A looming health crisis- Antimicrobial resistance

GS-Paper-3 Antibiotic resistance (PT-MAINS)

Context: Antimicrobial resistance is growing exponentially and needs to be tackled before it is late. While the COVID-19 pandemic continues to wreak havoc on our daily lives, a silent pandemic has been brewing in the background for decades. Governments need to factor in new research and bring in businesses and consumers as active stakeholders before it is too late.

Facts

• Antimicrobial resistance (AMR) is growing at an alarming rate. Globally, about 35% of common human infections have become resistant to available medicines.
• About 700,000 people die every year because available antimicrobial drugs — antibiotics, antivirals, antiparasitics and antifungals — have become less effective at combating pathogens.
• Resistance to second and third-line antibiotics — the last lines of defence against some common diseases — is projected to almost double between 2005 and 2030.
• In India, the largest consumer of antibiotics in the world, this is a serious problem.
• According to a study published in The Lancet, an estimated 58,000 newborn children die annually from sepsis in India alone because antibiotics can no longer treat certain bacterial infections.
• We have long known that microorganisms develop resistance to antimicrobial agents as a natural defence mechanism.
• We have also known for some time that human activity has significantly accelerated the process. The misuse and overuse of antimicrobials for humans, livestock and agriculture is probably the biggest reason for this, but other factors also contribute.

Role of environment and pollution in AMR

• Once consumed, up to 80% of antibiotic drugs are excreted un-metabolised, along with resistant bacteria.
• Their release in effluents from households and health and pharmaceutical facilities, and agricultural run-off, is propagating resistant microorganisms.
• Wastewater treatment facilities are unable to remove all antibiotics and resistant bacteria.
• In India, there is the capacity to treat only about 37% of the sewage generated annually. The rest is discharged into natural water bodies without treatment.
• An analysis of single wastewater discharge from a treatment facility in India catering to drug manufacturers found concentrations of antibiotics high enough to treat over 40,000 people daily.
• Water, then, maybe a major mode for the spread of AMR, especially in places with inadequate water supply, sanitation and hygiene.
• Wildlife that comes into contact with discharge containing antimicrobials can also become colonised with drug-resistant organisms.

Key initiatives

This issue has been on the radar of scientists for several years.

• The United Nations Environment Programme (UNEP) identified antimicrobial resistance as one of six emerging issues of environmental concern in its 2017 Frontiers Report. In that same year, the UN Environment Assembly pressed the need to further understand the role of environmental pollution in spreading AMR.
• UN agencies are working together to develop the One Health AMR Global Action Plan (GAP) that addresses the issue in human, animal, and plant health and food and environment sectors.
• The Centre and State governments in India can strengthen the environmental dimensions of their plans to tackle antimicrobial resistance. It is particularly important to promote measures that address known hotspots such as hospitals and manufacturing and waste treatment facilities.
• This has started to an extent. Early in 2020, the Ministry of Environment, Forest and Climate Change (MoEF&CC) issued draft standards which set limits for residues of 121 antibiotics in treated effluents from drug production units. These standards await finalisation. And in July this year, the Ministry of Health and Family Welfare and MoEF&CC constituted the inter-ministerial Steering Committee on Environment and Health, with representation from WHO and UNEP.

**Atul Bagai is Head, UN Environment Programme, Country Office, India

Additional notes

• Antimicrobial resistance is a major public health problem in South East Asian countries. It is known that the infectious disease burden in India is among the highest in the world and burden of poor sanitation and malnutrition exacerbates these conditions.
• Presently under various national health program there are definite policies or guidelines for appropriate use of antimicrobials like Integrated Management of Neonatal and Childhood Illness (IMNCI) in diarrheal diseases and respiratory infections, but these are not available for other diseases of public health importance like enteric fever and others.
• During the recent H1N1 pandemic, national guidelines were framed and implemented regarding restricted sale and use of **oseltamivir in the country.
• Another major issue is that there is no national data based on antimicrobial resistance in different pathogens except for those where there is a specific national health program. Networking of laboratories in the Revised National Tuberculosis Control Program in the country generated some useful data on drug resistance in tuberculosis and recently a laboratory network has also been established for antimicrobial testing of HIV under National AIDS Control organization.
• Meta analyses of the drug susceptibility results of various laboratories in India reveal an increasing trend of development of resistance to commonly used antimicrobials in pathogens like Salmonella, Shigella, Vibrio cholerae, Staphylococcus aureus, Neisseria gonorrhoeae, N. meningitidis, Klebsiella, Mycobacterium tuberculosis, HIV, plasmodium and others.
• New resistance mechanisms, such as the metallobeta-lactamase NDM-1, have emerged among several gram-negative bacilli. This can render powerful antibiotics ineffective, which are often used as the last line of defence against multi-resistant strains of bacteria.
• In addition, various studies in South India highlighted the drug resistance pattern like multidrug-resistant Extended-Spectrum β-Lactamase Producing Klebsiella pneumonia, Ciprofloxacin resistant Salmonella enteric serovar Typhi, the emergence of vancomycin-intermediate staphylococci, fluoroquinolone resistance among Salmonella enteric serovar Paratyphi A, Pseudomonas aeruginosa and Acinetobacter baumannii resistant to ceftazidime, cefepime and ciprofloxacin.

