Motion to Take Note
That this House takes note of the report Tackling Drug-Resistant Infections Globally: Final Report and Recommendations, published on 16 May.
My Lords, it is my privilege to be able to introduce a debate on the subject of tackling drug-resistant infections and in particular to take note of, and certainly to welcome and take forward in our debate, the review on antimicrobial resistance led by my noble friend Lord O’Neill. It is a great pleasure to see him in his place for the debate.
In his 1945 Nobel Prize lecture Alexander Fleming said, some 17 years after his discovery of the antibiotic properties of penicillin:
“Then there is the danger that the ignorant man may easily underdose himself … He buys some penicillin and gives himself, not enough to kill the streptococci but enough to educate them to resist penicillin”.
Those words were prophetic in terms of the emergence of antibiotic resistance, which did indeed occur shortly thereafter. But for the subsequent 40 years or thereabouts, although such resistance did regularly emerge, the discovery and development of new antibiotics gave us all an increasing reassurance that no longer would we fall victim to infections either as readily or as rapidly as did our forebears. The burden of mortality, particularly in developed countries, has shifted from infectious diseases to non-communicable disease. Over time, however, the development of increasing antibiotic resistance across a range of bacterial infections has outstripped the limited further development of novel antibiotics, and the extent of the use of the drugs which are currently available has increasingly prompted the development of organisms capable of near universal resistance.
In this decade, and especially over the past three to four years, we have seen a most welcome high-level political and scientific awareness and response to the risks we face from antimicrobial resistance. In this country, not least following the urgings of the Chief Medical Officer, to whom I pay tribute in this regard, the coalition Government adopted in 2013 a five-year strategy. In 2014 the Prime Minister asked my noble friend Lord O’Neill and his team to look at the global response. Working with the Wellcome Trust, the review has produced a series of reports over time describing the extent of the risks we face, how to seek to contain those risks by extending the life of our existing antibiotics through reducing unnecessary use not only in humans but also in animals and the environment, how to speed up diagnosis so as to deliver the right treatment by limiting the use of antibiotics to what is necessary, and to promote the development of new drugs, vaccines and other approaches to combating infections.
Those several papers were brought together in May this year in the review’s final report. I am most grateful to your Lordships’ House for the opportunity to debate that report soon after its publication, and in particular to do so in the wake of the discussions at the G7 and the G20, and in anticipation of the UN high-level meeting on antimicrobial resistance next Wednesday, to take place in the General Assembly. I see our short debate as needing to enable this House to talk about how we move forward from the analysis, work and achievements thus far to try to generate more action and measurable progress. If we do not, my noble friend Lord O’Neill’s report quantifies the risk we face: in the next 35 years the mortality attributable to AMR could rise from 700,000 across the world to some 10 million. Our children and grandchildren could be vulnerable to infections we thought we had conquered.
We need to avoid seeing this as simply a future threat. It is a clear and present danger. If I may, I will delve into the review’s report for one example, which I thought conveyed that very persuasively. It is about dealing with drug-resistant E. coli. Its prediction of what it might look like in 35 years’ time was that some 40% of the economic impact of drug-resistant infections would be attributable to drug-resistant E. coli. But that drug-resistant E. coli is already with us. Incidence of carbapenem-resistant E. coli has doubled between 2008 and 2013 in the United Kingdom alone. There are countries in Europe where it is endemic. The last-line antibiotic to combat it is not always now effective. There are isolated incidents of it failing.
In its methodology, the review conducted research to look at what would happen if, over the next decade, there was an increase in drug resistant E. coli similar to the increase in the last decade of a parallel pneumococcal bacterium. Using that assumption, it would mean that in Europe by 2026, which is only 10 years from now, 40,000 more people would die from E. coli infections as a result, but if we were to develop the additional new and rapid diagnostic systems we need, that in itself could save 6,000 of those lives. If a new antibiotic to combat it were available, a further 7,300 lives could be saved. That is a measureable, specific example of the threat we face and combat, not at some distant time, but now.
We should thoroughly welcome the report and focus on how we now turn this into action. If the House will forgive me, I will not dwell on the importance of the reduction of infection itself through the adoption of the most rigorous means of dealing with hygiene and clinical practice. We have done that a lot over the years. We can demonstrate in this country that after 2006 and all the way through to now, and, I am happy to say, under the coalition Government in the last Parliament, we continued to see a dramatic reduction in the incidence of MRSA and Clostridium difficile in our hospitals. We can take some pride in what we have achieved, but it needs to be true for combating all bacterial infections.
In addition, we need now to have measurable progress. Key to that is surveillance. This is a global threat and we need surveillance globally to be at a high level. I am sure my noble friend the Minister will refer to the Government’s Fleming fund, which gives us a place and resources that can make a dramatic impact on that surveillance. However, my first of a number of suggestions is that through the Department for International Development and the deployment of our international aid budget we can say to the people of this country that that budget can be of direct, significant benefit to them, not only if we deploy it in reinforcing basic health systems in many of the most vulnerable countries—the importance of developing that basic health infrastructure was demonstrated during the Ebola outbreak—but also if we go on to make sure we have lab capacity and surveillance systems, diagnostics and treatment protocols enabling us to combat the rise of drug-resistant infections.
We need quantification of this here and in developed countries. As with everywhere in my experience of healthcare systems, understanding variation and the reasons for it, and combating the worst to bring everybody to the level of the best, are critical. The quantification in this respect shows at least a threefold variation in the use of antibiotics in developed countries. Some use far more antibiotics than other countries. We are not the least: countries such as the Netherlands have extremely good records on antibiotic use. We need to bring everybody not through their national action plans but in the global system to the best possible level of activity.
I focus for a moment on animal health. The One Health model, in working together with the veterinary world, characterises the approach of the World Health Organization to this. It is really important that we reduce the unnecessary use of antibiotics in animal health. Of course, we cannot say that there should not be proper use of antibiotics for animal health but we must reduce the level of prophylactic use in animals. We should look—as I know the Americans are, and we are in Europe—for the elimination of antibiotic use simply for the promotion of growth in animals rather than for treatment. We should make sure that the use of antibiotics in animals is properly subject to veterinary supervision. We should also consider reserving the necessary but small number of last-line antibiotics for human health purposes rather than have them deployed in animal health, with the finite risk of infections forming drug resistance in animal populations and spreading to humans.
The improvement of rapid diagnostics is terrifically important. The Longitude Prize demonstrated public awareness and support for developing cheap, accurate and rapid point-of-care test kits for bacterial infection. That is vital and I hope we will hear more about it. The technology platforms and many of the assays are there. In the NHS, often there is a tendency for innovation, for promoting innovation and seeking to bring it forward, but then it all stops at the moment it should be rolled out through a procurement process within the NHS. In this context, now is the moment to think about putting into the NHS mandate, to be published later this year, specific proposals relating to the NHS England approach to the rollout of rapid diagnostics and the resistance of antibiotic use in the NHS. For example, in America, two-thirds of antibiotics are frankly not needed by those to whom they are prescribed.
I will not dwell on regulated co-operation but frankly we must do a lot of that in clinical trials. Some 80% of the cost of developing a new drug is in clinical trials. If we can make clinical trial practice across the world more consistent and easier to achieve, we will do an enormous amount to bring through new medicines. We must do that; we must bring through new antibiotics. Vaccines have a lot to offer in this respect. Perhaps at the moment we underestimate what we can do. It would make an enormous difference in reducing the overall use of antibiotics if some common infections, such as Clostridium difficile, were capable of being immunised against. We would see the prospective benefit of that. We should use vaccines as a cost-effective approach wherever we can.
On generating new treatments, the US has gone down the road of generating antibiotic incentives though the GAIN system, which gives priority review and market exclusivity. Frankly, if we want a global response we should look at how successful that system is. The US has approved five new antibiotics so far under that proposal. It could be allied to market entry reward, as the review recommends, and that reward could be made much more affordable across the world if market exclusivity—even a transferable market exclusivity—could be allied to it.
