Kerala first state to act on antibiotic immunity, a public health crisis

Staphylococcus aureau Magnification 20,000

  • The state of Kerala has launched the Kerala Antimicrobial Resistance Strategic Action Plan (KARSAP) to deal with the issue of rising resistance to important drugs.
  • Through an end-to-end programme that involves education and prevention, the state hopes to deal with the issue of antimicrobial resistance, which makes many life-saving drugs ineffective.
  • With Kerala Government taking the lead, it is hoping that other state administrations will also follow suit.

In a significant move for the public health sector, Kerala has become the first state in India to launch an action plan to combat the growing cases of antimicrobial immunity, arising primarily from irrational use of medicines and excessive antibiotics used in livestock and poultry.

Antimicrobial Resistance (AMR) is a global health problem but less addressed in developing countries like India. With the state introducing the Kerala Antimicrobial Resistance Strategic Action Plan (KARSAP), it is also a call for the rest of the country to address the crisis.

The World Health Organisation (WHO) defines AMR as “the ability of a microorganism (like bacteria, viruses, and some parasites) to stop an antimicrobial (such as antibiotics, antivirals and antimalarials) from working against it. As a result, standard treatments become ineffective, infections persist and may spread to others.” Basically, with irrational usage of antibiotics the medicines become ineffective to cure infections.

In the larger perspective, antibiotic residues affect the environment negatively by polluting water sources and soil through which it can enter in to the food chain and harm the ecosystem balance.

Unveiling KARSAP, Kerala Chief Minister Pinarayi Vijayan called for the rational use of antibiotics. “Self medication of people has turned out to be a public health hazard. Antibiotics are life saving drugs, inappropriate use will make them inefficient for even smaller infections. Through this plan, the health department should ensure that the entire medical fraternity, including retail pharmacies and the general public use these medicines rationally,” he said.

India among world’s largest consumers of antibiotics for human health. Irrational use of over-the-counter medicines could cause resistance against life-saving antibiotics. Photo by Maksym Kozlenko/Wikimedia Commons.

Kerala Health Minister K.K. Shailaja said that the plan will be implemented with the help of the health, animal husbandry, fisheries, agriculture and environment departments. “AMR harms our ecosystem as well as the human and animal health. KARSAP is an advanced step in Kerala’s health sector, we wish other states also follow an action plan to tackle this major public health and environmental hazard,” she said.

Awareness is the first step 

According to the plan the state will be first focusing on providing awareness and understanding of AMR through effective communication, education and training. That includes training programme for farmers, veterinarians and fisheries professionals. “Proper surveillance across different sectors, human, animal/food and environment sector, is another focus of the plan. Rationalise the use of antibiotics in use in health, animals and food; continuous research on AMR; banning of certain medicines as growth promoters in poultry farming, aquaculture, etc., will be the initial steps in the plan,”  a senior official at the health directorate in Kerala told Mongabay-India.

The action plan was drawn by incorporating different sectors of health department and with the technical support of the WHO. Medical colleges, hospitals, pharmaceuticals, laboratories, agriculture, fisheries and animal husbandry departments will be incorporated in the action plan.

Amit Khurana, programme director, food safety and toxins programme at Centre for Science and Environment, an environmental NGO, told Mongabay-India that it is necessary for each state to have an action plan against AMR along with a national policy. “Since food, agriculture, animal husbandry, health fisheries etc. are state affairs, each state should have a policy. AMR is a major public health concern, people should be given proper awareness about it,” he said.

He also pointed at environmental dimensions of AMR which can badly affect the ecosystem. “The effluents from farms, hospitals, laboratories can easily reach water and soil. Which can affect our food chain. Basically we become nonreactive to any antibiotics. We will not be able to prevent or cure even small infections,” he said.

Medicines can make their way into soil, water and the environment  

A report by Kerala’s Directorate of Medical Education (DME) states that per year Kerala consumes medical drugs worth around Rs. 20,000 crores (Rs. 200 billion), with antibiotics making up 20 percent of the total drugs consumed.

“Poultry farmers in Kerala also use a variety of antibiotics either as growth promoters or for controlling infections. Many prescription medications used for human and animal health ultimately find their way into the environment and can affect the health and behaviour of wildlife,” the report says.

Waste from hospitals, households, municipal sewage treatment plants, animal farms, land application of animal wastes and slaughter houses can accumulate antibiotic contents in soil and water sources, says the report.

