August 19, 2010
A study published in the Lancet on August 11th has been causing a stir in India and abroad, for a range of reasons. Leading government figures have expressed dismay that the paper suggests that people who travel to India for surgeries should be concerned about acquiring bacterial infections that are highly resistant to treatment because of genes like New Delhi metallo-lactamase 1 (NDM-1). On the other hand, many doctors have said that this should be a wakeup call for India to look inward, and improve antibiotic use and hospital infection control policies.
The paper, titled Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study, is co-authored by researchers from six institutes in India, as well as others in the UK, Pakistan, Sweden and Australia. Interestingly, however, the Indian press frequently refers to it as a UK study written by UK scientists. The researchers found isolates of NDM-1, conferring multidrug resistance (including resistance to reserved drugs such as carbapenems), in E. coli and K. pneumoniae from Haryana, Chennai, the UK and other sites in India and Pakistan. Many of the patients from the UK had recently traveled to South Asia. The paper cautioned against encouraging UK patients to seek care in India, suggesting that this could be costly for the country in the long run.
Complaints from the Indian healthcare community have centered on the fact that NDM-1 is not necessarily from India. The Indian Council of Medical Research (ICMR) Director protested statements from the UK about the dangers of getting an operation in India specifically, noting that similar resistant strains have been reported from other countries. Professor NK Ganguly, former director of the ICMR and the National Working Group chair for GARP-India, agreed, telling the Times of India that it is wrong to say that NDM-1 comes from India, since similar strains have already been discovered in Europe. The first author of the paper, a research student at the A.L. Mudaliar Post-Graduate Institute of Basic Medical Sciences, told the Press Trust of India, That it was transmitted from India is hypothetical. Unless we analyze samples from across the world to confirm its presence, we can only speculate. He continued that he was worried by the spin that has been given to the article, and had meant only to show its prevalence in India. He said that some of the interpretations made in the article were added without his knowledge.
Health Secretary Ms. K Sujatha Rao expressed shock that the Lancet published what she called an unscientific article with a conflict of interest (due to funding from pharmaceutical companies). Some Rajya Sabha members have even called the study a conspiracy, by pharmaceutical companies and European hospital chains, to damage medical tourism in India.
Additionally, some Indian doctors have argued that this discovery is being blown out of proportion. One doctor told the Times of India that multidrug resistant bacteria have been encountered at the All India Institute of Medical Sciences, but can sometimes be dealt with successfully using various drugs. Another was quoted by the Hindustan Times that NDM-1 is a false alarm, since he has not seen any cases in his hospital. The doctor went on to posit that nosocomial infections are far more common in Britain and the West than in India.
However, the lack of reliable data on nosocomial infections in India (and elsewhere) makes it difficult to substantiate such claims. One large study conducted by the International Infection Control Consortium from 2004-07 in hospitals in seven Indian cities found that, compared to CDC National Nosocomial Infections Surveillance figures from the U.S., catheter-related bloodstream infection and ventilator-associated pneumonia rates were higher in India than the U.S., whereas catheter-associated urinary tract infection rates were lower in India. The majority of studies on nosocomial infection rates in India are limited to a single hospital or ward, making this study more reliable than most.
In contrast to the dismay expressed by many here, a number of doctors have instead said that this should be a wakeup call for the Indian healthcare community. The ICMR director was sympathetic towards this view, saying that the irrational use of antibiotics is a problem in India, and there is a need for an Indian hospital-infection control registry.
Hopefully the Lancet paper will bring attention to the issue, and spur scientific discussion and further research. Viable, virulent bacteria that are resistant to commonly used antibiotics, once evolved, are a threat to populations everywhere. Instead of pointing fingers, efforts should be made to create reliable national and international surveillance systems. This will bring some hard data to the debate, as well as arming doctors and policymakers with the information they need to prevent outbreaks.
Alice Easton is the India Country Coordinator for the Global Antibiotic Resistance Partnership (GARP) at CDDEP.
