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How the world needs to deal with the two devils of COVID-19 and AMR

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Dr Abdul Ghafur, coordinator of the 2012 Chennai Declaration on AMR and Consultant in Infectious Diseases, Apollo Hospital, Chennai, speaks to Viveka Roychowdhury about his recent recovery from COVID-19 (“a moderately bad experience, it’s not so nice to be infected with COVID-19!”), the connection between the “two devils” – AMR and COVID-19, and how he hopes that a “super virus” has finally convinced policy makers, politicians and public that there are “super bugs” causing AMR and the need for stricter antibiotic stewardship policies in all hospitals. Edited excerpts …

Could you share your experience as a corona warrior fighting the pandemic in your hospital as well as a patient recovered from SARS-nCoV2?

After I realised I had contracted the COVID-19 virus, I was admitted to Apollo Hospital, Chennai; the same hospital I work for, in the month of June.  I have now recovered and am back to work again.

It’s difficult to say exactly where I contracted the virus. I live and work in Chennai. I treat a lot of COVID-19 positive patients in my outpatient department. You can only reduce the chances of contracting the virus by following precautions, but cannot eliminate the possibility completely. It’s unfortunate that I contracted the virus, but lucky enough to recover, unlike thousands of healthcare workers across the world who succumbed to the pandemic. It was a moderately bad experience; it’s not nice to be infected with COVID-19! But I have recovered now and am back in action!

You are the coordinator of the Chennai Declaration on Antimicrobial Resistance (AMR), which was released in 2012, as a series of recommendations to policymakers to tackle AMR in India. Experts expect to see increased levels of AMR as many people are self-medicating with antibiotics for even simple fevers, out of fear and to prevent hospitalisation. Your comments?

India has one of the highest rates of AMR in the world. It prepared a national antibiotic policy in 2011 and National AMR Action Plan in 2017.  A few of the states have formulated state action plans but the implementation is still in very early stages and not satisfactory at all.

Before the COVID-19 pandemic, AMR was considered one of the most important health and economic challenges that the healthcare field and the world is facing, which is why the Global Action plan and the National Action plans were prepared.

And then, COVID-19 appeared out of nowhere. Now, the whole world’s attention is focused on COVID-19. So, will the COVID-19 distract our attention from the AMR issue? Not really. They are two devils working together. COVID-19 kills patients and AMR helps COVID-19 to kill patients.

For instance, most patients have mild respiratory infections due to COVID-19. Many of these patients are treated with antibiotics even though they should not be getting them. However, in those countries where the antibiotic stewardship programme is very premature, patients are prescribed antibiotics even for mild cases of COVID-19. In mild COVID-19, just like any other mild respiratory tract infection, people misuse antibiotics. But this practice (antibiotic misuse) was prevalent well before the pandemic and continues during the COVID-19 era as well. There are some centres where antibiotic stewardship is strict, where antibiotics are not used for COVID-19 patients except in very severe cases. Many COVID-19 patients have severe pneumonia and doctors can’t differentiate if it is due to COVID-19 itself or a secondary bacterial infection. Antibiotics may have a role in these cases.

If you look at the published data from a few countries, the bacterial infections are quite delayed manifestations in COVID-19. In one study from China, the median duration of development of secondary bacterial infections in admitted COVID-19 patients is 17 days. It means that with COVID-19 patients, you don’t need antibiotics at an early stage, you need it at a later stage.

AMR is a silent tragedy, unlike the explosive COVID-19! It was difficult to convince the public and politicians about superbugs and AMR. Even after years of international efforts, the public in most countries does not know what AMR is. The political leadership of many countries still don’t know what AMR is. When we were talking about losing trillions of dollars due to AMR, no one was listening.

Nonetheless, with COVID-19, overnight, the whole world’s public and political leadership knew about the super virus! Even though they don’t know about super bacteria, they know about this super virus!

Now the public and the policymakers know the importance of bugs and how dangerous they are to people if you don’t tackle them properly. We now know that bugs can kill and they can put us under lockdown, with the global economy losing trillions of dollars and the public losing jobs and income.

At least now, the policymakers and politicians should be ready to act on AMR.

For years we’ve been asking people, as well as doctors and nurses, to wash their hands. And now people wash their hands!

