Directors' Blog

Did you miss our InfectedNZ campaign with Figure.NZ? Don’t worry – we’ve put together a collection of resources and Twitter Q+A to help answer your burning questions.

Resources

• InfectedNZ blogs
• Science Media Centre – Antimicrobial resistance – expert Q+A
• Science Learning Hub – teacher and student-orientated information about fighting infections, the immune system, and the work of some researchers.
• NZ Herald online“The big read: is the world on the brink of an antibiotic apocalypse?”
• The Spinoff “In the fight against the superbug apocalypse, don’t fall for the idea that infectious diseases only happen somewhere else.”
• Newshub. “Online campaign highlights dangers of infectious diseases.”
• Newshub. “Antibiotics will soon stop working, scientists warn.”
• NewstalkZB “Antibiotic resistance a growing threat to world health.”
• The Spinoff “Calling a vagina a vagina: why cutesy code words are terrible for our sexual health.”
• Waikato Times “Urgent action needed to combat killer infections.”

Twitter Q+A

I am an ardent defender of people being free to choose what they do with their own life, even when I would not make the same decision. Partly this is because studying economics gave me an appreciation of how individual decision making is surprisingly effective at producing good outcomes, and partly it is me following the golden rule: I don’t like people telling me what to do so I try to refrain from telling others what to do.

I make an exception when it comes to antibiotic use.

The difference being that most health choices that people make primarily affects themselves. However, when people misuse antibiotics this presents a direct threat to my health. Misuse increases the risk of bacterial resistance to antibiotics which compromises the effectiveness of treatments I may need in the future. In economics, we call this an externality – when the choice an individual makes has a direct flow on effect to a third party. When externalities are present the result of individual decision making is not likely to be the best possible outcome.

When it comes to antibiotics there are a number of ways in which individual decision making is clearly causing bad outcomes. When people demand antibiotics to treat illnesses that do not require it, they are not considering the contribution their unnecessary use will make to future resistance. One more person taking antibiotics won’t make much of a difference, right? And if it helps this pesky cold go away then so be it!

Thankfully, in New Zealand we do have safeguards in place to mitigate overuse. Antibiotics are only available by prescription from a medical professional. This is a major step in combatting overuse that could occur if patients were able to self-medicate. Sadly, many countries do not have these responsible safeguards in place and overuse is rampant.

Doctors who are too willing to prescribe antibiotics to placate patients are part of the problem. The Center for Disease Control and Prevention estimates that one in three prescriptions for antibiotics in the US are unnecessary. Monitoring prescribing behaviour by doctors is important to ensure responsible prescription behaviour is taking place.

Incorrect usage after prescription is another issue. For example, people who stop taking antibiotics before finishing the prescription increase the risk of bacteria developing resistance to antibiotics. It is not easy to prevent this from happening but the government can take an active role in education campaigns to inform and persuade the public to use antibiotics correctly.

Agricultural usage is also a major concern. Antibiotics can play an important role in reducing bacterial disease in farm animals, especially important for animals living in cramped conditions which are particularly susceptible to outbreaks. However, the use of antibiotics at the farm contributes to growing resistance. Regulation to monitor agricultural usage is critical. So too is regulation to ensure farm conditions are suitable to limit the risk of disease. Consumers can also help here by choosing to purchase free-range eggs and meat, or reducing their consumption of animal products.

Antibiotic resistance is a looming threat that could have far-reaching and deadly consequences. A world where we cannot rely on antibiotics to treat infections is a very scary thought but a very real possibility if we do not take action. We take antibiotics for granted at our peril.

There are many things that both the public and the government can do to combat antibiotic resistance, but the first step is to raise awareness. Campaigns like Antibiotic Awareness Week and InfectedNZ are crucial to addressing this growing problem.

So when it comes to most health choices individuals make, I’m happy to live and let live, even when the choices may not seem like a good idea to me. But when it comes to antibiotics, I want a firm regulatory hand of government to ensure responsible use. My future health may depend on it.

About

Dr Rachel Webb is a research fellow at the New Zealand Initiative. She has a PhD in economics from the University of Canterbury, specialising in the area of health economics.

What is InfectedNZ?

Hey, Aotearoa. It’s time we had a chat about infectious diseases and what we’re going to do about the looming antimicrobial armageddon. That’s why we’ve asked leading health, social and economic researchers, and people with personal stories, to help us get real about our vulnerability and discuss solutions. Follow their blogs right here at tepunahamatatini.ac.nz and watch the conversation spread across social media with #infectedNZ.

