Antibiotic-Resistant Bacterial Infections
(11 years, 3 months ago)
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Lord Crisp
To ask Her Majesty’s Government what is their assessment of the risks posed by antibiotic-resistant bacterial infections; and what plans they have to reduce such risks.
Lord Crisp
My Lords, first, I thank noble Lords who are taking part in this debate and say how much I look forward to their insights, which I know will come from very different perspectives. I suspect that there will be an enormous amount of agreement. I know that the Government are taking this matter extremely seriously and that, in the words used in my Question, they recognise the risks and are developing plans to reduce such risks. I hope that this debate will enable them to be even more bold and creative in their approach.
I will talk for a moment about that shared understanding, which I will put in very simple layman’s terms. No doubt others will expand on it. The first point is that antibiotics have been a great benefit to humanity in tackling everything from TB and pneumonias to sexually transmitted diseases and bacterial infections of all kinds—not just in this country of course but world wide, including in some of the poorest countries of the world. I happen to chair Sightsavers, which uses an enormous amount of antibiotics in dealing with trachoma in the poorest countries of the world.
Antibiotics are the basis of much modern practice. We assume now that we can tackle infections. Infamously, it was the American Surgeon General who said in 1968 that,
“the war against diseases has been won”.
Those words no doubt came back to haunt him. The problem is that the bacteria are fighting back, in large part due to misuse—people failing to complete courses of treatment and therefore to wipe out the infection. The bacteria did not know that the war was over; evolving and becoming drug resistant, the stronger ones survived. The result, as we know, is that globally we have multidrug-resistant TB, and infections that cannot be treated in countries as disparate and different as India and Israel. This has been known for a long time, and the problems coming forward have been known for a long time. It was the House of Lords Science and Technology Committee’s 7th report in 1998 that first drew attention to this. In the same year, the World Health Assembly raised it as a serious issue.
There has been considerable research over many years. I am indebted to one of the world’s experts, Professor Otto Cars of Uppsala University in Sweden, for setting out the evidence for me. It is compelling. Imagine a world without effective antibiotics. Our English Chief Medical Officer, Dame Sally Davies, said that if we do not take action, we may all be back in an almost 19th-century environment where infections kill us as a result of routine operations. We will not be able to do a lot of our cancer treatments or organ transplants.
It is not just the burden of disease that is at issue here but the economic impact. It has long been known to be significant, but new work coming forward from Professor Richard Smith of the London School of Hygiene and Tropical Medicine, and Professor Joanna Coast of the University of Birmingham, suggests that, when wider impacts are taken into account, the costs are even higher than anticipated. These economic arguments are extremely important in raising the issue up the world priority list. It is significant that the World Economic Forum sees antibiotic resistance as a major threat. There are other important issues around animals that I will not mention in this short debate. My noble friend Lord Trees will say something about them.
I congratulate the Chief Medical Officer on drawing this issue to the attention of the country and of the world in her 2011 annual report. I also congratulate the Government on supporting her to raise the matter at the World Health Assembly at the G8 summit and, I hope, at the UN in September. Her report sets out the issue in detail and notes that there are some drugs that are the last line of resistance, to which we should give special attention now. She and the experts who wrote Chapter 5 of her report drew attention to a number of solutions.
The first is new drugs, but at the moment there are few antibiotics manufacturers and few new antibiotics in the pipeline. Thanks to AstraZeneca, I understand more about the business model and the problems in dealing with drugs of last resort. The simple issue is that they are kept on the shelf; they are in reserve. It is important that we have them, but they do not get used very much and they do not lead to sales. Therefore, the economic model does not work. Even with the more common antibiotics that we use more regularly, we only use them for a short period as therapeutic drugs, not as long-term drugs that will produce a long-term income and therefore provide a return on the massive investment required for development.
AstraZeneca and many others argue that there is a need for very substantial changes to regulation to allow for shorter and easier development times, and even for antibiotics to be treated as a different category of drugs. They also point to the need for investment to secure development. This also makes the argument that vaccines are important in heading off disease. I well understand that not every new drug or vaccine is a significant advance, but there is enormous scope here for Government, and the public and private sectors, to work together to develop a new way of developing these drugs. My noble friend Lady Mar will say a bit more about vaccines in a moment.
Another aspect of the issue is the development and use of new diagnostics. If we can get people into treatment faster, we will be quicker to control the bacteria. At the moment it can be days before technicians know what strain they are dealing with.