So, it’s like a vindication for what people like you have been saying, while warning us about AMR.

Yes. To convince them how serious the superbug bacteria are, we needed a super virus. That’s how nature reacts when we don’t listen to what she was trying to tell us. She found another way of trying to convince us.

The positive side is that now since the people are aware of the bug, there is better handwashing, masking, social distancing. This behavioural change would have indirectly reduced the incidence of respiratory tract infections, with the potential for a reduction in antibiotic usage in the country.  But to know for sure, we need data at the national level.

So, do experts like you expect to see a rise in AMR?

The COVID-19 pandemic might have reduced antibiotic usage because hospital admissions have dropped. Occupancy, especially in the private hospitals, was just 20-30 per cent, due to the COVID-19 scare and the lockdown. While there might be antibiotic misuse in COVID-19 patients, the overall usage of antibiotics might have reduced, as the number of patients was lower. But we can’t say for sure unless we have nation-wide data.

On 9th July, more than 20 biopharmaceutical companies announced the launch of the AMR Action Fund, which aims to bring two to four new antibiotics to patients by 2030. Do you think the solution is new antibiotics? Or the better use of what we have?

We need both new antibiotics as well as better use of the ones we have. We need new antibiotics because that is the immediate solution. However, adding new antibiotics when there is no, or poor antibiotic stewardship is like adding fuel to the fire. We need better use of existing antibiotics as well as better infection control, better sanitation and more awareness. In countries like India, unless we can improve infection control and sanitation, the situation will remain the same.

What will be the long-term impact of this pandemic on India’s healthcare sector? More funds have been spent on the sector in the past few months than probably ever before. But, will these facilities be of use post the pandemic? How can they be set up in such a way that they can be used post the pandemic as well? 

COVID-19 exposed the weaknesses of our healthcare system. The government realised these weaknesses in the system and that they need additional funds to invest in better infrastructure and manpower for the management of COVID-19.

If authorities believe the COVID issue is a short-term phenomenon, it’s not going to be beneficial. The government should increase the expenditure on healthcare as a percentage of GDP from the current 1-1.25 per cent to at least four to five per cent. That is the only long-term solution.

We need the private healthcare system, no doubt about it, but the backbone of the healthcare system should be government-based. In many of the states, only the government hospitals are managing COVID-19 patients. Of course, private healthcare systems gave wonderful support but the backbone of the COVID-19 care in the country has been the government healthcare system.

So, COVID-19 should be a lesson to the government to increase its spending on healthcare to improve the public healthcare system.

What should be the role of the private healthcare sector in such a pandemic? Just as we are implementing the lessons learnt from previous wide spread infections like HIV/AIDS, SARS, Ebola, what can be learnt from the COVID-19 pandemic which will make us better prepared for the next such disruption?

If you take the example of Tamil Nadu, private hospitals were involved in the pandemic quite early, and that helped the state a lot. Many of the private hospitals in the state, especially in Chennai, are admitting COVID-19 patients and giving good support to the government (healthcare system) backbone.

Many of the other states failed to involve private hospitals in the early stages and by the time they did, the situation was already overwhelming.

Secondly, in India, we will now see the spread of COVID-19 to small towns and villages. The bigger metros and larger towns are seeing or have seen the peak of the pandemic. Now, we are going to see it spread to the towns and villages, where there is a serious shortage of hospitals that can deal with COVID cases. So, in a month or so, the real strength of our healthcare system will be tested. This will be the time when the role of ASHA workers and other basic healthcare workers will really come out. The bigger metros and larger towns have big hospitals, both government and private, but what will happen when villages are affected?

For instance, I have a friend in Ghana who has now tested positive for COVID-19. Even though he is in the capital city of Ghana, he had to drive 12 kms to reach a hospital. And he was telling me that his oxygen saturation level was dropping and he himself was driving to the hospital. So, what will happen to people in India’s villages who test positive for COVID-19 and then must travel to larger hospitals for treatment? This is when we will really see the extent of the problem.

Thus, I would say that besides investing in public hospitals in the cities, we also need to focus on funding government hospitals in India’s smaller metros and villages so that people their do not need to travel to cities for treatment, be it in normal times or during public health emergencies like the COVID-19 pandemic.

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