Let me conclude. Those are some of the key areas; I have not attempted to talk about all 10 key recommendations. Getting that One Health approach by working on animal as well as human health, as I have described, and really focusing on rapid diagnostics, where we could make an enormous impact quickly with technology that is already available, can take us a long way. However, we need the global system to respond. The G7 recommendations that I read seemed compelling and supportive but did not actually involve much pledging—for example, to support the global innovation fund which Her Majesty’s Government have put in place. That fund needs to be matched and added to by other countries around the world to bring forward new treatments. In the G20 conclusions, I saw that one paragraph at the end—almost an afterthought—simply called for a report back over the course of the coming year to the Berlin meeting. That seemed disappointing.
I look very much for the UN high-level meeting to take measurable and decisive actions in this respect. It is always difficult. I was a chair of a High-Level Meeting on Non-communicable Diseases, back in 2011, where we thought that we might be able to generate a response similar to that of the high-level meeting on HIV many years before. I do not think that it happened. However, what we need for antimicrobial resistance is for the UN high-level meeting next Wednesday to generate the sort of global response in tackling this threat that we saw years back by the UN high-level meeting in relation to HIV. That is what I would like us to achieve. I hope that more of the contributions in today’s debate will prompt that to happen. I am grateful to your Lordships.
My Lords, this timely debate is a chance to congratulate the noble Lord, Lord O’Neill, on the excellent series of reports that he has produced. We should surely also use this opportunity to acclaim Dame Sally Davies, the Chief Medical Officer, who espoused this cause early on and has probably done more than anyone else to raise ABR issues on the political agenda, not just in the UK but worldwide.
Antibiotic resistance is growing so fast that 700,000 people already die each year from untreatable infections. The pathogens such as typhoid which once succumbed swiftly to penicillin and other antibiotics now fight back; they are becoming killers again. Just this year, doctors have noted the emergence of resistance to colistin, which is the last line of defence against some very resistant bacteria. There is real worry that within a decade, transplants and even orthopaedic operations will become hazardous because of the intractable risk of infection, so ABR is a global threat that hangs over us. The O’Neill report emphasised that by 2050, 10 million lives a year and a cumulative $100 trillion of economic output might be at risk due to the rise of drug-resistant infections, unless we can develop new drugs and make more prudent use of what we have.
My comments will focus on avoiding the overuse of drugs. I have zero expertise in medicine—my scientific field is space research and astronomy—but I have become a small-time crusader for the AMR cause, for reasons that I will explain by offering a bit of history from 300 years ago.
In the 18th century, the most pressing scientific challenge was measuring time and determining longitude at sea. In 1714, the Government set up what was in a sense the first scientific quango: the Board of Longitude. The board established the first challenge prize: a reward of £20,000, a huge sum in those days, for the first person to devise a way to determine longitude, with specified precision. Famously, it was John Harrison, a working-class Yorkshireman and an outsider, who triumphed with his marine chronometer, an extraordinary high-tech artefact of its era.
In the 300 years since, this initiative has been emulated by many challenge prizes. One, for instance, was the stimulus for Lindbergh’s transatlantic flight. More recently, the American government agency DARPA has sponsored competitions for driverless vehicles and for robots that can do complex tasks in hazardous environments. The California-based XPRIZE foundation promotes privately sponsored prizes. It aims to revitalise,
“markets that are currently stuck due to existing failures or a commonly held belief that a solution is not possible”.
As the current Astronomer Royal, I thought that the tercentenary of the Longitude Prize was worth celebrating with a national prize to address a contemporary challenge. Government support was forthcoming and allowed a reward of £10 million. Nesta, which has established expertise in this area, agreed to oversee the administration of the prize and has done a splendid job.
What should the challenge be? There is no manifest number one problem, as there was in the 18th century. A committee I chaired came up with a list of six possible challenges. All were presented on BBC TV and in the press, after which there was a public vote. The most popular choice was a project to tackle antimicrobial resistance.
A well-designed prize must meet several criteria. It should engage many contestants and, ideally, unleash investment amounting to far more than the prize itself. It must not require huge facilities accessible only to big battalions. Success must require genuine breakthroughs but be credibly achievable within five years. It should be configured, as was the original Longitude Prize, so that intermediate steps towards the target may get a reward. For an individual, a university group or a small company, the prize money is a significant incentive; if a big company wins, the publicity is more important. Either way, all have a motive to participate.
Of course, £10 million is a trivial sum compared to what is needed for developing new drugs, but there are bite-sized challenges relevant to AMR where it is an appropriate incentive. The target our expert advisers chose was to devise cheap, accurate, rapid and easy-to-use point-of-care kits to test for bacterial infections. These kits might be a strip of sensitised paper or a lab on a chip combined with a smartphone app, and they must be capable of being used anywhere in the world to identify the nature of someone’s infection. This would reduce the overuse or misuse of antibiotics and thereby help ensure that the antibiotics we have now will be effective for longer. The O’Neill report argued that currently, more than half of prescriptions for antibiotics may be unnecessary or inappropriate and that developing a globally available test will be part of the solution to keeping these drugs viable for another generation.
The prize has attracted more than 150 registrations and remains open for more. Entries are whittled down by an expert panel. Many were clearly not credible, and some entrants are encouraged to team up with others. Entries have come from many countries, but to be eligible they must involve a UK company or institution and carry out manufacturing and/or design of the winning solution in the UK, or lab test or showcase the winning solution in the UK.
This year, incidentally, the Americans launched a challenge prize with similar goals and a similar scale of jackpot, although with a US focus. That prize will concentrate on the 18 identified bugs that pose special health threats in the US, but it is being co-ordinated with ours. The American prize has set a maximum time of 90 minutes for its test to be used and to give results, which is appropriate for use in out-patient and in-patient settings, including pharmacies. The Longitude Prize has set the time limit at only 30 minutes, as we are looking for a test that will work in the field, in all health settings, including where antibiotics can be bought over the counter.
Those of us involved in these prizes welcome the fact that the O’Neill report highlights the importance of rapid diagnostics. We hope the Longitude Prize will help to speed up existing work in this area and generate some novel ideas. Moreover, a feature of prizes is that they can attract public interest. Nesta has been working hard on this in the UK, even developing a computer game based on the principles of antibiotic resistance to illustrate the science.
If overprescription of antibiotics were the only problem, it would be challenge enough. But of course, it is already much worse than that, because in the US, China and many other countries, as the noble Lord, Lord Lansley, indicated, antibiotics are being used for animals in a prophylactic context. I gather that the EU is banning this, and we hope that that will be followed.
Finally, it is worth noting that this challenge is clearly one that must be tackled globally. It therefore tends, rather like climate change in a way, to slip down the agenda compared to more parochial issues. It is also rather like climate change in that, although it is important now, it is going to be even worse in the future, so the benefits of action will accrue even more to the next generation than to us. For that reason, in order to ensure it does not slip down the agenda, the public need to keep up the pressure. The O’Neill report included a global awareness campaign as one of its priorities, and I echo the view expressed already by the noble Lord, Lord Lansley, that the forthcoming UN meetings will offer a boost to this cause.
My Lords, the House will be most grateful to my noble friend Lord Lansley for giving us the opportunity to debate the report and recommendations of the review on antimicrobial resistance, chaired by my noble friend Lord O’Neill, to whom we are all greatly indebted.
In the short time that antibiotics have been available to clinicians, the United Kingdom has played a leading role in their development, and indeed in the development of diagnostics, vaccines and other products vital for the prevention and treatment of infection. I say “short time”, because the first clinician to witness the miraculous potential of penicillin was Charles Fletcher, in February 1941, when he was working as a research student for Professor Howard Florey—later of course Lord Florey, and a Nobel Prize winner along with Sir Alexander Fleming. Professor Florey gave him the task of testing whether it was safe to give penicillin to patients. Told to find the worst case of bacterial infection in the Radcliffe Infirmary, he chose an Oxford policeman who had been infected after a scratch on this face due to contact with a rosebush. After four days of treatment, he was on the way to making a full recovery—it was totally remarkable. But then of course the penicillin supplies ran out, as there was no industrial process for producing this material, and the patient relapsed and never recovered.
As my noble friend reminded us, Sir Alexander Fleming and others warned us of the danger of resistance, which he was aware of soon after his epic discovery of the antibiotic properties of the mould Penicillium notatum way back in the 1920s. It remains a total mystery to me, incidentally, how apparently rational people around the world can witness the remorseless advance of resistance within microbes and yet reject the concept of Darwinian evolution; there it is, in all its clarity.