The third and perhaps biggest point is about better stewardship and conserving what we have. This is even more difficult, but it is the basis for everything else. The CMO’s report describes good practice that will achieve this. There are 10 top tips for effective antibiotic prescribing that should be followed in this country. Imagine for a moment the situation in every country in the world; every clinic or village in China or India needs a battery of actions. There is a need for education professionals in those areas to have the equivalent of our 10 top tips, as well as for greater public awareness and education. That is no easy task. We should remember that many of us in our country do not take drugs in the way that we should. Also, in those countries we must tackle counterfeit medicines and restrict over-the-counter sales. We should also see changes to harmonise regulation. This is phenomenally difficult, but it is not enough to put our own house in order; we will be affected by what happens elsewhere in the world.
We need all these approaches combined: new drugs, new diagnostics, better practices and stewardship, action across the whole healthcare system and, indeed, across the whole world. Here I come to the point that I really want to talk to the Government about: this needs remarkable political effort. It is about reframing the issue and building political support, and I will be interested to hear what the Government have in mind.
I will make two points. First, this is an enormous threat. Indeed, you can galvanise people around the threat: it is real and it will impact in terms of illness and economy. However, it is also an opportunity. I am indebted to my friend and colleague Dr Ilona Kickbusch, and to Professor Cars, for pointing out that we should treat antibiotics as a global public good and that there is an alternative way of seeing this problem. It is about a vision of a world in which the peoples of the world really do in practice have a right to health and healthcare, something most nations have signed up to—many, like ours, since the UN declaration of 1948. In that world, nations develop, share and look after those things, such as antibiotics, which are a benefit to us all.
We have already seen how this can be done in tackling other threats such as global pandemics. Although there is always controversy about that, nevertheless great progress has been made in creating a network for surveillance and tackling issues. There is more to do. We have also seen it with the millennium development goals, working towards a vision where no woman dies as a result of pregnancy, although there is much more to do there as well. In other words, I am arguing for setting ourselves the goal of preserving antibiotics for the future as one of science’s great benefits for humanity, and for driving this forward politically and technically, in every way in which we can.
My second point is simply that the UK can play an extraordinarily important leadership role here. It is well respected in health. We have the credibility of having a health system which seeks to look after every person within it. We also have credibility because of the world-leading role that has been played in development; here I compliment both this Government and the previous one. We can be bold and ambitious in taking a lead. No nation is better placed to do so, with our connections in the Commonwealth, across the Atlantic, and in Europe. The key is to bring together a group of like-minded countries, as this and previous Governments have done on other things, starting with those who are already taking this seriously. We should set out a vision and pathway, and take on these issues step by step. The Chief Medical Officer has already started this, but it is important to add political weight and depth to her work. It is not just about health but about economics and foreign policy. It is a step in building a better world, where we have and share the means to offer better health to everyone.
I therefore look forward to hearing the Government’s response to these points, and to knowing how they will turn their undoubted commitment in this area into something even bigger and bolder. Will they seek to take a global lead on this? How will they do so? I also greatly look forward to hearing from other noble Lords.
Baroness Masham of Ilton
My Lords, I thank my noble friend Lord Crisp for securing this most important debate. I declare an interest as, over the years, my life has been saved by the use of antibiotics, and I personally know how important they are for the correct infection.
Is there a problem of people sharing medication such as antibiotics, or stopping taking them when they feel better, thus causing drug resistance? After I brought up the subject of MRSA in your Lordships’ House in 1996, I was a member of the Science and Technology Select Committee’s sub-committee on resistance to antibiotics and other antimicrobial agents from 1997 to 1998, chaired by the noble Lord, Lord Soulsby of Swaffham Prior. We went to Washington, Atlanta and Boston. The amount of research being undertaken in America left a lasting impression. I am pleased that there is a vet speaking in this debate. It is most important that there is good co-operation between human and veterinary medicine.
Antibiotic-resistant bacterial infections are a worldwide problem, and given the economic situation we are in, there should be the greatest cohesion. In the community there is a dangerous toxic substance produced by some strains of staphylococcus aureus called Panton-Valentine leukocidin which can kill within 24 hours. The infection can be contracted from gorse bushes, in military camps, colleges and playgrounds—that is, places where young people often gather together. It seems to be more prevalent in the USA and therefore we should be learning from that country. It is vital that a quick and correct diagnosis is made, and GPs and hospital doctors must be aware of the symptoms that suggest an illness could be PVL-positive MRSA.
