Antimicrobial resistance (AMR) is one of the defining scientific, health and economic challenges of our time. Without urgent and meaningful action to address specific diseases and system-level issues, patients, families and communities around the world will face a tremendous threat in the years ahead from untreatable infections. While AMR is fundamentally driven by pathogens’ ability to evolve, its impact is greatly amplified by factors that span economic, healthcare, and agricultural domains.
Given the breadth of the AMR issue, specific initiatives aimed at solving individual components of the problem won’t be enough. Rather, addressing AMR will require a comprehensive effort from multiple partners – governments, civil society and industry – working together with shared accountability for actual outcomes. These partners must improve how we prevent infections in the first place, effectively deploy and deliver current tools across all countries, and spur the development of new innovations.
At Johnson & Johnson, we will be a part of the solution to AMR. We have focused efforts across our business to address many facets of the AMR challenge, and are championing a new sustainable ecosystem model to work with partners and further change the trajectory of health for humanity.
Click here for the Executive Summary: Antimicrobial Resistant Policy Statement.
Whether you are a nurse in South Africa, a cancer survivor on chemotherapy in Europe, a newborn in China, or a patient about to undergo surgery in the United States, the possibility of acquiring an infection that is resistant to many, if not all, available therapies is alarmingly high. While the circumstances of people like these and many others around the world are the result of unique health systems and market failures, the shared threat of AMR is one of the most pressing global healthcare issues of our time. Despite many laudable efforts, more needs to be done to maintain and increase the awareness of this important issue, and move beyond calls for action toward activities that drive meaningful change. Failure to act will have a staggering impact on both global public health and the global economy.
From a health perspective, AMR today is responsible for an estimated 700,000 annual deaths worldwide, including more than 50,000 in the United States and Europe alone. By 2050, those numbers could increase to 10 million globally – a greater global impact than we currently face from diseases like cancer and diabetes.1 As a nation’s health and wealth are intensely intertwined, AMR is expected to have a catastrophic economic impact as well, drawing parallels to the 2008 global financial crisis. Cumulatively, AMR could cost the global economy more than $100 trillion between 2014 and 2050.2 This makes AMR one of the most significant global health security issues that nations face. These threats have been detailed in several reports, including O’Neill AMR Review, the Access to Medicine Foundation’s AMR Benchmark, the WHO’s AMR Global Report on Surveillance, the World Bank report on Drug-Resistant Infections, the AMR Industry Alliance's 2018 Progress Report and others.
Resistant pathogens travel and cause outbreaks within and across national borders. While the impact and threat of AMR is truly global, its main causes and consequences play out differently in developing and emerging markets compared to developed countries. That said, three responsive strategies are critical in every context:
1) Preventing individuals from acquiring resistant infections: Broad awareness and education strategies are needed to advance infection prevention. In addition, vaccines play a crucial role in preventing a range of AMR-relevant infectious diseases around the world. Other tailored strategies are needed depending on the local context. In places like the United States and Europe, Hospital Acquired Infections (HAIs) are a major driver of AMR infections that can be prevented with appropriate tools.
2) Treating existing infections: Giving patients with AMR infections the best chance at recovery requires preserving and extending the effectiveness of current therapies. To do so, they must be appropriately used in humans and animals to protect therapeutic effectiveness. Surveillance is also a key enabler to track prevalence of resistant pathogens and effectiveness of existing therapies. Finally, environmental protections must be established and adhered to. All of this requires robust health systems be in place to diagnose, track, and treat AMR infections.
3) Discovering and developing new tools to reverse the trend of growing drug resistance: Infectious pathogens will continue to evolve and develop resistance to new and existing therapies. The unique nature of the AMR market (where product use should be carefully restricted after approval so treatments reach the appropriate patients at the right dosages) drives the need for tailored incentives to reward innovation and spur further R&D investment. Furthermore, new diagnostics are essential to ensure antibiotic use is limited to those with appropriate infections.