Now, thanks to this highly influential review, commissioned by our Government, the United Kingdom is continuing its leading role in developing strategies on a global scale to meet the challenges of rising drug resistance. Like the noble Lord, Lord Rees, I pay tribute to the role of Dame Sally Davies in keeping this on the agenda both nationally and internationally.
At the World Economic Forum at Davos in January, the global pharmaceutical industry signed up to what was described as the declaration on combating antimicrobial resistance, which called on Governments around the world to do more than just issue statements of intent and to take concrete action, in collaboration with the companies that had signed up, to support investment in the development of new products to meet the challenges of rising drug resistance. The review has suggested one-off payments to firms that develop drugs that meet predefined criteria of unmet needs, to be paid on top of sales revenue. Not surprisingly, the 85 companies that signed up to the declaration at Davos supported that proposal, and said that if Governments offered them money they would do everything they could to earn it.
Clearly, the business model of expecting new antibiotics, or other products developed at great cost, to be funded by sales is doomed to fail—there is bound to be a market failure. These new products need to be kept as a last line of defence against so-called superbugs and held in reserve for the most difficult cases. Any incentive to maximise sales would be perverse in the extreme. We have heard already about the issues of the irresponsible use of antibiotics in agriculture. One such new treatment is colistin. Last year, genes resistant to this new treatment were discovered in hospital patients in China, and the agricultural use of colistin is thought to be responsible.
If, in the words of the Davos declaration, we are looking to Governments for concrete action, the first priority for our Government in the UK must be to run out a model for the UK that delinks payments for antibiotics from the volume of sales. If such a model could be piloted by, say, 2017, that would be concrete action indeed. It would also be a great stimulus to British innovation, which remains a world leader in the field. That does not apply just to large pharmaceutical companies; quite modest-sized companies are involved as well.
The review calls for the establishment of a global innovation fund for early-stage and non-commercial research, a highly important recommendation and potentially of great significance to all companies that are innovating in this area, particularly to small firms that struggle to comply with the funding arrangements of organisations such as Combating Bacterial Resistance in Europe, the Innovative Medicines Initiative and other funding sources.
The appalling story of colistin-resistant bacteria, attributed to agricultural use, emphasises the importance of the review’s recommendations on antimicrobials in agriculture, on which it published a report in December 2015. The review says that,
“in some parts of the world antimicrobial use is far greater in animals than in humans; in the US, for instance, more than 70 percent of medically important antibiotics are used in animals … Much of the use of antibiotics in animals is not therapeutic … Instead, significant volumes are used either prophylactically amongst healthy animals, to stop the development of an infection within a flock … or simply for growth promotion”.
That is a scandalous state of affairs.
The review proposes three broad interventions to take bold global action to substantially reduce the use of antibiotics in agriculture. This is a global issue; to be fair to the EU, in some ways it has led the field from what was an appalling situation, not just in livestock production but in fish farming, which was absolutely scandalous. We need global action. The proposals in the review were, first, to set global targets to reduce antibiotic use in food products; secondly, the rapid development of minimum standards to reduce antimicrobial manufacturing waste released into the environment—that is a pause for thought; can you really imagine antimicrobial waste being released into the environment? It has happened—and, thirdly, improved surveillance and monitoring to check progress against global targets, which was referred to earlier.
The pharmaceutical companies that signed up to the Davos declaration accepted their responsibility in delivering at least some of these measures, alongside the Governments, who also have to deliver. However, I am not persuaded that the language of the declaration, prepared by the global pharmaceutical industry, is totally appropriate. It calls for,
“more judicious use of antibiotics in livestock”.
That does not sound very robust. The overuse of antibiotics in livestock husbandry is not just injudicious; it is scandalously irresponsible. Immediate action by the companies that sell such products is urgently required, as well as by those Governments who allow it.
The ball is now in the court of the G20 Finance Ministers. As my noble friend said, we have to move from statements of intent to concrete action. We look forward to the United Nations high-level meeting on 21 September. The members of the review team, led by my noble friend Lord O’Neill, have potentially done a wonderful service for patients around the world in setting out its list of 10 specific actions to be followed up by Governments. It is now time for their wise advice to be followed by concrete and timely actions.
My Lords, I join others in congratulating the noble Lord, Lord Lansley, on securing this debate, which, I dare to suggest, in terms of the significance of the global problem that we are discussing, is one of the most important that we have had in this House for some time.
I begin with a quotation:
“This enquiry has been an alarming experience, which leaves us convinced that resistance to antibiotics and other anti-infective agents constitutes a major threat to public health, and ought to be recognised as such more widely than it is at present”.
That is not a quote from the O’Neill report; it is the opening statement of the summary of recommendations from the seventh report of the House of Lords Science and Technology Committee, published in 1998 and entitled Resistance to Antibiotics and Other Antimicrobial Agents. The inquiry was chaired by my friend, mentor and fellow vet Lord Soulsby of Swaffham Prior, who retired from the House at Christmas. The report went on to make a number of recommendations that have an uncanny similarity to the ones we are now considering in the O’Neill report. Such is the nature of human progress; it takes us a while to become convinced of emerging threats.
I wholeheartedly welcome the O’Neill report, and the political support that it received from the last Prime Minister deserves commendation. In common with other noble Lords, I also congratulate Dame Sally Davies on her championing of this important issue. If antimicrobial resistance was a serious problem in 1998, its significance has increased enormously since, especially as a result of globalisation and a dramatic increase in the large-scale movement of people.
I shall focus my remarks in this debate on the veterinary aspects of this issue and focus particularly on bacterial resistance to antibiotics—which I shall refer to as “antibiotic resistance”—which is a problem in human health, as we are hearing, that is relevant to antibiotic use in animals. In that context, I should point out that the estimates of the costs that have been quoted already, provided by the consultants to the O’Neill commission, in terms of human life and in financial terms—10 million deaths per year by 2050 and a cost of US $100 trillion, truly shocking figures—refer to antimicrobial resistance. That is to say, they include such problems as resistance to protozoa, malaria, viruses such as HIV, as well as bacteria such as the human tubercle bacillus, all of which are huge causes of human morbidity and mortality, but there is no connection with chemotherapy in animals.
None the less, there are undoubtedly substantial human health problems which relate to bacteria which also affect animals and where animal usage has been implicated as a source of resistant strains. These particularly involve bacteria associated with gastro-enteric infections and the environment, such as E. coli, campylobacter and MRSA.
As the O’Neill commission laid out, the solutions to this problem involve reductions in drug usage, the development of new therapeutic and diagnostic agents and vaccines and the application of a global approach. I shall deal with those issues in that order and, as I said, mainly from a veterinary aspect.
First, I assure the House that, with respect to the UK and the EU, the veterinary bodies take the issue of antibiotic resistance very seriously. There are numerous high-level initiatives to reduce antibiotic usage in animals and to ensure their responsible use when necessary for animal health and welfare. In the UK and the EU, antibiotics are available only on prescription, and I assure the noble Lord, Lord Lansley, that the use of any antibiotics for growth promotion has been banned in Europe and the UK since 2006. Certain antibiotics critical for human use are still in veterinary use, such as fluoroquinolones and third and fourth-generation cephalosporins, and they are receiving particular attention from the veterinary community.
The Veterinary Medicines Directorate of Defra, the British Veterinary Association and its subdivisions, the British Small Animal Veterinary Association and the British Equine Veterinary Association, the National Office of Animal Health and an organisation called RUMA—the Responsible Use of Medicines in Agriculture Alliance—as well as industry organisations, have all been active in recent years in promoting the responsible use of antibiotics and in promoting and introducing measures accurately to record and reduce their usage. Indeed, the Royal College of Veterinary Surgeons has incorporated in its guide to professional conduct a professional obligation on vets to use responsibly all antimicrobials, so it could be a matter which triggers a professional disciplinary offence.
The British Poultry Council, which represents 90% of the poultry meat industry, established an antibiotics stewardship programme in 2011, which introduced a voluntary ban on cephalosporins in 2012, and is committed to reduce fluoroquinolone use and cease all use of colistin in British poultry, which two noble Lords have mentioned. It reported a 44% drop in total antimicrobial usage between 2012 and 2015, despite a 5% increase in poultry meat production.
