We live in a bacterial world and there are consequences of messing around: Ramanan Laxminarayan

For only the fourth time in its history, the United Nations General Assembly will discuss a global health problem at its annual high-level meeting when heads of state travel to New York. The General Assembly is meeting on Wednesday to discuss the threat of antibiotic resistance, which claims 7,00,000 lives every year. The international body has in the past deliberated on the most severe health threats like AIDS and Ebola.

Public health experts expect that the UN will call for global attention to the problem, ask member countries to reduce the use of antibiotics, phase out unnecessary use and provide access to people who really need them.

Antibiotic resistance is a pubic health threat that can set back our medical achievements since the discovery of penicillin. Antibiotic resistance, also called antimicrobial resistance and often abbreviated to AMR, occurs when microorganisms develop evolutionary mechanisms to become resistant to the drugs we use to treat infections caused by them, thereby rendering the drugs ineffective. This resistance is caused by overuse and irresponsible use of antibiotics, essentially killing all weaker microbes in the environment till only the stronger and deadlier ones survive and thrive.

India has the highest use of antibiotics and also rapidly rising antibiotic resistant infections. Nearly 60,000 newborn babies die from antibiotic resistant neonatal infections in India every year. A recent paper on the Delhi Neonatal Infection study or DeNIS published in The Lancet showed how babies in three public hospitals – AIIMS, Safdarjung Hospital and Maulana Azad Medical College – contracted sepsis that was untreatable because the bacteria causing the infections were resistant to drugs.

Scroll.in spoke to Ramanan Laxminarayan, director of the Center for Disease Dynamics, Economics & Policy in Washington DC and distinguished professor of public health at the Public Health Foundation of India about India's dire need to clean up its hospitals to counter the public health threat

How does a newborn get sepsis? Is it a sign of our taking antibiotics for granted that we have not paid so much attention to it?
Newborn sepsis is not such an uncommon phenomenon. It accounts for about a fifth to a quarter of newborn deaths around the world depending on country. In India, we have the highest number of newborn deaths in the world and we also have the highest numbers of newborn sepsis cases and deaths in the world.

Sepsis is basically a systemic blood infection that affects babies as soon as they are born – if they are born in an unclean environment, which is why you have to keep babies clean as soon as they are born. They are not born with a whole lot of immunity apart from what they get from their mothers, which is why they are very susceptible to infection. I think we know that keeping newborns clean is important in a cultural sense but is is not what actually happens. When babies are born in hospitals where there has been significant antibiotic overuse, and where a lot of the bacteria are essentially resistant to the antibiotics, then you have the additional complication that not only do you have a newborn with an infection, you have a newborn with an untreatable infection. That’s what you’re seeing in the large numbers of sepsis deaths in the DeNIS study that appeared in The Lancet Global Health last week.

Many newborns do die and the rate at which they die is pretty shocking. In that study a quarter of children were suspected to have sepsis and, I think, nearly half of the children where they actually had the bacteria in them – that’s the rate at which newborns die of sepsis. You wouldn’t want 50% of your child dying within 30 days of being born. That’s just unacceptably high for any society – and certainly for a society that aspires to be a global superpower.

The rates of newborn sepsis in India has to come down tremendously, the numbers have to come down tremendously. This has been a challenge for us because if you see the number of kids dying under the age of five – that has come down over time because of better vaccination, better nutrition, less diarrhoea and so forth. But this part around infant mortality, which is under the age of one, and particularly neonatal mortality, which is under the age of 30 days, has been persistently high. This is what we have to address in a very serious way.

We have been trying to address infant mortality by encouraging institutional deliveries. But with antibiotic resistant infections acquired in the hosptials, are institutional deliveries going to be affected?
It is certainly three steps forward, two steps back. Without a doubt, institutional deliveries are good for the mother. If there is a complication, institutions are in a better position to take care of her – they have oxygen, they have someone who can probably perform a surgery to prevent maternal bleeding and there are a lot of things that institutions are good for. The last thing we want is this to be a reason for people to go back and want to deliver at home.

However, if you are going to take a mother and baby into a hospital, we have to make sure that hospitals are clean sterile environments. Currently, even the three best public facilities, which are the three that were covered in the study were not clean sterile environments – and if you look at other public institutions in the country, they are in much worse shape than them. Your ability to survive the first 30 days should not be a function of whether your parents can get you into a private ward and have super sterile facilities.

I’m not saying that private hospitals do not have this problem. Some of them are not very sterile either and have high rates of neonatal sepsis

Institutional births should continue but I think this is where Swachh Bharat should start. Start where Indians enter the world, start at the very beginning – clean up that environment and make sure it is sterile.

Besides, newborns what are the groups of people who might be most affected by this?
Newborns are the most vulnerable to infections and so that is the group that you see first. The other group that is vulnerable is the elderly. That observation has also grown in India. Any time you see someone who has gone into a hospital for some other reason and they say: “She died of multi-organ failure” – what that really means is that they died of systemic infections that the doctors could really not control with antibiotics. That is really just a euphemism for multi-drug resistance in the pathogen that he or she was infected with.

