After creating a huge controversy by claiming that foreign patients who were treated in India developed antibiotic resistance, authors of the superbug New Delhi metallo-B-lactamase-1 (NDM-1) bacteria study published in the United Kingdom-based medical journal The Lancet now say that poor sanitation and unregulated antibiotic use presented an immense challenge and should be of great concern to the Indian health authorities and the World Health Organisation.

Responding to queries in the latest edition of the journal, the authors of the controversial study (Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological and epidemiological study) quoted a UN report saying that 650 million people in India did not have adequate sanitation, and the sewage treatment system in Delhi struggled to cater to 50 per cent of the population.

“Such facts, coupled with India's heavy and unregulated antibiotic use, doubtlessly explain why seven of eight returning Swedish tourists experienced gut colonisation with bacteria producing extended spectrum B-lactamases (ESBLs) and why India has the highest community ESBL rate in the world,” they said.

No recognition

India has failed to recognise, let alone implement, the necessary WHO antibiotic recommendations issued in 2001. “Escheriachia coli with NFM-1 have been found as gut colonists in returning travellers (to The Netherlands, Sweden) from India, and might be transmitted via the faecal-oral route, providing a reservoir of future infection,” the respondents, Timothy R.Walsh, Mark A Toleman, Jayanta B.Sarma, Seema Irfan, Neil Woodford and David, have written.

At the same time, the authors have expressed ‘delight' over the efforts by the Indian authorities in developing new strategies to combat the pressing issue of antibiotic resistance. “This development, plus an open and broad engagement with the worldwide scientific community to expand resistance surveillance and to better understand risk factors for NDM-1, will assist us all in combating the problem,” the article said.

Response to criticism

In response to the major criticism from correspondents, Indian officials and hospital surgeons, and those who rejected the link to India, the authors said that this was directed at the sentence: “‘It is disturbing, in context, to read calls in the popular press for U.K. patients to opt for corrective surgery in India with the aim of saving the National Health Service (NHS) money. As our data show(s), such a proposal might ultimately cost the NHS substantially more than the short-term saving and we would strongly advise against such proposals.' This quote was taken, by critics of our paper, to be a general warning against medical tourism, which currently caters for 4,50,000 patients per year, generates $2 billion per year, and is expected to increase by 30 per cent per year.”

Used earlier

On the naming of the bacteria, the authors say that NDM-1 follows nomenclature for metallo-B-lactamases that started in 1999 with VIM-1 (Verona imipenemase), and includes SPM (Sao Paulo metallo) and SIM (Seoul imipenemase). “No one objected when two research papers (including an Indian study), which were published before our article, used the NDM-1 epithet. Furthermore, Pseudomonas delhiensis was named after the capital by Indian scientists,” the authors said.

The Indian Network for Surveillance of Antimicrobial Resistance, in its reaction to the article, has recommended mandatory surveillance of drug resistance, and said regulatory policies to control abuse of antibiotics in hospitals and communities should be strictly implemented, especially in developing countries.

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