All those measures are to be commended, and the total usage of antibiotics in the UK in animals is substantially less than that in humans. Progress shows what can be done, but we cannot be complacent, and more needs to be done, as I shall discuss. Suffice it to say that total antibiotic usage in animals in the UK is now close to the 50 milligram per kilogram target suggested in the O’Neill report. The veterinary profession is committed to continue these trends in the interests of public health while at the same time balancing the legitimate need to protect animal health, welfare and food production.
There is an urgent need in veterinary as well as human medicine to develop better diagnostics and better vaccines for infectious diseases, as the O’Neill commission urged and several noble Lords have said. These have the potential substantially to reduce the use of antibiotics. For example, the burgeoning aquaculture industry, particularly salmon farming, has made a remarkable reduction in antibacterial usage in the UK. Despite a huge increase in productivity from about 60 million tonnes in 1993 to 180 million tonnes in 2014, antibiotic usage in the sector is now very low. It is about one to two tonnes per year, which may sound quite a lot, but I assure your Lordships that it is small compared to the 419 tonnes total in all animals in the UK and 531 tonnes in humans—those are the 2013 figures. That progress in aquaculture has been achieved mainly by the development of vaccines and other management processes.
That is what is happening in the UK and Europe, but to reduce antibiotic resistance by reducing and controlling usage it is essential that action takes place on a global scale. There are no restrictions on antibiotic usage in animals or humans in many parts of the world, including in areas where there may be particularly high densities of human and animal populations and very high levels of contact between the two. Resistant strains which arise by natural selection in animals or humans due to uncontrolled use of antibiotics anywhere in the world can arrive in the UK within hours. About 60 million people per year travel through Heathrow airport alone, each carrying millions of microbes on two legs, many of which may have been acquired only hours previously. The O’Neill commission rightly emphasised this fact, even in the title of its report, Tackling Drug-Resistant Infections Globally. Whatever we do here in the UK—already a lot is being done in both the medical and veterinary worlds, but we need to do more—will be rendered ineffectual because of global human traffic, and we will not eliminate health risks anywhere unless we can secure concerted global action to address that.
At the same time as encouraging responsible use of antibiotics, there is an urgent need to discover and develop new antibiotics and new ways to combat bacterial infections. These may be by innovative therapeutic techniques, and the UK’s vibrant and creative scientific and commercial sector is at the cutting edge of these developments. A number of exciting developments are badly in need of support. That may initially come from traditional research grant sources—I commend the initiatives that have recently been announced. Other developments may require creating appropriate financial incentives for investment. A major problem with antibiotics, as with many other therapeutics, is that relatively small amounts of drugs are used only occasionally on only a small proportion of the population. The market sizes are not such as to provide the incentives for industry to respond. Industry is very successful in responding when there are market rewards consistent with the high cost of developing and registering therapeutic drugs. The O’Neill report rightly comments on that and makes a number of exciting and creative suggestions on how to mobilise the creativity of industry by creating artificial marketing opportunities.
In addition to therapeutic agents, we must do more to stimulate research on vaccine development. Earlier, I illustrated how important that can be in terms of aquaculture. There are challenges there with respect to some of the bacteria involved, but in general we have been extremely successful in science in developing vaccines to bacteria, and I am optimistic that solutions will be found and that vaccination will substantially reduce the need to use therapeutic interactions.
Lastly, management systems are hugely important; I do not have time to discuss them in any detail, but we need more research into improved management, particularly in animal husbandry systems.
In conclusion, I welcome the debate and the attention that the subject is receiving. Although only a proportion of the problems of antimicrobial resistance in humans is related to animal usage, there is a very high level of awareness in the veterinary community about this problem and a commitment to the responsible use of antibiotics and a reduction in the usage. The magnitude of this problem globally merits much more investment in research and development of vaccines, antibiotics, innovative therapies and new diagnostics, as well as improved management systems. Above all, the uncontrolled use of antibiotics, like climate change, is an issue that must be tackled globally.
My Lords, I congratulate my noble friend Lord Lansley on securing this debate on what is one of the greatest health and economic challenges of our age. Antimicrobial resistance—AMR—which is causing the rise in drug-resistant infections, is killing around 700,000 people worldwide. In the UK alone, it is resulting in 3,000 deaths a year, with an estimated cost to the NHS in excess of £180 million per annum. Without global action, AMR will kill another 10 million people annually by 2050, according to recent models referenced by my noble friend Lord O’Neill in his recent report on this issue. According to my noble friend’s findings, the increase in death and illness is set to wipe approximately $8 trillion off the world’s annual output by 2050. Previous speakers have referred to Dame Sally Davies, who frightened me when she described the threat of antibiotic resistance as being as great as the threat of terrorism.
The problem has been well documented and assessed; we now need to move on from discussing the problem to supporting the development and rollout of solutions. Policy discussion must go beyond just antimicrobial stewardship and the restriction of the use of existing antibiotics.
I note that at the May 2016 G7 summit, the then Prime Minister stressed the scale of the global problem of AMR and committed the UK to supporting British pharmaceutical companies to be at the forefront of bringing new products to market. Indeed, the report of the noble Lord, Lord O’Neill, called on the Government to provide:
“Better incentives to promote investment for new drugs and improving existing ones”.
I hope that the Minister will be able to reiterate this commitment on behalf of the new Prime Minister. Supporting the development of new antibiotics must be a key policy pillar in the Government’s antimicrobial strategy both at home and abroad.
This afternoon I would like briefly to touch on an example of the types of solutions that exist beyond better antimicrobial stewardship, which is combating AMR at home and abroad. In my career as a dentist, I was aware of some of the important work being done using oxygen in oral health care. I am excited that oxygen is now at the forefront of work to address AMR with the development of reactive oxygen technology.
Reactive oxygen is a British-led innovation which represents a new generation in antibiotics. It works by generating highly reactive, free-radical oxygen species, mainly hydrogen peroxide—one of nature’s fundamental defences against infection. It has been advanced by a small UK company, Matoke Holdings. Its chief executive, Ian Staples, is working with eminent clinicians, researchers and academics across Manchester, Southampton and Birmingham universities, including Dr Matthew Dryden of the University of Southampton School of Medicine and Professor Jonathan Cooke of Manchester University Pharmacy School and Imperial College London. These British scientists have developed a unique technology to precisely control levels and the rate of release of reactive oxygen, harnessing its ability to fight infection. No Gram-negative, Gram-positive or multiresistant bacteria tested to date have survived contact with reactive oxygen in either laboratory or clinic, including MRSA and Pseudomonas aeruginosa.
However, direct use of the gas is prohibited because ozone should not be inhaled. Professor Eddie Lynch, a colleague of mine, has shown that primary root carious lesions can successfully be treated with a novel ozone delivery system able to avoid any toxic risk. The system includes a source of ozone and a dental hand-piece with a removable silicon cup for exposing the tooth’s lesion to the gas. Although it is many years since I observed this treatment, it was very effective, with no side-effects. It could be considered a valid alternative to conventional drilling and filling for the management of primary root carious lesions.
I was delighted to hear from Matoke Holdings earlier this year. Reactive oxygen is one alternative that can play a vital role in tackling drug-resistant infection. The first product from this innovation, Surgihoney RO, is already approved by the EU regulatory body as a topical antimicrobial gel with antibiofilm action for wounds, burns and ulcers, including diabetic, and it has already been prescribed through the NHS. It has also been used by volunteers in Uganda and Ethiopia to prevent and treat infections, taking this British innovation to parts of the world where it is desperately needed. This is made possible given it is a low-cost, effective antimicrobial that is easy to use and does not require refrigeration. But, such innovative products need to be made available more widely to support some of the most vulnerable international communities.
The technology is now rapidly being developed to tackle other complex clinical infections for which conventional antibiotics are failing, including cystic fibrosis, chronic rhinosinusitis and recurrent urinary tract infections. Such technology has huge potential to deliver significant savings to the NHS and international health economies by providing a new effective treatment for chronic wounds, reducing amputations and days spent in hospital and nursing care. Such British innovative technology, which represents a new generation in antibiotics, needs to be brought to the forefront of the policy discussion about how we tackle AMR, both within the UK and globally.