The overuse of antibiotics and thus the increasing resistance of bugs to them have led to fears that soon we may run out of effective treatments. Microbes are mutating faster than scientists can come up with new antibiotics. According to the World Health Organisation, some 440,000 new cases of multidrug-resistant tuberculosis are diagnosed every year, causing at least 150,000 deaths. A mutant strain of gonorrhoea, which has emerged in Asia, could be more devastating than AIDS. Antibiotic-resistant strains of e-coli are on the rise, particularly among the elderly, and there are risks from common infections such as pneumonia and urinary tract infections.
What can be done to give the pharmaceutical industry incentives to develop more antibiotics? The absence of rapid diagnostic tests for tuberculosis is further compounded by a widespread inability to screen for drug-resistant bacteria. An ideal diagnostic test for respiratory tract infections should be rapid, cheap, easy to use, sensitive and specific, and should screen for many micro-organisms and their antibiotic resistance. The diagnostic platform should be transportable and robust; ideally, it should also be able to be run on solar power for use in remote healthcare settings in developing countries. In Australia there is such a portable box, called the “lab without walls”, so progress is being made. To achieve this across the world, physicians, scientists, biotechnology companies, funding agencies and Governments need to work together to drive the development of improved diagnostic tests for both developed and developing countries.
Here in the UK we have seen the emergence of multidrug-resistant tuberculosis among homeless people. This should be a wake-up call for us all. I have great admiration for the Find&Treat service, which works with the most vulnerable and excluded people in our society to ensure that they can access diagnostic services and complete tuberculosis treatment. Homelessness is an independent risk factor for multidrug-resistant disease, as is birth in east Asia or eastern Europe or a history of previous tuberculosis treatment. Funding for the Find&Treat service is secure only until March next year, and it still has not been able to replace its only current mobile unit, which is on its last legs. The unit goes around hostels for the homeless and other places in order to test the vulnerable. I stress that the effective control of TB is important to wider public health, and interventions must be made in complex cases. I hope that Public Health England will take this on and work with NHS England.
A dual HIV/MDR TB infection complicates patient management, compromises treatment options and leads to poorer treatment outcomes and greater disease transmission. Basic and clinical research is needed to explore any possible causal relationship between HIV infection and MDR TB specifically.
Extensively drug-resistant TB, which is resistant to at least four of the core anti-TB drugs, and MDR TB both take substantially longer to treat than ordinary TB and require the use of second-line anti-TB drugs, which are more expensive and have more side effects than the first-line drugs. Very worryingly, in some countries extensively drug-resistant TB is on the increase. The modern world is now very accessible. There should be no complacency. All Governments across the world should realise the risk to their populations posed by antibiotic-resistant bacterial infection, and should work closely with the World Health Organisation.
The Countess of Mar
My Lords, I am grateful to my noble friend Lord Crisp for enabling us to debate this important subject today. I draw the Committee’s attention to my interests in the register, and I am also a member of the All-Party Parliamentary Group on Antibiotics.
We have been given warnings of the dire effect of the overuse of antibiotics that results in antibiotic resistance for many years. In 2011 Dr Margaret Chan, director of the World Health Organisation, warned:
“The implications go beyond a resurgence of deadly infections to threaten many other life-saving and life-prolonging interventions, like cancer treatments”—
which my noble friend mentioned—
“surgical operations, and organ transplantations”.
As both Dr Chan and the Chief Medical Officer have stated, the R&D for new antimicrobials has practically run dry.
Noble Lords have given graphic examples of the cost of antibiotic resistance. I will try to look ahead and inject a glimmer of hope into the current gloomy scenario, and expand a little on what my noble friend Lord Crisp proposed. If modern medicine is to progress, the infrastructure of academic and industrial antibiotic research discovery and development needs to be rebuilt. We know that the current estimates for one new drug to reach the market range from $100 million to $10 billion, with antibiotics at the lower end of that scale. For 20 new classes to reach the market, the costs are phenomenal.
What can be done? There needs to be an overarching framework within which the very best knowledge is brought together. The key to progress will be the development of well informed guidelines and information to help current and future research activities to focus on well funded innovation. Because the problem is potentially so huge and widespread, there is a need for a global initiative as well as a UK one. For the global initiative, it has been suggested that something along the lines of the post-war Marshall plan, which helped to rebuild Europe, might provide the beginning of a solution. This would have to be paid for at a continental level—for example, by the European Union, the USA and Asian countries.
