Dr Mark Toleman, a senior research fellow, is part of the research team led by Prof. Tim Walsh of Cardiff University’s School of Medicine that discovered the NDM-1 superbug in New Delhi’s drinking water supply. He speaks to Sarju Kaul about the research, which is considered controversial in India, and what remedial action needs to be taken to stop the spread of the superbug.

Q: Last year, your team was the first to identify NDM-1 superbug prevalent in the Indian subcontinent. Now, the same superbug has been discovered in New Delhi’s drinking water supply. Why did the team study Delhi water supply and how did the discovery come about?
A: It was quite obvious from our first study that a number of patients that had NDM-1 bacteria were coming to hospitals wanting to be treated for the infection. So, it was obvious to us that it was a community-acquired infection rather than just a hospital-acquired infection. The fact that you can pick it up in the community is significant and the next thing we obviously wanted to do is to conduct research to find if that was correct or not.
Unfortunately, if you look at the differences in the first two papers — the first paper had about 20 authors and the second paper only had four authors. The reason for that is that your government intimidated all the Indian scientists who were working with us and wanted to work with us. They were threatened with loss of livelihood etc. and it was impossible for us to conduct the second study with Indian authors.
The simple reason that the samples of water supply came from New Delhi was just the fact that the Commonwealth Games were on at the time and that’s where Channel Four News crew was staying. It was very easy for them to just go around New Delhi and collect samples. Of course, if the Commonwealth Games were in Chennai, or Calcutta or somewhere else then we would have had samples from there. The fact that the samples came from New Delhi was simply because that was the easiest place to get them from.

Q: Your team found the superbug in four per cent of water samples and in pools and rivulets in heavily-populated areas of Delhi. Given the levels of sanitation in India and the state of drinking water supply, what is your conjecture as a scientist about the prevalence of the superbug in India or the subcontinent?
A: I guess it is extremely widespread due to all the factors that you have mentioned. We would very much like to study that and to understand all the factors that have enabled the spread of the superbug because if we could study this, then we could start to implement measures to reduce the spread and reduce the incidence of it.
The spread is also aided by temperatures prevalent in the city. And not just India, but many other places in the world, that might aid the movement of genes between bacteria. We are just trying to understand the factors which would allow the spread of this.

Q: What does the discovery of the superbug in water supply mean for people who are inadvertently ingesting it? What does it mean for India specifically and for the rest of the world?
A: For the individuals who drink contaminated water, what basically happens is that the superbug ends up in the digestive system. What is likely that has happened is that many people are actually carrying this bacteria with NDM-1 in it as normal flora. Normally, that’s not a problem if you are fit and healthy person with a good immune system. Most of the time, it’s not a massive problem. It does become a problem if, for example, when the Ecoli bacteria with the superbug causes infection of urinary tract, which is very difficult to treat. A proportion of urinary tract infections go on to cause blood poisoning and could become life-threatening. That’s a serious worry indeed. If a person is at a greater risk when they are battling other illnesses, in those cases this bacteria is a very difficult to treat.
Take the example of Sweden which has very tight legislation about the use of antibiotics and an exceptional careful testing system for the spread of superbugs and contamination in hospitals. When anybody is admitted to hospital in Sweden they are always swabbed to find out if they are carrying any resistant bacteria.
A recent, but limited study, in Sweden had about 100 volunteers who were going on a holiday to different places in the world. They were swabbed before they went and when they returned they were swabbed again. The results of the study were basically that visitors to Asian countries had a higher incidence of picking up resistant bacteria and India, in particular, had the highest rate. The problem in India and Bangladesh and Pakistan is basically not just your problem, it is also our problem. If we can help with the problem that you have, it’s going to have a knock-on effects on the problems that we have. It is in the interest of countries of Europe and the wider world to help India in overcoming this.