While reactive oxygen technology is being pioneered by one British SME, this needs to be supplemented by strong government support for innovation to address this global challenge at scale and at pace. Investing in British research and development and supporting British enterprise will support our economy and allow us to export solutions to the threat of AMR across the globe. British innovation can still be a leader in the post-Brexit world. I ask the Government to do all they can to put British enterprise and R&D at the forefront of their strategy to combat AMR and to ensure that they look at the innovative new solutions that are already out there.
My Lords, like others, I congratulate the noble Lord, Lord Lansley, both on securing this debate and on his very cogent introduction today.
My contribution will concentrate on the global health aspects of the report, particularly in relation to malaria and artemisinin resistance. I draw attention to my interests in this area, as set out in the register. Much of what I will say draws on the recent report of the All-Party Group on Malaria and Neglected Tropical Diseases, and the Malaria Consortium, entitled, Racing Against Time: Protecting the Gains Achieved in Malaria Control Against Drug Resistance. It was dedicated to the memory of Dr Sylvia Meek of the Malaria Consortium—its co-author—who died tragically young very soon after completing the report. Sylvia dedicated her life to the fight against malaria with both passion and intellectual rigour. I pay tribute today to the enormous contribution she made, and the example of service she gave in international health.
Malaria control is one of the great global health success stories of this century. Deaths have declined by 60% across the world since 2000, which equates to 6.2 million fewer deaths than would have occurred. The incidence of new cases is down by 37%. The UK has played a major part in this achievement: at government level, through NGOs like Malaria Consortium, and through the enormous scientific contribution of our centres of excellence, particularly the Liverpool School of Tropical Medicine and the London School of Hygiene and Tropical Medicine. Progress has been achieved through collaborative action and the development of new tools—treatments, diagnostics, vector control, prevention strategies—and their effective deployment in endemic countries. The research continues, not least on the development of an effective vaccine against malaria.
But all this progress and all the investments we have made are threatened—and the history of malaria teaches us that progress has been threatened and lost in decades past—by the declining effectiveness of vector control because of the growth in resistance to insecticides and, in particular, to artemisinin combination therapies, which are the most effective treatment we now have for malaria. Resistance to ACTs is already a significant threat to health in south-east Asia and it will be a global threat if it spreads. Drug resistance has been detected in five countries in the Greater Mekong Subregion: Cambodia, Myanmar, Thailand, Vietnam and the Lao People’s Democratic Republic. If it spreads to other parts of south Asia, and worst of all to Africa, a global public health crisis will occur.
Drug-resistant malaria parasites have not yet been detected in Africa, but, following the pattern of the spread of previous resistant strains—as I said, we have been here before—drug-resistant malaria is a distinct and worrying possibility. At the moment, despite ongoing work to develop replacement drugs and a vaccine, no new treatment for malaria is in the pipeline if ACTs were to become ineffective. If resistance were to reach Africa, where the malaria burden is greatest, the impact could be devastating, leading not only to a massive increase in deaths but to massive costs—both medical costs and productivity losses.
I welcome the publication of this report and the opportunities it gives us to tackle the threat and existence of antimicrobial resistance. There are certain areas to which I wish to draw attention. One is recommendation 4, on improving global surveillance of drug resistance. The noble Lord, Lord Lansley, rightly drew attention to this, and I would like to endorse what he said. Strong disease surveillance systems are critical to monitoring and responding to the spread of disease resistance, as well as to the management and elimination of diseases such as pneumonia and malaria. Effective surveillance systems allow resources to be directed to the most affected populations, enabling us to identify gaps in programme coverage, detect outbreaks and assess the impact of interventions. The Ebola crisis provided a stark warning of the need to strengthen surveillance, particularly at community level, as I saw for myself when I visited Sierra Leone 18 months ago at the height of the epidemic. However, countries like Sierra Leone need support to substantially strengthen disease surveillance so that it becomes a core intervention and part of their public health systems. I encourage the Government to prioritise surveillance and would be grateful if the Minister, either in summing up today or separately in writing, told me what plans there are to help countries strengthen their surveillance.
The other recommendation to which I would like to draw attention is promoting new, rapid diagnostics as one of the ways of cutting the unnecessary use of antibiotics. Universal access to accurate diagnosis prior to treatment is a critical element of decreasing the irrational use of drugs, which is one of the causes of their reducing efficacy. The increase in availability of malaria rapid diagnostic tests over recent years has improved the rational use of artemisinin combination therapies. In 2014, for the first time, more RDTs were distributed through the public sector globally than ACT treatments. The availability of RDTs was also crucial in extending the accurate diagnosis and treatment of malaria at community level through trained volunteer community health workers, allowing for the differential diagnosis and treatment of febrile illness and reducing the common blanket prescribing of antibiotics for almost every sick child.
In Uganda, I had the privilege of seeing community health workers, some of whom were barely literate, doing an amazing job of differential diagnosis and effective treatment in the middle of the night with a two year-old with a high temperature. It is extraordinary what can be achieved. Developing new, accurate and easy-to-use diagnostic tools for other diseases, such as neglected tropical diseases like dengue and Zika, would support efforts to eliminate them and deserves priority.
Finally, the announcement of the Ross Fund is much to be welcomed, particularly the £350 million that has been committed to fight antimicrobial resistance. We hope that surveillance will be at the centre of the Ross Fund’s strategy. I would be grateful if the Minister provided an update, either today or in a letter, on the progress of the fund, along with details of how and when funding is likely to be allocated.
The UK Government, through DfID programmes and support for the Global Fund—HIV and TB being other areas, like malaria, threatened by antimicrobial resistance—have made a huge contribution to the fight against those three diseases, particularly in leadership on malaria. I hope the Minister will commit not only to the robust and speedy implementation of the recommendations in this report, but also to continuing the British Government’s commitment to their leadership role in the fight against malaria.
My Lords, I too congratulate the noble Lord, Lord Lansley, on initiating this debate. Antimicrobial resistance is a global health disaster waiting to happen, so it could not be more important and it cannot be understated. The report we are debating today is extremely comprehensive and makes a large number of very important recommendations, most of which are practicable and very cost effective. I was glad to see that they focus mainly on reduction and prevention.
Developing new antimicrobial products is important, but it is a bit like closing the door after the horse has bolted. We must shut the stable door and stop the horse bolting in the first place. Global co-operation and a massive awareness campaign about the problem of drug-resistant infections will be essential to tackling it. I have my doubts about whether this could ever really work, but it must if we are to defeat this terrible threat. Given the difficulties and cash shortages of some of the countries that would need to be involved, we would do well concentrate on two things: what we can control within our own shores, and co-operating where we can with international initiatives and funding projects in poorer countries, perhaps with the DfID funding for the Department of Health referred to in yesterday’s debate on smoking.
If we are to be able to reduce the prescribing of antimicrobials to humans, we need to reduce the pressure on doctors from patients who do not really need them. That will take public education and a culture change—and of course we know that a lot of them do not work anyway, so it will save money as well. But we also need to improve rapid diagnosis, as has been said, and develop the use of vaccines and other alternatives to the use of antibiotics.
Vaccine programmes have been very cost effective over the decades, often saving society more than 10 times the cost of their development. But, as the report points out, new vaccines relevant to AMR are more complex and therefore more costly to develop. The report’s authors therefore recommend a greater level of investment in this area with funding from government, charities and international organisations. I do not go back in your Lordships’ House as far as 1998, but this recommendation cast my mind back to the House of Lords Select Committee on Science and Technology report in 2002-3, entitled Fighting Infection. I was a member of that committee. In our report we said:
“We were particularly impressed, when we visited the National Institutes of Allergy and Infectious Disease in the US, to hear about their Small Business Initiatives. Small companies willing to take financial risks inherent in developing a vaccine could apply for up to $100,000 to cover initial development costs. If the company then patented the vaccine they were obliged to make every effort to bring it to market … Pharmaceutical companies invest ten or twenty times less money in vaccine R&D than in therapeutics. They regard the public expectation that vaccines should not have any side-effects as a particular burden. Such public anxiety requires vaccines to be more thoroughly tested than other pharmaceutical products in order to reveal any potential side-effect. This informs companies’ risk-analysis of products to decide whether or not to further develop or to market … Pharmaceutical companies desire clearer guidance from Government about levels of demand”.
