Indian Express Articles - Super Bug
Health Systems Research India Initiative
Science, sense and sensation
The Lancet article reports that some of the enterobacteriace (which reside in gut flora) have become resistant to carbapenems, a powerful group of broad spectrum antibiotics. Since this bacterial enzyme was supposedly first described in a Swedish patient who had traveled to India, it was named New Delhi metallo-beta-lactamase, or NDM-1.
Antibiotic Resistance Is A Growing Global Concern: Resistance to many antibiotics, among many bacterial species, has been reported from around the world. Even in enterobacteriace, resistance due to NDM-1 as well as other mechanisms has been reported in many countries. In Greece, for example, klebsiella pneumoniae (one of the enterobacteriace family) has been reported to have 46 per cent to 63 per cent resistance rates for several high grade antibiotics, including carbapenems.
Bacterial resistance to antibiotics is an evolutionary phenomenon. The more the bacteria are challenged by antibiotics, the more the bacteria will evolve to beat them. It is not surprising, therefore, that many of the antibiotic resistant strains first emerge in developed countries, since new antibiotics are initially tried out for several years in those countries, before they reach other markets.
In developing countries, the problem is compounded by inappropriate prescribing practices (in the absence of monitored guidelines), extensive over-the-counter sales, self-medication and poor adherence to a full-course regimen. As the number of new antibiotics coming out of the research and development pathway is very limited, global concerns mount as new resistant bacterial strains emerge.
Why should India be concerned? : More than any potential adverse effect on medical tourism, we should be concerned about the likely spread of multi-drug-resistant bacterial strains (including NDM-1) among our population. The Lancet study reported that 1 per cent of the isolates from Chennai and 13 per cent of the isolates from Haryana contained these strains. An earlier study from the Hinduja Hospital in Mumbai reported that 22 out of 24 carbapenem resistant isolates exhibited NDM-1.
Even though these studies are not representative of all of India or even of the hospitals in a particular region, having been limited to a few select hospitals, the potential for spread should be a cause for concern. Strains containing the NDM-1 gene are more easily transmissible than the other pathways of carbapenem resistance, because of the way the genetic information is carried in the cell. The widespread presence of enterobacteria and the easy transmissibility of this resistance gene can lead to serious infections, especially in immunocompromised individuals and in hospital settings, if timely measures are not taken for surveillance, infection prevention and control.
What do we need to do? Our response should integrate infection surveillance, prevention and control strategies as well as regulation of antibiotic use. Hospital and community-based infection surveillance sites should be set up in different regions of India to monitor infection rates, bacterial types and resistance patterns. Prevention practices like handwashing should be promoted among the general public as well as health personnel. Hospital waste disposal systems should be scrutinised and strengthened. All health care facilities should be certified for meeting infection control standards. Antibiotic prescriptions should be as per approved and periodically updated guidelines issued by professional experts identified by the government. Since antibiotic use is also in widespread in veterinary medicine as well as livestock breeding, surveillance and regulatory systems must cover both human and animal populations. A competent agency, akin to the Health Protection Agency of UK, should be set up in India to deal with the guidelines and regulatory aspects of infection control. Pharmacists should be monitored, to curb over-the-counter antibiotic sales for unapproved indications.
No time for finger pointing: Virtually all countries have weaknesses to contend with, in the area of infection control. Even in the UK, a study in 2006 revealed that only 12 per cent of hospital personnel washed their hands both before and after examining a patient with methicillin resistant staphylococcus aureus (MRSA), which was a deadly threat in UK at that time.
The practice of naming bacteria after the place of their first isolation or supposed origin needs to be done away with. With bacteria all over the world evolving to become resistant to new antibiotics, there can be no certainty as to where a resistant strain emerged first — only the serendipity of first reported isolation.
Where the study is weak: It is true that the sampling design is one of convenience and is not representative of different regions of India or types of hospitals. Nevertheless, the identification of easily transmissible resistant strains anywhere calls for prompt public health action. The study, however, overreaches when it concludes that there is a high risk of UK citizens coming to India for medical treatment acquiring multi-drug resistant infections. That cannot be based on 14 patients with a history of hospitalisation in India for 12 different conditions. Without knowing the total number of persons from UK who were hospitalised for treatment in India during this period, we do not know whether these 14 constituted a very small fraction or a large fraction. The authors do not provide data to compare the multi-drug resistant bacterial infection rates in British medical visitors to India versus rates for similar hospitalisation in UK during the same period.
Even if the UK health authorities were concerned about potential exposure of persons from UK to antibiotic-resistant bacteria in India, the concluding paragraph was out of place in an article with multi-country authorship, published in an international journal. However, resentment about these gratuitous remarks on medical tourism should not blind us to the need for serious national efforts for prevention of both infections and antibiotic resistance. The health of a billion-plus Indians matters much more than whether some foreigners will come to India for “medical value travel”.
The writers are president and senior public health specialist respectively at the Public Health Foundation of India
Source: http://www.indianexpress.com/story-print/662362/
2.Medical malpractice
In recent years, India has become a preferred destination for medical tourism because patients in the West know that they can get a standard of healthcare equal to any hospital in their own countries, at a fraction of the cost. Pharmaceutical companies and for-profit hospitals in the West see this as a threat, but make no attempt to reduce the cost of healthcare or improve its accessibility. New scientific discoveries must be hailed, but to use science as way to discredit a particular country is deplorable.
I have been in the medical profession for over 35 years and am familiar with the way medicine is practiced in different parts of the world. I now see a change in the way some companies perceive medical research. They use it as a means to promote one line of treatment over conventional lines, for maximising profits. This discredits the entire medical profession and makes the patient mistrust allopathic treatment. In order to protect the interests of its people, the government passes stronger regulations that stifle further development and research. If we could use medical research in a responsible and unbiased fashion and embrace its purpose of alleviating suffering and not maximising profits, our patients will reinstate their faith in doctors.
The writer is a cardiac surgeon and founder of the Narayana Hrudayalaya multi-specialty hospital
Source: http://www.indianexpress.com/story-print/662368
Thanking You,
Best Regards,
Team HSRII