Kerala takes a pioneering step to curb antimicrobial resistance

Kerala takes a pioneering step to curb antimicrobial resistance

Subject: Science and tech

Section: Health

H1 rule: 

In 2011, the Indian government introduced the H1 rule to prohibit the over-the-counter (OTC) sales of antibiotics without a prescription, responding to the growing concern over antimicrobial resistance (AMR).

Challenges faced:

However, due to the healthcare system’s heterogeneity across the country, the implementation of this rule faced significant challenges.

Modifications:

• In 2013, following the Chennai Declaration document and initiative by medical societies in India, the Indian government modified the rule to limit the OTC restriction to second and third-line antibiotics, allowing the sale of first-line antibiotics without a prescription. 

Aim of modification: This modification was aimed to ensure that life-saving antibiotics remained accessible to the public, especially in remote areas of the country where doctors might not be readily available.

Initiative by Kerala: 

• Despite a decade passing since the rule’s announcement, no State government had adopted it until Kerala recently initiated Operation AMRITH (Antimicrobial Resistance Intervention for Total Health).
• AMRITH programme enforces the original H1 rule, mandating a doctor’s prescription for acquiring any class of antibiotics.

Factors in Kerala’s adoption: 

• Kerala’s high doctor-patient ratio, even in villages, facilitates the enforcement of this rule.
• The high literacy rate in the State is poised to contribute significantly to the efficient implementation of the rule. 
• An informed populace is more likely to understand the importance of regulations like these and adhere to them, facilitating smoother execution and compliance. 

Paradox : 

• While it is highly commendable that Kerala is implementing the H1 rule to rein in AMR, it is unlikely to have a significant impact on drug-resistant infections in the immediate future.
• The effects of this initiative may take several years to manifest.
• However, it will foster a culture of respecting antibiotics and encourage further actions to combat AMR.

Unnecessary usage of antibiotics: 

• Over 50-70% of antibiotic prescriptions by doctors are deemed unnecessary and irrational.

Reasons :

a. The unavailability of laboratory facilities to make a correct diagnosis of bacterial infections.

Even if they are available, these tests are more expensive than a course of antibiotics.

Enhancing laboratory facilities for accurate infection diagnosis, especially with affordable rapid diagnostic tests to determine the necessity of antibiotics, is therefore vital.

b. Patients wrongly believe that antibiotics is a quick remedy for a fever episode of any cause.

Solution: Educating patients about the limitations of antibiotics and discouraging them from pressuring doctors for unnecessary prescriptions is vital.

What is needed : 

• Kerala demands hospitals to disclose the incidence of hospital-acquired infections.
• Antimicrobial resistance is a socioeconomic problem, and combating it requires measures: 

a. improve public health infrastructure

b. sanitation facilities

c. governance in order to decrease the transmission of infections and the dependence on antibiotics.

The influence of these factors on antimicrobial resistance rates is typically greater than that of the total volume of antibiotics used.

What other measures required:

• To reduce the spread, healthcare facilities must follow the correct standards for infection prevention. .There must be a system where all hospitals report rates of hospital-acquired infections to the State government. Ideally, the data should be made public.

In practice: Currently, all NABH hospitals collect this data every month and take measures to reduce hospital-acquired infections.

What is needed :

• However, it is crucial that all hospitals follow suit and share the data with the State.

Possible outcomes: 

• There will be immediate long-term benefits in lowering AMR-related fatalities if measures to reduce hospital-acquired infections are successfully implemented.

Other essential measures:

a. rationalizing antibiotic use in hospitals.

b. banning the growth-promotional use of antibiotics in poultry farms, fish farms, and agriculture based on existing rules.

Some innovative solutions: 

• Kerala will do well if it supports and promotes the development of new antibiotics, diagnostics, and vaccines by entrepreneurs. .Karnataka and Maharashtra-based startups have achieved remarkable progress in this domain.

Potential of startups: 

• Startups based on novel service delivery models may help us make better use of human resources in relation to antibiotic stewardship and infection prevention.

Multi-pronged approach : 

• While enforcing the OTC regulation is a welcome step, but curbing antimicrobial resistance requires a multipronged approach, including:

a. reforms to physicians’ prescribing practices

b. mandating that hospitals report healthcare-associated infection rates.

c. Strictly enforcing the OTC regulation without addressing the other issues, which are major drivers of antimicrobial resistance, may not help the cause.

Conclusion: 

Enforcing the H1 rule is a relatively easy goal. The real challenge will be tackling the major drivers of AMR.