[Skip to content]

GoSomething to say?
Join the forum, ask us a question, or comment
on the blog
Search our Site
Email Newsletter
Sign up for our free weekly
newsletter
Advertisement
.

Medical travel accused of causing a “threat to global healthcare”: NDM-1 inferred antibiotic resistance

Concerns raised over bacteria

 The publication of a clinical paper in the Lancet, one of the UK’s leading medical journals, has received widespread media coverage, raising concerns about the risks of medical travel, and the resulting “threat to global healthcare”. The paper, “Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study” (registration required – free), highlights cases where bacteria that make an enzyme called NDM-1 (New Delhi metallo-β-lactamase 1) are being “imported” into the UK by patients who have been to countries such as India and Pakistan for surgery abroad.

 

Media identify “health tourism” and “medical tourism” to India and Pakistan as cause

Of course, there is a risk that any patient undergoing surgery whilst abroad (many of whom will be holidaymakers who have been hospitalised, as opposed to medical travelers) may return to their home country with a hospital (or country) acquired infection. The concerning aspect of the current story is that “health tourism” and “medical tourism” have been named and shamed in the Lancet article itself and in the media coverage that it has stimulated.  Many of the patients acquiring the infection had travelled to have cosmetic surgery in India. Other reasons for hospitalization abroad in NDM-1 affected patients included bone-marrow transplant, dialysis, heart disease, pregnancy, traffic accidents, and burns.

The research carried out by experts at Cardiff University, the Health Protection Agency and international colleagues has identified this new “superbug” in fifty patients in the UK to date; the authors express concern that it may pose a global threat.

The NDM-1 enzyme can exist within different types of bacteria making them resistant to the carbapenem group of antibiotics.  The enzyme was first identified in Sweden in 2008. A diabetic patient who had been hospitalised several times in New Delhi returned to Sweden with an abscess. The infection proved resistant to carbapenem and following DNA sequencing a novel enzyme was identified and christened New Delhi metallo-β-lactamase 1. Problems arising from the NDM-1 enzyme have also been highlighted in the USA, Canada, the Netherlands and Australia.

The main worry is that the enzyme may increase resistance to antibiotics in other more common bacteria; media coverage has described it as “a new global health threat”, and an “unbeatable enzyme that could make all bacterial diseases resistant to antibiotics” and reports such as “medical tourism spreads superbug to UK” and “British researchers warn medical tourists of new antibiotic resistant superbug” have appeared.

In July 2009, the UK's Health Protection Agency put out a national alert about NDM-1, describing NDM-1 as "a notable public health risk". In June 2010, the US Centre for Disease Control (CDC) reported the first instance of NDM-1 in the United States.  The CDC alert asked that clinicians encountering carbapenem-resistant gram-negative bacteria should ask patients about contact with India or Pakistan in taking the patient history.

 

Medical travel businesses.... take note

The medical travel industry needs to take these developments seriously. In Canada, Dr. Johann Pitout of the University of Calgary who wrote a commentary on the Lancet article has warned: “The take-home message for the Canadian public is, if you travel to the subcontinent and you get admitted to hospital for whatever reason, medical or cosmetic surgery, and you come back and get sick, you should tell somebody you’ve been in hospital in India or Pakistan.” He also suggests screening and testing of anyone returning to Canada after medical procedures in India or Pakistan.

The closing comments of the clinical paper sum up the potential threat:

“It is disturbing, in context, to read calls in the popular press for UK patients to opt for corrective surgery in India with the aim of saving the NHS money. 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 reality... is it a threat to medical travel?

17 of the 37 patients in the study had a history of travel to India or Pakistan, and 14 had been in hospital in those countries. Some had had cosmetic surgery in India, others received treatment for cancer and other serious conditions. It is also clear that NDM-1-producing bacteria are widespread through the Indian subcontinent. So this is not something that is unique to medical travel.

Nevertheless, perceptions can be formed by the way that the media represents a story. The coverage of this clinical paper will no doubt raise doubts with patients and consumers about the safety of medical travel. Many will believe what they read in the press and see on the TV.

Comment

Add your comments below

Comments provided below do not represent the views of IMTJ. Comments will be published "as is" and will not be edited by IMTJ staff. IMTJ is hosting these comments, and is not  undertaking an editorial role in the content of these comments. However, it is editorial policy not to publish comments which have been submitted anonymously.

Use the comment submission form below
How is it that all infections allegedly originate in east! Is west sterile? was not the AIDS epidemic the gift of US of A! discovered and exported to Thailand and then to rest of the world. No human is immune to infections, specially those who try to sterlize too much or due to lack of immune exposures. So NDM seems to be the brainchild of grapes are sour scientists who are trying to stem the inevitable globalisation of a well established 6000 year old civilisations ministrations to the world ie Ayurveda and now allopathic too!

manisha Kukreja Bhatla (27/09/2011 17:07:45)

This piece of news was a “one-day wonder” that started off by being reported as having been transmitted by people who had gone for cosmetic treatment to India and Pakistan. As the day wore on, it became organ transplant! This was not live, minute-by-minute investigative reporting, but simply the fact that cosmetic surgery is 'more sexy' than organ transplant when you are reporting news items like this. The first question to have come to anyone's mind, had it been reported as organ transplant or cancer treatment, would have been, "why did they need to go abroad? Is something wrong with the NHS?"
"God forbid, no, of course not' would be the the short answer, that would have put paid to the news item that was not!
This brings me to the last point; is there a vested interest in this, which is to deter people from going abroad to have treatment? I wonder, but please do not believe all you see at face value; if Jesus Christ came to London and walked on the River Thames, the headlines would read, "Jesus can't swim!"

