Improving sanitation and hygiene measures are key to tackle antimicrobial resistance in India

  25 August 2020

By Sumanth Gandra MD, MPH

India is facing a major public health crisis, with widespread antimicrobial resistance (AMR) reported in humans, animals, and the environment.1,2 Resistance to many commonly-used antibiotics in humans has reached alarming levels, with more than 70% of some bacterial species now resistant to fluoroquinolones and third-generation cephalosporins.1 High levels of resistance have also been found to last-resort antibiotics such as carbapenems, and resistance to the final-frontier antibiotic, colistin, has also recently emerged.3,4,5

Multiple factors have conspired to lead to high levels of AMR. India is the world’s largest consumer of antibiotics for human health,6  with heavy consumption of broad-spectrum antibiotics.1 Access to antibiotics without a prescription, willing private healthcare prescribers, and a lack of diagnostic facilities and education in the public healthcare sector, have all contributed to the overuse and misuse of antibiotics within the country.1 However, the per-capita consumption of antibiotics in India is much lower than several high-income countries.7

In spite of low per-capita antibiotic consumption, the AMR prevalence is high as evidenced by high level colonization of antibiotic resistant bacteria among healthy adults in the community. In one study in an urban area in South India, the fecal carriage rate of extended spectrum beta-lactamase (ESBL) producing Enterobacteriaceae among healthy individuals was 34%.8 In another study among healthy persons from a remote rural community it was shown that 19% harbored ESBL-producing E. Coli.9 This high AMR prevalence in the community is most likely due to poor sanitation which plays a major role in the spread of antibiotic-resistant bacteria. This is supported by a recent study which reported that this spreading of resistant bacteria is the major factor contributing to high levels of AMR especially in low and middle income countries (LMICs).10 Unfortunately, 40% the Indian population still has no access to even basic facilities for the disposal of human waste.11

In recognition of the gravity of the situation, and following the lead of the World Health Organization (WHO),12  the Indian Ministry of Health and Family Welfare published India’s National Action Plan on AMR in April 2017.13  Fortunately, one of the key strategic priorities set out in India’s National Action Plan is to reduce the incidence of infection through effective infection prevention and control (IPC). The importance of hygiene and sanitation in the community is emphasized, with a range of activities proposed to promote personal hygiene and increase hand hygiene compliance across social groups.

Improving sanitation and hygiene in the community is integral to achieving infection prevention, reducing the use of antibiotics and AMR in India. The home and other everyday life settings provide multiple opportunities for the spread of infection and transmission of drug-resistant organisms within the community. These risks have recently been highlighted by Maillard et al, writing in the American Journal of Infection Control.14 In this position paper, we highlight the importance of the hands and contact surfaces within the home and other community settings as reservoirs of potentially infectious micro-organisms. The importance of targeted hygiene within community settings is stressed to reduce illness rates and the need for antibiotics and, also to reduce the circulation of resistant bacteria within the community. Evidence is presented demonstrating high levels of bacterial contamination on the hands,15,16,17 and in the homes,18,19,20 of people living in LMICs such as India, which is unsurprising given the lack of basic sanitation available in many of these countries.

Good hand hygiene is essential to prevent the spread of infection in India and other low-income countries in which sanitation is poor.21 Studies in LMICs suggest that hand washing interventions can be associated with significant reductions in the incidence of diarrhea and respiratory infections,22 which may translate into fewer people receiving inappropriate antibiotics they do not need. It is therefore concerning that only 60% of the Indian population has access to basic hand washing facilities at home,11 and less than half of all schoolchildren always wash their hands with soap when they are at school.23 The challenges associated with the AMR situation in India are unprecedented and will not be overcome without major investment and a concerted and unified effort. The national action plan provides a promising framework upon which some of the key drivers of AMR can be addressed, however the greatest reduction in AMR could be achieved by addressing the spread of AMR.24 This requires providing better sanitation, better access to clean water and improving personal hygiene.

Dr. Gandra received research contracts from the Center for Disease Control and Prevention, The World Health Organization. Provide consultation to The Global Hygiene Council

Sumanth Gandra MD, MPH
Assistant Professor of Medicine
Division of Infectious Diseases, Department of Medicine
Washington University School of Medicine
Campus Box 8051
4523 Clayton Ave.
St. Louis, MO 63110


1 Gandra S, Joshi J, Trett A, Lamkang AS, Laxminarayan R. Scoping Report on Antimicrobial Resistance in India. November 2017. Washington, DC: Center for Disease Dynamics, Economics & Policy. Available from: Accessed July 8, 2020.

