 "Antibiotic apocalypse")
On a recent trip to India, Shyla Jehangir, a paediatrician practising in the UK, was startled when she read a prescription her sister had recently been given for a cough and cold. She told me she recovered quickly but that was hardly surprising the antibiotics her doctor had prescribed were strong enough to cure Lazarus! says Jehangir, referring to the Biblical character supposed to have been miraculously revived from the dead by Jesus Christ.
This is just one instance of a situation, public health researchers and doctors agree, that is being routinely played out across India over-prescription of antibiotics, especially for minor ailments. Years of over-prescription is one of the principal factors contributing to what is now recognised globally as a public health crisis the rise of bacterial infections that no longer respond to the antibiotics that we have. In India, the issue of infections caused by multi-drug resistant bacteria, or "superbugs", came to the spotlight with the discovery of NDM-1, or New Delhi metallo beta lactamase-1, so named because it was found in a Swedish patient who had been to India in 2009.
While naming the bacteria after New Delhi caused a political furore, with theories doing the rounds that this was done to malign Indias medical tourism industry, the factors that led to such a situation remain largely unaddressed, even today.
Indias knee-jerk reaction came even as alarm bells about antibiotic or antimicrobial resistance are being sounded across the globe. Englands chief medical officer recently said the danger to the nation posed by the resistance to antibiotics should be ranked alongside terrorism and was a ticking time bomb, while the office of the chief scientist in Australia described antibiotic-resistant infections as a looming public health issue. Earlier this year, the World Economic Forum listed antibiotic resistance in its global risks report.
India is yet to get a national policy to deal with the growing threat of antibiotic resistance or carry out nation-wide surveillance studies on antibiotic use and the growing resistance to it. After the superbug scare, a committee was set up by the government and a national policy for the containment of antibiotic resistance was framed but was later shelved. This was partly because one of the recommendations included a ban on over-the-counter sale of antibiotics which was criticised by experts on the grounds that it would adversely affect patients who might not have regular access to doctors, says Ashish Pathak, associate professor at the department of paediatrics, RD Gardi Medical College, Ujjain. But things may finally be changing. India is initiating nation-wide surveillance studies on antibiotic use and growing resistance under the Indian Council of Medical Research, so that we can formulate a national policy, says Camilla Rodrigues, consultant microbiologist and chairperson of the infection control committee at Hinduja Hospital in Mumbai. The study is expected to commence in January.
The most irrational antibiotic prescriptions are for the common cold and flu and for upper respiratory infections because these are caused by viruses, and antibiotics, which are supposed to fight bacteria, would be of no use, says Pathak, also a post-doctoral fellow in global health at Swedens Karolinska Institute, who was in Bangalore recently to conduct a workshop on the issue of antibiotic resistance.
There are various reasons why things have come to such a pass. Doctors prescribe antibiotics because they are more comfortable doing so and prefer not to lose a patient to a rival. Plus patients occasionally insist on them too. Lack of microbiological lab facilities, which would help in more accurate prescriptions, is another factor. Sudarshan Ballal, medical director of Bangalore-headquartered Manipal Hospitals, says the healthcare industry must bear the responsibility for the current state of affairs because we have been less than judicious in prescribing antibiotics. While Manipal Hospitals has some guidelines about the prescription of antibiotics, he acknowledges that its practically impossible to monitor every prescription. This is largely a matter of self-regulation. In the United States, where he used to work, Ballal says hospitals allow only certain antibiotics to be prescribed. If others were needed, a committee would have to approve the use, unless it was a life-threatening situation. Contrast this to India, where patients even self-prescribe antibiotics. As a result, bugs in India are already resistant to antibiotics like penicillin and ampicillin, while these are still in use in the US, he says.
