With the average Indian taking some 11 antibiotic pills a year, the country consumed about 12.9 billion units in 2010. Credit: Bigstock

By Ranjita Biswas
KOLKATA, India, Aug 28 2014 (IPS)

In 2011, the World Health Organisation (WHO) warned: “Combat Drug Resistance – No Action Today, No Cure Tomorrow.” The slogan was coined in honour of World Health Day, urging governments to ensure responsible use of antibiotics in order to prevent drug-resistant viruses and bacteria, or ‘super bugs’.

The warning is even more salient in 2014, particularly in India, a country of 1.2 billion people that recently earned the dubious distinction of being the worst country in terms of antibiotic overuse in the world.

With the average Indian taking some 11 antibiotic pills a year, the country consumed about 12.9 billion units in 2010, up from eight billion units in 2001.

"It’s a delicate, personal, ethical, medical issue. We can’t live without antibiotics. What is needed is prudent use." -- Ashok J. Tamhankar, national coordinator for the Indian Initiative for Management of Antibiotic Resistance (IIMAR)
An analysis of national pharmaceutical sales data published in ‘The Lancet Infectious Diseases’ last month found that Brazil, Russia, India, China, and South Africa accounted for 76 percent of the increase in antibiotic use around the world.

Western countries are now waking up to the alarming impact of over-consumption of antibiotics, which results in drug resistance. In Europe alone, drug-resistant strains of bacteria are responsible for 25,000 deaths a year.

In July, British Prime Minister David Cameron warned that the world could be “cast back into the dark ages of medicine” due to deadly bacteria eventually developing resistance to drugs through mutation, and as a result of “market failure” to develop new classes of antibiotics over the last 25 years.

In developing countries like India, changing lifestyles are contributing to the casual and careless use of drugs.

Ramanan Laxminarayan, research scholar and lecturer at Princeton University, told IPS the reason behind the proliferation of antibiotics in this country is “a combination of increasing income and affordability, easy access without a prescription, willingness of physicians to prescribe antibiotics freely, and a high background of infections that should ideally be contained by better sanitation and vaccination.”

People forget, he said, that “antibiotics do have side effects and […] they are less likely to work for you when you really need them.”

According to the Lancet’s report, the largest absolute increases in consumption between 2000 and 2010 were observed for cephalosporins, broad-spectrum penicillins and fluoroquinolones.

The authors cautioned, “Many broad-spectrum antibiotic drugs (cephalosporins, fluoroquinolones, and carbapenems) are sold over the counter without [the] presence of a documented clinical need.”

Moreover, added Kolkata-based physician Surajit Ghosh of the Indian Public Health Association, some patients choose to refill their own prescriptions without consulting a proper physician, in a bid to reduce the burden of doctor’s fees.

For a country like India with limited healthcare facilities and a doctor-patient ratio of one doctor to every 1,700 people, as well as 29 percent of the population languishing below the poverty line, the emergence of super bugs could be disastrous, experts say.

“With our high background rate of infections, we rely on antibiotics more than developed countries do,” stated Laxminarayan.

“Therefore, the impact of super bugs is likely to be much greater for many in our country who cannot afford the newer, more powerful antibiotics. Think of it as the price of fuel or kerosene going up. The rich will manage wherever they are, but the poor will be hit hard.”

He predicts that the most common diseases to be affected by antibiotic overuse will likely be “hospital infections, particularly those causing sepsis, pneumonia and urinary tract infection.”

Wary of this possible development, many are shifting to alternative medicines, via the Indian Systems of Medicine and Homoeopathy (ISM&H), which includes Ayurveda, siddha, unani, homoeopathy and therapies such as yoga and naturopathy.

Currently, there are over 680,000 registered ISM&H practitioners in the country, most of who work in the private sector.

Swati Biswas* tells IPS, “My husband was ailing for sometime and an operation was advised. But he contracted an infection in the nursing home and his operation was postponed.

“He never recovered after coming home and expired after two months. I spent thousands of rupees on medication for him to no avail. Now I go to a doctor of homeopathy for my problems. I’ve had enough of Western doctors and hospitals,” she added.

Meanwhile, a network known as the Indian Initiative for Management of Antibiotic Resistance (IIMAR) has been formed to promote awareness on this issue.

