Super Bug Crisis: Urgent need to act as a nation
Antimicrobial Resistance (AMR) is one of the biggest challenges the world is facing today. AMR crisis has seriously affected not just the global health care systems but economic, social and political fields as well. Antibiotics are the corner stones of modern medicine. Modern medicine cannot function without antibiotics. At the global level AMR can kill 10 million people every year and global economy can lose 100 trillion US dollars by 2050.
What is AMR (super bug crisis)?
This is a scenario where antibiotics are ineffective against bacteria and other disease-producing microbes. That means, even if we administer powerful antibiotics to a patient with severe infection, these antibiotics cannot kills bugs and so the patient will succumb to the infection and then die. This is a global challenge affecting all continents and countries, though the severity and the extent vary among different regions. South Asia is seriously hit by the resistance crisis.
What are the reasons behind the super bug crisis?
1.Irrational antibiotic usage by the medical community. It is a well-known fact that doctors around the world prescribe antibiotics, even to those patients where an antibiotic is not necessary.
2.Unregulated Over The Counter (OTC) sale of antibiotics without prescription. General public purchase antibiotics from pharmacies, without doctor’s prescription. This is one of the main areas of irrational antibiotic usage and antibiotic resistance. Though India has a rule (H1 rule) regulating this practice, the rule is not implemented across the country.
3.In hospitals, ineffective sanitation and infection control facilities result in the spread of super bugs from one patient to another.
4.Growth promotional use of antibiotics: Antibiotics are extensively used as growth promotional agents in poultry, fish and cattle farming. Animal feed is mixed with antibiotics and then fed to animals. May I stress the point that growth promotional antibiotic use is not to prevent or treat infections in animals. The purpose is just to make them grow fat and fast! Seventy percentage of the antibiotics manufactured by the global pharmaceutical industry is used for this growth promotional purpose. Colistin is the last resort antibiotic used in hospitals to treat super bug infections in patients. The same colistin is extensively used in poultry, cattle and aqua farming as a growth promotional agent. Antibiotic resistant super bugs develop inside the intestine of these animals. While consuming the meat, these super bugs enter human intestine. Poultry litter is used as manure in vegetable farming. So vegetables get contaminated with these super bugs. Though these bacteria remain dormant in human intestine, these can produce serious infections when opportunity arises. Cancer chemotherapy, intestinal surgery, urinary tract infections, hospitalisation are all such opportunities. Most antibiotics and in some scenarios, all antibiotics are ineffective in treating such infections.
5.Pharmaceutical industry is shying away from investment in antibiotics research and development. The industry needs at least one billion dollars and ten years to develop and market an antibiotic. Once marketed, the product will be profitable only if it is extensively used. Well, this is a basic marketing strategy for any product! But, in the case of an antibiotic, extensive usage will generate resistance to the antibiotic and the molecule will become ineffective! So naturally pharmaceutical industry prefers to invest in cardio vascular drugs, cholesterol lowering drugs, cancer drugs and other groups that may not become ineffective on extensive usage.
6.Sanitation issues in the community help these super bugs spread along the sewage channels, rivers, ponds and lakes.
India has one of the highest AMR rates in the world. A population of 130 crores, with socio economic disparity, sanitation issues in the community, hospitals of varying standards with inadequate facilities in most, tropical climate with a plethora of infectious diseases, irrational antibiotic usage in hospitals and in the community are the main reasons contributing to this highly complex scenario. Out of 75000 hospitals (exact number not available) in the country, only less than 500 have received accreditation from NABH (National Accreditation Board for Hospitals & Healthcare Providers). These hospitals maintain acceptable minimum basic infection control standards. We don’t even know the standard in majority of hospitals in the country.
Superbug crisis has made the maximum impact among cancer patients. Chemotherapy given to cancer patients makes their immunity very low. They are highly vulnerable to infections, especially superbug infections, resulting in high death rates of these patients. In countries like India with high super bug rates; Bone marrow transplantation and high dose chemotherapy have become very high-risk procedures.
Is there a solution to the AMR crisis?
1.Rational usage of antibiotics in hospitals and in the community. This is one of the most important measures to reduce the generation of super bugs. Usage of antibiotics as growth promotional agents in farming must be discouraged. Indian Government recently banned the growth promotional usage of colistin.
2.In developing countries with high existing superbug rates, rational antibiotic usage alone cannot contain the crisis. Improvement in sanitation scenario in the community and infection control infrastructure in hospitals are much more important measures.
3.Public must be educated on the importance of containing AMR crisis. We cannot improve the sanitation scenario in the community without wholehearted participation of the public, politicians and the media. Swachh Bharat Abhiyan is probably the most important initiative that can help us contain the AMR crisis.
4.Our research organizations must inspire our scientists and pharmaceutical companies to develop new antibiotic molecules. We cannot always depend on foreign pharmaceutical companies. We must strive hard to attain self-reliance in the field of antibiotic discovery and drug development.
5.International Initiatives such as Global AMR action plan, prepared by World Health Organisation, must be adapted to the Indian scenario. Blindly following international recommendations, without understanding Indian realities will result in failure of the policies. We should develop our National AMR containment strategy, based on Indian solutions and a Swadeshi concept.
Antimicrobial resistance is a global challenge that needs local solutions!
Dr Abdul Ghafur, Coordinator, Chennai Declaration on AMR
Consultant in infectious diseases, Apollo Hospital, Chennai more
conditions. The Hospital/dispensary Incharge/Head should be made accountable
for any lapse. 3rd party inspection on monthly basis should be introduced. BIS will
be of little help in this area. more