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  Table of Contents  
EDITORIAL
Year : 2013  |  Volume : 31  |  Issue : 2  |  Page : 111-113
 

India needs an implementable antibiotic policy


Department of Microbiology, All India Institute of Medical Sciences, New Delhi - 110 029, India

Date of Submission12-Jun-2013
Date of Acceptance12-Jun-2013
Date of Web Publication19-Jul-2013

Correspondence Address:
A Kapil
Department of Microbiology, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0255-0857.115212

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How to cite this article:
Kapil A. India needs an implementable antibiotic policy. Indian J Med Microbiol 2013;31:111-3

How to cite this URL:
Kapil A. India needs an implementable antibiotic policy. Indian J Med Microbiol [serial online] 2013 [cited 2017 Aug 17];31:111-3. Available from: http://www.ijmm.org/text.asp?2013/31/2/111/115212


I remember a famous quote by Albert Einstein- "I do not know how the world war III will be fought, but world war IV will be fought with sticks and stones." Though we would never wish any other WW to happen, I am tempted to employ the quote as an analogy with the use of antibiotics as a weapon to treat infections.

Antimicrobial resistance is a global challenge. The spectrum and the extent of the problem may vary in different countries. There have been major international efforts to tackle the scenario, and India is also expected to make significant contribution toward such efforts.

The publication in Lancet Infect Diseases in 2010 [1] on the origin of NDM-1 (New Delhi metallo beta lactamase) gene in India created lot of furor in the medical as well as political circles. Unfortunately, the discussion in the study was skewed toward health tourism and the naming of NDM-1 rather than the serious issue of tackling antibiotic resistance in India and the region. After initial anger and denial from the side of Indian authorities and scientists, efforts were initiated to tackle the problem subsequently. In a country of 1.2 billion population, any problem however small, becomes large in terms of numbers contributing to the global data. Therefore, it becomes our responsibility to make an honest effort to tackle the problem. Another positive fall out of the wide media coverage on this publication was sensitization of the public to this problem, which also in a way motivates political commitment.

When we look at the mechanism of evolution of antimicrobial resistance, it is evident that nature has its own strategies. Acquisition of resistance genes is a part of "survival of the fittest" strategy of bacteria, like any other living being. While we cannot do much to stop that, we can surely slow down the process by reducing selective pressure on bacteria causing infectious diseases. While micro-organisms can fight out their battle amongst themselves out there in the ecosystem, we should do our best to prevent them transgress these boundaries or slow the process of their acquiring resistance determining genes. This is where we need to be proactive and for India it is a time for introspection. There is a need for a national policy which is practical and implementable, may not be ideal to begin with. The inputs and evidence generated by experiences in other countries regarding various policies and interventions can be a good resource to learn from. The gaps identified in implementation or utility of different strategies are well documented by countries that have national policies in place. Taking these experiences, India has to identify its own problems and infrastructure and seriously put forward strategies, honestly showing the world that it would make all the possible efforts to contain this problem.

Though a national policy and recommendations were published in 2011, [2] it could really not be put into practice due to many practical issues impeding its implementation . There was some ban on the "over the counter" sale of drugs but again that did not translate into actual legal responsibility. Problems that India faces are multi-factorial. The health infrastructure is very diverse, there are corporate accredited hospital conforming to international standards on one hand and the other extreme is a general civil hospital with minimal emphasis on quality due to many constraints. Health being a state subject, uniform implementation of restriction of antibiotic sales is a difficult task. Then in many rural and remote areas with inaccessible medical facilities, there is hardly any qualified doctor available to make "prescription only" policy for sale of antibiotics. The local "paramedic" is prescribing and dispensing antibiotics. Due to the lack of laboratory infrastructure, collecting and monitoring national data on antimicrobial resistance is a challenging task.

"Chennai declaration" was one serious initiative taken by the Indian scientists toward the goal of tackling antimicrobial resistance in India. A pre-conference symposium of the 2 nd annual conference of Clinical Infections Disease Society (CIDSCN 2012) was held in Aug 2012 at Chennai, rightly named as "A roadmap to tackle the challenge of antimicrobial resistance - A joint meeting of Medical Societies to India." The uniqueness of this meet was that it was the first ever meet of Indian medical societies and policy makers with an intent to tackle global antimicrobial resistance from the Indian perspective. The participants included representatives of various societies like Indian Medical Association, Association of Physicians of India, Infectious Disease Society, Microbiology society, Transplant society, Oncology Society and Gynecology Society along with representatives from Medical Council of India, drug controller general of India, Indian council of Medical research and National accreditation board of Hospitals, World Health Organization, State government representatives, and many scientific associations and societies. The international experts from different countries with a national policy in place shared their experience in implementing guidelines. The intention was to gain a broad consensus and the range of opinions to guide formation of the road map. The ethos of the meeting was very much not to look back but rather to look forward and make joint efforts to tackle the menace of antibiotic resistance. All participants emphasized on the need of an implementable and practical approach to draft a policy which may be less ambitious and more liberal to begin with. Step by step introduction of stricter recommendations could be tried later once we have succeeded in implementing the current liberal recommendations. This joint effort called "Chennai Declaration" comprised major recommendations for an implementable policy for India with inputs from all participants. [3] Chennai declaration proposals are considered to be implementable due to the simplicity of the document, experience learned from the failure of the previous policy, expertise of the participants and collaboration of all the major stake holders.

