This wonderful interaction session with Dr. Ghafur was dedicated to understanding the complexities of the Antibiotic Resistance (hereafter, AR) saga.
As opposed to the popular belief that the extent of antibiotic consumption solely directs the development of antibiotic resistance, Dr. Ghafur asserted that the type of antibiotic, the duration and dosage of its consumption, and the type of bacteria, all play a key role.
He emphasised that factors like large population, socio-economic disparities, severe sanitation related issues, etc. make India’s antibiotic usage related challenges very different from those of the western countries. Dr. Ghafur explained how many Indian medical societies, realising the consequent need for India’s own antibiotic policy, came together to draft a joint recommendation in 2012 on how to tackle AMR in India in the form of the Chennai Declaration, with the primary aim of supporting the then government to effectively reimplement the National Antibiotic Policy of 2011.
He then put forth a global statistical picture of AR, asserting that about 70% of the antibiotic usage is in animal husbandry. Of the remaining 30%, over-the-counter use accounts for about 15%. Even if half of the remaining consumption is based on irrational prescriptions, it equals to just 7.5%, which is relatively a very small percentage of the total antibiotic resistance burden. Hence, Dr. Ghafur emphasised the need to prioritise educating the public, and not just the doctors, about the dangers of irrational use of antibiotics along with the need for proper sanitation measures, the lack of which worsens the AR crisis.
Dr. Ghafur believes that antimicrobial resistance (AMR) is a very complex challenge and requires complex solutions. In addition to counselling patients to finish their prescribed antibiotic courses, over the years, doctors have reduced the duration of these courses. While it may take several years or decades to ban antibiotic overuse and even growth promotional use in animal husbandry, there is an urgent need for people/teams like us to bring about alternative scientific solutions to combat AR, and AMR in general, asserted Dr. Ghafur.
He stated that we have essentially run out of antibiotics to treat severe bacterial infections and until new antibiotics are developed against multidrug resistant and pan resistant bacteria, combination therapy is the only way out, though it also increases the cost of treatment.
Dr. Ghafur added that while COVID-19 is killing people worldwide, it is also an excellent opportunity for activists and experts to discuss about AR, a silent killer behind the ongoing pandemic, (due to the extensive use of antibiotics to treat COVID-19 related secondary bacterial infections), and even AMR, because people now respect microbes and understand the importance of infection control through simple hygienic measures like washing hands properly. In this sense, Dr. Ghafur regards COVID-19, and other viral outbreaks, an indirect blessing, and very rightfully so!
While there would always be some concerns with regards to synthetic biology and genetics, in general, Dr. Ghafur believes that we, as practitioners of science, can ensure its development only by continuing to delve into its depths, albeit responsibly and while taking all necessary precautions.
Dr. Ghafur concluded by emphasising that our project idea is very good and, if successfully implemented in countries like India with a huge poultry farming industry, it could prove to be extremely useful in reducing the multidrug resistant bacterial contamination of the environment. He remarked that what youngsters like us are doing, by developing such scientific methodologies and practical solutions, could go a long way in combating AMR globally.
The Root Cause of Antibiotic Resistance:
Dr. Ghafur started by first clarifying a common misconception that the probability of occurrence of antibiotic resistance (hereafter, AR) is governed simply by the extent to which a certain antibiotic is consumed; the type of antibiotic, the duration as well as the dosage of its consumption and, most importantly, the bacteria in question - all equally influence the probability of development of AR in humans (animals, in general).
He added that previously doctors used to counsel their patients that if an antibiotic is prescribed to them, they must finish the course because if they don’t, the bacteria would become resistant and the drug may not be effective in the future. While the counselling is still very much prevalent and pertinent, over the years, the duration of the prescribed course has come down significantly. The lower the dosage, but the higher the consumption of the antibiotic, the more the chance for a bacteria to become resistant. Hence, it’s not the overuse but the misuse of antibiotics that leads to resistance, asserted Dr. Ghafur.
The Chennai Declaration:
Dr. Ghafur has been an integral part of the formulation of the Chennai Declaration and he briefed us about how it actually came into being. He remarked that, in India, the National Antibiotic Policy was put out in 2011 but there was no serious effort for its implementation in the country then. So, many medical societies of india, like the infectious diseases society, the surgical society, more than half a dozen other medical societies, along with NABH, ICMR, Drug Controller General of India and many other stakeholders, came together to draft a joint recommendation on how to tackle AMR in India in the form of the Chennai Declaration which was published in 2012 and submitted to the then government of India. This helped restart discussions at the highest level with multiple meetings held on how the recommendations could be implemented with the Union Health Ministry.
Dr. Ghafur justified the need for India’s own antibiotic policy by stating that India is a country with 1.3 billion people, many states, socio-economic disparity and the huge issue of sanitation. Indian challenge is very different from those of the western countries and thus, India cannot follow their policies. The aim of the Chennai Declaration, hence was to convince the then national union government that India too could implement an antibiotic policy and that all the stakeholders understood the limitations of and were willing to support the Indian government. This inspired the reinitiation of the implementation of the National Antibiotic Policy of 2011.
