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SuperbugsKillIndiasBabiesandPoseanOverseasThreatNYTimes.com

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ASIA PACIFIC

Superug Kill India aie and Poe an

Overea Threat
GARDINR HARRIS

DC. 3, 2014

AMRAVATI,IndiaAdeadlyepidemicthatcouldhaveglobalimplicationsis
quietlysweepingIndia,andamongitsmanyvictimsaretensofthousandsof
newbornsdyingbecauseoncemiraculouscuresnolongerwork.
Theseinfantsarebornwithbacterialinfectionsthatareresistanttomost
knownantibiotics,andmorethan58,000diedlastyearasaresult,arecent
studyfound.Whilethatisstillafractionofthenearly800,000newbornswho
dieannuallyinIndia,Indianpediatricianssaythattherisingtollofresistant
infectionscouldsoonswampeffortstoimproveIndiasabysmalinfantdeath
rate.NearlyathirdoftheworldsnewborndeathsoccurinIndia.
ReducingnewborndeathsinIndiaisoneofthemostimportantpublic
healthprioritiesintheworld,andthiswillrequiretreatinganincreasing
numberofneonateswhohavesepsisandpneumonia,saidDr.VinodPaul,
chiefofpediatricsattheAllIndiaInstituteofMedicalSciencesandtheleader
ofthestudy.Butifresistantinfectionskeepgrowing,thatprogresscould
slow,stoporevenreverseitself.Andthatwouldbeadisasterfornotonly
Indiabuttheentireworld.
InvisitstoneonatalintensivecarewardsinfiveIndianstates,doctors
reportedbeingoverwhelmedbysuchcases.
Fiveyearsago,wealmostneversawthesekindsofinfections,saidDr.
NeelamKler,chairwomanofthedepartmentofneonatologyatNewDelhisSir
GangaRamHospital,oneofIndiasmostprestigiousprivatehospitals.Now,
closeto100percentofthebabiesreferredtoushavemultidrugresistant

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infections.Itsscary.
Thesebabiesarepartofadisquietingoutbreak.Agrowingchorusof
researcherssaytheevidenceisnowoverwhelmingthatasignificantshareof
thebacteriapresentinIndiainitswater,sewage,animals,soilandevenits
mothersareimmunetonearlyallantibiotics.
Newbornsareparticularlyvulnerablebecausetheirimmunesystemsare
fragile,leavinglittletimefordoctorstofindadrugthatworks.Buteveryoneis
atrisk.UppalapuShrinivas,oneofIndiasmostfamousmusicians,diedSept.
19atage45becauseofaninfectionthatdoctorscouldnotcure.
Whilefarfromaloneincreatingantibioticresistance,Indiasresistant
infectionshavealreadybeguntomigrateelsewhere.
Indiasdreadfulsanitation,uncontrolleduseofantibioticsand
overcrowdingcoupledwithacompletelackofmonitoringtheproblemhas
createdatsunamiofantibioticresistancethatisreachingjustaboutevery
countryintheworld,saidDr.TimothyR.Walsh,aprofessorofmicrobiology
atCardiffUniversity.
Indeed,researchershavealreadyfoundsuperbugscarryingagenetic
codefirstidentifiedinIndiaNDM1(orNewDelhimetallobetalactamase1)
aroundtheworld,includinginFrance,Japan,OmanandtheUnitedStates.
AnjuThakursdaughter,bornprematurelyayearago,wasoneofthe
epidemicsvictimsinAmravati,acityincentralIndia.DoctorsassuredMs.
Thakurthatherdaughter,despiteweighingjustfourpounds,wouldbefine.
Herhusbandgavesweetstoneighborsincelebration.
Threedayslater,Ms.Thakurknewsomethingwaswrong.Herdaughters
stomachswelled,herlimbsstiffenedandherskinthickenedclassicsignsof
abloodinfection.Asaprecaution,doctorshadgiventhebabytwopowerful
antibioticssoonafterbirth.Doctorsswitchedtootherantibioticsandswitched
again.Nothingworked.Ms.Thakurgaveapuja,orprayer,tothegoddess
Durga,butthebabysconditionworsened.Shedied,justsevendaysold.
Wetriedeverythingwecould,saidDr.SwapnilTalvekar,the
pediatricianwhotreatedher.Ms.Thakurwasinconsolable.Ineverthought
Idstopcrying,shesaid.

