What is the problem?

Hello. Today we’re joined by Professor Davies, who’s come to talk to us about the global problem of antimicrobial resistance. Hello, Sally. Hello. Professor Davies, could you introduce yourself to us and tell us about what you’ve done in the past in relation to antimicrobial resistance and what your role is now, please? I am a haematologist, but I became chief medical officer in England and senior medical advisor to the UK government in 2010. And early on in my time, I realised that antimicrobial resistance manifested by drug-resistant infections was out of hand. And not only was it soaring nationally, in the UK, and abroad, but we’d got an empty pipeline, so not enough– hardly any new drugs coming through.

And there really wasn’t much of a focus on it. And I thought that we needed to campaign to try and get people to understand the severity of the problem and then take some action. Thanks. Could you tell us why are antibiotics so important? Why are they so crucial to modern medicine? Well, actually, you’ve said it. Antibiotics underpin modern medicine. In the old days before Fleming discovered penicillin, we would see scratches, even from shaving, could kill someone because they would get a blood infection that was out of control. But now if you get an infection, whether it’s in your blood or your tissues, we can treat it if it’s bacterial, and the bugs are not resistant, effectively.

But we use antibiotics to prevent infections with miscarriages or Caesarean sections. We use antibiotics to underpin gut surgery or new hip joints. We have antibiotics as essential for people with renal failure, with cancer treatments, and with transplantation. So modern medicine is underpinned by effective antibiotics, and we risk losing it. Thanks for the great explanation of how important antibiotics are, but what’s the nature of the problem that we’re facing in terms of antibiotic resistance? Well, drug-resistant infections are now killing a lot of people, at least 7,000 people worldwide. And that’s going to go up to 10 million a year by 2050 if we don’t take action.

Moreover, as it goes up, more than 28 million people will be driven into abject poverty. So this is a serious issue. And if you look at the UK, we know that every day, on average, we have 165 blood infections that are resistant to first-line antibiotics. In the rich countries, we know we’re already, when patients get drug-resistant infections, doubling the time they spend in hospital, so doubling the cost, and doubling the mortality. But this is a problem all over the world. Indeed, it’s worse in low and middle-income countries than in the rich countries. But I do want to put on record, of course, that far more people are still dying now from lack of access to antibiotics than resistance.

It’s just the tipping point is going to come when they’re getting access, but this resistance level has risen so much that the risk of dying is there. So in some degrees, we might say that antibiotic resistance has a twofold problem. We have a problem with the use of drugs, but we also have a problem with access to drugs. And in many ways, it might be regarded as a development problem. Absolutely. They’re in tension, aren’t they?. We don’t want people to use antibiotics when they don’t need them. We want appropriate use. Some people call it stewardship. But at the same time as not over-using them, many poor people can’t get the drugs they need.

And some of the more modern drugs are not being licensed in the poor countries either, so that’s very unfair and not right. So just moving on to that last point you were talking about, the licensing of drugs, I read recently that a number of new antibiotic companies have gone bankrupt, which is adding to the problem of the development of new drugs. What do you think that we can be doing to help new drugs get into the pipeline and then to eventually reach clinic? It’s really scary at the moment.

Even if scientists find a new drug, do all the testing of toxicity, do the trials, and go through to regulation, and then the company goes broke, it shows that we’re not paying enough for antibiotics. The classic example at the moment is Achaogen who produced a really good antibiotic, but the licence they were given by the FDA was just for complicated urinary tract infections. They wanted it for pneumonias as well. They then couldn’t sell it as broadly as they wanted. Meanwhile, they had to transfer all their R&D staff to selling. They went broke. That is not the right way to handle novel, new antibiotics. So we’ve discussed the importance of antibiotics and the nature of the problem we’re facing.

So I’d like to pose to you to the question now– if you were omnipotent for a day, and you could really make some difference to antibiotic resistance, what would you tackle first? What would your priorities be? Well, in the low and middle-income countries, I’d start with preventing infections. Do they have wash? Do they have clean water, effective sanitation? Are they getting the vaccines for the children and the adults that will protect them, and is there infection prevention and control in their hospitals and health centres? Of course, this is the one health issue. Are their people using antibiotics appropriately in the food chain? More than 70% of antibiotics worldwide are used in the animal sector, including fish farming.

Over 70% of those are used for growth promotion instead of using proper hygiene. So you have to have a look not only what’s happening in the human sector, but also in the food chain, particularly the agricultural part. Given the increasing global population, then, do you think this is a major problem with our overall burden of resources? One might say that climate change is part of this. We’re facing a very growing world population. We need to provide food. How do we fit in combating antimicrobial resistance with that kind of problem? Well, clearly, a lot of agendas, including sustainability and welfare of animals, collide with the complexity of antimicrobial resistance.

