care (PHC) in tackling antimicrobial resistance (AMR), strategies to improving competencies of practitioners using evidence-based clinical protocols and public engagement in the responsible use of medicines. Moving toward prescription-only access to antibiotics requires that government involve, from the onset, different stakeholders, e.g. public, patients, practitioners, pharmacists and pharmaceutical industry in designing and applying policies that ensure access to antibiotics accompanied by measures that promote responsible use and limit excessive use.

Reproducible infection model for Clostridium perfringens in broiler chickens.

Experiments were carried out to establish an infection and disease model for Clostridium perfringens in broiler chickens. Previous experiments had failed to induce disease and only a transient colonization with challenge strains had been obtained. In the present study, two series of experiments were conducted, each involving four groups of chickens with each group kept in separate isolators. A coccidial vaccine given at 10 times the prescribed dosage was used to promote the development of necrotic enteritis. In the first experiment, cultures of C. perfringens were mixed with the feed at day 9, 10, 11, and 12, and the coccidial vaccine was given at day 10, whereas in the second experiment, C. perfringens cultures were mixed with the feed at day 17, 18, 19, and 20, and the coccidial vaccine was given at day 18. Chickens were examined at day 9, 11, 12, and 15 (Experiment 1), and at day 17, 18, 20, and 24 (Experiment 2). There was no mortality in any of the groups; however, chickens in the groups receiving both coccidial vaccine and C. peifringens developed the subclinical form of necrotic enteritis, demonstrated by focal necroses in the small intestine, whereas chickens in control groups or groups receiving only coccidial vaccine or only C. perfringens cultures developed no necroses. The results underline the importance of predisposing factors in the development of necrotic enteritis.

Shigella from humans in Thailand during 1993 to 2006: spatial-time trends in species and serotype distribution.

In Thailand during 1993-2006, a total of 9063 Shigella isolates from different medical centers were serotyped and trends over time and spatial clustering analyzed. Of 3583 cases with age information, 1315 (37%) cases were from children between 0 and 4 years and 684 (19%) from children between 5 and 8 years. Most infections were recorded during 1993-1994 (> 1500 per year), decreasing to < 200 in 2006. The relative species distribution also changed. During 1993-1994, Shigella flexneri accounted for 2241 (65%) of 3474 isolations. This proportion decreased to 64 (36%) of 176 infections in 2006. Most infections occurred during July and August, and fewest in December. S. flexneri clustered around Bangkok, and Shigella sonnei in southern Thailand. Most S. flexneri infections were caused by serotype 2a (1590 of 4035) followed by serotype var X (1249). For both serotypes, a pronounced decrease in the number of isolates occurred over time. A much smaller decrease was observed for serotype 3a isolates. Phase I S. sonnei was initially most common, but shifted gradually over phase I, II, to only phase II. No differences in spatial distribution were found. The three most common S. flexneri serotypes all clustered in, around, and west of Bangkok. Serotypes 2a and 3a also clustered in southern Thailand, whereas var X clustered north and northeast of Bangkok. In conclusion, looking at Shigella species, Thailand changed from being a developing country to a developed country between 1995 and 1996. In addition, major shifts in the types of S. sonnei were observed as were differences in spatial clustering of S. flexneri and S. sonnei and S. flexneri serotypes.

External quality assurance system for antibiotic resistance in bacteria of animal origin in Europe (ARBAO-II), 2003.

