Antibiotic Resistance A Major Threat to the Sustainable Development Goals Otto Cars Senior Professor, Infectious Diseases Founding Director ReAct-Action on Antibiotic Resistance, Uppsala university ReAct- Action on Antibiotic Resistance ReAct Europe Uppsala, psa SWE ReAct North America Baltimore, USA ReAct Africa Nairobi, KEN ReAct Asia Pacific Vellore, IND ReAct LA Cuenca, ECU www.reactgroup.org 1
Outline of this seminar What is antibiotic resistance? Why is it a threat to global health, economy and sustainable development? Q&A The current political landscape The need for global collective action Discussion The global complacency has put the world at risk 2
Antimicrobial resistance (AMR) Microorganisms becoming resistant to medicines which makes them ineffective Resistance to medicines against HIV Resistance to medicines against malaria Resistance to medicines (antibiotics) against bacterial infection including tuberculosis= Antibiotic resistance Antimicrobial resistance (AMR) Microorganisms becoming resistant to medicines, making them ineffective Resistance to medicines against HIV Resistance to medicines against malaria Resistance to medicines (antibiotics) against bacterial infection including tuberculosis= Antibiotic resistance 3
% surviing What Are Antibiotics? Antibiotics are small molecules that can enter bacteria and stop their growth or kill them They do not work against viruses (common cold, influenza etc.) Patients with pneumonia and bacteria in blood Penicillin Penicillin increased the chance of survival from 10% to 90% Days Untreated 4
The Golden Age of Antibiotic Discovery Numerous bacterial infections became treatable Pneumonia Urinary tract infection Wound infection Blood infection ( sepsis) Abdominal infections Bone and joint infections Chlamydia Gonorrhea.... Bacteria Have existed for 3.5 billion years Composes 30 % of the earth s biomass Every gram of surface soil contains 50 million bacteria We carry roughly as many bacteria in our bodies as human cells. 5
What is Antibiotic Resistance? Bacteria are experts in finding ways to avoid the effect of an antibiotic. This could be achieved by mutations or transfer of genes (from other bacteria) that either: - stops entry of the antibiotic - destroys it - makes it difficult to reach its target - pumping it out of the bacterial cell. Where are antibiotics used? Human medicine Veterinary medicine Livestock production Aquaculture Plant protection 6
Selection of antibiotic resistance Why the global complacency? ABR had/still has no disease face Lack of data on the global health and economic burden We have too late realized the ecological/environmental dimensions Misaligned financial incentives Disincentives for collective action The global self-deception: There will always be new antibiotics 7
The failing machinery. More that 70 years of antibiotic use Millions of tons. Lack of New Antibiotics 8
Rich countries continue to waste antibiotics Of the estimated 154 million prescriptions for antibiotics written in doctor s offices and emergency departmentsin the US each year, 30 percent are unnecessary. US CDC, 2016 60% of antibiotics prescribed by general practitioners in OECD countries are used for inappropriate purposes Cecchini M, Lee S. OECD Publishing, forthcoming 9
Total antibiotic use in 2011 European countries Versporten et al, Lancet Infectious Diseases, 20 March 2014 10
Access Excess Adapted from Källander, 2005 11
We are facing a public health crisis Antibiotic Resistance Drug Development Morbidity Mortality Costs Euro Surveill. 2015;20(45). 12
The burden of antibiotic resistance disproportionally falls on the developing countries Neonatal deaths due to resistant infections are increasing 214.000 newborn sepsis deaths Are attributable to bacteria that resistant to available antibiotics Laxminarayan et al Lancet. 2016;387:168 175. Mumhibili hospital, Tanzania The mortality rate from resistant bloodstream infection was 43% Blomberg et al. BMC Infect Dis. 2007 May 22;7:43. Lack of access to essential antibiotics Across developing countries fewer than a third of children with suspected pneumonia receive antibiotics United Nations Children s Fund (UNICEF) June 2012 Doctors Without Borders Special Hospital for Reconstructive Surgery in Amman...the growing number of Syrians who have acquired bacterial infections that are immune to almost all antibiotics. The only way to treat them is to amputate their affected limbs and inject them with last-resort drugs. 13
HUMAN MORTALITY BURDEN AVIAN FLU H5N1 449 ANTIBIOTIC RESISTANCE > 500.000 EBOLA 11,298 Antibiotic resistance figure is a world-wide projection based on data from EU,US and Thailand (WHO Global Reoprt of Surveillance) WHO/GIP, data in HQ as of 17 July 2015 WHO Ebola Situation Report 12 August 2015 http://www.cidrap.umn.edu/news-perspective/2012/06/cdcestimate-global-h1n1-pandemic-deaths-284000 SWINE FLU H1N1 284.000 Transforming our world: the 2030 Agenda for Sustainable Development 14
Antimicrobials are fundamental components of all health systems Non-human use of antibiotics The tension between food safety and food security Increasing demand for animal protein Projected increase of the consumption of antimicrobials in the food animal sector by 2/3 until 2030 Need for regional and context specific transformation strategies towards sustainable practices and alternatives to antibiotics Van Boeckel TP, Brower C, Gilbert M, Grenfell BT, Levin SA, Robinson TP, et al. Global trends in antimicrobial use in food animals. Proc Natl Acad Sci U S A. 2015 Mar 19;112(18):5649 54. 15
