Why are there so few new antibiotics being produced?
Developing a new antibiotic is time consuming, costly and, most of all, not guaranteed to succeed. As such, it is a risky endeavour for pharmaceutical companies to partake in. Furthermore, with AMR on the rise, newly developed antibiotics should be preserved except for when absolutely needed. Because of these constraints, the market for them is shrinking. All of this makes the development of new antibiotics unattractive for the private sector.
A number of companies are producing antibiotics (IFPMA, 2015) (Access to Medicine Foundation, 2018), but many of these are only variations on existing antibiotics. Such ventures are a safer bet for companies to invest in because less research is needed and approvals are faster due to similarities to existing approved drugs. However, these slightly modified antibiotics only overcome resistance for a short period of time.
How can proper economic investment in Research & Development help tackle AMR?
Discovering new antimicrobials and using them inherently poses the risk that those new drugs may develop resistance over time. Ideally, the newly discovered antimicrobials should be restricted for last resort use only, which makes the market unattractive for the private sector in terms of sales volumes.
Developing a new antibiotic can take over a decade and cost over €850 million (Drive-AB, 2018). It can generally be divided into two main phases: initial R&D development, which is done by SMEs and public institutions mostly, followed by drug development and testing, which is done by larger pharmaceutical companies. The AMR Industry Alliance reports investment of around 2 billion into AMR research across 22 companies in 2018 (AMR Industry Alliance, 2018). While a number of companies are producing antibiotics (IFPMA, 2015) (Access to Medicine Foundation, 2018), many of them are variations on existing antibiotics. While these are a safer bet for companies to invest in as less research is needed and approvals are faster due to similarities to existing approved drugs, these slightly modified antibiotics only overcome resistance for a short period of time. Research into novel antibiotic classes is very low.
As our last-resort antibiotics, such as colistin and carbapenem, lose their efficacy (CIDRAP, 2017) (Meletis, 2016) it is imperative that antibiotic R&D is prioritised so that we may have new and effective antimicrobials in time.
Could implementation of taxes for antibiotic use in human and animal health be one of the solutions to this major global health problem?
Taxing has been used previously to raise revenues or alter the behaviour of the public (e.g. tobacco) and it could be a solution to reducing the overall use of antibiotics. It could have the added benefit of providing a revenue stream to fund future research in antimicrobial development. However, O’Neill, in his extensive AMR review for the UK government, warns that the antibiotic tax’s impact will greatly vary depending on its context. It is therefore wiser to implement it at the national level rather than globally (AMR Review, 2016).
In the case of antibiotics, it might be more interesting to impose a tax on antibiotics only for animal-use. This would discourage their use in husbandry but would not directly increase the healthcare costs of citizens. Furthermore, it is unlikely that raising the costs of antibiotics for medicine would lead to behaviour changes from patients (AMR Review, 2016). In 2016, Belgium implemented a tax on veterinary antibiotics that began in April 2018 (KCE, 2019). This tax earns between 450,000 and 500,000 Euro annually which is then used to further fund initiatives to promote the prudent use of antibiotics. Although the tax has not been active long enough to attribute any strong reduction in usage to it, a 2019 report by KCE indicates that the tax itself may be too low to stimulate changes in behaviour (KCE, 2019).
Denmark also introduced taxes on veterinary antibiotics in 2013 which raised the tax on critically important antimicrobials such as fluoroquinolones and third- and fourth-generation cephalosporins to 11% (FAO, 2019). While the tax aimed to promote appropriate usage of antimicrobials in husbandry, the report, similar to the aforementioned Belgian case, also found little evidence of behavioural changes (FAO, 2019).
If AMR has already been an emerging issue for a long time, why are governments taking so long to act?
There are a number of reasons why governments are slow to react to AMR. For one, AMR is a very complex issue due to its global and multisectoral nature and simple national policy cannot have a strong effect on it. Furthermore, even if there is political will, the public has yet to seize the AMR issue wholeheartedly and demand concrete action from their governments. (Wellcome Trust Fund, 2019).