Antibiotic Discovery UK is a network of leading academic researchers and universities, together with SMEs, that have a common goal of revitalising antibiotic research in the UK. It has recently circulated to the Medical Research Council, the Biotechnology and Biological Sciences Research Council, the Engineering and Physical Sciences Research Council and the National Institute for Health Research a proposal for a cross-research council antibiotic research programme—CRCA for short—modelled on the Farr Institute and the MRC’s AIDS-directed programme of 1987, with the aim of conducting fundamental and developmental research into antibiotics for the prevention and treatment of bacterial infections. The programme plans to include work on basic bacteriology, antibiotic resistance, epidemiology, chemistry, drug design and drug evaluation. The CRCA would add to existing investment by research councils and charitable bodies. It believes that its programme would further enhance the UK’s international reputation and that it would provide a significant stimulus to the UK economy, and in particular to the pharmaceutical sector.
Members of Antibiotic Discovery UK point out that the UK is home to a wide range of outstanding scientists with innovative medical, biological and physical science skills. The CRCA programme would link at least eight universities across the UK and would foster strong links with industry as well as international co-operation. They acknowledge that this is an ambitious proposal but I believe that, if we are to crack this problem, a programme such as this is vital.
A multi-pronged approach such as that proposed by Antibiotic Discovery UK would include antibiotic discovery and development by discovering new molecules, mining past leads and exploiting natural products. It would improve researchers’ understanding of pharmacokinetics so that new combinations of drugs could be developed such as those currently used to treat TB and HIV. This would enhance antibiotic stewardship and research into antibiotic resistance through surveillance, diagnostics, epidemiology and mechanisms of resistance.
There is a clear need better to engage and fund academics alongside industrial partnerships to help to deal with this threat, but no one academic group or single institutional centre has the capacity or the capability to make significant inroads. There is great strength in numbers. Best practice and knowledge can be shared between academics and industry within the network, and innovation can flourish. There is a need for multi-institutional centres of excellence to tackle well validated targets such as cell wall biosynthesis, protein biosynthesis and DNA replication, as they offer multiple targets to hit. We now know that therapy should avoid hitting single targets, which will only result in the further speedy emergence of resistance.
On the subject of novel treatments for antibiotic-resistant conditions, I was interested to read that Professor Tony Maxwell of the John Innes Centre, together with a European consortium of researchers, is researching a compound derived from the South African toothbrush tree which inactivates a drug target for tuberculosis in a previously unseen way. Miracles come from all sorts of places.
The situation is not hopeless, but we need to ensure that researchers are encouraged to work together and that they are adequately funded. This matter is too important to be left to industry alone to deal with.
As I have a few minutes in hand, I will read to noble Lords the e-mail that we have all received today from Sue Davie, the chief executive of the Meningitis Trust. She says:
“I understand you are participating in a Speaker debate on ‘antibiotic resistant bacterial infections’ this afternoon. In light of the announcement today that the JCVI will not be recommending the Meningitis B vaccine, we would be grateful if you could raise the following issues, on behalf of Meningitis Trust/Meningitis UK … We welcome the Chief Medical Officer’s focus on antibiotic resistant bacterial infections and the efforts the government is making on this issue ... It is accepted that one of the best ways of limiting the rise of antimicrobial resistance is to properly use the interventions we do have available to combat infectious diseases—an excellent example of these are vaccines ... Can Earl Howe comment on the interim position statement of the Joint Committee on Vaccination and Immunisation (the independent body which advises the Government on vaccination) which has said that a vaccine which could prevent meningitis B disease will not be made available in the UK? … Meningitis is a disease with a very rapid onset, its symptoms are vague and unspecific. When a case is suspected the medical personnel need to flood the systems of these babies and children with antibiotics ... Kind Regards, Sue Davie”.
There is nothing worse than seeing a baby who lost their limbs because they had meningitis B and were not reached in time with antibiotics. Can the Minister give me a response on that?
Lord Trees
My Lords, I thank my noble friend Lord Crisp for initiating this important debate and draw attention to my various veterinary interests that are listed in the register. As some noble Lords have observed, this topic was the subject of a report in 1998 by the Science and Technology Select Committee of this House, chaired by the noble Lord, Lord Soulsby of Swaffham Prior. It was an important issue then and it is now even more important. A number of reasons have been eloquently articulated. I will point to three recent issues that have drawn attention to its importance.
