The Superbacteria are in the Beef … the Chicken, the Pork, and so on ….

Question: What’s wrong with feeding antibiotics to our food animals in order to make them grow quicker? Is it that:

(a) Antibiotic residue, i.e. some of the drug itself, gets into the meat?

Or,

(b) Superbacteria are created – i.e. bacteria resistant to antibiotics –  and they get into the meat?

Answer: (b). This chart from the US Centers for Disease Control lays it out nicely:

 

Bugs in the beef 3

 

The issue is ripe because a major industrial supplier of chicken in the US, Sanderson Farms, is waging an ad campaign that contends: those who claim they’re raising chickens without antibiotics are saying so only as a marketing gimmick, and; the real issue isn’t superbacteria in the meat, it’s antibiotic residue in the meat, and even that doesn’t pose a significant threat.

In response, the National Resources Defense Council posted a hot blog last month that’s being promoted by the science crowd. The tellingly-named piece, “Sanderson Farms: Spreading Deception and Antibiotic Resistance,” levels the charge that the company’s advertising is “… a blatant and unacceptable deception … [that tries] to divert the conversation from the grave and proven threat caused by drug-resistant bacterial contamination in food and the environment.”

The NRDC spells out what that “grave and proven threat” is. Notice that it’s consistent with what the CDC says, above (emphasis in original):

 

Antibiotic residues in meat is not the issue here. The real problem that has alarmed health experts around the globe is the proliferation of antibiotic resistant bacteria. Routine antibiotic use breeds antibiotic resistant bacteria that can leave the farm on the chicken manure (that is typically trucked away and applied to cropland), on colonized workers, on vented air blasted out of poultry houses or in the soil or water, and on the meat itself. Bacteria escaping via these pathways spread in our communities and environment, and can even share the genetic traits which confer antibiotic resistance with other bacteria, further spreading antibiotic resistance.

 

When superbacteria make us sick it means our illness is harder to treat. It means you’re looking at such things as a longer hospital stay, multiple readmissions, the need for Intensive Care, and/or surgery. This happens to over 2 million Americans a year. Even worse, sometimes we can’t be treated at all – at least 23,000 people die each year in the US because they’ve contracted superbacteria.

In the meantime, we have to resort to self-help: use separate cutting boards for meat & vegetables, wash the bacteria off the meat & vegetables before eating and, crucially, make sure to cook the meat at the proper temperature, to destroy the bacteria that’s embedded within. Cooking temps & more are listed in this helpful page from the CDC.

 

“Beyond Foolish”: America’s Healthcare Cuts

Fortune Brainstorm Health Tuesday, November 1, 2016 San Diego, CA 4:35 PM STOPPING GLOBAL PANDEMICS BEFORE THEY START Just a few months after the 2015 outbreak of Ebola was contained, another virus—called Zika—commanded the public stage. It took but 14 months after Zika’s first detection in Brazil for the virus to spread through Latin America and the Caribbean to Florida. So far, the threat has gone unchecked. And to be sure, after Zika, will come another global pathogenic threat—one, that public health experts worry, may do an even better job of outsmarting and overwhelming us. The question is whether technological advances can help us turn the odds. Can big data and genomic virus sequencing help us track emerging diseases, contain their spread and ultimately find antidotes for the next unknown pathology? Can it speed up the hunt for lifesaving vaccinations or drugs? The answers have an urgency like few others. Dr. Michael T. Osterholm,  Director, Center for Infectious Disease Research and Policy, University of Minnesota Dr. Moncef Slaoui, Chairman, Vaccines, GlaxoSmithKline PLC Moderator:  Bryan Walsh, International Editor, Time Photograph by Stuart Isett for Fortune Brainstorm Health

 

The Infectious Diseases Society of America has joined the fight.

Today they sent a letter to Congress warning that the President’s proposed cuts to federal funding for antibiotic resistance “would dismantle our nation’s infrastructure for preventing, detecting, and tracking threats from antimicrobial resistance [AMR] … [which] is in striking contrast to global efforts in this area.” And that “… not only are these infections a threat to public health, but if the patients survive, their lives are often changed forever.”

Zeroing in on the $1.2 billion cut to the Centers for Disease Control and Prevention – a 17% reduction – and especially the proposed cut to the CDC’s Antibiotic Resistance Solutions Initiative, IDSA says:

 

Removing or reducing these funds would disassemble our national infrastructure to fight AMR threats and drastically limit CDC ‘s and state health departments’ capacity to detect and track resistant threats, respond to and contain outbreaks of resistant pathogens, and support prevention and stewardship activities. A cut of this magnitude would impact every aspect of CDC’s work to protect us from AMR, including its support for state public health labs and research collaborations with academic institutions.

 

IDSA’s letter was signed by 60 organizations including the American Academy of Pediatrics, American Veterinary Medical Association, GlaxoSmithKline, Global Health Council, and the March of Dimes.

