Antimicrobial resistance is one of the most pressing public health issues of our time. With today marking the commencement of World Antimicrobial Awareness Week, it is worthwhile examining what antimicrobial resistance is and what it means for India.
The World Health Organization (WHO) defines antimicrobial resistance as “when bacteria, viruses, fungi, and parasites resist the effects of medications, making common infections harder to treat and increasing the risk of disease spread, severe illness and death. Antimicrobials are agents that are critical tools for fighting diseases in humans, animals and plants and include antibiotic, antiviral, antifungal and antiprotozoal medicines.
“Multiple factors – including overuse of medicines in humans, livestock, and agriculture, as well as poor access to clean water, sanitation and hygiene – have accelerated the threat of antimicrobial resistance worldwide.”
The objective of World Antimicrobial Awareness Week, the WHO explains, is “to increase awareness of global antimicrobial resistance…and to encourage best practices among the general public, health workers and policy makers to avoid the further emergence and spread of drug-resistant infections.” The importance of this is patent. The WHO identifies antimicrobial resistance as one of the “urgent, global health challenges” we face over the course of this next decade.
Of antimicrobial resistance, the WHO asserts that it “threatens to send modern medicine back decades to the pre-antibiotic era, when even routine surgeries were hazardous. The rise of [antimicrobial resistance] stems from myriad factors that have come together to create a terrifying brew, including unregulated prescription and use of antibiotics, lack of access to quality and affordable medicines, and lack of clean water, sanitation, hygiene and infection prevention and control.”
It is easy to see why. Without intervention, antimicrobial resistance could kill ten million people a year by 2050 compared to 700,000 at present.
India is well-acquainted with antimicrobial resistance. The country bears a substantial amount of the brunt of the phenomenon’s rise.
Earlier this year, a study by researchers at the Center for Disease Dynamics, Economics and Policy, published in The Lancet Infectious Diseases found India to be the second-largest consumer in the world of what are known as the “Watch” antibiotics. This class of antibiotics is defined by the WHO as “antibiotics that have higher resistance potential and includes most of the highest priority agents among the Critically Important Antimicrobials for Human Medicine and/or antibiotics that are at relatively high risk of selection of bacterial resistance.” Overall, India has been pinpointed as the largest consumer of antibiotics in the world, with a 103 percent jump in use between 2000 and 2015.
Last year, my colleague Nicholas Parry reported on a Public Health Foundation of India (PHFI) study which found the use of third- and fourth-line antibiotics are used virtually indiscriminately in India. These, Parry explained, ought to be “used as a last resort in cases where resistance is present to more commonly used medications…for antibiotics to be issued with such frequency, particularly in a situation in which they are not warranted, is a concerning revelation. Frequent use of antibiotics where they are unnecessary is one of the major drivers of antibiotic resistance.”
Sakthivel Selvaraj, one of the authors of the paper, told Down To Earth in an interview at the time that “the third line of antibiotics is to be prescribed only at hospital-level, usually in ICUs [intensive care units]; only if the severity of the infection has reached that stage. However, to our utter surprise, we found that they are being prescribed at primary care level. This is totally unscientific and unacceptable.”
The potential consequences of this are dire. As a 2019 study published in the Indian Journal of Community Medicine noted
“India carries one of the largest burdens of drug-resistant pathogens worldwide, including the highest burden of multidrug-resistant tuberculosis, alarmingly high resistance among Gram-negative and Gram-positive bacteria, even to newer antimicrobials such as carbapenems and faropenem since its introduction in 2010. Regional studies report high AMR among pathogens such as Salmonella typhi, Shigella, Pseudomonas, and Acinetobacter. Annually, more than 50,000 newborns are estimated to die from sepsis due to pathogens resistant to first-line antibiotics. While exact population burden estimates are not available, neonates and elderly are thought to be worse affected. Two million deaths are projected to occur in India due to AMR by the year 2050.”
Union Health Minister Dr Harsh Vardhan has spoken out on antimicrobial resistance during his tenure at the Ministry. At last year’s meeting of the G20 nations’ health ministers, “Vardhan called for alignment between United Nations agencies in combating antimicrobial resistance and outlined the government’s approach to the problem, including research and development for new drugs; a national action plan; and a surveillance system”, as Health Issues India reported at the time.
Earlier in the year, India joined a coalition of countries to combat antimicrobial resistance. “We all have a role to play to protect the efficacy of antimicrobial agents and to support the efforts of the different sectors at national, regional and global levels,” Renu Swarup, Secretary for the Department of Biotechnology at the Union Ministry of Science and Technology, said at the time. “Working together, we can address this threat and change the trajectory of health for humanity.”
To fight antimicrobial resistance, a number of initiatives have been unveiled in recent years. The launch of the Antimicrobial Resistance Multi Partner Trust Fund (AMR-MPTF); the Global Antibiotic Research & Development Partnership (GARDP); the Global Antimicrobial Resistance and Use Surveillance System (GLASS); and the AMR Action Fund are among those listed by the WHO.
Curbing overprescription of antibiotics; plugging the data gaps; cross-sectoral collaboration to innovate in solutions; and adhering to personal hygiene, sanitation, and food safety standards as communities and individuals are among the best practices. It will not be easy. But ten million lives a year – including two million in India – depend on a concerted, robust effort by stakeholders everywhere. When it comes to antimicrobial resistance, we are all stakeholders.