Daniel Berman, Head of Global Health, Nesta Challenges, highlights the need for radical change in how innovation is funded and prioritised to ensure an antibiotic future given AMR is still climbing, even though behaviours are changing
Antibiotics are a miracle of modern medicine, saving countless lives, but their effectiveness is being dulled by the relentless march of drug-resistance bacteria. One of the key drivers in this war of attrition has been the continued overuse and misuse of the limited number of antibiotics that are still effective.
Encouragingly, behaviours are changing as awareness of the superbug challenge grows. 125 countries are now carrying out drug resistance awareness campaigns while, closer to home, Public Health England (PHE) recently published a report revealing that there has been a 17% drop in GP prescribing antibiotics since 2014.
However, there is a significant note of caution here: this same PHE study showed that despite the reduction in prescriptions, there was still an estimated 9% rise in one year on the 2017 numbers. It estimated that there were 61,000 antibiotic-resistant infections in England during 2018.
Reducing prescriptions isn’t enough
Given the concurrent increase in drug-resistant infections, it’s abundantly clear that simply reducing prescriptions won’t be enough to turn the tide on superbugs. What is essential is the use of the correct antibiotic to treat a bacterial infection from the outset. To do this, however, we need rapid, point-of-care diagnostics – in the hands of anyone that prescribes medicine. Tests are needed to distinguish between bacterial and viral infections and to quickly inform medics which antibiotic will work for a given patient’s infection.
It might surprise many that in an on-demand world of ubiquitous technology, instant data and hypoconnectivity, the typical diagnostic tests that clinicians use today still take two to three days in a laboratory to produce a result. Tests that could be used on-the-spot in GP and pharmacy settings would radically transform our ability to get the right medicine to the right patient.
Unfortunately, one of the major roadblocks in the development of such tests is that the global market for point-of-care diagnostics for bacterial infections remains weak. Many involved in commissioning are looking for tests that will cost less than generic antibiotics. This is not going to happen. The tests need to be valued for their overall impact to the individual as well as their ability to slow down resistance, meaning antibiotics continue to work when we need them.
Based on the scale of the problem the case for increased use of diagnostics has never been stronger. The latest World Bank report on antimicrobial resistance (AMR) urges the development community to go beyond technical solutions that focus exclusively on the misuse of antimicrobials and instead redirect development efforts more broadly, so that they become “AMR-Smart”. There is no “silver bullet” but diagnostics are a critical part of the overall solution.
To facilitate innovation at the pace we need it to happen, we have to create a viable market for a range of products, from antibiotics to diagnostics. This was something that was initially proposed in the AMR Review by Jim O’Neil (May 2016). In particular, Market Entry Rewards were suggested, which would pay for innovation of priority antibiotics, assigning significant lump sums to companies that deliver new antibiotics to market. The logic is that if the research and development is de-risked with the reward then pharmaceutical companies would “play” in this space, delivering welcome private investment to the arena.
Nearly four years later, this concept has not achieved traction but NHS England is moving in terms of a creative new approach to stabilising an antibiotic future.
NHS subscription model
Instead of paying for each antibiotic pill, NHS England will use a Netflix-like subscription model. There will be two pilot service contracts in which a supplier of a new antibiotic will agree to cover a given population over a fixed period of time, for a fixed monthly fee. The advantages of this approach are many: the company will no longer have an incentive to promote their new medicine because if it is used sparingly they will earn the same revenue. The NHS will also set the contract price according to the value to the NHS as assessed by NICE. That means the value will include direct and indirect costs such as avoiding hospital admission. The value to the system approach will make all the difference. Although the UK market only represents 3% of the global market, this new policy approach is being watched closely by other countries who are being kept informed in real-time. There is also an urgent need to create incentives for diagnostic tests. They will be different from the approach to shore up the antibiotic market because the diagnostic market is very different.
We know from the teams competing in the £8 million Longitude Prize to develop a rapid point-of-care diagnostic that, until now, the lack of market-pull impedes their progress. They have difficulty finding venture capital investments unless they focus their product on the lucrative US market because investors are not convinced that health systems like the NHS will commission these new products.
Ultimately, AMR is not simply a British issue or one of developed economies; the impact of drug-resistant infections in low- and- middle-income countries is acute. It necessitates transnational thinking and cross-sector collaboration and investment. There may be a need to create an AMR Fund as has been done for AIDS, TB, malaria and vaccines. Up until now, funding has been provided to support the development of new antibiotics but not enough attention has been given to so-called “pull” mechanisms.
To mitigate and take ownership of the spiralling dangers of drug resistance, we need to tackle AMR on multiple fronts. The challenge is complex, but subsidising development of new products and transforming the market landscape will result in overcoming market failures. New diagnostics will help ensure that we do not return to the pre-antibiotic age.
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