Addressing the Next Pandemic in India

By Manjit Singh and Michael Hodin

AS India struggles with the growing Omicron wave of COVID-19, another pandemic is gathering force that could someday be equally lethal. While India — and the rest of the world — was caught flat-footed by COVID-19, there is still time to prepare for this looming public health threat, if political and healthcare leaders act now.

Antibiotics have been hailed as the wonder drugs of the last century, helping nations conquer infections that once killed people in the millions. Yet over time, bacteria build up resistance to these wonder drugs, rendering them less effective and making new infections more deadly — a biologically dictated race for survival that leads to antimicrobial resistance or AMR.

How serious is the problem? According to a new Lancet report, AMR kills an estimated 1.27 million people every year. The same report found there were nearly 22 AMR-attributable deaths per 100,000 annually in South Asia, the second highest of all the regions examined. Already, more than 58,000 newborns in India succumb to neonatal sepsis each year. By 2050, the total annual death toll from AMR could hit 10 million globally, nearly double the number of COVID-19 fatalities since the pandemic began nearly two years ago.

Historically, new antibiotics were developed to protect people from mutating bacteria and the resulting infections. Today, the pipeline for antibiotics is nearly empty, a result of poor government policy, lack of awareness and skewed marketplace incentives.

Inappropriate use and overuse of antibiotics accelerate this process, making it harder and harder to defend against infections. Between 2000 and 2015, consumption of antibiotics more than doubled in India. Further, there are concerns that without appropriate policy action, global usage is projected to continue to increase by 2020, especially in LMICs. A report by the Public Health Foundation of India found that many prescriptions are handed out for illnesses that can’t be treated by antibiotics at all. Even worse, antibiotics are routinely sold over the counter in India without a valid prescription.

A recent report by the Global Coalition on Aging found that India still has room for improvement when it comes to addressing AMR. Beyond the misuse of antibiotics, the report also cites a lack of funding both for AMR research and for implementation of India’s National AMR Action Plan (NAP), which expired at the end of 2021.

There are, however, several important steps India can take to alleviate the deepening AMR crisis and position itself at the front of tackling the AMR challenge.

First, the Indian government needs to fully fund the core plans of the NAP and ensure the plan is being properly implemented. As part of this effort, the government must improve plan oversight, promote greater coordination among stakeholders, and strengthen antibiotic stewardship programs to limit inappropriate use. Further, as only three states (Kerala, Madhya Pradesh, and New Delhi) have developed standalone action plans to date, the national government should compel all state governments to develop their own AMR action plans. In the coming year, India should also continue its work to develop its new National Action Plan, ensuring the new document is robust and comprehensive, yet practical and actionable.

Second, the government should build on current efforts to raise awareness by running large-scale campaigns to educate both care providers and patients about the growing danger of AMR. By educating providers about the dangers of overprescribing and the tradeoffs associated with inappropriate prescribing, and by informing patients about the need to use antibiotics more judiciously, India can make important strides in helping to optimize existing antimicrobials, while also curbing rates of resistance.

Third, India must work to strengthen infection prevention and control by improving water, sanitation, and hygiene (WASH) infrastructure and behavior, particularly in rural areas. Antibiotic waste from inadequately treated sewage (from human, veterinary, agricultural, manufacturing, and other sources) presents another serious concern that could also exacerbate AMR, and India should work to formulate a more effective regulatory framework to manage these issues.

Further, to play their part, more Indian manufacturers could consider adopting the AMR Industry Alliance’s recently published AMR standard, a framework for good environmental management of the production of antibiotics, and science-based discharge targets. Additionally, the government should integrate environmental criteria, including AMR-relevant considerations, into its process for evaluating vendors and suppliers for contracts and tenders, to encourage sustainable manufacturing practices more in line with Nordic countries. Finally, Indian judicial bodies, like the National Green Tribunal, can continue to compel state and federal agencies to enforce existing manufacturing and discharge standards.

In the coming years, India also has the opportunity to show its global leadership in one area critical to fighting AMR: antibiotic innovation. India has a rapidly growing economy and a strong corps of trained scientific researchers, which it can leverage to spur antimicrobial development. To help achieve this, the government should create a national innovation fund, modeled off the successful CARB-X and AMR Action Fund programs. The government can also pass regulatory reforms to expedite approval of newly developed antibiotics. Moreover, the Indian government can continue to pursue AMR research partnerships — like the one recently forged with the United Kingdom — to develop the next generation of treatments to defeat-drug resistant infections.

AMR has the potential to rival COVID-19 in terms of death and devastation. But this future path is not inevitable. India should act now to curb overuse of current antibiotics and restock the pipeline with new innovations that could emerge as the wonder drugs of the 21st century.

  • Manjit Singh is the director of Corporate Sustainability at Centrient Pharmaceuticals and a member of the AMR Industry Alliance. Michael Hodin is Ph.D. is CEO of the Global Coalition on Aging

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