How do we capture the societal value of antibiotics? Ramanan Laxminarayan University of Strathclyde & the Center for Disease Dynamics, Economics &

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1 How do we capture the societal value of antibiotics? Ramanan Laxminarayan University of Strathclyde & the Center for Disease Dynamics, Economics & Policy 6 September, 2017 DRIVE-AB Final Conference

2 WP1c members Co-leads John Rex, Ramanan Laxminarayan Academic partners Heidelberg University Axel Leporowski, Timo Goeschl University of Strathclyde Tim Bedford, Abigail Colson, Itamar Megiddo, Alec Morton, Razzaque Sarker Wageningen University Dusan Drabik, Justus Wesseler EFPIA partners MSD/Merck Harpal Dhillon, Cheryl Donnelly, Shuvayu Sen Pfizer Charles Knirsch Sanofi Florence Joly Roche Taimur Bhatti, Ka Lum DRIVE-AB ( is supported by the Innovative Medicines Initiative (IMI) Joint Undertaking ( under grant agreement no , resources of which are composed of financial contribution from the European Union s Seventh Framework Programme (FP7/ ) and EFPIA (European Federation of Pharmaceutical Industries and Associations) companies in kind contribution. 2

3 Antibiotics are different from other drugs. Resistance cost: Using an antibiotic selects for resistance. Transmission benefit: Treating one patient decreases overall incidence. Antibiotic resistant bacteria Microrao, CC-BY-SA 4.0

Antibiotics provide benefits that other drugs do not. Enabling value: Many surgical and medical procedures rely on prophylaxis with effective antibiotics.

4 Antibiotics provide benefits that other drugs do not. Enabling value: Many surgical and medical procedures rely on prophylaxis with effective antibiotics. Option or insurance value: We may want to have an antibiotic in reserve before we really need it, so it s ready if resistance arises or worsens. Diversity value: Having multiple antibiotics may reduce selection pressure and delay resistance. Cesarian the moment of birth Diliff, Free Art License

5 The value of an additional antibiotic depends on the number of resistant infections. A thought experiment: If Nearly every person on the planet will have at least one bacterial infection in a year Then 7 billion infections 1/10 will be serious and need antibiotics 700 million infections needing antibiotics 2-3% don t respond to most existing antibiotics million resistant infections Between 5 and 10% of MDR infections lead to death 1-2 million deaths from resistant pathogens 5

6 Absolute risk reduction (ARR) of infection with antibiotic prophylaxis in common surgical procedures and blood cancer chemotherapy in the USA Teillant et al, Lancet Infect Dis, 2015

7 Enabling value: The 10 procedures 7

8 Enabling value: Proportion of infections caused by pathogens resistant to standard prophylaxis 8

9 Enabling value: Number of additional infections 9

10 Enabling value: Number of additional deaths 10

11 Enabling value: Number of post-biopsy infections/yr 11

12 Option value antibiotics and infection control bear a striking resemblance to the firefighting infrastructure: the microbiology laboratory serves as the smoke detector, medical personnel are the firefighters, and antibiotics are the water supply. All of these elements have to be established before the fire (infection), since buildings burn (and patients die) far more quickly than infrastructure can be built. - Rex and Outterson

13 Unlike antivirals, vaccines, etc, the value of effective antibiotics during a pandemic remains unexplored. Velasco et al. (2012)

14 Policy A: withhold wide use of the broad-spectrum oral antibiotic until a pandemic occurs 14

15 Policy B: immediately begin wide use of the broadspectrum oral antibiotic 15

16 Option value: Sensitivity to pandemic hazard rate and prevalence of resistant strain

17 Diversity value Depends on number of existing therapeutic options and the extent to which these can be displaced by a new antibiotic Diversity value is still small since many therapeutic options remain probably under 10 million per year. 17

18 HTA is conducted according to set guidelines. There s no guidelines or methods advice specific to antibiotics. Antibiotics are treated like any other drug.

19 Recommendations for HTA of antibiotics. 1. Assessment should, as appropriate, include a sensitivity analysis of the impact of resistance to the new antibiotic, both initially and over time. 2. Analysis should take place at the population level. 3. In addition to the direct costs and benefits associated with treating one patient with an antibiotic, where relevant, the following benefits should also be taken into account a. Indirect benefits from avoided onward transmission b. Diversity benefits from the protective effects on existing antibiotics currently in use 19

20 A worked example: CRAB Carbapenem-resistant Acinetobacter baumannii Important cause of healthcare associated infections High morbidity High mortality (20%) Low prevalence Spellberg and Rex (2013) conduct a CEA of a hypothetical CRAB monotherapy, focused on direct benefits, which we extend to include indirect benefits.

21 Worked example: Estimated costs and benefits Point estimate Low High Total costs (millions) Direct cost (millions) Direct savings (millions) Transmission savings (millions) Diversity savings (millions) Total benefits (QALYs) Direct benefits (QALYs) 12, ,294 16,589 Transmission benefits (QALYs) 33,178 16,589 49,766 Diversity benefits (QALYs) 2, ,063 = 3,661 per QALY 21

22 Conclusions Antibiotic resistance is a complex issue, but the principles of public health planning still apply What is the need? Do the benefits exceed the costs? Current work represents a start in thinking about: Defensible techniques for modelling Reasonable processes for making decisions

23 Thank you! Twitter 23

24 References Rex, John H, and Kevin Outterson Antibiotic Reimbursement in a Model Delinked from Sales: A Benchmark-Based Worldwide Approach. The Lancet Infectious Diseases 16 (4): doi: /s (15) Spellberg, Brad, and John H. Rex The Value of Single-Pathogen Antibacterial Agents. Nature Reviews Drug Discovery 12 (12): doi: /nrd3957-c1. Teillant, Aude, Sumanth Gandra, Devra Barter, Daniel J Morgan, and Ramanan Laxminarayan Potential Burden of Antibiotic Resistance on Surgery and Cancer Chemotherapy Antibiotic Prophylaxis in the USA: A Literature Review and Modelling Study. The Lancet Infectious Diseases 15 (12): doi: /s (15) Velasco, et al. (2012). Systematic Review of Economic Evaluations of Preparedness Strategies and Interventions against Influenza Pandemics. PLOS ONE, 7(2), e

On behalf of the Infectious Diseases Society of America (IDSA), I am pleased to provide

On behalf of the Infectious Diseases Society of America (IDSA), I am pleased to provide Transmitted by Jonathan Nurse, Director of Government Relations, IDSA The Infectious Diseases Society of America s (IDSA) Fiscal Year 2015 Funding Statement Submitted to the House Appropriations Subcommittee