World Antibiotics Awareness Week

Jeremy Lefroy Excerpts

Thursday 16th November 2017 Westminster Hall

[Jeremy Lefroy (Stafford) (Con)]

It is a great honour to follow my right hon. Friend the Member for Chipping Barnet (Theresa Villiers) and my hon. Friend the Member for York Outer (Julian Sturdy) in this extremely important debate. As my right hon. Friend said, this issue is both important and urgent; it is not something that we can put off.

I declare my interests as a trustee of the Liverpool School of Tropical Medicine, which does research in this area, and as chair of the all-party parliamentary group on malaria and neglected tropical diseases, the significance of which I shall come to in a moment.

Both previous speakers outlined the importance of this subject. The O’Neill report said that we are looking at the possibility of 10 million deaths a year and the loss to global GDP. However, I do not want to dwell on that, because I want to talk about how we can make progress. We have to make progress because at the moment it is too slow. As the chief medical officer, Professor Dame Sally Davies, has said, we do not have time. “The Drugs Don’t Work”, to quote the title of her book.

There are four areas in which we need to make some progress. I do not claim any innovation in this. I listened to a lecture on the issue just last week and these were the four areas set out; I am just repeating what I have heard. The four areas are public education, drug discovery, the involvement of drug companies, and financial mechanisms such as advance market commitments. I shall take them in turn.

First, on public education, it is extremely important that we work together, that we bring the public with us. This country has had a great record over the years in preserving antibiotics for the most essential use, at least in relation to human health. My right hon. Friend described the problems in the animal health sector, but in the area of human health, we have preserved antibiotics. Compared with most countries in the world, we are extremely prudent in our use: doctors do not prescribe them unless they are really needed.

We can do more, however. We can involve the public—citizens—in the search for new antibiotics. I was introduced last week to a great scheme called Swab and Send, which can be looked up on the internet and which is run out of the Liverpool School of Tropical Medicine now. For a small amount—I think it is £30—people get five swab kits. They are encouraged to send in dust samples or whatever; they are encouraged to swab anywhere in their house where they think interesting cultures might be building up and to send the samples in to be tested in laboratories. I saw some of the results. Young people, children and adults all around the country are sending swabs to Liverpool for them to be tested and cultured to see whether potential new antibiotics can come out of that. The reason for doing it is that, just as with the fortuitous discovery of penicillin, we have, potentially, the answer—it could even lie somewhere in a corner of this room. We do not know, but let us get citizens involved in sending those samples in from all over the country and, indeed, the world and get them tested. We have an army of volunteer scientists and researchers out there who are able to help us to discover the next generation of antibiotics.

The second area is drug discovery. We have heard that it has been extremely difficult to make progress in drug discovery, for a number of reasons. I believe that the last major development was 30 years ago, so we have not had a new antibiotic for 30 years. The problem is that antibiotics are cheap. When drugs are cheap but developing them is expensive—it takes years, we have heard 15 years, and the cost can be in the hundreds of millions of pounds —it is simply not commercially possible for drug companies to engage in this kind of research and development. It needs a combination of public finance and private development and initiative.

At this point, I want to reflect on what has happened in relation to malaria, which I know a little about, over the last 16 or 17 years. The Medicines for Malaria Venture is a fine example of how we can have international co-operation. It supports pharmaceutical companies to develop new medicines for malaria that would not be able to be produced commercially. Seventeen years ago, in 2000, as I know myself having contracted the disease a number of times, the efficacy of standard treatments for malaria was poor, or they were pretty toxic. Resistance to chloroquine, which was the main drug, was high everywhere. Sulfadoxine-pyrimethamine, or SP, which had replaced chloroquine as the main drug in a number of places, was also becoming less effective. New drugs, based on the Artemisia annua plant, were emerging, but much more work needed to be done on them. Drugs were available, but they were not particularly well developed, and because they were single therapies, not combination therapies, there was the great risk that resistance to them would occur very quickly.

