David's New Book

Thursday, January 14, 2010

Connecting the dots . . . not.

For this blog, I was inspired by the events following the failed underwear bombing of a US bound airliner on Christmas day and research I did for my last blog on KPC carbapenemase. I contacted the CDC to see if they had any updated active (as opposed to passive) US surveillance data on these highly resistant pathogens. I was a little shocked by the response I received – don’t hold your breath.

In 1999, the department of Health and Human Services formed the Interagency Task Force on Antimicrobial Resistance. The basic premise was to get various government agencies form a common plan of attack for the problem, to communicate with each other and to develop cross-agency plans and projects. Aside from those agencies like the CDC, NIH and FDA, the Task Force ultimately included the Agency for Healthcare Research and Quality (AHRQ), Centers for Medicare Medicaid Services (CMS), the Health Resources and Services Administration (HRSA), the Department of Agriculture (USDA), the Department of Defense (DoD), the Department of Veterans Affairs (VA), and the Environmental Protection Agency (EPA). In this way, all aspects of the problem of resistance, antibiotic overuse, infection control, surveillance for resistance, antibiotic use in animals and crops, environmental contamination with antibiotics and our suffering antibiotic pipeline could be addressed in a coordinated way. Great idea! But what makes any of us think that the rest of government is better able to connect the dots than our various intelligence agencies?

The plan is available online through the CDC website (www.cdc.gov). Some agencies, especially the CDC, have done a good job in educational outreach of antibiotic resistance and have carried out some important surveillance under the auspices of the Task Force. The NIH, in 2006, established the Drug Discovery and Mechanisms of Antimicrobial Resistance (DDR) to provide appropriate expertise to review research grants on resistance. (Of course it took them 20 years to put this in place since it was first recommended by another task force back in 1986). Even though this year only 1 in 17 grants will be funded, NIH has succeeded in reversing a trend going back to the 1950s of not funding antibiotic research. The Centers for Medicare and Medicaid Services, as part of their quality initiative for hospital reimbursement has identified certain hospital acquired infections for which it will no longer pay. This one initiative may have considerable impact even though it is a controversial one. The FDA, as far as I can tell, has slid backwards in their goals of stimulating antibiotic discovery and development. Large pharmaceutical companies have continued to leave the field in the last decade and essentially none of those who halted antibiotic research have come back to it.

If I had to give the Interagency Task Force a grade after a decade of work it would be D. Why are they doing so poorly? There are two major reasons and you can guess what they are. Money is number one. These agencies all compete for funding within the federal budget. Those within HHS compete for HHS monies. The goals of the Task Force require funding which has never been forthcoming in any kind of systematic or dedicated way. Yet we lose more Americans every year to antibiotic resistance than to terrorism, automobile accidents, and war. We lost 58,236 Americans in the entire Vietnam War, but we lost 63,000 per year to antibiotic resistance just in our hospitals alone! That translates to over 630,000 Americans lost to resistance since the inauguration of the Task Force. Where are our funding priorities?

The other issue is that these agencies do not communicate well. The actions already undertaken by the various agencies were the result of efforts within each of them individually. Where is the coordinated attack? Where are the cross-agency goals and projects? This is related to the first problem – they compete for funding. They are all large bureaucracies that do not change their behavior quickly.

In my view, we need a centralized and independent authority with expertise in multiple facets of resistance and a reasonable budget. This budget can come in part from all the agencies already part of the Task Force. Let the agencies have some of their budget monies dangled in front of them that they would only be able to access with practical, important and coordinated plans to deal with multiple facets of the resistance problem. Let them compete for grant monies for a change.

FYI – We have just agreed to establish the EU/US Transatlantic Taskforce on Antibiotic Resistance, focused on appropriate use of antibiotics and strategies for improving the pipeline of new antibiotics. Lets hope it works better than the Interagency Task Force that has been in place for the last 10 years.