Antibiotic resistance: China battles population, size

Health care reform since 2011 bear results but more needs to be done

By Alok Gupta
Published: Friday 24 January 2020

China is one of the world's largest consumers of agricultural antibiotics: It consumed 162,000 tonnes antibiotics in 2013 — more than half the global total. About 52 per cent was used on livestock and 48 per cent by humans.

Antibiotic residues contaminate the environment. More than 50,000 tonnes antibiotics ended up in its water and soil, entering the food chain, found the Guangzhou Institute of Geochemistry of the Chinese Academy of Sciences (CAS). Resistance to antibiotics is thus expected.

Concerned over growing antibiotic resistance, China launched two major networks in 2005 — China Antimicrobial Resistance Surveillance System (CARSS) and the China Antimicrobial Surveillance Network (CHINET). While the former collects data on antibiotic usage, the latter is a database of bacterial resistance collected from 960 million people.

The data and the World Health Organization's (WHO) global efforts to curb the increasing use of antibiotics prompted China to rope in 14 ministries to initiate a five-year national action plan from 2016 to 2020.

The 2019 annual report from CARSS shows a significant decrease in the antimicrobial consumption in the country. Among inpatients in the core member hospital, usage decreased 0.5 percentage points from 36.9 per cent in 2018.

The decadal comparison shows a much stronger picture: a decline to 36.4 per cent in 2018 from 59.4 per cent in 2011. The use of antibiotics in surgeries decreased to 21.9 per cent from 41.5 per cent.

But the antibiotic use in tertiary general hospitals remains a severe issue. In these hospitals, antibiotics used among inpatients were nearly 38.6 per cent higher than that of core member hospitals, according to the report.

Last year, the amount of antimicrobials cumulatively consumed by inpatients in 157 general hospitals in the country was 11.7 billion, with daily defined doses (DDD) of 650.54 million. The report also listed the top three antibiotics consumed in the country: Quinolones (13 per cent), third-generation cephalosporin (13 per cent), cephalosporins (12 per cent).

Use, misuse and overuse of antibiotics wreaked havoc globally with bacteria evolving and making it difficult to cure a few diseases, CK Lee from WHO China told Down To Earth.

“In China’s case, population and geographical size make tackling antibiotic resistance challenging. But antibiotics consumption is slowing down due to the joint action by the government and medical staff including doctors and even patients,” Lee said. It took China more than a decade of planning and implementation.

In 2011, under a major healthcare reform, China launched a special campaign for the “rational use of antimicrobials in healthcare systems.” A system was created for the proper management of antibiotics with auditing and inspections.

Authorities set targets for reducing antibiotic prescriptions — they should make up less than 60 per cent of all prescriptions for hospitalised patients, and less than 20 per cent for outpatients.

Antibiotic uses in hospitalised patients were aimed to be less than 40 DDD per 100 patient days. For Mao Yuan, a doctor at Hegang People's Hospital in Heilongjiang province, the policy meant a change in the mindset of both medical staff and patients.

“We realised, as doctors, our role was not only to diagnose a patient but also patiently explain to them why they don’t need antibiotics,” she said. “Still, we need to work hard to ensure antibiotics are not overprescribed,” she added.

The extensive use of antibiotics in meat and agricultural products also contributes massively to the resistance. In order to reduce heavy antibiotic use in animal farms, China established a new government animal health administration system with 300,000 staff and 73,000 veterinarians.

The role of this workforce is to monitor, supervise, and provide assistance to farmers regarding the use of chemicals. The initiative was part of a national action plan to monitor the drug tolerance of animal-origin bacteria launched in 2009 with a surveillance system for the antibiotic use in animals and agriculture in place by 2013.

The policy was given more teeth with the implementation of two national action plans in 2015 and 2016. In 2015, the Ministry of Agriculture and Rural Affairs banned the use of four antimicrobials — lomefloxacine, pefloxacine, ofloxacin, norfloxacin — in animals.

Colistinsulphate was prohibited as a feed additive in 2017. The ministry also phased out the use of phenylarsonic additives in chicken and pig feed from May 2019. Strict enforcement can lead to 1,160 fewer cases of human cancer in the country, saving $85 million, said a risk analysis by researchers at Peking University and the University of Iowa.

The action comes amid a recent study that raises concern over rising antibiotic resistance among pigs and chicken in low and medium-income countries. Animal farms in northeastern China are facing increasing antibiotic resistance.

The country is already reeling under a crisis with the outbreak of African Swine Fever (ASF) that has wiped out nearly half of its swine population. Experts believe China — the world's largest consumer of pork — will witness a massive surge in pig farms in the coming years and a possibility of more use of antibiotics. 

The fact that China is one of the biggest manufacturers of antibiotics is also contributing to the problem of antibiotic resistance. In order to control the effluents released by the pharmaceutical industries, especially the antibiotics sector, China issued strict guidelines in the National Action Plan 2016.

The norms made Environmental Impact Assessment (EIA) more stringent by directing companies to follow the rules even for re-construction and extension of antimicrobial projects. An extensive evaluation system for measuring the key indicators of antibiotic effluent was also adopted.

A green signal was given for setting up enhanced surveillance systems. It also allowed changes to the regulations from time to time to keep up with technological advances in surveillance systems. 

The focus is to curb effluents disposed of by antibiotics industries from entering the water, soil and sewage systems. The policy also promotes research projects to measure the ecological impact of antibacterial agent contamination by pharmaceutical companies. 

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