Asked about the need for such an organisation, Ashok J. Tamhankar, IIMAR’s national coordinator, told IPS, “In a scientific meeting in Bangalore in 2008 many of the participants realised that antibiotic resistance is increasing in India. This is happening because there’s no awareness about it among the stakeholders.

“The ignorance and callousness are at every level of the society – from care providers like doctors, to pharmacists, lawmakers, manufacturers and [even] the consumers. So a platform was created to spread awareness through a blog.”

The initial group had only a handful of people, but now, he claims, it has more than 1,000 active members and many more passive ones from different walks of life.

“Only passing laws is not a solution,” Tamhankar stated.

“It’s the people who have to solve their problems with the help of the law. This is particularly important in the case of antibiotics. It’s a delicate, personal, ethical, medical issue. We can’t live without antibiotics. What is needed is prudent use,” he added.

People also hint at an unholy alliance between pharmaceutical companies and doctors that results in over-prescription of antibiotics for ailments that could easily be treated without them.

Back in 2012, IIMAR reported that the Medical Council of India (MCI) had received 702 complaints of such over-prescription in 2011-12, of which 343 were referred to state medical councils.

“In 2010-11, MCI received 824 such complaints, following which it cancelled the registration of 10 doctors and warned four others,” IIMAR reported.

“Chemist and [drug] associations are not interested in curbing their volume of business and the [pharmaceutical] industry is also silent for the sake of their profit,” says Ghosh.

According to the consulting firm Deloitte, pharmaceutical sales in India stood at 22.6 billion dollars in 2012, with a predicted rise to 23.6 billion in 2013. Sales are expected to touch 27 billion by 2016.

Ghosh feels there should be “antibiotic protocols for all hospital, clinics and dispensaries and this should be displayed in each healthcare-providing agency [and] institution. There should be statutory warnings on each pack of antibiotics, highlighting the hazards of misuse.”

“Time has come to raise [our] voices against the irrational use of antibiotics,” he concluded.

*Not her real name

Edited by Kanya D’Almeida

By Martin Khor
GENEVA, Apr 10 2014 (IPS)

The growing crisis of antibiotic resistance is catching the attention of policy-makers, but not at a fast enough rate to tackle it. More diseases are affected by resistance, meaning the bacteria cannot be killed even if different drugs are used on some patients, who then succumb.

We are staring at a future in which antibiotics don’t work, and many of us or our children will not be saved from TB, cholera, deadly forms of dysentery, and germs contracted during surgery.

Martin Khor

The World Health Organisation (WHO) will discuss, at its annual assembly of health ministers in May, a resolution on microbial resistance, including a global action plan. There have been such resolutions before but little action.

This year may be different, because powerful countries like the United Kingdom are now convinced that years of inaction have cause the problem to fester, until it has grown to mind-boggling proportions.

The UK-based Chatham House (together with the Geneva Graduate Institute) held two meetings on the issue, in October and last month, both presided over by the Chief Medical Officer for England, Dame Sally Davies.

This remarkable woman has taken on antibiotic resistance as a professional and personal campaign. In a recent book, “The Drugs Don’t Work”, she revealed that for her annual health report in 2012, she had decided to focus on infectious diseases.

“I am not easily rattled, but what I learnt scared me, not just as a doctor, but as a mother, a wife and a friend. Our findings were simple: We are losing the battle against infectious diseases. Bacteria are fighting back and are becoming resistant to modern medicine. In short, the drugs don’t work.”

Davies told the meetings that antibiotics add on average 20 years to our lives and that for over 70 years they have enabled us to survive life-threatening infections and operations.

“The truth is, we have been abusing them as patients, as doctors, as travellers, and in our food,” she says in her book.

“No new class of antibacterial has been discovered for 26 years and the bugs are fighting back. In a few decades, we may start dying from the most commonplace of operations and ailments that can today be treated easily.”

At the two Chatham House meetings, which I attended, different aspects of the crisis and possible actions were discussed. In one of the sessions, I made a summary of the actions needed, including:

– More scientific research on how resistance is caused and spread, including the emergence of antibiotic-resistance genes as in the NDM-1 enzyme, whose speciality is to accelerate and spread resistance within and among bacteria.

– Surveys in every country to determine the prevalence of resistance to antibiotics in bacteria causing various diseases.

– Health guidelines and regulations in every country to guide doctors on when (and when not) to prescribe antibiotics, and on instructing patients how to properly use them.

– Regulations for drug companies on ethical marketing of their medicines, and on avoiding sales promotion to doctors or the public, that leads to over-use.

