Can Kerala’s policy to limit the misuse of antibiotics lead to less AMR?

Sales of antibiotics through hospitals and medical shops across Kerala fell by ₹1,000 crore last year | Image credit: iStockphoto

With the successful operation of Amrith (Antimicrobial Resistance Intervention for Total Health) to completely stop the over-the-counter sale of antibiotics by the end of 2024, Kerala has seen a significant reduction in the irrational use of antibiotics by people. According to media reports, there has been a sharp drop of Rs 1,000 crore in the sale of antibiotics through hospitals and medical shops across Kerala in the last year.

In early January this year, Kerala became the first state in the country to ban the over-the-counter sale of antibiotics without a prescription. It was enforcing the Indian government’s 2011 Rule H1 banning the OTC sale of antibiotics without a prescription. The 2011 H1 rule prohibits the sale of all antibiotics – first, second and third line – without a prescription. Even when the Indian government in 2013 changed the rule to allow the first antibiotics to be sold over the counter without a prescription, Kerala went ahead and implemented the 2011 H1 rule. The 2011 rule was amended by the Indian government to allow the sale of first-line antibiotics as a complete non-prescription ban for all classes of antibiotics would have done more harm than good – it would have severely limited access to first-line medicines. medicines, especially in remote places where doctors are not always available. Kerala was able to implement the 2011 H1 rule as it has a high doctor-to-patient ratio, availability of doctors in most places and widely varying health-seeking behavior of people in the state.

While Kerala was able to implement the 2011 H1 rule and reduce the misuse of antibiotics, no other state in India has implemented even the amended 2013 H1 rule. Despite a good patient-doctor ratio, there are pockets in the southern states, including Tamil Nadu and Karnataka, where the availability of doctors is a problem and where people cannot easily visit a doctor for various reasons.

“Kerala’s proactive measures against Antimicrobial Resistance (AMR) are commendable but the fight against AMR cannot be confined to one state. AMR knows no borders and Kerala’s efforts to reduce antibiotic resistance will have limited impact unless neighboring states also adopt similar policies,” says Dr. Abdul Ghafur, Consultant Infectious Diseases, Apollo Hospitals, Chennai, and Coordinator, Chennai Statement on AMR. “Kerala should consider adopting the amended H1 rule of 2013, which monitors only second- and third-line antibiotics but allows the sale of first-line antibiotics over the counter to continue without strict monitoring. This approach would balance the need for antimicrobial stewardship with access to healthcare and economic considerations and ensure that Kerala is a practical and scalable example for other Indian states.

Currently, Kerala imports at least 60% of its broiler chicken, eggs and vegetables from neighboring states, many of which have no AMR regulations for humans, animals and agriculture. According to the Kerala State Planning Board report 2022-2027, vegetable production in the state meets only 40% of Kerala’s requirement. Similarly, Kerala produces only about 42% of its egg requirement while it relies on other states for the balance. As of June 2023 report in The HinduKerala imports almost 70% of broiler chicken from Tamil Nadu.

“Studies, including my own, have shown that these imported foods often carry antibiotic residues and drug-resistant bacteria, which enter the human gut and transfer their resistance genes to other bacteria. This creates a continuous cycle of AMR spread, undermining Kerala’s local efforts,” he says.

With no other state enforcing a national regulation on antibiotic use in agriculture and poultry, the production and spread of antibiotic-resistant bacteria will continue to be a major problem in India. With Kerala relying largely on other states for vegetables, eggs and broiler chickens, the state remains vulnerable to the constant import of antibiotic-laden products. “For Kerala’s AMR efforts to have a lasting impact, there are two possible courses of action – Kerala should become self-sufficient and stop importing poultry, eggs and vegetables from other states or it can work to convince neighboring states to implement stringent AMR control programs, “says Dr. Ghafur

Other states will only start enforcing strict AMR policies if they can be implemented. The 2011 H1 rule, which bans OTC sales of all classes of antibiotics, will not be enforceable by other states. It is for this reason that Kerala needs to step back and enforce the amended 2013 H1 rule to get neighboring states to enforce the rule and start the process of reducing antibiotic use in veterinary medicine and agriculture. “Adopting such a tiered, adaptable model will ensure that Kerala’s efforts to combat AMR are not in vain and will encourage other states to follow suit,” he says. “Once the modified H1 rule has been successfully implemented, at least in neighboring states, these states can gradually work toward a broader ban on the sale of OTC antibiotics.”