Why are superbugs winning the battle against antibiotics?

Despite widespread knowledge about the dangers of antibiotic and antimicrobial resistance – financial concerns are a key factor in the rise of "superbugs" .

This was the conclusion drawn by many of the health experts and policy makers from global institutions, from the United Nations to the World Health Organisation (WHO), Centre for Disease Control (CDC) in the US to the National Health Service (NHS) in the UK, who convened at the Expert forum on antimicrobial resistance, hosted by Swiss Re Institute at the Swiss Re Centre for Global Dialogue last month. On the agenda - how can we prevent antimicrobial resistant strains or "superbugs" from developing, contain their spread when they do, and produce antibiotics for the "unavoidable superbugs" of the not-too-distant future?

Preventing disease or profit loss?
It has been widely reported that the liberal use of antimicrobials in livestock to enhance and speed up growth rather than treating disease, has led to a significant rise in the production of these drugs and medicines. In fact, three quarters of all antimicrobials sold globally are administered to farm animals, according to Thomas Van Boeckel from the Swiss Federal Institute of Technology. In 2013 the total estimated production of antibiotics, worldwide, was 131,109 tonnes. This total is expected to grow to 200,235 tonnes by 2030, barring regulatory action.

Van Boeckel explained that routine use of antimicrobials helps animals to grow faster, therefore increasing profits for livestock farming and potentially aiding flagging agricultural economies – the threat to public health cannot be underestimated. Where there are resistant bacteria and viruses, there are "superbugs", which may find a human host who goes on to quickly infect others – especially at risk are children and the elderly.

Billion dollar debate
The NHS in the UK currently spends GBP 180 million on tackling superbugs, according the Chief Medical Officer for England, Dame Sally Davies, in a parliamentary hearing on 2 September 2018. Meanwhile in the United States, in 2013, antibiotic resistance generated an estimated USD 20 billion in health care costs, with additional costs to society for lost productivity as high as USD 35 billion a year, according the CDC.

Together with the experts at the conference, the CDC cited the overuse of antibiotics as the single most important factor leading to antibiotic resistance. Cutting down significantly on antibiotic applications in agriculture is the first step. The economic price agriculture has to pay would be more than balanced by benefits in the health sector, due to the saving of lives and costs of care.

Beyond resistance – the role of medics
Roger Kouyos from the University of Zurich highlighted the need for a change in prescription practices among doctors and the medical profession. Countries with lax practices see higher rates of antimicrobial resistance compared to those where standards are more stringent. Selling antibiotics over the counter is therefore counterproductive, echoed Jennifer Rohn from University College, London. Making antibiotics prescription-only again and regulating unauthorised internet pharmacies, some of which distribute antibiotics without medical supervision, would go further.

As a support for these measures, extra funding for hospital hygiene must be made a priority. In many countries with less developed health systems, the return on investment of these activities is much higher than investment in drug development, claimed Stephan Harbarth from the Infection Control Programme of the University of Geneva. This would also faciliate a drop of circulating resistances, Kouyos added. Where the measures above were successfully implemented, resistance declined.

New antibiotics – public health vs. the private sector
Despite all efforts, bacteria hang around longer than we do – they are simply tougher, smarter and more adaptable. We need new antibiotics to avoid a public health epidemic. Given the huge market, one would expect the big pharmaceutical companies are pumping billions into antibiotic development?

The opposite is true – billions instead go to cancer, arthritis, cholesterol and blood pressure drugs; therapies patients must take for decades. After all, an effective antibiotic heals a patient within days if effective. Recouping the cost of development and generating a profit would make antibiotics excessively expensive said Michael Altdorfer from the Swiss Biotech Association. Even if a novel antibiotic treatment costs USD 30,000 to 40,000 it is still much cheaper than the costs generated if a patient is in hospital for weeks or needs to back every month for more treatment. In his view high prices could be a deterrent to superfluous presctiption for humans and animals.

New ways to finance new antibiotics
Peter Beyer, from the WHO, showcased an example of funding for research and development - the WHO's Global Antibiotic Research & Development Partnership (GARDP), a joint initiative, together with the Drugs for Neglected Diseases initiative (DNDi), to develop and deliver new treatments for bacterial infections where drug resistance is present, emerging, or for which inadequate treatment exists. Today  funding for such projects comes mainly from foundations and government, and falls well short to manage the risks that lie ahead. More is being sought from the public and private sectors.

Christoph Spennemann of the Intellectual Property Unit of the United Nations Conference on Trade and Development (UNCTAD) presented an innovative solution in Germany enabling a health insurance company to invest in a health technology fund. The German health insurer – which cannot directly invest in risky drug developments – collaborated with a bank. The latter guaranteed the investment in case of failure. The set-up allowed releasing capital from health insurers – who have the financial interest for effective antibiotics – to drug developers.

Spennemann also presented a similar approach, with a different angle – proposing to pay producers of new antibiotics a fee for storing them in large volumes, and distributing them, only under a very restrictive prescription scheme: thus guarranteeing a regular revenue stream, which is attractive to the pharmaceutical industry, and, at the same time, confining the use of the drugs.

Building resilience against infections
Innovative finance, including insurance solutions, may provide much needed support in the war against bacterial pandemics, but as funding discussions only just begin, it may be some time before agriculture and pharma are ready to join the front line.

Article by Bernd Wilke, Senior Emerging Risk Manager, Group Qualitative Risk Management, Swiss Re