National Press Club address ‘Back to the future; life without effective antibiotics’

26 April 2012

Dr Janette Randall, Chair of NPS

**Check against delivery**

Acknowledgements

  • I would like to begin by acknowledging the custodians of the land on which we meet today – the Ngunnawal people, and to pay my respects to their elders past and present
  • To the Directors and members of the National Press Club, members of the media, NPS members and partners and guests

Thank you very much for the invitation to be here today.

This week as a nation we have remembered and honoured our diggers and the men and women who have given their lives in service for our country.

I would ask you to take a moment now and cast your minds back to World War I – a time before antibiotics were discovered; a time not so long ago.

Imagine if you will a young soldier on the battlefield, scrambling to get to back to the trenches. In his haste he trips and scrapes his elbow. He makes it back safely however, and feeling relieved, he washes the wound with some water and covers it up with a scrap of material he finds on the ground.

After a few days, the scratch becomes red and starts to hurt, the soldier feels feverish and his body starts to ache. The onset of nausea and headache makes life miserable for the soldier, so he seeks out a medic hoping for something to make him feel better. But there’s little the medic can do, the infection has set in and within a couple of days his young life slips away.

This story – and many like it – was common during World War I before the discovery of antibiotics. In conditions of poor sanitation with very few effective treatments, even an injury as minor as a scratch or a blistered toe could fast become life threatening for a soldier.

You may not realise it, but it’s estimated around one third of the casualties from World War I were from infectious disease – that’s about 5 million deaths. Literally millions of lives lost to infections which, had we had the miracle of antibiotics, may have been avoided.

But it wasn’t just on the battlefields where lives were being lost to bacterial infections. Before antibiotics, hospitals around the world commonly dealt with patients who were seriously ill and at risk of death because of an infection, sometimes from something as simple as a scratched knee. Children who contracted tonsilitis while playing together in the playground often faced long hospital stays, and a bout of bacterial pneumonia came with a dire prognosis. Surgical procedures, particularly those involving the bowel, were risky and often resulted in complications or death from secondary infections. More often than not, the treatment in those days included ‘a few kind words’ rather than a therapeutic intervention.

The world needed a cure for these bacterial diseases, and researchers and doctors rose admirably to the challenge. Indeed, Howard Florey was the first Australian awarded a nobel prize for physiology and medicine, for his work with Alexander Fleming and Ernst Chain in the discovery of penicillin.

Antibiotics became widely used in treatment during the 1940s and were heralded as a modern day miracle. By the 1960s and 70s experts thought that the war against infectious diseases had been fought and won.[1] It appeared we had found the ‘cure all’ pill – the medicine which stopped disease in its tracks, and sent it into retreat.

The use of penicillin and sulfonamide in World War II saved the lives of countless soldiers.[2] Antibacterial medicines bought doctors valuable time – the use of antibiotics for a soldier’s wounds slowed the spread of infection and gave surgeons the time they needed to carry out lifesaving operations.

They also proved invaluable in the fight against those bacterial infectious diseases which had cost so many lives in WW1.

But as penicillin conquered disease after disease, Alexander Fleming made the prediction that one day the bacteria would outsmart us and become resistant to penicillin treatment.[3]

And how right he was.

It’s hard to believe that in less than 100 years, we could discover and lose one of the most important advances in modern medicine. But the harsh reality is, we are fast heading towards that very situation.

The accelerating development and spread of antibiotic-resistant bacteria on a global scale has been identified by the World Health Organization as one of the greatest threats to human health today.

Just last year they issued an ominous warning – the world needs to act now or we risk losing the power of these miracle medicines forever.

You might be thinking this is something happening elsewhere, not in Australia. The reality is antibiotic resistance is on the rise within our community.

Let me share some statistics from recent years. They are certainly cause for alarm.

