Mon, Dec 08, 2014 page9

• ‘Superbugs’ killing Indian babies pose global threat

  As the overuse of antibiotics and chronic sanitation issues that plague the nation breed bacteria resistant to most known drugs that are wreaking devastation locally, similar problems abroad are causing worldwide alarm

  • By Gardiner Harris / NY Times News Service, AMRAVATI, India
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  A deadly epidemic that could have global implications is quietly sweeping India, leaving among the many victims in it wake tens of thousands of newborns who are dying because once-miraculous cures no longer work.

  These infants were born with bacterial infections that are resistant to most known antibiotics, with more than 58,000 dying last year as a result, a recent study found. While that is still a fraction of the nearly 800,000 newborns who die annually in India, the nation’s pediatricians say the rising toll of resistant infections could soon swamp efforts to improve the country’s abysmal infant mortality rate: Nearly one-third of the world’s newborn deaths occur in India.

  “Reducing newborn deaths in India is one of the most important public health priorities in the world and this will require treating an increasing number of neonates who have sepsis and pneumonia,” said Vinod Paul, who led the study and is chief of pediatrics at the All India Institute of Medical Sciences.

  

  Illustration: Yusha

  “But if resistant infections keep growing, that progress could slow, stop, or even reverse itself, and that would be a disaster for not only India, but the entire world,” he said.

  At neonatal intensive care wards in five Indian states, doctors reported being overwhelmed by such cases.

  “Five years ago, we almost never saw these kinds of infections,” said Neelam Kler, chairwoman of the department of neonatology at New Delhi’s Sir Ganga Ram Hospital, one of India’s most prestigious private hospitals. “Now, close to 100 percent of the babies referred to us have multi-drug-resistant infections. It’s scary.”

  These babies are part of a disquieting outbreak. A growing chorus of researchers say evidence is now overwhelmingly showing that a significant share of the bacteria present in India — in its water, sewage, animals, soil and even its mothers — are immune to nearly all antibiotics.

  Newborns are particularly vulnerable because their immune systems are fragile, leaving little time for doctors to find a drug that works, but everyone is at risk.

  Uppalapu Shrinivas, one of India’s most famous musicians, died on Sept. 19 at the age of 45 because of an infection that doctors could not cure.

  While far from alone in creating antibiotic resistance, India’s resistant infections have already begun to migrate.

  “India’s dreadful sanitation, uncontrolled use of antibiotics and overcrowding, coupled with a complete lack of monitoring the problem has created a tsunami of antibiotic resistance that is reaching just about every country in the world,” Cardiff University professor of microbiology Timothy Walsh said.

  Indeed, researchers have already found “superbugs” carrying a genetic code first identified in India — NDM1 (New Delhi metallo-beta lactamase 1) — around the world, including in France, Japan, Oman and the US.

  Anju Thakur’s daughter was born prematurely a year ago and became one of the epidemic’s victims in Amravati, a city in central India. After the birth, doctors had assured Thakur that despite weighing just 1.8kg, her daughter would be fine; her husband gave sweets to their neighbors in celebration.

  Three days later, Thakur knew something was wrong. Her daughter’s stomach swelled, her limbs stiffened and her skin thickened — classic signs of a blood infection. As a precaution, doctors had given the baby two powerful antibiotics soon after birth. They switched to other antibiotics once and then again, but nothing worked. Thakur offered a puja, or prayer, to the goddess Durga, but the baby’s condition worsened and she died at just seven days old.

  “We tried everything we could,” said Swapnil Talvekar, the pediatrician who treated her.

  Thakur was inconsolable.

  “I never thought I’d stop crying,” she said.

  A test later revealed that the infection was immune to almost every antibiotic. The child’s rapid death meant the bacteria probably came from her mother, doctors said.

  Health officials have warned for decades that the overuse of antibiotics — miracle drugs that changed the course of human health in the 20th century — would eventually lead bacteria to evolve in a way that made the drugs useless.

  In September, US President Barack Obama’s administration announced measures to tackle this problem, which officials termed a threat to national security.

  Some studies have found that developing nations have bacterial rates of resistance to antibiotics that are far higher than those in developed nations, with India the global focal point.

  Experts say bacteria spread easily in India because half of Indians defecate outdoors and much of the sewage generated by those who do use toilets is untreated. As a result, Indians have some of the highest rates of bacterial infections in the world and collectively take more antibiotics — which are sold over the counter there — than any other nationality.

  A recent study found that Indian children living in places where people are less likely to use a toilet tend to get diarrhea and be given antibiotics more often than those in places where toilet usage is more prevalent. On Oct. 2, the government began a campaign to clean the nation and build toilets, with Indian Prime Minister Narendra Modi publicly sweeping a Delhi neighborhood. However, the task is monumental.

  “In the absence of better sanitation and hygiene, we are forced to rely heavily on antibiotics to reduce infections,” Public Health Foundation of India vice president for research and policy Ramanan Laxminarayan said. “The result is that we are losing these drugs and our newborns are already facing the consequences of untreatable sepsis [blood infections].”

