Today's Editorial

02 March 2018

The post-antibiotics apocalypse

Source: By Chandra Bhushan: The Financial Express

A few months ago, a ten-month old daughter of my colleague contracted urinary tract infection, which is fairly common and is generally caused by a bacterium. A routine antibiotic course should have treated her. But, when her urine culture report came, it shocked everyone. This child had no history of antibiotic use and yet the bacteria, responsible for the infection, were resistant to most of the 21 antibiotics for which susceptibility tests were done.

Luckily, there were still few antibiotics left that were effective, and she was successfully treated. But, the question that remained unanswered was: how did she get infected with a superbug when she was never exposed to antibiotics? Was she born with resistant bacteria in her gut? Did the bacteria in her gut develop resistance through the consumption of antibiotic-laced food and water? Or, was she infected with this superbug present in the environment?

All three scenarios are possible. But this case and millions such cases, raises alarming questions about the rapid spread of antibiotic resistance and the future of healthcare. Antimicrobial resistance (AMR) arises when microbes survive exposure to a drug that would normally kill them or stop their growth. When bacteria acquire resistance to antibiotics, it is termed as the antibiotic resistance (ABR). When a person gets a disease due to these resistant bacteria, antibiotics fail to cure them.

ABR has become one of the world’s biggest health threats. It is estimated that every year, 0.7 million people die worldwide because of ABR. The death toll is expected to rise to 10 million by 2050 if no action is taken. India has one of the highest rates of ABR and it is also the largest consumer of antibiotics, followed by China and the US. ABR is leading to a greater spread of infectious diseases, and common procedures like joint replacements, gastrointestinal surgerycaesarean deliveryorgan transplants, etc, where antibiotics are used to prevent infection at the surgical site, are becoming increasingly risky.

A recent study on surgical site infections (SSI) after gastrointestinal surgery, covering more than 12,000 patients across 66 countries, discovered that one out of every four patients in low-income countries contracted SSI within 30 days of the operations because the antibiotics given to them, before and after the surgery, didn’t work. Studies like these give us a glimpse of the post-antibiotics world where even the common infections will kill people, as was the case before Alexander Fleming discovered Penicillin.

Alexander Fleming knew that antibiotic use will slowly lead to the emergence of ABR. He had warned that the misuse of antibiotics would accelerate resistance. This is exactly what happened. Resistance began to emerge within the 10 years of the large-scale introduction of Penicillin. But, scientists found newer antibiotics that allowed doctors to prescribe alternatives. However, since 1987, no new antibiotics have been discovered and microbes are fast becoming resistant to the older ones.

The resistance is not only happening because of the misuse and overuse in humans, it is being accelerated by the large-scale use of antibiotics in the food animals like, livestock, poultry and fisheries. Resistant bacteria from animals are now causing drug-resistant infections in humans. The growing demand of animal protein is rapidly increasing the use of antibiotics in the food animal industry. Antibiotics are routinely given to the animals as growth promoters (to fatten them) or to prevent occurrence of diseases. It is estimated that more antibiotics are now used for animals than humans. In the US, 70% of all antibiotics are given to the farm animals. Though exact data is not available, estimates show that India, too, is using more antibiotics in animals than humans.

The misuse of antibiotics in farm animals in India became a global news recently when a report published by The Hindu and The Bureau of Investigative Journalism alluded to the fact that the poultry industry in India is widely using Colistin as a growth promoter, and major chicken companies like Venky’s are legally selling Colistin to farmers. The problem is that Colistin is a last-resort antibiotic; when all antibiotics fail, it is used to treat life-threatening infections. The World Health Organization (WHO) has put this and few other antibiotics in the category of “critically important to humans”, so that they are restricted for use in the animals. Yet, it is freely available and used in the country to fatten chickens.

As ABR can spread easily to other countries and put citizens of those countries at risk, even if they have not misused Colistin, there is a genuine global concern about its misuse in India. In 2015, a similar report had called out China for the uncontrolled use of Colistin on pig farms, which led to the development of the Mobilised Colistin Resistance (MCR-1) geneThis gene is capable of moving from one type of bacteria to another and makes them resistant to Colistin treatment. As of 2017, MCR-1 has moved rapidly out of China and has been detected in more than 30 countries on five continents. In November 2016, the Chinese government banned the use of Colistin as a feed additive. But, over the last few years, India has started importing large amounts of Colistin from China, encouraging its misuse.

The Indian government is prickly about the issue of ABR. More often than not, it considers these studies as a western conspiracy to hurt Indian trade and tourism, especially medical tourism. But, the fact is that ABR is killing people and hurting the economy, with longer hospital stays and more expensive treatments. If we do not act now, the costs would be unbearable. The good news is that it is possible to reduce the use of antibiotics, save lives and grow the economy. Many European countries have drastically reduced the use of antibiotics in food animals by banning its use as a growth promoter and for disease prevention. Antibiotics are only allowed for treating diseased animals on prescription of veterinarians. They have achieved this by improving hygiene in the farms and by using alternatives. This has not led to any reduction in the meat production or adverse impact on the growth of the industry.

India, too, will have to do this by bringing in strict regulations and oversight. Currently, regulations on the import, sale and use of antibiotics are non-existent, or on papers. The situation is so bad that today one can walk into the Bhagirath palace in Chandni Chowk, in the heart of Delhi, and buy a kilogram of particular antibiotics directly imported from China. Easier still, one can log into and order Colistin for poultry feed supplement. In December 2014, the ministry of agriculture issued an advisory to states to stop the use of antibiotics as growth promoters in feed and feed supplements, and set-up a system to monitor sales and the use of antibiotics. But this advisory had no legal backing and has not been implemented.

Recently, India developed its National Action Plan on antimicrobial resistance (NAP-AMR) as part of the Global Action Plan adopted by the WHO. But again, India’s NAP-AMR has no legal backing or financial support. The recent Union budget actually downgraded the focus on AMR by merging a centrally sponsored scheme on AMR with other zoonotic disease programmes. But, this situation cannot continue for long. All the efforts that the government is making through “world’s largest healthcare programme” would come to naught in the absence of an effective programme to contain AMR. As an emerging global economy that wants to play an important role in global affairs and aspires for a seat on the UN Security Council, India has no other option but to take leadership on AMR issues. The quicker we realise this, the better it would be for the country and for the world.

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