Preparing for the next pandemic

The rampant use of antibiotics and its various combinations during the current pandemic and the overenthusiastic use of steroids have created a situation which was not foreseen. It is estimated that global mortalities due to AMR will touch 10 million by 2050. The unsustainable use of antibiotics and the discharge of untreated effluents and wastewater into water systems is increasing the resistance of bacteria towards antibiotics and is conducive for the growth of other potential pathogens. The World Health Organisation (WHO) has already raised alarms that the present batch of antibiotics and the ones which are in the pipeline are not enough to combat this threat.

The overuse and misuse of antibiotics, rampant earlier, further accelerates as the pandemic progresses. Many medical practitioners continue to prescribe antibiotics like azithromycin, doxycycllin and other combinations of broad spectrum drugs to treat the viral disease caused by the coronavirus, even in mild and asymptomatic cases. Further, the kith and kin of patients are resorting to self-medication that is fuelled partly by anxiety and misinformation.

The pandemic has put the focus back on the importance of correct prescription behaviour with a sense of responsibility and accountability. It is only wise that this renewed attention drives antimicrobial management and pushes for a behavioural change towards the consumption and prescription of antibiotics. While patients should also educate themselves, the onus lies with the medical community to emerge as champions of the cause. Apart from responsible prescription behaviour, the medical education curriculum should be revised so that necessary epidemiological expertise is cultivated. Further, the revision of the National List of Essential Medicines (NLEM) is imperative, and certain antibiotics should be reclassified.

While overuse and misuse of antibiotics and indiscriminate usages of antibiotics like Colistin in agriculture, livestock and poultry industry contribute to growing AMR, the discharge of untreated wastewater and effluents into water bodies is a significant contributor that often slips under the radar. Studies have shown that untreated wastewater from medical facilities is awash with chemical compounds that promote superbugs. The case of bla-NDM-1 superbug, first discovered in New Delhi in 2008 and then subsequently in the Arctic in 2019 underscores the global vulnerability when effluents are not treated.

Apart from medical facilities, the pharmaceutical industry is also responsible for the increased AMR. During the production process, manufacturing plants discharge their untreated effluents into water bodies which not only degrades the water quality but also allows the superbugs to enter the food chain. This is fast becoming a global problem as higher concentrations of antibiotics like ciprofloxacin, norfloxacin, oxytetracycline and ofloxacin are being found in rivers across the world. The dumping of untreated effluents needs concerted attention in China and India as these two countries combine to produce 80 per cent of the world’s antibiotics. The ill effects of untreated effluents have already been observed in the degrading water bodies of the two countries like the Yellow, Hai and Liao rivers in northern China and the waterbodies in the Indian cities of Ahmedabad, Bengaluru and Hyderabad.

The government displayed exemplary vision when it became the first country in the world to release a draft on the standards of antibiotic residue in effluents discharge. The draft once notified would provide the limits for the discharge of effluents from the manufacture of 121 antibiotics. This needs to be implemented in letter and spirit by all state governments. Further, the pharmaceutical industry should realise that sustainable production of antibiotics augurs well for their business. They should take lead and implement good manufacturing practices which lower the concentration of antibiotics in effluents.

The Covid-19 outbreak has reiterated that human health cannot be seen in silos. The world is an interconnected mesh of interactions between humans, animals, and the environment. The health and well-being of mankind cannot be achieved if equal priority is not attached to the health of the animal and environmental ecosystems. Increased AMR will wreak havoc. Effective microbiological surveillance of the agriculture and livestock industry and pharmaceutical manufacturing plants would allow for informed policy actions to mitigate AMR.

Moreover, the overuse and misuse of antibiotics in the medical ecosystem would have to be checked through robust anti-microbiological stewardship programmes across primary, secondary, and tertiary healthcare networks. NITI Aayog’s vision for public health surveillance in India stresses firmly the critical role of data in surveillance across three health matrices — human, animal, and environment. There have been some developments in this regard, but the situation warrants swift action. The present surveillance efforts are informed majorly through the Indian Council of Medical Research’s (ICMR) Antimicrobial Resistance Surveillance & Research Network (AMRSN) initiative. ICMR-AMRSN gathers epidemiological data from 25 public and private hospitals and laboratories. This small sample size is simply not representative of the behaviour of pathogens in various settings in a diverse country like India.

We need to be cognisant of the fact that a pandemic happens once every 100 years. But, if we do not learn our lessons, the next pandemic could be that of AMR, and it will be much sooner.

The writer is senior consultant-health, NITI Aayog