The first is the Chief Medical Officer’s report, published earlier this year, in which she chose infectious disease and drug resistance as the principal theme. Secondly, she suggested that the subject should be put on the National Risk Register for the UK. Thirdly, in June the UK hosted the G8 summit, and there was a separate meeting of science Ministers—the first such meeting at a G8—at which the Ministers singled out resistance to antimicrobial antibiotics as one of humanity’s most pressing concerns.
Today I will highlight two aspects of the subject. There are many more, including the drug pipeline, which was talked about by several noble Lords. I will focus on the role that the veterinary profession is playing in addressing the issue, which it takes very seriously; and on the global dimension of the threat.
The resistance of bacteria to antibiotics—I will refer to this as antimicrobial resistance—involves a complex interplay of interactions between different bacteria, hosts and antibiotics. Some bacteria exclusively infect animals. Resistance has developed in some strains, which is likely to be associated with the use of antibiotics in animals, and where the consequences will be confined to animals. Equally, some bacteria are unique to humans. A few of them have developed resistance, which, again, is likely to have its causes and consequences principally with humans.
Of course, some bacteria—so-called zoonotic bacteria —infect both humans and animals. The causes of their resistance, and the consequences of it, can affect both animals and humans. Those bacteria can move not only from animals to humans but from humans to animals. The picture is further complicated by the fact there are, as has been well described, antibiotic-resistant bacteria in wildlife and in the environment. There is a flux and flow of resistant bacteria and the genes that confer resistance within the biosphere.
As the Chief Medical Officer acknowledged in her report, and as was stated in a response by Department of Health Minister Dr Poulter to a Question from Glyn Davies in the other place on 27 February 2013, it is the use of antimicrobials in human rather than veterinary medicine that is the main driving force for antimicrobial-resistant human infections. Notwithstanding that, there are many organisations, in my profession particularly, that are working very hard to ensure the responsible and prudent use of antibiotics in animals.
Antibiotics have not been allowed as growth promoters in animals anywhere in Europe since 2006. In the UK, antibiotics are available only on prescription from a veterinary surgeon. The British Veterinary Association and the Federation of Veterinarians of Europe have worked very hard to promote the responsible use of antibiotics and have produced publicity and information, as has the Responsible Use of Medicines in Agriculture Alliance. My own college, the Royal College of Veterinary Surgeons, the governing body, has it embedded in its own professional code of conduct that:
“Veterinary surgeons who prescribe … medicines must do so responsibly”.
The consequence is that a vet could be struck off for irresponsible use.
We must continue to do all that we can to manage the prudent use of antibiotics in humans and animals in Britain and Europe. The forthcoming national cross-governmental strategy for antimicrobial resistance, which involves not only the Department of Health and the Chief Medical Officer but Defra and the Chief Veterinary Officer, is an excellent initiative which will define a coherent plan to address this problem.
However, this brings me to my second major point. The reality is that this is a global problem of massive scale, particularly in China and elsewhere in Asia. We must recognise that, whatever we do about the domestic use of antibiotics, the greatest threats will arise from overseas. This is a consequence of a number of factors. One is the gross use and, one might say, misuse of antibiotics in animals and humans. For example, in 2007, China produced 210,000 tonnes of antibiotics, of which about 100,000 tonnes were used in animals. Adjusting pro rata for the human population, that is 20 times the amount of antibiotics for animals than we used on animals in the UK at that time.
Many antibiotics are available over the counter in India, Asia and elsewhere, not exclusively on prescription. This leads to their misuse, the underdosing or curtailment of dosing regimes, both of which are factors in inducing antimicrobial resistance—as, of course, is the close contact of humans and animals in many of these settings in developing countries. All these factors contribute to high rates of antimicrobial resistance. Again, in China, in a survey of hospital infections in 2009, more than 60% of staphylococcus aureus infections were methicillin resistant—that is, MRSA—compared with less than 2% in UK hospitals.
This alarming genesis of antimicrobial resistance is coupled with the massive and rapid movement of people throughout the world. Just like pathogens themselves, such as the SARS virus and avian influenza, can move, antimicrobial-resistant bacteria can evolve in distant lands and arrive here in the UK within days if not hours. This is the downside to globalisation. When globalisation comes in the door, biosecurity goes out of the window.
We need to harness the economic gains from globalisation. We all think that it is a good thing, which brings economic gains. However, I suggest to the Government that perhaps we need to consider ways in which some of those economic gains of globalisation might be devoted to research in this area, to improving surveillance, to researching and developing rapid and effective detection and diagnostic technologies, and to helping us work with our colleagues overseas to mitigate the global threat of antimicrobial resistance. The good news is that the global nature of this problem is now being recognised. Now we need imaginative measures to counter that threat.
