Antibiotics stewardship cannot be the only route ahead, Abdul Ghafur argues

As the architect of the Chennai Declaration, possibly the first-ever attempt to draw up a roadmap to tackle antimicrobial resistance (AMR) in India, Abdul Ghafur who has had a ringside view of the march of deadly resistant bacteria as an infectious diseases specialist, has watched the progress of the movement over the last decade. And he is convinced that the time is ripe to tread the path not taken yet in handling AMR in the country. Citing multi-sourced global evidence to bolster his readings of the situation, he says the roadmap to handling AMR should be changed, for the developing world at least, and for India certainly. Antibiotics stewardship cannot be the only route ahead, he argues. Equally important, he says, is improving sanitation, and involving the common people in battling deadly resistant bacterial infections, in a chat with Ramya Kannan.

India drew up its national plan of action for countering AMR in 2017. What has been the progress, if any in the last couple of years?

India released the AMR action plan in 2017, two years after the WHO global AMR action plan, and we wanted all the states and UTs to prepare the state action plan, start implementation and succeed to an extent, by now. However, only two states have the State Action Plans in place - Kerala and Madhya Pradesh. What about the other states, and Union Territories?

Also, when you look at the national action plan – it is a cut and paste job of the WHO's global action plan, and the state action plan is quite similar to the national plan. And yet, it is my contention that no state needs more than a week to prepare an action plan on paper. So, at best, we can talk about limited success in formulating the action plans.

Why have we come to a state of ‘limited success?’ What drove us here?

The AMR action plans we have currently are bound to fail. And that is because the way we have gone about handling this challenge. There are the two types of challenges - the simple challenge and the complex challenge.

A simple challenge, for example, could be a technical problem. You call in people, experts, form a committee to find a pathway, form guidelines, and implement them. AMR, however, is a complex challenge - it is not just a technical or scientific challenge, but also a social, economic political challenge. However, when we started implementing or finding solutions for this problem, we made the mistake of approaching it as a simple challenge.

With other complex challenges, whether it is global warming or political conflicts between countries, war, or poverty, the world has worked to find dynamic solutions incorporating the political and social complexities involved. While AMR is a typical example of a complex challenge, we’ve still taken too few tracks to address the problem. On the one hand, there is the WHO global action plan and that is the most systematic implementation process happening across the world. At the same time, there are other movements, NGOs, the industry, working independently or collaborating with other organisations. The AMR industry alliance is on - where people are developing new antibiotics and they want to fast track development research and licensing for new antibiotics. That is probably one area, progressing comparatively better than the other components. If you have money, and time, the development of new drugs can happen.

Now, the WHO global AMR Action Plan was released in 2015. Developed countries including France, UK, and America have already implemented it, but in a sense they have a different kind of challenge. How many developing nations have done so? The key is to tweak the global plan for regional, national and sub national. Our prototype is India, which has a national plan and that is good, but how many states have formulated the state action plan, and how many have implemented it? In Kerala, there has been some discussions very early on, but we need to evaluate just how well the plan is being implemented. The only other state - Madhya Pradesh - announced its policy just about two months ago.

One of the ways to make sure more states comply is to get the Union Health Ministry to drive the push, so more states formulate their own action plans. In fact in the first meeting to formulate state plans that the WHO called for, along with the government, not even 50 % of the states turned up.

Let’s look at the framework now. There are three committees in Delhi: Intersectoral Committee which is chaired by the Union Health Secretary, with Secretaries of other departments; and then there's a Technical Advisory Committee that works with senior government officials such as the Drug Controller General of India, and a few experts (including myself); and there is a Scientific Committee, which is only for doctors, and experts. This group forms the guidelines and passes it over to the Technical Advisory Committee, which then advises the Intersectoral Committee. The Technical Advisory Committee has not met for a year, so no significant recommendation has been passed on to the Intersectoral Committee. So the crucial change of path that is required now has not been effected.

The thing is that the world does know how to tackle complex challenges in general, what is stopping us from employing those tactics for AMR?

What is this course correction you are recommending that the nation take now?