We recommended that,
“vaccine development should be facilitated and … that the Government should develop and maintain clear evidence-based guidelines about vaccine requirements and should create financial incentives to enable early research, development and commercialisation of vaccines”.
That was in 2003, and I fear that the same needs still exist today. What are the Government doing to encourage and enable the development of new vaccines? Do they have a similar scheme to assist smaller research companies to mitigate the risks associated with the development of vaccines and other treatments, such as the company producing reactive oxygen, mentioned by the noble Lord, Lord Colwyn? We have to accept that development will have to be done in the richer countries, of which we are one—and, of course, happily we also have the skills here.
I was glad to see the warnings about the prophylactic use of antibiotics in agriculture because excrement from livestock is subject to even looser waste management practices than human waste. So not only are we taking in those chemicals in the meat that we eat but they are also being flushed away into our rivers, streams, soils and also the sea, where they are picked up by fish. So even careful usage and hygiene on one continent can be neutralised by poor practice on another—hence the need for global action. Of course, this is in addition to the effect of the mass movement of people, referred to by the noble Lord, Lord Trees.
Clearly, the consumer needs more information about the antibiotics used in meat production. If we had that, I am convinced public pressure would reduce their use in food production. I absolutely agree with the comments of the noble Lord, Lord Lansley, and the noble Earl, Lord Selborne, about this. I hope that our departure from the EU will not stop us from banning more categories of use than we have already. But hygiene measures to prevent these products getting into the water we drink and the fish that we eat are also essential. That should include antimicrobials in development, which should be disposed of by pharmaceutical researchers in a way that does not pollute our water. I use the word “pollute” deliberately, because these products can be just as dangerous as the microbeads which have recently been brought to our attention as a great danger to marine life.
There is another danger which I did not notice mentioned in the report. That is the fact that bacteria can swap bits of their DNA with other bacteria—and this is very significant. A drug-resistant bacterium that passes through the intestines of any animal into the local waterway may not in itself be a pathogen that normally threatens human health, but that benign bug can share its drug-tolerating secrets with others. David Cummings, a biologist at Point Loma Nazarene University in San Diego explains in his paper on the subject:
“It’s not necessarily important what species is holding on to the DNA as long as the DNA is held on to and propagated. Then it can later be released to cause disease in an animal, plant or human”.
Of course, course, drug-resistant strains of bacteria—to go back to what the noble Earl, Lord Selborne, said about Darwinism—tend to be the fittest, and therefore survive. Cummings’s research has identified dangerous DNA in the river sediments around San Diego and across the Mexican border. He says:
“These coastal wetland habitats are becoming sinks and ultimately sources for drug-resistant bacteria—more importantly, sinks for the DNA that provide resistance”,
and he points his finger at very common things, such as pet waste, bird faeces, leaky sewer pipes and hospital waste effluent as the likely culprits.
Bacteria are very biologically clever and flexible. Not only are they able to develop resistance to our antibiotics and thrive but they can then pass that resistance on to other bacteria that can harm us. So our focus needs to be not only on pathogens and developing ways of killing them but on reducing the use of antimicrobials as a whole. In relation to that, I was very interested in the section of the report covering the provision of clean water and proper sanitation in four middle-income countries. These simple, fundamental basics of public health, which we take for granted here, can break the chain of infection and reduce the need for antibiotics by up to 60%. This in turn reduces the development of drug-resistant strains.
I saw for myself the practical benefits of improvements in these areas when I visited an area near Calcutta with UNICEF a few years ago. I have never seen more brand new toilets in a few short days in my whole life—and, of course, people were very proud of them, as well they might be. The benefits of clean water to the schoolchildren, with whom I washed my hands with soap before a meal, showed in their smiling healthy faces and their growth charts on the wall of the school. The benefits of proper toilets to the mothers, who earned money by manufacturing them, and then of having them available in their homes, were enormous and obvious. I have mentioned before the UNICEF project in a village where clean water was being pumped up from a well by a pump which was serviced regularly by the women. They may not have realised it, but they were not only saving their children from diarrhoea but were contributing to limiting the global development of antibiotic resistance.
The report also recommends the development of more rapid diagnostics and early recognition of human disease. Obviously, early treatment will require smaller quantities of antimicrobials. The Royal College of Nursing agrees. One key recommendation in its briefing was implementation of rapid diagnostic testing for suspected cases of pneumonia and investment in systems that capture the rationale for prescribing antibiotics to improve practice, reduce unnecessary prescribing and cut the cost to the NHS. The RCN also calls for a national strategy for infection prevention and control, but rightly points out that AMR is not exclusively a hospital or even a healthcare-related issue, and multisector engagement is necessary.
For so long, we have had so many very effective treatments for infectious diseases that we are in danger of being casual about infection control. After all, if we get an infection, the antimicrobials will deal with it, will they not? Well, perhaps not any more. The many factors that we have heard about in this debate that make it easy for micro-organisms to develop drug resistance, all put together, make me feel that the human race has become very cavalier about infection—we have in the West at least. For example, all hospital wards and departments that I have been in now have little machines at the entrance with antimicrobial stuff that you can rub on your hands. But do we always use them? I must admit that I do not always. When hospitals look superficially very clean, as most do, it is tempting to forget the millions of invisible but potentially dangerous microbes lurking in every corner. Of course we do not want to live in a completely sterile environment, because that would not allow our immune systems to develop strongly, and we need that. The human immune system is a wonderful thing but it cannot cope with overwhelming odds. We need to take all the recommendations of this excellent report to heart. As the report says, it will save money as well as lives. Can the Minister tell us how the Government plan to respond?
My Lords, it is a great pleasure to congratulate the noble Lord, Lord Lansley, on raising such an important and interesting Question for our debate today on the risks that we face, now and in the future, in relation to AMR. It is of course very timely, because of the imminence of the UN high-level meeting and also because of the work of the noble Lord, Lord O’Neill of Gatley, to whom I pay tribute—indeed, I am grateful to him for his summary of his report, which we received yesterday.
We have had the interim response to that report, and I understand that a full response is due shortly. Can the noble Lord, Lord Prior, say a little more about that full response and what he thinks might be in it? Can he also say a little more about the approach we are likely to take at the UN high-level meeting next week?
Noble Lords have referred to a lot of the recommendations of the noble Lord, Lord O’Neill; I will ask about two areas. The first relates to a global public awareness campaign. We know, as noble Lords have said this afternoon, that some have what can best be described as a cavalier approach to the use of antibiotics. I am interested to know what the UK’s approach is to negotiations on an international response, particularly on the need for a global public awareness campaign. The noble Baroness, Lady Walmsley, from her experience in Kolkata, intimated the kind of response that was possible, but we need a level of awareness for that to happen.
I also want to ask about work with the global finance and health community to develop a system that can reward pharmaceutical companies that develop new and successful antibiotics. I understand that the ABPI is working with the Minister’s department to create a UK model that would delink payments for antibiotics from volumes of sales, which would guarantee companies a return on investment. The current financial model does not provide the incentives that the companies need. Can the Minister say a little more about the progress that is being made in those discussions?
Vaccines have been mentioned by a number of noble Lords. I have had a comment from one of the companies that have briefed me—it was from Pfizer, in fact—that while the UK is a world leader in national immunisation programmes, its sense is that immunisation is not regarded by the Government as an,
“important component of its strategy to address AMR”.
Can the Minister confirm whether that is true or not? As Pfizer points out,
“This is despite evidence that improvements in vaccination could help to contain the rise of four different types of drug-resistant infections”.
The noble Lord, Lord Rees, very clearly set out the real risks faced, and he offered some interesting insights, I thought, into the use of prizes to stimulate solutions and to work up novel ideas. Does the Minister think that this might be something that is developed in the future?
We have heard a number of ideas. The noble Lord, Lord Colwyn, raised the issue of reactive oxygen. I am not sure that I entirely followed the technical details, but I got the point. He essentially said that there is a regulatory difficulty with its introduction. It would be interesting to know whether the Government are looking at this as a potential area for development.
