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Issue #1781      June 14, 2017

Taking Issue – Rob Gowland

Superbug pollution

Most of us these days are aware of the increasing risk posed by so-called superbugs, bacteria and fungi that are immune or resistant to the drugs that are meant to kill them. Steps to combat or limit this phenomenon include phasing out the indiscriminate inclusion of antibiotics in cattle feed, stricter adherence to hygiene protocols and control over the use and dissemination of antibiotics within the community.

However, the pharmaceutical industry is very big and very profitable. And, like all large corporate entities, it is also very greedy. So the manufacture of pharmaceuticals is increasingly farmed out to under-developed, low-wage countries in order to increase profits. If keeping costs down conflicts with efforts to prevent possible infection, guess which will be given priority in these conditions?

Most of the world’s antibiotics are produced in China and India. The densely populated and increasingly prosperous city of Hyderabad in southern India was once an international trading centre for diamonds and pearls. Today, it is a major international hub for the pharmaceutical and biotech industries, producing millions of tons of medicines, chemicals and pesticides each year.

Around 170 companies making bulk drugs like antibiotics operate in and around Hyderabad. Companies in Europe and the US, as well as health authorities like WHO and the UK’s NHS are reliant on drugs being produced in these factories. As India’s drug production industry has grown, so has the prevalence of superbugs – a national crisis intensified by the widespread overuse and misuse of antibiotics, which are easily bought over the counter, and poor sanitation.

A group of scientists based at the University of Leipzig worked with German journalists to take an in-depth look at pharmaceutical pollution in Hyderabad where thousands of tons of pharmaceutical waste are produced by the city’s factories each day. The results of their investigation were published in the prestigious journal Infection.

The researchers took water samples from rivers, lakes, groundwater, drinking water and surface water from rural and urban areas in and around the industrial estate, as well as pools near factories and water sources contaminated by sewage treatment plants. Four were taken from taps, one from a borehole, and the remaining 23 were classed as environmental samples.

The samples were tested for bacteria resistance to multiple drugs – known as MDR (Multiple Drug Resistant) pathogens – the technical name for superbugs. The researchers then tested 16 of the samples for the antibiotics and antifungals used to treat infections.

All samples apart from one taken from tap water at a four star hotel were found to contain drug-resistant bacteria. Previous studies have shown how exposure to antibiotics and antifungals in the environment causes bacteria and fungi to develop immunity to those drugs. The most serious super bug is probably the gene NDM-1, named after New Delhi where it was first discovered in 2008. NDM-1 gives bacteria the ability to produce enzymes which break down carbapenems, a group of powerful antibiotics which are used to treat infections that have become resistant to other drugs. Bacteria that are able to resist carbapenems have been called the “nightmare” bacteria by the US Centre for Disease Control and Prevention because half of all people who contract a bloodstream infection from them die.

Almost all the samples contained bacteria and fungi resistant to multiple drugs.

The researchers concluded that environmental pollution and poor management of wastewater in Hyderabad is causing “unprecedented antimicrobial drug contamination” of surrounding water sources. Madlen Davies, of the US Bureau of Investigative Journalism wrote in May that “The presence of drug residues in the natural environment allows the microbes living there to build up resistance to the ingredients in the medicines that are supposed to kill them, turning them into what we call superbugs. The resistant microbes travel easily and have multiplied in huge numbers all over the world, creating a grave public health emergency that is already thought to kill hundreds of thousands of people a year.”

The Hyderabad area has long been criticised for its pollution. In 2009 it was classified as “critically polluted” in India’s national pollution index but the situation has continued unabated despite decades of campaigning by Indian NGOs. Last year India’s Supreme Court ordered the country’s pharmaceutical companies to operate a zero liquid waste policy, but “massive violations” have reportedly occurred, says the Infection report.

India has become the epicentre of the global drug resistance crisis, with 56,000 newborn Indian babies estimated to die each year from drug-resistant blood infections, and 70% to 90% of people who travel to India returning home with multi-drug-resistant bacteria in their gut, according to the study.

The amounts of antimicrobials found in the investigation were “eye-wateringly high,” said Dr Mark Holmes, a microbiologist at the University of Cambridge. Concentrations of the antibiotics clarithromycin and ampicillin were found at levels more than 100 times higher than the safe limit. Levels of the common antibiotic ciprofloxacin were found to be up to 700 times above that recommended while levels of moxifloxacin – used to treat lung, skin and sinus infections as well as tuberculosis – were up to 5,500 times higher than the recommended limit.

A sample taken from one Hyderabad sewer contained concentrations of the antifungal drug fluconazole – a drug used in ointments for fungal infections such as thrush and athlete’s foot or given intravenously for more serious infections – at levels 950,000 times higher than the recommended safe limit! The researchers repeatedly analysed this finding to make sure it was correct. “To our knowledge, this is the highest concentration of any drug ever measured in the environment,” wrote the authors.

“The quantities involved mean the amount in the water is almost the same as a therapeutic dose,” said Mark Holmes, calling on the Indian authorities to investigate immediately by testing each factory’s effluent. “That’s not just getting rid of a few tablets down the toilet,” he said.

Pharmaceutical pollution is not the only way in which antibiotics get into the Indian environment – excrement from people and animals and waste from hospitals and farms also contain residues of the drugs. But Professor Joakim Larsson, of the University of Gothenburg, believes the levels of antimicrobials found could not be explained by anything else other than industrial discharges. “So it tells us that the problem is still there, it needs to be solved,” he told German journalists who worked on the report.

The pharmaceutical industry in Hyderabad produces “enormous amounts” of waste each day, says the Infection report. Effluent is transported in trucks to one waste treatment plant, it says, where it is treated before being sent to a mega sewage plant. There, it is mixed with sewage and further treated then discharged into the nearby Musi River.

Adhering to the zero liquid waste policy ordered by the Supreme Court requires expensive technology, and some waste is still clandestinely sent to the waste treatment plant or dumped straight into the surrounding environment, according to the report.

There are reams of regulations and stipulations that manufacturers have to adhere to in order to export their products to the US and Europe – known as the Good Manufacturing Practices (GMP) framework. These focus on making sure drugs are safe, pure, and effective.

Stringent inspections by the World Health Organisation as well as American and European authorities check that these rules are being followed.

However these regulations do not address environmental concerns. Inspectors have no mandate to sanction a factory for polluting, failing to treat its waste or other environmental problems – this falls within the remit of local governments.

Within India, there are environmental regulations covering what ingredients factories are allowed to produce, how they use water and how they dispose of their waste. In Hyderabad, the Telangana State Pollution Board (TSPCB) inspects factories based on these.

However these inspections have been labelled toothless by local and international campaign groups. In November 2015, an analysis of TSPCB inspection reports by the Centre for Science and Environment in Delhi found that 15 bulk drug manufacturers within one industrial area alone were producing ingredients for which they did not have permission, using more water than the permitted limit, and dumping more effluents and hazardous waste than allowed.

The European Public Health Alliance, an umbrella group for more than 90 non-profit organisations, says the situation must be rectified “by including legally binding environmental standards in GMP protocols, particularly with regard to contamination with antimicrobial substances – as a condition for authorisation and import of drugs,” said a spokesperson.

“Voluntary agreements are not enough to stop a race to the bottom, where pharmaceutical companies exploit weak links in global supply chains, in places where there is little or no enforcement of vital environmental standards.”

Big Pharma, as the heavyweights in the industry are called, is backed by big money, so don’t expect anything to be done in a hurry – not if it means cutting into profits.

Next article – Another Fallujah, Dresden … Hiroshima?

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