As we know, cuts to infectious disease medicine are only part of what’s planned for American healthcare overall.

On Monday the American Medical Association weighed in, expressing special concern for our “most vulnerable citizens,” and the “ravaging” impact of public health epidemics. In their letter to Senate leaders they wrote, “Medicine has long operated under the precept of Primum non nocere, or ‘first, do no harm.’ The draft legislation violates that standard on many levels.”

How much harm? Yesterday, a report in the Annals of Internal Medicine gave us a number: “… if you take health insurance away from 22 million people, about 29,000 of them will die every year, as a result.” AIM is the official organ of the American College of Physicians, the nation’s largest medical specialty society.

However, that number doesn’t include the public health epidemics the AMA is worried about.

Michael Osteholm, PhD, MPH, (pictured above) runs the Center for Infectious Disease Research and Policy at the University of Minnesota. He recently penned a commentary in Fortune arguing we’re risking the lives of millions because we’re woefully unprepared for the next pandemic:

 

… at a time when infectious diseases are significantly more capable of wreaking international havoc … Trump has lost sight of the greatest national security threat of them all: a disease outbreak killing millions of people.

Solutions to huge lurking regional threats such as Ebola, mosquito-borne illnesses like Zika, and bioterrorism from anthrax or a genetically engineered smallpox virus are only three, four, and five on our list.

The number one threat—a worldwide lethal influenza outbreak equal to or greater than the 1918–19 Spanish flu pandemic—would literally read like the outline for an apocalyptic horror film. And the H7N9 strain we chose for an imagined but scientifically plausible scenario in our book is currently percolating to the surface in Southeast Asia.

Our number two threat—antimicrobial resistance—is a slow-moving tsunami that within decades could bring us back to the infectious Dark Ages, when a simple scrape could kill and untreatable tuberculosis was rampant.

It is beyond foolish to neglect the danger of infectious diseases on human and animal health. The threat of a killer virus or bacteria wreaking havoc in the U.S. is far greater than any military or terrorist assault …

 

 

 

 

 

Stanford Medical School threads the needle on how to teach infectious disease. Even better – you can take their course.

Vetter

 

Medicine has an image problem. As Malcolm Gladwell told Medscape’s Eric Topol, MD, “One thing that has always motivated me in writing about healthcare is that the world of healthcare does a very bad job of storytelling about itself. It represents itself to the public very poorly. The gap between the reality of medicine and the way the public thinks about medicine is growing, not shrinking.” Dr. Topol agreed: “Storytelling is a big deal, and it isn’t done enough in medicine or science.”

The Stanford University School of Medicine wants to change that. As part of their Re-imagining Medical Education initiative, they’re offering an open online 6-week course on infectious disease to the public called “Stories of Infection.” It “introduces learners to a variety of infectious diseases using a patient-centered, story-based approach. Through illustrated, short videos, learners will follow the course of each patient’s illness, from initial presentation to resolution.”

To get a sense of the course, here’s a partial transcript from the case presentation of the first patient you meet, David Vetter (above photo), whose story you may be familiar with:

“… To understand the importance of the immune system, we’re going to look at the case of a boy who made medical history by surviving for 12 years without a functioning immune system. In the process, David Phillip Vetter talked the medical world not only about his immune deficiency disorder. But also about the ethical dilemmas doctors can face when a temporary medical solution ends up becoming up a permanent one. On September 21st, 1971, David was delivered by Caesarean section at the Texas Medical Center in Houston. And within seconds, he was transferred into a sterile plastic bubble that would become his home for the next 12 years. David suffered from a rare genetic condition called Severe Combined Immunodeficiency, or SCID, that left him without a functioning immune system. The Vetters had lost their first son to an overwhelming infection that resulted from the same disorder. Because SCID is linked to the X chromosome, the Vetters knew there was a 50% chance their second son, David, would also have the disorder. But the prospect of a bone marrow transplant from David’s sister, Catherine, offered hope. Catherine would have been a perfect match for bone marrow transplant in the Vetter’s first son if he had survived long enough to undergo the procedure. So the family and physicians on David’s team saw the potential for a cure, if in fact, David carried the faulty X chromosome …

Three days after David Vetter was born, his diagnosis of SCID was confirmed, meaning that he would be just susceptible to severe infections as his brother. Having lost one child to the disease less than a year before, David’s mother was fearful of reaching into the bubble to touch David using the integrated rubber gloves that hung at regular intervals along the walls of the sterile chamber. She said in an interview, I felt if I could stay distant from him, then if the worst happened, I could handle it better. So I was hesitant to reach into the glove and touch him. But once I did, I was hooked for life.

