Drug-Resistant Infections

Lord Trees Excerpts

Thursday 15th September 2016 Lords Chamber

[Lord Trees (CB)]

My Lords, I join others in congratulating the noble Lord, Lord Lansley, on securing this debate, which, I dare to suggest, in terms of the significance of the global problem that we are discussing, is one of the most important that we have had in this House for some time.

I begin with a quotation:

“This enquiry has been an alarming experience, which leaves us convinced that resistance to antibiotics and other anti-infective agents constitutes a major threat to public health, and ought to be recognised as such more widely than it is at present”.

That is not a quote from the O’Neill report; it is the opening statement of the summary of recommendations from the seventh report of the House of Lords Science and Technology Committee, published in 1998 and entitled Resistance to Antibiotics and Other Antimicrobial Agents. The inquiry was chaired by my friend, mentor and fellow vet Lord Soulsby of Swaffham Prior, who retired from the House at Christmas. The report went on to make a number of recommendations that have an uncanny similarity to the ones we are now considering in the O’Neill report. Such is the nature of human progress; it takes us a while to become convinced of emerging threats.

I wholeheartedly welcome the O’Neill report, and the political support that it received from the last Prime Minister deserves commendation. In common with other noble Lords, I also congratulate Dame Sally Davies on her championing of this important issue. If antimicrobial resistance was a serious problem in 1998, its significance has increased enormously since, especially as a result of globalisation and a dramatic increase in the large-scale movement of people.

I shall focus my remarks in this debate on the veterinary aspects of this issue and focus particularly on bacterial resistance to antibiotics—which I shall refer to as “antibiotic resistance”—which is a problem in human health, as we are hearing, that is relevant to antibiotic use in animals. In that context, I should point out that the estimates of the costs that have been quoted already, provided by the consultants to the O’Neill commission, in terms of human life and in financial terms—10 million deaths per year by 2050 and a cost of US $100 trillion, truly shocking figures—refer to antimicrobial resistance. That is to say, they include such problems as resistance to protozoa, malaria, viruses such as HIV, as well as bacteria such as the human tubercle bacillus, all of which are huge causes of human morbidity and mortality, but there is no connection with chemotherapy in animals.

None the less, there are undoubtedly substantial human health problems which relate to bacteria which also affect animals and where animal usage has been implicated as a source of resistant strains. These particularly involve bacteria associated with gastro-enteric infections and the environment, such as E. coli, campylobacter and MRSA.

As the O’Neill commission laid out, the solutions to this problem involve reductions in drug usage, the development of new therapeutic and diagnostic agents and vaccines and the application of a global approach. I shall deal with those issues in that order and, as I said, mainly from a veterinary aspect.

First, I assure the House that, with respect to the UK and the EU, the veterinary bodies take the issue of antibiotic resistance very seriously. There are numerous high-level initiatives to reduce antibiotic usage in animals and to ensure their responsible use when necessary for animal health and welfare. In the UK and the EU, antibiotics are available only on prescription, and I assure the noble Lord, Lord Lansley, that the use of any antibiotics for growth promotion has been banned in Europe and the UK since 2006. Certain antibiotics critical for human use are still in veterinary use, such as fluoroquinolones and third and fourth-generation cephalosporins, and they are receiving particular attention from the veterinary community.

The Veterinary Medicines Directorate of Defra, the British Veterinary Association and its subdivisions, the British Small Animal Veterinary Association and the British Equine Veterinary Association, the National Office of Animal Health and an organisation called RUMA—the Responsible Use of Medicines in Agriculture Alliance—as well as industry organisations, have all been active in recent years in promoting the responsible use of antibiotics and in promoting and introducing measures accurately to record and reduce their usage. Indeed, the Royal College of Veterinary Surgeons has incorporated in its guide to professional conduct a professional obligation on vets to use responsibly all antimicrobials, so it could be a matter which triggers a professional disciplinary offence.

The British Poultry Council, which represents 90% of the poultry meat industry, established an antibiotics stewardship programme in 2011, which introduced a voluntary ban on cephalosporins in 2012, and is committed to reduce fluoroquinolone use and cease all use of colistin in British poultry, which two noble Lords have mentioned. It reported a 44% drop in total antimicrobial usage between 2012 and 2015, despite a 5% increase in poultry meat production.

