UNDERSTANDING THE ECONOMICS

OF MICROBIAL THREATS

PROCEEDINGS OF A WORKSHOP

V. Ayano Ogawa, T. Anh Tran, and Cecilia Mundaca Shah, Rapporteurs

Forum on Microbial Threats

Board on Global Health

Health and Medicine Division

THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001

This activity was supported by contracts between the National Academy of Sciences and the U.S. Agency for International Development; U.S. Army Medical Research and Materiel Command (10003469); U.S. Centers for Disease Control and Prevention (10003518); U.S. Department of Homeland Security (10003591); U.S. Department of Justice: Federal Bureau of Investigation (10003863): National Institute of Allergy and Infectious Diseases/National Institutes of Health (10003776), Uniformed Services University of the Health Sciences (10004290), and U.S. Food and Drug Administration (10002125); and U.S. Department of Veterans Affairs (10003856), and by the American Society for Microbiology, EcoHealth Alliance, Infectious Diseases Society of America, Johnson & Johnson (10003710), Merck & Co., Inc., Sanofi Pasteur, and The University of Hong Kong. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

International Standard Book Number-13: 978-0-309-48302-5
International Standard Book Number-10: 0-309-48302-6
Digital Object Identifier: https://doi.org/10.17226/25224

Additional copies of this publication are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu.

Copyright 2018 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America

Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2018. Understanding the economics of microbial threats: Proceedings of a workshop. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/25224.

PLANNING COMMITTEE ON UNDERSTANDING THE ECONOMICS OF MICROBIAL THREATS¹

PETER A. SANDS (Chair), Executive Director, The Global Fund to Fight AIDS, Tuberculosis and Malaria

TIMOTHY BURGESS, Director, Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences

ELIZABETH CAMERON, Vice President, Global Biological Policy and Programs, Nuclear Threat Initiative

PETER DASZAK, President, EcoHealth Alliance

MARCOS A. ESPINAL, Director, Department of Communicable Diseases and Health Analysis, Pan American Health Organization

TIMOTHY G. EVANS, Senior Director, Health, Nutrition, and Population, World Bank

JENNIFER L. GARDY, Senior Scientist, BC Centre for Disease Control; Associate Professor, School of Population and Public Health, University of British Columbia, Canada

THOMAS V. INGLESBY, Director, Center for Health Security, Johns Hopkins Bloomberg School of Public Health

DEAN T. JAMISON, Professor Emeritus, Global Health, University of California, San Francisco; University of Washington

JONNA A. K. MAZET, Professor of Epidemiology and Disease Ecology; Executive Director, One Health Institute, School of Veterinary Medicine, University of California, Davis

JOSHUA MICHAUD, Associate Director, Global Health Policy, Kaiser Family Foundation

JAMI TAYLOR, Board Advisor, Stanton Park Advisors

Health and Medicine Division Staff

CECILIA MUNDACA SHAH, Director, Forum on Microbial Threats, Board on Global Health

V. AYANO OGAWA, Program Officer, Board on Global Health

T. ANH TRAN, Senior Program Assistant, Board on Global Health

ALEXANDRA PRIOR, Intern (June–July 2018), Board on Global Health

JULIE PAVLIN, Director, Board on Global Health

___________________

¹ The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution.

This page intentionally left blank.

FORUM ON MICROBIAL THREATS¹

PETER DASZAK (Chair), President, EcoHealth Alliance

KENT E. KESTER (Vice Chair), Vice President and Head, Translational Science and Biomarkers, Sanofi Pasteur

MARY E. WILSON (Vice Chair), Clinical Professor of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco

KEVIN ANDERSON, Senior Program Manager, Science and Technology Directorate, U.S. Department of Homeland Security

TIMOTHY BURGESS, Director, Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences

DENNIS CARROLL, Director, Global Health Security and Development Unit, U.S. Agency for International Development

JEFFREY S. DUCHIN, Health Officer and Chief, Communicable Disease Epidemiology and Immunization Section for Public Health, Seattle and King County, Washington

EMILY ERBELDING, Deputy Director, Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health

MARCOS A. ESPINAL, Director, Department of Communicable Diseases and Health Analysis, Pan American Health Organization

KEIJI FUKUDA, School Director and Clinical Professor, The University of Hong Kong School of Public Health

JENNIFER L. GARDY, Senior Scientist, BC Centre for Disease Control; Associate Professor, School of Population and Public Health, University of British Columbia, Canada