The report also quotes a Science Daily article which states, “Many of the more than 4,000 prescription medications used for human and animal health ultimately find their way into the environment. As these chemicals make their way into terrestrial and aquatic environments, they can affect the health and behaviour of wildlife, including insects, fish, birds and more.”

Reports indicate that the poultry industry uses antibiotics as a growth promoter. Photo by Amrithraj/Wikimedia Commons.

A surveillance study was conducted by Thiruvananthapuram General Medical College (GMC) between January 2017 and August 2017 for infections of public health importance namely blood stream infection (BSI), skin and soft tissue infection (SSTI), respiratory tract infection (RTI) and urinary tract infection (UTI) as well as six pathogens of public health importance (Acinetobacter spp., E.coli, Klebsiella spp., Pseudomonas aeruginosa, Staphylococcus aureus and Enterococcus spp.).

Based on the microbiological study on samples collected, it was identified that, “extended-spectrum beta-lactamases (ESBL, enzymes produced by certain types of bacteria) production and carbapenem (a highly effective antibiotic) resistance was found upto varying degrees in E. coli, Klebsiella spp., Pseudomonas aeruginosa and Acinetobacter spp.”

The report also says that clinical isolates studied at the Rajiv Gandhi Centre for Biotechnology (RGCB), Thiruvananthapuram, Kerala also identifies resistance to many more drugs. “Out of 109 clinical strains of Acinetobacter spp., a majority were resistant to penicillin (95.4 percent), ceftriaxone (94.5 percent), ceftazidime (94.5 percent), cefepime (87.2 percent), gentamicin (86.3 percent) and tetracycline (81.6 percent),” it says. These studies pushed Kerala to launch its strategic plan to tackle AMR.

According to Union Ministry of Health and Family Welfare (MoHFW), India is among the nations with the highest burden of bacterial infections. A report of the ministry states that 410,000 children, aged five years or less, die from pneumonia in India annually, accounting for almost 25 percent of all child deaths in India. The crude mortality from infectious diseases in India today is 417 per 100,000 persons. AMR is major public health threat in the country, says the report.

The report also observes that resistance is not limited to the old and frequently used threats. “There has also been a rapid increase in resistance to the newer and more expensive drugs, like carbapenems. Available data indicates rising rates of AMR across multiple pathogens of clinical importance,” the report says.

Antibiotic use in animals, affects ecosystem and food chain

AMR problem is not limited to clinical or hospital setting.  It raises a larger concern involving food animals, livestock as well as environmental contamination.  In 2012, India manufactured about a third of the total antibiotics produced globally. As per MoHFW report a major amount of it were aiming at livestock and poultry.

With regards to consumption of antimicrobials in food animals, India accounts for three percent of the global consumption and is the fourth highest in the world. Increased trend of use of antibiotics for non-therapeutic purposes like growth promotion in livestock and food animals also identified a major reason for AMR.

Antibiotic residues in dairy products has been raised as a major public health concern by National Dairy research Institute in Haryana. But there are no substantial studies done in India to tackle the issue.

A report by the Centre for Science and Environment points to large-scale unregulated use of antibiotics as growth promoters in poultry industry. In a local study done by CSE’s Pollution Monitoring Laboratory (PML), it says that 40 percent of the chicken samples had antibiotic residues and more than one antibiotic was found in 17 percent of the samples.

Though compared to livestock and poultry the antibiotic usage in aquaculture is less, that was also a concern. “Amount of antibiotics used in fisheries may be much smaller in quantity than that used for terrestrial, intensive livestock rearing, the major problem is that more antibiotics which are clinically important in humans finds use in the aquaculture sector,” says the MoHFW report.

Amit Khurana of CSE points out that “resistant bacteria in chicken droppings can easily get transferred to consumers and handlers. They enter into environment, which is a huge concern. This an issue with long term effect.”

The WHO backgrounder on AMR observes that many bacteria carried by animals are antimicrobial resistant which cause disease in humans. It also adds that “these bacteria, which are frequently antimicrobial-resistant, can contaminate our food supply from farm to fork, such as through slaughtering and processing. Fruits and vegetables may also be contaminated by such bacteria at the farm or later through cross-contamination.”


Banner image: Bacteria escaping destruction by human white blood cells. Photo by NIAD/RML.

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