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Suggested Citation:"Front Matter." 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: 10.17226/25224.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

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 PREPUBLICATION COPY­ Uncorrected Proofs —

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 Pre- vention (10003518); U.S. Department of Homeland Security (10003591); U.S. Department of Justice: Federal Bureau of Investigation (10003863): National Insti- tute 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:  International Standard Book Number-10:  Digital Object Identifier:  https://doi.org/10.17226/25224 Additional copies of this publication are available for sale from the National Acad- emies 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 Medi- cine. 2018. Understanding the economics of microbial threats: Proceedings of a workshop. Washington, DC: The National Academies Press. doi: https://doi. org/10.17226/25224. PREPUBLICATION COPY­ Uncorrected Proofs —

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institu- tion to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the char- ter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. C. D. Mote, Jr., is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. PREPUBLICATION COPY­ Uncorrected Proofs —

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typi- cally include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opin- ions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPY­ Uncorrected Proofs —

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, The World Bank Group 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 ­ apporteurs r and the institution. v PREPUBLICATION COPY­ Uncorrected Proofs —

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. vii PREPUBLICATION COPY­ Uncorrected Proofs —

RIMA F. KHABBAZ, Deputy Director for Infectious Diseases; Director of Office of 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, 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 viii PREPUBLICATION COPY­ Uncorrected Proofs —

Reviewers T his Proceedings of a Workshop was reviewed in draft form by indi- viduals 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, Engi- neering, 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 com- ments and draft manuscript remain confidential to protect the integrity of the process. We thank the following individuals for their review of this proceedings: THOMAS CUENI, International Federation of Pharmaceutical Manufacturers & Associations HELLEN GELBAND, Independent Consultant EDUARDO GONZALEZ-PIER, Center for Global Development PETER A. SANDS, The Global Fund to Fight AIDS, Tuberculosis and Malaria Although the reviewers listed above provided many constructive com- ments 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 exami- nation 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 rap- porteurs and the National Academies. ix PREPUBLICATION COPY­ Uncorrected Proofs —

Acknowledgments T he 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 work- shop, 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. xi PREPUBLICATION COPY­ Uncorrected Proofs —

Contents ACRONYMS AND ABBREVIATIONS xix 1 INTRODUCTION 1 Workshop Objectives, 3 Organization of the Proceedings of the Workshop, 4 2 THE ECONOMICS OF GLOBAL HEALTH AND MICROBIAL THREATS 7 Perspectives on Priorities for Using Economics for Global Health, 7 Reflections from the Keynote Presentation, 11 3 THE ECONOMIC COST OF ENDEMIC INFECTIOUS DISEASES 13 Economic Case for Eradicating Polio, 13 Economic Impact of HIV/AIDS, 16 Costs and Value of Tuberculosis Control, 19 Discussion, 22 4 THE ECONOMICS AND MODELING OF EMERGING INFECTIOUS DISEASES AND BIOLOGICAL RISKS 29 Cost of Pandemic Influenza, 29 Assessing Economic Vulnerability to Emerging Infectious Disease Outbreaks, 32 xiii PREPUBLICATION COPY­ Uncorrected Proofs —

xiv CONTENTS Epidemic Risk Modeling: Measuring the Effect of Aversion Behavior and Cascading Social Responses, 35 Impact and Future of Global Catastrophic Biological Risks, 37 Discussion, 41 5 THE COST DIMENSIONS OF ANTIMICROBIAL RESISTANCE 47 Considerations for Estimating the Cost of Antimicrobial Resistance: Direct Versus Indirect Costs, 47 Cost-Effectiveness of Interventions to Limit the Spread of Antimicrobial Resistance: A Perspective from OECD, 51 Reconceptualizing Antimicrobial Resistance to Build the Investment Case, 53 Discussion, 55 6 INVESTING IN NATIONAL PREPAREDESS INITIATIVES AGAINST MICROBIAL THREATS 61 Epidemic Preparedness: Lessons from Liberia, 62 Potential Challenges and Opportunities for Investing in National-Level Preparedness, 64 Using the Performance of Veterinary Services Pathway to Bolster Preparedness, 66 Costs and Benefits of Implementing a One Health Approach Against Microbial Threats, 68 Discussion, 70 7 ACCELERATING RESEARCH AND DEVELOPMENT OF ANTIMICROBIAL MEDICAL PRODUCTS 75 Commercial Perspectives on Opportunities and Barriers to Discovery and Development of Antimicrobials, 75 Discussion, 81 8 REIMAGINING SUSTAINABLE INVESTMENTS TO COUNTER MICROBIAL THREATS 87 Economics of International Collective Action to Control Microbial Threats, 87 Overcoming Economic Bottlenecks in Delivering Medical Products to Address Microbial Threats Across Africa, 90 Discussion, 94 PREPUBLICATION COPY­ Uncorrected Proofs —

