Restriction on across the counter sales of antibiotics

The Union Health Ministry is considering a new National Antibiotics Policy for the country to handle increasing antibiotics resistance in the country.

Union Health secretary Keshav Desiraju said the government was considering a new policy in the light of an older policy drawn up in 2011, soon after the NDM-1 controversy broke out. That policy was later withheld ostensibly because of widespread protests against certain key recommendations: It had recommended a complete ban of across the counter antibiotics; and specified that high end antibiotics could be used only in tertiary care centres.

Experts claim that a policy is of vital importance to ensure that further obstinate strains do not develop. Most hospital administrators are concerned about treating a growing percentage of patients with strains of bacteria that are resistant to carbapenem — powerful third line antibiotics. This is especially so in the corporate, private hospitals, where the use of expensive antibiotics is more common, explains Abdul Ghafur, infectious diseases consultant, Apollo Hospitals.

In the three years after the first National Antibiotics Policy was shelved, resistance rose in hospitals, Dr. Ghafur says. “About three years ago, NDM-1 was three per cent in big Indian hospitals, now there is proof that it is between 20-50 per cent.” Today, according to him doctors are seeing patients resistant even to colistin, a drug that could once be used against multi-resistant, gram negative bacteria. Consequently, the mortality is pretty high. “In fact, we are heading towards a pre-Fleming situation, the bacteria are seemingly invincible,” he says.

In 2010, Timothy Walsh, professor of medical microbiology at Cardiff University, Wales, described in an issue of The Lancet, the emergence of a new enzyme that made bacteria resistant to all known antibiotics. The enzyme New Delhi Metallo 1 (NDM1) was named after the city in which it was found, Dr. Walsh explained. India took objection to naming the bacteria after the country and some of that objection was rooted in the potential threats to medical tourism in the country.

In a recent interview to The Wall Street Journal, Mr. Walsh was quoted as saying that “India has failed to respond to the urgent need to regulate the sale and use of antibiotics, track the incidence of resistance or improve sanitation.” The article also attributes this to “poor sanitation, unregulated use of antibiotics and an absence of drug resistance monitoring.”

The Chennai Declaration (chennaideclaration.org), known since as a milestone event, was held in August 2012, and brought together representatives of various specialist groups to put their heads together and draw up a road map to tackle antimicrobial resistance in the country. Dr. Ghafur, who was one of the organisers, says, “There was no controversy any more, because we were all scared and we wanted to solve this thing fast.”

The Chennai Declaration pushed for the creation of a national antibiotic policy, this time, one that would be implementable. It also suggested the possibility of adopting a “liberal approach.” To start with, they suggested that restriction be placed on across the counter sales of an initial list of antibiotics, and that additional drugs could be added to the list in a phased manner. They also recommended that a national antibiotic resistance surveillance system be established with representation from all regions in the country, government and private hospitals.

Rational use of antibiotics

Once such a national policy is formulated, whole hearted support for this policy by the state Health department is essential for implementation, says A. Muruganathan, president, The Association of Physicians of India. It is also important to ensure that the policy is implemented in full, and checks be placed to hold and punish violators, he adds. The Declaration also called for training of young medical professionals on proper use of antibiotics.

Welcoming the government move to come up with a new policy wholeheartedly, Dr. Ghafur also adds, “Even if we start today with a national policy, things will naturally not change at once. But it is key that we bring in a culture of rational use of antibiotics.”

Mr. Desiraju clarified that the manner and extent to which “The Chennai Declaration” has had an influence on the National Antibiotics Policy could only be estimated when a final view emerges. The various components of the policy are still under discussion.