– Educating the public on using antibiotics properly, including when they should not be used.

– A ban on the use of antibiotics in animals and animal feed for the purpose of inducing growth of the animals (for commercial profit), and restrictions on the use in animals to the treatment of ailments.

– Promoting the development of new antibiotics and in ways (including financing) that do not make the new drugs the exclusive property of drug companies.

– Ensuring that ordinary and poor people in developing countries also have access to the new medicines, which would otherwise be very expensive, and thus only the very rich can afford to use them.

On the first point, a new and alarming development has been the discovery of a gene, known as NDM-1, that has the ability to alter bacteria and make them highly resistant to all known drugs.

In 2010, only two types of bacteria were found to be hosting the NDM-1 gene – E Coli and Klebsiella pneumonia.

It was found that the gene can easily jump from one type of bacteria to another. In May 2011, scientists from Cardiff University who had first reported on NDM-1’s existence found that the NDM-1 gene has been jumping among various species of bacteria at a “superfast speed” and that it “has a special quality to jump between species without much of a problem”.

While the gene was found only in E Coli when it was initially detected in 2006, now the scientists had found NDM-1 in more than 20 different species of bacteria. NDM-1 can move at an unprecedented speed, making more and more species of bacteria drug-resistant.

Also in May 2011, there was an outbreak of a deadly disease caused by a new strain of the E Coli bacteria that killed more than 20 people and affected another 2,000 in Germany.

Although the “normal” E Coli usually produces mild sickness in the stomach, the new strain of E Coli 0104 causes bloody diarrhoea and severe stomach cramps, and in more serious cases damages blood cells and the kidneys. A major problem is that the bacterium is resistant to antibiotics.

Tuberculosis is a disease making a comeback. In 2011, the WHO found there were half a million new cases of TB in the world that were multi-drug resistant (known as MDR-TB), meaning that they could not be treated using most medicines.

And about nine percent of multi-drug resistant TB cases also have resistance to two other classes of drugs and are known as extensively drug-resistant TB (XDR-TB). Patients having XDR-TB cannot be treated successfully.

Research has also found that in Southeast Asia, strains of malaria are also becoming resistant to treatment.

In 2012, WHO Director General Margaret Chan warned that every antibiotic ever developed was at risk of becoming useless.

“A post-antibiotic era means in effect an end to modern medicine as we know it. Things as common as strep throat or a child’s scratched knee could once again kill.”

The World Health Assembly in May is an opportunity not to be missed, to finally launch a global action plan to address this crisis.
(END/COPYRIGHT IPS)

Excerpt:

Livestock production has long been suspected as a key incubator of antibiotic resistance in the United States. Credit: Bigstock

By Carey L. Biron
WASHINGTON, Mar 27 2014 (IPS)

Pharmaceutical companies have overwhelmingly agreed to new U.S. government guidelines aimed at decreasing the use of antibiotics in the raising of livestock, new data shows.

In December, the U.S. Food and Drug Administration (FDA), the federal government’s main regulator for these sectors, unveiled a new, voluntary programme to reduce the use of “medically important” antibiotics, the hundreds of drugs considered important for human health."Any time antibiotics are used for routine disease prevention, that’s a sign that something else is wrong with the livestock system.” -- Sarah Borron

The agency targeted 26 of the world’s largest manufacturers of livestock antibiotics, requesting their compliance. On Wednesday, the FDA announced that all but one of those companies, accounting for more than 99 percent of the supply, had agreed to the new guidelines.

“As of March 26, [25 companies] have agreed in writing that they intend to engage in the judicious use strategy by seeking withdrawal of approvals relating to any production uses and changing the marketing status of their products from over-the-counter to use by [veterinary] prescription,” the FDA stated Wednesday.

“FDA is encouraged by the response thus far and will continue to monitor ongoing participation and provide public updates on a periodic basis.”

The only targeted company not to agree to the new guidance is PharmaqAS, a Norwegian manufacturer of drugs used on farmed fish. A spokesperson for the company told IPS that its products are only used to treat diseased fish rather than to promote growth in livestock, and Pharmaq “interpreted the proposed voluntary program not to be relevant for our products.” However, it is currently reviewing the FDA request.

