Irresponsible use of antimicrobials, including antibiotics, is accelerating the rise of ‘superbugs’. These superbugs are causing infections that were once easily treatable by antimicrobials but are now becoming increasingly difficult to treat and, in some cases, turning life-threatening. Unnecessary use of antimicrobials coupled with poor infection prevention measures and lack of new antimicrobials has resulted in a full-blown global health crisis of Antimicrobial Resistance (AMR). The climate crisis is also affecting patterns of infectious diseases which may lead to an increase in the use of antimicrobial drugs and a rise in AMR. 

While the problem of AMR has reached a tipping point in India, there are countless and yet, often unheard of superheroes – in research labs, hospitals, and on the ground, among communities – who are working very hard to stop the rise of these deadly superbugs. In our SaS-AMR Champions Series, commemorating the World Antimicrobial Awareness Week (WAAW2021), we bring to you conversations with some of these ‘Superheroes Against Superbugs’ that we hope would inform, inspire, and encourage us all to act against AMR to ensure a healthy future for all.

Jyoti Joshi, Head of South Asia, Center for Disease Dynamics Economics and Policy (CDDEP), is a public health researcher studying various drivers of antimicrobial resistance (AMR) and has co-authored a critical scoping report on the Antimicrobial Resistance in India. Jyoti has also been closely involved in improving immunization coverage across India including the Mission Indradhanush launched by the Government of India. In this interview, Jyoti shares important information and insights on various aspects of AMR and reminds us that solving this crisis would require action at every level of society globally. 

While over the counter sales of antibiotics are cited as a key driver of AMR in India, many in our country do not even have access to these essential medicines. How can we tackle this excess versus access problem in our country?

Jyoti: Access to medicines is a critical indicator to understand the state of the health services in any geography and is usually described as “having medicines continuously available and affordable at public or private health facilities or medicine outlets that are an hour’s walking distance from the home.” However, the factors influencing this access are not just within but beyond the health system and include socio-cultural, economic and behavioural factors. Lack of access to essential medicines (including antibiotics) contributes to inappropriate antibiotic use – excess or over-the-counter use- leading to AMR. 

“Antibiotics should not be substitute for poor sanitation and hygiene, unsafe drinking water, lack of primary care services, inadequate systems and human resources in health, the lack of provision of precise, rapid and accurate diagnostic services or even good logistics and supply systems for quality assured antibiotics and vaccines. “

Today, AMR rates in bacteria, like Enterobacteriaceae, in India are one of the highest in the world due to inappropriate/overuse of antibiotics. While high-income countries have an organised, controlled distribution system for antibiotics between prescribers and dispensing pharmacists, in low and middle-income countries, poor prescription & dispensing practices and the practice of self-medication contributes to over the counter (OTC) antibiotic use. Sustained awareness and behaviour change activities with health professionals and consumers to develop an understanding of when and how to use antibiotics is critical for curtailing OTC antibiotic use.

What are some social, cultural and economic factors of AMR? 

Jyoti: Research has shown that antibiotics have become a ‘quick fix’ in modern societies. They are a quick fix for care in fragmented health systems; for the productivity of humans, animals and crops and for hygiene in settings of minimised resources; and a quick fix for inequality in political, socio-cultural and economic settings. 

Inappropriate antibiotic use is intricately linked to social insecurity, economic stability, lack of access to healthcare, and is accelerated by poverty, corruption, deprivation, inequity and poor health systems. These lead to inappropriate antibiotic prescribing practices by untrained and unaware prescribers, dispensers and the practice of self-medication by people as they try to overcome the challenge of infectious diseases in the everyday struggle of survival. 

“To address AMR, we need to address these root causes and invest in resilient and caring health systems, economic prosperity, equitable access to health, and alleviate poverty globally.”

What are some key policies and programmes in India to address the problem of AMR? 

Jyoti: India first announced the National Policy for Containment of AMR for India in 2011 following the spotlight on the danger of AMR and its transfer potential through genes like the  New Delhi Metallo-beta-lactamase 1 (NDM-1). This was followed by the Jaipur Declaration on containment of AMR in the region together with other Southeast Asian countries. Subsequently, under the twelfth five-year plan, the National Programme on the Containment of Antimicrobial Resistance was launched under the aegis of the National Centre for Disease Control. The India Council of Medical Research (ICMR) has also taken several initiatives like the launch of the Antimicrobial Stewardship, Prevention of Infection and Control (ASPIC) program in 2012 and a national network on surveillance of AMR in laboratories based at tertiary care academic centres in 2013.

In March 2014, the Central Drugs Standard Control Organization (CDSCO) implemented Schedule H1 to curtail inappropriate antibiotic use. The Schedule H1 includes 24 antibiotics, such as third- and fourth-generation cephalosporins, carbapenems, antituberculosis drugs, and newer fluoroquinolones which must be sold only with a prescription from a registered medical practitioner, and the pharmacist must maintain a separate register with the patient’s name, contact details of the prescribing doctor, and the name and total quantity of drug dispensed. The register has to be retained for at least three years and is subject to audit by the government. 