  • 2008 data report around 1,700 deaths per year in our hospitals from hospital-acquired MRSA (multiresistant staphylococcus aureas)-infections.[4]
  • While MRSA (or Golden Staph) was once thought to be a problem confined to hospitals and aged care facilities, MRSA now reaches much wider than that, with experts saying around 25% of all MRSA infections are now acquired in the community setting.
  • Of more concern, over the 10 years from 2001-2010, the incidence of MRSA in the Australian community has doubled from 10 to over 20% of all reported staph infections.
  • In Australia our antibiotic use is also contributing to the global effect; new strains of resistant bacteria have emerged here for both staphylococcus aureus and neisseria meningitidis (the cause of meningococcal meningitis). The multidrug resistant tuberculosis crisis in Papua New Guinea is already affecting North Queensland, and the incidence of vancomycin-resistant enterococci – first detected in Australian hospitals in 1994, has gone from ZERO to over 30%.[5]
  • Looking further afield, every year in the European Union it is estimated that over 25,000 people die of antibiotic-resistant bacterial infections, mostly acquired in hospitals.  
  • The estimated total cost to society of antibiotic resistance in the European Union alone is estimated to be € 1.5 billion.[6]
  • Longer durations of illness and more complex treatment increase health care costs and hence the financial burden on families and societies. We need to ask ourselves what is the cost if we don’t address this issue in Australia?

So what has led us to this point?

The overuse and misuse of antibiotics globally is an error in judgment for which we may pay dearly.

Our complacency in the way we use these medicines has led to overuse, with little consideration given to the impact they may be having on an individual’s health, that of the population, or indeed the health of future generations.

Australians are among some of the highest users of antibiotics in the developed world. Around 22 million prescriptions are dispensed every year – that’s a script for every man, woman and child in Australia each year.

We sit well above the OECD average in terms of antibiotics used per capita/per day. In fact, our usage is more than double that of the Scandinavian countries where antibiotic use is less socially desirable – and where health outcomes appear to be no worse than countries with high antibiotic usage.

Every year antibiotics are unnecessarily prescribed for conditions where they have no or limited impact - for viral illnesses where antibiotics have no effect, and for simple bacterial infections  where our own immune system could easily fight the infection without needing help from antibiotics.

So who is responsible?

Is it doctors? After all, they write the prescriptions.

It’s fair to say doctors do play their part by providing unnecessary scripts in some instances. Most antibiotic prescribing in Australia occurs without scrutiny.  Our system is lacking in its ability to track antibiotic usage in an effective way,  and to provide feedback to doctors on their prescribing decisions. There is also insufficient information, such as local resistance patterns,  to help doctors make informed treatment decisions. And it is true that prescribers are often responding to patient expectations and demand.

So is it patients then? Do they need to stop asking?

It turns out we’re not shy when it comes to asking for antibiotics.

Recent research by NPS found many Australians go to their doctor expecting to be prescribed antibiotics. In fact, 1 in 5 of those surveyed said they expected their GP to prescribe antibiotics for themselves or their child for a cough or cold. When asked if they expect to be prescribed antibiotics for an ear, nose, throat or chest infection, this number jumped to almost 4 in 5 (79%), with many consumers failing to realise that these infections are also largely caused by viruses

Parents were twice as likely (14% vs 6%) to request antibiotics to treat their child’s cold or cough as opposed to themselves, with fathers more likely to ask than mothers (22% vs 9%).

For many doctors, when a patient walks through their surgery doors with an expectation or request for antibiotics, it can be hard to say no. With waiting rooms often overcrowded, particularly during cold and flu season, a patient demanding or expecting antibiotics will often leave with a script – just in case.

But why is this a problem?

The fact is, every time we use antibiotics incorrectly or inappropriately, we encourage the development of antibiotic resistant bacteria. These are bacteria which have, over time, changed their DNA to withstand an assault from antibiotics. While the community is starting to understand that the widespread use of antibiotics can cause resistance at a population level, what is not appreciated is that individuals prescribed an antibiotic are twice as likely to develop bacterial resistance to that drug within their normal flora. This effect may persist for up to 12 months.[7],[8] What is even more alarming is that once we carry these resistant bacteria, we can pass them onto others including those who may be more vulnerable than ourselves. This is significant because it introduces an element of individual harm and also individual responsibility that has been largely unappreciated.

If we continue our behaviours unchecked, we do risk returning to an era like I described in World War I – where infections from something as simple as a scratch have the potential to kill.

We are fast approaching a situation where by the time our children have become adults, we may have run out of effective antibiotics.