She soon took on the challenges of caring for her baby boy along with his team of physicians who were confident they could cure him. David’s diapers, clothes and food had to be sterilized and inserted into the bubble through a system of air locks. But Baby David appeared to be thriving and growing in this sterile environment. No one had anticipated that David’s sister would not be a match for bone marrow transplant. And that David would somehow become trapped in the bubble that had been built to temporarily protect him.

As David grew, his awareness of his circumstances did too. And a story that had once held the promise of ending as a medical miracle slowly became an ethical nightmare.

During his years in the isolator, many studies were performed on David’s immune system. At the age of four, he was found trying to poke holes in the bubble. And doctors were forced to explain to him the very real risks that faced him if any microbes were allowed into the sterile environment. Psychologists who worked with David encouraged him to escape the bubble using his imagination. And his mother remembers taking many make believe trips into outer space with David in those early years. Teachers delivered lessons through the plastic walls of the bubble and David turned out to be an exceptionally bright boy. In 1975, engineers at NASA designed a spacesuit that would allow David to leave the hospital. But David was very anxious about being exposed to pathogens outside of his regular environment, so the suit was only worn six times. All of these worries and challenges of living inside the bubble took a took a toll on David’s emotional state as he grew. The isolator was moved from the hospital to David’s home when he was nine years old. And his mother remembers him watching other boys playing outside through a window in their home. And she noticed the downturn in her son.

David became increasingly withdrawn. As the family’s desperation grew in the years that followed, more research from Boston offered some hope. Physicians there had managed to perform form a successful bone marrow transplant using a non-matching donor. Though the procedure was still in its experimental stages, David, who was now 12 years old, received a bone marrow transplant from his sister. At first, the transplant appeared to have been successful. But then several weeks later, and still living inside the isolater, David spiked a fever and developed an intestinal hemorrhage. On February 22nd, 1984, David was removed from his sterile chamber and wheeled into a hospital room where his mother stroked his skin for the first and last time. Like many children who realize they’re going to die, David wanted to know if it was going to hurt and if his loved ones would be there with him. Once he was reassured on those two counts, he courageously faced death as he had faced life, and he passed away …

 

***

Stanford also says “We will … examine the relationship between socioeconomic conditions and infectious disease” – and they aren’t kidding. For example, in Santi’s case, a 3-year old boy who contracted a virulent strain of E. coli by eating a hamburger from a fast food restaurant, the clinical presentation included these pointed words:

Like many commercially produced food products, the hamburger that Santi ate contained meat from many different animals raised in confined animal feeding operations, or CAFOs. Lakes of animal manure frequently surround these factory farms and during slaughter, underpaid workers are all too often forced to rapidly separate the useable meat from waste. Spillage of intestinal content is common in slaughter houses like these and if the resulting meat isn’t completely cooked, dangerous pathogens can be transmitted to humans through food.

 

The course by no means lacks intellectual rigor, hinted at in an email you receive after you sign up: “… these intimate and moving stories … are part of our medical students’ required course on microbiology and immunology.” So for instance, the clinical presentation of MRSA through the story of a 20-year old college football player includes this little nugget:

Methicillin-Resistant Staph Aureus is an example of how bacteria can evolve in the presence of antibiotics to develop resistance. Penicillin and others antibiotics of the beta-lactam family work by binding to penicillin binding proteins, bacterial proteins, which are essential for maintaining the bacterial cell wall. But these bacterial proteins can evolve their structure, so that they are no longer efficiently bound by beta-lactam antibiotics. In the case of MRSA, a gene called mecA encodes a particular form of penicillin-binding protein, PBP2A, which allows the bacteria to grow and divide in the presence of most beta-lactam antibiotics. mecA isn’t located on the bacterial chromosome. It’s located on a mobile genetic element called the staphylococcal chromosome cassette, or SCCmec. This cassette can be passed directly from one bacterium to another through horizontal gene transfer, which allows the population of bacteria to develop antibiotic resistance even more rapidly.

 

Don’t let that scare you. The genetics component of the course is not at all front and center; a graphic that accompanied this case presentation explained it quite nicely, and even better, it was not on the test that followed!

***

When Malcolm Gladwell said we need to use stories to close the gap between the reality of medicine and the public’s perception of it, I assumed he meant something like the usual tale of heroic medical intervention. Where the public remains on the outside looking in, and the feeling can sometimes be akin to voyeurism.

But Stanford had a better idea: they’ve brought us into the medical world and they’ve made us part of the story. Real cases are presented. You really do care about the patient. And that emotion follows you as you work through the relevant biology to make sure this doesn’t happen on your watch – which of course cannot be strictly true. We’re not in it for the M.D. But that’s the whole point – it feels as if we are – and so the difficulties of study almost fade into the background. It leaves you wondering why they’d teach medicine any other way.

