Context:

• The Union Government of India, aware about the challenges posed by antimicrobial resistance (AMR) in the country.

 

Anti microbial resistance

• Anti microbial resistance is the resistance acquired by any microorganism (bacteria, viruses, fungi, parasite, etc.) against antimicrobial drugs (such as antibiotics, antifungals, antivirals, antimalarials, and anthelmintics) that are used to treat infections.
• As a result, standard treatments become ineffective, infections persist and may spread to others.
• Microorganisms that develop antimicrobial resistance are sometimes referred to as “superbugs”.
• Antimicrobial resistance is now regarded as a major threat to public health across the globe.

 

Basis of Antimicrobial Resistance:

• Some bacteria due to the presence of resistance genes are intrinsically resistant and therefore survive on being exposed to antibiotics.
• Bacteria can also acquire resistance. This can happen in two ways:
  • By sharing and transferring resistance genes present in the rest of the population, or
  • By genetic mutations that help the bacteria survive antibiotic exposure.

 

How it Happens?

• Some bacteria due to the presence of resistance genes are intrinsically resistant and therefore survive on being exposed to antibiotics.
• Bacteria can also acquire resistance. This can happen in two ways:
• by sharing and transferring resistance genes present in the rest of the population or
• by genetic mutations that help the bacteria survive antibiotic exposure.
• Once the resistance has been acquired, it can spread in the rest of the population of bacteria through reproduction or gene transfer.

 

Reasons for Spread of AMR

• Antibiotic consumption in humans
  • Unnecessary and injudicious use of antibiotic fixed dose combinations could lead to emergence of bacterial strains resistant to multiple antibiotics.
• Social factors
  • Include self-medication.
  • Access to antibiotics without prescription.
  • Lack of knowledge about when to use antibiotics.
• Cultural Activities
  • Mass bathing in rivers as part of religious mass gathering occasions.
• Antibiotic Consumption in Food Animals
  • Antibiotics which are critical to human health are commonly used for growth promotion in poultry.
• Pharmaceutical Industry Pollution
  • The wastewater effluents from the antibiotic manufacturing units contain a substantial amount of antibiotics, leading to contamination of rivers and lakes.
• Environmental Sanitation
  • Untreated disposal of sewage water bodies - leading to contamination of rivers with antibiotic residues and antibiotic-resistant organisms.
• Infection Control Practices in Healthcare Settings
  • A report on hand-washing practices of nurses and doctors found that only 31.8% of them washed hands after contact with patients.

 Concerns:

• AMR is already responsible for up to 7,00,000 deaths a year.
• A threat to prevention and treatment of infections - medical procedures such as organ transplantation, cancer chemotherapy, diabetes management and major surgery (for example, caesarean sections or hip replacements) become very risky.
• Increases the cost of healthcare with lengthier stays in hospitals, additional tests and use of more expensive drugs.
• It is putting the gains of the Millennium Development Goals at risk and endangers achievement of the Sustainable Development Goals.
• No new classes of antibiotics have made it to the market in the last three decades, largely on account of inadequate incentives for their development and production.
• Without urgent action, we are heading to antibiotic apocalypse – a future without antibiotics, with bacteria becoming completely resistant to treatment and when common infections and minor injuries could once again kill.

 

AMR in India:

• India, with its combination of large population, rising incomes that facilitate purchase of antibiotics, high burden of infectious diseases and easy over-the-counter access to antibiotics, is an important locus for the generation of resistance genes.
• The multi-drug resistance determinant, New Delhi Metallo-beta-lactamase-1 (NDM-1), emerged from this region to spread globally.
• Africa, Europe and other parts of Asia have also been affected by multi-drug resistant typhoid originating from South Asia.
• In India, over 56,000 newborn deaths each year due to sepsis are caused by organisms that are resistant to first line antibiotics.
• India has undertaken many activities like Mission Indradhanush — to address low vaccination coverage — strengthened micro-planning and additional mechanisms to improve monitoring and accountability.
• The Ministry of Health & Family Welfare (MoHFW) identified AMR as one of the top 10 priorities for the ministry’s collaborative work with the World Health Organisation (WHO).