Lord Turnberg
My Lords, this has been a remarkable and important debate. I am grateful to the noble Lord, Lord Crisp, for laying out the issues so clearly, and for the many valuable contributions made by other noble Lords.
The noble Lord, Lord Crisp, spoke very persuasively about the global impact of infectious diseases, especially in the third world, a point re-emphasised by the noble Lord, Lord Trees. However, I am going to narrow my focus to the problems in the UK. There is little doubt that infectious diseases that we once thought had been conquered never really went away. They are rearing their collective head once again. With about 5,000 deaths a year from gram-negative sepsis in the UK alone, we cannot afford to be complacent. No sooner have we managed to get a grip on one set of antibiotic-resistant bacteria, MRSA and Clostridium difficile, than another set has appeared, but the fact is that we managed to have an impact on MRSA through a concerted and focused effort. That suggests at least that we can do something if we put our minds to it.
However, we are now faced with a new set of antibiotic-resistant germs that pose a major threat to the population, in particular to highly susceptible subgroups of the population. These are the gram-negative bacteria, particularly E. coli and Klebsiella species, which make up more than a third of all causes of bacteraemia reported to the Health Protection Agency—now the public health laboratories. It is worth noting that septicaemia due to E. coli has a 30% mortality rate. These bacteria are now the biggest threats, but others are creeping up on us. We are seeing more cases of resistant gonorrhoea, a very common disease, and multidrug-resistant TB, which is much less frequent at least in the UK but still very disturbing—a point well made by the noble Baroness, Lady Masham. The reasons for all these rises are complex and multiple. They include the increase in the number of vulnerable patients—the very young and the very old, and those with diseases that lower their resistance, such as cancers and leukaemia—and the powerful immunosuppressive treatments that they need. Bringing them close together in a hospital or a care home increases their risk. We have heard about the overprescribing of broad-spectrum antibiotics that allow the evolution of resistant strains.
Perhaps the major impact of inappropriate or over- prescribing has been felt in Asia, particularly in China and the Indian subcontinent, with their huge populations, as the noble Lord, Lord Trees, emphasised. Here, there has been a dramatic rise in antibiotic-resistant strains and they are increasingly being imported as international travel grows. There are now no more frontiers that can stop the spread of germs. So what is to be done?
It is possible to reduce the spread of antibiotic resistance. We reduced the incidence of MRSA and C. difficile by a combination of spreading good practice—with handwashing or alcohol hand rubs at the bedside, and nasal swabbing of all admissions to pick up carriers—and better management of intravenous lines and better infection-control measures. They all played a part. The noble Lord, Lord Trees, spoke about the zoonoses. Stopping a few years ago the practice of using antibiotics in animal feeds to promote growth must also have been very valuable. Concerted action can therefore work. We must once more pay attention to the recommendations of the Chief Medical Officer in her admirable report of 2011. Here it was proposed that we should ensure that NHS trusts and their chief executives manage, report and audit infection rates. That was successful before, and we must place even more emphasis on it in the duties placed on NHS England and CCGs. Spreading the message yet again about thoughtful prescribing of antibiotics, both in general practice and in hospitals, has never been more important.
However, we also need some different approaches. We desperately need better and quicker diagnostic tests for bacteria and their resistance. It now takes about 48 hours or more to get a report from the laboratories on what bacteria are responsible for an infection. Meanwhile, one is faced with treating a serious infection blindly or not at all—a point made by the noble Lord, Lord Crisp, and the noble Baroness, Lady Masham. Tests are becoming available, using genetic profiling or next-generation sequencing, that will bring the time for diagnosis down to a very few hours. If we can get there, antibiotic prescribing will become much refined and we will be able to avoid giving ineffective antibiotics. There is also a desperate need for new antibacterials.
It is unfortunately the case, as has been emphasised by a number of noble Lords, that the pharmaceutical company pipelines are pretty low at the moment. The cost of the development of new drugs is prohibitive and too often drug companies are inhibited by overregulation and cost. The noble Baroness, Lady Masham, mentioned that and the noble Countess, Lady Mar, underlined the point. It has been suggested that the Government might encourage investment in R&D by industry through such measures as prolonging the period during which the patents for new antibacterial drugs may be retained, or by a more favourable tax regime for companies developing those drugs. Perhaps we should take note, too, of the ideas expressed by the noble Countess, Lady Mar, about a multipronged attack; I found those very attractive. It seems to me that we must do more in these two areas: more research into rapid diagnostic techniques and more engagement with and encouragement for industry to develop new antibacterials.