Johnson & Johnson’s Contributions to Addressing AMR
As the world’s largest, broadly based healthcare company, Johnson & Johnson is committed to changing the trajectory of health for humanity. In today’s world, it is impossible to achieve this goal without addressing the global threat of AMR. From tackling multidrug-resistant tuberculosis, the largest cause of AMR deaths, to working to prevent hospital acquired infections (HAIs) and more, we have a diverse set of investments and commitments.
Policy & Advocacy: In addition to the product-specific approaches outlined below, we have leveraged our size and scale to promote a shared accountability in addressing the issue of AMR. We are a proud signatory to the AMR Roadmap and the Davos Declaration on Combating AMR and remain committed to their one-health principles. We have been active members of the AMR Industry Alliance, testified before the US Congress on the topic, and have provided input and support to other international and domestic actions to address AMR including the US National Action Plan for Combatting Antimicrobial Resistant Bacteria, ongoing World Economic Forum AMR working groups, and the EU Action Plan on AMR.
Drug-Resistant Tuberculosis (DR-TB): Globally, more people die of tuberculosis than any other infectious disease, and drug-resistant tuberculosis accounts for roughly one-third of all current AMR fatalities. The standard of care for multidrug-resistant TB (MDR-TB) treatment up until recently required a complex regimen of ~14,000 pills and injections taken over the course of 24 months with significant side effects and only moderate success. Simpler, safer, and more effective treatments are essential to decrease the overall burden of DR-TB.
Recognizing the longstanding need to address the threat posed by DR-TB and the inability of current tools to effectively address it, Johnson & Johnson, through our Janssen Pharmaceutical Companies, sought to develop novel treatments that could offer new hope to patients and healthcare providers. After a discovery, research and clinical development program spanning nearly two decades and involving 15 clinical trials, SIRTURO® (bedaquiline) received accelerated approval by the US FDA at the end of 2012 for the treatment of MDR-TB, as part of combination therapy.3 It was the first TB drug with a novel mechanism of action to be approved in more than 40 years. With this approval, we received a Priority Review Voucher from the US FDA. The drug also received conditional approval in the EU in 2014. A Phase III study, multi-country registry data collection, and pediatric program are ongoing and part of the FDA and EMA post-approval commitments.
Following approval, numerous steps have been taken to promote broad, equitable access to SIRTURO® while ensuring appropriate use and stewardship in line with WHO guidelines to prevent the development of resistance. We are proud that this approach was noted as the most comprehensive for any single AMR product in the recently published Antimicrobial Resistance Benchmark. Our efforts include a global distribution agreement through the Global Drug Facility, targeted access programs in certain high-burden countries (e.g., South Africa, India, etc.) and a four-year donation program through USAID. Equity-based tiered pricing is in place to ensure affordability in specific markets, and manufacturing agreements have been put in place to ensure a steady supply.
To support the rollout and appropriate use of SIRTURO®, Johnson & Johnson has been working with a variety of local, national and global stakeholders. This includes providing healthcare provider training (e.g., audiometry and ECG testing equipment/training) and undertaking appropriate pharmacovigilance and surveillance activities to monitor resistance to SIRTURO® and companion treatments within the same regimen. Through these access mechanisms and supporting programs, we have provided more than 82,500 courses of SIRTURO® for patients in 114 countries.4
To build on this success and further simplify the DR-TB treatment regimens, we have a variety of additional research programs underway:
- We have ongoing, internal and collaborative research programs exploring novel targets and mechanisms.
- We recently signed a Memorandum of Understanding with India’s Institute of Microbial Technology (IMTECH), part of the Council of Scientific & Industrial Research.
- We joined the TB Drug Accelerator in 2017.
This research investment and our continued efforts to expand access to SIRTURO® are all part of our global effort to ensure no patient faces the burden of untreatable TB.