The Medicines for Malaria Venture was set up with the specific aim of working with companies to bring potential drugs through research and development to the market. I am proud to say that, since 1999, the United Kingdom has been the second largest provider of funding to that excellent organisation after the Bill & Melinda Gates Foundation, which has funded more than half the total expenditure since then, which is something like $1 billion.

What have we seen as a result of the $1 billion of expenditure over 17 years? We have seen a transformation. In 2000, there were 10 products around and being worked on: six at the research stage and four at the translational stage. There was none at the product development stage and none on the market. Where are we now, 17 years later? There are 21 in research, nine at the translational stage, seven at the product development stage and 10 on the market. That is a huge return on investment. Obviously, it was not just the investment of the $1 billion or so with MMV; it was also investment by private companies working alongside MMV that put a lot of their own money into it.

Now, therefore, we have not only a good range of very effective drugs available globally that have saved millions of lives—one estimate is 6 million; it is possibly more than that—but a very healthy pipeline: 30 drugs at the research and translational stages and another seven at the product development stage. That is exactly what we need to see for antibiotics, and not just in the future but now. There we have a model. It may not be exactly the right model for antibiotics, but it is a model. That shows that it can work and not just in relation to malaria drugs; we have seen it work in relation to drugs for so-called neglected tropical diseases. An equivalent organisation is bringing forward drugs in that area. We have seen it with vaccines. The world has come together to produce better vaccines or more vaccines to cover more diseases through the Global Alliance for Vaccines and Immunisation.

We therefore have models for drug discovery, but we need to ensure that they involve the drug companies. This cannot be done just by the public sector. The drug companies have enormous expertise and great researchers; they just need the incentive to work on the development of new antibiotics to a much greater extent. We are not talking about doing one or two; we are talking about looking at dozens and dozens. That is why it needs a co-ordinated and global approach. I think the drug companies are willing. They are out there, they are able to do it and they want to do it; they just need a bit of co-ordination and incentive—a bit of a push—and also the public encouragement that comes from knowing that this is something that we all want to do and that will benefit the entire world.

We need to look at how that finance could be introduced. I have talked about advance market commitments. That is the possibility that has been suggested to me. It has been done before. Just over a decade ago, advance market commitments were developed for vaccines. We have vaccines available around the world now, inoculating children and preventing them from getting debilitating or killer diseases, because of the commitment made by our Government in 2005-06 and other Governments, with again the UK taking the lead. That is an area in which we have expertise and have already shown commitment. Therefore, it is absolutely right, as my hon. Friend the Member for York Outer and my right hon. Friend the Member for Chipping Barnet have said, that the UK should be taking a lead in this. At this time, when perhaps our global position is changing, what could be better than showing global leadership in an area that is of great benefit to all humanity and showing that global Britain is a reality, not just a form of words?

Just a few words on how advance market commitments work. In the case of vaccines—there is no reason why it could not work in the same way for antibiotics—there is an agreement for money to subsidise the purchase of a future drug at a given price, so that people know that they are going to sell that drug at a certain price, which means that they can invest in the research and development. That gives manufacturers the incentive to invest not only in that R and D, but in capacity. We need to build that capacity. Clearly, in the case of vaccines, that was enormous because vaccine plants are extremely expensive; in the case of antibiotics, the expense would be less, but nevertheless significant. Then there is the agreement that, once a fixed amount of sales, in terms of numbers or value, has been reached, the manufacturer is contractually obliged to sell the drugs affordably in the markets or to license the technology. Let us be frank: these drugs are not going to make large sums of money for people. They have to be available at prices that everybody in the world, whether they get them through a health system or purchase them individually, can afford.

[Theresa Villiers]

Listening to my hon. Friend’s speech, it occurs to me that, in other areas of medical research, we see a hugely positive impact from the charitable sector. Should we be trying to read across the lessons from other areas of medical research and to get these fantastically successful charities involved in raising money for AMR research?

