THE CONTEXT: According to a report published in The Lancet (Global burden of Bacterial AMR in 2019: A Systematic Analysis) about 4.95 million deaths in 2019 are associated with AMR and 1.27 million deaths were caused due to AMR. Anti-microbial Resistance is a leading cause of death around the world, with the highest number of deaths occurring in low-resource settings. Everyone is at risk from AMR, but young children are particularly affected. The following article explains the causes of AMR and the challenges involved, from a scientific and public health perspective.
ABOUT AMR
- Antimicrobial resistance is the resistance acquired by any microorganism (bacteria, viruses, fungi, parasites, etc.) against antimicrobial drugs (such as antibiotics, antifungal, and antiviral drugs) that are used to treat infections. As a result, standard treatments become ineffective, infections persist, and may spread to others.
- Resistant microbes are more difficult to treat which necessitates alternative mechanisms or higher doses, both of which are either more toxic or expensive.
- Microorganisms that develop antimicrobial resistance are sometimes referred to as “superbugs”.
- Antimicrobial resistance occurs naturally, but the misuse of antibiotics in humans and animals is accelerating the process. Antimicrobial resistance is now regarded as a major threat to public health across the globe.
Bacterial antimicrobial: resistance occurs when changes in bacteria cause the drugs used to treat the infection to become less effective.
CAUSES OF ANTIBIOTIC RESISTANCE
OVERUSE:
- Overuse of antibiotics by consuming more antibiotics than prescribed.
- Overuse of antibiotics in livestock and fish farming. Consumption of antibiotically treated livestock such as chicken further increases resistance.
- Using antibiotics in farm animals can promote AMR. Drug-resistant bacteria can be found in meat and food crops that have exposure to fertilizers or contaminated water. The chances of Zoonotic diseases passing on to humans can increase.
MISUSE:
- Misuse by taking a prescribed antibiotic incorrectly or taking antibiotics to treat viral infection. Patients generally do not complete the entire antibiotic course.
- Include self-medication.
- access to antibiotics without prescription.
- Lack of knowledge about when to use antibiotics.
PHARMA WASTE AND DISCHARGE:
- Antibiotics discharge or waste from pharma firms and hospitals. For instance, Hyderabad’s pharmaceutical industry has been pumping massive amounts of antibiotics into local lakes, rivers, and sewers. This has led to an explosion in resistance genes in these water bodies.
HEALTHCARE SETTINGS:
- Poor infection control in healthcare settings.
- Poor hygiene and sanitation.
- A report on hand-washing practices of nurses and doctors found that only 31.8% of them washed hands after contact with patients.
EXCESSIVE USE OF FDC DRUGS:
- Excessive use of Fixed Dose Combinations (FDC) Drugs due to their low price and convenience enables anti-biotic resistance to grow at a significant rate. This may also lead to the emergence of bacterial strains resistant to multiple antibiotics.
WRONG DIAGNOSIS:
- Health professionals sometimes prescribe antimicrobials “just in case,” or they prescribe broad-spectrum antimicrobials when a specific drug could have satisficed. Using medications in such a fashion increases the risk of AMR.
RISING CHALLENGES BECAUSE OF AMR
THREAT TO PREVENTION OF INFECTIONS: Medical procedures such as organ transplantation, cancer chemotherapy, diabetes management and major surgery (for example, cesarean sections or hip replacements) will become very risky.
GLOBAL THREAT: AMR poses a serious threat to global health, food security, and development.
SIDE EFFECTS: Increased side effects from the use of multiple and more powerful medications.
COSTS AND CASUALTIES:
- The danger of antimicrobial resistance is those treatable illnesses like pneumonia, tuberculosis, or minor infections could become incurable. This would put a greater economic and emotional burden on families and on our healthcare system.
- Increased cost and length of treatments and increased deaths.
RISK TO GAINS MADE IN THE PAST:
- Without effective antibiotics for the prevention and treatment of infections, the achievements of modern medicine are put at a risk.
- Antimicrobial resistance is putting the gains of the Millennium Development Goals at risk and endangers the achievement of the Sustainable Development Goals.