Backing it all up, wherever possible, is data from the good folk at Figure.NZ. Their super duper charts are based on data sourced from public repositories, government departments, academics and corporations. Check out their #infectedNZ data board and sign-up to create your very own data board on any topic that floats your boat.

Two years ago, to commemorate the 300th anniversary of the original Longitude Prize, the UK government offered a ten million pound prize for the solution of a significant global problem. The original Longitude prize was set up in the eighteenth century by the British Admiralty to tackle the difficult problem that mariners faced of determining their longitude at sea. Three centuries later, it was decided that the challenge addressed by new prize would be chosen by the British public by popular vote.

Voters were asked to chose between challenges such as “How can we fly without damaging the environment?” and “How can we ensure everyone has nutritious sustainable food?”. In the end, the public chose to fight the rise of antibiotic resistance in bacteria: the first team “to create a cost-effective, accurate, rapid, and easy-to-use test for bacterial infections that will allow health professionals worldwide to administer the right antibiotics at the right time” will win the prize, provided this occurs before a cut-off date of 2019.

In New Zealand we held the Great New Zealand Science Project (don’t bother googling it, as the site will now try to sell you the services of a personal trainer “Effective Personal Workouts? That’s not Rocket Science !!?!”). The 2012 campaign encouraged the New Zealand public to vote for a range of science challenges and, like the people of the UK, the public voted for a project for “Fighting Disease”. I’ve always found it remarkable that of the ten National Science Challenges that were chosen by the government, not one tackles infectious disease.

In the end there were four challenges that involved the health sciences: “A Better Start”, “Healthier Lives”, “Aging Well”, and “High-Value Nutrition”. The Healthier Lives Challenge, which at first glance seem best placed to tackle infectious disease, addresses what it calls four of New Zealand’s main non-communicable diseases: “Cancer, Cardiovascular disease, Diabetes and Obesity”. The Better Start Challenge grapples with obesity, learning, and mental health problems in children and teenagers. Aging Well concerns “brain and body health”, as well as ways “to reduce disability and moderate the impact of age-related illness such as dementia, stroke, depression and frailty.”

So despite a mandate from the public, the National Science Challenges shied away from taking on infectious disease. The report of the panel that selected the Challenges noted that research into infectious disease did not meet their threshold for additionality (that is, what would a science challenge add to the health science sector) or for current scientific capacity in New Zealand. To appraise these comments, we need to look at what else is going on in the health science system.

With that in mind, the other major source of health science funding in New Zealand is the Health Research Centre (HRC). They fund a very wide range of projects, and those awarded since 2016 are listed here. To what extent does the HRC fund research into infectious disease?

It’s actually quite hard to tell. I pulled down two years of data from the HRC website concerning projects that were awarded funded in 2006 and 2014. Running through the list project-by-project, my estimate is that only 3% of the HRC funding in those years was allocated to researchers to study infectious disease. For the most part, HRC funding in these years mirrors the “Healthier Lives” Challenge (cancer, cardiovascular disease, diabetes and obesity) with nods to a “A Better Start” and “Aging Well”.

This week’s #InfectedNZ discussion has highlighted some of the challenges New Zealand faces from infectious disease. There is clearly concern amongst the public and amongst the scientific community about this, particularly the potential threat from antibiotic resistant bacteria. There are also significant costs to our healthcare system: as the figure below shows, we have nearly 100,000 hospital admissions per year due to infectious disease.

It is hard to argue that a National Science Challenge in infectious disease would not have provided additionality: it would evidently have provided much needed resource in an area to which we devote less than 3% of our health research funding. If the panel that selected the National Science Challenge was correct, then it would seem we don’t have the scientific capacity in New Zealand to address infectious disease. This should be a serious concern in light of the conversation this week. Perhaps it is time to do something about it.

About

Shaun Hendy is the Director of Te Pūnaha Matatini. Shaun is an advocate for multi-disciplinary research and teaching, and lectures in the University of Auckland’s Department of Physics and the University’s Centre for Innovation and Entrepreneurship.

What is InfectedNZ?

Hey, Aotearoa. It’s time we had a chat about infectious diseases and what we’re going to do about the looming antimicrobial armageddon. That’s why we’ve asked leading health, social and economic researchers, and people with personal stories, to help us get real about our vulnerability and discuss solutions. Follow their blogs right here at tepunhahamatatini.ac.nz and watch the conversation spread across social media with #infectedNZ.

Backing it all up, wherever possible, is data from the good folk at Figure.NZ. Their super duper charts are based on data sourced from public repositories, government departments, academics and corporations. Check out their #infectedNZ data board and sign-up to create your very own data board on any topic that floats your boat.

