Here's What's Causing India's 'Superbug' Problem

It's not as simple as reducing the nation's massive antibiotic consumption.
Hindustan Times via Getty Images

Last August, a Nevada woman in her 70s was hospitalized after returning from an extended trip to India. She was infected with multidrug-resistant Klebsiella pneumoniae — what doctors call a “nightmare superbug” — that showed immunity from 26 antibiotics. She died in September from multiple organ failure and sepsis.

Superbugs — the term unofficially refers to bacterial and fungal infections resistant to various antibiotics ― are a growing health problem worldwide. The World Health Organization warned in 2015 of an approaching “post-antibiotic” era. Current estimates are that drug-resistant infections annually kill about 700,000 people around the world — a figure that could reach 10 million by 2050.

“It’s just a fact of evolution — the more antibiotics that are around, the more bacteria has been exposed to antibiotics, the more opportunity they have to acquire these resistances,” Sarah Fortune, a professor of immunology and infectious diseases at Harvard University, said. “And, we’ve been living with antibiotics for 60 years now and bacteria has had plenty of time to develop their defenses.”

India is a notorious hotbed for antibiotic resistance. According to a study on antimicrobial resistance published last year, 60,000 newborn lives are claimed each year in the country by antibiotic-resistant infections.

Another 2016 study examining the evolution of resistant microbes in India found that the over-prescribing and unregulated use of antibiotics, antibiotic use in agriculture and for livestock, and a lack of regulation of the discharge of antimicrobial waste into the environment all contribute to the superbug problem.

These factors exist in other countries, Barun Mathema, an assistant professor in epidemiology at New York’s Columbia University and an expert in infectious diseases, told HuffPost. Superbugs exist across the globe; it’s a problem rearing its ugly head in China, South Africa, Australia and even in U.S. hospitals.

Even so, India is considered the global breeding ground for the problem. What makes India’s situation unlike other developing nations, says Mathema, is the “extent and degree” of the factors that fuel superbugs.

According to the 2016 study, “antibiotic use is a major driver” of the development of diseases that become resistant to the drugs. Indeed, in 2010 India consumed more antibiotics for human health per person than any other country. What’s more, the nation’s intake spiked by 62 percent from 2001 to 2010.

Such consumption is spurred by overprescription and overuse. Previous research found that antibiotics are prescribed and sold in certain parts of India for conditions ― such as diarrhea and upper respiratory infections caused by viruses ― that don’t require them. There’s also conflict of interest: one study found doctors are compensated by pharmaceutical companies and pharmacists for prescribing antibiotics.

Recently, the Indian Council of Medical Research (ICMR) issued guidelines for antibiotic stewardship, which include advising hospitals on how to administer treatment that best suits the patient’s needs. Kamini Walia, a senior scientist at ICMR, told HuffPost there’s growing interest in the voluntary guidelines.

Informing the public is also important.

“The culture in India, in some parts of the U.S. and many countries around the globe is to lean on antibiotics for most illnesses, even if there is a low chance they are due to bacteria at all,” Kavita Trivedi, adjunct clinical assistant professor of medicine at California’s Stanford University, told HuffPost. “We must educate the public about when it is appropriate to demand antibiotics because if we don’t, the burden is solely on the prescribers.”

The problem lies beyond the culture of antibiotic prescriptions

Prescriptions contribute to overuse, but so does the over-the-counter availability of many antibiotics until recently. For example, India has had one of the highest over-the-counter sales of carbapenems, an antibiotic used to treat multidrug-resistant bacteria.

In 2014, the government re-categorized many antibiotics, including carbapenems, to make them prescription-only. But implementation of the regulation remains murky. According to Walia, antibiotics are still obtainable over the counter to serve those who do not have access to doctors. Previous research found poor access to affordable and effective antibiotics kills more children in India than drug-resistant infectons.

“The per capita consumption of antibiotics is high but uneven,” Ramanan Laxminarayan, the New Delhi-based director of the Center for Disease Dynamics, Economics & Policy and lead author of the 2016 study of India’s superbug problem, told HuffPost. “There are many that are dying in rural areas because of lack of access to antibiotics while others in urban settings are using them indiscriminately. There is a serious inequity issue here.”

Other factors come into play. A 2013 study found “waste water treatment plants serving antibiotic manufacturing facilities” to be responsible for transferring resistance genes. Laxminarayan, who calls India an “epicenter” of superbugs, said that with India being is one of the world’s largest manufacturers, the levels of reported antibiotic pollution are “appalling.”

Walia said there is also a “huge amount” of antibiotic use in animals in India. Laxminarayan said mixing antibiotics with animal feed is a practice that should be stopped immediately.

Jean Patel, the science team lead for the Antimicrobial Resistance Coordination & Strategy Unit at the U.S. Centers for Disease Control, said “stopping even some of the inappropriate and unnecessary use of antibiotics in people and animals would help greatly in slowing down the spread of resistant bacteria.”

Patel added that concern is growing “about travelers who might be become infected with resistant bacteria as a result of receiving health care abroad or in areas of the United States where resistant bacteria might be more prevalent.”

With antibiotic resistance popping up in many nations, India is in a unique position: according to Laxminarayan, its battle with superbugs provides the opportunity for the nation to be “on the forefront of addressing [antimicrobial resistance] and setting up an example for other countries.”

And given that India’s problem doesn’t stay within its borders ― as illustrated by the Nevada woman’s death ― the nation’s superbug issue is a global public health challenge.

“In this day and age, any country’s problem is another country’s problem too,” Mathema said.

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