 

Antibiotics fail to treat pneumonia 22% of the time – but that may be due to a faulty diagnosis, not an ineffective drug

Pneumonia 3

 

Nearly 1 in 4 patients treated with antibiotics for community-acquired (vs. hospital-acquired) pneumonia required additional antibiotic therapy. Of the 251,947 cases identified, 55,741 patients (22.1%) needed further antibiotic treatment or ended up in the hospital. Failure rates were similar, regardless of the class of antibiotic used.

These were the conclusions of researchers from the LA Biomedical Research Institute at Harbor-UCLA Medical Center in Torrance, California, and presented last weekend at the American Thoracic Society 2017 International Conference, as reported by Medscape Medical News.

The researchers also found that:

(1) Patients older than 65 years were nearly three times more likely to be hospitalized than younger patients.

(2) Treatment for community-acquired pneumonia was more likely to fail if patients had at least one other medical condition.

(3) There were significant regional variations in patient resistance to certain antibiotics; people on the East Coast did better than those on the West Coast. “There might be less antibiotic resistance [on the East Coast as] [d]ifferent antibiotics have resistance in different parts of country,” said James McKinnell, MD, one of the researchers.

“We found it very surprising how frequently treatment fails,” said McKinnell. And, since older patients are more vulnerable they should be treated more carefully, “potentially with more aggressive antibiotic therapy.”

But there’s a problem: What if the failure of the antibiotic had nothing to do with the drug itself but was because the patient didn’t have a bacterial-driven pneumonia – or a pneumonia at all – to begin with?

Shimshon Wiesel, DO, who was not involved in the study and practices internal medicine at Staten Island University Hospital, told Medscape that the data the researchers used was problematic as it only gave the diagnosis entered when the patient was seen:

“It doesn’t tell you how the patient presented, or what workup was done.” The patient might have had bronchitis or a subtle presentation of lung disease; “these are known to fail on antibiotics,” he said. “The biggest reason for treatment failure” is related to diagnostic criteria. [My emphasis.]

The patient may also have had a viral-driven pneumonia, a complication of the viruses that cause colds and the flu, which accounts for about one-third of pneumonia cases.

As it happens, support for Wiesel’s observation can be found in the most read article on Medscape right now, “Making the Correct Diagnosis: The Cornerstone of Antibiotic Stewardship.”

It’s co-authored by the always-enlightening (e.g. here and here) Brad Spellberg, MD, infectious disease specialist and Chief Medical Officer of the Los Angeles County-University of Southern California Medical Center.

He agrees that a basic rule of prescribing is that you have to give the right antibiotic, at the right dose, for the right duration of therapy. But he reminds us that up to 50% of antibiotic prescriptions in the United States continue to be unnecessary or inappropriate. And what’s overlooked, he says, is a more fundamental principle that must underpin effective antibiotic stewardship: making the correct diagnosis.

Spellberg’s article presents 6 cases that illustrate this critical principle and the impact it has on appropriate antibiotic usage. These cases are based on real patients he has encountered recently. He presents them not because they are unusual but rather because they are typical of clinical situations that happen tens of thousands of times per year in the United States – and typical of how doctors get it wrong. It’s a must-read and an involving-read: with each case presentation, the reader is asked to make the right treatment call. See how you do.

A Personal Story

We may think of a serious infection as something akin, say, to a broken arm: it’s painful, you apply a fix, and after a while you’re good to go. But that’s not how infectious disease works, especially those that are resistant to antibiotic treatment. Resistant infections can mean multiple surgeries, a bad reaction to an antibiotic, repeated flare-ups, and having to deal with the prospect of death. Emotional trauma will sometimes set in and linger for years. The effect will be felt by the whole family.

Linaman2To understand why it works this way we offer the story of Chris Linaman. He injured his ACL playing basketball. He needed surgery to repair the ligament and it proved successful. But several weeks into his recovery he contracted MRSA. Here’s Chris explaining what happened:

Can you tell us about your MRSA infection, and how it affected you and your family?

Chris: My nightmare started as a basketball injury. I’d had a successful ACL surgery, and several weeks into my recovery was doing great and thought my incision was fully healed. But that all changed very quickly. After a weekend trip to visit friends, I went to sleep on a Sunday night feeling fine, and woke up Monday morning to find my knee had swollen to the size of a melon. It was bright red and hot to the touch. Within hours, my MRSA infection had been diagnosed, and I was in emergency surgery—the first of several surgeries I would need over the course of four days.

Unfortunately, that wasn’t the end of my struggle to survive MRSA.

Just a few days after being sent home from the hospital, my wife found me nearly unconscious, with a swollen face and a temperature of 105 degrees. She rushed me back to the hospital, and the doctors told her to begin making plans because they didn’t expect me to make it. Luckily, the spinal tap showed the infection had not yet gotten to my brain. But I needed to have even more surgeries to get rid of it, and I also lost my epidermis—the outer layer of my skin—over my entire body, due to an allergic reaction to the antibiotic they were using to treat me.