But in general in rich countries where people are meat eaters, they’re eating more meat than is good for them. So there’s no doubt that if we shared out the protein, we could feed many more people. But we have to make sure that as we grow protein for the human market that it is properly done and that we are not using antibiotics inappropriately. For instance, fish is one of the proteins that in production is going up fastest. Most of it is through fish farming. And in most countries, they just tip antibiotics into the feed, and then it’s released into the waterways, the oceans, and contaminating our environment, which can drive resistance as well.

So it’s very important that we get control of this. If you look at salmon and trout farming in Norway and Scotland, they use vaccines, so they hardly need antibiotics. Thank you. So you were talking– this is a really major problem. Do you have any examples for our participants about the problem that we’re facing? Are there any particular anecdotes that you have about seeing the increase in resistance? Take typhoid. There was an outbreak that started in Hyderabad that was resistant and then moved to Pakistan. And because of the resistance, 40% of the children have been dying in this really big outbreak. Yet normally, with good treatment and rehydration and antibiotics, the death rate is in single figures.

Another example is how people with immune deficiency are more prevalent to infections. And, you know, if you have cancer, you’re more likely to get an infection. And it can come from an operation or a scratch, but generally it comes from your own gut. And I was hearing only recently that in a hospital in India– and this is not a special hospital. It will be common across India. 30% of patients with cancer, when they present, have drug-resistant bacteria in their guts. So the infections they will catch from their own guts will be resistant. So if we’re carrying it in our own bodies, what can we do?

What can people– what can our participants in their communities, in their local– what can we do to try and help prevent antibiotic resistance? Well, each and every one of us, wherever we live, can make sure that we try and prevent infections– washing hands before using food, washing hands after going to the lavatory. But in addition, we need to use antibiotics carefully and sensibly. So if you have a virus infection, like a cold or coronavirus, antibiotics will have no impact. They only work with bacteria. So please listen to the doctor or nurse. And if they say, no, you don’t need them, don’t push for them. Don’t take them.

We’ve talked about the problem that we’re facing now, but what’s causing this problem? What’s driving resistance? And have we known about this for a long time? Well, actually, it’s always been there, resistance to antibiotics. We’ve even discovered resistant genes up the Amazon where they haven’t had antibiotics. Fleming, in 1945 when he got his Nobel Prize, predicted this would happen. What happens is if you take antibiotics, they can have three results. They can kill the bug, they can be irrelevant, but actually, they can also push selection from when a mutation arises that allows the bacteria to continue to multiply in the presence of that antibiotic. And that driving force is really upped if you use antibiotics badly.

If you use too many of them, if you use them for too short a time, too low a dose, you can drive resistance. And that’s why I’m so concerned about the massive use in animal growth or animal rearing, of growth promotion, the profligate use of antibiotics in fish farming, just tipping it in with the feed, which also happens with chickens and beef in some places. I mean, we have to use them appropriately and carefully. So we’ve known about this problem for a long time, so why are we only doing something now? Have we reached a tipping point, or is there some other reason why we’re choosing to tackle it now?

Well, we’re going to get to a tipping point where more people get drug-resistant infections and suffer from that, many dying, than don’t get antibiotic treatment when they need it. And those will cross over. But why are we doing something? Well, I think Britain can feel proud that we, since 2013, have really been pushing on developing awareness of the problem to try and drive action– working with the WHO, working with the Food and Agriculture Organisation, the Organisation for Animal Health and the UN in New York. Indeed, a high-level dialogue in the first half of 2020 is scheduled in New York on this subject.

We also are funding the Fleming Fund, 265 million pounds of support to low-income countries to help them develop their strategies, their national action plans, and their surveillance so that they know the size of the problem, and they can then start to take action on it. It’s very difficult, if you haven’t measured the problem, to take action. And politically, it’s much easier if you haven’t measured it to say, well, actually, we don’t have a problem. We all have a problem. The only question is, how bad is it? We’re currently facing a major epidemic of a novel coronavirus in Wuhan in China.

What do you think that tells us about our ability as global entities to tackle emerging infectious diseases, and indeed, the problem with AMR? Do you think there’s an interlinking between the two? I think there is in the sense that it’s waking everyone up to the fact that we have not conquered infectious diseases. As many people will know, of the last 24 major new infectious diseases, 22 came from animals. We’ve got ebola breaking out regularly in Africa. We have MERS in the Middle East, and now we have coronavirus.

And it shows also how scary it is, and how you have to use standard, old-fashioned public health to try and contain it of clean water, sanitation, quarantine, and looking after people in very standard manners. But it also demonstrates the importance of vaccination programmes. And it’s not just vaccination against bacteria that matters. Think about flu vaccination. Flu is one of the biggest causes of pneumonia happening, and old people in particular are dying of bacterial pneumonia because they had flu. Coronavirus is probably the same. So get the flu vaccination, and you’re protected from flu, and you won’t get pneumonia. So it shows us the value of all of the interconnected bits of modern medicine. Thank you, Sally.

That was a really interesting interview. Thank you very much for joining us today. Thank you.