Can Kerala’s policy to limit misuse of antibiotics reduce AMR?

Sales of antibiotics through hospitals and medical stores in Kerala fell by ₹ 1,000 crore last year | Photo credit: iStockphoto

With the successful launch of AMRIT (Intervention on Antimicrobial Resistance for Total Health) which aims to completely end the sale of over-the-counter antibiotics by the end of 2024, Kerala has made the population antibiotic free. Logical usage has seen a significant decline. According to media reports, the sale of antibiotics through hospitals and medical stores in Kerala has fallen by Rs 1,000 crore in the last one year.

In early January this year, Kerala became the first state in the country to ban the wholesale sale of over-the-counter antibiotics. In doing so, it implements the Indian government’s 2011 H1 rule to ban OTC sales 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 tweaked the law in 2013 to allow the sale of first-line antibiotics without a prescription, Kerala went ahead and implemented the 2011 H1 rule. The 2011 Act was amended by the Government of India to allow the sale of first-line antibiotics because a complete ban on OTC sales for all classes of antibiotics would do more harm than good—it would even harm first-line Very limited access. Medicine, especially in remote areas where doctors are not always available. Kerala was able to implement the 2011 H1 rule because it has a high doctor-patient ratio, availability of doctors in many places, and widespread healthcare-seeking behavior of people in the state.

While Kerala has been able to implement the 2011 H1 regulation and reduce antibiotic misuse, no other state in India has implemented even the 2013 H1 amended law. Despite the good patient-doctor ratio, there are pockets in southern states, including Tamil Nadu and Karnataka, where availability of doctors is an issue 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 will have limited impact in reducing antimicrobial resistance.” Unless neighboring states adopt a similar policy.” Kerala should consider implementing the amended H1 Act of 2013, which only monitors second- and third-line antibiotics while non-prescription first-line ones. Allowing the sale of antibiotics to continue without serious oversight. This approach will balance the need for antibiotic stewardship with healthcare access and economic considerations, ensuring that Kerala sets a practical and scalable example for other Indian states.

Currently, Kerala imports at least 60% of broiler chicken, eggs and vegetables from neighboring states, most of which do not have AMR regulations for humans, animals and agriculture. According to the Kerala State Planning Board report 2022-2027, vegetable production in the state will meet only 40% of Kerala’s requirement. Similarly, Kerala produces only 42% of its egg requirement while relying on other states for the balance. As of June 2023 report HinduKerala imports about 70% of broiler chicken from Tamil Nadu.

“Studies, including my own, have shown that these imported food products often contain 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 outbreaks, which undermines Kerala’s regional efforts,” he says.

With non-enforcement of national regulations on antibiotic use in agriculture and poultry, the production and spread of antibiotic-resistant bacteria will be a major problem in India. With Kerala largely dependent on other states for vegetables, eggs and broiler chickens, the state continues to import antibiotic-laden products. “For Kerala’s AMR efforts to have a lasting impact, there are two possible courses of action – Kerala should be self-sufficient and stop importing poultry, eggs and vegetables from other states or it can convince neighboring countries to AMR plans to implement strict action, says Dr. Ghafoor.

Other states will only begin implementing stricter AMR policies if they are implemented. The 2011 H1 rule, which bans OTC sales of all classes of antibiotics, will not be enforceable by other countries. It is for this reason that Kerala should step back and implement the 2013 H1 amended law to encourage neighboring countries to implement the law and start the process of reducing the use of antibiotics in veterinary and agriculture. “Adopting such a step-by-step, scalable 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 amended H1 Act is successfully implemented in at least neighboring states, these states can gradually work towards a more comprehensive ban on the sale of OTC antibiotics.”