Ultimately, the doctors were able to get the infection under control within a few weeks, but the road to recovery was long and painful. Even after my infection was cleared, and I was out of the hospital, my body was still reeling from all it had been through. My leg muscles were wrecked from all of the surgeries, and it took extensive physical therapy to get me back to anything resembling normal. To help put it in perspective, my original ACL surgery had been in early May, and it wasn’t until mid-July that I was even able to walk around the block in my neighborhood, a feat that took more than an hour.

Beyond the physical trauma, the whole ordeal also nearly ruined our family financially, and it was emotionally devastating as well. At the time, our two kids were just 2 and 4 years old, and they didn’t understand what was going on. It still breaks my heart to think about it. Those were the darkest days of my life, and, honestly, it’s hard to believe that I’m still here.

Why do you think it’s so important for superbug survivors to share their stories?

Chris: I don’t think enough people realize the extent of what’s at stake. People have maybe heard the term “post-antibiotic” era but don’t really understand what that could mean to them and their families. While it’s still very difficult for me to talk about—even today, more than 10 years later—sharing my experience can help show what that future could look like if we don’t keep up the fight and do what we can today. As horrible as my MRSA infection was, I’m the “good” outcome—I survived. Way too many others have not.

***

The CDC tells us that: (1) In the US alone more than two million people are sickened every year with antibiotic-resistant infections, with at least 23,000 dying as a result (2) Almost half of these deaths are due to MRSA alone, and (3) These numbers are based on conservative assumptions and are likely minimum estimates.

Chris Linaman told his story this week to The Pew Charitable Trusts. His full interview can be found here.

The National Security Beat: Bugs v. Bullets – Who’s the Mightier?

Whether caused by a bug or a bullet death is death, injury is injury, and disability is disability. Yet how we assess these threats – from microbe & man – and how we marshal our resources to meet them is starkly different. Left to the political class, national security is defined exclusively as guys with guns: so that’s what gets national attention, drives government policy and funding priorities.

SecurityHowever, a growing chorus of voices across the science and medical community are challenging that worldview saying that not only is it wrong, it’s dangerously wrong, because we’re turning a blind eye to what hurts us more – and has always hurt us more – microbes.

For example, the New England Journal of Medicine reminds us that “in the past 100 years, the ‘Spanish Flu’ of 1918–1919 [which killed more people than WWI] and HIV–AIDS, caused the deaths of nearly 100 million people.” The article was tellingly titled “The Neglected Dimension of Global Security – A Framework for Countering Infectious Disease Crises.”

In today’s world, “We are just one major global pandemic away from significant economic and humanitarian catastrophe … [therefore] “we can no longer view disease pandemics solely through the lens of health because they threaten whole economies and large swaths of humanity,” said Judith Rodin, in her opening remarks at the prestigious National Academy of Medicine’s forum, “The Neglected Dimension of Global Security: A Framework to Counter Infectious Disease Crises.”

Michael Osterholm, PhD, MPH, founding director of the Infectious Disease Center for Research & Policy at the University of Minnesota, agrees: “Infectious disease is the deadliest enemy faced by all of human kind,” he says. In his new book Deadliest Enemy, he explains why: Because it has “the potential to alter the day to day functioning of society, halt travel, trade, and industry, or foster political instability.”

bugs 1In Osterholm’s view “there are only two microbial threats that … fit this description” for pandemic potential. One is “antimicrobial resistance and the very real threat of moving ever closer to a ‘post-antibiotic era’ … a world more like that of our great-grandparents where deaths due to infectious diseases we now consider treatable are once again commonplace.” The other is influenza, “the one respiratory-transmitted infection that can spread around the world in short order and strike with lethal force.” Some variant of the bird flu, for example.

This new thinking is nicely summed up in an interview that took place at the University of Arizona before a public audience this past February. David Gibbs, Professor of History, was speaking with “arguably the most important intellectual alive today,” Noam Chomsky, Professor Emeritus of Linguistics at MIT.

After discussing the threats posed by climate change and nuclear war, the two weighed in on infectious disease. Professor Gibbs nicely frames the issue. The italicized emphases in Chomsky’s reply are mine.

Professor Gibbs: “In popular discussion, the phrase ‘national security’ has come to mean security against military threats almost exclusively. This narrative downgrades the significance of nonmilitary threats, such as climate change, antibiotic resistant bacteria, or viral epidemics. It would seem that there is an imbalance between perceived military threats, which receive overwhelming governmental funding and press attention on the one hand, and nonmilitary threats, which receive relatively little on the other hand. How do we account for the apparent overemphasis on military threats?”

Noam Chomsky:

Well [with] military threats, you can see them actually, you can imagine it. People don’t think about it enough. But if you think about it for a minute, you can see that a nuclear attack could be the end of everything. These other [nonmilitary] threats are kind of slow, maybe we won’t see them next year. Maybe the science is uncertain, maybe we don’t have to worry about it. Climate change is the worst, but there’s others.

