Good afternoon, members of the committee. Thank you for the invitation to speak about antimicrobial resistance and its link to TB, tuberculosis. I'd like to begin with a short summary of that issue globally.
TB is the only major drug-resistant infection in existence that is transmitted through the air. All you need to do to contract it is to breathe. TB was declared a national and global health emergency in 1993. Since then, we've had 50 million people die from that disease. Another 28 million will die within 15 years, which is the time frame set globally for its elimination by the sustainable development target. At the current rate of progress, however, it will take 10 times as long to to get to that point of elimination.
The economic and human toll along the way for eradicating TB and the antimicrobial resistance that exists within TB is devastating, so the first lesson I want to convey is that the price of inaction in AMR is enormous.
In infectious diseases, TB is the leading killer in the world, with 1.7 million people dying from it in 2016. Of that number, and relevant for our discussion, are the 240,000 people who died from drug-resistant TB. The worrying fact in TB is also that the majority of new drug-resistant cases are now caused by primary infection, meaning that drug-resistant patients are directly infecting new patients. As a conclusion, I note that TB is responsible for almost one-third of the deaths globally that are caused by antimicrobial resistance.
New diagnostic tools and testing strategies are necessary and essential to find and treat the millions of cases of people with TB. The WHO estimates currently that nearly 40% of TB patients and 75% of all drug-resistant TB cases go undetected and never get diagnosed properly and put on treatment. Presumptive diagnosis is used rather than confirmed testing for TB, and the inappropriate use of drugs that evolves from that has increased drug-resistant strains of the disease, so another lesson to learn in the AMR debate is that testing and treating go hand in hand.
Treatment of TB with antibiotics is very complicated, unlike many other infections. It takes six months to nine months, with a regimen of at least four different drugs—four different antibiotics—that need to be adjusted based on body weight. Treatment is not always compatible with HIV antiretrovirals, which is a serious problem given that TB is the largest killer of people living with HIV. Treatment for multidrug-resistant TB requires almost 14,000 pills and 240 injections. Even then, the WHO reports only a 50% treatment success globally. Due to this complexity, treatment for the most drug-resistant patients can cost up to $1 million in a place like Canada.
In addition to the devastating effects on people in their most productive years, TB jeopardizes economic and social development. An analysis released last week and done by KPMG estimates that in 15 years' time, during the period of 2000 to 2015, TB-related mortality caused the loss of $616 billion for the global economy. If action is not taken, future TB-related mortality may lead to a further loss of almost a trillion dollars. Again, the cost of inaction is massive.
Also, no country is exempt. Forecasts indicate that the greatest human toll from TB will actually be in low- to middle-income countries in southeast Asia and Africa; however, the G20 countries will be the ones most affected economically, bearing almost two-thirds of the economic devastation of this disease. It's estimated that by 2050 drug-resistant TB may cause a lost economic output of almost $10 trillion inside the G20, and another $6 trillion outside the G20.
The latest WHO reports from 2016 show clearly that progress is too slow to reach our goals of eradication, but with a strengthened global commitment to research and development, I believe we can find new and highly innovative TB diagnostics and drugs that can bring the most devastating disease in history to an end. For exactly that reason, developing new drugs and regimens that can cure all forms of TB is why the TB Alliance, where I work, was established in the year 2000.
I would like to take a minute to update you on the progress we have made in that global fight since 2000, and what we can accomplish together in the next five to 10 years or so.
At TB Alliance, we now coordinate, as a public-private partnership, the largest pipeline of drugs, containing everything from early-stage candidates to treatments ready for registration in the next five years. We are actually on the doorstep of a major breakthrough in treating all forms of TB, including all drug-resistant forms. When we get sufficient investments, we can introduce for every person with TB an effective treatment that takes no more than six months, even to treat the most resistant forms of the disease, without the side effects, mortality, and failure that we currently see in treatment.
We've also made significant progress in highlighting the path that over the next 10 years will allow us to treat all patients, however they are currently diagnosed with resistance, in three months or less with the same once-a-day, all oral, highly effective, safe, and affordable TB treatment.
This means we can eradicate drug-resistant TB in the next 10 years. Science is not holding us back, but a lack of funding and political will is. The current glacial pace of TB research funding is well-documented and is costing both lives and livelihoods.
To succeed, I think we can learn a number of lessons in antimicrobial resistance in the wider sense because we've been fighting TB for such a long time.
First of all, I want to mention as a conclusion that we cannot address antimicrobial resistance without dealing with TB. The global response to AMR is fundamentally incomplete if it neglects TB.
We also need global coordinated and pooled investments into research. Product development is expensive and can best be done globally and in a coordinated manner to share risk and broaden transparency. It requires a global action plan and investment, whereas many national R and D plans and grants are strictly linked to national R and D capacity and economic interests.
Despite recognizing TB as the cornerstone of the global fight against AMR, it has often been excluded from health funding programs, for instance the new CARB-X program that my previous colleague talked about. However, I would like to call out JPI-AMR, which is a funding scheme for early research in antimicrobial resistance where Canada participates as a funder and that has announced for the first time in 2018, it will include TB in its portfolio of potential diseases it will allow funding to go to. I want to recognize that, and mention that TB needs to be included in all such AMR programs in the future.
Another point I would like to stress is that academic research is obviously very important, but it is not the same as product development. Many governments believe that their significant investment in academic research and early discovery will be translated into products by effectively using the pharmaceutical industry. However, TB is a poverty-related disease and doesn't have a market. In antimicrobial resistance, one of the things we want to do is use the antibiotics we have as little as possible. That's in effect exactly against what a pharmaceutical company would look for in a market, and therefore, there's very little interest from industry to go into this market space.
In addition to direct benefits to patients, we need to invest in tomorrow's cure as the ethical imperative. In dealing with TB and AMR, it's vital to provide universal health coverage and boost economic prosperity. New technologies will not only save millions of lives but also boost economic prosperity. It will lead to dramatically lower costs for health care systems, given the price we currently pay for dealing with drug-resistant TB. It will drastically reduce the burden on our overworked health care providers and free up resources for overstretched government budgets.
I would like to end by indicating the critical role Canada has in having, fulfilling, and realizing G7 and G20 commitments that were made this year, in 2017, specifically to support increased investments in research and product development. Canada will host the G7 in 2018 and should be building on prior commitments and acting to make research and product development an integral part of the search for solutions in AMR. This should include supporting new or enlarged mechanisms for the development of new drugs, diagnostics, and vaccines working against TB. The recommendations in the recent OECD report on “Tackling Antimicrobial Resistance: Ensuring Sustainable R&D” should serve as a guideline. The report suggests that to improve the R and D pipeline and bring four new antibiotics to the market over the next 10 years, we need an additional globally pooled fund of $500 million U.S. per year, and TB should be included in such a plan.
In conclusion, I would like to share my belief that the major limiting factor to a world without TB is a stronger commitment from the global community, including all of you. Without sufficient investment, we will fall short in our combined efforts to once and for all eradicate TB.
I would like to thank you and the committee for providing this opportunity for dialogue, and obviously I would be open to any questions you may have.