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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