The capital has a superbug problem

As the national capital, Delhi may be India's seat of power, but it doesn't have complete control over its own health--an aspect that is frequently affected by the actions of its neighbours. Be it the thick smog that envelops the capital and brings the life of its residents to a grinding halt during winter, or the hidden manner in which the city ignorantly consumes antibiotic-treated food and water. Similarly, Delhi may not be home to pharmaceutical manufacturing factories, but neighbouring states with such facilities often dump waste into common water bodies. This cyclical fate is unlikely to change, say experts, until the states it shares borders with straighten up their act and have their own action plans in place.

Delhi’s unique predicament calls for unique solutions when it comes to antimicrobial resistance (AMR), a crisis identified as one of the top ten global threats to humanity. Antibiotics, our defence strategy against harmful microbes causing life-threatening infections, have disturbed the balance within and without. After the World Health Assembly adopted a global action plan on AMR in 2015, India followed in 2017, and Delhi became the third state to launch its plan in January 2020. 

In alignment with the national action plan, Delhi’s own has identified six strategic objectives: awareness and education; laboratory network for early diagnosis and surveillance; infection prevention and control; optimising antibiotics’ use; research; and, lastly, collaboration between national and international NGOs to implement it at the grassroots level, says Dr Sangeeta Sharma, nodal officer for the Containment of AMR for the Government of the National Capital Territory (NCT) of Delhi.

Since AMR affects all spheres of life, it is addressed with a One Health approach, where the health of humans, animals, plants, and environments is taken into account in a unified manner. This has posed a bureaucratic challenge--it requires the health, food, animal husbandry, environment, and industry ministries to work together.

Progress report

As part of the capital’s action plan, doctors, pharmacists, and nurses have undergone training programmes to build capacity, and students and teachers are being educated about antibiotic misuse and resistance. “Often, antibiotics are prescribed ‘just in case’ for conditions like coughs, colds, upper respiratory illnesses, and acute watery diarrhoea, which are predominantly viral and do not require these medicines,” says Dr Sharma, who is also the president of the Delhi Society for Promotion of Rational Use of Drugs (DSPRUD). “In 2022, we launched an integrated diagnostic and antimicrobial stewardship programme to improve diagnosis and reduce unnecessary antibiotic prescriptions. So far, we have trained more than 1,000 doctors, 1,600 nurses, and 450 clinicians.”

When it comes to pharmacists, the focus has been tackling self-medication by buyers and preventing over-the-counter sales of antibiotics. “The DSPRUD also undertook awareness drives for the schools urging people to not use medicines without a doctor’s go-ahead and not to buy antibiotics (especially HI1 drugs) over the counter without prescription,” Dr Sharma adds.

Food is not something that the Union Territory produces daily, and neither is most of its poultry. All of it comes from the states surrounding it.

The plan calls for a particular focus on school students, encouraging and training them to spread the word among the general public. “We wanted children to talk to their parents and keep tabs on antibiotic use within their families, as we saw in the case of the firecracker campaign in Delhi, where there was a deeper penetration of the message,” says Dr Ravindra Aggarwal, chief coordinator, AMR, Government of NCT of Delhi.

Over two years, awareness campaigns organised in collaboration with the WHO, DSPRUD, and the National Centre for Disease Control have reached out to 900,000 students and 3,500 teachers. Most recently, a partnership with the non-profit organisation ECHO India enabled over 250 teachers to be trained, across October and November. Discussions among educators have been centred on the identification of misuse and its prevention, with the aim that the teachers will spread knowledge among their students and communities, Dr Aggarwal added.

Also read: Inside Tamil Nadu's battle against AMR

Unique predicament

 “As a coastal state, Kerala prioritises aquaculture. Whereas Delhi lacks a coast or farmland, thus relying on neighbouring states for food supplies. In that sense, it is a consumption state. Food is not something that the Union Territory produces daily, and neither is most of its poultry. All of it comes from the states surrounding it,” says Dr Robin Paul, a senior veterinarian and consultant at the Food and Agriculture Organization.

The city’s multi-tiered healthcare infrastructure also presents unique challenges. The Union Territory houses a diverse range of healthcare settings, from sub-centres and primary health facilities to super-specialty centres, each with their distinct problems and varying complexities. “The use of antibiotics varies greatly, from minor surgeries to transplants. To preserve the efficacy of antibiotics in life-threatening operations, we need to know which antibiotic to use in the first place,” Dr Sharma adds. The formulation of Delhi’s action plan involves 120 stakeholders from 17 different levels of healthcare to address this multi sectoral and multidisciplinary challenge, she explains.

Also read: Kerala is winning the battle against AMR and how!

Niggling challenges

The COVID-19 pandemic caused a shift in priorities, Dr Aggarwal says, causing AMR to be put on the backburner. “Afterward, we tried but could not set the desired tempo, as leadership at the level of the Directorate General of Health Services (DGHS) in the Delhi government changed.”

Alongside policy, regulation remains a challenge. The Food Safety and Standards Authority of India (FSSAI)’s decision to expand its list of flagged antibiotics, and the intent to tighten norms on the maximum residue levels of antibiotics in animal products, has emerged as a silver lining; these new norms will be effective from April 2025.

Dr Vijay Pal Singh, a veterinarian at the Council of Scientific & Industrial Research--Institute of Genomics and Integrative Biology (CSIR-IGIB), calls attention to the use of antibiotics in animal care--an alarming issue that is understudied. The former joint director at the FSSAI highlights a study conducted at the CSIR-IGIB, which found that dogs in the university's vicinity were completely resistant to the most commonly used antibiotics. Yet, these drugs continue to be rampantly prescribed to animals in veterinary care. “This research, as well as awareness and training programmes to avoid the use of antibiotics in animals, is immensely lagging,” Dr Singh says.

Part of the problem stems from the lack of an established and accepted term for AMR-related fatalities. “I may die from multiple organ failure or another condition, but it will not be marked as AMR. It is an orphaned issue that cannot be quantified or named, and thus, the urgency of the threat is overlooked,” Dr Singh adds.

The veterinarian also points to the absence of a unified platform to share data. “One Health is an entirely completely academic exercise at the moment. Each agency--the FSSAI, Export Inspection, and CDSCO--has its own regulations and laboratories.” Thus, these agencies tend to work in silos. Tackling AMR calls for mandatory surveillance to make informed decisions--which could be facilitated by a consolidated platform that keeps various stakeholders apprised of developments. “For instance, if a certain food item contains too many antibiotics, human doctors should be aware [of this] so that they can adjust their prescriptions accordingly,” Dr Singh explains.

As the rolling out of the second National Action Plan nears, Dr Sharma says that firm guidelines will be established. “However, implementing the plan’s strategic objectives is a monumental task. The government alone cannot do it. All sectors, including NGOs, must leverage each other’s strengths to make meaningful progress,” she says.

{{quiz}}