  Some health experts and officials say that the killer bugs are largely confined to hospitals, where heavy use of antibiotics leads to localized colonies.

  However, the nation’s top neonatologists suspect the large number of resistant infections in newborns in their first days of life demonstrate that these dangerous bacteria are thriving in communities and even pregnant women’s bodies.

  “Our hypothesis is that resistant infections in newborns may be originating from the maternal genital tract and not just the environment,” Paul said in an interview.

  In an ongoing study in Delhi at several government-run hospitals made available to the New York Times, which has so far included more than 12,000 high-risk newborns, about 70 percent of the babies’ infections were found to be immune to multiple powerful antibiotics, confirming the results of earlier and smaller studies.

  Doctors interviewed in hospitals across India said that a large number of the infections they found in newborns were resistant to many antibiotics. Awareness of the problem has begun to grow, with medical associations calling for efforts to reduce unnecessary antibiotic use.

  However, there is keen sensitivity to any alert to the dangers. A 2010 discovery of a New Delhi superbug caused intense controversy because of fears that publicity would threaten India’s profitable medical tourism industry. Government officials have stopped some studies of the problem, Walsh said.

  The effects of antibiotic-resistant bacteria on treating disease in India could be enormous. Tuberculosis is just one example of the challenges doctors face there. India has the world’s largest number of tuberculosis cases and recent studies using the latest genetic tests have shown that as many as 10 percent of untreated patients in places as far apart as Mumbai and Sikkim have resistant infections. These patients are catching resistant bugs at home, not hospitals, making the epidemic very difficult to control, National Institute for Research in Tuberculosis director Soumya Swaminathan said in an interview.

  “It’s startling and very worrying,” Swaminathan said.

  Unless the government makes profound and dramatic changes, tuberculosis in India might soon become untreatable, she said.

  Although resistant bugs are everywhere, hospitals have become factories for untreatable superbugs. A government program that pays women to have babies in hospitals has in 10 years more than doubled the share of hospital born babies to 82 percent, but New Delhi has done little to increase hospital capacity to deal with the crush. Maternity wards often have two or three women in each bed, making it easy for infections to spread rapidly.

  Besides being desperately crowded, many hospitals are unhygienic, allowing the bugs to flourish. A UNICEF survey of 94 district hospitals and health centers in Rajasthan last year found that 70 percent had possibly contaminated water and 78 percent had no soap available at sinks, while 67 percent of toilets were unsanitary.

  Doctors across the nation responded to the sanitation crisis in hospitals by giving antibiotics freely.

  In Haryana State, for instance, almost every baby born in hospitals in recent years was injected with antibiotics ragardless of whether they showed signs of illness, said Suresh Dalpat, deputy director of child health in Haryana.

  “Now, with proper training, we are bringing that down,” Dalpat said.

  All those drugs create resistant bacteria that find their way into hospital sewage, which is mostly dumped untreated into rivers, canals and pits in the surrounding community where pregnant women can become infected.

  The most frequent causes of resistant newborn infections are bacteria like Klebsiella and Acinetobacter, which are found in untreated human waste. Such bacteria rarely infect newborns in developed nations, Paul said.

  However, India and other developing nations are by no means alone in threatening the future of antibiotics. Overuse of the drugs in chicken, hog and cattle farms in the US has led to the rise of resistant strains there, and research has shown that as many as half of antibiotic prescriptions in the US are unnecessary.

  The US Centers for Disease Control and Prevention estimated last year that 2 million people are sickened by resistant bacteria every year in the country and 23,000 die as a result. However, efforts to crack down on inappropriate antibiotic use in the US and much of Europe have been successful, with prescriptions dropping between 2000 and 2010. Still, this drop was more than offset by growing antibiotic use in the developing world.

  Global sales of antibiotics for human consumption rose 36 percent between 2000 and 2010, with Brazil, Russia, India, China and South Africa accounting for 76 percent of that increase. In India, much of that growth has been driven by private doctors who deliver about 90 percent of care and are often poorly trained. Much of the doctors’ income comes from drug sales.

  Just as worrisome has been the rapid growth of India’s industrialized animal husbandry, where antibiotics are widespread. Most large chicken farms use feed laced with antibiotics banned for use in animals in the US. A New Delhi science group recently found antibiotic residues in 40 percent of chicken samples that it tested.

  However, the effects in children are perhaps the most heart-wrenching.

  After her baby’s death a year ago, Thakur, 21, was soon pregnant again. She gave birth on Sept. 21 to a baby girl.

  On a visit shortly after the baby’s birth, Thakur was shivering from a severe infection while staying in a home with no toilet or running water. She nursed her tiny infant, Khushi, under a small shrine with pictures of Durga and Krishna.

  Nearly two months later, Thakur reported that she and the baby were fine.
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