PHARMACEUTICALS AND GLOBAL HEALTH: INEQUALITIES
AND INNOVATION IN THE 21ST CENTURY
ANTIMICROBIAL RESISTANCE AND
GLOBAL HEALTH SECURITY
UNIVERSITY OF SUSSEX
July 19th 2013
Professor Anthony Kessel
Director 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
Anton van Leeuwenhoek
1676
Florence Nightingale
antiseptic hand wash
discovery of bacteria
1840s
1847
proposition of germ theory
hygiene in field hospitals
Ignaz Semmelweiss
Theory of Miasma
Joseph Lister
1864
1870
causal link between bacteria and disease
introduction of antiseptic
surgery
Louis Pasteur
1890
Robert Koch
Germ Theory
Timeline II: From germ theory to antimicrobial
therapy
William S. Halstead
1890
Alexander Fleming
Introduction of
surgical masks
introduction of surgical
1897
gloves
1928
discovery of
penicillin
Johannes Mikulicz-Radecki
Pre-antibiotic age
Selman Waksman
discovery of
sulfonamides
1943
Streptomycin
is discovered
1932
Gerhard Domagk
Antibiotic age
“The time has come to close the
book on infectious diseases”
1967
Surgeon Gen. William Stewart
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
1948
Treatment for plant
diseases
Resistance observed
1952
in Staphylococci
TB & MDR-TB ‘global health emergency’
First MDR case
Penicillin resistance
1955
Methicillin resistance
in S. aureus
S. Dysaentriae
outbreak in Japan
Streptomycin first used in agriculture
Pre-antibiotic age
*http://www.bbc.co.uk/news/health-16592199
1961
First case of MRSA
1993
First confirmed case of completely
drug-resistant TB in Mumbai*
WHO declaration
2011
Complete drug resistance
Post-antibiotic age?
Flu isolation wards 1918
Reserve Constable Albert Alexander
John 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 Indication
No Quinolones, Rare Cephalosporin
Consequences of inadequate initial
antibiotic treatment
Pneumonia
% of hospital mortality
70%
Critical illness
Blood stream infection
61.9%
60.8%
60%
50%
40%
42.0%
33.3%
28.4%
30%
17.7%
20%
10%
0%
p<0.001
p<0.001
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
p<0.001
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 develop
a 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