The U.S. meat industry has come under increased criticism in recent years over the widespread practice of feeding low levels of antibiotics to healthy livestock over an extended period, as a way of forcing animals to put on weight more quickly. Motivated by surging reports of antibiotic-resistant “superbugs” around the world, public health officials have increasingly looked for ways to decrease this practice.

At base, the new guidance offers a simple tweak to labelling requirements for antimicrobial drugs intended for livestock. These 25 companies will no longer include reference to their drugs’ growth-enhancing potential on their labels, in effect outlawing the practice by farmers.

The use of antibiotics for truly sick animals will still be allowed, but only with a prescription from a registered veterinarian.

While public interest groups are supportive of the fact that U.S. regulators are finally taking action over growing antibiotic resistance, many are concerned that the FDA’s guidelines are too weak.

“We did some analysis of the drugs being affected by the guidance and found that of the drugs that will stop being used for growth promotion, 63 percent can still be used for disease prevention,” Sarah Borron, a researcher with Food and Water Watch (FWW), a watchdog group, told IPS.

“The problem is, that’s a very similar type of use. Farmers still give low doses of antibiotics to entire herds for long periods, and that still promotes the development of antibiotic resistance. Any time antibiotics are used for routine disease prevention, that’s a sign that something else is wrong with the livestock system.”

Concerns over the possibility of antibiotic resistance have been around almost since the discovery of antibiotics themselves. Credit: Bigstock

Some U.S. lawmakers are expressing similar concerns.

“This voluntary pro-industry approach is a step in the wrong direction,” Rosa DeLauro, a member of the House of Representatives, said when the plan was announced in December.

“Companies will either disregard the plan altogether or simply switch from using antibiotics for routine growth promotion to using the same antibiotics for routine disease prevention. For the good of public health, FDA should step up and implement tighter restrictions on antibiotic usage.”

DeLauro said that 80 percent of the antibiotics sold in the United States are given to healthy animals, often to “overcompensate for crowded and unsanitary conditions”.

23,000 deaths annually

Concerns over the possibility of antibiotic resistance have been around almost since the discovery of antibiotics themselves, a breakthrough that many say is among the most important of the modern age. Yet such reports have spiked in recent years.

While this resistance is a growing problem in countries on every continent, governments outside of the United States have taken more proactive steps. The European Union, for instance, has banned the use of antibiotics to fatten livestock since at least 2006.

Data from E.U. countries suggest that overall antibiotics use for livestock can be reduced fairly easily, through simple yet often cost-ineffective changes to farming practice.

The United States, meanwhile, has seen major outbreaks of food-borne illness with resistance in recent years.

In 2011, for instance, the U.S. company Cargill was forced to recall 36 million pounds of ground turkey, over concerns that it may have been contaminated with an antibiotic-resistant form of salmonella. Hundreds more became sick from similar infections this past October, reportedly traced to a chicken farm in California.

Also last fall, the Centers for Disease Control and Prevention (CDC), a federal agency, estimated that some two million people in the United States are getting sick from antibiotic-resistant infections every year, causing some 23,000 deaths. Further, the agency cautioned that those numbers were minimum estimates based on conservative assumptions.

In April, CDC director Dr. Tom Friedman told the U.S. House of Representatives that antibiotic resistance constitutes one of the country’s “most serious health threats”.

Livestock production has long been suspected as a key incubator of antibiotic resistance in the United States. Yet the FDA ultimately decided to make its new programme voluntary rather than mandatory.

The agency says it took this decision in order to speed up what would otherwise have been a long and likely contentious regulatory process. But analysts like FWW’s Borron say this is cause for concern.

“Whenever there’s voluntary guidance, we worry about whether companies will follow,” she notes. “In this instance, there’s the sense that the FDA has been working on something that the industry can accept.”

In this approach, the FDA appears to have been successful. Both the animal pharmaceuticals manufacturers and the meat industry appear to be backing the new guidelines, though some express some reservations.

“The response to FDA reflects the shared commitment of those who raise poultry and livestock to the judicious use of medicines for the care and well being of healthy animals,” Keith Williams, a spokesperson for the National Turkey Federation, a trade group, told IPS.

The pork industry, meanwhile, is warning that the new guidelines will mean “real changes” for producers. Liz Wagstrom, the chief veterinarian at the National Pork Producers Council, told IPS that “farmers will need to work with their veterinarians to come up with alternative strategies to keep their animals healthy.”

Pharmaceutical manufacturers will now have three years to phase in the new labelling requirements.