Interestingly, this meeting and its publication generated a lot of interest and response in international journals with editorials and commentaries. [4],[5],[6],[7],[8],[9],[10] As this was the first ever symposium where all medical societies and stake holders participated, it was considered as a symbol of the will and commitment of Indian scientific community toward the important issue of tackling antimicrobial resistance. Chennai declaration's recommendations could be the backbone of an antibiotic policy in India and other developing countries, helping policy makers, to draft realistic and implementable policy. Besides the publications appreciating this step, the coordinator of the roadmap meeting and Chennai Declaration, Dr. Abdul Ghafur, received letter of endorsement from the Royal college of Physicians, Edinburgh congratulating the Indian scientists on their efforts. The African Infection control network recommended Chennai declaration to African countries and Australian infectious diseases society officially supported the declaration.

Indian Ministry of Health and Family Welfare, after studying the document, invited the coordinator of the Chennai Declaration to discuss the possibility of incorporating the declaration recommendations in the national policy. One step taken by the Indian Council of Medical Research is an establishment of a national network on monitoring antimicrobial resistance which will begin with few tertiary care hospitals so as to standardize procedures and protocols and finally would extend to regional and state level hospitals for generating national data on antimicrobial resistance.

Indian Association of Medical Microbiologists (IAMM) was a part of the Chennai declaration ensuring the commitment of the Medical Microbiologists in tackling antimicrobial resistance. India is one of the very few countries with trained medical microbiologist, i.e., medical graduate with MD in Microbiology. The road map reiterates that medical microbiologists must play a proactive role in making a national antibiotic policy, implementing hospital infection control practices and formulating antimicrobial stewardship program. It can just begin with constructing antibiograms at local levels, sharing data with the treating units and putting forward standard protocols for empirical treatment of infectious diseases. Ensuring quality of laboratory data by accreditation of laboratories or participation in EQAS (which is provided by IAMM in India) and regular internal quality will ensure correctness of the data which will be globally comparable, besides generating confidence at all levels.

Emerging antimicrobial resistance is a challenge not only to the medical community but also to the public. The increase in morbidity and mortality due to drug resistance infections lead to increase economic burden to the country, hospitals, and the family. In India about 80% of the healthcare is provided by the private sector putting the cost to the patient. The evidence all over the world has shown that finally the political will and some enforcement from the government is an essential part of the implementation of national policies, nevertheless all concerned professional bodies have to come forwarded and join hands.

A nationwide awareness to educate everyone or to empower the patient may also be helpful. Some examples like "say no to TB serology campaign," use of respiratory precautions and cough etiquettes, practice of hand hygiene, drinking safe water etc., are public campaigns that have helped. The pressure a clinician feels when he is forced to write an antibiotic on patients' demand will decrease if the patient is aware of the judicious use of antibiotic.

Chennai declaration having provided an impetus to the national and the global tackling resistance efforts is expected to culminate in an antibiotic policy for India and other developing countries and such a policy to be implemented to the grass root level. Tackling antimicrobial resistance needs coordinated efforts of all stake holders. Microbiologists can and must play a major role in this endeavor.

 
 ~ References Top

1.Kumarasamy KK, Toleman MA, Walsh TR, Bagaria J, Butt F, Balakrishnan R, et al. Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: A molecular, biological, and epidemiological study. Lancet Infect Dis 2010;10:597-602.  Back to cited text no. 1
    
2.National Policy for containment of antibiotic resistance in India, 2011. DGHS, MoHFW, New Delhi 9. Available from: http://www.nicd.nic.in/ab _policy.pdf. [Last accessed 11.6.13].  Back to cited text no. 2
    
3.Ghafur A, Mathai D, Muruganathan A, Jayalal JA, Kant R, Chaudhary D, et al. The Chennai declaration: A roadmap to tackle the challenge of antimicrobial resistance. A joint meeting of medical societies of India. Indian J Cancer 2012;49:84-94.  Back to cited text no. 3
    
4.Goossens H. The Chennai declaration on antimicrobial resistance in India. Lancet Infect Dis 2013;13:106.  Back to cited text no. 4
    
5.Westly E. India moves to tackle antibiotic resistance. Nature 2012;489:192.  Back to cited text no. 5
[PUBMED]    
6.Ghafur A. The Chennai declaration: A Solution to the antimicrobial resistance problem in the Indian subcontinent. Clin Infect Dis 2013;56:1190.  Back to cited text no. 6
[PUBMED]    
7.Hopkins S. Improving antimicrobial stewardship and surveillance: The Chennai Declaration A landmark step towards combating the spread of antimicrobial resistance in India and worldwide. BMJ 2013;346:591.  Back to cited text no. 7
    
8.Mitka M. Indian public health leaders move to reduce antimicrobial resistance. JAMA 2013;309:531-2.  Back to cited text no. 8
[PUBMED]    
9.Voss A, Ghafur A. "The Chennai declaration"- Indian doctors' fight against antimicrobial resistance. Antimicrob Resist Infect Control 2013;2:7.  Back to cited text no. 9
[PUBMED]    
10.Holmes AH, Sharland M. The Chennai Declaration: India's landmark national commitment to antibiotic stewardship demonstrates that 'truth alone triumphs'. J Antimicrob Chemother 2013 [In Press].  Back to cited text no. 10
    




 

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