[Jeremy Lefroy]

My right hon. Friend is absolutely right. I referred earlier to the involvement of the Bill & Melinda Gates Foundation in the setting up of MMV, but there are so many other medical charities putting millions and sometimes tens of millions of dollars into these areas. That is the beauty of partnerships such as MMV, the Drugs for Neglected Diseases initiative and other partnerships: they take money from the commercial sector, charities, non-governmental organisations and from Government and everybody is working together—they are not in competition with each other over relatively scarce resources. The partnerships are using the benefits, in the case of companies, of their researchers and facilities; in the case of foundations, of their contacts, ability to deploy drugs on the ground and funding; and in the case of Governments, of the substantial funding that they can put in.

I want to conclude by saying that this is not pie in the sky—this is something we can do. We have proven in the case of malaria and other diseases that we can achieve tremendous results. We know there is a will. We know Government have a will. We know there is a will in other countries. It just needs a lot more urgency and more co-ordination. If the UK, through the Department of Health, and as my hon. Friend the Member for York Outer has said, through the co-ordination of the various Departments, were to take this by the scruff of the neck, we would have something by which the UK could again show world leadership not just in words, but in actions. I look forward to hearing from the Minister the plans that we have in that area.

--- Later in debate ---

[The Parliamentary Under-Secretary of State for Health (Steve Brine)]

In a rare and welcome twist for a Westminster Hall debate, I think I will have time to cover pretty much all the points that colleagues have raised.

Let me congratulate my hon. Friend the Member for York Outer (Julian Sturdy) on successfully securing this debate in World Antibiotics Awareness Week. As everyone has said, it gives us a great opportunity to draw attention to an important issue—or the important issue. On the way in, I said to my right hon. Friend the Member for Chipping Barnet (Theresa Villiers), “I didn’t know you were interested in this subject,” and she said, “This is a critical issue.” It has come on to her radar, so she has come to speak—brilliantly, I thought—in today’s debate. Say to many Members across the House, “We have a debate on AMR this afternoon,” and they would ask what that is. I do not think that will be the case for much longer, nor should it be, and I thank everyone for their contributions. Raising awareness of the importance of preserving antibiotics through their appropriate use and preventing infections in both humans and animals is part of the challenge.

Lord O’Neill has been rightly lauded and much mentioned this afternoon for his review of AMR, which was published last year. I agree that it is an excellent and accessible piece of work. The former Chancellor of the Exchequer, George Osborne, and David Cameron deserve great credit for having the foresight to ask him to do it. His review said that, by 2050, an estimated 10 million deaths a year could be caused globally by AMR if no action is taken. In comparison, cancer causes 8.2 million deaths per year—I am also the cancer Minister for England —and diabetes causes 1.5 million, to put that in context.

AMR is part of the Darwinian process of natural selection, as microbes adapt following exposure to antimicrobials. The problem is greatly amplified by the inappropriate use of antimicrobials—in particular, antibiotics. All Members who have spoken today mentioned public education. It was one of the four points made by my hon. Friend the Member for Stafford (Jeremy Lefroy). While he spoke, I googled Swab and Send—I was listening at the same time; I can multitask, contrary to popular belief—which looks absolutely excellent. I look forward to finding out a bit more about Dr Adam Roberts’ project; he has done excellent work.

If any Members or constituents wish to find out more about the science of AMR, I heartily recommend the new “Superbugs” exhibition at the Science Museum in London. It explains both what AMR is and how we are using science to tackle it. The exhibition is an excellent example of the cross-sectoral collaboration that has enabled the UK to take such a leading role in tackling AMR.