Its a catch-22 situation because when the patient comes to most tertiary care hospitals, he is invariably already on high-end antibiotics, and to treat his or her infections we have to use higher-end antibiotics. We have to treat patients with drug resistance , we cant turn them away either, So the only way to prevent cross transmission is enforcing strict infection control practices. says Hindujas Rodrigues, who works with the hospitals clinicians to de-escalate the antibiotics whenever possible. Between 2005 and 2009, the units of antibiotics sold in India increased by around 40 per cent, according to data provided by Pfizer. Another report by the Washington-based Center for Disease Dynamics, Economics and Policy found that the retail sale of carbapenems in India a powerful group of antibiotics meant to be used as a last resort went up from 0.21 units per million in 2005 to 1.23 in 2010. The high use of these last-line drugs in India could make these drugs ineffective if we do not act carefully now, warns CDDEP.
But its not just doctors who are to blame. India also does not have a policy regulating the use of antibiotics in livestock and agriculture, where it is used to improve growth. These antibiotics too enter the environment and help in the creation of drug-resistant bacteria. Neither do we have an effective policy for the disposal of antibiotics that will prevent it from entering the environment, such as the option to return antibiotics to pharmacies or hospitals. Poor public hygiene and sanitation are other factors.
The result of all this could be close to catastrophic. India has a high burden of infectious diseases and a high burden of drug-resistant infections. The country also has low health expenditure and low per capita income. So while patients in developed countries might be able to afford expensive antibiotics when currently available cheap antibiotics become ineffective, most Indian patients might not be able to afford such drugs, explains Ramanan Laxminarayan, who heads the Washington-based Center for Disease Dynamics, Economics and Policy . One of the gravest consequences of this is the emergence of multi-drug resistant tuberculosis strains. According World Health Organisations Global TB Report 2012, India has the worlds highest number of multidrug-resistant TB cases among notified patients.
Even more worrying is the fact that the pipeline for new antibiotics is practically dry. For pharmaceutical companies, research in antibiotics is not considered to be as lucrative an investment as that in drugs for chronic diseases like diabetes, since the shelf-life for the former will be much shorter, with patients developing resistance. We are running out of options, says Rodrigues, echoing global experts who are increasingly speaking out about the frightening prospect of a post-antibiotic world.
This is just one instance of a situation, public health researchers and doctors agree, that is being routinely played out across India over-prescription of antibiotics, especially for minor ailments. Years of over-prescription is one of the principal factors contributing to what is now recognised globally as a public health crisis the rise of bacterial infections that no longer respond to the antibiotics that we have. In India, the issue of infections caused by multi-drug resistant bacteria, or "superbugs", came to the spotlight with the discovery of NDM-1, or New Delhi metallo beta lactamase-1, so named because it was found in a Swedish patient who had been to India in 2009.
While naming the bacteria after New Delhi caused a political furore, with theories doing the rounds that this was done to malign Indias medical tourism industry, the factors that led to such a situation remain largely unaddressed, even today.
Indias knee-jerk reaction came even as alarm bells about antibiotic or antimicrobial resistance are being sounded across the globe. Englands chief medical officer recently said the danger to the nation posed by the resistance to antibiotics should be ranked alongside terrorism and was a ticking time bomb, while the office of the chief scientist in Australia described antibiotic-resistant infections as a looming public health issue. Earlier this year, the World Economic Forum listed antibiotic resistance in its global risks report.
| FACTORS LEADING TO SPREAD OF ANTIMICROBIAL RESISTANCE (WHO, 2012) |
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India is yet to get a national policy to deal with the growing threat of antibiotic resistance or carry out nation-wide surveillance studies on antibiotic use and the growing resistance to it. After the superbug scare, a committee was set up by the government and a national policy for the containment of antibiotic resistance was framed but was later shelved. This was partly because one of the recommendations included a ban on over-the-counter sale of antibiotics which was criticised by experts on the grounds that it would adversely affect patients who might not have regular access to doctors, says Ashish Pathak, associate professor at the department of paediatrics, RD Gardi Medical College, Ujjain. But things may finally be changing. India is initiating nation-wide surveillance studies on antibiotic use and growing resistance under the Indian Council of Medical Research, so that we can formulate a national policy, says Camilla Rodrigues, consultant microbiologist and chairperson of the infection control committee at Hinduja Hospital in Mumbai. The study is expected to commence in January.