India’s National Action Plan (NAP) on AMR was launched in Sep 2017 for the period 2017-2021. In line with the Global Action Plan (GAP) on AMR, it aims to improve awareness and education, strengthen surveillance and lab capacity, optimize antibiotic use in One Health sectors, reduce the incidence of infections, promote investments in AMR activities and research and an additional objective to strengthen India’s leadership on AMR. Subsequently, however, only 3 states (Kerala, Delhi and Madhya Pradesh) have announced State Action Plans on AMR.

How well have these plans been implemented?

As per the Indian NAP, the human health sector has seen several developments to address AMR. At the national level, the National Antimicrobial Surveillance network (NARS-Net) has been established in 29 labs across 24 states to determine the magnitude and trends of AMR in different geographical regions of the country for seven priority bacterial pathogens of public health importance:  Klebsiella spp., Escherichia coli, Staphylococcus aureus, and Enterococcus spp., Pseudomonas spp, Acinetobacter spp., Salmonella enterica serotypes Typhi and Paratyphi. Today, a surveillance system for Healthcare-Associated Infections (HAIs)  has also been established in the country. To improve antibiotic use, common unified National Treatment Guidelines for antimicrobial use in infectious diseases to guide hospitals have been released but OTC antibiotic use remains common. In early 2020, the National Guidelines for Infection Prevention and Control in Healthcare facilities were also released by MoHFW and helped address AMR and COVID-19.

In the animal sector, however, actions to address AMR have been slow. India is presently the fifth largest consumer of antibiotics in food animals (poultry, pigs, and cattle) and antibiotic use is projected to grow by 312%, making India the fourth-largest consumer of antibiotics in food animals by 2030.  Encouragingly, in 2020, India announced a ban on the manufacture, sale and distribution of use of colistin (a last-resort antibiotic in critical care units) for food-producing animals, poultry, aqua farming and animal feed supplements. The food regulator, FSSAI, also laid down standards for antibiotic residue in honey after residues were detected in several brands in the Indian market. However, the use of most antibiotics as growth promoters in animal feed remains unregulated making the animal products unsafe food. Surveillance of antibiotic use in the animal sector is also lacking at the moment.

In the environment sector, as a pharmaceutical hub of the world, India raised hopes for establishing environmental standards for antibiotic residues in pharmaceutical plant effluents. Though draft standards were developed in this regard the move was shelved in 2021. This would have been an important step towards addressing the environmental impact of AMR and demonstrating India’s leadership on the issue. 

“The different pace of action in each of the sectors shows the long road ahead for our country to address AMR in a collaborative, intersectoral way. “

In your view, what are some critical challenges of raising public awareness of AMR in India? Are there any countries that have done well in this regard?

Jyoti:  Raising awareness on the issue among all stakeholders is the ultimate way forward to address the problem. However, unless AMR is understood as a One Health challenge in which all sectors – human, animal health, agriculture, food safety and the environment – take action to address it and work together, the problem will only accelerate. AMR is not a competing priority for establishing a vertical program rather a goal to be achieved while attaining other priorities like socio-economic development, employment generation, universal health coverage and improved water and sanitation. 

Most developing countries are struggling with the issue of implementing National Action Plans (NAPs) on AMR but there are several which have achieved milestones in different sectors. Netherlands and Denmark have done a remarkable job of phasing out veterinary antibiotic use for growth promotion. The UK has taken the lead in monitoring and reducing antibiotic use by prescribers in the national health services (NHS). Among developing countries, Thailand has done the uphill task of establishing a surveillance system for antibiotic use in the human and veterinary sectors and measuring improvement in AMR awareness and education through repeated surveys.  

What would be your call to action to help tackle the problem of AMR?

Jyoti: AMR is not a challenge that can be addressed in isolation by one sector or one set of professionals, be it health, veterinary or environment. I would call upon nations to recognize the interconnected nature of this threat and work towards intersectoral collaboration to address the challenge. The Mucormycosis (black fungus) outbreak due to unprecedented and inappropriate use of steroid drugs during the second wave of the COVID-19 pandemic is a stark reminder of the many facets of AMR.    

“Unless we stop using antibiotics as a shortcut to increase farm productivity or improve health systems, we are faced with an uncertain future with repeated outbreaks of life-threatening drug-resistant infections. Like for climate change, future generations will hold us accountable for the impending apocalypse of AMR.”

Interview by Team SaS and G Bhargavi Krishna Sree; Bhargavi is a research scholar, with an inclination to study and understand the coordination between the synthesis of various cell wall components in bacteria. She uses E. coli, an established model organism to study these natural processes.

Cover Art by Mahek Kothari

Learn more about AMR and what you can do to stop the rise of superbugs here.