But is it just our past coming back to haunt us, or have we created an even bigger dilemma?

The bacteria in our community are now stronger and more resistant to antibiotic treatment than ever before.

We don’t just risk returning to a pre-antibiotic era, we are facing a post-antibiotic era where the bacteria are smarter, more virulent and cause nastier and more complex infections. Data shows that the timeline between a new antibiotic becoming available, and the development of resistance to that antibiotic, is getting shorter and shorter.[9]

The success of antibiotics has also led to complacency in terms of infection control. Many programs to measure and stop the spread of infection have ceased over time. Overcrowding and poor sanitation in many parts of the world add to the problem.

Now factor in globalisation. The  increases in population mobility achieved via air travel means these bugs can travel further and faster. Communities are suddenly faced with superbugs that they have never seen before, carried by unsuspecting travellers. I think you can see the potential for a perfect storm.

You may be asking yourselves, why can’t we just invent new antibiotics?

Well potentially we could – but in fact we’re not.

The reduction in infectious diseases and the explosion in chronic conditions such as heart disease and diabetes has understandably encouraged our medicines industry to invest where the need exists.

The time to bring a new drug to market can exceed a decade, and in the early 1990s around 50% of pharmaceutical companies either ended or decreased their investment in antibiotic research.

We are seeing the implications of this now with the absence of new antibiotics coming through the pipeline. Only one antibiotic is approved for release by the US Food and Drug Administration in 2012.[10]

But let’s think about it from industry’s perspective for a moment. If we are smart, a new antibiotic reaching the market today should have its use restricted so that we have effective treatments when they are really needed; if we continue to be cavalier, a new antibiotic will be used widely and resistant bacteria will develop quickly rendering it no more useful than the shelves of antibiotics we already have. It’s not an attractive business proposition.

Clearly we need new strategies to support both the development and funding of antibiotics – we need to recognise them as the life saving drugs that they have become.

So with stronger bugs, and very few medicines being developed to treat them, we are facing a dangerous situation if we don’t act now.

Ultimately the responsibility for this crisis rests with all of us.

So what can we do about it?

Well after all the doom and gloom, I believe there is cause for optimism  - if we change our behaviour now there is a good chance we can slow or even reverse the development of antibiotic-resistant bacteria.

But we need to take action at all levels – individuals, health professionals, communities, media, industry and government. We must act strongly, and we must act now.

Where do we begin?

Based on our research,  addressing the misconceptions held by every day Australians when it comes to antibiotics and antibiotic resistance is clearly a good place to start.

It’s fair to say our attitudes towards antibiotics are fairly ingrained into the psyche of many Australians, so trying to change this is no small task.

But engaging the community is essential to the success of any public health intervention, so this week NPS launched the consumer phase of its new campaign against antibiotic resistance.

To run over five years, the campaign will raise awareness among Australians about antibiotic resistance and its causes, and encourage positive behaviour change so that consumers are not seeking antibiotics for conditions where they are not needed.

On Monday we launched advertising and community service announcements on television, in print and online, to raise awareness of this important public health issue.

We are asking all Australians to take an active role by becoming resistance fighters and join the fight against antibiotic resistance. By taking a few simple steps, everyday Australians can help to combat the development and spread of antibiotic resistant bacteria in the community.

Through a dedicated Facebook page, people can login and commit to a few simple actions that will potentially have a large impact on our usage of antibiotics.

  • Don’t ask or expect antibiotics if you have a cold or flu, as these are caused by viruses which antibiotics cannot and do not treat.
  • When prescribed antibiotics for an infection, take them exactly as directed as not doing so increases antibiotic resistance.
  • Always practice good hygiene to stop the spread of germs
  • And spread the message to encourage others to become resistance fighters as well.

Other tools and resources to help change attitudes and behaviours towards antibiotic use include online content, educational material for use in workplaces and community settings and an antibiotics iPhone app (being launched early next month) which will help people to take their prescribed antibiotics exactly as directed.

Our research told us that young people have less knowledge about the correct use of antibiotics than older generations, which is why interventions that engage this age group are a particular focus for NPS.