CONTENTS xv 9  OOKING TO THE FUTURE: POTENTIAL NEXT STEPS L FOR USING ECONOMICS TO MANAGE MICROBIAL THREATS 97 Modeling the Economics of Emerging Infectious Diseases, 98 Stimulating Research and Development for Antimicrobials, 99 Incentivizing National Governments to Invest in Preparedness, 102 Synthesis and General Discussion, 105 10 CLOSING REMARKS 111 Research, Convenings, and Policy, 111 Final Thoughts, 112 REFERENCES 115 APPENDIXES A WORKSHOP STATEMENT OF TASK 123 B WORKSHOP AGENDA 125 C BIOGRAPHICAL SKETCHES OF WORKSHOP SPEAKERS AND MODERATORS 131 PREPUBLICATION COPY­ Uncorrected Proofs —

Boxes, Figures, and Tables BOXES 2-1 Four Potential Priority Areas for Using Economic Analysis to Improve Decision Making in Global Health Investments, 9 8-1 Hidden Economic Costs and Bottlenecks for Amina Across Supply Chains, 91 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, 94 FIGURES 3-1 Multiple pathways link HIV infection and gross domestic product (GDP), 17 3-2 Percentage of respondents using financial coping strategies related to tuberculosis (TB) infection in South Africa, 21 3-3 Cost-effectiveness ratios of potential tuberculosis intervention strategies in South Africa, 22 3-4 Conceptual framework for identifying demand and supply constraints in the context of introducing interventions in the care pathway, 23 xvii PREPUBLICATION COPY­ Uncorrected Proofs —

xviii BOXES, FIGURES, AND TABLES 4-1 Constraints in the U.S. health care system for ventilation therapy by capacity level, 31 4-2 A simplified framework of the economic impacts of an infectious disease, 33 4-3 Epidemiologic models accounting for adaptive human behavior, 36 4-4 Human behavior affects peak influenza prevalence, 38 5-1 Impact of antimicrobial resistance (AMR) on additional health expenditures, 49 5-2 Impact of antimicrobial resistance (AMR) on world gross domestic product, 50 6-1 Impact of Ebola on gross domestic product (GDP) growth in Liberia, 2012–2016, 63 6-2 The Performance of Veterinary Services (PVS) gap analysis tool in four steps, 67 6-3 Real options economic modeling to analyze timing and cost of policy implementation to address pandemic threats, 69 8-1 The distribution of health aid across country-specific and global functions in 2013, 89 8-2 Multiple overlapping supply chains for medical products in Nigeria, 92 TABLES 4-1 Epidemiology of Public Health Emergencies of International Concern, Ebola Versus Zika, 34 5-1 Cumulative Costs of Antimicrobial Resistance (AMR) in Trillions (in 2007 U.S. dollars), 51 PREPUBLICATION COPY­ Uncorrected Proofs —

Acronyms and Abbreviations AMR antimicrobial resistance ART antiretroviral therapy ARV antiretroviral BARDA Biomedical Advanced Research and Development Authority CARB-X Combating Antibiotic-Resistant Bacteria Biopharmaceutical Accelerator CDC U.S. Centers for Disease Control and Prevention DRG diagnosis related group EID emerging infectious disease EPR emergency preparedness and response FDA U.S. Food and Drug Administration G20 Group of 20 GCBR global catastrophic biological risks GDP gross domestic product GPEI Global Polio Eradication Initiative JEE Joint External Evaluation xix PREPUBLICATION COPY­ Uncorrected Proofs —

xx ACRONYMS AND ABBREVIATIONS IFPMA International Federation of Pharmaceutical Manufacturers & Associations IHR International Health Regulations IMI Innovative Medicines Initiative IPV inactivated polio vaccine LPAD Limited Population Pathway for Antibacterial and Antifungal Drugs program MDG Millennium Development Goal OECD Organisation for Economic Co-operation and Development OIE World Organisation for Animal Health OPV oral poliovirus vaccine PPR peste des petits ruminants PVS Performance of Veterinary Services R&D research and development SARS severe acute respiratory syndrome SDG Sustainable Development Goal SIR susceptible-infected-recovered TB tuberculosis TME transferable market exclusivity VAPP vaccine-associated paralytic polio VDPV vaccine-derived poliovirus WHO World Health Organization WPV wild poliovirus PREPUBLICATION COPY­ Uncorrected Proofs —

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Microbial threats, including endemic and emerging infectious diseases and antimicrobial resistance, can cause not only substantial health consequences but also enormous disruption to economic activity worldwide. While scientific advances have undoubtedly strengthened our ability to respond to and mitigate the mortality of infectious disease threats, events over the past two decades have illustrated our continued vulnerability to economic consequences from these threats.

To assess the current understanding of the interaction of infectious disease threats with economic activity and suggest potential new areas of research, the National Academies of Sciences, Engineering, and Medicine planned a 1.5-day public workshop on understanding the economics of microbial threats. This workshop built on prior work of the Forum on Microbial Threats and aimed to help transform current knowledge into immediate action. This publication summarizes the presentations and discussions from the workshop.

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