Other Anti-Infective Vaccines & Therapies: Beyond DR-TB, we have many ongoing research projects to develop new drugs or vaccines for AMR-relevant diseases, both in developed and developing countries. According to the AMR Benchmark published by the Access to Medicines Foundation, Johnson & Johnson has one of the largest antimicrobial (including anti-viral) R&D pipelines within the research-based pharmaceutical industry, with 48 projects targeting 15 priority pathogens, including novel therapies and vaccines.5 These include projects targeting E. coli, influenza, Respiratory Syncytial Virus (RSV), hepatitis B, and HIV. For RSV and influenza, we are complementing our work on new therapeutics with additional efforts to develop an evidence base that supports appropriate and broader adoption of more sensitive and rapid diagnostic testing to improve care and management of patients with acute respiratory infections.
Hospital Acquired Infection Prevention: As noted, one of the major drivers of AMR-related infections in developed markets like the United States and Europe is HAIs. Many of these HAIs are preventable with appropriate strategies in place. Across our business units within our Medical Devices segment, we seek to reduce the risk of these infections through a variety of antimicrobial and sterilization tools and technologies. These include:
- DePuy Synthes’ Expert Tibial Nail (ETN) PROtect, which releases antibiotics locally into the implant’s surrounding;6
- Certain DePuy Synthes’ bone cements (e.g., SMARTSET® GHV & GMV) contain the antimicrobial gentamicin;
- Ethicon Biopatch®, a chlorhexidine protective disk, shown to reduce catheter-related blood stream infections (CRBSI);
- Ethicon Plus sutures coated with the antimicrobial triclosan, shown to reduce surgical site infection (SSI);
Ongoing research and development into related products across these businesses will continue to identify and evaluate innovative ways to protect vulnerable patients and health workers.
Environmental Considerations: Across our Company, Johnson & Johnson takes a proactive, comprehensive approach to minimize the environmental antibiotic exposure from our research and manufacturing. We have a defined environmental risk-management strategy to reduce the risk of antibiotic discharge during manufacturing. Elements of this strategy are publicly available.7 This includes establishing and applying science-based discharge limits and auditing both our own sites and third-party manufacturers. To help drive standardized approaches to evaluating environmental, health and safety performance of suppliers across the pharmaceutical industry, including antibiotics suppliers, we are active members of both the AMR Roadmap Manufacturing Work Group and the Pharmaceutical Supply Chain Initiative. We have reported transparently on our progress in this area both through the Access to Medicines Foundation’s Antimicrobial Resistance Benchmark as well as the AMR Industry Alliance Progress Report.
The complexity of the AMR landscape and the potential for catastrophic impact on the lives of people and caregivers around the world requires that stakeholders across multiple sectors (e.g., government, industry, civil society) work together toward shared goals. While this can be challenging, global efforts around HIV, polio eradication and other efforts show it is achievable.
Together we must address multiple AMR systemic failures, including the lack of early research, the high cost and risk of technology development, and barriers to finding, diagnosing and treating patients across all high-, medium- and low-income geographies. Solving for any one issue in isolation is not enough: incentivizing companies to develop new innovative medicines will not matter if health systems are not able to deliver them to patients and maintain their effectiveness. Conversely, even the best health systems will not be able to help patients if companies do not continue creating innovative tools.
At Johnson & Johnson, we have publicly pledged our support and are aligned with the calls to action outlined in the Davos Declaration on AMR and the AMR Roadmap. We believe that, as an industry, our responsibility is to bring our skills and experiences in discovery, R&D, market access and promoting appropriate use to the table.
We see the following areas as critical for encouraging company engagement, and support corresponding investments and initiatives championed by governments and other stakeholders to build more robust health systems.
R&D Incentives: The global pipeline for new products targeting resistant infections is not sufficient, given the size and scale of the challenge posed by AMR. In some cases, this may be due to scientific barriers that can be broken down with additional investments in basic research, though the range of resistant pathogens is very large and constantly changing, which requires a diverse body of research. In most areas though, incentive models do not align with the unique AMR marketplace, where product use should be restricted to the right patients. As there is no one-size-fits-all approach to this challenge, we support a basket of incentive programs designed to spur additional at-risk investment in AMR development. With few exceptions, the lack of such investment to date has directly contributed to the AMR crisis we see today.
