30 Jun 2016
The Ticking Time Bomb of AMR – What can we do and where should we go next? ran on 8 June at the Royal Society of Edinburgh. The event was organised by SCI in collaboration with the Royal Society of Edinburgh and The Young Academy of Scotland. It included an exhibition showcasing research and innovation around antimicrobial resistance (AMR), as well as a workshop looking at stakeholder perspectives.
Pressing questions around AMR were considered by an expert panel that included some of the UK’s leading figures in human and animal health and science. It was chaired by Dr Francisca Mutapi, Reader in the School of Biological Sciences, University of Edinburgh and a member of the Young Academy of Scotland. Each question was answered by two panel members and there was also a chance for the audience to join in.
The panel comprised:
Professor Dame Sally Davies FRSE
Chief Medical Officer;
Professor Ross Fitzgerald
Molecular Bacteriology, Roslin Institute;
Dr Ian Laurenson
Consultant Medical Microbiologist, Royal Infirmary of Edinburgh, Honorary Clinical Senior Lecturer;
Professor Dilip Nathwani
Honorary Professor of Infection at the University of Dundee;
Professor Stuart Reid FRSE
Principal at The Royal Veterinary Collage, London;
Dr Jack Scannell
Innogen Institute, Honorary Fellow;
Chief Veterinary Officer for Scotland; and
Professor Mark Woolhouse FRSE
Infectious Disease Epidemiology at the University of Edinburgh
Question 1: Does the recent discovery of the MCR-1 colistin resistance gene indicate that the time has come to stop using antibiotics in farming?
Sheila Voas: the simple answer is definitely no; quoting Gandhi, she said a country can be judged by how it treats its animals. Using antibiotics is better for animal welfare, but they must be used appropriately in all sectors and by all prescribers.
Stuart Reid: we need to think more carefully about how we use antibiotics in animals and we need to consider animal and human health. Antibiotic use in animals should be reduced, but how would you do that? There are issues to consider, such as how much we are prepared to pay for food, and how you would effect a ban in a global ecosystem. He believes it’s down to persuading multinationals to take action that would have an impact across the supply chain.
Question 2: Countries such as France and Greece are much worse at over-prescribing antibiotics compared to, say, the Netherlands; the USA is much more lax with antibiotics in farming. Will there be a co-ordinated international effort to fight resistance?
Sally Davies: different countries are starting from different points, and this could be down to factors such as behaviour, culture and availability – whether you can easily get antibiotics over the counter, or via the internet for example. She said it is important to work ‘as Europe’ to cut down on antibiotics, and that she hopes that a United Nations push will have an international impact.
Mark Woolhouse: it isn’t a simple matter. He compared the issue to climate change, where a single target on global warming created a clear message. But what would the target be on AMR prescribing? And how do you make access to AMDs more difficult while making sure you don’t deny access to people who need it (for example in the developing world)? ‘It’s a difficult balancing act,’ he said.
Question 3: How can we improve the engagement of patients and the public in the fight against antimicrobial resistance?
Ian Laurenson: events such as this are important, but he believes educating children in schools is crucial. Projects such as e-bug are helping children to learn about hygiene and how microbes spread, he said. For the general public though, you have to ‘make it real’, he added; for example, by highlighting the impact of local untreatable or difficult to treat infections.
Dilip Nathwani believes public health campaigns need to pass the ‘Glasgow cabby’ test – if you spoke about AMR to a Glasgow taxi-driver you’d get a blank look. You need a simple message, such as ‘smoking kills’, he said. We need to learn from other effective public campaigns. Eloquent patient stories are important, and so is using all forms of communication, including social media, to get across the message that what we see as routine infection prevention and care is at risk. We need to educate patients and the public, but also health professionals, he added. There needs to be an emphasis on shaping and changing behaviour.
Question 4: Can antibiotics become financially lucrative for private companies? How do you incentivise and fund research towards creating medicines you hope you will never use and, therefore, will never get an income from using a conventional sales model?
Jack Scannell: there are ways and means of incentivising companies. These could include sponsoring what in effect would be an R&D lottery, whereby companies are rewarded for coming up with an effective drug, whether or not it is used. The important thing is that the companies have to believe that the prize is big, and trust that whoever is running it will pay out if they win.
Stuart Reid: the issue involves big pharma and small companies (where much of the initial research is taking place). There needs to be partnership, and we shouldn’t be constrained by our own imaginations, he said. There are small biotech companies with big ideas.