ANTIBIOTIC APOCALYPSE:
- Without urgent positive action, we might be heading to a future without antibiotics, with bacteria becoming completely resistant to treatment and when common infections and minor injuries could even prove fatal.
STEPS TAKEN BY THE WORLD HEALTH ORGANISATION (WHO)
GLOBAL ACTION PLAN:
Global action plan on antimicrobial resistance with 5 strategic objectives:
- To improve awareness and understanding of antimicrobial resistance.
- To strengthen surveillance and research.
- To reduce the incidence of infection.
- To optimize the use of antimicrobial medicines.
- To ensure sustainable investment in countering antimicrobial resistance.
REVISION OF ANTIBIOTICS PROTOCOL:
WHO has revised the antibiotics protocol to curb antibiotic resistance in 2017. This was the biggest revision of the antibiotics section in the essential medicines list (EML) which is being used by countries to develop their own local lists of essential medicine.
- Under this, WHO has divided the drugs into 3 categories viz – access, watch, and reserve.
- The access category includes commonly used antibiotics available at all times for the treatment of a broad range of common infections.
- The watch category covers antibiotics that are recommended as a first or second choice treatment for a small group of infections. Prescription of these drugs should be minimized to avoid further development of resistance.
- The reserved category includes antibiotics that are considered last-resort options and should be used only in the most severe circumstances like life-threatening infections caused by multi-drug resistant (MDR) bacteria.
ANTIMICROBIAL RESISTANCE IN INDIA
- AMR is of particular concern in developing nations, including India, where the burden of infectious disease is high and healthcare spending is low. India is among the nations with the highest burden of bacterial infections and hence the impact of AMR is likely to be higher in the Indian setting.
- India has been referred to as ‘the AMR capital of the world’. While on one hand, the emergence of newer multi-drug resistant (MDR) organisms pose newer diagnostic and therapeutic challenges, on the other hand, India is still striving to combat old enemies such as tuberculosis, malaria, and cholera pathogens, which are becoming more and more drug-resistant.
- Factors such as poverty, illiteracy, overcrowding, and malnutrition further compound the situation. Lack of awareness about infectious diseases in the general masses and inaccessibility to healthcare often preclude them from seeking medical advice.
- According to the World Health Organisation (WHO), antibiotic resistance may cause an increase in the death of Indians to 20 lakhs per year by 2050.
- The National Health Policy 2017 highlights the problem of antimicrobial resistance and calls for effective action to address it.
- MDR-TB and XDR-TB in India: The World Health Organisation estimates approximately 4.1 million people across the world suffer from tuberculosis, but these cases continue to remain undiagnosed and unreported. A total of 1.5 million people died from TB in 2020 making it the second leading infectious killer only after Covid-19.
- MDR-TB: Multidrug Resistant TB
- XDR-TB: Extremely Drug-Resistant TB
- While India is on a mission to become TB free by 2025, the report by Haystack Analytics indicates that the country continues to bear the largest share of TB cases in the world, with 65% of the cases being reported in the most economically productive population segment of 15-45. Not only this can have a detrimental impact on the economy, but the situation can also aggravate considerably, if not addressed in due time.
- XDR-TB has become a new threat to the control of TB in many countries including India. Its prevalence is not known in India as there is no nationwide surveillance. However, there have been some reports from various hospitals in the country
STEPS TAKEN BY INDIA IN FIGHT AGAINST AMR
RED LINE CAMPAIGN:
- It was launched in 2016.
- Under this, Prescription only antibiotics were marked with a red line to curb irrational use.
- The government has also backed it up with an awareness campaign that red-line medicines should not be taken without a prescription.
ANTI-MICROBIAL RESISTANCE FUND:
- India-focused seed fund.
- Investment by the Department of Biotechnology (DBT) through the Biotechnology Industry Research Assistance Council (BIRAC).
- It will help groups in India compete for the Longitude prize (for groups that develop effective and affordable diagnostic kits to detect antimicrobial resistance).
AMRRSN:
National Anti-Microbial Resistance Research and Surveillance Network (AMRRSN) was established by the Indian Council of Medical Research (ICMR).
- To strengthen surveillance of AMR in the country.