I should also say that we have had an amazing amount of briefing for this debate. I was interested to hear from Brightwake the potential for using disinfectants as chemical agents, since they have excellent biocompatibility and can be used more on topical infections or wounds with a high risk of infection. Brightwake says that use in Germany has shown pre and post-surgical infections are the lowest recorded. My understanding is that there is a problem for manufacturers to get these agents through the regulatory process, because the cost of introducing a so-called “medical substance” into a medical device is very prohibitive.
None of us knows the impact of Brexit on the regulation of medicines and medical devices, but it might be worth looking at areas in which a speeded-up and rather more streamlined approach might be helpful in the future. Can the Minster’s department have a look at that?
The noble Baroness, Lady Hayman, made some very telling points about malaria and the all-party report. I think that she and I are both interested to know whether the Government will take forward the recommendations and how they will do so.
We have talked about what is to be done globally, but there is much that can still be done in this country. GPs are clearly at the front line in terms of the prescribing that they undertake, and my impression is that many of them have responded to the challenge but there is a clear variation in performance. I was interested in the reference by the noble Lord, Lord Colwyn, to veterinary surgeons and the guidance—or what I think is rather more than guidance—issued by the Royal College of Veterinary Surgeons; it sounded much more like a requirement in relation to their clinical practice. I wonder whether there is something to be learned there in relation to the inappropriate use of antibiotics in human medicine. Can the Minister comment on where we are with GPs and whether there are things that we can do, none the less, to improve their overall performance?
I also refer the Minister to a comment that I have received from the BMA:
“In hospitals it is often unclear which staff have ‘ownership’ of antimicrobial prescribing and responsibility for minimising resistance”.
That is very interesting because—as the noble Lord, Lord Lansley, referred to—it has clearly been important that, at the end of the day, both the board of the organisation and individual senior officials have a clear responsibility for infection control. I wonder whether we need a similar approach when it comes to antimicrobial prescribing.
Three speakers—the noble Earl, Lord Selborne, and the noble Lords, Lord Lansley and Lord Trees—spoke about the issue of animals. They made some very telling comments. The noble Lord, Lord Lansley, asked about veterinary supervision of the use of antibiotics in animals; he also referred to the inappropriate use of what might be described as the antibiotics of last resort in animals, which should be reserved only for humans—I think that there is a great deal of sympathy for that.
The noble Lord, Lord Trees, spoke of the responsible attitude of veterinary bodies in the UK and EU and the considerable progress that has been made over the past few years. I think that it is right to acknowledge that progress and to acknowledge the farming community as a whole for its general co-operation on those measures.
But what about countries where there is absolutely no control of the use of antibiotics in animals? Is the Minister confident that this will be tackled in future global negotiations and discussions because this is clearly a very worrying situation? I am not an expert on the international food trade, but one of the major concerns of UK farmers is that very high standards are required of them, whether in relation to the inappropriate use of antibiotics or on animal welfare, but they are forced to compete with countries which do not have these high standards. This is a very broad canvas, but clearly the issue of animals should be taken very seriously.
Overall, this has been an extremely constructive debate. I recognise that the Government, particularly under the previous Prime Minister, were taking a progressive approach in this area. I very much hope that this will continue under the current Prime Minister, and that we will see a wholehearted response to the report of the noble Lord, Lord O’Neill, very soon.
My Lords, this has been an excellent and informative debate. I join others in thanking my noble friend Lord Lansley for securing it, and for his very important contribution to it. However, it is slightly sobering to think that this issue was raised in the House of Lords as long ago as 1998, as the noble Lord, Lord Trees, said, and again in 2003, as the noble Baroness, Lady Walmsley, said. It is easy to write these reports but quite a different thing to act upon them.
I was struck by the comments of the noble Lord, Lord Rees of Ludlow, on longitude, and how that prize won in the 18th century by one of the great British entrepreneurs, John Harrison, transformed navigation. Prizes have a role to play, not just for the money but in raising the profile of issues and gaining public knowledge about what is going on. However, there is another issue here. We should not be afraid of money. If scientists working in British hospitals or universities are able to make money from winning a prize, or indeed from royalties or shared royalties for an invention, we should encourage that. I sometimes think that we are way off the pace compared with the culture in the US in that regard. My noble friend Lord Colwyn referred to reactive oxygen technology. That may well be one of the new technologies that could win a prize of this kind. Certainly, we should look at that technology very closely in our fight against infection.
I pause for a moment to try to imagine a world without antibiotics, before Alexander Fleming’s great discovery of penicillin in 1928. It is worth noting that he discovered penicillin in 1928, but its use was not commercialised until the mid-1940s, so the take-up of new inventions and innovations was not as fast then as we would have liked. In those days, even a minor infection following a wound caused by a thorn in the garden or a shaving cut could result in disastrous consequences. In that pre-antibiotic age, 40% of deaths were due to infections. The emergence of antibiotics changed all that. Today, the equivalent figure has fallen from 40% to 7%. Much of modern medicine, such as cancer treatment, and much of modern surgery, is possible only because of antibiotics. However, we have been wasteful with this precious resource. As my noble friend Lord Lansley pointed out, when Alexander Fleming won the Nobel Prize in 1945, he said in his acceptance speech that,
“the thoughtless person playing with penicillin treatment is morally responsible for the death of the man who succumbs to infection with the penicillin-resistant organism”.
He was, indeed, prophetic. As my noble friend Lord Selborne almost said, in the evolutionary race, bacteria have a huge advantage over human beings. Populations of bacteria can reproduce and double within four to 20 minutes in the right circumstances. Our profligate use of antibiotics in humans and animals has accelerated that evolutionary process.
Fleming was, of course, right in voicing his fears, because that is precisely what has happened today. In a post-antibiotic era, routine operations such as removing an appendix, inserting a pacemaker or a standard hip replacement could again be very hazardous. Childbirth, too, may once again threaten a woman’s life and child mortality could increase. As the noble Baroness, Lady Hayman, said, this problem could indeed set back all the successes that we have had in combating malaria.
The dilemma we face today is in two parts: a rise in antibiotic-resistant bacteria on the one hand; and the lack of new antibiotics coming on to the market on the other. In fact, we have not seen any truly new antibiotics for decades. This is in stark contrast to the rapid post-war development of new antibiotics. Already in the UK, we are seeing 5,000 deaths per year from sepsis, half of which are due to a resistant form of the bacteria. The numbers of infections complicated by AMR are expected to increase markedly over the next 20 years. If a widespread outbreak were to occur, we could expect around 200,000 people to be affected by a bacterial blood infection that could not be treated effectively with existing drugs. High numbers of deaths could also be expected from other forms of AMR. This is precisely why the Government asked my noble friend Lord O’Neill to conduct a review of the economic and social consequences of antimicrobial resistance. It is interesting to note that a senior, well-respected economist with particular expertise in emerging economies was chosen to conduct the review, as this issue goes beyond just a health problem. It is potentially a health, social and economic problem that threatens us on a global basis. In the Government’s risk register, AMR is a tier 1 risk, along with terrorism and a flu pandemic.
As the review has pointed out, antimicrobial resistance is not just a human health problem; it is of huge significance in the animal health, environment and agriculture sectors. It is only by tackling the problem in the round—a One Health approach—that we will make a difference globally. It is worth quoting from the foreword to the report of my noble friend Lord O’Neill, which states that,
“without policies to stop the worrying spread of AMR, today’s already large 700,000 deaths every year would become an extremely disturbing 10 million every year, more people than currently die from cancer. Indeed, even at the current rates, it is fair to assume that over one million people will have died from AMR since I started this Review in the summer of 2014 … The cost in terms of lost global production between now and 2050 would be an enormous 100 trillion USD if we do not take action”.
The review’s final report makes it clear that action is in part for nations to take in response to their particular circumstances, and that in other respects action will have to be taken globally. This mirrors the approach the UK has been taking towards AMR. As regards the Government’s response on a domestic level, the UK’s approach has been built around a five-year antimicrobial resistance strategy, first published in 2013. The report from my noble friend’s review has now given us the opportunity to reinvigorate and strengthen key elements of our existing strategy. New ambitions announced at the G7 leaders’ summit in May this year, and by our new Prime Minister at the G20 last week, are an example of the immediate effect of the review. Our aim now is to halve by 2020 the number of inappropriate antibiotic prescriptions within the NHS. We are also taking steps to halve the number of the healthcare-associated Gram-negative bloodstream infections, like E.coli, which pose the biggest threat to human health. This is not to say that the NHS has not made progress already on antibiotic prescribing. In fact, between April and December 2015, 2 million fewer prescriptions were dispensed compared with the same period in 2014. That is a reduction of a little over 7%. However, we have a long way to go and we know how difficult it is to change behaviour. More accurate diagnostics will clearly be a key part of this programme. As my noble friends Lord Colwyn, Lord Lansley and Lord Selborne said, the take-up of innovation is hugely important.