Initiated in 2003 by the European Union, ARBAO-II aims to establish a monitoring of antimicrobial susceptibility among the veterinary laboratories in all European countries based on validated methodologies. This includes an external quality control system for the most important bacterial pathogens. In 2003 two trials were performed. The first on Salmonella and Escherichia coli involved 31 laboratories in 18 countries and the second on Staphylococcus and Streptococcus included 22 laboratories in 15 countries. For the E. coli strains, 92.8% of the results complied with the reference MICs, for Salmonella 93.7%, for Streptococcus 80.4% and for Staphylococcus 93.1%. Most problems were observed when testing florfenicol (79.2% correct), gentamicin (84.2%) and amoxicillin + cl (84.9%) in E. coli; streptomycin in Salmonella (62.5%); gentamicin (56.7%), lincomycin (71.4%), clindamycin (75.4%), TMP + sulfonamides (75.7%) and chloramphenicol (78.5%) in Streptococcus; erythromycin (81.5%) and oxacillin (78.2.5%) in Staphylococcus. A few laboratories caused most deviations. However, there was no correlation between good performance for one bacterial group and good performance for other groups. This study showed that most laboratories are capable of performing correct susceptibility testing for E. coli and Salmonella, even though performance of some laboratories can be improved, and that some problems exist for Staphylococcus and Streptococcus. This clearly shows the need for continuous harmonisation of methodologies within the EU.

The effects of tertiary wastewater treatment on the prevalence of antimicrobial resistant bacteria.

The effects of tertiary wastewater treatment on the prevalence of antimicrobial resistant bacteria were investigated in two large-scale municipal treatment plants during a period of six months. Total and relative numbers of resistant bacteria were determined in raw sewage, treated sewage and anaerobically digested sludge by bacteriological counts on media selective for coliforms (MacConkey agar) and Acinetobacter spp. (Baumann agar). In addition, the level of antimicrobial susceptibility was determined by the disc-diffusion method in 442 Acinetobacter isolates identified by colony hybridisation with a genus-specific DNA probe. Independent of the different antibiotics and media used, the total numbers of resistant bacteria in treated sewage were 10-1000 times lower than in raw sewage. Based on linear regression analysis of data on bacteriological counts, the prevalences of antimicrobial-resistant presumptive coliforms and Acinetobacter spp. in treated sewage and digested sludge were not significantly higher compared with raw sewage. On the contrary at one plant, statistically significant decreases were observed in the prevalence of ampicillin-resistant presumptive Acinetobacter spp. (p = 0.0188) following sewage treatment, and in the prevalence of either ampicillin-resistant presumptive Acinetobacter spp. (p = 0.0013) or ampicillin- and gentamicin-resistant presumptive coliforms (p = 0.0273 and p = 0.0186) following sludge treatment. The results obtained by bacteriological counts were confirmed by antimicrobial susceptibility testing of Acinetobacter isolates. Based on logistic regression analysis, isolates from treated sewage and digested sludge were generally not significantly more resistant compared with isolates from raw sewage. Based on these evidences, it was concluded that tertiary wastewater treatment did not result in a selection of antimicrobial resistant bacteria.

Differences and similarities among experts' opinions on Salmonella enterica dynamics in swine pre-harvest.

A workshop was conducted to elicit expert opinion on infection status and transmission of salmonella in pigs at the farm of origin, during transport and during lairage. A second objective was to compare opinions regarding risk factors for salmonella introduction and control at the farm level between experts from different countries. Thirty-six experts from 11 countries filled in a paper-and-pencil questionnaire during an international conference. Experts from all countries agreed on the risk of salmonella introduction related to live animals and the importance of general hygiene and all-in/all-out management for salmonella control. However, workshop participants from Denmark put more weight on factors related to feed while experts from USA rated factors related to rodents and people contact higher. The experts believed that 21-33% of pigs coming from a chronically infected farm would be infected with salmonella, but only one-third of the infected pigs would be shedders. Regarding transport and lairage, the US participants believed that contamination was occurring in the majority of pigs regardless of initial infection status and particularly during lairage; in contrast, the Danish experts were more optimistic with respect to the contamination and infection risk. US experts believed that the incidence of salmonella shedding would be high among pigs infected during transport and lairage and that an important proportion of 'carrier' pigs would start shedding. Our results reflect the differences in the level of salmonella infection and implemented control strategies between countries as well as the different philosophies that professionals have. The differences in opinion regarding salmonella dynamics could be due either to true differences in risk as a consequence of distinct management and transport practices in Denmark and USA or to a difference in perception.