- To enable compilation of national data of AMR at various levels of health care.
NATIONAL ACTION PLAN TO COMBAT ANTIMICROBIAL RESISTANCE, 2017:
- Enhancing awareness among the masses and strict adulteration laws.
- Strengthening surveillance.
- Improving the rational use of antibiotics.
- Reducing infections.
- Promoting policies and research in antimicrobial resistance.
- Support neighboring nations in the fight against infectious diseases
AMR RESEARCH & INTERNATIONAL COLLABORATION:
- ICMR has taken measures to develop new drugs /medicines using international collaborations for strengthening medical research in AMR.
INITIATIVES TO CONTROL OVERUSE OR MISUSE OF ANTIBIOTICS:
- ICMR has launched an antibiotic stewardship program (AMSP) on a pilot project basis in twenty tertiary care hospitals across India to check the misuse and overuse of antibiotics in hospital wards and ICUs.
- On the advice of ICMR, DCGI has prohibited 40 fixed-dose combinations (FDCs) which were found inapplicable.
- ICMR collaborated with the Indian Council of Agriculture Research, Department of Animal Husbandry, Dairy and Fisheries, and the DCGI to prohibit the use of Colistin as a growth promoter in animal feed in poultry.
- The government has also capped the maximum levels of drugs that can be used for growth promotion in meat and meat products.
CHALLENGES FOR INDIA IN ITS FIGHT AGAINST AMR
TWIN CHALLENGE:
- India faces a twin challenge of fighting the over consumption of antibiotics while ensuring that the poor and vulnerable have easy access.
LACK OF AWARENESS:
- Lack of awareness among medical practitioners as well as the general public on the rational use of antibiotics further aggravates the problem.
COORDINATION GAP:
- Coordination among various ministries and between the center and state governments.
- A cross-cutting program dealing with antimicrobial resistance across multiple microbes has been lacking.
ABSENCE OF A ONE HEALTH APPROACH:
- One Health Approach to addressing AMR recognizes that human well-being is inextricably tied to the health of animals and the environment.
ABSENCE OF STRINGENT RULES:
- The absence of stringently framed and implemented regulatory frameworks to limit the use of antimicrobials in livestock and food animals, especially for non-therapeutic purposes, has been one of the drivers of antibiotic overuse at the community level.
- The rules and regulations that were taken were not strict enough to prevent pharmaceutical firms to sell last-resort drugs to farmers or discharging waste into water bodies.
- In India, current effluent standards do not include antibiotic residues, and thus they are not monitored in the pharmaceutical industry effluents.
THE WAY FORWARD
- Infection control in healthcare facilities:
- Health professionals prescribe antibiotics only when they are needed.
- Preventing infections by maintaining hygiene.
- Creating awareness about the use and abuse of antibiotics:
- Individuals to use antibiotics only when prescribed.
- Only give antibiotics to animals under veterinary supervision.
- Vaccinate animals to minimize the need for antibiotics.
- Use alternatives to antibiotics when available.
- A robust national action plan to tackle antibiotic resistance.
- Improve surveillance of antibiotic-resistant infections.
- Invest in R&Dfor new antibiotics to keep up with resistant bacteria as well as in new diagnostic tests to track the development of resistance.
THE CONCLUSION: There is a need to urgently address antimicrobial resistance in a holistic way by integrating human, animal and environmental health. All countries need to work together to limit the spread of Antibiotic-Resistant Genes (ARGs). Even though national action plans have been laid down by most countries, these plans have yet to move from paper to the ground as antibiotics continue to be freely used,therefore to contain AMR, there is a need for a One Health Approach through coherent, integrated, multi-sectoral cooperation and actions.
MAINS QUESTIONS:
- “Addressing AMR requires a multipronged and multisectoral approach. The urgency to develop new drugs should not discourage us from instituting measures to use the existing antimicrobials judiciously.” Comment.
- “The progress under the National Action Plan for AMR(2017) has been far from satisfactory.” Critically analyze.
- What do you understand by Antimicrobial Resistance (AMR)? Explain the reasons for the spread of AMR and the challenges involved to control it.
