The 68th session of the World Health Assembly, the top decision-making body of the WHO, which met in Geneva last month, endorsed a global action plan to tackle antimicrobial resistance (AMR), which is compromising the ability to treat infectious diseases.
Ironically, the session was presided over by Jagat Prakash Nadda, the health minister of India — the current president of the assembly — a nation that is witnessing rampant misuse of antibiotics both among humans and animals and is facing a major AMR threat.
Says Amit Khurana, programme manager, food safety and toxins, Centre for Science and Environment (CSE), New Delhi: “The AMR threat to India is huge for several reasons. India has a high load of infectious diseases including multi-drug resistant tuberculosis, poor sanitation and waste management, inadequate drug regulatory framework, ineffective implementation and current antibiotic prescription and consumption practices in human and animals which are leading to overuse and misuse of antibiotics thereby increasing resistance.”
While several experts that Khaleej Times spoke to refused to put down a figure relating to the number of deaths that can be attributed to drug resistance, there have been reports that the number adds up to more than half a million a year and could possibly rise to two million by 2050.
According to Ramanan Laxminarayan, vice-president, research and policy, Public Health Foundation of India and senior research scholar at Princeton University, and a globally acknowledged expert on AMR, that estimate seems high. “According to our estimates (published in the Lancet) 58,000 neonatal deaths (in India) are attributable to sepsis caused by resistant organisms each year, the highest numbers in the world.”
Antibiotic resistance is a global public health threat, but nowhere is it as stark as in India, he observes. “Crude infection disease mortality in India today is twice that in the United States,” Laxminarayan told this correspondent. “A mix of poor public health systems and hospital infection, remaining burden of infectious disease, inexpensive antibiotics and rising incomes are coming together to create a significant burden of resistant pathogens that are increasing the burden of neonatal sepsis and healthcare associated infections.”
A research paper that he co-authored and which appeared recently in America’s respected scientific journal, Proceedings of the National Academy of Sciences, ranked India among the top-five countries using antibiotics in animal-food production. The research paper predicted that India’s antibiotics consumption could double over the next 15 years. The widespread use of antimicrobials in livestock contributes — by means of natural selection — to the emergence of antimicrobial-resistant bacteria (ARBs) and has significant public health implications, he warns.
A study by CSE found antibiotics being used as growth promoters in several animal feed pre-mix. Some of the samples even had a presence of antibiotics such as colistin, known as a last-resort antibiotic. “Colistin is largely used as a growth promoter in food producing animals such as chickens rated for meat,” points out Khurana of the CSE. “This overlap is worrisome as it is responsible for greater emergence of resistance.”
Laxminarayan warns that antibiotic use in animals is rising in India and without restrictions on their use in the livestock sector there be even greater selection pressure for resistance.
Dr Abdul Ghafur, Chennai-based infectious diseases consultant and coordinator of the ‘Chennai Declaration Recommendations’ — which was a move by several medical bodies to help formulate a national policy to tackle AMR— told Khaleej Times that most hospitals in India still do not take infection control very seriously.
“The national policy for containment of AMR is not yet implemented,” he says. “We do have a rule to regulate over the counter sale of antibiotics without prescription, but it has not yet been implemented nationwide. We also have a national standard treatment guideline prepared by the health ministry, but not yet made popular in the medical community.”
Ghafur says that all tertiary care hospitals in India are facing the problem of pan-drug resistance, but unfortunately only a few have published the relevant data. “Pan-drug resistance means there are no antibiotics to treat infection,” he notes. “This is known as the pre-Alexander Fleming era or the post-antibiotics era. We are going back to the dark ages of medicine.”
Last year, the WHO had warned of such a possibility. “A post-antibiotic era — in which common infections and minor injuries can kill — far from being an apocalyptic fantasy, is instead a very real possibility for the 21st century,” a WHO report had said. Ghafur says India has a national policy on the use of antibiotics, but it does not have a national strategy to tackle AMR.
Adds Khurana of CSE: “AMR requires multi-sectoral intervention. Well-coordinated action is required from several ministries and departments such as health, food, agriculture, drugs, animal husbandry and environment. In certain cases implementation lies with states and may vary across India.”
According to him, the national policy on antibiotics is focused on human use and does pay attention to overuse among animals. “As a country we do not know how much antibiotics we produce, consume in humans and animals. We should now aim to develop a time bound action oriented plan.”
There are no laws to regulate non-therapeutic use of antibiotics in animals. Dr Manilal Valliyate, director, veterinary affairs, PETA India, and co-opted member of the Animal Welfare Board of India and member, Kerala State Animal Welfare Board, says animals on factory farms are commonly fed antibiotics to enhance their growth, increasing antibiotic resistance in both humans and animals.
Last year, the Department of Animal Husbandry, Dairying and Fisheries had urged that antibiotics should not be mixed with the feed of animals used for food for non-therapeutic use. And the Drugs Controller General of India had called for the implementation of a 2012 law that mandates a gap between the time an animal is given a drug for medical purposes and sale of food products from that animal.
“However, any adequate implementation of these well-meaning advisories remains doubtful and in question,” he bemoans.
Valliyate says that to meet the growing demand, the meat, egg and dairy industries are choosing space and productivity over the welfare of animals. “Most animals raised for food today are housed in extremely filthy, severely crowded conditions without access to fresh air, sunlight or space,” he points out.
Diseases are rampant, so farmers pump the animals with antibiotics, resulting in antibiotic-resistant superbugs and aggressive mutations of pathogens, he adds. Some of the antibiotics, including penicillin and tetracycline, are also used to treat people. “As a result, when people get sick, the antibiotics they’re prescribed do not always work because their overuse in farmed animals has led to the development of antibiotic-resistant superbugs,” explains Valiyate.
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