Water, sanitation and hygiene as a systemic fix to prevent antimicrobial resistance in India
Two images have stuck with me for years. In 2013, I was in a delivery room in a district hospital in Rajasthan - delivery beds stained with dried blood and surgical instruments lying in disinfectant solution that had not been changed in days. The nurse briskly told me that the hospital had a high delivery caseload. They did not have enough water to wash the bed thoroughly after every birth, and had insufficient resources to buy disinfectants. Mothers were administered antibiotics immediately after birth to prevent any infections.
Three years later in 2016, I visited an area hospital in a southern State to gain insights into the status of water, sanitation and hygiene (WASH) in health care settings. The doctor in charge of the neonatal intensive care unit proudly showed me a board noting that the hospital had six newborns with sepsis, all of whom were being treated successfully. The hospital was fairly well equipped, but had a water scarcity problem, especially during the summer months. I recall these two conversations in light of the Universal Health Coverage Day (12 December).
Antibiotics save lives, yet their overuse and misuse leads to the growth of ‘superbugs’, antibiotic-resistant strains of infection and diseases, and consequently antimicrobial resistance (AMR). If unaddressed, AMR threatens to kill 10 million people annually by 2050, and cause colossal economic losses of $100 trillion for the global economy.
A 2013 study in The Lancet estimated that approximately 58,000 babies born in India die each year from superbugs. The Delhi Neonatal Infection Study Collaboration found a high incidence of sepsis and a strikingly high rate of antimicrobial resistance among pathogens in newborns delivered in tertiary care hospitals in New Delhi. Dr. Vinod Paul, one of the study collaborators, has repeatedly warned about the stark dangers of AMR among newborns and how this threat undermines the progress made to improve survival rates among neonates.
India has indeed made tremendous strides in reducing maternal and neonatal deaths through various initiatives that promote antenatal care, maternal nutrition, institutional deliveries, and better care for newborns. However, poor quality of care, which includes limited access to water, sanitation, handwashing facilities, and waste management services, increases the risk of life-threatening infections because of unhygienic health care settings. This, in turn, leads to greater use of and dependence on antibiotics to combat these avoidable infections and contributes to AMR.
As of 2016, 9.2% of health facilities in India did not have water, 45% lacked sanitation, and 41.7% were in need of hygiene facilities. When health care facilities have inadequate WASH, pregnant women may avoid or delay seeking care, and leave such facilities sooner than they should after giving birth. Health care providers working under such conditions are unable to maintain hygiene and prevent infections. Such circumstances place a new mother and her baby at the risk of sepsis.
This then necessitates antibiotic use to save mothers and their babies.
Using antibiotics as a ‘quick fix’ is risky
A recent article in the British Medical Journal (2019) powerfully states “….antibiotics function as a quick fix for lack of hygiene, acting as substitutes for the non-hygienic conditions that health workers and individuals work and live within”. Antibiotics are needed and important to treat infections and are a medical breakthrough of our time. Yet, overdependence on this “quick fix” averts problems in the short-term, but distracts from deeper systemic issues that have long-term adverse health and financial implications for India.
Therefore, systemic “fixes” that strengthen health systems, such as ensuring universal health care and quality of care, are critical.
Within this, actions to ensure functional and adequate water, sanitation, hygiene infrastructure, waste management services, and equipping health care providers with skills and measures for infection prevention and control, can contribute towards reductions in avoidable infections and resultantly lower use of unnecessary antibiotics in health facilities. Additionally, proper solid, liquid and biomedical waste management in health care settings can curb the spread of AMR through contaminated water sources and the environment. Dr. Ashok J Tamhankar, National Coordinator of the Indian Initiative for Management of Antibiotic Resistance, highlights the neglected link between antibiotic use and misuse in health care settings, and water sources and environment contaminated with hospital effluents containing antibiotics.
While research is limited to the extent to which antibiotic presence in water contributes to AMR in India, it underscores the potential complex linkages between antibiotics use in health care settings and the environment around us.
Apart from antibiotic use in health care settings, diseases such diarrhoea and pneumonia, linked with poor WASH in community settings, are routinely treated with antibiotics 1. These diseases, common in children under 5 years, are, to some extent, preventable through improved access to WASH facilities and hygiene promotion in communities, schools and anganwadis. For instance, washing hands with soap at critical moments (i.e., after contact with faecal matter, before contact with food) is estimated to reduce diarrhoeal diseases by 47% and respiratory infections by 23%, having tremendous health benefits for children .
The solutions to the complex issues of quality of care and AMR are multifaceted and call for multi-sectoral action. India is already taking steps to address AMR, improve WASH in health care settings, and ensure that all households have access to toilets. The Swachh Bharat Mission has successfully constructed 100 million household toilets across rural and urban India over five years (2014-2019), reducing the risk for diarrhoeal diseases, especially among young children, and reduced household health care costs . From 2015, the Ministry of Health and Family Welfare implemented the Swachhta Guidelines for Health Care Facilities and the Kayakalp awards , invigorating efforts towards ensuring cleanliness in public health facilities at all levels (primary to tertiary). In response to the global AMR threat, India developed the National Action Plan for AMR in 2017 . The plan outlines six strategic priorities, five of which either involve action on WASH or engagement of WASH sector actors to tackle this issue. The third strategic priority directly relates to WASH through steps to reduce the incidence of infection through effective infection, prevention and control measures in health care facilities and in communities. The Delhi Declaration on Antimicrobial Resistance, signed in 2017, highlights inter-ministerial consensus on AMR, affirming the Government of India’s commitment to execute the six strategic priorities through inter-sectoral action . Until now, Kerala is the only State to develop a State Action Plan for AMR.
India is committed to addressing AMR. The urgent need now is to accelerate progress. Specific interventions must be intensified to stop avoidable infections and diseases that necessitate antibiotic use. Handwashing with soap, toilet use, and prevention of water contamination must be promoted as important preventative measures in communities, schools, anganwadis and health care settings. Kayakalp needs to be revitalised in health care settings with a stronger focus on infection prevention and control measures, along with securing access to water, sanitation, hygiene and waste management facilities and services. Greater awareness, leadership and coordination across sectors, government and non-government, is urgently required for action against AMR.
For all of us - images of delivery beds and neonatal units across health facilities in India should serve as constant reminders that quick fixes with antibiotics must be replaced with deeper systems strengthening approaches that keep our mothers and babies safe from harm in the short and long-term.