All of this runs alongside our campaign for health professionals. We have an ambitious goal to reduce the incidence of antibiotic prescribing by 25% in five years. This will bring Australia in line with the OECD average of defined daily dose of antibiotics per capita/per day and give us a real chance to reduce the incidence of antibiotic-resistant bacteria in the Australian community.

To help us achieve this, we are working with GPs, pharmacists, nurses and other health professionals to promote the use of best-practice guidelines for infections, encourage symptomatic management of colds and flu, and to facilitate better patient conversations when discussing antibiotic resistance and the correct use of antibiotics.

NPS has a long track record of successfully working with individuals and health professionals to change behaviour and achieve better health outcomes.

However, this is a public health issue that ultimately demands a multisectoral response. Everyone needs to play a part.

There are some excellent examples of work internationally that can help guide us as Australia grapples with this issue.

In Sweden in 1994, a program involving collaboration between government, industry and the media was established.

The end result was a 22% reduction in antibiotic prescribing over 4 years. In 2010, a study showed that 78% of the Swedish population was willing to abstain from antibiotics. One of the key success factors to their work was engagement of the media, and keeping this issue at the forefront of the public’s mind.

We need a similar approach here in Australia if we hope to have a real impact.

Great leadership is already being provided – by clinicians, academics, professional and consumer groups, and government. We have a National Medicines Policy that is the envy of the world, and a support structure that can enact real change. Recently the Australian Health Ministers’ Advisory Council (AHMAC) established a national committee to address the issue of antibiotic resistance. This involves partners from across relevant sectors and includes the Australian Commission for Safety and Quality in Health Care, the National Health and Medical Research Council and NPS. Reporting to the Chief Medical Officer, this committee will be fundamental in focusing political attention at both a state and commonwealth level.

But these are big issues to tackle.

Australians need to understand this issue and be galvanised to act at an individual level.

Prescribers need access to prescribing information, local resistance data, and the latest evidence-based clinical practice guidelines.

Across different healthcare settings antimicrobial stewardship must become a clinical priority and be supported by robust policies and guidelines. As alluded to earlier, a national surveillance mechanism to monitor antibiotic resistance and antibiotic usage is a fundamental, but currently missing, building block.

Ongoing research is needed to help us to understand the emerging issues in this space.

Industry and health researchers must be supported to invest in R&D and the development of new antibiotics. Australia has an opportunity to take the lead internationally in this space so I encourage government and industry to explore new mechanisms to fund drug development and bring antibiotics to market through innovative reimbursement models.

Once developed, we need an effective regulatory framework to preserve and safeguard the way we use these medicines.

Government needs to take the lead and recognise where cooperation across portfolios is needed – this issue is not restricted to the health sector. The veterinary, agriculture and manufacturing sectors also have prime roles to play. A high level body involving all stakeholders is urgently needed to ensure a coordinated approach and to make the best use of available resources through collective and focused effort.

I believe we currently have a wonderful opportunity – policy makers and funders are both concerned and engaged; clinicians are recognising the need for restraint; industry is open to new models of drug development; and consumers are receptive to our messages. The environment is primed for change, and the time to act is now.

When Howard Florey won his noble prize in 1945, Prime Minister Robert Menzies remarked that ‘in terms of world well-being, Florey was the most important man ever born in Australia’. His work is estimated to have saved the lives of over 6 million Australians. Let us all work together to ensure his legacy is preserved.


[1] Burnet M. Natural history of infectious diseases. 3rd ed. Cambridge: Cambridge University Press, 1962:18

[2] http://www.lib.niu.edu/2001/iht810139.html
         
[7] Cotelloe C. et al. BMJ 2010;340:c2096
 
[8] Nasrin D, et al. BMJ 2002;324:1-4.
 
[9] Pray L. Antibiotic R&D: resolving the paradox between unmet medical need and the commercial incentive. Cambridge Healthtech Institute (Insight Pharma Reports), Needham, MA, 2008.
 
[10] IDSA Capitol Hill talk by Brand Spellberg, 11 May 2010. www.idsociety.org/content.aspx?id=4810

ENDS

Independent, evidence-based and not-for-profit, NPS enables better decisions about medicines and medical tests.We are funded by the Australian Government Department of Health and Ageing.