In an address to the 2022 World Antimicrobial Resistance Congress in Washington D.C. in September, Xavier Becerra, United States Secretary for Health and Human Services, described antimicrobial resistance as “…the second punch [after Covid-19] that gets those who are least prepared, the most vulnerable, and the most underserved.”
Antimicrobial resistance (AMR) is one of the major threats to global health, food security and development as it threatens the effective prevention and treatment of infections caused by bacteria, parasites, viruses and fungi. In 2019 alone, it is estimated that 1.27 million deaths were attributed to bacterial AMR. AMR occurs when bacteria, viruses, fungi and parasites change over time and no longer respond to medicines making infections harder to treat and increasing the risk of disease spread, severe illness and death.
Secretary Becerra told the AMR Congress that “The only thing we’re really missing on AMR is the money…please do not waste this moment…let’s make this into a movement.”
In the United States, Becerra’s remarks reflect signs of renewed progress in the mission to develop medications for antibiotic resistant infections. Amongst the potential major steps are the much-trumpeted PASTEUR Act, centred around a subscription model (also known as the “Netflix model”) to incentivise new antibiotic development and which so far has 64 co-sponsors in the US House of Representatives and four in the Senate, along with President Joe Biden’s appropriated funding in his Fiscal Year 2023 budget proposal to tackle AMR.
Becerra called on the meeting’s participants to continue to press for action globally. But is money really all that is required? What kind of action is needed to transform this political moment into substantial and sustainable progress in meeting the challenge of antimicrobial resistance? And what does this mean for people living in low- and middle-income countries?
Signs of progress
I attended the Congress at the invitation of the Asia-Europe Foundation (ASEF), an organisation that supports dialogue and cooperation between countries in Asia and Europe. In 2018, I helped ASEF organise a meeting on tackling the challenge of AMR, which concluded that it is important to combine efforts to strengthen stewardship and reduce unnecessary use of antibiotics with measures to strengthen health services and ensure universal access to effective treatment for common infections, including in low- and middle-income countries.
There have been important developments since the 2018 meeting. It is now widely accepted that governments need to support the development of new antibiotics, since the market for them is likely to be small in the short-term, if their use is reserved for when they are really needed. This support needs to combine push and pull incentives for drug development.
There has been substantial progress in government funding of research and development, especially by small technology companies. An important example of international cooperation is CARB-X, which is funding a significant number of projects. The introduction of pull incentives has been slower. The UK has pioneered the subscription model that that United States Government is looking to follow through the PASTEUR Act. While the PASTEUR Act will provide substantial funding for newly developed drugs, if passed, it will be important for other countries to establish similar schemes and to coordinate with one another to effectively manage the global market.
More than money
A recent set of consultations with senior scientists, research funders, and the private sector in the UK revealed that in addition to more money, it is important to build the capacity for each stage of the development of new antibiotics. This is an important lesson from the experience of the response to Covid-19, whereby a big surge in funding led to the rapid development of vaccines and therapeutics because of the prior existence of skilled scientists and of a highly developed scientific infrastructure. For example, the Diamond Light Source Synchrotron, a national resource in high technology science, supported the rapid development of effective therapeutics for Covid-19. The rapid forging of new partnerships between research institutes and private companies also played an important role.
The consultation concluded that there is a need for strategic leadership of a coherent approach to build the capacity to develop new treatments of a wide variety of infections. The strategy will need to combine relatively long-term funding to build infrastructure and a cadre of young researchers with project funding to address specific problems. It will be important to strengthen cooperation between countries to make good use of available resources.
Several panels at the World AMR Congress emphasised that it is impossible to solve the problem of AMR in one country. Resistant organisms can be found in all parts of the world and they spread quite easily. Actions to support the development of new antibiotics need to be complemented by measures to strengthen health systems in all countries and ensure adequate levels of finance to enable them to provide access to appropriate antibiotics, while limiting unnecessary use.
One important initiative to address this challenge is a recent agreement by Shionogi, a medium size pharmaceutical company, the Clinton Health Access Initiative, and the Global Antibiotic Research and Development Partnership (GARDP) to license the use of cefiderocol, a new antibiotic, to 135 countries, where this drug would not otherwise be available. This will involve licensing local drug manufacturers. This is a test of a new approach for making effective treatments available world-wide and a small step towards building a more equitable global system for antibiotic production.
The G7 in 2023
In early 2023, ASEF will use its convening power to co-host in Tokyo a follow-up to the 2018 meeting to coincide with Japan’s presidency of the G7 in 2023 and ahead of the G7 Heads of State Summit in Hiroshima in June. Our aims in D.C. were to engage with current thinking and initiatives for addressing AMR and to identify potential public and private sector participants for the Tokyo meeting.
It will be important that the G7 take all perspectives into account in defining priorities for tackling AMR. Member states need to recognise the importance of international cooperation to address a problem that has truly global dimensions. This must involve creating a capacity to identify emergent problems, mobilise a scientific effort to develop countermeasures, and ensure equitable access to vaccines and effective antibiotics. G7 countries can play an important leadership role in building a global effort to tackle this problem.