A groundbreaking new study published in the Lancet warns that antimicrobial-resistant (AMR) pathogens could kill over 39 million people by 2050. Recently, the World Health Organization also published its first-ever guidance on antibiotic pollution from manufacturing ahead of the UN General Assembly High-Level Meeting on antimicrobial resistance. In this context, understanding the threat of antimicrobial resistance from a broader perspective becomes important.
What is antimicrobial resistance (AMR), and why is it a global concern?
Antimicrobial resistance (AMR) is a condition in which bacteria, viruses, fungi and parasites no longer respond to antimicrobial medicines, which include antibiotics, antivirals, antifungals and antiparasitics. As a result, infections become difficult or impossible to treat, increasing the risk of disease spread, severe illness, disability and death. It is the result of evolution of microbes in a situation where there is a misuse or overuse of antibiotics.
What is the difference between antibiotic and antimicrobial resistance?
According to World Health Organisation- Antibiotic resistance occurs when bacteria change in response to the use of antibiotics. Bacteria, not humans, become antibiotic resistant.
These bacteria may then infect humans and are harder to treat than non-resistant bacteria. Antimicrobial resistance is a broader term, encompassing resistance to drugs to treat infections caused by other microbes as well, such as parasites (e.g. malaria), viruses (e.g. HIV) and fungi (e.g. Candida).
Increasing AMR— A Global Concern
Accoridng to WHO— “ Antimicrobial resistance (AMR) is one of the top global public health and development threats. It is estimated that bacterial AMR was directly responsible for 1.27 million global deaths in 2019 and contributed to 4.95 million deaths.”
AMR has emerged as a global concern as it transcends the political boundaries and poses a threat to all of humanity. Animals and plants are also susceptible to diseases caused by pathogens, making them vulnerable to AMR.
“Already widely recognised as a major global health challenge, AMR is anticipated to worsen in the coming decades with Lancet predicting that more than 39 million people around the world could die from antibiotic-resistant infections over the next 25 years.The report, based on a new study by the Global Research on Antimicrobial Resistance (GRAM) Project, is the first global analysis of antimicrobial resistance trends over time.”
What are the key factors contributing to the rise of AMR in India?
A survey conducted by the Indian Council of Medical Research (ICMR), the country’s top body for the formulation, coordination, and promotion of biomedical research, indicates that antimicrobial resistance continues to rise throughout the country. Thus, it becomes crucial to know about the key factors that contribute to the rise of AMR in India.
Excessive use of Antimicrobial Drugs: The irrational excessive use of antimicrobial drugs is the key reason for the rise of AMR as it leads to the creation of resistant or extremely resistant superbugs, which can circulate in hospitals, through drinking water, or sewers.
“AMR happens because of indiscriminate use of antibiotics over the counter. Many do not follow the prescribed dose as advised by the doctor, abandoning them midway, or use them for similar symptoms that may arise later, ignoring the doctor’s advisory.” says Dr Abdul Ghafur, infectious diseases expert at Apollo Hospital, Chennai.
Anonna Dutt writes— “ Many Indians have a tendency to pop an antibiotic for a fever, without even checking if the fever is caused by a bacterium. An antibiotic is of no use for viral infections such as influenza, but consuming it can drive up resistance in the population.
Many find it difficult or expensive to go to a doctor for a simple sickness, and instead prefer to take a pill that perhaps their local chemist has recommended.”
Do you know?
Superbugs are microorganisms—bacteria, viruses, fungi, and parasites—that have evolved to resist medications, including antibiotics, antivirals, antifungals, and antiparasitic drugs. These organisms develop resistance through genetic mutations, often accelerated by the overuse or misuse of these medications.
Lack of Hygiene Practices: Another reason for the increase in antimicrobial resistance (AMR) is the inadequate hygiene practices and the lack of proper infection control in hospitals and clinics, which facilitate the spread of resistant bacteria.
Lack of Proper Diagnostics: A significant factor contributing to the rise in AMR is the prescription of antibiotics by doctors without proper diagnostics of the patient, relying solely on symptoms to determine the likely cause of the infection.
Pharmaceutical waste: “Pharmaceutical waste from antibiotic manufacturing can facilitate the emergence of new drug-resistant bacteria, which can spread globally and threaten our health. Controlling pollution from antibiotic production contributes to keeping these life-saving medicines effective for everyone,” Dr Yukiko Nakatani, WHO Assistant Director-General for AMR ad interim, said.
Type of environmental AMR pollution sources (Source: UNEP)
Unregulated Access to Antibiotics: An area of great concern is the unregulated access to antibiotics in the animal husbandry, dairy, and poultry sectors. While we are rightfully aware and concerned about the sale of antibiotics without prescription to humans, the regulation of antibiotic sales for non-human consumption generally goes unnoticed.
