A paper issued yesterday by policy institute Chatham House concludes that not enough progress has been made on recommendations from a series of reports that alerted the world to the rising threat of antimicrobial resistance (AMR).
The AMR Review, commissioned in 2014 by former UK Prime Minister David Cameron and chaired by British economist Lord Jim O'Neill, outlined the threat of AMR to global public health and highlighted the potential costs of inaction in eight separate reports issued over 2 years. Among the highlights from the first AMR Review paper were two startling figures—that drug-resistant infections could cause the deaths of 10 million people by 2050 and could cost the global economy up to $100 trillion if the problem was not addressed in the coming years.
In the final report, issued in May 2016, O'Neill laid out 10 recommendations for addressing the problem, led by a call for a massive global public awareness campaign, improved hygiene and infection control, a reduction in the unnecessary use of antibiotics in agriculture, and better incentives to promote investment in new antibiotics.
While the AMR Review has raised the profile of AMR on the international agenda and stimulated a number of initiatives, the author of the new paper says an assessment of progress on those recommendations reveals that not enough action has been taken.
"It appears that the threat, in spite of many warnings, is not perceived to be sufficient to merit the exceptional policy action many consider necessary," Charles Clift, PhD, a senior consulting fellow at the Centre on Global Health Security at Chatham House, writes in the report.
Some progress, but not enough
Although the assessment emphasizes the lack of progress on many recommendations, it also points to some successes. Clift observes that resources have flowed into AMR awareness campaigns, several high-income countries have had considerable success in reducing antibiotic use in food-producing animals, new funding initiatives for early-stage antibiotic research have proliferated, and a coordinated structure for global leadership on AMR is starting to take shape.
The report, which incorporates insights from a Chatham House expert roundtable held in May, also highlights progress on AMR surveillance, pointing to the World Health Organization's creation of the Global Antimicrobial Resistance Surveillance System (GLASS).
But Clift argues that there is limited evidence regarding the impact of AMR awareness campaigns on antibiotic use, and that little is known about how to tailor these messages to local circumstances. Furthermore, he notes, the recommendation for regulations on non-prescription antibiotic sales has run into the reality of inadequate healthcare systems in many low- and middle-income countries (LMICs), where access to clinicians is often limited and antibiotics are easy to obtain and seen as a quick fix.
Compounding this problem in many LMICs is low compliance with infection prevention and control (IPC) measures and lack of investment in clean water and improved sanitation.
"IPC is not an issue just for healthcare facilities but also for the wider community, where the absence of adequate water, sanitation and housing is a primary driver of the spread of infectious diseases and hence antibiotic use," Clift writes. "As a result, there is a need for a multisectoral approach."
Clift also points out that while high-income countries are reducing antibiotic use in livestock, the situation in LMICs is different. In these less-regulated countries, the move to more intensive meat production is encouraging farmers to use more antibiotics. And because surveillance is limited in these countries, there is little data on antibiotic use and AMR levels in animals.
"Therefore, as the Review recommended, a priority must be to improve surveillance systems and undertake more research, including on how to promote the transition to lower antibiotic use in LMICs," Clift writes.
Little support for new antibiotics, diagnostics, vaccines
But the report saves its strongest criticism for the lack of progress on the AMR Review's calls for incentives to promote investment in new antibiotics, diagnostics, and vaccines. In particular, Clift singles out the lack of international movement on the creation of market entry rewards that would incentivize pharmaceutical companies to invest in new antibiotics.
The AMR Review estimated that governments and philanthropic organizations would need to contribute $16 billion over 10 years to fund a market entry reward system that would provide an upfront payment of $1.6 billion to companies that deliver a new, critically needed antibiotic. The idea was that this reward would make antibiotic development more commercially attractive, encourage pharmaceutical companies to invest in new antibiotics, help delink profits from the volume of antibiotics sold, and ensure that the new drugs are used appropriately.
While the idea has been supported in subsequent reports and is frequently cited as a potential solution to the financial challenges of antibiotic development, no such fund has been created.
"On the key issue of a global scheme of market entry rewards on the scale considered necessary by the Review it is now becoming clear, following the recent G20 meeting in Osaka, that there is little, if any, progress being made towards a substantive outcome," Clift writes.
Meanwhile, the market for new antibiotics continues to deteriorate, and many pharmaceutical companies have abandoned their antibiotic development programs. Similarly, Clift adds, the absence of financial incentives for developing vaccines and affordable rapid diagnostic tests—which could help reduce AMR by avoiding the need for antibiotics and cutting empirical prescribing—has not been addressed on a meaningful level.
Not taking '10 commandments' seriously
In a foreword to the report, O'Neill calls the lack of progress on these fronts "remarkably disappointing."
"What is missing, despite endless words, is a firm commitment of monies from governments or pharmaceutical companies," he writes.
O'Neill's concern is that governments are waiting for the crisis to escalate to justify large-scale spending on AMR, while pharmaceutical companies are waiting for governments to panic and start throwing more money at the problem.
Although O'Neill agrees that there has been progress on 7 of the 10 recommendations—which he calls the 10 commandments of AMR—he argues that the urgency of the situation requires bolder action from everyone who has a stake in the issue.
"Unless key players are prepared to behave differently and make bolder decisions, the challenge is never going to be solved, whether that be policymakers, drug companies, doctors, farmers and, ultimately, all 8 billion of us," he writes.
Oct 8 Chatham House Review of Progress on Antimicrobial Resistance
May 2016 AMR Review Final Report and Recommendations