Q: The first study had pointed out that the superbug was prevalent in other countries of the Indian subcontinent apart from India. Did your team try and do a comparative study of the spread of the superbug in all the countries of the subcontinent?
A: All these things are the studies what were are desperate to do and these very much need to be done. We intend to do these if we possibly can. If your government would move from the absurd denial they are at the moment that they have got a problem, it would a step towards a solution.
At the moment, it appears that your government is acting like an alcoholic, if you like, denying the fact that there have a problem. In fact, there is a problem and what they need to do is to bring the problem out in the open, instead of trying to hide it.

Q: The research about superbug led to a lot of controversy in India. Has your latest research received any response for the medical and health authorities or the government in India?
A: To start with, there was quite an officious reaction to the paper from the Indian government, which was a shame really because on our part we have been doing this kind of work for the last 10 years and India has certainly not been singled out in any way. These particular types of resistant mechanisms are our bread and butter, if you like it, and this is what we do. The problems in India, not just India, but South Asia in general, enable these mechanisms to spread quickly.
The biggest factor in this is the massive use and abuse of antibiotics in India. That essentially is the driver of this. The basic fact is that all antibiotic resistance, or almost all antibiotic resistance, mechanisms that we have been studying actually make the bacteria less fit and they don’t grow as well as a normal bacteria. When you reduce the use of antibiotics and control them sensibly and use them prudently, you won’t see the emergence of resistance, certainly not as quickly and the antibiotics will last longer and save many more people’s lives.
These are the kind of things that we are mainly concerned about and many nations in the Western world are concerned about the increase in bacterial resistance. The spotlight has come on India mainly because most nations have been implementing prudent policies realising that these are very precious drugs. Unfortunately, India is yet to do so. There is talk about it, even the talk about it is a major step ahead and we applaud the Indian government for doing that. It really needs to be implemented as soon as possible.

Q: What would the research team advice the Indian government to do to fight the superbug and how can common people in India at their level fight this menace? What kind of advice would you give the World Health Organisation on this issue?
A: This obviously must be the number one priority and as India is becoming a wealthier nation, the first thing to handle is the drinking water supply. It desperately needs sorting out. If this was sorted out it would reduce the incidence of disease, all kinds of disease, and the associated issues. The next would be sorting out the sanitation issues.
What we would like to see implemented is a surveillance system throughout India. Prof. Time Walsh, in particular, has been trying for the last several years to set a global antibiotic surveillance system so that it would be open and transparent to all nations and not to point fingers, but to actually find where the problems are and to sort out those problems.
These superbugs are immune to our last resort antibiotics and the next generation antibiotics needed to cure these bacteria are more than eight years away. Most of our pharmaceutical companies don’t have much ongoing research in this area because there is very little money in it and consequently the antibiotics needed to cure this will not be available for long. For the next 10 years, there is no answer to this problem in terms of chemotherapy.

Q: There were allegations after you first paper on NDM-1 that the nomenclature of the superbug was to target growing medical tourism in India. How do you react?
A: There is absolutely no truth in that. We were already working on that. The medical tourism in India is completely a side issue. At the time we were working on this, we read an article in the Independent that the National Health Service was sending people to India for operations. Both Tim and I reacted, “Well, that won’t be a good idea.”
It would be irresponsible of us to say that we don’t see a problem with medical tourism. We do see a problem with it. If people funded by the NHS go to India, they would pick up an infection and bring it back, the add-on costs would be massive. It would morally wrong of us not to say something and close our eyes. We are not trying to put people off from visiting India. It looks like a wonderful country, I have never been there myself. I would like to visit India, it probably won’t be a good idea to visit right now.
We have no interest in Indian economy whatsoever. In fact, the stronger the Indian economy is, the better off India is in sorting out these particular issues.
We would like to be seen as a friend of India and not somebody who is pointing a finger. The only reason is that we are trying to get the Indian government to wake up. It seems to me that they are so complacent that the only thing that’s going to make them wake up is if there are knock-on effects. It would be much better for them to wake up now, and do something about it.