New Delhi: A strain of bacteria highly resistant to almost all antibiotics was detected in 2009 in a Swedish tourist who was diagnosed with pneumonia. Within weeks it had acquired a global footprint that included Pakistan, the UK, North America and Japan.
The bacteria was later traced to drinking water in Delhi and came to be termed by the scientific community as the “superbug” NDM-1 or New Delhi Metallo-beta-lactamase-1. The drug resistant nature and the ability to spread rapidly define the narrative of a new strain of malevolent bacteria that pack deadly potential.
Equating the threat to terrorism, professor Sally Davies, England’s chief medical officer, recently said, “If we don’t take action, then we may all be back in an almost 19th century environment where infections kill us as a result of routine operations.” She then went on to identify antibiotic resistance as a national threat.
Davies was speaking at the release of the annual report by her office on Infections and the rise of Antimicrobial Resistance in March.
The warning is particularly relevant to India where several diseases have become resistant to the first line of treatment. In the past few years, drugs used to treat mass killers like tuberculosis, typhoid and malaria have been rendered useless, giving rise to superbugs. In August 2010, the medical journal, The Lancet, identified NDM-1 as the world’s newest superbug that evolved due to the overuse of carbapenems—a class of broad-spectrum antibiotics.
A combination of factors such as the over-the-counter (OTC) availability of drugs and indiscriminate self medication has led to India staring at a number of diseases resistant to antibiotics.
Typhoid fever, caused by Salmonella typhi, is a classic case of a complication in the management of a simple disease due to drug resistance. It spreads through contaminated food and water or contact with those infected.
For the past two decades, the public health community has watched with growing concern the increasing incidence of drug-resistant strains of typhoid. Further, with globalization facilitating easier movement of people, the disease is being reported even in developed countries such as the US.
After a seven-year study, the Journal of the American Medical Association established in 2009 that cases of typhoid in the US were caused largely by travel to the Indian subcontinent. The researchers further noted with concern that the patients were coming back with strains of the disease resistant to frontline antibiotics such as ampicillin, chloramphenicol and trimethoprim-sulfamethoxazole. “We are seeing cases of typhoid not responding to standard drugs which it used to a decade earlier. Some drugs have been phased out and we are already using third generation of antibiotics to treat simple cases of typhoid,” said N.P. Singh, director of medicine at Pushpanjali Crosslay Hospital in New Delhi.
“Very soon we will see patients who are non-responsive to third-generation drugs as well. It is time to be judicious and focus on early diagnosis and treatment instead of indiscriminately prescribing medicines from day one,” he added.
The Indian government’s National Policy for Containment of Antimicrobial Resistance came into force in 2011 but is yet to make an impact on the OTC sale of drugs and prescription practices that are fuelling drug resistance across a spectrum of diseases in India.
“We have a practice of self medicating, which combined with loosely implemented policies have led to this situation,” said G.N. Singh, Drug Controller General of India (DCGI).
“We are in the process of putting a stricter system in place where habit-forming drugs, anti-tubercular and anti-microbial medicines will be available only on prescriptions The government will take a call on educating doctors about better prescription practices to ensure rational use of medicines. Also, pharmacists have a major role to play if we have to control this growing threat,” he added.
With 2.2 million suffering from the disease, India has the highest burden of tuberculosis in the world. By conservative estimates, at least 70-80,000 cases of drug resistant TB are reported in India each year. Each person with untreated MDR (multi-drug resistant) TB goes on to spread the infection to at least seven other people.
The disease becomes resistant to drugs due to people dropping out midway through the treatment, besides wrong dosage and incorrect combinations. The first line of treatment for the disease caused by the Mycobacterium tuberculosis bacteria is a combination of rifampicin, isoniazid, ethambutol and pyrazinamide. When the bacterium does not respond to isoniazid and rifampicin, the most powerful first-line anti-TB drugs, it is considered MDR TB.
According to experts, this is largely going untreated in India with the Global TB Report 2012 confirming only 4,237 cases of MDR TB.
“The MDR-TB problem in India cannot be ignored unless we are prepared for an even bigger problem down the road,” said professor Ramanan Laxminarayanan, director at the Center for Disease Dynamics, Economics & Policy (CDDEP), based in New Delhi.
“In South Africa, 3% of the TB cases reported are mutli-drug resistant (and) the government spends nearly half its drug purchase on treatment of MDR TB. Every case of untreated drug-resistant TB generates up to seven secondary cases and India is looking at an epidemic of drug resistant cases because hardly any drug resistant cases are treated,” he said.
Much like tuberculosis and typhoid, the best weapon against malaria, artemisinin, has also lost its potency in the past decade. In 2007, the World Health Assembly, the World Health Organization’s decision-making body, recommended moving to artemisinin combination therapies (ACT) due to growing concern about resistance.
“In India it is common to use mono therapy for treatment of malaria despite government guidelines against it,” said Manish Kakkar, specialist in communicable diseases at the Public Health Foundation of India (PHFI).
“The mono therapy, use of only artemisinin, provides quick relief. However, it should be used only for serious cases like cerebral malaria to avoid resistance. Yet, it is common in India to reach for monotherapy when ACT could treat the patient. This is a serious concern because it is the only treatment we have and if indiscriminate use of artemisinin leads to resistance, it could make treatment of simple case complicated,” he added.
The scientific community fears that the post-antibiotic era will see a resurgence of afflictions where mass killers won’t be cancers or cardiovascular diseases but hitherto curable infections.