Adrita Bhattacharya-Craven, The Geneva Association
David Tordrup and Rebekka Aarsand, Triangulate Health Ltd, UK
Most of us have been prescribed antibiotics during a visit to the doctors – maybe for a chest infection, a skin infection, strep throat, or other infections we think of as mild or trivial. However, these infections can become life threatening when the antibiotics needed to treat them stop working. Far from being a distant and a dystopian future scenario, the failure of antibiotics is already estimated to cause 700,000 deaths each year, a figure that is expected to rise to millions in just a few decades. As well as being a threat to public health, antimicrobial resistance poses a palpable risk to insurers, with direct implications extending along three main dimensions: absolute mortality risk, mortality risk by age, and cost per case of insured illnesses.
‘Antimicrobial Resistance’ (AMR) is one of the top 10 threats to global health.1 It is the collective descriptor of the failure of routine treatments used for all kinds of infections, including antibiotics and antifungal medicines. The number of individuals estimated to lose their life to an infection that cannot be treated due to resistance is expected to rise to a staggering 10 million each year by 2050 if the current trend is not reversed,2 a number which invokes the spectre of a never-ending COVID-19 pandemic, where the current death toll in comparison stands at around 5 million.3 Given the low awareness of AMR in societies and issues around the availability and quality of data, current estimates may not truly reflect the extent of the crisis. Are we in danger of failing to heed the early warnings of another global public health crisis?
AMR is not a new concept. In fact, Alexander Fleming, the father of penicillin and arguably of the revolution in healthcare brought about by effective antibiotics, predicted the problem as early as 1945:
"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."4
In this uncannily forward-looking statement, Fleming not only recognised that the misuse of antibiotics would lead to resistance, but that resistance would lead to excess mortality from infection. This does not just apply to the relatively narrow spectrum of ill health caused by trivially-acquired infections, it threatens the entire fabric of recent medical advances.
Pioneers such as Robert Koch and Louis Pasteur, more than 100 years ago, described how microbes are the cause of common illnesses. This revolution in understanding enabled the medical community to incrementally improve their practices, such as using sterile techniques, and to develop technologies that more recently have enabled medical treatments such as chemotherapy and treatments for autoimmune diseases.
However, these advances rely on the availability of effective antimicrobials, which is increasingly threatened by antimicrobial resistance because of ‘misuse or overuse’ of antibiotics.5 This threatens a return to a pre-antibiotic era. As such, AMR has direct implications for health and life insurers because of its impact on both health outcomes and the overall cost of providing medical care. Furthermore, the irrational use of antimicrobials in commercial livestock heightens the risk of contamination in the local environment such as water bodies, exacerbating the risks to human health. In the following, we outline a subset of medical interventions that are of particular relevance to insurers and underwriters.
1. Surgical interventions
Any surgical intervention is associated with a risk of subsequent infection of the surgical site and/or systemic infection. Today, such infections can be treated with antimicrobials, but infections are increasingly caused by resistant pathogens.
Despite the increasing availability of targeted cancer therapies, chemotherapy treatment is still widely used, and cancer patients undergoing it are more susceptible to infection due to side-effects on the immune system. In a recent global cohort study of approximately 1,300 children and adolescents with cancer,6 20% had severe COVID-19 infection and death occurred in about 4% of the patients. The findings illustrated that infectious disease can have a much larger impact on children with cancer compared to the general paediatric population. Thus, a lack of effective antimicrobials would put this already vulnerable patient group at higher risk of morbidity and mortality from bacterial infections.
3. Opportunistic infections
Bacterial infections tend to accompany other primary health complaints, such as viral infections of the respiratory tract or of skin or mucous membranes. The risk of such infections is generally greater in the elderly population. Persons with reduced mobility are also at risk of pressure ulcer infections. Inadequate treatment of these infections could therefore increase the risk of mortality and morbidity among the elderly.
4. Healthcare-associated infections
Finally, many bacterial infections arise from non-surgical medical interventions. Invasive medical procedures, such as the use of catheters, shunts or ventilators as is needed for severe COVID-19 sufferers, are inherently associated with infection risk. The setting in which these infections occur may be particularly conducive to multi-drug resistant pathogens.
How big is the problem?
Globally, antibiotic consumption increased by 46% between 2000–2018, making the job of mitigating the risks of AMR even more challenging.7 A report from the Organisation for Economic Co-operation and Development (OECD) summarised a series of stark statistics for common infectious agents finding that several types of pathogens responsible for urinary tract infections, neonatal meningitis, surgical site infection and foodborne infections are resistant to common antibiotics in up to a staggering 30–40% of infections in G7 countries.8
In the U.S., more than 2.8 million episodes of antibiotic-resistant human infections occur each year, leading to at least 35,000 deaths.9 In the European Union, an estimated 25,000 deaths are attributed to resistant infections annually, as well as 2.5 million additional hospital bed days due to morbidity, triggering a direct cost burden of around EUR 900 million to health systems and EUR 1.5 billion to society overall.10
Why should insurers be worried?
