doi:10.1038/nindia.2016.110 Published online 25 August 2016
Pharmacies in India are contributing to the emergence of antimicrobial resistant superbugs by encouraging improper use of antibiotics, according to a study1. In parallel, tuberculosis (TB) cases in the country are being vastly under reported – a situation that might significantly fuel drug resistance with implications for patients across the globe2.
These findings – part of a scientific stealth operation and published simultaneously – come as a warning for India, a country with the world’s largest consumer base of antibiotics and highest burden of TB.
The first study by researchers at Canada's McGill University in partnership with Indian institutions, aimed to assess the medical advice and drug dispensing practices of Indian pharmacies for patients with "presumed" and "confirmed" tuberculosis.
"It was a sort of an undercover operation spread over two years," Srinath Satyanarayana, the lead author at McGill University, told Nature India.
The researchers trained about a dozen people to pretend to be suffering from TB symptoms or with microbiologically confirmed pulmonary TB. The "fake" patients were then sent to 622 selected pharmacies in three Indian cities (Delhi, Mumbai, and Patna) to seek help. They returned with all the medication needed, dispensed to them by the pharmacists.
The study revealed that the pharmacies frequently gave antibiotics and steroids to those who presented with TB symptoms and rarely referred them to appropriate care thereby contributing to delays in TB diagnosis and increasing transmission of the infection in the community.
According to the researchers their study, first of its kind in India, shows the critical importance of engaging pharmacists for reducing misuse of antibiotics, and for fighting TB.
In the second study led by Nimalan Arinaminpathy from the School of Public Health at the Imperial College London, researchers calculated nationwide sales of anti-tuberculosis drugs across the private sector in India and concluded there were 2.2 million TB cases in the private sector in 2014. This was two to three times higher than current estimates.
"Thus, India’s private sector is treating an enormous number of patients for TB, appreciably higher than has been previously recognised," Madhukar Pai, Director of McGill Global Health Programmes told Nature India.
According to the authors, this has worrying implications for the emergence of drug-resistant strains of tuberculosis because, in the private sector, patients are usually sent off with their medication without advice or support and they stop taking the medication – without completing the full course.
"For example, Mumbai currently has a worrying epidemic of drug-resistant tuberculosis and the private sector has a role in this,” says Arinaminpathy.
The authors suggest that India should urgently increase surveillance in the private sector to arrest this alarming trend.
1. Satyanarayana, S. et al. Use of standardized patients to assess antibiotic dispensing for tuberculosis by pharmacies in urban India: a cross-sectional study. Lancet Infect. Dis. (2016) doi: 10.1016/S1473-3099(16)30215-8
2. Arinaminpathy, N. et al. The number of privately treated tuberculosis cases in India: an estimation from drug sales data. Lancet Infect. Dis. (2016) doi: 10.1016/S1473-3099(16)30259-6