All posts by dswanbeck

India: The Front Line in the War Against Antibiotic Resistance

by Emma Louise Keeler

In 1967, epidemiologist and United States Surgeon General William Stewart proclaimed that “the war against infectious diseases has been won.” Fifty-two years later, not only is the war against infectious diseases far from over, but humanity is increasingly on the losing side due to antibiotic resistance. Nowhere are our losses more apparent than in developing nations. The battle against resistant-pathogens is not one that each nation can fight separately; in order to win, nations must work multilaterally. Each year in the U.S. at least 2 million people are infected by antibiotic-resistant bacteria; of these people, at least 23,000 will die as a result of the infection. In order to fight resistance within our own country, it is necessary to first confront it at one of its origins — India.

For five decades, antibiotic resistance has placed a burden on India’s healthcare system and society. Resistance has undermined attempts to treat both common and lethal infectious diseases. Pneumonia, the number one cause of death for Indian children, causes approximately 410,000 deaths annually. Most, if not all, of these deaths are directly related to the shortage of effective antibiotics. Over 50% of bacterial infections in Indian hospitals are caused by antibiotic-resistant bacteria, and 24% of bacteria are resistant to last-resort, intravenous antibiotics called “carbapenems.”

India’s governmental and economic conditions have generated an ideal breeding ground for resistance. The availability and insufficient regulation of antibiotics have promoted inappropriate antibiotic usage and subsequent resistance. Although it is illegal to sell unregulated antibiotics, millions are sold annually due to the lack of enforcement. A study published by the British Journal of Clinical Pharmacology revealed that nearly two thirds of the fixed-dose combination antibiotics sold in India have not received regulatory approval. This is particularly concerning when considering India’s place as one of the five BRICS countries (Brazil, Russia, India, China, and South Africa), accounting for 75% of the 36% rise in worldwide antibiotic consumption between 2000 and 2010. Out of the BRICS countries, India is responsible for 23% of the increase in retail sales.

Indian medical professionals often irresponsibly prescribe antibiotics at an incorrect dose, frequency, or duration. For example, 45 to 80% of patients with symptoms of acute respiratory infections, common colds, or diarrhea are given an antibiotic despite most of these ailments being viral, not bacterial. The issue of inappropriate prescriptions is exacerbated by both a lack of microbiology facilities and little willingness of patients to undergo tests.

For decades, India’s notoriously poor healthcare infrastructure has suffered from inadequate public finance. The Indian government has also turned a blind eye to the determinants and effects of resistance. However, the recent emergence of the enzyme New Delhi Metallo-beta-lactamase-1 (NDM-1) has galvanized the government into instituting antibiotic-related policies. A Ministry of Health and Family Welfare task force announced a national antimicrobial policy, the National Policy for Containment of Antimicrobial Resistance, that will focus on conducting infection and resistance surveillance, promoting rational drug use through education, banning the selling of antibiotics over-the-counter and restricting the use of potent antibiotics (i.e. carbapenems).

In 2010, 13% of infection-causing bacteria in India were “superbugs” endowed with the NDM-1 enzyme. This enzyme was first isolated from a Swedish patient of Indian origin in 2008 and was shortly detected in India, hence the name New Delhi Metallo-beta-lactamase-1. This specific enzyme makes bacteria resistant to all beta-lactam antibiotics (i.e. penicillins, cephalosporins, carbapenems). Once a bacterium acquires this enzyme, it is virtually unharmed by mainstream antibiotics. Furthermore, this enzyme can be passed between different bacterial pathogens through horizontal gene transfer.

Each year, more than 5.4 million Indians travel internationally, in addition to the 20 million Indian nationals living throughout the world. Due to this, India’s issue of antibiotic resistance, especially that related to the NDM-1 enzyme, is no longer confined to its borders — it is a worldwide concern. Effective antibiotics are as much a globally shared resource, as they are a shared responsibility. The battle against antibiotic resistance must be fought together, starting with an understanding of the situation in other nations.