Potentially life-threatening infections can arise across several everyday health and social care settings. The direct risk of mortality or long-term morbidity and disability resulting from routine surgery will increase with AMR, with a particularly adverse effect on the elderly. At what point will insurers/payers and health providers have to reconsider the risk of replacing an arthritic joint due to the risk of an untreatable infection? When will AMR sway the risk-benefit balance of cancer interventions? We already see worrying signals from the U.S., where a 30% reduction in the efficacy of antibiotics is estimated to claim 6,000 deaths per year from infections from just seven medical procedures.11 It is not currently clear what will happen when trivial infections turn deadly or how we will manage the risk of mortality from serious pneumonia. The implications for cost inflation across the board may also be significant, when harder to treat infections result in increased hospitalisation, longer lengths of stay or the use of newer and more expensive antimicrobial agents.
What can insurers do?
These facts paint a bleak picture that warrants urgent multisectoral action. Yet, the discourse on AMR has remained all too niche in global public health and pharmaceutical research and development. The AMR Industry Alliance formed following the Davos Declaration in 2016 to combat this growing crisis is mainly comprised of pharmaceutical, diagnostics and biotechnology companies with no notable involvement of payers or providers from the private sector.12 With up to 80% of healthcare provided privately in some parts of the world,13 however, voluntary health insurers have an important role to play in sensitising certain segments of this market to limit their risk exposures. Similarly, it is not clear if life insurers are factoring in the adverse effects AMR may have on their mortality tables.
Engaging with the insured population as well as sensitising insurance administrators and private providers about health, social care or old-age residential care settings are some of the simple, effective and inexpensive starting points for insurers to improve user awareness of AMR.
Insurer-led interventions need not be full of technical jargon, rather, they should contain messages that can influence consumer and provider attitudes towards antibiotics simply and at scale. On the demand side, insurers are optimally placed to improve user awareness of AMR. Knowledge about appropriate use of antibiotics and the risks of AMR vary widely by country and such knowledge is often incomplete.14 Engaging with the insured population as well as sensitising insurance administrators and private providers across health, social care or old-age residential care settings are some of the simple, effective and inexpensive starting points. On the supply side, as payers of products and services, insurers can directly influence when and how antibiotics are prescribed. Collaboratively devising standardised clinical protocols with providers to promote rational prescribing across varied care settings, monitoring use and integrating an ‘AMR surveillance strategy’ in any quality assurance interventions could be some of the early steps. Insurers can even go further by integrating such a strategy with the way they reimburse providers to incentivise good and deter inefficacious practice.
Failure to take action against AMR could mean that the next superbug renders antibiotics useless, resulting in an unprecedented crisis to human health and economic prosperity that is perhaps far more fateful than COVID-19. The past two years have given us a flavour of the devastation that can be brought about by a small, unknown pathogen. It is now timely that the industry musters all the foresight it can and work collaboratively to avert the next big public health crisis in the making.
Failure to take action against AMR could mean that the next superbug renders antibiotics useless, resulting in an unprecedented crisis to human health and economic prosperity that is perhaps far more fateful than COVID-19.
 WHO. 2019. Ten Threats to Global Health in 2019. https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019
 Interagency Coordination Group on Antimicrobial Resistance. 2019. No Time to Wait: Securing the Future from Drug-resistant Infections. https://cdn.who.int/media/docs/default-source/antimicrobial-resistance/amr-gcp-tjs/iacg/summaries/iacg_final_summary_en.pdf?sfvrsn=f346e650_5
 Sillankorva, S., M.O. Pereira, and M. Henriques. 2019. Editorial: Antibiotic Alternatives and Combinational Therapies for Bacterial Infections. Frontiers in Microbiology 9: 3359. Doi: 10.3389/fmicb.2018.03359
 WHO. 2020. Antibiotics Resistance. Key Facts. https://www.who.int/news-room/fact-sheets/detail/antibiotic-resistance
 Mukkada et al. 2021. Global Characteristics and Outcomes of SARS-CoV-2 Infection in Children and Adolescents with Cancer (GRCCC): A Cohort Study. The Lancet 22 (10): 1416–1426.
 University of Oxford. 2021. Global Antibiotic Consumption Rates Increased by 46 Percent Since 2000. https://www.ox.ac.uk/news/2021-11-16-global-antibiotic-consumption-rates-increased-46-percent-2000
 OECD. 2015. Antimicrobial Resistance in G7 Countries and Beyond: Economic Issues, Policies and Options for Action. https://www.oecd.org/els/health-systems/Antimicrobial-Resistance-in-G7-Countries-and-Beyond.pdf
 CDC. 2019. Antibiotic Resistance Threats in the United States 2019. https://www.cdc.gov/drugresistance/pdf/threats-report/2019-ar-threats-report-508.pdf
 Utt, E., and C. Wells. 2016. The Global Response to the Threat of Antimicrobial Resistance and the Important Role of Vaccines. Pharmaceuticals Policy and Law 18: 179–197. https://content.iospress.com/download/pharmaceuticals-policy-and-law/ppl442?id=pharmaceuticals-policy-and-law%2Fppl442
 Teillant, A., S. Gandra, D. Barter, D.J. Morgan, and R. Laxminarayan. 2015. 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): 1429–1437. https://pubmed.ncbi.nlm.nih.gov/26482597/
 AMR Industry Alliance. 2016. AMR Declaration Launched. https://www.amrindustryalliance.org/mediaroom/launch-of-the-declaration/
 Health Systems Global. The Private Sector in Health. https://healthsystemsglobal.org/thematic-groups/the-private-sector/