Problems

1. Presently there is no national program for prevention of drug resistance and there is an inadequacy of quality assured laboratories, insufficient data analysis and dissemination, absence of national guidelines on antimicrobial usage, and no control on the sale of these drugs for public consumption.
2. In India, around 5% of GDP is spent on health out of which the public health sector contributes 0.9% and a major portion of the remaining is by the private health sector. Again around 80% share of private health sector contribution comes from out of pocket expenditure mostly for medicines and In private sector, many of the doctors are poorly trained or unlicensed.
3. Provision of essential medicines by the public sector is one of the measures to prevent antimicrobial resistance. But the non-availability of some medicines because of irregular supply and problems related to monitoring the external and internal drug quality will further increase the problem.
4. Inappropriate and irrational use of medicines provides favourable conditions for resistant microorganisms to emerge and spread.
5. Prescription of antibiotics by the doctors according to patient needs without any indications and involvement of pharmacists in direct sale of drugs to patients increase the problem of antimicrobial resistance.
6. Compounding this problem, consumers and the public lack knowledge regarding the appropriate use of antibiotics.
7. Self-medication and poor compliance are the other factors responsible for antimicrobial resistance among consumers. So, behavioural pattern of the health care providers and consumers is of paramount importance in the emergence of antimicrobial resistance.
8. Inadequate national commitment to a comprehensive and coordinated response and ill-defined accountability with respect to antimicrobial use and resistance is an issue to be considered. Weak surveillance and regulatory system is also important determinant of antimicrobial resistance.

AMR results in many consequences.

1. The patient remains sick for a longer period thus requiring prolonged treatment usually with expensive and at times toxic drugs which results in increased morbidity and mortality.
2. The burden on the health system also increases. Hospital-acquired infection in vulnerable patients with resistant strains is another major threat in the Indian context.
3. The success of treatments such as organ transplantation, cancer chemotherapy and major surgery would be compromised without effective antimicrobials for care and prevention of infections.
4. All these have a substantial effect on the economy at the individual level and society level. Many infectious diseases risk becoming uncontrollable and could derail the progress made towards reaching the targets of the health-related United Nations Millennium Development Goals set for 2015.
5. Recently the growth of global trade and travel has allowed resistant microorganisms to be spread rapidly to distant countries and continents.

Recent developments

Large number of new initiatives have been launched by various agencies to contain this problem which includes.

India Clen (Indian Clinical Epidemiology Network) which has generated some quality data on AMR in pathogens like pneumococcus, and H.influenzae across the country.

• IIMAR (Indian Initiative for Management of Antibiotic Resistance) was launched in March 2008, with WHO support, by a consortium of NGOs to promote the prudent use of antimicrobials.
• INSAR (Indian Network for Surveillance of Antimicrobial Resistance) is a network of 20 laboratories in the private as well as public sectors across the country to generate quality data on AMR
• WHO has supported a few community-based surveillance studies to determine the antimicrobial resistance as well as use of antimicrobial agents and generated some baseline data on Antimicrobial use and resistance in five pilot sites in India (Delhi, Mumbai, Vellore) and South Africa (Durban, Brits).
• Chennai Declaration” by a consortium of the Indian Medical Societies.
• Redline campaign for educating the public.
• National Action Plan on AMR 2017.

Challenges

• Strengthening of Surveillance Data
• Standard Operating Guidelines
• Improvement in antibiotic prescription practices
• Over-the-counter sale of antibiotics
• Poor sanitation, endemic infections, malnutrition
• Limited public awareness and government commitment
• Lack of coordination and fragmentation of effort
• Perverse incentives.

Strategies

• Establish a national alliance against antimicrobial resistance with all key stakeholders as its members. There should be an integrated approach between provider and consumer sides to effectively prevent the antimicrobial resistance. From the provider side policy makers, planners, practitioners and prescribers, pharmacists and dispensers, institution managers, diagnostic and pharmaceutical industries, department of animal husbandry and from the consumer side patients and community is important in this regard.

• Implement appropriate surveillance mechanisms in the health and veterinary sectors to generate reliable epidemiological information, baseline data, trends on antimicrobial resistance, utilization of antimicrobial agents and impact on the economy and health through designated national and regional reference centres. Discourage non-therapeutic use of antimicrobial agents in veterinary, agriculture and fishery practices as growth-promoting agents.
• Develop national standard treatment and infection control guidelines and ensure their application at all levels of health care and veterinary services through training, continuous educational activities, the establishment of functional drugs and therapeutic committees and hospital infection control committees in health facilities with the focus on proven cost-effective interventions such as isolation, hand washing.
• To regulate and promote rational use of medicines and ensure proper patient care at all levels, there is a need to take necessary steps to stop the counter sale of antibiotics without physicians' prescriptions and ensure uninterrupted access to essential medicines of assured quality at the hospital and community.
• vaccination strategies should be improved to further reduce the burden of infections.
• Conduct of operational research for a better understanding of the technical and behavioural aspects of prevention and control of antimicrobial resistance. Utilize the outcomes of these research studies or interventions in policy and program development improvement in the national context.
• Constructive interactions with the pharmaceutical industry for ensuring appropriate licensure, promotion and marketing of existing antimicrobials and for encouraging the development of new drugs and vaccines.
• Educational and awareness programs for communities and different categories of health care professionals.
• Strengthen communicable diseases control program to reduce disease burden and accord priority to the discipline of infectious diseases in medical education and health services.