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Antibiotic Treatments for Short-term Morbidity in India

Thiagu Ranganathan (thiagu.ranganathan@ gmail.com) teaches at the Institute of Economic Growth, New Delhi.

The proportion of patients receiving antibiotic treatment for short-term morbidity in India is estimated using nationally representative survey data, the Indian Human Development Survey conducted in 2011–12. It is found that antibiotic usage varies across different parameters: the types of symptoms, the primary source providing medical advice/ treatment, number of days the patient was ill, age group of the patient, and the month in which the survey was conducted.

Rational use of antibiotics is of vital concern in the area of public health. Underuse and overuse of antibiotics both have important long-term implications for human health. An important concern related to excessive usage of antibiotics is that it tends to increase the prevalence of antibiotic-resistant populations of bacteria (Laxminarayan and Chaudhury 2016). Overuse of antibiotics, thus, could reduce its clinical value, though access to antibiotics is also essential for dealing with several diseases. This means that responsible use of antibiotics would involve dealing with dual obligations: to make the clinical value of antibiotics accessible to all today, and simultaneously to maintain its clinical value for future (Dyar et al 2016).

In this sense, antibiotic usage poses one of the most complex challenges related to sustainable access of resources across generations. There are various efforts being made to deal with this intricate problem.1 A key to addressing this challenge is the understanding of the current levels and patterns of usage of antibiotics. This article is an attempt in this direction and it estimates the proportion of patients using antibiotics in India with the help of nationally representative household survey data.

India was the largest consumer of antibiotics for human health in 2015 (CDDEP 2015). According to the estimates of the IMS Health MIDAS database, the consumption of antibiotics in India in 2015 was around 13 billion standard units,2 which translates roughly to 10.6 standard units per person.3 The consumption of antibiotics in China came a distant second at around 10 billion standard units. Though total consumption is highest in India, there were few other countries with higher per person antibiotic consumption. Figure 1 presents the antibiotic use per person in different countries.

Apart from the high consumption of antibiotics, its usage in India has also been showing an increasing trend. The use of antibiotics increased from 7.4 standard units per person in 2004 to 10.6 standard units per person in 2015, an increase of 44% over a period of 11 years. This indicator was almost constant in the preceding five years. The linkage between per capita income and antibiotic use has been documented (CDDEP 2015: Figure ES-2), and rising per capita incomes could be one of the reasons for rising trends in antibiotic use in India starting from 2004. Figure 2 (p 78) presents the trends of antibiotic use in India from 2000 to 2015.

Along with excessive usage, there are also other problems like dumping of waste by the pharmaceutical industry, which have resulted in a widespread increase of antibiotic resistance genes in the environment (Bengtsson-Palme et al 2014). The reporting of the antibiotic-resistant bacteria called New Delhi metallo-β-lactamase-1 (NDM-1) across different parts of the world has also meant that the concerns of excessive antibiotic usage is a global problem and not restricted to any single country (Kumarasamy et al 2010; EPW 2010; Maurya 2014). It is in this context that this article presents the prevalence of antibiotic treatment for short-term morbidity by patients in India.

Survey Details

The data used is from the Indian Human Development Survey (IHDS) conducted in 2011–12.4 The IHDS is a large-scale nationally representative survey that was conducted under the supervision of the National Council of Applied Economic Research (NCAER) in collaboration with the University of Maryland. The survey covers almost all the states and union territories of India, except Andaman and Nicobar Islands, and Lakshadweep. The survey used two-stage stratification and was conducted over a sample of 42,152 households, including 27,579 households in rural areas and 14,573 urban households. The survey also collected details related to 2,04,569 individuals in these households.

Along with various socio-economic details of the household, the survey also collected extensive information related to education and health of the household members. With regard to information related to health, the survey collected data on short-term morbidity (fever, cough and diarrhoea) and long-term morbidity (cancer, tuberculosis, high blood pressure, heart diseases, diabetes, leprosy, asthma, polio, paralysis, epilepsy, mental illness, AIDS, accidents, etc) of household members. The data related to short-term morbidity has been analysed in this article.

On short-term morbidity, the survey collected information related to the number of days any individual was ill in the 30 days preceding the survey, the symptoms the patient had, the type of treatment received, the source of medical advice or treatment, and the expenditure incurred in dealing with the illness. The types of treatment were categorised as pain killer/cough syrup, antibiotic, other allopathic, ayurvedic, homeopathy, home/herbal remedy, surgery, and others. From these variables, we can estimate the percentage of patients who received antibiotic treatment.

