Professor Anthony Kessel Thanks: Jasper Littmann, Mark Wilcox 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

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Timeline I: Discovery of microbes and the first systematic infection control policies in hospitals Anton van Leeuwenhoek Florence Nightingale Joseph Lister 1676 1847 1870 antiseptic hand wash proposition of germ theory causal link between bacteria and disease discovery of bacteria hygiene in field hospitals introduction of antiseptic surgery 1840s 1864 1890 Ignaz Semmelweiss Louis Pasteur Robert Koch Theory of Miasma Germ Theory 3 3

Timeline II: From germ theory to antimicrobial therapy William S. Halstead Alexander Fleming Selman Waksman 1890 Introduction of surgical masks 1928 discovery of sulfonamides “The time has come to close the book on infectious diseases” 1943 introduction of surgical gloves discovery of penicillin 1897 1932 Streptomycin is discovered 1967 Johannes Mikulicz-Radecki Gerhard Domagk Surgeon Gen. William Stewart Pre-antibiotic age Antibiotic age 4 4

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 Penicillin resistance First MDR case TB & MDR-TB ‘global health emergency’ 1948 Treatment for plant diseases Methicillin resistance in S. aureus 1955 1993 First confirmed case of completely drug-resistant TB in Mumbai* Resistance observed in Staphylococci S. Dysaentriae outbreak in Japan 1952 1961 WHO declaration 2011 Streptomycin first used in agriculture First case of MRSA Complete drug resistance Pre-antibiotic age Post-antibiotic age? *http://www.bbc.co.uk/news/health-16592199 6 6

Flu isolation wards 1918

Reserve Constable Albert Alexander John Radcliffe Hospital. Dec 1940. First penicillin treatment for staph infection 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 8

Antimicrobials by Indication No Quinolones, Rare Cephalosporin

Consequences of inadequate initial antibiotic treatment 42.0% 17.7% p<0.001 Critical illness Blood stream infection 61.9% 28.4% p<0.001 % of hospital mortality 60.8% 33.3% 0% 10% 20% 30% 40% 50% 60% 70% p<0.001 Pneumonia 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 1993-1995 7 4 1996-1998 3 9 1999-2001 8 2002-2004 2005-2007 2008-2010 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