Clean water and sanitation 2.4 billion people in the world lacks access to toilets and 1.8 billion are using drinking water that is contaminated with feces Poverty and inequality The median overall cost to treat a resistant bacterial infection in India: 700 USD The time a rural male casual worker in India has to work to earn this amount: 442 days Access to essential antibiotics is a prerequisite to reduce inequalities Chandy, S: The Journal of Infection in Developing countries. Vol 8, sept 2014 16
The costs for antimicrobial resistance reach far beyond the health sector US$100 trillion by 2050* * Review on Antimicrobial Resistance. Review on Antimicrobial Resistance:Tackling a crisis for the health and wealth of nations. (2014). AMR containment represents a high-yield investments with the annual rate of return reaching 88% per year. Cost of inaction: loss at 1.1% to 3.8% global GDP by 2050 (World Bank) 17
Can we learn from climate change? Overconsumed resource Fossil fuels Antibiotics Consequence of overconsumption Climate change Antibiotic resistance Affects everyone YES YES High income countries can reduce use without negative consequences YES YES Demand of the resource from LMICs is increasing Transformation towards sustainability is urgent YES YES YES YES Non- renewable resource YES? Sustainable alternatives exist YES NO Global agreement exist YES NO Antimicrobial Resistance The current political landscape 18
Towards a global response 2001 2015 Five strategic objectives of the Global Action Plan 1. Improve awareness and understanding of antimicrobial resistance 2. Strengthen the knowledge and evidence base 3. Reduce the incidence of infection; 4. Optimize the use of antimicrobial medicines 5. Develop the economic case for sustainable investment 19
Global Status of National Action Plans No response No national action plan Under development Plan approved Operational plan with monitoring arrangements Plan with fund, is being implemented 20
Political declaration on the UN General Assembly High level meeting 21 sept 2016.to provide practical guidance for approaches needed to ensure sustained effective global action to address antimicrobial resistance. Antimicrobial resistance (AMR) has featured prominently in the Declaration issued by Ministers of Foreign Affairs of the Group of 77 and China at their 40th annual meeting, held at the United Nations (UN) in New York on 22 September 2017. The Ministers emphasized the need to support, as a matter of urgency, research and development of antimicrobials, especially new antibiotics, vaccines, diagnostic tools and innovation, including in traditional and herbal medicine. They highlight that this must be done while ensuring that R&D efforts are needsdriven, evidence-based, and a shared responsibility, and that these efforts must be guided by the core principles of affordability, effectiveness, efficiency, and equity through delinking research and development costs from prices and sales volume. 21
Innovation Access Conservation/ Stewardship A systems view needed Towards a new financial model for R&D of novel antibiotics Needs driven - based on analysis of pipeline vs resistance and its burden Incentives that stimulates R&D of priority antibiotics Solving the scientific challenges Collaboration and knowledge sharing De-linking return of investment from price and volume sales Controlled use and distribution Equitable global access and affordability 22
Current ongoing processes CARBX ( US Government, Wellcome Trust) Innovative Medicines Initiative ( IMI) New Drugs for Bad Bugs ( EU commission and European Pharma) G20 Innovation Collaboration hub WHO Development and Stewardship Framework GARDP (Partnership between Drugs for Neglected Disease initiative DNDI & WHO ) Fundamental systems changes needed Antibiotics Volume sales Marketing Cultural beliefs, misperceptions Misaligned financial incentives Irrational use of antibiotics Insufficient prevention 23
Some challenges The world s response has been too slow, too weak and too narrow! Politicial will and financial commitments have so far been insufficient: - Antibiotic effectiveness should be seen as a global resource - Transformation of health and agricultural systems needed Communication challenges for long term behavioural change Meeting the challenges 1. Including LMICs in all processes on devising ways to manage AMR 2. Mainstreaming AMR into all relevant SDGs 3. Specific AMR indicators in health system strengthening programs 4. New economic models for urgently needed antimicrobials diagnostics and vaccines 5. Funding for AMR capacity building in LMICs 6. Mobilizing civil society 24
Solutions require commitment from all research and policy areas Agriculture Human medicine Veterinary medicine Security Environment Development aid /Foreign policy Finance Trade Research and education Natural sciences Social/behavioural sciences Law, ethics. Given these global coordination issues, there is a clear role for a binding international legal framework to encompass the issues of access, conservation and innovation 25