While I am on the subject of science museums, may I give a shameless plug to my constituency—this does not happen often for a Minister? Public awareness is critical and that was a key point in the O’Neill report. A few weeks ago, I went to the Winchester Science Centre, which has just launched a new partnership with the University of Southampton. It has a brilliant new exhibit on AMR called, “The most dangerous game in the world”, which gives children—it is mostly children who visit the centre—the chance to understand what AMR is. They play an interactive game to try to understand the threat it poses to us and what we are doing to tackle it. Through the Association for Science and Discovery Centres—there are science centres all around the country; some will be in the constituencies of Members here today—we have the chance to raise the profile of the public education role that is needed for AMR. I suggest that raising awareness among our young people would be a brilliant place to start.

This debate is timely as it follows the publication last week of the all-party group’s antibiotics report, which was mentioned by my hon. Friend the Member for York Outer. The report made recommendations for us and others to consider in our development of future action plans to combat AMR. I thank the group for the report. Its recommendations will be useful as we develop the refreshed UK AMR strategy and the new action plan; the current one comes to the end of its five-year life at the end of 2018. In addition, the UK strategy makes the commitment to assess the effectiveness of the implementation plan at the end of the five-year period. The policy innovation research unit at the London School of Hygiene and Tropical Medicine is undertaking a full evaluation of the current UK five-year strategy, looking at the evidence underpinning the key mechanisms of change across human and animal health sectors. Its work will further inform the development of the refreshed strategy.

It is World Antibiotics Awareness Week and European Antibiotics Awareness Day is on Saturday 18 November. The two events take a “one health” approach, with human and veterinary health professionals working closely to give a unified message on the subject. They provide opportunities to engage with healthcare professionals and the public on AMR and what we can all do to help to address it. As part of World Antibiotics Awareness Week, letters are sent from the chief professional officers for England and other national leaders inviting colleagues who are working in the NHS, local authorities, universities and professional organisations to support activities for the week. Links are provided to a wealth of AMR-related resources.

Our chief medical officer, the much mentioned—rightly so—Professor Dame Sally Davies, works closely with her opposite numbers in Edinburgh, Cardiff and Belfast. She falls within my responsibility and I see her regularly. We always talk about this, and her book, “The Drugs Don’t Work”, which was mentioned by my hon. Friend the Member for Stafford, is a brilliant piece of work. I recommend it to anybody with an interest in the subject.

The national Keep Antibiotics Working campaign was launched across the country last month by Public Health England, for which I have ministerial responsibility, to raise awareness of AMR and, using TV, radio and social media advertising, to reduce demand for antibiotics by the public. I hope that Members have seen, heard and watched that campaign.

In addition, the antibiotic guardian scheme, which was mentioned by the hon. Member for Glasgow North (Patrick Grady), was launched in 2014, providing brilliant tools for healthcare professionals to raise awareness. That has now signed up more than 50,000 individuals, of whom I am one—people pledge personally to commit themselves to use antibiotics more prudently. When I signed up I did not see in the drop-down options a dram of whisky, but why not? The people behind that website are probably listening or watching, so surely it is only a matter of time.

The debate is also timely in that the Government are due to publish shortly the third annual progress report on implementation of the UK five-year AMR strategy. The report will set out the range of activity that went on through 2016—we look at the year before—to implement the strategy and points to the reduction in antimicrobial use in 2015 throughout the UK. Data for England in 2016, published just last month, show a continuing reduction in antimicrobial use in humans. Significantly, the annual sales data for antimicrobial use in animals, published last month, show a 27% drop in the use of antibiotics in food-producing animals since 2014. That meets the Government commitment two years ahead of target.

At this point I want to touch on colistin, which my hon. Friend the Member for York Outer referred to. Sales of colistin decreased by 83%—below the maximum target recommended by the European Medicines Agency—during the lifetime of the plan so far. On whether a review is looking into colistin use, I am not aware of any specific review, but its use is highly restricted and controlled now; it has dropped by 83%, as I said, and we continue to monitor it extremely closely, I am sure he will be pleased to hear.