Question 5 – What is the most feasible way to address the burgeoning AMR challenge in developing countries?
Dilip Nathwani: there needs to be a will to do it and governments and other influential bodies have to support it. He said that tackling the issue in developing countries requires action on a number of fronts, including regulation, surveillance and sanitation and hygiene. The latter can be very
effective at reducing the greatly misused practice of treating diarrhoeal diseases with antibiotics. Other options to be explored include the use of vaccines and better use of existing drugs
Ross Fitzgerald: we have to improve our understanding of what is actually happening around this issue in developing countries. “We need to do a better job of surveillance and understanding
usage,” he said. This would require significant input from developed countries.
Question 6 – How can we motivate behaviours amongst users of antimicrobials that may not immediately benefit the decision maker, but have important societal benefits?
Sheila Voas spoke about the issue in animals and said there are a number of important groups involved, including vets, farmers and owners of pets. We must remember that those making decisions about animal use will also be influenced by messages about use (and resistance) affecting humans, including concerns about the consequences for themselves and their families. It’s not as simple as a single target covering all animal species, she said.
Ian Laurenson: targets have worked in areas such as Clostridium difficile infection and antimicrobial prescribing. It’s also important to get the message across that antimicrobials can have toxic side-effects; they are not totally benign. He suggested some of the target audience might be motivated to take action by the thought of negative impact on their grandchildren if we don’t effectively tackle AMR.
Question 7 – Is AMR the inherent issue for life, including microbes, on Earth; i.e., intractable due to the evolution power of life? This means we can only delay the process but not completely address it.
Mark Woolhouse: many of the drugs we use are from natural compounds – and resistance is natural too. He said that we use antibiotics to cover up some of our own deficiencies; for example, in public health, hospital hygiene and animal husbandry. Prevention is a good strategy but isn’t the only solution. Human ingenuity will be important in winning the battle, but it won’t be easy, and will require long-term action.
Ross Fitzgerald: history has shown that resistance will develop even in drugs that appear to be immune to it. If we understood better how resistance worked we could use antibiotics more effectively; for example, by ‘resting’ drugs for a time.
Question 8 – Does the O’Neill Report go far enough?
This question referred to the recent report by the economist Jim O’Neill, who was asked to analyse
AMR and propose solutions to tackle it internationally.
Sally Davies: Jim O’Neill did what the Prime Minister asked him to do in terms of looking at the cost to society, but he looked at much else besides. ‘He went into areas we didn’t expect him to, but he was right to,’ she said. She said we need to move through to action, and not just at a UK level.
Jack Scannell: the Report contains many valuable insights and potential solutions. He spoke of the importance of investing in diagnostics to improve the way we decide on treatments. While it is important to think internationally, it is worth thinking about unilateral action too.
Dilip Nathwani: diagnostics are important, but you need to take a global view. Some countries
don’t even have basic microbiology capability.
Stuart Reid: the O’Neill Report is a ‘starting point’.
Questions from the floor
A GP said that he and his colleagues have a dilemma because of the constraints of a ten-minute appointment slot with no resources to do a quick test to see if someone really needs antibiotics. Dilip Nathwani agreed that social norms and patient expectations are difficult to deal with.
The question was asked whether there should be legislation or guidance to encourage more stringent prescribing among vets. Stuart Reid admitted that ‘we need to get our own house in order’ and Sally Davies said that there are moves to set a target to reduce prescribing. But Sheila Voas said that blanket targets are meaningless. Assuming one size fits all allows some sectors to wriggle out of making change, because usage is already at a level lower than the overall target; whereas sectors with higher usage will benefit from a cumulative total which masks the extent of usage, she added.
Other questions considered issues such as the lack of availability of unmedicated animal feed in some parts of the world; whether we could learn from The Netherlands, which has legislated to reduce antimicrobial prescribing; and how to scale innovation across the NHS. Sheila Voas pointed out that The Netherlands has achieved a reduction, but had started from a higher point than the UK. Dilip Nathwani said that targets have been ‘transformational’ in humans; and Jack Scannell said that the NHS was a small market, in global terms, and that most pharma R&D is paid for in the US, because that’s where companies want to sell.
Asked how to effect culture change, and society’s will for over-cheap food, Mark Woolhouse replied that consumer demands go beyond price. There is general agreement that educating the next generation of medics and vets is very important, so changing attitudes in vet and medical schools is key.