[“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 Dr. Vinod Paul, chief of
pediatrics at the All India Institute of Medical Sciences and the leader of the
study. “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.”]
 |
|
A mother nursing her newborn at a hospital in Haryana,
where almost every
baby born in hospitals in recent years has been injected with antibiotics.
Credit Kuni Takahashi for The New York Times
|
AMRAVATI, India — A
deadly epidemic that could have global implications is quietly sweeping India,
and among its many victims are tens of thousands of newborns dying because
once-miraculous cures no longer work.
These infants are
born with bacterial infections that are resistant to most known antibiotics, and more than 58,000 died 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, Indian pediatricians say that the rising toll of resistant infections
could soon swamp efforts to improve India’s abysmal infant death rate. Nearly a
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 Dr. Vinod Paul, chief of
pediatrics at the All India Institute of Medical Sciences and the leader of the
study. “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.”
In visits to
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 Dr. 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 multidrug resistant infections. It’s
scary.”
These babies are
part of a disquieting outbreak. A growing chorus of researchers say the
evidence is now overwhelming 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 Sept. 19 at age 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 elsewhere.
“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,” said Dr.
Timothy R. Walsh, a professor of microbiology at Cardiff University.
Indeed, researchers
have already found “superbugs” carrying a genetic code first identified in
India — NDM1 (or New Delhi metallo-beta lactamase 1) —around the world, including in France, Japan,
Oman and the United States.
Anju Thakur’s
daughter, born prematurely a year ago, was one of the epidemic’s victims in
Amravati, a city in central India. Doctors assured Ms. Thakur that her
daughter, despite weighing just four pounds, would be fine. Her husband gave
sweets to neighbors in celebration.
Three days later,
Ms. 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. Doctors switched to other antibiotics and switched again. Nothing
worked. Ms. Thakur gave a puja, or prayer, to the goddess Durga, but the baby’s
condition worsened. She died, just seven days old.
“We tried everything
we could,” said Dr. Swapnil Talvekar, the pediatrician who treated her. Ms.
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 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, the
Obama administration announced measures to tackle this
problem, which officials termed a threat to national security.
Some studies have found that developing
countries have bacterial rates of resistance to antibiotics that are far higher
than those in developed nations, with India the global focal point.
Bacteria spread
easily in India, experts say, 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 among the highest
rates of bacterial infections in the world and
collectively take more antibiotics, which are sold over the
counter here, 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 with more toilet use. On Oct. 2, the Indian
government began a campaign to clean the country and build toilets, with Prime
Minister Narendra Modi publicly sweeping a Delhi neighborhood. But the task is
monumental.
“In the absence
of better sanitation and hygiene, we are forced to rely heavily on antibiotics
to reduce infections,” said Ramanan Laxminarayan,
vice president for research and policy at the Public Health Foundation of
India. “The result is that we are losing these drugs, and our newborns are
already facing the consequences of untreatable sepsis,” or blood infections.
Some health
experts and officials here say that these killer bugs are largely confined to
hospitals, where heavy use of antibiotics leads to localized colonies.
But India’s top
neonatologists suspect the large number of resistant infections in newborns in
their first days of life demonstrates 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,” Dr. Paul said in an interview.
In a continuing
study in Delhi at several government-run hospitals that has so far included
more than 12,000 high-risk newborns, and was made available to The New York
Times, 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 Indian medical associations calling for
efforts to reduce unnecessary antibiotic use. But there is keen sensitivity
here 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, Dr. 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. India has the
world’s largest number of 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, Dr. Soumya Swaminathan, director of the National
Institute for Research in Tuberculosis, said in an interview.
“It’s startling
and very worrying,” Dr. Swaminathan said. Unless the government makes profound
and drastic changes, tuberculosis in India may soon become untreatable, she
said.
Although
resistant bugs are everywhere here, 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 the government did little to increase hospital capacity to
deal with the crush. Maternity wards often have two and three women in each
bed, allowing 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 hand-washing sinks, while 67 percent of
toilets were unsanitary.
Doctors across
India have responded to the sanitation crisis in hospitals by giving
antibiotics freely.
In Haryana, for
instance, almost every baby born in hospitals in recent years was injected with
antibiotics whether they showed signs of illness or not, Dr. Suresh Dalpat,
deputy director of child health in the state of Haryana, said in an interview.
“Now, with proper training, we are bringing that down.”
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 in India are bacteria like Klebsiella
and Acinetobacter, which are found in untreated human waste. Such bacteria
rarely infect newborns in developed nations, said Dr. Paul.
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 United
States has led to the rise of resistant strains there, and research has shown
that as much as half of antibiotic prescriptions in the United States are
unnecessary.
The Centers for
Disease Control and Prevention estimated last year that two million people are
sickened by resistant bacteria every year in the United States and 23,000 die
as a result. But efforts to crack down on inappropriate antibiotic use in the
United States and much of Europe have been successful, with prescriptions
dropping from 2000 to 2010. That drop was more than offset, however, by growing
use in the developing world.
Global sales of
antibiotics for human consumption rose 36 percent from 2000 to 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 here and are often poorly trained. Much of
these 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 here use feed laced with
antibiotics banned for use in animals in the United States. A New Delhi science
group recently found antibiotic residues in 40 percent of chicken samples
tested.
But the effects
in children are perhaps the most heart-wrenching. After her baby’s death a year
ago, Ms. 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, Ms. 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, she reported that she and the baby were fine.