Zahid Hamid (17/08/2010 12:56:59)

This piece of news was a “one-day wonder” that started off by being reported as having been transmitted by people who had gone for cosmetic treatment to India and Pakistan. As the day wore on, it became organ transplant! This was not live, minute-by-minute investigative reporting, but simply the fact that cosmetic surgery is 'more sexy' than organ transplant when you are reporting news items like this. The first question to have come to anyone's mind, had it been reported as organ transplant or cancer treatment, would have been, "why did they need to go abroad? Is something wrong with the NHS?"
"God forbid, no, of course not' would be the the short answer, that would have put paid to the news item that was not!
This brings me to the last point; is there a vested interest in this, which is to deter people from going abroad to have treatment? I wonder, but please do not believe all you see at face value; if Jesus Christ came to London and walked on the River Thames, the headlines would read, "Jesus can't swim!"

Zahid Hamid (17/08/2010 12:56:16)

As I read this article, couldn't help but think of the old adage, "Buyers beware." It could also be construed as saying that patients should be more focused on quality and safety, and not make decisions where the main consideration is cost..

James Pruss (17/08/2010 06:50:15)

We have also had the story hit the press and radio here in Australia. We have had many calls and emails about it and we only promote Thailand and the Philippines. Shows how many people just read the headlines and not the story which clearly states Pakistan and India to Britain.

Robert Graham (17/08/2010 00:23:57)

Old problem - new bug.
When I was working at the Rotterdam University Clinic in the 1990s the problem was MRSA (methicillin-resistant S. aureus). We soon realized that these infections were linked to "medical travel", mainly accidents abroad, and we first believed that it did originate in countries such from the Middle East or Northern Africa. Independent of this a procedure was put in place that every patient from abroad was isolated until proofed MRSA free. This nation wide policy now makes the Netherlands one of the countries with the lowest incidence of MRSA (about 3 %). Countries without such a policy such as Germany, the US, the UK, Japan have a MRSA rate between 30-70%. It does not matter that now there is a new bug, what matters is that each hospital/health care provider knows what he has to do to minimize the spread within his own patient population what can be done to avoid it spreading into other institutions. These are pure QA questions, there need to be standard testing of each incoming and outgoing patient, and as soon as a certain incidence level is reached, the health travel business has to stop until the level drops again below the accepted limit. Has this anything to do with Pakistan or India? I don't think so, I think it is a problem of not having sound Quality Assurance / Quality Control procedures allow to identify and resolve problems.

High quality providers in the medical travel industry will in the future provide QA information, such as numbers of procedures performed, incidence of AEs, incidence of infection rates, average length of stay per procedure, etc., etc. I have been involved in this type of QA projects before and am willing to help if any of the providers in "medical travel" decides to move away from just shiny web pages and low prices to “Quality Services”.

siegfried.armbruster(at)patranslations(dot)com

Siegfried Armbruster (16/08/2010 20:16:10)

Unfortunately, this bogus, politically-motivated article perhaps does more damage to hospitals in America....since patient travelling there for care run a MUCH higher chance of acquiring MRSA than they do NDM-1 in India.....

Steven Watkins (16/08/2010 18:49:36)

Medical travel will continue to be a punching bag for media and the medical profession until it finally takes its proper place as one of several health care choices for consumers seeking medical treatment. Sadly, because so many medical professionals dismiss or disparage going for treatment abroad, patients are reluctant to talk about cross-border care they may have had. It should be standard practice for all patients and all doctors to discuss recent travel, whether 100 km or 10,000 km, that might affect a patient's diagnosis or treatment.

Julie Munro (16/08/2010 17:33:58)

I am sure there is some use of scare tactic in this as well, and I feel the way they have given the name to bacteria on New Delhi, it smells bit suspicious. More over, this sort of thing can certainly happen to those travelers who seek treatment at any hospital. While in Medical Tourism it is important to follow the guidelines and policies of good care providers. I think, and I am sure, the level of professionalism in any good and judicious hospitals in India and Pakistan are as good as in any hospital in UK or USA. I am sure, bit more scientific approach will prove some fault with the primary doctors treating some of these cases, rather these patients developed those bugs in India/ Pakistan. Sad part of this is that they have tied it with cosmetic surgery/ medical tourism and named the bug to New Delhi, which gives the idea of the state of the mind and low mental approach of the scientists.
I am sure, Medical Tourism will not be affected, as I always believe it is not medical tourism or health travel, it is a genuine change in the dynamics of globalization and healthcare is not exception. More and More people will get treated away from those expensive and long waiting list, care providing destination to destinations of low cost and easy access.
Good Luck Healthcare Travel and Wellness Visit.

Mubbashir Iftikhar (16/08/2010 17:29:53)

While NDM-1 aftershocks will likely take a short term toll, medical travel as an established component of global healthcare is here to stay. India and South Asia got a bad rap on this one: the destination country is secondary to quality assurance vis a vis patient safety concerns. Patients and third-parties wishing to reduce risks of cross-border medical care should seek out trustworthy hospitals and clinics with lowest rates of MRSA and other antibiotic-resistant bugs.

Josef Woodman (16/08/2010 14:56:29)