* * * * *
The most irrational antibiotic prescriptions are for the common cold and flu and for upper respiratory infections because these are caused by viruses, and antibiotics, which are supposed to fight bacteria, would be of no use, says Pathak, also a post-doctoral fellow in global health at Swedens Karolinska Institute, who was in Bangalore recently to conduct a workshop on the issue of antibiotic resistance.
There are various reasons why things have come to such a pass. Doctors prescribe antibiotics because they are more comfortable doing so and prefer not to lose a patient to a rival. Plus patients occasionally insist on them too. Lack of microbiological lab facilities, which would help in more accurate prescriptions, is another factor. Sudarshan Ballal, medical director of Bangalore-headquartered Manipal Hospitals, says the healthcare industry must bear the responsibility for the current state of affairs because we have been less than judicious in prescribing antibiotics. While Manipal Hospitals has some guidelines about the prescription of antibiotics, he acknowledges that its practically impossible to monitor every prescription. This is largely a matter of self-regulation. In the United States, where he used to work, Ballal says hospitals allow only certain antibiotics to be prescribed. If others were needed, a committee would have to approve the use, unless it was a life-threatening situation. Contrast this to India, where patients even self-prescribe antibiotics. As a result, bugs in India are already resistant to antibiotics like penicillin and ampicillin, while these are still in use in the US, he says.
Its a catch-22 situation because when the patient comes to most tertiary care hospitals, he is invariably already on high-end antibiotics, and to treat his or her infections we have to use higher-end antibiotics. We have to treat patients with drug resistance , we cant turn them away either, So the only way to prevent cross transmission is enforcing strict infection control practices. says Hindujas Rodrigues, who works with the hospitals clinicians to de-escalate the antibiotics whenever possible. Between 2005 and 2009, the units of antibiotics sold in India increased by around 40 per cent, according to data provided by Pfizer. Another report by the Washington-based Center for Disease Dynamics, Economics and Policy found that the retail sale of carbapenems in India a powerful group of antibiotics meant to be used as a last resort went up from 0.21 units per million in 2005 to 1.23 in 2010. The high use of these last-line drugs in India could make these drugs ineffective if we do not act carefully now, warns CDDEP.
But its not just doctors who are to blame. India also does not have a policy regulating the use of antibiotics in livestock and agriculture, where it is used to improve growth. These antibiotics too enter the environment and help in the creation of drug-resistant bacteria. Neither do we have an effective policy for the disposal of antibiotics that will prevent it from entering the environment, such as the option to return antibiotics to pharmacies or hospitals. Poor public hygiene and sanitation are other factors.
* * * * *
The result of all this could be close to catastrophic. India has a high burden of infectious diseases and a high burden of drug-resistant infections. The country also has low health expenditure and low per capita income. So while patients in developed countries might be able to afford expensive antibiotics when currently available cheap antibiotics become ineffective, most Indian patients might not be able to afford such drugs, explains Ramanan Laxminarayan, who heads the Washington-based Center for Disease Dynamics, Economics and Policy . One of the gravest consequences of this is the emergence of multi-drug resistant tuberculosis strains. According World Health Organisations Global TB Report 2012, India has the worlds highest number of multidrug-resistant TB cases among notified patients.
Even more worrying is the fact that the pipeline for new antibiotics is practically dry. For pharmaceutical companies, research in antibiotics is not considered to be as lucrative an investment as that in drugs for chronic diseases like diabetes, since the shelf-life for the former will be much shorter, with patients developing resistance. We are running out of options, says Rodrigues, echoing global experts who are increasingly speaking out about the frightening prospect of a post-antibiotic world.