Anti-microbial resistance in India

Antimicrobial resistance is an important concern for the public health authorities at a global level. However, in developing countries like India, recent hospital and some community-based data showed an increase in the burden of antimicrobial resistance.

What is AMR?

Antimicrobial resistance (AMR) is the ability of a microorganism (like bacteria, viruses, and some parasites) to stop an antimicrobial (such as antibiotics, antivirals and antimalarial) from working against it. As a result, standard treatments become ineffective, infections persist and may spread to others. When an organism is resistant to more than one drug, it is said to be multidrug-resistant.

Two main contributing factors are,

• Excessive use of antimicrobials and,
• Inadequate infection control policies facilitating the spread of resistant microorganisms.

Challenges

• Strengthening of Surveillance Data
• Standard Operating Guidelines
• Improvement in antibiotic prescription practices
• Over the counter sale of antibiotics
• Poor sanitation, endemic infections, malnutrition
• Limited public awareness and government commitment
• Lack of coordination and fragmentation of effort
• Perverse incentives.

The journey so far:

• AMR is one among 10 global health threats list published by WHO, which demand immediate attention.
• Understanding the gravity of the problem, the World Health Assembly has adopted the Global Action Plan on AMR in the year 2015 as a part of the tripartite collaboration with World Health Organization, Food and Agricultural Organization, and World Organization for Animal Health. India’s National Action Plan (NAP) for AMR was released in April 2017 by the Union Ministry of Health and Family Welfare. The objectives of the NAP include improving awareness, enhancing surveillance measures, strengthening infection prevention and control, research and development, promoting investments, and collaborative activities to control AMR. On the basis of the NAP, various states have begun the process of initiating their State Action Plans.
• A National Policy for containment of Antimicrobial Resistance (AMR) in the country was formulated in the year 2011 and has been widely disseminated. The said policy envisages enforcement and enhancement of regulatory provisions for the use of antibiotics for humans as also for veterinary use.
• The Drugs and Cosmetic Rule, 1945 were amended in 2013 to incorporate a new Schedule H1 under the said rules containing 46 drugs which include third and fourth generation antibiotics, anti TB drugs and certain habit forming drugs for having strict control over the sale of these drugs. The Drugs falling under Schedule H1 are required to be sold in the country with conditions
• A National Programme for Containment of AMR has also been initiated in 12th Five Year Plan
• The Government of India has signed Memorandum of Understanding/Agreement for cooperation in health with several countries. AMR has been identified as one of the area of cooperation in agreements with some of these countries including Sweden, Netherland and U.K.
• Indian Council of Medical Research (ICMR) has signed a Memorandum of Understanding (MoU) with the Research Council of Norway (RCN), and also initiated collaboration with National Institute of Health, USA (NIH) and Centers for Disease Control, Atlanta, USA (CDC) regarding antimicrobial resistance. 

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Way forward

• Establish a national alliance against antimicrobial resistance with all key stakeholders as its members.
• There should be an integrated approach between provider and consumer sides to effectively prevent the antimicrobial resistance
• Implement appropriate surveillance mechanisms in the health and veterinary sectors to generate reliable epidemiological information, baseline data, trends on antimicrobial resistance, utilization of antimicrobial agents and impact on the economy and health through designated national and regional reference centres.
• Private pharmaceutical industries must take it upon themselves to distribute drugs in a responsible manner.
• Philanthropic charities must fund the development of new antibiotics, while citizen activists must drive awareness.
• These stakeholders must appreciate that the only way to postpone resistance is through improved hygiene and vaccinations.
• Discourage non-therapeutic use of antimicrobial agents 
• Develop national standard treatment and infection control guidelines 
• Conduct of operational research for better understanding of the technical and behavioural aspects of prevention and control of antimicrobial resistance. 
• Strengthen the communicable diseases control program to reduce disease burden and accord priority to the discipline of infectious diseases in medical education and health services.

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Conclusion

There exist lacunae in the structure and functioning of the public health care delivery system with regard to quantification of the problem and various determining factors related to antimicrobial resistance. There is an urgent need to develop and strengthen antimicrobial policy, standard treatment guidelines and a national plan for containment of AMR in India. There should be more focus on research related to public health aspects of AMR at community and hospital level. Information Education Communication activities with monitoring and evaluation of the existing health care delivery system for both health care providers and consumers to improve drug use, should be undertaken simultaneously.