My questions for the Minister are as follows: what efforts are the Government making to ensure that NHS England, the CCGs and hospital trust boards are keeping infection control high on their agenda? In what way are the Government ensuring that the laboratories of Public Health England are given the necessary research funds to develop new rapid diagnostic tests for bacterial resistance? Have the Government paid any attention to the incentives they need to provide for the pharmaceutical industry to invest in a search for new antibacterials? I have not spoken about the area of vaccines, although clearly it is very important. The noble Countess, Lady Mar, drew to our attention the issue of the meningitis B vaccine, and I hope that the noble Earl will be able to respond to that.
This has been a valuable debate on an important subject and I look forward very much to the noble Earl’s response.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I shall begin by saying how grateful I am to the noble Lord, Lord Crisp, for securing this important debate, and indeed to all speakers for their thoughtful contributions. The Government recognise that few public health issues are of greater importance than antimicrobial resistance. The scale of the threat was set out this March in Volume 2 of the Annual Report of the Chief Medical Officer on Infection and the Rise of Antimicrobial Resistance. Her call to action highlights the key issues that we need to tackle. These include, for example, good infection prevention and control measures to help prevent infections rather than a reliance on antibiotics, plus good techniques for diagnosing and deploying the right treatment. Equally important is ensuring that patients and animal keepers fully understand the importance of the treatment regimens prescribed, coupled with stronger surveillance measures to identify quickly new threats or changing patterns in resistance, and working to develop a sustainable supply of new antimicrobials.
Noble Lords will know that antimicrobial resistance refers to the ability of certain bacteria to survive after exposure to an antimicrobial that normally would be expected to kill them or inhibit their growth. Antimicrobial resistance affects us all, but some groups in society are particularly susceptible to infections and will feel the impact of antimicrobial resistance more than others. These groups include children, older people, and those with weakened immune systems such as cancer patients undergoing treatment, transplant patients and HIV/AIDS patients. An increase in difficult-to-treat infections will affect everyone as most of us will belong to vulnerable groups at some stage in our lives. Moreover, we know already that mortality is greater with resistant infections.
Antimicrobial resistance has obvious human costs, but it is also costly in terms of healthcare expenditure. It is estimated that antimicrobial resistance costs the European Union approximately €1.5 billion in healthcare expenses and lost productivity each year. This is indicative not only of the scale of the problem but of the fact that antimicrobial resistance requires action at the national and the international level.
At the national level, we will be publishing a comprehensive new cross-government five-year strategy to tackle antimicrobial resistance, which will have three strategic aims. The first is to improve the knowledge and understanding of antimicrobial resistance, through better information, intelligence and supporting data and through developing more effective early warning systems to improve health security. The second key aim is to conserve and steward the effectiveness of existing treatments, through improving infection prevention and control and through development of resources to facilitate the optimal use of antibiotics in both humans and animals. The third aim is to stimulate the development of new antibiotics, diagnostics and novel therapies by promoting innovation and investment in the development of new drugs and by ensuring that new therapeutics reach the market quickly.
A key component of antimicrobial stewardship is infection prevention and control. I would like to take this opportunity to reassure your Lordships that we will maintain a focus on healthcare-associated infections. Existing provisions, such as that requiring all healthcare providers to demonstrate compliance with the code of practice on the prevention and control of infection, will remain in place. The new NHS infrastructure also offers opportunities. For example, antimicrobial resistance has been included in key documents such as the Government’s proposed mandate for the NHS for 2014-15, which is currently subject to public consultation.
The noble Lords, Lord Crisp and Lord Turnberg, and the noble Baroness, Lady Masham, rightly noted the need for improved diagnostics. Public funders of research already invest widely in the development and evaluation of rapid diagnostic tests for infectious agents. In fact, just this month, the NIHR launched a themed call for antimicrobial resistance research and the development of new tests. The research and development of new tests is within the scope of this initiative.
