Antimicrobial Resistance (AMR) is a silent but devastating crisis unfolding beneath the surface of our public health systems and threatening to undo decades of medical and scientific progress.
The urgency to enhance prevention, control and surveillance for AMR cannot be overstated. Central to this effort is the National Action Plan on Antimicrobial Resistance (NAP-AMR), which was launched in 2017, to establish and strengthen governance mechanisms and stakeholders' capacity to reduce the impact of AMR. However, to monitor AMR, the integration of wastewater surveillance (WWS) into the NAP is imperative.
Antibiotic usage in India is unregulated and overused in areas of healthcare, agriculture, and animal husbandry. Estimates suggest that by 2050, AMR could lead to 10 million deaths annually worldwide, with India bearing a significant portion of that burden. It also escalates healthcare costs through longer hospital stays, more expensive treatments, and increased resource utilisation.
Additionally, it leads to productivity losses and broader economic impacts, with projections suggesting that AMR could cost the global economy between $300 billion and $1 trillion annually by 2050. Hence, addressing AMR is crucial for both public health and economic stability.
Given the scale of this challenge, there is an urgent need to go beyond the traditional surveillance methods, which are primarily reliant on clinical data from tertiary care hospitals and often hampered by procedural delays and fail to capture the full range of AMR concentrations in the environment.
Wastewater surveillance (WWS) or wastewater-based epidemiology (WBE) is part of a broader environmental surveillance concept that involves the systematic and clinical collection of sewage water to detect pathogens and identify the prevailing trends in a community.
It gained prominence during the COVID-19 pandemic as an early warning tool to detect SARS-CoV-2 and its emerging variants and has also been previously used for the global eradication of poliovirus.
One of the advantages it offers over clinical surveillance is that it provides a snapshot of AMR trends, even detecting drug-resistant microorganisms in asymptomatic sources. This gives the ability to track and predict AMR outbreaks, identifying hotspots for targeted interventions.
Additionally, tracking the trends and mapping the results with antibiograms, specifically in hospital environments, could be beneficial for hospitals with their stewardship programs.
Despite the potential of WWS, it remains severely underutilised in India’s NAP strategy. The priorities of the action plan cover surveillance for AMR residues in the environment, but it should evolve to include crucial tools such as wastewater-based epidemiology.
This integration can potentially happen through a national wastewater surveillance network that can be synergised with the existing systems for disease or AMR surveillance, while working in tandem with regular surveillance. The provisions of such measures in the NAP can additionally be used to generate data that can aid organisations and municipalities with their respective stewardship programs by complementing already undertaken efforts, which can also help influence policy decisions.
Creating such frameworks within NAP requires affirmative action rather than recognition. The action plan should prioritise standardised protocols for the sampling, transport, and analysis of wastewater that align with India's specific needs. Followed by capacity building and training measures for improving technical skills in areas such as sample collection, laboratory analysis, and data modelling.
Wastewater surveillance can be initiated as part of pilot projects under NAP-AMR at various locations such as animal abattoirs or pharmaceutical companies and with dedicated funding long-term sustainability and integration can be ensured.
One of the critical advantages of wastewater surveillance is the early warning system it creates, leading to preemptive public health actions.
For instance, alarming concentrations of drug-resistant pathogens surveyed through wastewater can inform prescription practices in medical treatment and improve patient outcomes. This proactive approach could significantly reduce the burden on healthcare systems, curtailing the need for longer hospital stays, more expensive treatments, and the associated economic impacts.
Furthermore, the comprehensive data generated from WWS can guide policymakers in making evidence-based decisions, ensuring that public health strategies are informed by the latest and most accurate information available. As global efforts to standardise data collection and reporting continue to evolve, this data will become even more critical, enabling India to play a leading role in the international fight against AMR.
As we advance towards the second edition of the National Action Plan on Antimicrobial Resistance (NAP-AMR), it is important to recognise and integrate wastewater surveillance as part of this approach. The threat of AMR is growing, with estimates suggesting it could lead to 10 million deaths annually worldwide by 2050, with India bearing a significant share of that burden.
Policymakers, healthcare professionals, and researchers must champion wastewater surveillance as a frontline tool in the fight against AMR, ensuring that India is fully equipped to address this escalating challenge.
Dr Randeep Guleria is the former Director- AIIMS, Delhi, Chairman- Institute of Internal Medicine & Respiratory and Sleep Medicine, Medanta.
The opinions expressed in this article are those of the author and do not purport to reflect the opinions or views of THE WEEK