 

 

Steps taken to address AMR Issue

• National programme on AMR containment
  • Launched during 12th FYP in 2012-17. 
  • Under this programme, AMR Surveillance Network has been strengthened by establishing labs in State Medical College. 
  • 30 sites in 24 states have been included in this network till 30th March 2021.
• National Action Plan on Antimicrobial Resistance (NAP-AMR) focusing on One Health approach was launched on 19th April 2017 with the aim of involving various stakeholder ministries/departments. 
  • Delhi Declaration on AMR– an inter-ministerial consensus was signed by the ministers of the concerned ministries pledging their support in AMR containment.  
  • In the line with NAP-AMR three states have launched their state action plan
    • Kerala has launched KARSAP
    • Madhya Pradesh has launched MP-SAPCAR 
    • Delhi has launched SAPCARD 
• AMR Surveillance Network:  ICMR has established AMR surveillance and research network (AMRSN) in 2013, to generate evidence and capture trends and patterns of drug resistant infections in the country. This network comprises 30 tertiary care hospitals, both private and government.
• AMR Research & International Collaboration: ICMR has taken initiatives to develop new drugs /medicines through international collaborations in order to strengthen medical research in AMR.
  • ICMR along with Research Council of Norway (RCN) initiated a joint call for research in antimicrobial resistance in 2017.
  • ICMR along with the Federal Ministry of Education and Research (BMBF), Germany has a joint Indo-German collaboration for research on AMR.
• Initiatives to control overuse or misuse of antibiotics:
  • ICMR has initiated antibiotic stewardship program (AMSP) on a pilot project basis in 20 tertiary care hospitals across India to control misuse and overuse of antibiotics in hospital wards and ICUs.
  • On the recommendations of ICMR, DCGI has banned 40 fixed dose combinations (FDCs) which were found inappropriate.
  • ICMR worked in collaboration with  Indian Council of Agriculture Research, Department of Animal Husbandry, Dairy and Fisheries and the DCGI to ban use of Colistin as growth promoter in animal feed in poultry.

Guidelines issued

• National Guidelines for Infection Prevention and Control in Healthcare Facilitieshave been released by MoHFW in Jan 2020.
• ICMR has developed evidence based treatment guidelines for treatment of ten syndromes of infections. It aims to rationalize the usage of antibiotics on Essential Medicines Formulary (EMF) and to establish consistency in the treatment of various infectious conditions.
• Further, ICMR has also issued the Treatment Guidelines for Antimicrobial Use in Common Syndromes” in 2019.  

 

Information Education & Communication (IEC) Activities

• Media material has been developed to create awareness among various stakeholders regarding AMR and appropriate use of antibiotics.
  • The key priority areas include zoonotic diseases (emerging and re-emerging), food safety and antibiotic resistance.
  • Program for Strengthening Inter-sectoral Coordination for Prevention and Control of Zoonotic Diseases’ was launched in the 12th Five-year plan (2012-17) which is still continuing as “National One Health Program for Prevention and Control of Zoonoses” in 15th Finance Commission (2021-26) period.
    • This scheme aims to operationalize “One Health” Mechanisms for prevention and control of Zoonoses by strengthening inter-sectoral coordination among all stakeholders. 
    • In this regard, the National Institute of One Health is being established at Nagpur  which will house the BSL IV laboratory.
• ICMR has undertaken a project on an “Integrated One Health Surveillance Network for Antimicrobial Resistance” in collaboration with Indian Council of Agriculture research (ICAR) to assess the preparedness of Indian Veterinary laboratories to participate in integrated AMR surveillance network. 
  • ICMR has also created a veterinary standard operating procedure (Vet-SOPs) for enabling comparison of antimicrobial resistance patterns in animals and humans.

Shortcomings in fighting AMR

• A cross-cutting programme dealing with antimicrobial resistance across multiple microbes has been lacking.
• Absence of a One Health Approach in addressing AMR – which recognizes that human well-being is inextricably tied to the health of animals and the environment.
• The absence of stringently framed and implemented regulatory frameworks to limit the use of antimicrobials in livestock and food animals, especially for non-therapeutic purposes, has been one of the drivers of antibiotic overuse at the community level.
• In India, current effluent standards do not include antibiotic residues, and thus they are not monitored in the pharmaceutical industry effluents.

Steps to fight against AMR

• Infection control in healthcare facilities.
• Creating awareness about the use and abuse of antibiotics.
• Vaccination can combat drug resistance by reducing the cases of infection and as a result reducing the need for antibiotics.
• Strengthening resistance tracking so that data on antimicrobial resistant infections and causes of infection can be gathered to enable formulation of specific strategies to prevent the spread of the resistant bacteria.
• Self-medication should be shunned.
• Antibiotics should be used only when prescribed by the doctor.
• Appropriate and safe use of antibiotics- taking antibiotics only when needed, choosing the right antibiotic and completing the full prescription.
• Invest in the search for new antibiotics to keep up with resistant bacteria as well as in new diagnostic tests to track the development of resistance.

Way Forward

• AMR has the potential to return the world to a pre-antibiotic era when medicines could not treat even simple infections.
• Therefore, to contain AMR, there is need for a One Health Approach through coherent, integrated, multi sectoral cooperation and actions, as human, animal and environmental health are integrated.
• Development of antibiotic resistance breakers (ARBs) to restore effectiveness of older classes of antibiotics.