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.
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