Can Kerala’s policy to limit antibiotics misuse lead to reduced AMR?

Sale of antibiotics through hospitals and medical stores across Kerala reduced by ₹1,000 crore in the last year
| Photo Credit: iStockphoto

With the successful launch of Operation Amrith (Antimicrobial Resistance Intervention for Total Health) to completely stop the over-the-counter sale of antibiotics without prescriptions by the end of 2024, Kerala has seen a sharp decline in the irrational use of antibiotics in people. According to media reports, there has been a sharp fall of ₹1,000 crore in the sale of antibiotics through hospitals and medical stores across Kerala in the last one 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. By doing so, it was enforcing the Indian government’s 2011 H1 rule to prohibit 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 tweaked the rule to allow first-line antibiotics to be sold over-the-counter without a prescription, Kerala went ahead and enforced the 2011 H1 rule. The 2011 rule was modified by the Indian government to allow the sale of first-line antibiotics as a complete ban on OTC sales for all classes of antibiotics would have caused more harm than good — it would have greatly restricted access to even the first-line medicines, especially in remote places where doctors are not always available. Kerala was able to enforce the 2011 H1 rule as it has a high doctor-patient ratio, availability of doctors in most places, and the vastly different health care-seeking behaviour of the people in the State.

While Kerala has been able to enforce the 2011 H1 rule and reduce antibiotic misuse, no other State in India has enforced even the modified 2013 H1 rule. Despite having a good patient-doctor ratio, there are pockets in the 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 laudable but the fight against AMR cannot be limited to one State. AMR knows no borders, and Kerala’s efforts will have limited impact in reducing antimicrobial resistance unless neighbouring States too adopt similar policies,” says Dr. Abdul Ghafur, Consultant in infectious diseases at the Apollo Hospital in Chennai, and Coordinator, Chennai Declaration on AMR. “Kerala should consider adopting the modified H1 rule of 2013, which monitors only second and third-line antibiotics while allowing the sale of first-line antibiotics without a prescription to continue without strict monitoring. This approach would 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 neighbouring States, many of which have no AMR regulations in place for humans, animals and agriculture. According to the Kerala State Planning Board report 2022-2027, vegetable production in the State meets just 40 % of Kerala’s requirement. Similarly, Kerala produces only about 42% of the eggs requirement while relying on other States for the balance. As per a June 2023 report in The Hindu, Kerala imports nearly 70% of broiler chicken from Tamil Nadu.

“Studies, including my own research, have shown that these imported food products 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, which undermines Kerala’s local efforts,” he says.

With no other State enforcing the 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 majorly on other States for vegetables, eggs and broiler chicken, the State continues to be vulnerable to the continuous 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 the neighbouring States to implement strict AMR action plans,” says Dr. Ghafur.

Other States will begin enforcing strict AMR policies only if they can be implemented. The 2011 H1 rule, which prohibits the OTC sale of all classes of antibiotics, will not be implementable by other States. It is for this reason that Kerala has to step back and enforce the modified 2013 H1 rule to get the neighbouring States to enforce the rule and initiate the process of reducing antibiotic use in veterinary and agriculture. “The adoption of such a stepwise, adaptable model will ensure that Kerala’s efforts to combat AMR are not in vain and will inspire other States to follow suit,” he says. “Once the modified H1 rule is successfully implemented at least in the neighbouring States, these States can progressively work towards a more comprehensive ban on OTC antibiotic sales.”