So the newborns are first, then come the elderly. For people between the ages of 12 or 13 all the way through to about 55 or 60, the body’s immunity is strong enough to ward off all kinds of infection. Unless you are in a situation where you are in a car crash and you land up in a hospital when you are still susceptible to that kind of infection. But if everything goes well and you don’t have to be near a hospital, then you’re absolutely fine for now.

How are we trying to fight antibiotic resistance?
We are trying to fight resistance primarily by innovating and coming up with new antibiotics, which can stay ahead of the resistant pathogens. Now, that has slowed down for a number of reasons. New drugs are expensive to develop, the regulatory hurdles are much more than they were 40 years ago, and it just takes a lot of money. The bugs, on the other hand, can stay ahead of us through resistance.

A video that came out last week from researchers at Harvard shows that within 12 days bugs can figure out how to live in an environment that has thousand times the antibiotics that would have killed them off on day one. We are seeing evolution at work. Evolution has worked for us in many ways, which is why we have opposable thumbs and large brains but evolution can also work against us and this is a way that it is working against us. The way in which we can slow down the rate of resistance is by using antibiotics appropriately and not expose bacteria to high levels of antibiotics when it is not essential. If we continue to do this we are really shooting ourselves in the foot.

Also, even if I am responsible with my use of antibiotics that doesn’t protect me from these newly evolving resistant strains and the infections out there does it?
No, it doesn’t. Although, the more antibiotics an individual consumes puts him at greater risk for bacterial infection that is not treatable. Bacteria are everywhere – they are in our nose, in our armpits, in our skin, in the air and everywhere around us. If your own environment, which is your skin and your gut, has resistant bugs because you have been overusing antibiotics the chance that you will have an infection is much greater. People who overuse antibiotics harm themselves primarily for the reason I mentioned and because of the unpleasant side effects of antibiotics.

You are also more likely to give a resistant pathogen to the people who are closest to you, like your family members. You might not be infected. You might just be carrying it around colonised, which means that you might have Staphylococcus aureus in your skin but if you have your grandmother staying with you and you give her the bug, which is now resistant because of your overuse of the antibiotic, she ends up with a resistant bug and she could die of it.

I don’t think people understand that we live in a bacterial world and there are consequences of messing around with their world.

Which of the widely used drugs are losing their efficacy and which kinds of microbes pose the most danger?
The class of bugs called Gram negative bacteria – so called because they don’t turn with a Gram stain – are very difficult to treat because there are very few drug options for them. One of the things we see in the DeNIS study is that 80% of Acinetobacter infections are multi-drug resistant. This means that we have a serious problem right here. We have essentially lost our ability to treat these infections.

Now keep in mind that the way we recover from bacterial infections is with two engines. You might have seen those trains with two engines, one in the front and one at the back. The two engines are the body's immunity and antibiotics. It is not as if without antibiotics you wont get better from a bacterial infection. One engine which is the body’s immunity will keep pulling forward and fighting the infection off. But the antibiotics are there to make sure that, when you are going uphill, you actually make it up the hill without backsliding.

It is not that all is lost without antibiotics – but a lot is lost without antibiotics.

So there are things like chemotherapy and surgery that will be very difficult to do with more antibiotics becoming ineffective?
It will become very difficult not only because you might get a resistant infection and die. Let’s say, I am 80 years old and my doctor is telling me to get a hip replacement and I am worried about surgery but I also know that if I go for surgery there is a 5% chance or 10% chance that I will get an infection that won’t be treatable and I will die a horrible death that way, then I will just say, “Forget it, I don’t want a hip replacement surgery.”

So we choose these options because of the idea that they are safe and put us in a better place. What the resistant bug has done to my ability to improve my quality of life through modern surgical intervention is to change my choice and that is important.

It is really a problem of regulating the use of antibiotics. But considering that between looking at pharmacies and doctors prescribing and handing out these drugs, factories making them – who may not be treating their effluents properly – and the use of antibiotics in poultry farms and the antibiotics entering the environment through them, where do we start addressing the problem?
There are quite a few things to do and they all have to be done soon and simultaneously. We should start with cleaning up hospitals. There should be much higher standards for not getting hospital infections and hospitals should be shut down if they can’t meet those standards. You can’t offer a service that is killing your customers.

In fact, most Indian hospitals don’t know, recognise or acknowledge that we have a serious problem in hospitals. Individual doctors will tell you, but the management and so called senior doctors will come out and say that they don’t have infections at all, which is completely bogus.

The first thing is to recognise that we have a problem, the second is to have reporting of infections and then we have to work together to solve the problem. You have to have better diarrhoea precaution, that there is better hand hygiene, that people are not coming into patients rooms freely without using hand sanitiser. Modern medicine is very invasive and you can’t have modern medicine and say that you’ll just be unclean and not wash your hands.

We really have to clamp down on the sale of antibiotics, particularly the more powerful ones. For an Al Jazeera documentary called The Rise of India’s Superbugs, I told them to go near AIIMS and see if they could buy colistin, which is a last line drug for people with Gram negative infections that are not treatable. They went to four pharmacies and were able to buy it in all four pharmacies without a prescription. Is this possible to regulate? Of course. You can’t buy an opioid drug there without a prescription but antibiotics are not receiving that level of attention.