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Increasing Antimicrobial Resistance (AMR) in India- Signs of Impending Doom

According to a recently released report by the National Centre for Disease Control (NCDC), Antimicrobial Resistance (AMR) in India, is one of the highest in the World. The World Health Organization has recognized AMR as one of the top 10 global public health threats.

What is Antimicrobial Resistance? What are the Different Kinds of Antimicrobial Resistance?

Antimicrobial Resistance (AMR) is the resistance of microorganisms (bacteria, virus, parasites and fungi) to an antimicrobial agent (antibiotics, fungicides, antiviral agents and parasiticides), to which they were first sensitive.

Extent of AMR in India according to the National Centre for Disease Control (NCDC) report on AMR

1. Bacteria like E. coli, Klebsiella, Acinetobacter, Staphylococcus aureus, enterococcus have become resistant to even the latest generation of antibiotics.

2. Third-generation antimicrobial drugs like cephalosporins, imidazoles, amino-glycosides, ceftriaxone, metronidazole, amikacin and piperacillin, used to treat cold, fever, skin diseases and urinary tract infection have become ineffective.

3. Inappropriate use of antibiotics in human, animal and agricultural sectors has generated superbugs that are resistant to these antibiotic drugs, which spread due to inadequate sanitation and improper infection prevention in healthcare.

Types of Antimicrobial Resistance

What are the reasons behind the growth of Antimicrobial resistance in India?

1. Misuse of antimicrobial medicines- The use of antibiotic medicine in non-bacterial infections, use of over-the-counter antibiotics, self-medication and emergence of fixed drug compositions, have contributed to the increase in antimicrobial resistance in India. For ex- Overuse of antimicrobial medicines during the Covid-19 outbreak.

2. Inadequate laboratory facilities- India lacks severely in the laboratory network and capacity to support Clinicians/Doctors with the bacterial culture test and suggesting an appropriate antibiotic.

3. Lack of trained healthcare personnel– There is lack of adequate training of healthcare personnel in antibiotic selection, escalation, and de-escalation.

4. Inadequacy of healthcare facilities- Overcrowded hospitals have left very little time for the doctors to examine patient’s medical history, conduct proper blood tests and then recommend proper antimicrobial treatment.

5. Inappropriate use of antimicrobes in agriculture and allied sectors– The overuse of antimicrobials in agriculture and allied sector have led to increase in AMR. For ex- Use of Colistin as growth promotional agent in poultry farming has led to Colistin AMR in India.

6. Inadequate monitoring- India lacks proper monitoring system to control the antibiotic prescription and dispensing practice by health system. For ex- Ineffective monitoring to stop the sale of over the counter antibiotics.

7. Crony capitalism- The pharmaceutical industry incentivises the sale of antibiotics by being hand in gloves with the health care personnel like doctors, pharmacists etc.

8. Contamination around pharmaceutical manufacturing sites- The untreated waste from the pharmaceutical industries releases large amounts of active antimicrobials into the environment.

9. Inadequate sanitation facilities- Poorly functioning sanitation systems like open defecation, poorly contained septic tanks have led to increase in AMR.

10. Improper infection prevention in healthcare institutions- AMR has also spread due to the lack of proper infection prevention mechanism in hospitals, clinics and laboratories. For ex- Candida auris acquired by hospital patients.

11. No new antimicrobial developments- The exit of big pharma from antibiotic development and lack of investment from venture capitalists to support the commercial viability of antibacterial agents, has pushed AMR into a global health crisis.

What are the challenges posed by spread of Antimicrobial Resistance?

1. Threat to the health care system- The Antimicrobials helped in significantly reducing the mortality rates low and middle-income countries (LMICs) of Asia and Africa. The ineffectiveness would impair the modern health system by failing to prevent infections post a routine surgery or cancer treatment.

2. Loss of Human Lives- AMR is responsible for up to 7 lakh deaths a year (GRAM project report). For ex- E.coli and MRSA (Methicillin Resistant Staphylococcus Aureus) are among the drug-resistant bacteria that lead to most deaths.

3. Economic Brunt- As per an estimate by the Global Research on Antimicrobial resistance (GRAM) project, AMR can lead to an economic brunt on the world economy to the tune of US$ 1 trillion by 2050.

4. Looming possibility of next pandemic- There is a looming possibility that the next pandemic will be caused by a superbug. For ex- Concerns about the spread of C. Auris superbug.

What steps have been taken towards controlling AMR?

1 Domestic Steps and Actions

Ban of antimicrobial usage in Agriculture The Government of India has passed an order banning the use of streptomycin and tetracycline in agriculture and the growth promotional use of colistin in poultry farming.

National programme on AMR containment It was launched during 12th FYP in 2012-17. Under this programme, AMR Surveillance Network has been strengthened by establishing labs in State Medical Colleges.

Delhi Declaration on AMR An inter-ministerial consensus was signed by the ministers of the concerned ministries pledging their support in AMR containment.

Chennai Declaration New H1 rule was introduced which banned the use of only second and third-line antibiotics. (H1 rule was brought out to regulate over-the-counter use of antibiotics)

Red Line campaign To prevent irrational use of prescription-only antibiotics and create awareness on the dangers of taking antibiotics without prescription.

2 Global Steps and Actions

Funding support through PPP model Early stage funding from public-private partnerships like CARB-X (the Combating Antibiotic Resistance Bacteria Biopharmaceutical Accelerator) to small companies for antibacterial projects.

GAIN Act, 2012 The U.S. Congress has enacted the Generating Antibiotic Incentives Now Act (GAIN Act) of 2012. It provides benefits to manufacturers of Qualified Infectious Disease Products (QIDPs) including five years of additional non-patent exclusivity.

WHO’s Global Action Plan (GAP) on AMR, 2015 WHO has launched this comprehensive global action plan to reduce the incidence of AMR by improving awareness and understanding about AMR, optimisation of antimicrobial usage and initiating effective sanitation and hygiene.

What should be the way ahead in reducing AMR?

AMR is a complex socio-economic and political challenge and not just a scientific issue to be solved by doctors and researchers alone.

1. Improvement of Sanitation and Hygiene- The sanitation in hospitals and basic access to personal hygiene must be improved to reduce the spread of AMR.

2. Implementation of the Chennai Declaration on AMR- The new H1 rule which banned the use of only second and third-line antibiotic must be implemented at the earliest to prevent the over-the-counter sales of antibiotics.

3. Investment in Public Health infrastructure- The investment in public health infrastructure like network of laboratories, hospitals, recruitment of trained medical professionals must be enhanced at the earliest. For ex- NCCD reports points out that states with good public health systems have lower AMR.

4. Improving governance and monitoring framework- Environmental governance, planning and regulatory frameworks must be enhanced to combat the menace of AMR. For ex- Involve the Ministry of environment to stop the contamination of antimicrobials.

5. One Health Approach- Any actions on AMR must be guided by the ‘One Health Approach’- a holistic approach that links the health of humans with our shared environment. This will help in reducing the use of biopesticides and fungicides in agriculture.

6. Robust investment in R&D of new antibiotics- Funding support must be taken from the AMR Action Fund for the development of new and power antibiotics.

7. Awareness Generation on AMR- Peru’s efforts on patient education to reduce unnecessary antibiotic prescriptions must be used as a learning point.

The development of resistance to antimicrobials is a major public health problem all over the world. It makes even minor infections tough to treat, causing severe illnesses and deaths. Hence, a clarion call to end this menace must be taken at local, national and global levels that would eventually help in attainment of SDG 3 , (ensuring health and well-being of all).

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