Drug-Resistant Infections

Lord Lansley Excerpts

Thursday 15th September 2016 Lords Chamber

Moved by

[Lord Lansley]

That this House takes note of the report Tackling Drug-Resistant Infections Globally: Final Report and Recommendations, published on 16 May.

[Lord Lansley (Con)]

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.

--- Later in debate ---

[Lord Lansley]

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.

Motion agreed.