The survey also categorised the different locations as metros (Delhi, Hyderabad, Bengaluru, Chennai, Kolkata, and Mumbai), other urban areas, more developed villages, and less developed villages. The villages were classified into more developed and less developed based on infrastructure indicators. Various indicators, like paved roads with easy access to urban areas, postal and telephone connections, spread of electricity, and number of televisions, were used to classify villages into approximately two equal groups (Desai et al 2015). The usage of antibiotics could be different across these four categories of locations due to variations in the presence of healthcare facilities, quality of healthcare, lifestyle, and incomes, among other things.

Short-term Morbidity

Of all the individuals considered in the analysis, 17.5% had a symptom of an illness (fever, cough, or diarrhoea) for at least one day in the 30 days prior to the survey. Of these individuals, 97.5% received some form of treatment. The details of the treatment received by them are presented in Table 1.

 

From Table 1, we observe that around 23% of the patients received antibiotic treatment. Around 11% used pain killer/cough syrup, while 63% underwent other allopathic treatment. The proportion of people who used homeopathy and other treatments were minimal. The proportion of patients receiving antibiotic treatment is highest in metros (29%) followed by other urban areas, more developed villages, and less developed villages. Kotwani and Holloway (2011) estimate that around 40% of patients in Delhi had used antibiotics in the period between December 2007 and November 2008. The estimate of the same for Delhi was 37% based on the current survey. Most of the survey in Delhi was conducted in the months of June, August and January. There could be a higher proportion of patients using antibiotics in months like November and December. The association between the month of conducting the survey and antibiotic usage is also important and will be presented later in the article.

Antibiotics are given for wide range of illnesses. The data collected in the survey mainly pertains to incidence of fever, cough and diarrhoea. An individual can suffer from more than one of these symptoms of illnesses simultaneously. Of all the individuals with short-term morbidity, 53% suffered from fever and cough, 27% suffered from only fever, and 8% had fever, cough and diarrhoea. The proportion of people receiving antibiotic treatment across the different combinations of symptoms is provided in Table 2 (p 79).

 

From Table 2, we find that the proportion of individuals receiving antibiotic treatment was the least for patients with only cough (18%) and the most for those suffering from fever, cough and diarrhoea (27%). In the six metros, the proportion of patients using antibiotic treatment was as high as 49% for those suffering from all three symptoms of fever, cough and diarrhoea. There are chances that there is significant misuse of antibiotics for the various symptoms identified in the survey. Previous studies have looked into misuse of antibiotics among patients with cough, diarrhoea and fever. For instance, Chatterjee et al (2015) find from their survey of 200 clinicians that cough and cold (79%), fever (65%), and diarrhoea (62%) were the most common conditions of antibiotic misuse.

There could also be heterogeneity among practitioners in prescribing antibiotics for these diseases. Kanungo et al (2014) report the practices of diarrhoeal management practices of allopathic practitioners in slums of Kolkata and found that better knowledge of diarrhoea lowered the likelihood of prescribing antibiotics for it. Thus, the use of antibiotics will also depend on the knowledge of the person providing medical advice/treatment. Table 3 presents the details of the source of medical treatment/advice and antibiotic use.

 

From Table 3, we find that chemists advise the use of antibiotics to a high proportion (31%) of patients. They do so in urban areas other than metros (28%) and villages (35% and 33% in more and less developed villages, respectively). In metros, doctors/nurses advice/prescribe use of antibiotics in higher proportions (29%) than chemists (21%). It is interesting to note that the vaidya/hakim in more developed villages also advise the use of antibiotics to a high proportion (33%) of their patients.

Table 4 looks at the use of antibiotics based on the number of days of morbidity. We find that highest proportion (24.4%) of patients treated with antibiotics was for those with morbidity for four to seven days in the 30 days prior to the survey. Even for morbidity that lasted one to three days in a month, 23.7% patients used antibiotics and this percentage is quite consistent across different types of locations. It is quite possible that some of those cases were severe enough to warrant immediate antibiotic intake.

In other cases, it could be likely that even though the illness was not severe, early use of antibiotics cured the patients and prevented them from a severe illness that could have occurred at a later stage. Even if such is the case, it is very difficult to categorise all cases of antibiotic use within one to three days morbidity as effective use of antibiotics. A part of the usage in such cases could be due to the pressure of recovering fast for both the patient and the person providing treatment/advice. In such instances, the trade-off between individual antibiotic usage and sustainable access of effective antibiotics becomes stark and we face a critical knowledge gap in this regard (Dyar et al 2016).

