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Story Publication logo January 17, 2012

India's Super-Resistant Bacteria: "Everybody Is Hell Scared"

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Bacterial infections impervious to the world's most powerful antibiotics—endowed with the superbug...

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Open gutters carrying waste water from washing, cooking and human excretion line the alleys of a Delhi slum. Image by Sonia Shah. India, 2012.

Over 50 percent of bacterial infections in Indian hospitals are resistant to commonly used antibiotics, and surveys show that many widespread bacterial pathogens in India are also resistant to powerful, broad-spectrum antibiotics.

In 2010, a team of South Asian and British scientists analyzed bacterial infections in a hospital around New Delhi, and found that 24 percent could also resist hospitals' last-resort intravenous antibiotics, called "carbapenems," and 13 percent were endowed with a super-resistant gene, dubbed "New Delhi metallo-beta-lactamase 1," or NDM-1, which confers resistance to carbapenems along with at least 14 other antibiotics.

"Everybody is hell scared," says medical microbiologist Chand Wattal, of Sir Ganga Ram hospital in New Delhi.

Since then, NDM-1 bacteria have been found in drinking water supplies and in puddles around New Delhi, and in patients in over 35 countries, says University of Cardiff microbiologist Tim Walsh. Many of these patients are "medical tourists" who have traveled from Europe, the Middle East, and the Americas to India or Pakistan for inexpensive medical care.

There are few new drugs in development to treat the microbes that NDM-1 plagues. In Western hospitals, "gram-positive" bacteria, which are structurally vulnerable to antibiotics and disinfectants, tend to dominate. In hospitals in India and other tropical countries "gram-negative" bacteria, which are encased in tough outer membranes that can repel antibiotics and antiseptics, are more common. With most drug industry research and development focused on Western markets, "places like India will just have to wait for new drugs for gram-negatives" while the death toll from untreatable infections inevitably rises, says Public Health Foundation of India's Ramanan Laxminarayan, .

Effective containment measures may prove difficult to implement in India. The country has one of the world's highest burdens of infectious disease, and antibiotic use is unchecked, with both rampant overuse and under-use that lead to resistant strains.

In slums like Ekta Vihar, where barefoot children play in narrow alleyways lined by open gutters, many cannot afford a full course of antibiotics when they fall ill. A common practice, says Dr. Sharmila Lal, who has worked in Delhi slums for ten years, is to buy just a few tablets instead, risking the development of drug-resistant bugs. Elsewhere, the more affluent consume antibiotics for conditions that don't require them, such as colds and diarrhea, surveys show.

Nor is there much capacity for the kind of medical microbiological surveillance required to track the spread of antibiotic resistant bacteria. According to Laxminarayan, the country's disease surveillance program effectively collects information from only two of the country's 640 districts.

The politics of national pride further complicate the picture. The new super-resistant gene was first discovered in Europe, in patients who'd traveled to India or Pakistan for medical care. But when British scientists named it after the city from which it seemed to originate, and warned in the medical journal The Lancet that medical tourists might be at risk, Indian politicians, news media, and physicians cried foul.

India's National Centre for Disease Control spent "days openly denying" the public health relevance of NDM-1, The Times of India reported. The Indian Express wrote that NDM-1 was a "conspiracy to hurt Indian medical tourism."

India's booming medical tourism industry brings in hundreds of thousands of foreign patients every year, seeking respite from the high cost and long wait-times for surgeries at home.

New Delhi cardiothoracic surgeon Naresh Trehan, who treats medical tourists, doesn't appreciate his city being implicated in a new superbug. Resistant bugs are a worldwide problem, Trehan says. After all, "when AIDS was discovered, you didn't call it New York-1," he says.

As the controversy over NDM-1 swirled, the Indian government quickly convened an advisory committee on the issue of antibiotic resistance, and floated an ambitious proposal to ban the sale of antibiotics without a physician's prescription. It was withdrawn after protests from pharmacists and others, who said it would have impeded access to life-saving antibiotics among the rural poor. But the policy had little likelihood of being implemented in any case, as health policy is decided at the state level in India, not the federal level.

It may be that NDM-1 has to gain more notoriety and "get a lot more scary," as The Times of India put it, before the political will to do something about the problem coalesces. How many lives will be ravaged by infection in the meantime remains to be seen.

"The bugs are not waiting for us to catch up on our surveillance; they are merrily going ahead," says Laxminarayan. "It is not that the end of antibiotics is somehow coming," he says. "It is already here in many instances."

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