All those measures are to be commended, and the total usage of antibiotics in the UK in animals is substantially less than that in humans. Progress shows what can be done, but we cannot be complacent, and more needs to be done, as I shall discuss. Suffice it to say that total antibiotic usage in animals in the UK is now close to the 50 milligram per kilogram target suggested in the O’Neill report. The veterinary profession is committed to continue these trends in the interests of public health while at the same time balancing the legitimate need to protect animal health, welfare and food production.

There is an urgent need in veterinary as well as human medicine to develop better diagnostics and better vaccines for infectious diseases, as the O’Neill commission urged and several noble Lords have said. These have the potential substantially to reduce the use of antibiotics. For example, the burgeoning aquaculture industry, particularly salmon farming, has made a remarkable reduction in antibacterial usage in the UK. Despite a huge increase in productivity from about 60 million tonnes in 1993 to 180 million tonnes in 2014, antibiotic usage in the sector is now very low. It is about one to two tonnes per year, which may sound quite a lot, but I assure your Lordships that it is small compared to the 419 tonnes total in all animals in the UK and 531 tonnes in humans—those are the 2013 figures. That progress in aquaculture has been achieved mainly by the development of vaccines and other management processes.

That is what is happening in the UK and Europe, but to reduce antibiotic resistance by reducing and controlling usage it is essential that action takes place on a global scale. There are no restrictions on antibiotic usage in animals or humans in many parts of the world, including in areas where there may be particularly high densities of human and animal populations and very high levels of contact between the two. Resistant strains which arise by natural selection in animals or humans due to uncontrolled use of antibiotics anywhere in the world can arrive in the UK within hours. About 60 million people per year travel through Heathrow airport alone, each carrying millions of microbes on two legs, many of which may have been acquired only hours previously. The O’Neill commission rightly emphasised this fact, even in the title of its report, Tackling Drug-Resistant Infections Globally. Whatever we do here in the UK—already a lot is being done in both the medical and veterinary worlds, but we need to do more—will be rendered ineffectual because of global human traffic, and we will not eliminate health risks anywhere unless we can secure concerted global action to address that.

At the same time as encouraging responsible use of antibiotics, there is an urgent need to discover and develop new antibiotics and new ways to combat bacterial infections. These may be by innovative therapeutic techniques, and the UK’s vibrant and creative scientific and commercial sector is at the cutting edge of these developments. A number of exciting developments are badly in need of support. That may initially come from traditional research grant sources—I commend the initiatives that have recently been announced. Other developments may require creating appropriate financial incentives for investment. A major problem with antibiotics, as with many other therapeutics, is that relatively small amounts of drugs are used only occasionally on only a small proportion of the population. The market sizes are not such as to provide the incentives for industry to respond. Industry is very successful in responding when there are market rewards consistent with the high cost of developing and registering therapeutic drugs. The O’Neill report rightly comments on that and makes a number of exciting and creative suggestions on how to mobilise the creativity of industry by creating artificial marketing opportunities.

In addition to therapeutic agents, we must do more to stimulate research on vaccine development. Earlier, I illustrated how important that can be in terms of aquaculture. There are challenges there with respect to some of the bacteria involved, but in general we have been extremely successful in science in developing vaccines to bacteria, and I am optimistic that solutions will be found and that vaccination will substantially reduce the need to use therapeutic interactions.

Lastly, management systems are hugely important; I do not have time to discuss them in any detail, but we need more research into improved management, particularly in animal husbandry systems.

In conclusion, I welcome the debate and the attention that the subject is receiving. Although only a proportion of the problems of antimicrobial resistance in humans is related to animal usage, there is a very high level of awareness in the veterinary community about this problem and a commitment to the responsible use of antibiotics and a reduction in the usage. The magnitude of this problem globally merits much more investment in research and development of vaccines, antibiotics, innovative therapies and new diagnostics, as well as improved management systems. Above all, the uncontrolled use of antibiotics, like climate change, is an issue that must be tackled globally.