Table 5 shows the proportion of patients in different age groups using antibiotics. We find that, for all of India, the proportion of patients using antibiotics was the highest (26%) for those in the 41–59 age group. In metros, this was highest for those in the age group of 4–14 years (33%). For children less than three years too, 24% were treated with antibiotics.5

The use of antibiotics could also exhibit seasonality as the prevalence of short-term diseases is also seasonal. Figure 3 (p 80) presents the antibiotic usage across the months in which the survey was conducted with the households. We find that, for all of India, antibiotic usage was highest among those surveyed in May (32%) and lowest among those surveyed in September (16%). In metros, the usage was highest in December (75%) and lowest in October and November (0%). But, this was probably because only nine households had been surveyed in October and November in metros.

Discussion and Conclusions

This article presents the estimates of the proportion of patients using antibiotics in India in 2011–12 using nationally representative survey data. Around 23% of patients used antibiotics for treatment of short-term morbidity. The usage in metros was the highest (29%) and was the lowest in less developed villages (21%). Among those who received treatment from chemists, a high proportion of patients (31%) used antibiotics. Among different age groups, 33% of patients in the 4–14 age group and living in metros received antibiotic treatment. This is quite high compared to other age groups and is an area of immediate concern. Irrational usage of antibiotics in childhood could have severe implications for the health of an individual at later stages of life (Blaser 2014).

A few caveats apply while interpreting these estimates. A single respondent for each household answered the questions for all members of the household. So, there is a possibility of missing out on details of short-term morbidity and the exact nature of treatment of some members in the household. There is also a chance that the respondent had understood the treatment wrongly. Since the respondents might not know exactly which of the treatments were antibiotic in nature, they might have reported some incorrectly. Also, the month in which the surveys happened could have an impact on the estimates. Around 38.1% of the households were surveyed from April to June and the remaining were surveyed across the remaining nine months. Only 18% of the households were surveyed from September to December, which might be a factor in underestimating the proportion of patients using antibiotics.

Even with the above caveats, this article opens avenues for understanding antibiotic usage in India. Apart from the demand-side, there is also a need to look at supply-side aspects that impact antibiotic usage. For instance, Kotwani and Holloway (2013) analyse the supply-side dimensions of antibiotics in New Delhi. The understanding of knowledge and perceptions regarding antibiotics among the general population is also critical. Kotwani et al (2016) analyse the knowledge and perceptions of antibiotic use and resistance among school students and teachers in Delhi. Another aspect that needs to be studied is that of regulation. The release of treatment guidelines by the National Centre for Disease Control in 2016 has been a welcome step in the realm of regulation (NCDC 2016). These guidelines provide a benchmark to evaluate intake and prescription of antibiotics. Future studies could evaluate the appropriateness of the guidelines and also evaluate the actual prescriptions/intake and compare these with the guidelines.

Notes

1 The Global Antibiotic Resistance Partnership (GARP) is a case in point of such efforts.

2 Standard units are defined as the equivalent of one pill, capsule or ampoule.

3 This indicator could be an underestimate of actual use (ResistanceMap 2017b).

4 There was another round of data that was collected in 2004–05, but it did not collect data related to antibiotic use. So, this data has not been used for analysis.

5 The National Family Health Survey–3 finds that around 13% of children in the age group of less than five received antibiotic treatment in 2005–06 (IIPS and Macro International 2007). In the current survey, for the same age group, the estimate of the proportion is 22%.

References

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Kotwani, A, C Wattal, P C Joshi and K Holloway (2016): “Knowledge and Perceptions on Antibiotic Use and Resistance among High School Students and Teachers in New Delhi, India: A Qualitative Study,” Indian Journal of Pharmacology, Vol 48, No 4, pp 365–71.

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ResistanceMap (2017a): “Antibiotic Use,” Center for Disease Dynamics, Economics & Policy, Washington DC, https://resistancemap.cddep.org/AntibioticUse.php.

— (2017b): “Methodology: Antibiotic Use,” Center for Disease Dynamics, Economics & Policy, Washington DC, https://resistancemap.cddep.org/MethodologyAU.php.

Updated On : 27th Nov, 2017

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