Points to Ponder:
— How superbugs evolve?
— What is the impact of AMR?
What initiatives has the Government of India undertaken to combat AMR?
Acknowledging the challenges posed by antimicrobial resistance (AMR) in the country, the Government of India has taken various measures to address the issue.
National Programme on AMR Containment: It was launched during the 12th Five Year Plan (2012-17). The main objectives of this program are:
— Establish a laboratory-based antimicrobial resistance (AMR) surveillance system in the country to generate high-quality data on antimicrobial resistance.
Conduct surveillance of antimicrobial usage in different healthcare settings.
— Strengthen infection control practices and promote the rational use of antimicrobials through antimicrobial stewardship activities.
— Raise awareness among healthcare providers and the community about antimicrobial resistance and the rational use of antimicrobials.
Do you Know?
In addition to death and disability, AMR has significant economic costs. The World Bank estimates that AMR could result in US$ 1 trillion additional healthcare costs by 2050, and US$ 1 trillion to US$ 3.4 trillion gross domestic product (GDP) losses per year by 2030.
National Action Plan (NAP) on AMR: India was among the first countries to develop a comprehensive NAP on Antimicrobial Resistance in 2017. The plan focuses on a One Health approach, involving various stakeholder ministries and departments.
AMR Surveillance Network: ICMR established the Antimicrobial Resistance Surveillance and Research Network (AMRSN) in 2013 to collect evidence, track trends, and identify patterns of drug-resistant infections in the country.
Research & International Collaboration on AMR: ICMR has also initiated internation collaborations to develop new drugs and strengthen medical research in AMR.
What steps should be taken to address the challenge of AMR in India?
The increasing threat of antimicrobial resistance (AMR) requires collective efforts to tackle this challenge. Experts have also emphasized the necessity of integrated strategies to address the rising trend of AMR in India.
Regulating use of antibiotics in various sectors: Usage of antibiotics in various sectors must be regulated to address the challenge of rising antimicrobial resistance (AMR) in India.
Dr Kapil Zirpe, former president of ISCCM, organising secretary of Best Of Brussels, and director of the stroke unit, said, “80 percent antibiotics are used in poultry farms. Governments should strictly control the use of antibiotics in poultry farms. India ranks top in antibiotic use across the world. Every year, we see a rise in antibiotic use, 7–8% in outpatients and 11 % in indoor patients,”
Dr Suranjit Chatterjee writes— “Antibiotics are often used in livestock farming to promote growth and prevent diseases. Their overuse in animals can lead to the development of resistant bacteria, which can then be transmitted to humans through food consumption.”
Effective Sanitation & Hygiene: Awareness should be increased among the people about the importance of hygiene, as various types of infections can be prevented by improving sanitation, implementing hygienic practices, and promoting vaccination.
Additionally, it is important to understand the role of the environment in the spread of AMR. Untreated wastewater and effluents, including releases from antibiotic manufacturing units and healthcare facilities, can contaminate the environment, leading to the spread of AMR. To keep the environment safe and prevent AMR contamination and transmission, we need effective sanitation, sewage, and waste treatment infrastructure.
Dr Kamini Walia, one of the authors of the recently released ICMR annual report on Antimicrobial Resistance Research and Surveillance Network (January-December 2023), said that it is not fair to ask people who are only trying to get better quickly, to not consume antibiotics.
“Instead, we have to prevent infections so that people do not feel the need to take antibiotics,” said. “This can be achieved through improving hygiene and measures like frequently washing hands. It can also be achieved through vaccinations.”
Prioritise implementation of NAP on AMR: Efficient implementation of NAP-AMR should be prioritised. The suboptimal implementation of it in the absence of resources should be addressed.
Common people should be educated regarding unnecessary use of antibiotics, doctors said. (File/ Representational)
Promotion of Responsible Behaviour among Citizens and Doctors: People should be educated on the dangers of overusing antibiotics. For craeting the awareness help of academia and civil society organisations (CSOs) can be taken.
Dr Kamini Walia— “Academia can help understand the environmental dimensions of AMR better, develop new technologies and provide training and education to healthcare professionals. CSOs can raise awareness and advocate for policy changes.”
Doctors must be educated to ensure appropriate use of antibiotics, saving the stronger ones for hospital based patients, and getting the patients tested to see which infection they have.
One Health Approach: The environment plays a crucial role in the development, transmission, and spread of AMR. Therefore, the response must be based on a One Health approach, recognizing that humans, animals, plants, and the environment are interconnected and indivisible at the global, regional, and local levels.
The battle against AMR is often viewed as the responsibility of the healthcare sector. It is crucial for other stakeholders, particularly those overseeing food, drinking water, and the environment, to share equal responsibility. Failing to do so will make it difficult to win the battle against AMR.