Note: This opinion piece addresses the issue of antimicrobial resistance and has no connection with the ongoing Coronavirus pandemic.
Antibiotics were first used in India around the time of the Second World War. Dr Dersmond, who was a house staffer at Madras Medical College, remembers that Penicillin was worth its weight in gold. According to some old doctors, urine of patients was collected to extract and recover any Penicillin that was passed.
Before the discovery of antibiotics, millions used to die of common diseases like Typhoid and tuberculosis that are treatable today. My grandmother died of typhoid in the 1930s and my father was quarantined for half a year when he was diagnosed of tuberculosis in the 1940s. It was not until many years later that antibiotic/antimicrobial resistance (AMR) became an issue.
So what is antibiotic resistance or AMR? Microbes are tiny organisms like bacteria, fungi, viruses, and parasites. They cause infections. AMR is when these microbes develop resistance to antibiotics. As a result, the antibiotic used to treat infections is no longer effective. This limits the treatment options available. Therefore many of the most common infections become more difficult to treat. Sometimes AMR means that they result in death.
For instance, two of the most common antibiotics Chloramphenicol was effectively used until the 1980s to treat typhoid and Isoniazid (INH) was used with thiacetazone to treat tuberculosis. In the 1980s, they started to be ineffective. Resistance to the star antibiotic Penicillin was documented as early as 1942 in hospitalized patients. In response to the growing ineffectiveness of Penicillin, Methicillin was developed in the 1950s to supersede Penicillin. Methicillin also became ineffective for staphylococcus aureus. Soon enough, tuberculosis resistant to Streptomycin and later Rifampicin were reported from hospital wards in the late 1980s.
Since then the global epidemic of drug-resistance has grown and claims over 700,000 lives annually. It is projected to touch 10 million by 2050 unless there is positive action. India has one of the largest burdens of drug-resistant pathogens worldwide, including the highest burden of multidrug-resistant tuberculosis. Annually, more than 50,000 new-borns are estimated to die from sepsis due to pathogens resistant to first-line antibiotics. Two million deaths are projected to occur in India due to AMR by the year 2050.
Numerous causes have been linked with the spread of AMR. Among these, the misuse of antibiotic drugs is often blamed. Misuse of antibiotics occurs in several ways – irrational combinations, overuse, incomplete courses of prescribed drugs, improper disposal of unused products or improper burial or incineration of infected body parts, stool and urine.
Policy makers across the world identified such practices and developed interventions. For instance, the oral chloramphenicol-streptomycin combination, Chloro-Strep was banned by Government of India. Culture-sensitivity tests were done wherever possible before administering antibiotics. And hospitals, doctors and pharmacists were trained about rational therapy in order to prevent illogical use or misuse.
Similarly, 10 countries in the European Union have adopted extended producer responsibility schemes targeting the unused medicines which used to be thrown away. These schemes make it the responsibility of the drug manufacturing companies to buy back date-expired/unused drugs and dispose them safely.
Food Systems and AMR
Despite such interventions new developments in global economics gives rise to newer threats. One of the biggest consumers of antibiotics is the livestock sector. It is administered to chickens, pigs, cattle and farmed seafood to prevent infection and promote growth. In 2015, a group of Princeton University researchers developed the first ever global map of antibiotic consumption. According to the report, the total estimated consumption of antibiotics in livestock was 61,151 tons in 2010 alone. This number is projected to rise by 67% by 2030, and nearly double in Brazil, Russia, India, China, and South Africa mostly driven by the growth in demand for livestock products and a shift to large-scale farms where antimicrobials are used routinely. A similar but relatively lower threat is posed by the use of antibiotics in plant protection.
A much less spoken about source of antibiotic pollution that is fueling the global AMR crisis is the factories that manufacture antibiotics. Over 100,000 tonnes of pharmaceutical products are consumed globally every year. India’s pharmaceutical exports stood at US$ 17.27 billion in 2017-18 and are expected to reach US$ 20 billion in 2020 making it the second largest manufacturing hub after China. After antibiotics are manufactured, the untreated Active Pharmaceutical Ingredients or APIs are often released in wastewater streams. This has been shown to contribute to the spread of antimicrobial resistance (AMR). Effectively, every human being on earth is getting minimal quantities of antibiotic. Even commensal flora (normally present in the intestine) are becoming resistant. Multiple scientific investigations have found high concentrations of antibiotics and drug-resistant bacteria in the environment of Hyderabad. Hyderabad hosts the largest concentration of bulk drug manufacturing units and so this is one of the highest concentrations drug-resistant bacteria in the world.
In this context, the recently announced the draft rules (effluent standards) by India’s Ministry of Environment, Forests and Climate Change (MoEF&CC) is a welcome proposition. If the government follows through with the ambitious approach set out in the draft rules, India will be firmly in the forefront of global efforts to tackle AMR as a result of pollution from drug manufacturing. On other fronts more work is needed!
The author is the Director of State Health Resource Center, Chhattisgarh (2014-2020)
Note: The MoEF&CC is inviting comments/suggestions on Environmental Standards for Bulk Drug and Formulation (Pharmaceutical) Industry. To send your comments click here