If you had read articles written back in 2010, people like me sincerely believed that AMR was caused primarily by the misuse of antibiotics by the medical community. We all wrote a few lines about infection control, but 90% of our articles, research papers was about irrational antibiotics usage. I did not write about environmental sanitation. I did not write about most of the things that I know today, because that the concept has changed over the last 10 years. At that time, we thought that antibiotic stewardship was the most important component in tackling AMR, along with infection control, and then made a mention of the importance of sanitation. Now if you ask me, what is the most important component of tackling AMR, I will say in a developing country such as India – it is sanitation. I will put sanitation right on top, then I will put in infection control, and then, antimicrobial stewardship, rational antibiotics usage - whether at the hospital or over the counter.

Why? Thanks to scientific evidence that has emerged, since, and changed our perspective. A commentary published in Antibiotics, an open access journal, recently showed that AMR rates were found ‘positively correlated with higher temperature climates, poorer administrative governance, and the ratio of private to public health expenditure.’ When a more complex analysis was done, then better infrastructure (e.g., improved sanitation and potable water) as well as better administrative governance (e.g., less corruption) were strongly and statistically significantly associated with lower AMR indices. And this is significant: the comment stated that ‘Surprising, and contrary to most current beliefs, antibiotic consumption was not strongly associated with AMR levels. This empirical evidence implies that contagion, rather than antibiotic usage volumes, is the major factor contributing to the variations in antibiotic resistant levels across countries.’

Yet another paper published in the September issue of the Journal of Antimicrobial Chemotherapy concluded that the prevalence of infections by antibiotic resistant bacteria is inversely proportional with the Gross National Income per capita, at the global level. Therefore, it went on the urge that public health interventions designed to limit the burden of AMR also consider determinants of poverty, inequality, especially in lower middle income, and low income countries. A 2018 paper available now in Pubmed, by Bürgmann H. et al says water and sanitation represent a key battlefront in combating the spread of AMR.

Put simply, the studies showed the clear link between higher AMR rates and poor hygiene and sanitation, and poorly administered regions, and lower incomes. So we need to handle all these social and economic determinants that seem to be pushing up our infection rates.

What of antibiotics stewardship then? What place does it have in the revised scheme of things?

In developing countries such as India, the resistance rate is already high. You can't pull back the rate even if you manage to rationalise antibiotics usage in all Indian hospitals and regulate over the counter sales. Antibiotics stewardship alone may not make any significant change in the resistance scenario, because the bugs are already out there, spreading in hospitals at a high rate and spreading in the community as well. There is no doubt antibiotics stewardship is a major component of tackling AMR, especially as a long term strategy, and to safeguard new antibiotics introduced into the market.

In these circumstances, you need to give preference to preventing the spread in the hospital by improving personal hygiene and strengthen the community by improving sanitation. Our National AMR Action Plan must read these elements in now. Currently, only a small part mentions the role of sanitation.

We should now place sanitation as the most important component of fighting AMR, armed with all the evidence. Awareness about personal hygiene, washing hands with soap and water the right way, for instance will go a long way in promoting sanitation. If we don't make these changes now, the same saga will continue, and the Global Action Plan too will fail. After all, AMR is not immune to the Butterfly Effect. Globally we are all interconnected – high AMR rates in Chennai, for instance, will have an impact on Australia and London, why, even the Arctic regions. We will have to, of course, continue advocating restraint in antibiotics usage, and infection control in hospitals, because this challenge, as I said earlier, is complex and needs a multi-pronged approach. But we will have to rejig our priorities.

What is the course of action now, as far as addressing antibiotics resistance goes?

At the moment there is one WHO action Plan. That should be our base, but developed and developing nations should conduct their own background analyses and tweak that plan to suit their specific local requirements. India should tweak its own national plan to address the more urgent issues, and remember that with a challenge as dynamic as AMR, there needs to be fine tuning periodically. It is also important to make sure states also engage similarly with their local issues and draw up a state action plan suitable for themselves.

While the WHO can provide handholding and technical support, the government of each nation needs to drive this AMR challenge itself, leading from the front.

There needs to be some demonstrable political intent to thrash this issue out, reflected by equally robust field level implementation by multiple stake holders. Putting people at the centre of this fight is important, especially if we need to ameliorate the social and economic contributors to contagion.