Antimicrobial resistance was directly responsible for as many as 1.27 million deaths globally in 2019, according to a publication in the medical journal The Lancet that came out in January.
The World Health Organisation (WHO) defines antimicrobial resistance as “when bacteria, viruses, fungi and parasites change over time and no longer respond to medicines making infections harder to treat and increasing the risk of disease spread, severe illness and death.” The WHO even declared antimicrobial resistance to be one among the top 10 global public health threats facing humanity.
While the Lancet analysis said 1.27 million deaths were directly caused by AMR, it also said that in all, 4.95 million deaths were associated with bacterial anti-microbial resistance that year.
The Lancet paper found that out of 23 bacterial pathogens and 88 drug-pathogen combines analysed, six led in terms of deaths associated with resistance, namely, E. coli, S. aureus, K. pneumoniae, S. pneumoniae, A. baumannii and Pseudomonas aeruginosa. They accounted for 73.4% of the deaths due to antimicrobial resistance and the WHO has identified these as primary pathogens.
While drug resistance in lower respiratory infections, such as pneumonia, caused over 400,000 deaths and was associated with 1.5 million deaths, drug resistance in bloodstream infections caused around 370,000 deaths and was also associated with close to 1.5 million deaths, the analysis also found. Young children were particularly at risk, the analysis said, noting one in five deaths associated with antimicrobial resistance occurred in children under five years.
So what causes antimicrobial resistance? Overuse and misuse of antibiotics, buying them over the counter are largely considered key factors but what role do hygiene and sanitation play? How are antibiotics used in the farming sector, and has the Centre’s recent ban on the use of an antibiotic in poultry farming had an impact? What has India done and what more needs to be done to minimise the long-term impacts of this health threat ?
In an interview with The Hindu, Dr Abdul Ghafur, consultant, infectious diseases, Apollo Hospital, Chennai and former Technical Advisory Member, National Antibiotic Policy, answers these and other questions regarding antimicrobial resistance. Here are some of the edited excerpts.
How is India placed when it comes to antimicrobial resistance? Are we particularly vulnerable?
India has one of the highest antimicrobial resistance rates in the world. Every day as a clinician, I come across infections resistant to most antibiotics. We call it multidrug resistance. We treat infections where not even one antibiotic is effective and that's called pan drug resistance.
Unfortunately, we don't have antibiotics to treat some of the infections that we see in everyday life, especially in intensive care units and cancer and transplant patients. If you don't have the right antibiotic to treat a severe infection, the patient will not recover from the infection.
We need to know what causes antimicrobial resistance. Number one, irrational usage of antibiotics. That means we don’t use the right antibiotic at the right dose at the right time for the right indication. And who is responsible for irrational antibiotic usage? We will say doctors but they are not the ones responsible for antimicrobial resistance. There are so many stakeholders. If you look at the overall antibiotic usage at the global level, you will know that 70% of the antibiotics manufactured by pharmaceutical industries is utilised in animal farming -- growth promotional usage. Only 30% is used in the human world and of the human usage, half is over-the-counter purchases made by the public without a doctor’s prescription. Irrational antibiotic usage is just one of the several components of the antibiotic resistance crisis. There are several other determinants -- governance standards in a country, infrastructural standards such as quality of drinking water and sanitation levels also determine antimicrobial resistance, making it a complex challenge. Antibiotic resistance is because of irrational antibiotic usage on one end, and on the other end, the pharmaceutical industry has stopped investing in antibiotics as they do not find it profitable.
Did we see a widespread use of antibiotics over the last two years, because of the COVID-19 pandemic ?
The COVID pandemic has affected antibiotic usage in two ways. In the initial phase of the pandemic, the overall hospital admission dropped while COVID admissions increased. So, the high-end antibiotics to treat severe infections probably reduced because the overall number of hospitals admission reduced.
At the same time, the utilisation of ordinary antibiotics increased to treat secondary infections in COVID patients. So COVID pandemic has affected antibiotic utilisation in positive and negative ways. Whether this differential utilisation of antibiotics impacted antimicrobial resistance is difficult to predict. Antibiotic resistance is not directly proportional to the antibiotic usage, there are several other determinants causing antibiotic resistance. We need long-term follow ups to know the impact of COVID pandemic on antibiotic resistance.
The Lancet paper mentioned that antibiotic antimicrobial resistance poses a threat to people of all ages and young children, especially those under five years of age, were found to be particularly at high risk. Why is this?
Pneumonia was the number one disease causing mortality due to antibiotic resistance, according to the Lancet paper. Pneumonia is one of the major killers in children below five years of age. There is a bacteria called pneumococcus causing pneumococcal pneumonia and that's one of the major killers across the world. That is why there is the high mortality due to antibiotic resistance in children under five years of age.
How do we prevent this? There's a vaccine called pneumococcal vaccine. We could not introduce this vaccine in our national program for several years, because of the high cost of these pneumococcal vaccines. But a few months ago, the government introduced pneumococcal vaccines in our national [immunisation] programme, because low-cost pneumococcal vaccines manufactured by Indian companies became available. And hopefully, that will reduce the under-five mortality due to pneumococcal pneumonia to a great extent.
In 2019, the Indian government issued an order banning the last line antibiotic colistin for use in animals to crack down on this misuse in the poultry industry. Is this a step in the right direction and what more can be done?
It's a major step in the right direction. Colistin is the most sought-after antibiotic in hospitals. It is the last resort antibiotic in hospitals.
Colistin is mixed in the poultry feed to make chickens grow fast and fast, it is a global phenomenon, and is rampant in the poultry farming in India. When fed to poultry, there will be colistin-resistant bacteria in chickens. This will come out in poultry litter that will contaminate the poultry meat. And poultry litter is a major fertilizer for vegetable farming.
And in 2018, we did a study to analyse the presence of colistin-resistant bacteria in Indian chicken samples and vegetable samples. Out of the 100 samples we collected 50, half of them, were positive for colistin-resistant bacteria. Many countries use colistin for growth-promotional purposes.
China had banned colistin several years ago but India was importing it from China, and we were using it in our poultry farming. And we banned it only in 2019. Currently, we don't know the extent of colistin usage in poultry farming. The COVID pandemic started immediately after the ban. But it is worth studying the food and vegetable contamination of colistin-resistant bacteria post the pandemic period.
What other steps in terms of policies or frameworks has India taken and what more needs to be done?
In 2012, the medical societies in India released the Chennai declaration initiative on antimicrobial resistance to tackle the challenge of AMR in the country.
In 2015 the WHO released the global action plan and India released the National Action Plan in 2017. And we expected all the states to prepare a state action plan. But even after five years, only two or three states have prepared the state action plan and initiated implementation even though at a very rudimentary level.
Most of the states haven't even prepared a state action plan on paper on how to control the challenge of antimicrobial resistance in India. All states should formulate a state action plan and when we implement an action plan, we have to give importance to all components.
When we started the implementation of the antimicrobial resistance action plan, we failed to involve the public to the level that they should have been involved. Because of the pandemic, we have learnt that the public is the most important stakeholder. Antimicrobial resistance cannot be tackled by doctors or the scientific community alone. We need the public, policymakers and politicians coming together to tackle the challenge.