Take pandemics. There could easily be a severe pandemic. A lot of that comes from something we don’t pay much attention to: Eating meat. The meat production industry, the industrial production of meat, uses an immense amount of antibiotics. I don’t remember the exact figure, it’s probably like half the antibiotics. [It’s around 80%.] Well antibiotics have an effect: They lead to mutations that make them ineffective. We’re now running out of antibiotics that deal with the threat of rapidly mutating bacteria. A lot of that just comes from the meat production industry.

Well, do we worry about it? We ought to be. You go into a hospital now, it’s dangerous. We can get diseases that can’t be dealt with, that are moving around the hospital. A lot of that traces back to industrial meat production. These are really serious threats, all over the place. … but it’s hard to bring out the enormity of these issues, when they do not have the dramatic character of something you can show in the movies, with a nuclear weapon falling and everything disappears.

Chomsky’s seemingly simple reasoning actually has a lot of hard science behind it; in fact, it garnered one researcher the Nobel Prize in Economics in 2002 for explaining the wayward thinking behind poor decision making in areas such as risk assessment. In brief: We assume that if examples of something come easily to mind they must also be more frequent. But that’s false. The classic example that has made its way into first year university textbooks is the easy availability of images we call up – when, for example, national security is discussed – of planes crashing into the World Trade Center. That’s exactly what Chomsky means when he says that “something you can show in the movies” will trump the mundane, regardless of how menacing the mundane may actually be.

And what’s more mundane than microbes: those unpronounceable, polysyllabic, Latin-named, invisible creatures, that never say anything, carry guns or topple buildings, that are talked about in code in fancy journals that no one has heard of, by people – scientists – a rather reclusive species that most of us have never met?

Act Now or Pay Later

The science community is begging us to understand that the standard risk assessments coming out of Washington about what really threatens to harm us are not just wrong, but that if we don’t heed what really matters, the DC consensus will also prove to be tragically wrong. The latest evidence in support of this view comes to us in a recently-released book and in an upcoming documentary film.

Deadliest Enemy 2In “Deadliest Enemy: Our War Against Killer Germs,” Dr. Michael Osterholm, founding director of the Infectious Disease Center for Research & Policy at the University of Minnesota, says that “infectious disease is the deadliest enemy faced by all of human kind,” because it has “the potential to alter the day to day functioning of society, halt travel, trade, and industry, or foster political instability.

In Osterholm’s view “there are only two microbial threats that … fit this description” for pandemic potential. One is “antimicrobial resistance and the very real threat of moving ever closer to a ‘post-antibiotic era’ … a world more like that of our great-grandparents where deaths due to infectious diseases we now consider treatable are once again commonplace.”

The other is influenza, “the one respiratory-transmitted infection that can spread around the world in short order and strike with lethal force.” Some variant of the bird flu, for example.

The pandemic potential of infectious disease is also the subject of the documentary “Unseen Enemy” whose global broadcast on CNN is April 7 in the US & Canada. The film is endorsed by the prestigious National Academy of Medicine who are holding an advance screening in Washington on April 3, which will include a panel discussion of experts moderated by Dr. Sanjay Gupta. Presumably it will be available on CNN at a later date.

It’s important to understand that what’s driving this pandemic potential is us. The filmmakers sum it up nicely: “Population growth, mass urbanization, deforestation, climate change and increased travel have dramatically increased the risk that familiar diseases will spread and mutate, and new ones will emerge. As people enter new spheres of biodiversity, they come into closer contact with other species, allowing viruses to jump from animals to humans and then spread more widely.”

One more thing. Pandemics are about more than just numbers or the disease itself. They’re also about how they scar our psyche with fear, suspicion, and even panic; for example, the Ebola scare of 2014. Take a look at this CBS report that came out at the time, “Ebola Panic Spreading Much Faster than Disease in U.S.,” which reads, in part, “The threat of Ebola is generating a considerable amount of fear and misinformation across the country, not to mention a growing number of false alarms. Fears about Ebola have reached a fever pitch in recent days.”

Here’s the thing: all that countrywide fear – yet there was only one case of Ebola that ever arose within the borders of the United States.

The films must-see trailer says we either get on board with this issue now or we’re gonna pay for it later.

(Dr. Osterholm’s book deserves fuller treatment & will be the subject of a future column.)

Medical Self-Defense: Your GP probably shouldn’t be allowed to prescribe antibiotics as they’re not the drug we thought they were. This means you have to learn about them.

Interesting perspective, as always (e.g. here & here), from Brad Spellberg, MD, Chief Medical Officer of the Los Angeles County-USC Medical Center, on how to fix the overprescription problem of handing out antibiotics like candy “just-in-case“: only allow the infectious disease specialist to prescribe them.

