Saturday, August 14, 2010

'Superbug' scare. Myths and facts

A scientific article in the Lancet has created big commotion in the media both in India and outside.It is being said that a bacteria which is resistant to all known antibiotics is wide spread in India and Pakistan and is being spread to other countries including U.K through medical tourism.This bacteria termed the 'superbug' is supposed to bring an end to the antibiotic era. Indian Government has come out with a clarification saying the media scare in UK is unwarranted.
Let me try to separate facts from myths in this issue.
Fact 1
WHO has identified antibiotic resistance as one of the greatest threats to human health. In the European Union (EU), about 25 000 patients die every year from infection with multidrug-resistant bacteria, and such infections result in health-care costs and lost productivity totalling at least €1·5 billion per year. Methicillin-resistant Staphylococcus aureus alone infects more than 94 000 people and kills nearly 19 000 in the US every year, more deaths than are caused by HIV/AIDS, Parkinson's disease, emphysema, and homicide combined.
Fact 2
Bacteria with Carbapenemase  activity is a fast emerging threat in the field of antibiotic resistance all over the World as you can see from this article. India is actually a late entrant in this field.
Fact 3
There are 4 classes of Carbapenemase A,B,C and D.Each have different sub groups.So there are a large number of such bacteria producing different Carbapenemase isolated from all over the World.
Fact 4
New Delhi metallo-beta-lactamases[ NDM-1] belonging to B sub group of Carbapenemase was first detected in a Klebsiella pneumoniae isolate from a Swedish patient of Indian origin in 2008.It was given such a name assuming that the patient got it while hospitalized in New Delhi.
Fact 5
Further study in India indicated that NDM 1 enzyme producing bacteria are fairly common in a tertiary hospital in Mumbai.
Fact 6
In short NDM1 enzyme  is the major cause for antibiotic resistance in Ecoli and Klebsiella species in India.In other countries enzymes are different and are named differently like    VIM-1 (for “Verona integron-encoded metallo-β-lactamase” first isolated in Verona, Italy,)       SPM-1 (for “Sao Paulo metallo-β-lactamase”),         GIM-1 (for “German imipenemase”)    SIM 1 (for Seoul imipenemase)   etc.
Fact 7
The Lancet article in question is only about NDM 1 producing bacteria. It is a good attempt to find out the extend of spread of antibiotic resistance in bacteria in India.
Fact 8
It showed NDM in UK not only in those who had surgical procedures in India but also in many who have never visited India..Out of the 37 samples with NDM1 collected in UK, only 17 samples had history of travel to India or Pakistan.
The article in Lancet says
'It is disturbing, in context, to read calls in the popular press for UK patients to opt for corrective surgery in India with the aim of saving the NHS money. As our data show, such a proposal might ultimately cost the NHS substantially more than the short-term saving and we would strongly advise against such proposals'.
This is an unscientific comment not based on any data.The authors have not proved that NDM 1 enzyme producing bacteria in UK was imported from India. More than 50% of patients in UK detected to have NDM 1 has never traveled to South Asia.Also the comment is not taking into consideration other groups and sub groups of Carbapenemase enzyme producing bacteria which are more prevalent in UK than in India.

         The author of the article in Lancet seems to show undue haste in blaming medical tourism for antibiotic resistance in UK.

It is true that Indian health system abuses antibiotics like most other 3 rd World countries.While protesting the unfair conclusion of the author of the article let us hope that the concerned authorities will open their eyes to the lack of antibiotic policies in most health care centers of India and implement strict regulations so that patients both native and foreign are protected from emergence of resistant bacteria.


palscape said...

Thanks for the very balanced and insightful post on this issue.

Regarding the comment by the authors of the Lancet Infection Diseases article in the discussion section, I am not in total agreement with their conclusion either. But I would also like to point out that the authors have made a very narrow assertion.

To wit, they suggest that NHS' plan to reduce cost by outsourcing surgeries to India may not be cost-effective in the long run due to the dangers of superbug infection. Given the data showing incidences of such bugs showing up in India, it is perhaps not an unreasonable point to make.

Charakan said...

Palscape, It is true that Indian hospitals have many bacteria resistant to most of the antibiotics available now.This is true of most hospitals in the World.As this study proved more than half of patients carrying NDM 1 enzyme had never come to India/Pakistan.So the article author's contention that NHS outsourcing to India will be more costly than doing the procedures in UK itself because of 'superbug' has no basis as per this study. If they have done a cost analysis of few out sourced cases and few cases which were done in UK and come to such conclusion it would have been acceptable.

The conclusion of the Lancet journal article should have been like this.
"This study proves that multi drug resistant enterobacteria carrying NDM1 enzyme are prevalent in many centers in India and Pakistan.They are also seen in patients in UK both in those who had traveled to South Asia and those who have not.More studies are needed both in South Asia and UK to find out the exact nature of the spread of this resistant bug.This is most urgently needed because India has recently become a favored destination for outsourcing NHS procedures."

If the article had such a conclusion it would have been much more acceptable.