In response to the comments of the noble Lord, Lord Hunt, about the regulatory regime in a post-Brexit world, I say that the Brexit situation enables us to look again at our regulatory and licensing regime to see whether we can streamline it to make it quicker and less expensive than any other regulatory system in the world. Maybe in another debate we should come back on that in the context of life sciences more generally in a post-Brexit era.
The Government will additionally set an overall target for antibiotic use in livestock and fish farmed for food. The use of antibiotics as an aid to growth or a prophylactic against infectious disease is clearly highly undesirable. As the noble Lord, Lord Trees, said, we have largely ruled it out within the UK and Europe but in many parts of the world it is still a major problem.
Other recommendations in my noble friend’s review range from the issue of awareness-raising and behaviour change through to the question of how we might create the incentives to antimicrobial research and development that are so very much needed. Infectious disease has slipped down the priority list over the last 70 years and it is time that it came back to the top of the list. The Government will publish in the course of the next few days a full account of how they will address each of the recommendations in my noble friend’s review.
On the international dimension of the Government’s response to antimicrobial resistance, your Lordships will be well aware of the significant part that Dame Sally Davies, the Chief Medical Officer, has played—the noble Lord, Lord Rees, and other noble Lords drew attention to it—in raising the profile of AMR not only in this country but around the world. She has been and will continue to be a tireless champion, raising awareness of this huge threat to public health. The Government share her views fully. AMR has to be tackled on a global basis. In fact, in the last two years, the UK has played a central role in the WHO’s global action plan, which is largely mirrored by the World Organisation for Animal Health and the UN Food and Agriculture Organization. Each of these is important and each creates clear aspirations.
Our current focus is on the UN General Assembly high-level meeting next week to drive further international commitment and action to tackle AMR on a global scale. This objective will not be achieved easily or without perseverance. There is, however, good reason to believe that the effort and investment will bring real results. Indeed, the leaders’ communiqué from the G20 summit earlier this month acknowledged the threat that AMR poses to public health, growth and global economic stability, and committed to return to the subject next year. In the meantime, the leaders have asked international organisations with a particular interest, including the WHO and the OECD, to report back on options to address the serious shortfall in the number of new antibiotic and other drugs—a topic central to the analysis in my noble friend’s report. We are confident that the UN General Assembly high-level meeting on 21 September will not only raise awareness but pave the way for a positive declaration that will include a strong UN follow-up mechanism to monitor progress, locking in global commitments.
Our commitment will continue to allow us to provide support to low and middle-income countries. For example, our £265 million Fleming fund will support these countries to improve laboratory capacity and surveillance to tackle infectious disease. We are also working hard to promote research and innovation in antimicrobial resistance; for example, in fields of new diagnostics and vaccines. We have also committed £50 million towards setting up a global AMR research innovation fund to help countries tackle the threat.
The noble Baroness, Lady Hayman, asked a question on the Ross fund. The fund will provide £1 billion to develop, test and deliver a range of new products for infectious disease, such as malaria, Ebola and other neglected tropical diseases. The UK has invested over £200 million in product development, which has contributed to the launch of over 13 new vaccines, diagnostics and drugs in the last five years. This is a fourfold increase compared to the total global product development for the world’s most vulnerable between 1975 and 2000.
In conclusion, this is a hugely serious issue. AMR kills many people at the moment and could kill many millions more in the future. It also has huge economic consequences for the world. I will end by giving the last word to my noble friend Lord O’Neill, who has done so much to raise awareness of this great issue. I quote the last paragraph of his foreword to the latest report:
“Although AMR is a massive challenge, it is one that I believe is well within our ability to tackle effectively. The human and economic costs compel us to act: if we fail to do so, the brunt of these will be borne by our children and grandchildren, and felt most keenly in the poorest parts of the world”.
My Lords, I have been in your Lordships’ House for less than a year and once again I am reminded of how much relevant expertise can be brought to an important subject—in this case an extremely important subject—even in the course of a short debate. I am most grateful to all noble Lords who contributed to the debate. It not only gave force to the report we are taking note of and reinforced our thanks to my noble friend Lord O’Neill of Gatley and his colleagues for an excellent review that is a basis for taking action, but illustrated in a number of specifics how that action should be taken forward, highlighting some of the opportunities that lie ahead in tackling the extremely dangerous situation in which we might otherwise find ourselves.
I was grateful to my noble friend Lord Rees—if I may call him that on a Cambridge basis. The Longitude Prize and the work that went into it demonstrated magnificently that there is public recognition and awareness of the importance of tackling antibiotic resistance and doing so rapidly. I had not realised that there is a 30 minute/90 minute distinction between us and the United States, but I am with the Longitude Prize panel here in saying that we are looking for 30 minutes. These kinds of rapid, desktop, easy-to-use diagnostics can make a fabulous difference: first, in identifying viral rather than bacterial infections—innumerable prescriptions are issued for antibiotics for what turns out to be a viral infection—and in identifying what character of infection we are dealing with and to what antibiotics it may be susceptible. That will make a dramatic difference, and what the noble Lord said about that work was encouraging. That is of the moment; in the current few months that work is being reviewed and it will be reviewed regularly over the period ahead.
I am grateful to my noble friend Lord Selborne for sharing the expertise of the Science and Technology Committee. We were reminded of the previous work of the committee, to which he brought his expertise. He reminded us that the survival of the most adaptable organisms is a demonstration of the underlying biological power of bacterial infection which we have to deal with—we have to be eternally vigilant about that. I will pick out one other thing. He talked quite rightly about the Davos declaration and the relationship with the pharmaceutical industry. The declaration in January was important but we have to take this forward.
I am not sure that I have yet heard from my noble friend Lord Prior in his response to the debate how we can mobilise on a global basis a system of incentives for market entry that we know will be effective in mobilising the pharmaceutical industry’s capacity—to the extent that it has such capacity—to find new treatments. Clearly there is a desire on the part of the industry for this to happen and a desire on the part of Governments to make it happen, but different and distinctive approaches are being taken, whether it is the American one, the market-entry process or the European support for innovation. We need to bring these together, and if we are to deal with this globally, we need to look for a global solution among some of the leading countries. My personal view is that a combination of extended market exclusivity plus a market-entry incentive could be affordable and achievable. I hope that that will be taken forward by some of the leading Governments working together.
The noble Lord, Lord Trees, reminded us compellingly of what has been done in this country and needs to be done elsewhere. That is the essence of it: it is about taking the example of this country and making it global in tackling inappropriate and extensive antibiotic use in animal health, agriculture and the environment. That can be done, as we have demonstrated here.
As the noble Baroness, Lady Walmsley, among others, said, there may be a role for us in trade control and in trying to make sure that it is not productive or profitable for people in other countries to produce food through the inappropriate use of antibiotics. We should certainly look at that.
I am grateful to my noble friend Lord Colwyn for talking about how we can find new treatments. I was always aware of the disinfectant properties of hydrogen peroxide but I was not aware that reactive oxygens specifically could achieve the control of infections in individuals.
The noble Baroness, Lady Hayman, rightly illustrated why vaccines could constitute the most cost-effective and important approach. The noble Baroness, Lady Walmsley, also mentioned vaccine development, and these questions need to be taken up.
Finally, with the high-level meeting coming up, I will say this to my noble friend the Minister: I hope that the Government will take every opportunity next Wednesday to encourage those at the meeting to look for quantified progress in the way that our national action plan does and some other national action plans do. There is no reason now why we should not look for a global action plan that has quantifiable targets. Allied to that, we need more pledges to support the funding that the British Government are putting forward. I hope that, through the high-level meeting, there will be structural follow-up.
The Minister referred to the G20 and said that it was looking to return to this next year, but that is not sufficient. We want structural action to take place straight after that meeting. I am very grateful to your Lordships for their contributions.