In an interview with Open Forum Infectious Diseases, the impeccably qualified Dr. Spellberg put it this way:

 

Oncologists don’t let non-oncologists prescribe chemotherapy. The single biggest mistake that our specialty made over decades and decades is that we’ve allowed anyone to prescribe these drugs, and the perception has been that they’re so safe and so effective you don’t need to be an expert in them. The result of that is a complete lack of control of use.

And you know as well as I Paul when you’re rounding on ID and you get consults and you go, “I can’t believe the drugs these folks are using.” Well, if we had the ability to say, “No you don’t get to use those drugs, only we can authorize the use of those drugs,” we would have a much better ability to protect these drugs.

 

Here’s the problem Spellberg’s addressing: Around a third of all antibiotic prescriptions handed out in the U.S. are done so in error. It’s either the wrong drug, the wrong duration, the wrong dosage, or the antibiotic shouldn’t have been given out in the first place, typically because the illness is viral, not bacterial. As a consequence, we’re losing our antibiotics. And since they’re wedded to the everyday practice of medicine – e.g. to prevent infections in surgeries, burn patients, & cancer patients undergoing chemo – the loss of them would mean a serious decline in health care, and perhaps something worse than that.

Spellberg concedes that “the cat is out of the bag,” that we’re not going to be able to take away the antibiotic prescription privilege from the family doctor. Therefore, Spellberg implies, we need to practice medical self-defense. In the same way that we learn good health habits, basic first aid & CPR, we simply have to learn when and when not to use antibiotics. It’s actually not very hard, and it’s interesting stuff. Here’s the short version, from the CDC. But the best messaging out there – this is interesting – remains this eye-opening public forum put on by the Harvard School of Public Health. Don’t be intimidated because it’s Harvard. The discussion is for everyone. And it’s got it all. Our take on it is here.

 

The W.H.O. Issues a Plea to Governments Across the World to Target 12 Superbugs

mrsa bt 3

Yesterday, the World Health Organization published its first ever list (below) of antibiotic-resistant “priority pathogens” – a catalogue of 12 families of bacteria that pose the greatest threat to human health.

The 12 bugs on the list are classified as critical, high and medium priority, based on their level of resistance to treatment, their mortality rates, their prevalence in the community, and the burden on the health system they cause.

MRSA is listed as a high priority, i.e. those bacteria that cause a large number of deaths and infections in otherwise healthy people. The US Centers for Disease Control said the same thing in 2013 when it ranked superbugs having the most impact on human health. The CDC Threat Report also used 3 categories – Urgent, Serious, and Concerning – and ranked MRSA’s threat level as “Serious” on the basis that (1) it alone is responsible for about half of the 23,000 deaths caused each year in the US by antibiotic-resistant bacteria, and (2) it causes more than 80,000 serious infections each year.

However, there’s a crucial difference between the WHO and CDC reports: The WHO’s intent is to “spur governments to put in place policies that incentivize basic science and advanced research and development.” Dr. Marie-Paule Kieny, WHO’s Assistant Director-General explains:

Antibiotic resistance is growing, and we are fast running out of treatment options. If we leave it to market forces alone, the new antibiotics we most urgently need are not going to be developed in time.

The science community believes that because antibiotic-resistant bacteria are a global issue, that the solution has to be global too; namely, a coordinated game plan that’s bought into by world governments, especially the major players on the global stage.

Which brings us to our problem – the United States, and whether or not they’re willing to play ball.

In 2015 the Obama administration rolled out its National Action Plan for Combating Antibiotic-Resistant Bacteria, a 5-year strategy to address what the president called “an issue of great importance to the public health of America and the world … [i.e.] antibiotics becoming less effective … one of the most serious public health issues we face today.” The plan was quarterbacked by the president’s science advisor, John Holdren, PhD, and the President’s Council of Advisors on Science and Technology (PCAST).

As of today, however, there’s still no presidential science advisor. The Action Plan and PCAST are in limbo. For this and other reasons, US scientists are livid and in an unprecedented move will march on Washington on April 22 to publicly air their concerns.

All of this matters because according to a highly-regarded UK government report, antibiotic-resistant disease will cause more deaths than cancer by 2050.

Yesterday’s report by the WHO was a call to action to prevent that from happening. It was also an admission that it will take a village – a global government village – to address the problem. And that if someone doesn’t want to do their fair share, it will hurt all of us.

