Formulating antibiotic policy: Analysis of India's ban on colistin use in food producing animals

Antibiotics remain key tools for maintaining human health, and in many settings, food production. However, emergence of antibiotic resistance has become a global challenge, one that has resulted in multi-national calls for policy to improve antibiotic use. One such call has been to restrict the use of antibiotics deemed critically important for human health, such as colistin, during the production of food producing animals. Between 2016 and 2019 numerous countries, including India, implemented policies to heavily restricted the use of colistin in livestock. While this represents a key shift in the antibiotic policy landscape, other classes of critically important antibiotics continue to be used during food production. This paper provides a policy analysis of India's 2019 colistin ban to provide insight into how this came to be and to identify factors which could shape the development of future legislation. The analysis revealed that while antibiotic reform in food production had been in the background of India's policy agenda for some time, it took key-focusing events to shift the policy climate into a period of action. These focusing events included reporting of mobile colistin resistance genes in bacteria isolated from pigs in China and colistin resistant bacteria isolated from food samples in India. Consistent narratives had been built around colistin's role as a last resort antibiotic which, together with relatively low proportion of colistin resistance in bacteria isolated from human patients, framed legislation as a worthwhile endeavour for policy makers. In addition, India acted as a global player in antibiotic stewardship and followed the precedent set by several other countries in restricting colistin use during food production. As most colistin for animal use was imported into India from China, and viable alternative animal treatments existed, there was limited industry opposition that could block legislation. We suggest evaluation of these five critical factors (focusing events, consistent narratives, worthwhile endeavour, precedent for change, and industry opposition) should be part of the policy formulation process for legislation regarding the use of other critically important antibiotics in food production.