This is just the beginning; our work is by no means complete. Last month, Responsible Use of Medicines in Agriculture launched a set of sector-specific reduction targets that we aim to and will deliver by 2020. The Government have also set challenging ambitions to halve the number of healthcare-associated gram-negative bloodstream infections and the inappropriate use of antimicrobials in humans by 2020-21. Gram-negative infections are growing in incidence. Gram-negative bacteria are more resistant to antibiotics and are increasingly resistant to most available antibiotics.

E.coli infections, for example, make up the bulk of the healthcare-associated gram-negative bloodstream infections we aim to reduce. A report published by Public Health England last month revealed that four in 10 patients with an E. coli bloodstream infection in England cannot be treated with the antibiotic most commonly used in hospitals; that relates to a point made by the hon. Member for Burnley (Julie Cooper). In 2017-18 we aim for a 10% reduction in all E.coli infections. Just two days ago, on Tuesday, the Secretary of State hosted an event with over 200 frontline staff from primary and secondary care to share good examples of actions to tackle such infections—I am sure that colleagues from Lancashire were there—and to develop improvement plans for 2018.

The consumption of antibiotics is a major driver of the development of antibiotic resistance. We have implemented a range of initiatives to help prescribers to improve their use of antibiotics, including the provision of guidance and tool kits and the use of behavioural change initiatives and financial incentives. AMR local indicators are provided in the Public Health England Fingertips portal, bringing together local information on prescribing and infection rates to allow local teams to benchmark their performance against others in similar areas so they can develop strategies for improvement that are appropriate for their local circumstances.

That gives me a chance to touch on the point made by my right hon. Friend the Member for Chipping Barnet, who mentioned sustainability and transformation partnerships. We absolutely expect AMR to be included, and it was included in the planning guidance for developing STPs. Take-up in local areas has been limited, but I suggest that MPs apply pressure to their local STPs by encouraging the STP leads to consider AMR. For the record, STPs that are in my good books—the apples of my eye—are Cheshire, Wider Devon and the Black Country. If Members wish, they can refer their STP leads to those as places to look for good practice that are involving AMR in their planning.

Most Members who have spoken have touched on new drugs; my hon. Friend the Member for Stafford certainly did so at great length. Although preventing infections and protecting the antibiotics that we have are the first two pillars of any approach to tackling AMR, the third is promoting the development of new drugs and alternative treatments. However, as has been said, no new treatments have been brought to market for many years. We fully support action to address this market failure through market incentives such as market entry rewards, championed by the O’Neill review, and other solutions, and we welcome the commitment made this year by G20 leaders to consider how such solutions could be implemented regionally and internationally. My hon. Friend’s ideas are welcome, and he is dead right in calling for a co-ordinated approach and for us to give them a bit of a push, to use the expression that he used.

[Jeremy Lefroy]

My hon. Friend’s commitment to the subject shines through; it is great to see his leadership. I gently suggest that although global work and co-operation are extremely important and will, in the end, produce the kind of results that we need, we could take a step ourselves as the United Kingdom. The amount of money required to start something like, for instance, the Medicines for Malaria Venture is not great, particularly if it comes from a combination involving Government. The UK has provided 20% of the funding, as I said, alongside the Gates foundation. Sometimes it takes quite a time to get the world to work together. Perhaps we could consider doing something ourselves with as many co-operators as we can, and getting it going right now. As my right hon. Friend the Member for Chipping Barnet (Theresa Villiers) said, we could consider using the official development assistance budget, because this is for the benefit of everybody in the world, and it certainly is for poverty reduction.

[Steve Brine]

My hon. Friend is quite right. I have made a note and passed it back to the team. There are many pulls, of course, on the UK aid budget—that is a topical subject about which he knows far more than I do—but I will definitely take away that point and speak to our colleague, the new Secretary of State.

