India has a massive antibiotic resistance problem, and it's up to the states to solve it

On September 21, United Nations had a high-level meeting on antimicrobial resistance, which required commitments from heads of state to address the causes of antimicrobial resistance. The declaration resulted from the meeting also requires countries to come up with a two-year plan to curb the use of antibiotics in humans, animals and agriculture.

The pressure is on India, the world's largest consumer of antibiotics and where carelessness in antibiotic use and environmental antibiotic pollution has been documented.

While the government drafted policy measures to tackle the problem, it has not been so forthcoming on the issue.

In 2010, when the Lancet published a study identifying an enzyme that rendered bacteria resistant to broad spectrum of antibiotics as New Delhi Metallo-beta-lactamase-1, it raised the hackles of the Indian government. The authors had said that they detected the bacteria in patients from the United Kingdom who had been to India and Pakistan for treatments. The health ministry described the report as “malicious propaganda” at the time.

The following year, though, the health ministry released a policy document, the National Policy for Containment of Antimicrobial Resistance. However, little was done to implement the policy.

In August 2012, all major medical societies of India got together in Chennai to formulate a roadmap to tackle the challenge of drug resistance in India. The stakeholders, including policy makers, adopted a document called Chennai Declaration.

Just a year before the Chennai Declaration was formulated, the medical community and other organisations were dragging their heels on antimicrobial resistance, said Dr Abdul Ghafur, who co-ordinated the historic Chennai meeting. “It was a topic of stigma for everyone," he said. "But for me, and other clinicians, management of patients was becoming very difficult. I am an infection expert in a cancer centre. I see people die everyday because of drug resistance. They are the worst hit in this crisis.”

At the time, no politician or pharmaceutical company came forward to support the cause.

In the past few years, the government has taken some steps to tackle the problem. In February this year, Union Health Minister JP Nadda launched a multimedia campaign called "Medicines with the Red Line" to raise awareness on the rational use of medicines which carry a red line on their strip. This was the first mass campaign by the government that acknowledged the public health crisis and attempted to address the issue.

While there are some policy level changes, the government is not committing to implementing these policies at the international level.

“We have not made any promises,” said Dr Jagdish Prasad, director-general of health services, referring to the commitment made at the United Nations high-level meeting. “In such a big nation, we cannot promise anything. We have promised surveillance, which we will follow through.”

Hospital surveillance

Prasad was referring to surveillance of hospital acquired infections conducted in 10 hospitals across the country by both the health department and by the Indian Council for Medical Research.

Hospital acquired infections refer to infections that develop as a direct result of healthcare interventions such as medical or surgical treatment or from being in contact with a healthcare setting. Surveillance would include monitoring the infection levels, their impact, and the intervention at various healthcare facilities.

The initial results of the survey are not good, Prasad said. While not disclosing more details, he said that the surveillance showed the presence of several bacteria in hospitals there are resistant to drugs. The health department has released hospital infection control guidelines and standard treatment guidelines, which are available online. They are also holding workshops for doctors from secondary and tertiary level hospitals.

“We will also start an awareness multimedia campaign for the public soon,” said Prasad.

In 2013, the Drugs and the Cosmetics Act has already introduced schedule H1 for third and fourth generation antibiotics for which the chemist has to maintain prescription records for a period of three years, which is open to inspection. There were already some drugs on schedule X that could only be stored in hospitals, and not be sold over the counter.

States not proactive

While the Centre can make policies and educate the states, it is finally up to the state administration to take up the cause. Health is on the state list and the final implementation of any policy is done by the states.

“We have put out guidelines for them," said Prasad. "But implementation is very messy in this country. The state health secretaries keep changing.”

Whether it is the rational use of antibiotics, restriction of over-the-counter drug dispensation, self medication, or controlling the use of antibiotics to raise animals, the state has to take a stronger stand.

“With respect to state implementation, we see the maximum resistance," said Ghafur. "If we go to the district level, there will be even amore resistance. We have to communicate with the grass root level people.”

The lack of medical education poses yet another problem. “You can pass a masters in medicine without answering a single question on antibiotics,” said Dr Chand Wattal, senior microbiologist with Sir Ganga Ram Hospital in Delhi. Wattal has conducted research in the area of drug resistance and was also part of the committee that drafted the 2011 policy.

There is some resistance from the unexpected quarters, like pharmacists. In Maharashtra, the pharmacists went on strike several times opposing the stringent implementation of antibiotic regulations, including that of the need for a pharmacist in each chemist shop.

Prasad said that formulating a law can also be completely useless in this respect. “We passed the Clinical Establishment Act in the Centre. Very few states have adopted it,” he said.

Kerala leads the way

The only way forward, Prasad observed, is to “educate, educate and educate.”

Some states though, have taken some initiative.

“Kerala came up with an antibiotic plan this year, Tamil Nadu is thinking of one, Sikkim knows that they have a hospital infection problem that politicians are very well aware of," said Dr Ramanan Laxminarayan, Director of the Center for Disease Dynamics, Economics & Policy in Washington DC and Distinguished Professor at the Public Health Foundation of India, Delhi. "So we need to think of ways to bring this to the forefront, think of what the options are and act on them.”

Kerala seems ahead of others in this respect and has released a plan in January this year. For a few years now, Ghafur and Dr Sanjeev Singh, the medical superintendent of Amrita Medical Sciences in Kochi, have been lobbying with the government to take this issue seriously. The authorities have taken note.

“We have a five-pronged approach to tackle the problem,” said Singh. “We are training undergraduate, graduates, and postgraduates to understand the rational use of antibiotics and sensitising them about good practice. We are also training eight doctors in each district who in turn will train other doctors. We are also going to educate the patients and tell them that they do not need antibiotics for vomiting and diarrhoea.”

On September 23, 35 medical colleges changed their curriculum to include antibiotic stewardship, a programme that works for rational use of antibiotics.

For any policy against antibiotic resistance to work, there has to be multi-sectoral engagement of various departments including education, sanitation, animal husbandry, agriculture, and health among others. The key to tackling the issue head on is to engage politicians, feels Ghafur.

“Earlier, I would meet more doctors," he said. "It is more of an academic exercise. And it is safe. Nobody is going to oppose a big study. Now I only meet politicians. I not only meet the party in power, but also the opposition party. I do not want them to oppose any move.”