While
antibiotics are dispensed recklessly in some hospitals and pharmacies, others
die because they do not have access to them. Prescription: A comprehensive
antibiotic policy.
India has two diametrically opposed problems
when it comes to antibiotics: Many people die because they do not have access
to antibiotics, while others contribute to the spread of antibiotic resistance
when they overuse these drugs in situations where antibiotic use is not
warranted. Antibiotic resistant bacteria can withstand treatment with one or
more antibiotics, and antibiotic use paves the way for these bacterial strains
to spread by selectively killing off bacteria that are not resistant. Antibiotic
resistance is a major problem around the world, though lack of access to
antibiotics is largely limited to the developing world.
In developed countries, the impact of
antibiotic resistance in the short-term is lessened by the fact that many
patients can afford to take a newer, more expensive antibiotics when antibiotic
resistance causes the first-line treatment to fail. In India, many of the
newest drugs are out of reach for poor patients. Pneumonia is still the number
one killer of children in India, indicating that a large number of children do
not have access to the medicines that have made mortality from pneumonia low in
the developed world.
ACCESS
TO VACCINES
A second reason that so many children die of
preventable infectious diseases is that only 40 per cent of India's children
receive all the vaccines they are guaranteed under the Universal Immunisation
Programme (UIP). Access to vaccines not included in the UIP is even lower. If
more children were vaccinated for diseases such as pneumonia, the demand for
antibiotics to treat pneumonia would decrease. In turn, lesser use of
antibiotics would mean less antibiotic resistance. Despite support from
governmental agencies, and financial backing from the GAVI Alliance, efforts to
include a vaccine against Hib (one of the causes of pneumonia) in the UIP have
been held back by fierce opposition focusing on the paucity of data on Hib in
India.
In contrast to settings where antibiotics are
out of reach, in parts of the country where antibiotics are readily available
(often urban areas), their inappropriate use creates an environment conducive
to the development of resistance. According to IMS Health information,
antibiotic purchases in the retail sector in India increased by about 40 per
cent between 2005 and 2009. The lack of enforcement of prescription-only laws
coupled with the entrepreneurial spirit among some pharmacy owners means that
this use is largely unchecked.
However, it would be premature to place all
the blame on enterprising pharmacists when hospitals and clinics also
contribute to the problem. Poor infection control procedures in many hospitals
facilitate the spread of resistant infections among inpatients. Doctors
prescribe antibiotics because they do not have access to the diagnostic tests
they would need to pinpoint the cause of fever in their patients. They may
overprescribe out of concern that their patients will be disappointed if they
pay for a consultation but leave without a prescription for an antibiotic —
though this argument is less convincing in rural areas where few patients know
what an antibiotic is.
RESISTANCE
DATA
Widespread overuse of antibiotics means that
where antibiotic resistance is tested for, it is usually found at alarming
rates. Many hospitals publish the resistance data they collect, but reliable,
nationwide, time-series data is unavailable. Even less is known about
resistance rates outside hospitals. Media coverage of the worrisome findings at
those hospitals that do test is often misdirected; blame is easily placed on
specific facilities rather than recognising the lack of surveillance in other
hospitals.
Although much of the microbiology data
published in India is overlooked by the media, New Delhi
metallo-beta-lactamase-1 (NDM-1) is a major exception. NDM-1 is a gene that
confers resistance to several antibiotics and can be transferred between
different species of bacteria. It was first reported in 2009 in a Swedish
patient who had undergone surgery in New Delhi. Subsequent studies isolated the
resistance gene in Indian hospitals, and in drinking water and seepage in New
Delhi. Establishing that NDM-1 evolved in India would be difficult, but the
suggestion in the Lancet that UK citizens considering medical tourism in India
should think twice led to an uproar in India.
Antibiotic resistance has been a problem in
India for years, and will still be a problem after media focus on NDM-1 has
passed. Placing blame should not be the primary goal of research on this topic.
Instead, more research should be done to understand how it developed and
spread. In a positive development, the furore surrounding these studies and the
implication that it was unsafe to seek medical care in India raised awareness
that antibiotic resistance is a problem in India. This crisis situation spurred
the creation of an Antibiotic Task Force by the Ministry of Health and Family
Welfare.
PRESCRIPTION
VITAL
One of the controversial recommendations of
the Task Force was that the government should strictly prohibit sales of
antibiotics without the prescription of a registered medical practitioner.
Selling antibiotics without a prescription is already illegal, but rarely
enforced. Additionally, some antibiotics would be reserved for use as a
treatment of last resort in tertiary hospitals. Pharmacists' organisations were
concerned that these regulations would lead to decreased profits and, more
importantly, loss of access to life-saving drugs in isolated populations.
Speaking at the First Global Forum on
Bacterial Infections in New Delhi this past October, Indian Health Minister
Hon. Dr Ghulam Nabi Azad explained that the proposals of the Task Force are on
hold until the government develops methods of ensuring that increased
regulation of antibiotic sales does not mean access to lifesaving drugs is cut
off for segments of the population. Many rural areas do not have any Registered
Medical Practitioners, so it could become impossible for residents to obtain
legal prescriptions. The government will have to consider how to ensure access
where no Registered Medical Practitioners work before implementing rules across
the country.
NEED
FOR A POLICY
Other interventions to target antibiotic
overuse in India include raising awareness among pharmacists and doctors
through mandatory in-service training, regulating the currently uncontrolled
use of antibiotics in farm animals, and setting up a surveillance system to
measure resistance levels and determine if interventions are having an impact
on antibiotic use and resistance. Interventions to lessen the burden of
bacterial diseases, such as improving access to sanitation, would also slow the
spread of resistance by decreasing the need for antibiotic use.
Antibiotic resistance is a complex problem to
deal with in a country as diverse as India. A nuanced approach is necessary to
respond to the fact that while antibiotics are dispensed recklessly in some
hospitals and pharmacies, others die because they do not have access to the
antibiotics they need. Antibiotic resistance is neither new, nor limited to
India, but hopefully increased focus on the issue in the wake of the NDM-1
controversy will lead to the enforcement of a comprehensive antibiotic policy.
(The author is an Associate at Boston
Consulting Group in Chicago. From July 2009 to October 2011, she coordinated
the Global Antibiotic Resistance Partnership in India.)
(The article is by special arrangement with
the Centre for the Advanced Study of India, University of Pennsylvania.)
ALICE EASTON
Business Line
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