At Cure Kids, we are dedicated to raising funds in order for research to be carried out that will best contribute to our vision of a healthy childhood for everyone. As the Research Manager, I am fortunate enough to have a close connection with all the research projects we fund. I’m also lucky to be able to connect with many of our wonderful ambassadors, many of whom live with the conditions that we’re researching.

In 2014, we became patently aware – via a proposal from Dr Siouxsie Wiles – about the imminent crisis that we (and by we, I mean, everyone) are facing. Over 80 years ago, health research was advanced immeasurably – and with it, health outcomes – when a beautiful collision of science and happenstance would result in the discovery of penicillin from the fungus, penicilium.

Dr Alexander Fleming, the scientist who discovered penicilium, had some ominous words, when accepting his Nobel Prize in 1945, of which we have not taken heed, ‘The thoughtless person playing with penicillin treatment is morally responsible for the death of the man who succumbs to infection with the penicillin-resistant organism’.

Dr Fleming, in equal parts wisdom and humility, knew the limitations of his momentous finding. The world has blindly careered into what may become a post-antibiotic era; to the point, now, where there are very few effective bulwarks against what were once treatable, innocuous bugs, but are now pernicious soldiers with an ever-increasing arsenal.

Antibiotics have been a great defence against unwanted visitors for decades. They have been used to prevent infections in routine surgeries, treat preterm babies, as well as provide a defence when patients undergo chemotherapy. The problem is that imprudent use is rendering antibiotics useless. We have all presumed this is a sustainable use of antibiotics; it is not.

Much like other collective-action efforts, such as action on climate change, antibiotic resistance has not been given the time of day – nor funding – it needs.

So many of our Cure Kids ambassadors have compromised immune systems, where they are vulnerable to the invasiveness of these drug-resistant bugs. Cystic fibrosis, a life-limiting inherited lung disorder is characterised by thick mucus build-up in the lungs. This mucus provides an amenable breeding ground for the bug Pseudomonas aeruginosa, with strains arising unperturbed by previous effective treatments.

A multi-pronged attack is required if we are to stave off countless deaths. While medical institutions attempt to be better stewards during prescription, Dr Wiles and her team are scouring the treasure trove of unique fungi located in New Zealand and the South Pacific. These untapped fungi could well hold a solution, and we’d like to do all we can to expedite the process of bringing the world back to an era where antibiotics are once again a powerful force against sophisticated superbugs.

Cure Kids occupy a space which deals with both the lab end, and the clinical end. We are excited to lend our support to Dr Wiles’ quest, as we are all too aware of the havoc these superbugs can wreak on our children. Us adults have reaped the benefits of advances enabled by Dr Fleming’s finding. It is now incumbent upon us to afford these same benefits to our young ones.

About

Ryan Chandler is Research Manager for Cure Kids – a charity funding vital medical research so everyone can live a healthy childhood. Donate to help.

What is InfectedNZ?

Hey, Aotearoa. It’s time we had a chat about infectious diseases and what we’re going to do about the looming antimicrobial armageddon. That’s why we’ve asked leading health, social and economic researchers, and people with personal stories, to help us get real about our vulnerability and discuss solutions. Follow their blogs right here at tepunhahamatatini.ac.nz and watch the conversation spread across social media with #infectedNZ.

Backing it all up, wherever possible, is data from the good folk at Figure.NZ. Their super duper charts are based on data sourced from public repositories, government departments, academics and corporations. Check out their #infectedNZ data board and sign-up to create your very own data board on any topic that floats your boat.

What might the economic costs of antibiotic/antimicrobial-resistant infections be in New Zealand? The simple answer is – we don’t know. As far as I’m aware, there’s been no New Zealand studies publicly disseminated on this topic. Therefore, we have to look overseas for reported studies.

While the US Centers for Disease Control and Prevention (2013) stated the total economic cost of antibiotic-resistant infections to the US economy was difficult to calculate, they cited year 2000 estimates provided by the Alliance for the Prudent Use of Antibiotics (APUA), an international non-governmental organisation. Based on ~900,000 cases of antibiotic-resistant infections a year, the APUA estimates ranged as high as US$20 billion in excess direct healthcare costs, with additional costs to society for lost productivity as high as US$35 billion a year.  Given the number of cases reported has more than doubled over the past decade – CDC recently estimated that over 2,049,442 people are sickened every year with antibiotic-resistant infections, with at least 23,000 dying annually, who could once be easily cured – costs will have risen substantially. Furthermore, drug resistance related to viruses such as HIV and influenza was not included, nor was drug resistance among parasites such as those that cause malaria, so the true costs are likely even higher.