Accordingly, two Chennai Declaration documents were prepared - one original document and then as the government started implementing the antibiotic policy again, realising the need for time bound targets, another document as a five year plan was prepared to implement the National Action Plan (NAP) for AMR [released in April 2017] - the National Antibiotic Policy.
Urgent Need for Measures to Combat AR:
Dr. Ghafur stated that the medical and scientific communities’ belief that doctors are probably responsible for 80% of the AR globally and that AR can be tackled if the doctors prescribed medicines sensibly and rationally has changed over the last 10 years with increased awareness about the causes of the problem. He, accordingly, led us into some stats surrounding AR across the globe. About 70% of the global antibiotic use is for growth promotional purposes in animal husbandry. This leaves 30% for human use, out of which half of it is accounted for over-the-counter use without doctor’s prescription. Of the remaining 15% attributed to prescription by doctors globally, if even half of it is considered irrational, that amounts to only 7.5%, which is comparatively a very small percentage of the total. Hence, to tackle AR, instead of just educating and recommending doctors to prescribe antibiotics rationally, we actually need to educate the public - farmers, the government, politicians, media, patients, school children - about the dangers of irrational use of antibiotics and the necessity to reduce their over-the-counter use because it is the public and not the doctors who is the most important stakeholder of the AMR saga, asserted Dr. Ghafur. He added that besides developing a culture of rational antibiotic usage, there is an urgent need for measures to improve environmental sanitation, especially in developing countries like India where lack of sanitation is one of the most important determinants of AMR, because unless there is an improvement in environmental sanitation, whatever is done on rationalising antibiotic usage will be largely ineffective.
Dr. Ghafur believes that AMR is a very complex challenge and requires equally complex solutions on various fronts. He remarked that while the primary solution for the problem would be to ban the overuse of antibiotics (like the ban on the use of colistin as a growth promotional agent by the government of India), it cannot be done for all antibiotics and it would take several years or even decades to completely ban at least their use as growth promotional agents. Meanwhile, he asserted, there is a need for people/teams like us, who would bring about practical solutions and develop scientific methodologies to reduce the environmental contamination with antibiotics, and what youngsters like us are doing is just one but a very important component of the AMR saga.
Oh, how motivating is that!
Combination Antibiotic Therapy:
Dr. Ghafur remarked that where earlier only one antibiotic could be used to treat an infection, nowadays, a combination of two or even three antibiotics is required, though not for all infections, mostly for severe infections. He added that in his own long clinical practice, there have been times when, in case of severe infections, one or two antibiotics have worked while, at times, not even a single antibiotic has been effective and hence he believes that we have reached a stage where we essentially don’t have antibiotics to treat bacterial infections. Although it’s still controversial whether combination therapy is really the way forward, there is enough evidence to suggest that, in case of severe infections with multidrug and pan resistant bacteria, combination therapy helps. Dr. Ghafur insisted that it’s really a paradox because, though it increases the cost of therapy, until effective antibiotics are developed against resistant bacteria, combination therapy is the only way out.
COVID-19 - An Opportunity:
AMR is a silent killer for COVID-19 patients. Many COVID-19 patients develop secondary bacterial pneumonia and other infections whereupon doctors have to prescribe a lot of antibiotics and so antibiotic usage, including overusage, is a serious problem during the ongoing COVID era, asserted Dr. Ghafur. He added that, while COVID-19 is killing patients around the world and would also lead to a tremendous increase in the spread of AR, it is also an excellent opportunity to discuss AMR because now everyone knows about the importance of infection control and respects microbes, viruses and viral outbreaks. Efforts made over the years to convince people, especially the healthcare workers, to wash their hands properly largely failed, but the ongoing pandemic has made the whole world wash its hands properly and, in that sense, COVID-19 is an indirect blessing, remarked Dr. Ghafur. He believes that such viral outbreaks are opportunities for activists and experts to convince the government, politicians and the public about the importance of tackling microbes, and that now is the right time to talk about the dangers of resistant superbugs and how AMR is as serious a problem as COVID, Nipah or Ebola.
Synthetic Biology and Genetic Engineering:
Dr. Ghafur remarked that while people like him will always be a little concerned about genetic engineering because it may create superbugs, one shouldn’t be afraid to cross the boundaries and do genetics based research. Adding that science cannot develop if we, as its practitioners, are hesitant and afraid, he stated that the only thing we should keep in mind is that we must take all necessary precautions and do responsible research so as to, as he laughingly said, ‘prevent the generation of Frankensteins’.
Project Coli Kaze:
In his concluding remarks, Dr. Ghafur emphasised that our project idea is really good and restated that what youngsters like us are doing is a very important contribution towards combating AMR. He asserted that if we are able to successfully implement our project in poultry farms, especially in countries like India where there’s a huge unregulated use of antibiotics, it could play a major role in reducing the multidrug resistant bacterial contamination of the environment.