1. 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

2. 2

3. 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

4. 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

5. 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.”

6. 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? * 6 6

7. Flu isolation wards 1918

8. 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

11. Antimicrobials by Indication
No Quinolones, Rare Cephalosporin

12. 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: Kollef MH et al. Chest 1999; 115: Ibrahim EH et al. Chest 2000; 118:146-55

13. Newly marketed antimicrobial agents in UK 3-year periods 1990–2010
Antibacterial agents
Antiviral agents
Antifungal agents
Antiparasitic agents 10 1 2 7 4 3 9 8
Antimicrobial Chemotherapy. Eds. Finch RG, Davey P, Wilcox MH, Irving W. OUP, 2012.

14. 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?

15. 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

16. “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

17. 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