PHARMACEUTICALS AND GLOBAL HEALTH: INEQUALITIES AND INNOVATION IN THE 21ST CENTURY

ANTIMICROBIAL RESISTANCE AND

GLOBAL HEALTH SECURITYUNIVERSITY OF SUSSEX

July 19th 2013

Professor Anthony KesselDirector of Public Health Strategy, Director of Research and Development

Public Health England

Thanks: Jasper Littmann, Mark Wilcox

Timeline I: Discovery of microbes and the first systematic infection control policies in hospitals

1847

1864

Florence Nightingale

Louis PasteurIgnaz Semmelweiss

Joseph ListerAnton van Leeuwenhoek

1676

discovery of bacteria

antiseptic hand wash 1870

1890

Robert Koch

1840shygiene in field hospitals

proposition of germ theory

introduction of antiseptic surgery

Theory of Miasma Germ Theory

causal link between bacteria and disease

Timeline II: From germ theory to antimicrobial therapy

1928

1932

Johannes Mikulicz-Radecki Gerhard Domagk

Selman WaksmanWilliam S. Halstead

1890

introduction of surgical gloves

Introduction of surgical masks 1943

1967

Surgeon Gen. William Stewart

1897discovery of

penicillin

discovery of sulfonamides

Pre-antibiotic age Antibiotic age

Streptomycin is discovered

Alexander Fleming

“The time has come to close the book on infectious diseases”

The War is Over!

In 1967, the U.S. Surgeon General William Stewart stated:

“It is time to close the book on infectious diseases, and declare the war against pestilence won.”

Timeline III: From antimicrobial therapy to antimicrobial resistance

1955

1961

Streptomycin first used in agriculture First case of MRSA

TB & MDR-TB ‘global health emergency’

1948

Resistance observed in Staphylococci

Treatment for plant diseases 1993

2011

Complete drug resistance

1952S. Dysaentriae

outbreak in Japan

Methicillin resistance in S. aureus

Pre-antibiotic age Post-antibiotic age?

WHO declaration

First MDR case

First confirmed case of completely drug-resistant TB in Mumbai*

Penicillin resistance

*http://www.bbc.co.uk/news/health-16592199

Flu isolation wards 1918

Reserve Constable Albert AlexanderJohn Radcliffe Hospital. Dec 1940.First recipient of IV penicillin for purulent staphylococcal infection of head and neck; one eye enucleated.Produced by Florey, Chain and Heatley in Oxford

Antimicrobials by IndicationNo Quinolones, Rare Cephalosporin

42.0%

17.7%

p<0.001

Critical illness Blood stream infection

61.9%

28.4%

p<0.001

% o

f hos

pita

l mor

talit

y

60.8%

33.3%

0%

10%

20%

30%

40%

50%

60%

70%

p<0.001

Pneumonia

Consequences of inadequate initial antibiotic treatment

1. Kollef MH et al. Chest 1998; 113:412-420 2. Kollef MH et al. Chest 1999; 115:462-474 3. Ibrahim EH et al. Chest 2000; 118:146-55

Newly marketed antimicrobial agents in UK 3-year periods 1990–2010

Antibacterial agents

Antiviral agents

Antifungal agents

Antiparasitic agents

1990-1992 10 1 2 2

1993-1995 7 4 1 1

1996-1998 3 9 1 1

1999-2001 3 8 0 1

2002-2004 3 8 2 0

2005-2007 3 7 1 0

2008-2010 1 4 2 0

Antimicrobial Chemotherapy. Eds. Finch RG, Davey P, Wilcox MH, Irving W. OUP, 2012.

Would you developa new antibiotic if ...

• It took 10 years and cost several hundred million pounds?

• Chance of falling at the 1st, middle or last hurdle?

• If get to market, put on the top shelf (out of reach of most)?

• If unlucky, arrived at wrong place wrong time?

• If manage to prescribe, use for 5 days only?

What do we need to do?New national strategy / WHO

• Optimising Prescribing Practice• Improving Infection Prevention and Control• Raising Awareness and Changing Behaviour• Better research, better evidence• Developing new drugs and treatments• Improved surveillance• Strengthen international collaboration

“Super-wicked problems”

• Time for finding a solution to a policy challenge is running out

• Those seeking to solve the problem are part of the cause

• Central authorities to address the problem are either weak or non-existent

• Policy responses discount the future irrationally

For discussion: Change from ‘path dependency’

• Rationing of antibiotic use

• Create new antibiotics but don’t use them

• New ways to incentivise the drug industry