Acknowledging antimicrobial resistance (AMR) a matter of great concern, India plans to address this public health challenge in a mission mode in the next five years.
It will establish a National Authority on Containment of AMR (NACA) to provide oversight and monitoring to ensure sustained and effective national action for management of drug resistance in humans, animals and farming. Importantly, the government intends to initiate several activities to raise awareness and knowledge about AMR, to engage and encourage behavioural change at all levels, promote evidence-based prevention, infection control and sanitation programmes in accordance with the Swachh Bharat Abhiyan, Kayakalp and Swachh Swastha Sarvatra initiatives of the government.
India has drafted a National Action Plan on Antimicrobial Resistance (2017-2021) with focus on six strategic priorities which include improved awareness and understanding of AMR through effective communication, education and training (even among professionals); strengthening knowledge and evidence through surveillance of antimicrobial resistance human, animal, food and environment; reducing the incidence of infection in health care, animal health, community and environment settings; and optimizing the use of antibiotics in humans, animal and food with focus on strengthening regulations, access and surveillance of antimicrobial use. Also, the government will promote investment in AMR activities such as research and innovations with focus on development of new antibiotics, innovations in diagnostics and vaccines; and strengthening India’s leadership on drug resistance with focus on international, national and state or local level collaborations.
The government will involve research institutes, civil society, and encouraging public private partnerships in alignment with Make in India.
India made these commitments at the Inter-Ministerial Consultation on Antimicrobial Resistance in New Delhi last month where the participants pledged to adopt a “holistic and collaborative’’ approach towards prevention and containment of antimicrobial resistance.
“Antimicrobial resistance is a serious threat to global public health that requires action across all government sectors and society and is driven by many interconnected factors. Single, isolated interventions have limited impact and coordinated action is required to minimize the emergence and spread of antimicrobial resistance,’’ Union Health and Family Welfare Minister J P Nadda said.
Recognizing that emergence and spread of AMR was negating many 20th century achievements, particularly reduction in illness and death from infectious diseases, the Delhi Declaration brought out after the consultation, admitted that AMR was projected to kill millions of people worldwide as well as in India with massive social, economic and public health repercussions.
The Ministry of Health & Family Welfare (MoHFW) has identified AMR as one of the top 10 priorities for the Ministry’s collaborative work with the World Health Organisation. The National Health Policy 2017 identifies antimicrobial resistance as a problem and calls for effective action to address it.
India is among the nations with the highest burden of bacterial infections. An estimated 410,000 children aged five years or less die from pneumonia in India annually; with pneumonia accounting for almost 25% of all child deaths. The crude mortality from infectious diseases in India today is 417 per 100,000 persons. Consequently, the impact of AMR is likely to be higher in the Indian setting.
The emergence of resistance is not only limited to the older and more frequently used classes of drugs but there has also been a rapid increase in resistance to the newer and more expensive drugs, like carbapenems. Available data indicates to rising rates of AMR, across multiple pathogens of clinical importance, at the national scale. In 2008, about 29% of isolates of Staphylococcus aureus were methicillin resistant, and by 2014, this had risen to 47%. In contrast, in countries which have established effective antibiotic stewardship and/or infection prevention and control programs, the proportion of methicillin resistant Staphylococcus aureus (MRSA) isolates have been decreasing. Extended-spectrum betalactamase (ESBL) producing strains of Enterobacteriaceae have emerged as a challenge in hospitalized patients as well as in the community.
The burden of AMR in livestock and food animals has been poorly documented in India. Aside from sporadic, small, localized studies, evidence that can be extrapolated to the national level is lacking. Given that there are few regulations against the use of antibiotics for non-therapeutic purposes in India, the emergence of AMR from antibiotic overuse in the animal sector is likely to be an unmeasured burden in India, the background note of the Action Plan says. Drug resistant bacteria have been isolated from dairy cattle as early as the 1970s. One of the most common clinical issues encountered in the dairy farms is mastitis, which maybe sub-clinical or overtly symptomatic. Commonly thought to be a disease of production, milk from mastitic cows and buffaloes have been shown to contain a wide range of bacteria, with a wide spectrum of resistance against commonly used antibiotics.
As with the dairy sector, there is limited evidence available on the exact amount of antibiotic consumed within the poultry industry. In many cases, since the antibiotic is given as a growth promoter through the premixed feed, which comes with added antibiotics that are not even mentioned on the label, it is difficult to exactly estimate the dose or the consumption levels of antibiotics in the poultry sector.
The Food Safety and Standards Authority of India (FSSAI) banned the use of antibiotics and several pharmacologically active substances in fisheries. In contrast, there is no regulation in the poultry industry where many of the commercially available premixed feeds come with added antibiotics. These drugs can, of course, be added to the feeds separately by the farmers. Compared to the poultry and dairy sector, antibiotic resistance has been scrutinized more closely in the aquaculture sector. The existence of legislative provisions to contain the inappropriate and non-therapeutic use of antibiotics in fisheries is expected to impact the levels of AMR in the aquaculture sector but studies have proven otherwise, the note adds.
India has previously instituted surveillance of the emergence of drug resistance in disease causing microbes in the context of vertical programmes, like the Revised National Tuberculosis Control Programme (RNTCP), the National Vector Borne Disease Control Programme (NVBDCP), and the National AIDS Control Programme (NACP). However, a cross-cutting programme dealing with antimicrobial resistance across multiple microbes has been lacking.
To promote rational use of antibiotics, national treatment guidelines for antimicrobial use in infectious diseases has been released to serve as a reference guide for hospitals in the country for formulating their own local guidelines on the basis of which physicians will be trained. National infection control policy has been drafted and is in the process of finalization for strengthening infection control practices.
In 2010, India was the largest consumer of antibiotics, although the per capita consumption of antibiotics in India (10.7 units per capita) was lower than that seen in many other countries (e.g. 22 units per capita in USA).
Since March 2014 a separate Schedule H-1 has been incorporated in Drug and Cosmetic rules to regulate the sale of antimicrobials in India. About 24 antimicrobials belonging to third and fourth generation cephalosporins and carbapenems are covered under the schedule. These antimicrobials cannot be sold without a proper medical prescription and these drug packaging are required to be labelled with the following text along with red border.
With respect to consumption of antimicrobials in food animals, the global consumption was estimated to be 63,151 (±1,560) units in 2010; India accounts for 3% of the global consumption and is the fourth highest in the world, behind China (23%), the United States (13%) and Brazil (9%). The consumption of antimicrobials in the food animals sector in India is expected to double by 2030.
In 2004, in the 15 largest pharmaceutical companies, only 1.6% of the drugs in the development stages were antibiotics, and none of them were from novel classes, nor were they targeted to treat multidrug resistant agents. Despite the obvious need to develop newer classes of drugs to respond to the challenges of emerging AMR, there are few late stage candidates in the process of development. Additionally, pharmaceutical agencies have been reluctant to invest in research and development of antibiotics.