More recently, the UK government commissioned a review on antimicrobial resistance, in 2014, chaired by macroeconomist Jim O’Neill. As part of the two-year independent review, they estimated  losses to the world economy caused by reductions to the size and efficiency of the labour force resulting from three resistant hospital-acquired infections (Escherichia coli, Klebsiella pneumoniae, and Staphylococcus aureus)  and three major infectious diseases (HIV, tuberculosis, and malaria). By 2050, they projected that in a world without effective antimicrobial therapy, gross domestic product (GDP) per capita in high-income countries would be 2.3% lower each and every year compared to a world with no resistance. An older 2005 study led by the London School of Hygiene and Tropical Medicine (Richard Smith and colleagues) estimated current losses attributable to a level of MRSA (alone) of 40% in the UK at 0.4% to 1.6% of GDP – thus suggesting the review projections might be on the low side.

The review team recognised that their projected GDP losses will be an underestimation of the overall costs of antimicrobial resistance for several reasons. First, only six conditions were included as the research team was unable to identify sufficiently robust data on others. The worldwide extent of the problem is hard to pinpoint since data are incomplete, and there’s no standard for tracking such infections and associated deaths. That also makes totaling the economic impact — and exact death count — difficult to do. Second, people may choose not to undergo certain procedures because of the heightened risks involved, resulting in further morbidity and mortality. For instance, most intensive care medicine, and surgical procedures such as caesarean sections, organ transplantations, removing tumours, and hip replacements would not be possible if you don’t have effective antibiotics available that can deal with the infections that will result – modern medicine would be paralysed. And third, costs in the healthcare system and from reduced activity in travel and trade were also not included.

It’s possible we could slice and dice the costs above and apportion them to the New Zealand population. But the different methodological approaches taken, dissimilar healthcare systems, and varying usage of antibiotics in human and animal health may mean the results are not generalisable.

Given that the dangers of resistance are widely acknowledged, why hasn’t more been done in the past? One reason is that antibiotic resistance has fallen victim to evidence-based policy making, which prioritises health problems by economic burden and cost-effectiveness of interventions. While the estimated costs of antibiotic resistance are substantial, they have not been as high as in many (competing) therapeutic areas. Thus health economists have been unable to show that antibiotic resistance costs enough to be a health priority. However, the potential future costs of a world without effective antibiotics would be much larger than the cost of antimicrobial resistance today – one could draw an analogy with climate change – though it is currently not clear to what extent, or how quickly, the future burden of antimicrobial resistance will grow. The O’Neill review stated that antimicrobial-resistant infections (due to the six above conditions) are responsible for ~700,000 deaths globally each year, with this number likely to be an underestimate due to poor reporting and surveillance. By 2050, these deaths are projected to rise to 10 million a year: more than global annual cancer deaths.

International co-ordination towards the goals outlined in the Final Report and Recommendations of the Review on Antimicrobial Resistance (just published in May) is a way forward. In the words of an esteemed UK colleague, rather than see expenditure on antimicrobial policies as a cost, we should think of it as an insurance policy against a catastrophe; albeit one which we hope will never happen.

References

• US Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. Atlanta: CDC, Department of Health and Human Services. 2013.
• O’Neill J. Review on antimicrobial resistance. Antimicrobial Resistance: Tackling a Crisis for the Health and Wealth of Nations. 2014.
• O’Neill J. The review on antimicrobial resistance. Tackling Drug-Resistant Infections Globally: Final Report and Recommendations.  2016.
• Smith RD, Yago M, Millar M, Coast J. Assessing the macroeconomic impact of a healthcare problem: The application of computable general equilibrium analysis to antimicrobial resistance. Journal of Health Economics 2005; 24(6):1055–75.

About

William Leung is a lecturer in health economics at the University of Otago, Wellington, and is currently leading the economic evaluation of SHIVERS, a CDC-funded influenza project.

What is InfectedNZ?

Hey, Aotearoa. It’s time we had a chat about infectious diseases and what we’re going to do about the looming antimicrobial armageddon. That’s why we’ve asked leading health, social and economic researchers, and people with personal stories, to help us get real about our vulnerability and discuss solutions. Follow their blogs right here at tepunhahamatatini.ac.nz and watch the conversation spread across social media with #infectedNZ.

Backing it all up, wherever possible, is data from the good folk at Figure.NZ. Their super duper charts are based on data sourced from public repositories, government departments, academics and corporations. Check out their #infectedNZ data board and sign-up to create your very own data board on any topic that floats your boat.