JESSE L. GOODMAN, Professor of Medicine and Infectious Diseases; Director, Center on Medical Product Access, Safety, and Stewardship, Georgetown University

KAREN GROSSER, Vice President, Development, Infectious Disease, and Vaccine Therapeutic Area, Johnson & Johnson

EVA HARRIS, Professor, Division of Infectious Diseases and Vaccinology, University of California, Berkeley

CAROLINE S. HARWOOD, Gerald and Lyn Grinstein Professor of Microbiology, University of Washington

ELIZABETH D. HERMSEN, Head, Global Antimicrobial Stewardship, Merck & Co., Inc.

___________________

¹ The National Academies of Sciences, Engineering, and Medicine’s forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution.

RIMA F. KHABBAZ, Director, National Center for Emerging and Zoonotic Infectious Diseases, U.S. Centers for Disease Control and Prevention

MICHAEL MAIR, Acting Director, Office of Counterterrorism and Emerging Threats, U.S. Food and Drug Administration

JONNA A. K. MAZET, Professor of Epidemiology and Disease Ecology; Executive Director, One Health Institute, School of Veterinary Medicine, University of California, Davis

SALLY A. MILLER, Professor of Plant Pathology and State Extension Specialist for Vegetable Pathology, Ohio Agricultural Research and Development Center, The Ohio State University

SUERIE MOON, Director of Research, Global Health Centre, The Graduate Institute of International and Development Studies, Geneva

DAVID NABARRO, Advisor, Health and Sustainability, 4SD–Skills, Systems, and Synergies for Sustainable Development

KUMANAN RASANATHAN, Coordinator, Health Systems, Office of the World Health Organization Representative in Cambodia, World Health Organization

GARY A. ROSELLE, Chief of Medical Service, Veterans Affairs Medical Center; Director, National Infectious Disease Services, Veterans Health Administration

PETER A. SANDS, Executive Director, The Global Fund to Fight AIDS, Tuberculosis and Malaria

THOMAS W. SCOTT, Distinguished Professor, Department of Entomology and Nematology, University of California, Davis

JAY P. SIEGEL, Retired Chief Biotechnology Officer, Head of Scientific Strategy and Policy, Johnson & Johnson

PAIGE E. WATERMAN, Lieutenant Colonel, U.S. Army; Director, Translational Medicine Branch, Walter Reed Army Institute of Research

EDWARD H. YOU, Supervisory Special Agent, Weapons of Mass Destruction Directorate, Federal Bureau of Investigation

National Academies of Sciences, Engineering, and Medicine Staff

CECILIA MUNDACA SHAH, Director, Forum on Microbial Threats, Board on Global Health

V. AYANO OGAWA, Program Officer, Board on Global Health

T. ANH TRAN, Senior Program Assistant, Board on Global Health

ALEXANDRA PRIOR, Intern (June–July 2018)

JULIE PAVLIN, Director, Board on Global Health

Reviewers

This Proceedings of a Workshop was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the charge. The review comments and draft manuscript remain confidential to protect the integrity of the process.

We thank the following individuals for their review of this proceedings:

Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the content of the proceedings nor did they see the final draft before its release. The review of this proceedings was overseen by DAVID R. CHALLONER, University of Florida. He was responsible for making certain that an independent examination of this proceedings was carried out in accordance with standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the rapporteurs and the National Academies.

This page intentionally left blank.

Acknowledgments

The Forum on Microbial Threats staff and planning committee deeply appreciate the many valuable contributions from individuals who assisted us with this project. The workshop and this proceedings would not be possible without the presenters and discussants at the workshop, who gave so generously of their time and expertise. A full list of the speakers and moderators and their biographical information may be found in Appendix C.

This page intentionally left blank.