The WHO list:

Priority 1: Critical
1. Acinetobacter baumannii, carbapenem-resistant
2. Pseudomonas aeruginosa, carbapenem-resistant
3. Enterobacteriaceae, carbapenem-resistant, ESBL-producing

Priority 2: High
4. Enterococcus faecium, vancomycin-resistant
5. Staphylococcus aureus, methicillin-resistant, vancomycin-intermediate and resistant
6. Helicobacter pylori, clarithromycin-resistant
7. Campylobacter spp., fluoroquinolone-resistant
8. Salmonellae, fluoroquinolone-resistant
9. Neisseria gonorrhoeae, cephalosporin-resistant, fluoroquinolone-resistant

Priority 3: Medium
10. Streptococcus pneumoniae, penicillin-non-susceptible
11. Haemophilus influenzae, ampicillin-resistant
12. Shigella spp., fluoroquinolone-resistant

 

 

Minority Report 2: “Pre-Disease”

ISS

 

KENNEDY SPACE CENTER — This coming Saturday morning at ten o’clock, our friend Staphylococcus aureus will find itself buckled up inside a Dragon Spacecraft about to be launched some 250 miles into space so it can dock at the International Space Station (ISS), shown above.

The U.S.- Russian-manned ISS, which orbits the Earth 15 times a day at a speed of 17,000 mph, serves as a cutting-edge science lab because of its near zero gravity environment — the one where you see astronauts floating around the spacecraft like it’s a Disney ride.

As it turns out this microgravity environment is thought to have a pronounced effect on microbes: that it accelerates their rate of growth and reproduction, and therefore their (genetic) mutation rate. Accelerating an organism’s growth rate is a way of fast forwarding into the future, as if you were aging, say, a human, 20 years in just 365 days.

The idea is to place the Staph into that environment, under experimental conditions, and watch what it does. Specifically, to record all the different ways that Staph becomes resistant to an antibiotic as it morphs into Methicillin-resistant staphylococcus aureus (MRSA). You keep at it until you’ve mapped all of the various pathways Staph bacteria take on their road to resistance, in all its forms.

What the finished resistance map gets you is the ability to predict the future. It goes like this. Imagine, for example, that Big Louis comes to town to stick up a bank. He holes up at a local dive from which he cases the joint, decides when to strike, chooses a weapon, a disguise, a getaway car, and plans his escape route. The day of the robbery everything goes according to plan; the cops are called in and begin to work “backwards,” assembling the clues one by one, day by day, hoping they’ll lead to the guy whodunit before he gets away.

But what if, instead, the instant Big Louis hits town the cops know he’s there. They run his M.O. and learn everything within minutes: where he’s holed up, the crime he’s planning, his disguise, weapon, getaway plan, whether he has an accomplice, and so on, thus allowing them to scoop Big Louis at any point prior to the planned bank job.

 

MR 4

 

Where do the cops get all this information? This is the futuristic part: From having recorded not just every crime Big Louis has ever committed, but from having also recorded every crime he will commit over his lifetime. As if an experimenter had placed Big Louis in a time machine, pressed fast forward and recorded all of his future criminal behavior.

That, of course, is science fiction. But putting Staph aureus into a microgravity environment and accelerating its rate of growth and reproduction, recording each genetic change, plugging those changes into a data base, creating algorithms from that data that allow you to predict what Staph will do based on any given presenting genetic profile, and ultimately developing an antibiotic that targets that genetic profile, isn’t science fiction – as of this novel space experiment.

The project is led by Harvard’s Dr. Anita Goel, MD, PhD, whose one-of-a-kind resume is worth taking a look at. She admits that the space bug experiment is proof of concept. For example, they’re experimenting on 2 strains of Staph, yet there are hundreds, not to mention all the other different species of bad bugs that are out there. It’s as if, back to our crime analogy, they’re experimenting on Big Louis and his frequent accomplice, Little Ronnie Dinsdale, but leaving out the rest of the criminal underworld — Tony Soprano, Don Corleone, and so on — each with their own unique M.O.’s.

But here’s the thing. If the experiment works with either strain of Staph, then it means it will work with other disease microbes as well. And then … what about cancer cells?

Just 15 years ago we were introduced to the concept of “Pre-Crime” in the Tom Cruise film Minority Report. Pre-Crime was the name of the specialized police unit that arrested criminals based on foreknowledge of future crimes provided by psychics called “precogs.” Now replace psychics with scientists, have your foreknowledge based on microgravity enhanced “fast-forwarded” observations of the genomic changes in a superbug, and replace Pre-Crime with “Pre-Disease,” and we have Dr. Goel’s current work.

She chose to study Staph because MRSA kills more Americans every year than the combined total of emphysema, HIV/AIDS, Parkinson’s disease, and homicide. Worldwide, drug-resistant infections kill more than 500,000 people each year and by 2050 that number will exceed 10 million.

But if this notion of “Pre-Disease” intervention works we’ll have a different world. In fact, that’s what Dr. Goel said, with characteristic dry wit, in her 2010 TEDMED Talk: “Our aim with this is humble: We want to do nothing less than to revolutionize healthcare globally by enabling real time point of care diagnosis.”

Stay tuned.

 

 

 

 

 

 

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