2 Taneja N, Sharma M. Antimicrobial resistance in the environment: the Indian scenario. Indian J Med Res 2019; 149(2): 119-28.

3 Kaur A, Gandra S, Gupta P, Mehta Y, Laxminarayan R, Sengupta S. Clinical outcome of dual colistin- and carbapenem-resistant Klebsiella pneumoniae bloodstream infections: A single-center retrospective study of 75 cases in India. Am J Infect Control 2017; 45(11): 1289-91.

4 Pragasam AK, Shankar C, Verghese S. Molecular mechanisms of colistin resistance in Klebsiella pneumoniae causing bacteremia from India—A first report. Front Microbiol 2016; 7: 2135.

5 Manohar P, Shanthini T, Ayyanar R, et al. The distribution of carbapenem- and colistin-resistance in Gram-negative bacteria from the Tamil Nadu region in India. J Med Microbiol 2017; 66(7): 874-83.

6 Laxminarayan R, Chaudhury RR. Antibiotic resistance in India: drivers and opportunities for action. PLoS Med 2016; 13(3): e1001974.

7 Global increase and geographic convergence in antibiotic consumption between 2000 and 2015 Available from: Accessed August 20  2020

8 Babu R, Kumar A, Karim S, Warrier S, Nair SG, Singh SK, et al. Faecal carriage rate of extended-spectrum β-lactamase-producing Enterobacteriaceae in hospitalised patients and healthy asymptomatic individuals coming for health check-up. Journal of global antimicrobial resistance. 2016;6:150-3

9  Mathai D, Kumar VA, Paul B, Sugumar M, John KR, Manoharan A, et al. Fecal carriage rates of extended-spectrum β-lactamase-producing Escherichia coli among antibiotic naive healthy human volunteers. Microbial Drug Resistance. 2015;21:59-64

10 Anthropological and socioeconomic factors contributing to global antimicrobial resistance: a univariate and multivariable analysis Available from: Accessed August 20 2020 Accessed August 20 2020.

11 United Nations Children’s Fund (UNICEF) and World Health Organization (WHO). Progress on household drinking water, sanitation and hygiene 2000-2017. Special focus on inequalities. 2019. Available from: Accessed July 8, 2020.

12 World Health Organization. Global Action Plan on Antimicrobial Resistance. 2015. Geneva, Switzerland. Available from: Accessed July 8, 2020.

13 Ministry of Health & Family Welfare, Government of India. National Action Plan on Antimicrobial Resistance 2017-2021. April 2017. Available from: Accessed July 8, 2020.

14 Maillard JY, Bloomfield SF, Courvalin P, et al. Reducing antibiotic prescribing and addressing the global problem of antibiotic resistance by targeted hygiene in the home and everyday life settings: A position paper [published online ahead of print, 2020 Apr 18]. Am J Infect Control 2020; S0196-6553(20)30209–1.

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17 Pickering AJ, Julian TR, Mamuya S, Boehm AB, Davis J. Bacterial hand contamination among Tanzanian mothers varies temporally and following household activities. Trop Med Int Health 2011; 16(2): 233–9.

18 Medrano-Félix A, Martínez C, Castro-del Campo N, et al. Impact of prescribed cleaning and disinfectant use on microbial contamination in the home. J Appl Microbiol 2011; 110(2): 463–71.

19 Keshav V, Krüger CA, Mathee A, Naicker N, Swart A, Barnard TG. E. coli from dishcloths as an indicator of hygienic status in households. J Water Sanit Hyg De 2015; 5(3): 35158.

20 Sinclair RG, Gerba CP. Microbial contamination in kitchens and bathrooms of rural Cambodian village households. Lett Appl Microbiol 2011; 52(2): 144–9.

21 Kumwenda S. Challenges to Hygiene Improvement in Developing Countries. In: Potgieter N, Traore AN, eds. The Relevance of Hygiene to Health in Developing Countries. InTechOpen April 2019. Available from: Accessed July 8, 2020.

22 Mbakaya BC, Lee PH, Lee RL. Hand hygiene intervention strategies to reduce diarrhoea and respiratory infections among schoolchildren in developing countries: A systematic review. Int J Environ Res Public Health 2017; 14(4): 371.

23 Global Hygiene Council. Almost half of children are not always using soap when washing hands at school, new global survey finds. 1 July 2020. Available from: Accessed July 7, 2020.

24 Socioeconomic Enablers for Contagion: Factors Impelling the Antimicrobial Resistance Epidemic Available from: Accessed August 20, 2020.

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