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Atestlaterrevealedthattheinfectionwasimmunetoalmostevery
antibiotic.Thechildsrapiddeathmeantthebacteriaprobablycamefromher
mother,doctorssaid.
Healthofficialshavewarnedfordecadesthatoveruseofantibiotics
miracledrugsthatchangedthecourseofhumanhealthinthe20thcentury
wouldeventuallyleadbacteriatoevolveinawaythatmadethedrugsuseless.
InSeptember,theObamaadministrationannouncedmeasurestotacklethis
problem,whichofficialstermedathreattonationalsecurity.
Somestudieshavefoundthatdevelopingcountrieshavebacterialratesof
resistancetoantibioticsthatarefarhigherthanthoseindevelopednations,
withIndiatheglobalfocalpoint.
BacteriaspreadeasilyinIndia,expertssay,becausehalfofIndians
defecateoutdoors,andmuchofthesewagegeneratedbythosewhodouse
toiletsisuntreated.Asaresult,Indianshaveamongthehighestratesof
bacterialinfectionsintheworldandcollectivelytakemoreantibiotics,which
aresoldoverthecounterhere,thananyothernationality.
ArecentstudyfoundthatIndianchildrenlivinginplaceswherepeople
arelesslikelytouseatoilettendtogetdiarrheaandbegivenantibioticsmore
oftenthanthoseinplaceswithmoretoiletuse.OnOct.2,theIndian
governmentbeganacampaigntocleanthecountryandbuildtoilets,with
PrimeMinisterNarendraModipubliclysweepingaDelhineighborhood.But
thetaskismonumental.
Intheabsenceofbettersanitationandhygiene,weareforcedtorely
heavilyonantibioticstoreduceinfections,saidRamananLaxminarayan,vice
presidentforresearchandpolicyatthePublicHealthFoundationofIndia.
Theresultisthatwearelosingthesedrugs,andournewbornsarealready
facingtheconsequencesofuntreatablesepsis,orbloodinfections.
Somehealthexpertsandofficialsheresaythatthesekillerbugsarelargely
confinedtohospitals,whereheavyuseofantibioticsleadstolocalized
colonies.
ButIndiastopneonatologistssuspectthelargenumberofresistant
infectionsinnewbornsintheirfirstdaysoflifedemonstratesthatthese

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dangerousbacteriaarethrivingincommunitiesandevenpregnantwomens
bodies.
Ourhypothesisisthatresistantinfectionsinnewbornsmaybe
originatingfromthematernalgenitaltractandnotjusttheenvironment,Dr.
Paulsaidinaninterview.
InacontinuingstudyinDelhiatseveralgovernmentrunhospitalsthat
hassofarincludedmorethan12,000highrisknewborns,andwasmade
availabletoTheNewYorkTimes,about70percentofthebabiesinfections
werefoundtobeimmunetomultiplepowerfulantibiotics,confirmingthe
resultsofearlierandsmallerstudies.
DoctorsinterviewedinhospitalsacrossIndiasaidthatalargenumberof
theinfectionstheyfoundinnewbornswereresistanttomanyantibiotics.
Awarenessoftheproblemhasbeguntogrow,withIndianmedicalassociations
callingforeffortstoreduceunnecessaryantibioticuse.Butthereiskeen
sensitivityheretoanyalerttothedangers.A2010discoveryofaNewDelhi
superbugcausedintensecontroversybecauseoffearsthatpublicitywould
threatenIndiasprofitablemedicaltourismindustry.Governmentofficials
havestoppedsomestudiesoftheproblem,Dr.Walshsaid.
TheeffectsofantibioticresistantbacteriaontreatingdiseaseinIndia
couldbeenormous.Tuberculosisisjustoneexampleofthechallengesdoctors
face.Indiahastheworldslargestnumberofcases,andrecentstudiesusing
thelatestgenetictestshaveshownthatasmanyas10percentofuntreated
patientsinplacesasfarapartasMumbaiandSikkimhaveresistantinfections.
Thesepatientsarecatchingresistantbugsathome,nothospitals,makingthe
epidemicverydifficulttocontrol,Dr.SoumyaSwaminathan,directorofthe
NationalInstituteforResearchinTuberculosis,saidinaninterview.
Itsstartlingandveryworrying,Dr.Swaminathansaid.Unlessthe
governmentmakesprofoundanddrasticchanges,tuberculosisinIndiamay
soonbecomeuntreatable,shesaid.
Althoughresistantbugsareeverywherehere,hospitalshavebecome
factoriesforuntreatablesuperbugs.Agovernmentprogramthatpays
womentohavebabiesinhospitalshasin10yearsmorethandoubledthe

