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NDM-1 superbug poses threat to medical tourists

Indian officials accuse a study's authors of naming the mutant gene after New Delhi as a way of scaring patients away.

By — Posted Aug. 30, 2010

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Physicians could find their patients infected with a new antibiotic-resistant superbug, which has its origins in a few Asian countries. A new study lists medical tourism, defined as patients leaving their home countries to get procedures done more cheaply in other nations, as one possible reason for the mutant gene's distribution.

That conclusion was reached in a study and an accompanying editorial posted online Aug. 11 by Lancet Infectious Diseases. The study looked at 178 patients in India, Pakistan and the United Kingdom who were carriers of a mutant gene called NDM-1, and the gene's ability to resist most antibiotics. Researchers noted that the gene has also been seen in the United States.

The study sparked strong international reaction, not so much because of its medical conclusions, but because of concerns related to medical tourism. Some experts worldwide said NDM-1 might not be any more difficult to handle than methicillin-resistant Staphylococcus aureus or other organisms that, like NDM-1, have shown resistance to carbapenems, a newer class of antibiotics.

Medical tourism has been pushed by some in the U.S. with limited success. In Great Britain, there has been talk of whether the National Health Service should contract with foreign hospitals to save money.

"It is disturbing, in context, to read calls in the popular press for U.K. patients to opt for corrective surgery in India with the aim of saving the NHS money," the authors wrote. "As our data show, such a proposal might ultimately cost the NHS substantially more than the short-term saving, and we would strongly advise against such proposals. The potential for wider international spread of producers and for NDM-1-encoding plasmids to become endemic worldwide, are clear and frightening."

The reaction against the study's statements was particularly strong in India, which has marketed itself worldwide as a medical tourism destination. Indian officials were particularly miffed at what NDM-1 stands for -- New Delhi metallo-beta-lactamase 1.

They accused the study's authors of intentionally naming the gene after an Indian city as a way to scare patients away, and they further criticized coverage of the studies that claimed India had an endemic problem with antibiotic overuse that might be contributing to the spread of NDM-1.

"This phenomena is not India-centric -- the superbug is everywhere. It is wrong to blame India, its hospitals and our drug policy," V.M. Katock, secretary of health research in India, said in a published statement.

Dr. Timothy R. Walsh, professor of medical microbiology and antimicrobial resistance in the Dept. of Medical Microbiology at Cardiff University School of Medicine in the U.K., who also co-wrote the report, said the researchers felt a "moral obligation" to comment on that in the study as a service to British taxpayers who helped fund the study by way of a grant from the European Union.

While Dr. Walsh downplayed the medical tourism angle in an e-mail to American Medical News, he makes no apologies for linking the outbreak to India and its hospitals.

Medical tourism backers in the United States said they don't expect the Lancet study to have an impact on the number of American patients seeking care elsewhere. A 2009 study by the Deloitte Center for Health Solutions found that the number of Americans seeking care abroad might reach 1.7 million by 2012. But that number was adjusted from a prediction made a year earlier that 20 million would travel abroad for care by 2015 -- a revision that reflected a greater resistance to overseas travel for care than experts expected.

"Short term, it probably won't help medical tourism, but longer term, these kinds of incidents tend to raise very important issues and bring a new level of transparency to a sector, and ultimately get people more confident in their decision-making," said Josef Woodman, president of Healthy Travel Media and author of Patients Beyond Borders, a resource book for those thinking about traveling abroad for care. (See correction)

Woodman advised those thinking of traveling abroad and those in the business of arranging that travel to thoroughly vet any hospital before going there or referring patients to it. This type of outbreak will force the hospitals that want that business to be more transparent with their quality and safety strategies and outcomes, he said.

Sharon Kleefield, PhD, a faculty member at the Harvard Medical School in Boston, has spent the past 10 years working with private hospitals in India to educate and train clinical and administrative staff in quality and patient safety issues. She said many hospitals in the private sector are doing a good job in risk management and infection control.

Meanwhile, for physicians in the United States, experts expect that NDM-1, which the study's authors said often presents as a urinary tract infection, probably will not be seen very often. Still, the study's authors said doctors should know which patients are going outside their home country for care, and those patients should be "actively screened for multiresistant bacteria before they receive medical care in their home country."

Comments from Johann D.D. Pitout, MD, professor of pathology and laboratory medicine, and microbiology and infectious diseases at the University of Calgary in Canada, were included in an online editorial with the Lancet study. If this emerging public health threat is ignored, he wrote, "sooner or later the medical community could be confronted with carbapenem-resistant Enterobacteriaceae that cause common infections, resulting in treatment failures with substantial increases in health care costs."

"The consequences will be serious if family doctors have to treat infections caused by these multiresistant bacteria on a daily basis," he wrote.

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External links

"Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study," The Lancet Infectious Diseases, published online Aug. 10 (link)

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Correction

This article originally gave an incorrect title for Josef Woodman's book. It is Patients Beyond Borders. American Medical News regrets the error.

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