That point fits neatly into where I was going next. Although it will take time to develop an appropriate global model on the pull incentives, we are making significant progress on the push side. The UK has committed £50 million over the next five years to the global AMR innovation fund, which has been discussed in the House many times. The first tranche of £10 million will fund a bilateral UK-China AMR research collaboration, which we expect to open next spring.

At the same time, we are working with pharmaceutical companies through the joint Government-industry working group. A number of Members have said that this cannot all be left to the public sector, and it absolutely cannot. Through the working group, we are seeking to develop a NICE health technology assessment-based reimbursement model—another snappy title. As my hon. Friend the Member for Stafford said, that means that we would pay for antibiotics based on their value. A team at York University—I know that this will be of great interest to my hon. Friend the Member for York Outer—is working on the evaluation process and will report back to me in the spring. We will then decide on and announce the next steps. I hope that that is useful to Members.

To return to international issues, last week I attended the G7 in Milan—the presidency is held by Italy this year—to discuss international health matters. AMR was one of the three key items that we discussed, which shows the importance of taking a “one health” approach. It was a meeting with many challenging conversations as we attempted to produce a communiqué, which we did in the end, but I can report that the AMR discussion was not one of them. All attendees—the seven Governments, international bodies such as the World Health Organisation and other non-governmental organisations—were in complete alignment that AMR is an urgent global issue and the problems that it raises cannot be solved by individual countries. There was unanimity.

This was the third time that AMR had been prioritised on the G7 agenda, which shows our continued dedication to tackling it and the importance of countries working together. I had an interesting bilateral conversation with the Health Minister from Canada, which will assume the presidency next year in January. I urged her to keep the issue at the forefront of her mind; I hope that that went in. Each country needs to take action to tackle AMR, but we are obviously stronger together.

Our chief medical officer, to refer to Sally again, works tirelessly to raise the profile of AMR in the WHO and international circles. She travels far more than I, and ensures its place not just as a health and agricultural issue but as a political and financial one; a number of Members have mentioned the fiscal cost of AMR. The United Nations declaration secured in September last year made it clear that we will not be able to deliver the sustainable development goals if we do not tackle AMR. As a number of Members have been kind enough to mention, we have been at the forefront of shaping action on AMR through proactive engagement, and Dame Sally has an awfully big role to play in that.

Indeed, at the G7, the OECD recognised and acknowledged that the UK is leading the way in providing experience on how to tackle AMR. Although many challenges will come as a result of our decision to leave the European Union, in this area, as in so many others, we lead the world, and it is very much in the world’s interest to continue working closely with us and benefiting from our experience. The bottom line is: why wouldn’t they?

I will also mention the Japanese, who are passionate about tackling AMR and with whom I had conversations around the G7. I was pleased to learn that they are as dedicated as we are to addressing AMR. This week, our chief medical officer attended an AMR conference that they hosted in Tokyo with other Asian countries. I understand it went well and look forward to getting a formal readout when she returns.

Good global surveillance is essential to provide a co-ordinated global response, as underlined by last week’s G7 discussions. For that reason, we support low and middle-income countries through our £265 million Fleming fund to improve their surveillance capacity and capability. UK official development assistance will improve in-country laboratory capacity for AMR surveillance through a “one health” approach. It has already supported 31 countries worldwide to develop AMR national action plans that follow on closely from what we have done.

Many hon. Members have mentioned that a cross-Government approach is needed in Whitehall. That goes without saying. The officials advising me today are from the Department of Health and from the Department for Environment, Food and Rural Affairs. We work closely with officials and Ministers across Departments. AMR is a global problem that will not be addressed in the lifetime of any single strategy. Although the UK has led the way and made significant progress at home and overseas, this is a long-term, serious and urgent problem. I welcome initiatives such as World Antibiotics Awareness Week that enable us to continue to discuss the issue, give us a media hook to hang it on, keep it high on the agenda for professionals across all sectors and, vitally, keep it in the minds of members of the public.