This week, 18–24 November, marks World Antibiotic Awareness Week. The aim is to increase awareness of global antibiotic resistance and to encourage best practice among the general public, health workers and policy-makers to avoid the further emergence and spread of antibiotic resistance.
When engaging in the antibiotic awareness discussion, all too often we can find ourselves disproportionately focusing on the impending doom of antibiotic resistance, without contextualising this within the wider access picture. Globally, antimicrobial resistance is estimated to kill 700,000 people every year and predicted to cause 10 million deaths per year by 2050. To put that into context, 3 out of the top 10 biggest killers globally are communicable diseases: cumulatively, nearly 6 million deaths globally in 2016 were caused by lower respiratory infections (3 million), diarrhoeal diseases (1.4 million) and tuberculosis (1.3 million). In considering these three diseases alone, eight times as many people die from a lack of access to antibiotics as from resistance.
When it comes to access and resistance, we face challenges on two fronts. First, there is a lack of new antibiotics being developed to treat emerging infectious diseases and replace existing antibiotics rendered ineffective by the emergence of resistance. Second, we are increasingly witnessing unavailability and stockouts of older antibiotics due to fragile supply chains.
Developing new antibiotics: A bleak outlook
The lack of new antibiotics being developed is believed to be due to market failure and inadequate incentives as a result of particular characteristics of the antibiotics market that make these drugs unattractive for investment. Antibiotics are usually lower cost and used for short periods of time compared with longer term treatments for chronic conditions, which are more lucrative. Additionally, stewardship efforts mean that any new innovative antibiotic that comes to market will typically be reserved as a last resort in order to minimise the emergence of resistance and ensure longevity of use. Ironically, new, innovative antibiotics are victims of their own success.
All the above, makes for a low-volume market and lower return on investment, which is at odds with the pharmaceutical business model. To highlight this, combined global patented antibiotic sales amount to $4.7 billion per year. By comparison, a single cancer drug can generate double that for any single company.
In order to overcome this conundrum, there needs to be a concerted effort to continue to foster antibiotic research & development through innovative and collaborative R&D models such as public–private partnerships, known as product development partnerships (PDPs) – for example, GARDP, the Global Antibiotic Research & Development Partnership. This helps share the risk and cost of development. The 2018 Antimicrobial Resistance Benchmark highlights that 50% of R&D projects targeting key priority pathogens are being conducted in partnership.
Half of new R&D projects involve partnerships with public or non-profit partners
Access to existing, older antibiotics: A need for vision and a smarter approach
The picture for older, off patent antibiotics is equally worrying. Increasingly, we’re witnessing stockouts of these medicines. Pricing pressures on older antibiotics have resulted in manufacturers exiting the market, ultimately causing suppliers of the raw materials (active pharmaceutical ingredients) higher up the supply chain to go out of business. To date, we find ourselves relying on dangerously few raw material manufacturers, mainly situated in India and China.
Achieving the balance between access and healthy markets is no easy feat. However, countries can look to adopt good procurement practices. This includes negotiating rational, multisource tenders, which will diversify the number of companies supplying the market, thereby ensuring a healthy market. This needs to occur within a framework of strengthening regulatory systems to ensure these antibiotics fulfil safety and quality requirements.
The power of antibiotics in global health is indisputable. In this week of all weeks, it’s vital that we see the bigger picture of these miracle drugs, so that we recognise and confront the threats and challenges not just around resistance to antibiotics but – for millions of the poorest children and adults – in pure and simple lack of access.