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Antibiotic Resistance – A Major Threat to the

Sustainable Development Goals

Otto CarsSenior Professor, Infectious Diseases

Founding Director ReAct-Action on Antibiotic Resistance, Uppsala university

ReAct North America

Baltimore, USA

ReAct Europe

Uppsala, SWE

ReAct LA

Cuenca, ECU

ReAct Africa

Nairobi, KEN

ReAct Asia Pacific

Vellore, IND

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ReAct- Action on Antibiotic Resistance

www.reactgroup.org

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Outline of this seminar

• What is antibiotic resistance?

• Why is it a threat to global health, economy andsustainable development?

• Q&A

• The current political landscape

• The need for global collective action

• Discussion

The global complacency has put the world at risk

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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

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What Are Antibiotics?

• Antibiotics are small molecules that can enter bacteriaand stop their growth or kill them

• They do not work against viruses(common cold, influenza etc.)

% s

urv

iin

g

Penicillin

Untreated

Days

Penicillin

increased the

chance of

survival from 10%

to 90%

Patients with

pneumonia

and bacteria

in blood

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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.

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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

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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 alwaysbe new antibiotics

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The failing machinery….More that 70 years of antibiotic useMillions of tons….

Lack of New Antibiotics

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60% of antibiotics prescribed by general

practitioners in OECD countries are

used for inappropriate purposesCecchini M, Lee S. OECD Publishing, forthcoming

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

Rich countries continue to waste antibiotics

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Total antibiotic use in 2011 European countriesVersporten et al, Lancet Infectious Diseases, 20 March 2014

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Adapted from Källander, 2005

Access Excess

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We are facing a public health crisis

AntibioticResistance

DrugDevelopment

MorbidityMortality

Costs

Euro Surveill. 2015;20(45).

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The burden of antibiotic resistance disproportionally

falls on the developing countries

Mumhibili hospital, TanzaniaThe mortality rate from resistant bloodstream infection was 43%Blomberg et al. BMC Infect Dis. 2007 May 22;7:43.

Neonatal deaths due to resistantinfections are increasing214.000 newborn sepsis deaths Are attributable to bacteria that resistant to available antibioticsLaxminarayan et al Lancet. 2016;387:168–175.

Lack of access to essentialantibioticsAcross developing countries

fewer than a third of children

with suspected pneumonia

receive antibiotics”United Nations Children’s Fund

(UNICEF) June 2012

...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.

Doctors Without Borders Special Hospital for

Reconstructive Surgery in Amman

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HUMAN MORTALITY BURDEN

WHO Ebola Situation Report 12 August

2015

WHO/GIP, data in HQ as of 17

July 2015

http://www.cidrap.umn.edu/news-perspective/2012/06/cdc-

estimate-global-h1n1-pandemic-deaths-284000

ANTIBIOTIC RESISTANCE> 500.000AVIAN FLU

H5N1449

EBOLA11,298

SWINE FLUH1N1

284.000

Antibiotic resistance – figure is a world-wide

projection based on data from EU,US

and Thailand (WHO Global Reoprt of

Surveillance)

Transforming our world: the 2030 Agenda for Sustainable Development

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Antimicrobials are fundamental

components of all health systems

Non-human use of antibioticsThe 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.

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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

Access to essential

antibiotics is a

prerequisite to

reduce inequalities

Chandy, S: The Journal of Infection in

Developing countries. Vol 8, sept 2014

The median overall cost to treat a

resistant bacterial infectionin India: 700 USD

The time a rural male casual worker

in India has to work to earn this

amount: 442 days

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US$100 trillion by 2050*

The costs for antimicrobial resistance reach

far beyond the health sector

* 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)

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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

YES YES

Transformation towards sustainability is

urgent

YES YES

Non- renewable resource YES ?

Sustainable alternatives exist YES NO

Global agreement exist YES NO

Can we learn from climate change?

Antimicrobial Resistance

The current political landscape

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20152001

Towards a global response

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

Five strategic objectives of the Global Action Plan

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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

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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…….”

“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 needs-

driven, 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”.

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.

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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 pipelinevs 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

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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 )

Antibiotics

Fundamental systems changes needed

Marketing

Volume sales

Misaligned financial incentives

Irrational use of antibiotics

Insufficient prevention

Cultural beliefs, misperceptions

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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 challenges1. 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

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Solutions require commitment

from

all research and policy areas

Human medicine Veterinary medicineAgriculture

Environment

Research and education

Natural sciences

Social/behavioural sciences

Law, ethics ….

Trade

Security Development aid /Foreign policy

Finance

“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 “