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shareofhospitalbornbabiesto82percent,butthegovernmentdidlittleto
increasehospitalcapacitytodealwiththecrush.Maternitywardsoftenhave
twoandthreewomenineachbed,allowinginfectionstospreadrapidly.
Besidesbeingdesperatelycrowded,manyhospitalsareunhygienic,
allowingthebugstoflourish.AUnicefsurveyof94districthospitalsand
healthcentersinRajasthanlastyearfoundthat70percenthadpossibly
contaminatedwaterand78percenthadnosoapavailableathandwashing
sinks,while67percentoftoiletswereunsanitary.
DoctorsacrossIndiahaverespondedtothesanitationcrisisinhospitals
bygivingantibioticsfreely.
InHaryana,forinstance,almosteverybabyborninhospitalsinrecent
yearswasinjectedwithantibioticswhethertheyshowedsignsofillnessornot,
Dr.SureshDalpat,deputydirectorofchildhealthinthestateofHaryana,said
inaninterview.Now,withpropertraining,wearebringingthatdown.
Allthosedrugscreateresistantbacteriathatfindtheirwayintohospital
sewage,whichismostlydumpeduntreatedintorivers,canalsandpitsinthe
surroundingcommunitywherepregnantwomencanbecomeinfected.
ThemostfrequentcausesofresistantnewborninfectionsinIndiaare
bacterialikeKlebsiellaandAcinetobacter,whicharefoundinuntreated
humanwaste.Suchbacteriararelyinfectnewbornsindevelopednations,said
Dr.Paul.
Indiaandotherdevelopingnationsarebynomeansaloneinthreatening
thefutureofantibiotics.Overuseofthedrugsinchicken,hogandcattlefarms
intheUnitedStateshasledtotheriseofresistantstrainsthere,andresearch
hasshownthatasmuchashalfofantibioticprescriptionsintheUnitedStates
areunnecessary.
TheCentersforDiseaseControlandPreventionestimatedlastyearthat
twomillionpeoplearesickenedbyresistantbacteriaeveryyearintheUnited
Statesand23,000dieasaresult.Buteffortstocrackdownoninappropriate
antibioticuseintheUnitedStatesandmuchofEuropehavebeensuccessful,
withprescriptionsdroppingfrom2000to2010.Thatdropwasmorethan
offset,however,bygrowinguseinthedevelopingworld.

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Globalsalesofantibioticsforhumanconsumptionrose36percentfrom
2000to2010,withBrazil,Russia,India,ChinaandSouthAfricaaccounting
for76percentofthatincrease.InIndia,muchofthatgrowthhasbeendriven
byprivatedoctorswhodeliverabout90percentofcarehereandareoften
poorlytrained.Muchofthesedoctorsincomecomesfromdrugsales.
JustasworrisomehasbeentherapidgrowthofIndiasindustrialized
animalhusbandry,whereantibioticsarewidespread.Mostlargechickenfarms
hereusefeedlacedwithantibioticsbannedforuseinanimalsintheUnited
States.ANewDelhisciencegrouprecentlyfoundantibioticresiduesin40
percentofchickensamplestested.
Buttheeffectsinchildrenareperhapsthemostheartwrenching.After
herbabysdeathayearago,Ms.Thakur,21,wassoonpregnantagain.She
gavebirthonSept.21toababygirl.Onavisitshortlyafterthebabysbirth,
Ms.Thakurwasshiveringfromasevereinfectionwhilestayinginahomewith
notoiletorrunningwater.Shenursedhertinyinfant,Khushi,underasmall
shrinewithpicturesofDurgaandKrishna.
Nearlytwomonthslater,shereportedthatsheandthebabywerefine.
A version of this article appears in print on December 4, 2014, on page A1 of the New York edition
with the headline: Superbugs Kill Indias Babies and Pose an Overseas Threat.

2015 The New York Times Company

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