We applaud the various “push” mechanisms, such as BARDA’s CARB-X, set up to encourage innovation in this area. We see opportunity for further use of “pull” and market-based incentives such as:
- Priority Review Vouchers: Building on our experience with SIRTURO®, we are a strong proponent of the US Priority Review Voucher (PRV) system, which grants companies that successfully develop a drug for certain underserved diseases or populations a voucher for expedited review of another therapeutic candidate. While the market value of a PRV is highly variable, and does not in itself provide recompense for a full-scale drug development program, we believe this system should be maintained in the United States and explored elsewhere as an incentive for AMR research.
- Transferable Exclusivity Vouchers: Similar to PRVs, Transferable Exclusivity Vouchers (TEVs) could be a powerful motivator for companies to invest in AMR research or other areas of unmet medical need. These incentives would allow companies that develop specific neglected medicines to extend the exclusivity period of a separate product in a defined therapeutic category for a defined time. Like PRVs, they have the advantage of not requiring any appropriated funding from governments. We support further exploration of this model.
- Market Entry Rewards: New products targeting resistant infections should be used judiciously, which poses a challenge in the current landscape where innovator companies have only a limited period in which products have marketing exclusivity. Providing a reward for companies that reach a defined milestone (i.e., bringing a product to market), can overcome this barrier. Implementing this effective solution necessitates that governments or other sources secure adequate funding for these rewards.
- Special Procurement / Health Technology Assessment: We support preproposals for special procurement mechanisms or health technology assessments that address the complexity and unique nature of the AMR marketplace. These assessments should appropriately value innovations in this marketplace compared to older standard of care products that have decreasing efficacy over time as resistance grows. New economic models are needed that account for the societal value, and address the challenges of demonstrating the value of innovative antibiotics approved based on data from non-inferiority trials. Doing so will help improve the predictability of demand and overall investment in research.
Regardless of the additional incentive models that may be pursued, it is important that existing regulatory exclusivities and Intellectual Property (IP) protections be maintained for companies that bring innovations to the market. As we have experienced with SIRTURO®, these protections are a key element of any comprehensive strategy to stimulate innovation and access to new treatments.
While many of the previously mentioned incentive models have been proposed to bring new drugs to market, specific incentive tools to address the gap of fit-for-purpose diagnostic tools and technologies are also needed. Finally, we support initiatives like the Coalition for Epidemic Preparedness (CEPI) and others that seek to incentivize the development and access to new vaccines that can limit the spread of resistant infections.
Regulatory Approval: The approval of therapies targeting resistant infections poses unique challenges in clinical design and evaluation. We commend the various guideline changes and legislative efforts to streamline regulatory pathways (e.g., ADAPT in the United States, the FDA / EMA / PMDA Tripartite Agreement, etc.). Building on this progress, we believe further gains can be made by continuing to harmonize and converge regulatory data requirements across countries. Where appropriate, mutuThrough these access mechanismsThrough these access mechanismsal recognition of stringent approvals can expedite access worldwide.
Appropriate Use & Access: Ensuring new and existing anti-infective tools and products are used appropriately is paramount to addressing the AMR issue globally. This requires concerted action on several fronts:
- Health Infrastructure & Delivery: The most critical factor to addressing the threat of AMR is the existence of a robust health system that can effectively find and treat AMR infections, and work to prevent their spread. We have been proud to work with the government of South Africa and others in their accelerated case finding, training and treatment programs. We aim to ensure they have the appropriate technology to promote appropriate access of SIRTURO® and we encourage donors and governments to make the necessary investments to deal with this critical challenge. This includes training healthcare workers and providing them with appropriate infrastructure, ensuring patients have access to essential care and services, tracking and reporting resistant infections, and more.
Globally, we are proud to champion the Universal Health Coverage (UHC) movement and believe that actions to address AMR will be most sustainable when taken as part of country-level efforts to achieve UHC.