Another example of what the Government are doing is that, from April 2014, the NIHR aims to fund 12 health protection research units for five years. These will be partnerships between universities and Public Health England. A number are expected to cover infectious disease areas and could potentially aim to include research on rapid diagnosis within their research programmes. From 1 September 2013, the Department of Health will provide a total of £4 million over four years to establish four National Institute for Health Research diagnostic evidence co-operatives to catalyse the generation of evidence on the clinical validity, clinical utility, cost-effectiveness and care pathway benefits of in vitro diagnostics. Based in NHS organisations and involving multidisciplinary teams, they will enable collaboration between a range of stakeholders, including providers of NHS pathology services and NHS commissioners. Two of the four DECs have identified diagnostics for infectious diseases as areas of focus.
The Government are well aware that they cannot deliver the action required to tackle antimicrobial resistance on their own. We need a societal shift, where antimicrobial resistance is seen as a priority that everyone can help address. To this end, we will continue to use the annual European Antibiotic Awareness Day to provide online educational materials that the NHS can use for local initiatives. In previous campaigns we reminded people that colds, and most coughs and sore throats, get better without antibiotics. That is because they are caused by viruses and not bacteria, and antibiotics only work on bacteria.
Although the scientific consensus is that use of antimicrobials in human medicine is the main driving force for antimicrobial-resistant human infections, use in the veterinary sector contributes to overall resistance rates. I listened with care and interest to the noble Lord, Lord Trees, on this aspect. We recognise that antibiotics, used responsibly, remain a vital part of the veterinary surgeon’s toolbox, without which animals suffering from a bacterial infection could not be treated effectively. As the noble Lord, Lord Trees, emphasised, the use of antibiotics in veterinary medicine is controlled by veterinary prescription and is equivalent to the arrangements for humans. In this way we are minimising antibiotics being used routinely and encouraging their responsible use. The Government’s position on the use of antibiotics in farming is very clear; we do not support the routine prophylactic use of antibiotics in animal health. I am pleased to say that Defra will be strengthening its guidance to ensure that this point is brought out very clearly. We very much welcome the support of the Royal College of Veterinary Surgeons on these prescribing issues.
Both the noble Lord, Lord Trees, and the noble Lord, Lord Crisp, referred to the vital need for international action. The Government recognise that to achieve many of the objectives of their strategy it is essential that the international community is actively engaged, and I can tell the Committee that the Government have been at the forefront in galvanising action at an international level. For example, this May my right honourable friend the Secretary of State for Health delivered the keynote address at the World Health Assembly, with antimicrobial resistance as a focus. Last month we ensured that antimicrobial resistance was a focal point of the G8 science meeting on 12 June. Furthermore, we held a special event at Chatham House to engage international experts on ways and means to tackle this complex problem. The noble Baroness, Lady Masham, and the noble Countess, Lady Mar, will be reassured to know that incentivising the development of new drugs was covered at this meeting, and I assure the noble Lord, Lord Turnberg, that the UK will continue to progress this issue.
A number of noble Lords, not least the noble Lord, Lord Crisp, referred to the barriers to producing new drugs. The discovery and development of new drugs takes time—up to 10 or even 15 years—and a barrier to developing new antibiotics is, as the noble Lord, Lord Crisp, rightly said, the relatively low private return on investment for antimicrobials relative to making investments in other therapeutic areas. Our work on strengthening international collaboration will be key to new drug development because international agreement to address this issue, as I said, is essential; it is too large an issue to tackle alone. We will build on existing international research collaborations, including public/private partnerships, as well as taking action internationally.
The noble Baroness, Lady Masham, referred to PVL. We agree that the PVL toxin needs to be recognised and treated rapidly. Guidance is available for professionals and is currently being reviewed. However, the available evidence indicates that the prevalence of PVL infections is low in the UK. She also referred to E. coli. E. coli bloodstream infections are increasing year on year. The department’s expert advisory committee asked the HPA—now Public Health England—to undertake enhanced surveillance of E. coli and to have experts advising on prevention strategies. However, many E. coli infections are not associated with healthcare.
Regarding the interim decision by the JCVI on the meningitis B vaccine, I will write to the noble Countess. The JCVI has just published on its website today a call for comments from stakeholders. It will consider those responses before finalising its statement on meningitis B immunisation. The consultation is for six weeks.
The measures contained in our strategy are comprehensive and far-reaching. To ensure that they are brought to fruition, a high-level cross-government steering group will be established to oversee implementation, monitor progress and publish progress reports. The actions that I have outlined set out a broad canvas. We have heard the warnings from the CMO and we are acting on her message. The new UK antimicrobial resistance strategy will set out what needs to be done across a broad front, both nationally and internationally, and, using our combined efforts, we aim to be better placed to confront the spectre of antimicrobial resistance before it is too late.