Contents

ACRONYMS AND ABBREVIATIONS

1 INTRODUCTION

Workshop Objectives

Organization of the Proceedings of the Workshop

2 THE ECONOMICS OF GLOBAL HEALTH AND MICROBIAL THREATS

Perspectives on Priorities for Using Economics for Global Health

Reflections from the Keynote Presentation

3 THE ECONOMIC COST OF ENDEMIC INFECTIOUS DISEASES

Economic Case for Eradicating Polio

Economic Impact of HIV/AIDS

Costs and Value of Tuberculosis Control

Discussion

4 THE ECONOMICS AND MODELING OF EMERGING INFECTIOUS DISEASES AND BIOLOGICAL RISKS

Cost of Pandemic Influenza

Assessing Economic Vulnerability to Emerging Infectious Disease Outbreaks

Epidemic Risk Modeling: Measuring the Effect of Aversion Behavior and Cascading Social Responses

Impact and Future of Global Catastrophic Biological Risks

Discussion

5 THE COST DIMENSIONS OF ANTIMICROBIAL RESISTANCE

Considerations for Estimating the Cost of Antimicrobial Resistance: Direct Versus Indirect Costs

Cost-Effectiveness of Interventions to Limit the Spread of Antimicrobial Resistance: A Perspective from OECD

Reconceptualizing Antimicrobial Resistance to Build the Investment Case

Discussion

6 INVESTING IN NATIONAL PREPAREDNESS INITIATIVES AGAINST MICROBIAL THREATS

Epidemic Preparedness: Lessons from Liberia

Potential Challenges and Opportunities for Investing in National-Level Preparedness

Using the Performance of Veterinary Services Pathway to Bolster Preparedness

Costs and Benefits of Implementing a One Health Approach Against Microbial Threats

Discussion

7 ACCELERATING RESEARCH AND DEVELOPMENT OF ANTIMICROBIAL MEDICAL PRODUCTS

Commercial Perspectives on Opportunities and Barriers to Discovery and Development of Antimicrobials

Discussion

8 REIMAGINING SUSTAINABLE INVESTMENTS TO COUNTER MICROBIAL THREATS

Economics of International Collective Action to Counter Microbial Threats

Overcoming Economic Bottlenecks in Delivering Medical Products to Address Microbial Threats Across Africa

Discussion

9 LOOKING TO THE FUTURE: POTENTIAL NEXT STEPS FOR USING ECONOMICS TO MANAGE MICROBIAL THREATS

Modeling the Economics of Emerging Infectious Diseases

Stimulating Research and Development for Antimicrobials

Incentivizing National Governments to Invest in Preparedness

Synthesis and General Discussion

10 CLOSING REMARKS

Research, Convenings, and Policy

Final Thoughts

REFERENCES

APPENDIXES

A WORKSHOP STATEMENT OF TASK

B WORKSHOP AGENDA

C BIOGRAPHICAL SKETCHES OF WORKSHOP SPEAKERS AND MODERATORS

This page intentionally left blank.

Boxes, Figures, and Tables

BOXES

2-1 Four Potential Priority Areas for Using Economic Analysis to Improve Decision Making in Global Health Investments

8-1 Hidden Economic Costs and Bottlenecks for Amina Across Supply Chains

8-2 Selected McKinsey & Co. Findings on Cost Savings (in U.S. dollars) on Last Mile Delivery of Health Commodities Across 1,121 Primary Health Facilities in a Nigerian State

FIGURES

3-1 Multiple pathways link HIV infection and gross domestic product (GDP)

3-2 Percentage of respondents using financial coping strategies related to tuberculosis (TB) infection in South Africa

3-3 Cost-effectiveness ratios of potential tuberculosis (TB) intervention strategies in South Africa

3-4 Conceptual framework for identifying demand and supply constraints in the context of introducing interventions in the care pathway

4-1 Constraints in the U.S. health care system for ventilation therapy by capacity level

4-2 A simplified framework of the economic impacts of an infectious disease

4-3 Epidemiologic models accounting for adaptive human behavior

4-4 Human behavior affects peak influenza prevalence

5-1 Impact of antimicrobial resistance (AMR) on additional health expenditures

5-2 Impact of antimicrobial resistance (AMR) on world gross domestic product (GDP)

6-1 Impact of Ebola on gross domestic product (GDP) growth in Liberia, 2012–2016

6-2 The Performance of Veterinary Services (PVS) gap analysis tool in four steps

6-3 Real options economic modeling to analyze timing and cost of policy implementation to address pandemic threats

8-1 The distribution of health aid across country-specific and global functions in 2013

8-2 Multiple overlapping supply chains for medical products in Nigeria

TABLES

4-1 Epidemiology of Public Health Emergencies of International Concern, Ebola Versus Zika

5-1 Cumulative Costs of Antimicrobial Resistance (AMR) in Trillions (in 2007 U.S. dollars)

Acronyms and Abbreviations