Antimicrobial Awareness Week 2021: The fight to make Kerala antibiotic literate is on

The Kerala Antimicrobial Resistance Strategic Action Plan (KARSAP) was launched October 25, 2018 by Kerala Chief Minister Pinarayi Vijayan. The introduction of this initiative in the presence of the state health minister, the World Health Organization (WHO) Representative and senior officials from Departments of Agriculture Development & Farmers’ Welfare, Animal Husbandry, Environment, Health and Fisheries emphasises that KARSAP is truly a ‘One Health’ initiative.

KARSAP was the first such state-level action plan to be released in India. KARSAP has six strategic priorities which are aligned with the National Action Plan on AMR as well as the global action plan.

The six strategic priorities reflect the ‘One Health’ approach and need for inter-sectoral co-ordination. They are:

• Awareness and understanding: This includes education, training, communication and IEC activities with regard to AMR in all sectors including human health, animal husbandry, fisheries, dairy, aquaculture, horticulture and environment.
• Knowledge and evidence: This includes AMR surveillance and strengthening of laboratory networks in all relevant sectors.
• Infection prevention and control: Activities in human health, animal husbandary, environment and community.
• Optimising use of antimicrobials: Through regulations and antimicrobial stewardship in humans, animals and food.
• Innovations, research and development in all relevant sectors.

Multiple workshops and brainstorming sessions were conducted in 2018 and 2019 involving relevant stakeholders and an action plan was created to achieve the short-term as well as long-term targets identified under KARSAP.

This plan included a roadmap framed with the help of Delhi-based non-profit Centre for Science and Environment for Kerala to phase-out non-therapeutic antibiotic use and to reduce the use of critically important antibiotics (for humans) in the poultry sector.

A framework for AMR surveillance in environment was also drawn up. Recommendations with regard to setting standards for antibiotic residues for effluents from all point sources, upgradation of effluent treatment plans and regulation to ban use of poultry litter in aquaculture were also drafted.

KARS-NET (Kerala antimicrobial resistance surveillance network) was established in 2017 with the help of the WHO country office for India and National Centre for Disease Control (NCDC). 

It was established to strengthen laboratory capacity for AMR surveillance in the state and to collate data to generate representative antibiograms for providing evidence based information for action

Initially, the AMR surveillance network included only tertiary care institutions in the government sector. To get representative data from private hospitals, primary and secondary care institutions, KARSAP was systematically expanded to include other institutions, including private medical colleges and laboratories. By end of 2019, KARS-NET had expanded to include 22 satellite centres with GMC Thiruvananthapuram as the focal point.

 KARS-NET objectives are

• Foster standardisation, strengthening and expansion of AMR surveillance in Kerala;
• Analyse and report KARS-NET data to the state government and NCDC on regular basis;
• Contribute towards the estimation of extent, burden and monitoring of AMR in Kerala; and
• Detect emerging resistance and its spread in Kerala

During the November 2019 annual review of KARSAP activities by the state health minister, it was decided to make Kerala an antibiotic literate / aware state by 2021. World Antibiotic Awareness Week activities carried out in Kerala in November 2019 were focussed on the same theme.

The broad objectives envisaged under the antibiotic literate Kerala campaign are:

• Universal awareness about the importance of having access to antibiotic free food and water.
• Universal awareness about the importance of consuming antibiotics only on doctor’s prescription.
• Universal awareness about importance of safely disposing unused or date expired antibiotics. (For this, Kerala has started a unique campaign termed PROUD or Programme on removal of unused drugs, which is a joint venture of the Kerala State Drugs Control Department and All Kerala Chemists and Druggists Association).
• Awareness among school students of the threat posed by AMR.

Till the end of January 2020, all programmes were being conducted as planned and Kerala was slowly but surely on its way to become a truly antibiotic literate state by 2021.

The state was on track to achieve the short-term and long-term targets envisaged under KARSAP within the stipulated time frames. However the emergence of the novel coronavirus disease (COVID-19) pandemic put brakes on the smooth running of KARSAP.

The first case of COVID-19 in India was diagnosed in Kerala January 30, 2020. From then on, the state has prioritised the utilisation of all healthcare resources to tackle the scourge of COVID-19.

This is considering the epidemiological vulnerability of Kerala owing to its density of population which is twice the national average, the large proportion of the elderly due to increased life expectancy and due to increased prevalence of diabetes mellitus and hypertension among the young.

When the state geared up to smother the impact of the ‘visible pandemic of COVID-19’, it was only natural that activities under KARSAP aimed at ‘invisible pandemic of AMR’ got disrupted.

Impact of COVID-19 on KARSAP 

• All microbiology labs under KARS-NET started functioning round-the-clock to perform molecular diagnosis of SARS-CoV-2 and hence, antimicrobial surveillance in the state took a back seat. Further expansion of KARS-NET was not attempted due to possible attrition in the wake of COVID-19.
• The link nurses posted in ICUs to capture and audit healthcare associated infections (HCAI), were posted in COVID-19 areas by turn. This loss of continuity impacted capturing HCAI rates like VAP, CA-UTI, CLABSI, SSI etc.
• Antibiotic utilisation metrics calculation was also affected similarly.
• Since the focus was on COVID-19, activities planned to make Kerala antibiotic literate by 2021 could not be carried out. It was decided in the 2021 review meeting to extend the timeline to 2023.
• The annual intersectoral review meeting of KARSAP in 2020 was not conducted.
• Activities planned under environmental surveillance could not be performed in view of the lockdown and other restrictions.
• Since the focus was on COVID-19, research activities under KARSAP also got deferred.

Impact of KARSAP on COVID-19 

• Since all the healthcare workers [HCWs] in the state had already been trained in IPC practices like donning, doffing, droplet and airborne precautions, etc as part of KARSAP, the mortality among HCWs in Kerala is 0.06, which is one of the lowest in the world.
• Adherence to mask etiquette, cough etiquette, social distancing, hand hygiene, etc were high in Kerala, resulting in plateauing of both the first and second COVID-19 waves. This ensured that the number of COVID-19 cases in the state even during the peak of the second wave never exceeded the capacity of healthcare infrastructure. The spreading out of cases over a long period of time in contrast to the rapid peak and descent of the epidemic curve witnessed in other states ensured that Kerala was never short of oxygen or COVID-specific medications. All these contributed to the low COVID-19 case fatality rate in Kerala.
• Adherence to very good IPC practices in ICUs and glycaemic optimisation ensured that incidence of COVID-19 associated mucormycosis in Kerala was very low compared to other states.
• Due to strict adherence to mask and cough etiquette, hand hygiene, etc there was a significant decrease in respiratory infections in the state other than COVID-19. The sale of antibiotics in the state in 2020 was 30 per cent less compared to that in 2019.
• The ‘Hub and spoke’ model for antimibrobial stewardship pioneered by General Hospital Ernakulam was converted to a hub and spoke model for molecular diagnosis of COVID-19.

To borrow Franklin D Roosevelt’s words, ‘smooth seas never made skilful sailors’, COVID-19 was a tempest that KARSAP had to negotiate. Hopefully the worst is past and we, battered and bruised by the COVID-19 experience, but much wiser, have regrouped and are determined to achieve the seemingly ambitious target of making Kerala an antibiotic literate state by 2023.

Aravind Reghukumar is head of the infectious diseases department at Govenment Medical College Thiruvananthapuram

Views expressed are the author’s own and don’t necessarily reflect those of Down To Earth

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