- Diagnostics: As noted by the US Centers for Disease Control (CDC), overprescribing of antibiotics is a significant problem that contributes to drug resistance: more than 40% of outpatient antibiotic prescriptions are for acute respiratory infections, and it is estimated that half of these are not necessary.8 We support the CDC’s recommendations for prescribers and patients to promote appropriate use of antibiotics. Additionally, we believe there is an important need for diagnostics that can help ensure the right treatments are used for the right patients. Beyond the R&D incentives mentioned previously, reimbursement reforms are also needed to encourage doctors and providers to use these diagnostic tools.
- Medical Devices: With respect to medical devices, we support the creation and adoption of guidelines that favor use of technologies designed to reduce the risk of HAIs in hospitals, and policies that encourage health workers and hospitals to adopt systematic checklists regarding the use of these technologies.
- Animal Use: While we do not have an Animal Health business, we do recognize the importance of good antibiotic stewardship in animal populations and support global and local efforts that limit the inappropriate use of antibiotics in these settings. We support ending the use of prophylactic dosing of antibiotics for infection-prevention and growth promotion, as well limiting use of antibiotics in animals that are critical for human use.
Environmental Considerations: We support the environmental management and transparency principles captured in the Antimicrobial Resistance Roadmap document. We encourage other manufacturers of antibiotics to endorse, embrace and enact these principles as well, and report on their progress in meeting these principles.
An Ecosystem Approach: While we see implementing the policy solutions mentioned above as critical to ensuring additional industry engagement in AMR, they will not be sufficient if implemented in isolation. As we learned from our experience with SIRTURO®, working collaboratively with all stakeholders in a country is what ultimately creates rapid improvements and drives patient outcomes. Solving for AMR will require a new way of thinking, where stakeholders work transparently in mission-oriented consortia designed to enforce better collaboration and create mutual accountability for results. The incentives of all stakeholders – industry, government and civil society – must be aligned toward reducing the further development of resistant infections and the delivery of better health outcomes for patients and caregivers.
We therefore believe we need a new sustainable pathogen-specific ecosystem model to deliver against AMR. Success will require committed leadership across sectors, ambitious yet measurable priorities and targets, detailed execution plans, regular performance management, and public accountability. To that end, we have designed a bold yet pragmatic model which, we believe, can achieve this for DR-TB and provide a blueprint for broader applicability to AMR. More details will be available in the months ahead.
Anti-infective drugs have been one of the most effective health innovations in the history of modern medicine, responsible for dramatic gains in life expectancy globally. They are the backbone of modern medicine. And yet, without meaningful, collective action we risk squandering these gains and returning to an era where infection outpaces innovation and patients are left without treatment options. Working together, we can address this threat and change the trajectory of health for humanity.
Last Updated: May 2018
3 Approval is through Subpart H--Accelerated Approval of New Drugs for Serious or Life-Threatening Illnesses.
4 As of 31 December 2018
5 Priority pathogens identified by the Access to Medicines Foundation based on lists from the World Health Organization and/or the US Centers for Disease Control.
6 As of this publication, this device is not cleared or approved for use in the United States.
7 Pharmaceuticals and Personal Care Products in the Environment Policy (https://www.jnj.com/about-jnj/company-statements/impact-of-pharmaceuticals-and-personal-care-products-in-the-enviroment);
Annual Health for Humanity Report (http://healthforhumanityreport.jnj.com/downloads);
Responsibility Standards for Suppliers (https://www.jnj.com/about-jnj/company-statements/responsibility-standards-for-suppliers);
Control of Pharmaceutical Manufacturing Discharges Maturity Ladder Approach (http://onlinelibrary.wiley.com/doi/10.1002/etc.3163/pdf; http://onlinelibrary.wiley.com/doi/10.1002/etc.3260/full);
PSCI Research Library (https://pscinitiative.org/resource?resource=289);
Temple University / WET Center database of PNECs (http://www.nsfwetcenter.org/wp-content/uploads/2016/10/WET-Center-Phamaceutical-PNEC-list-3.pdf).