Wednesday, May 25, 2016

Antibiotics, Politics, UK, EU, USA

Well, the UK’s O’Neill Commission released its final report on tackling antibiotic resistance. This is a very detailed report looking at all sides of the problem and trying to take a global perspective. I won’t review it today – but you can read it yourselves.  There is a nice review in The Atlantic. 
I want to talk about the relationship between our public perceptions, priorities and policies and provide a contrast between the US and the UK in that regard. The UK, under Prime Minister David Cameron and Chief Medical Officer Dame Sally Davies, has undertaken the battle against antibiotic resistance in a public and committed way.  News articles and press releases are constant. The Review on Antibiotic Resistance (I call it the O’Neill Commission) was undertaken under UK leadership. The UK has made enormous strides in educating the public on the dangers of inappropriate antibiotic use and the consequences of resistance. The UK has established strong guidelines for the stewardship of antibiotics and has provided teeth to help make sure physicians comply with these guidelines.  They have also carried out extensive public education campaigns to try and decrease patient demand for antibiotics for inappropriate indications. These efforts have begun to bear fruit with a demonstrated decrease in antibiotic prescribing. Combined with the general strategy proposed by the AMR Review under O’Neill to incentivize the antibiotic pipeline, the UK program show us all a way forward – at least in general terms.

How does the US look compared to the UK? Does our Surgeon General call for antimicrobial stewardship or incentives for antibiotic discovery or development?  A look at his website shows no headliners for antibiotics at all.  A search for articles on antibiotics on the website turns up older documents from previous surgeon generals. Although there are one or two articles on the need to reduce inappropriate antibiotic use, there is nothing like what can be found in the UK.
What about the presidential campaign in the US. I was unable to find anything meaningful from any of the candidates on the problem of antibiotic resistance by searching on Google. A search of the candidates’ websites shows nothing specific about antibiotics.  Hillary Clinton has posted her thoughts on HIV-AIDS, but not on antibiotics and antibiotic resistance.  Neither Bernie nor Donald have anything to say.

How about the use of antibiotics in animals?  Europe including the UK have essentially banned the use of antibiotics in animal feed for the purpose of growth promotion. The UK is now considering other proscriptions such as against the use of certain antibiotic prophylactic regimes for poultry and other animals as has been done by certain other EU countries. In the US – we’re still working on gathering data.  Again our candidates are silent.

Has the US really done nothing?  No.  President Obama has been more engaged in the problem of antibiotic resistance than any other US President in history. A number of important initiatives have been established under his watch. These include a report from his Council of Advisors on Science and Technology and a subsequent plan for implementing many of the suggestions from that report.  There has even been an increase in funding for NIH and BARDA to support these plans. Our regulatory agency has made great strides in providing feasible pathways for the development of new antibiotics, but they still lag behind Europe in that regard. The CDC website is replete with information, but we are just beginning to carry out surveillance for antibiotic use and we do not have the kind of teeth that UK and Europe do to alter prescribing habits. There has been nothing like the attention given to antibiotic resistance in the UK and in Europe. There is little discussion in the US of the kind of post-market incentives that will be so important going forward.

I am supposed to head to Amsterdam next week to attend a meeting of Drive-AB – the EU-funded effort to actually find ways to implement the strategies being promulgated by the O’Neill Commission. In thinking about this meeting, I am of two minds.  I am disappointed that the US is not more of a leader in this area.  But I also agree with President Obama (and, help me, Donald Trump) that Europe needs to do more to pull its own weight. 

Historically, the US has accounted for about 50% of the total pharmaceutical market.  As of 2013, it still accounted for over 40%.  That’s one country – 40% of the world dollar volume in prescription drug sales.  If you look at sales of new drugs, the US is responsible for 55% of sales.  When translated into pharmaceutical company profits, the US still dominates.  Since these sales are, to a certain extent, rolled back into research and development, one could conclude that the US has been subsidizing global pharmaceutical R&D for decades.

So I look forward to incentives for antibiotic R&D coming, to a large extent, from Europe!

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