Maryn McKenna

Journalist and Author

News round-up

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I’m deep into writing again and therefore slipping on posting; apologies to regular readers! But here are some items of importance from the past week:

  • Wednesday (Aug. 20) marked the first anniversary of Illinois‘ signing and immediately enacting the MRSA Screening & Reporting Act, the first state law to mandate that hospitals screen all ICU and other high-risk patients for MRSA colonization and to isolate and treat them until they are clear. This law would never have been passed without the extraordinary advocacy of MRSA survivor Jeanine Thomas, founder of the MRSA Survivors Network (site here and in the blogroll).
  • Also as of Wednesday, California came within one step of passing its own MRSA laws, SB 1058 and SB 158. They await the signature of Gov. Arnold Schwarzenegger — but with California’s budget in a $15.2 billion deficit freefall, new legislation there may be held hostage until a budget deal is agreed. Important addition: SB 1058 is also called “Nile’s Law,” after Nile Calvin Moss, who died of MRSA in April 2006. His parents Carole and Ty have pushed relentlessly for a MRSA law in his memory.
  • Plus, a great find thanks to Carole Moss: The Washington State Department of Health has put together an excellent pamphlet, Living with MRSA, that explains MRSA infection, colonization, decolonization and infection-control care at home in excellent everyday language.
  • And finally, another blog worth knowing about: GERMblog, written by Dr. Harley Rotbart, professor and vice-chair of pediatrics at University of Colorado School of Medicine and author of Germ Proof Your Kids: The Complete Guide to Protecting (Without Overprotecting) Your Family from Infections. I interviewed Dr. Rotbart recently for a magazine story and his advice was clear, science-based and sensible. His blog is now in the blogroll.

Surveillance to stop MRSA: Where, when, how costly, how much?

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My colleague Joanne Kenen — longtime health policy correspondent for Reuters, now a staff member at the New American Foundation, and a Henry J. Kaiser Family Foundation Media Fellow with me in 2006-07 — very kindly invited me to guest-blog at the New Health Dialogue. Most of the post is reproduced below, but please be kind and visit them so they can record the hits!

Stopping the spread of MRSA in hospitals is one of the most contentious topics in infectious disease policy right now. A small sample of the, umm, highly divergent views on the subject filled up the letters pages of the Journal of the American Medical Association last week. Community-associated MRSA has grabbed the public’s attention over the past year, but hospital-acquired MRSA remains a huge problem — so much so that the Center for Medicare and Medicaid Services has proposed treating it as a medical error and declining to reimburse hospitals for the extra care that must be given to a patient when it occurs.

Within health care, there is vociferous debate over how to control MRSA. Because MRSA can live on the skin, nostrils and other body sites for a long period of time before causing an infection — either in the person colonized by the bug or in someone else who acquired it from the colonized person — many hospitals espouse a program of checking new patients who are most likely to be carriers, including patients in high-risk units such as ICUs, new admits from long-term care facilities, and people who have had MRSA infections on the past. But a small set of institutions are pursuing a more aggressive program, variously called “active surveillance and testing,” “universal screening” or “search and destroy,” that checks every inpatient for MRSA colonization and confines them to isolation until the bug has cleared.

“Search and destroy” was the topic of an important JAMA paper and editorial last March that decided the effort wasn’t worthwhile. (A simultaneously published paper in the Annals of Internal Medicine completely disagreed.) The five letters in JAMA tear the topic apart, examining definitions, methodology, cost-effectiveness, adherence to infection control and more. The most intriguing suggests that “search and destroy” contains a hidden agenda: That if hospitals can demonstrate patients were carrying MRSA on admission, they may be able to make a case for any subsequent infections not being their fault — and so escape the lowered reimbursement rates that CMS proposes.

Oh no they *didn’t*…

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The Environmental Protection Agency will allow apple growers in Michigan to spray the human antibiotic gentamicin on apples to control an apple-tree disease, fire blight.

This because the disease had already become resistant to a previously used, different human antibiotic, streptomycin.

The Infectious Diseases Society of America tries to get them to see reason:

“At a time when bacteria are becoming increasingly resistant to many of our best antibiotics, it is an extremely bad idea to risk undermining gentamicin’s effectiveness for treating human disease by using it to treat a disease in apples.” (IDSA President Donald Poretz, MD in a press release.)

Gentamicin is used against staph and against a range of Gram-negative bacteria, and is an important drug for bloodstream infections in newborns. In a bizarre irony, the EPA bans its use on imported fruits/vegetables — because of fears of fostering resistance.

The decision in the Federal Register here. The original EPA proposal here. A Clinical Infectious Diseases article about human antibiotic use in plant agriculture here. And somewhere in the immediate vicinity, me clutching my head and wandering away muttering.

A note on flackery.

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I believe in transparency (see Operating Instructions in the right-hand column), and some comments have been submitted to the blog recently that I was not willing to publish. So it’s time to declare a policy.

Here it is: I will not allow any comments that advertise any products, explicitly or by linkage, period full stop.

I am my readers’ filter; that’s the responsibility I accepted when I started this blog, and I take it seriously. So anything that might be published in this space goes through me first. If anyone out there has a product — pharma, natural, alternative, antibacterial, whatever — my email is on the right. Send me a note, send me some literature; especially send me some data. I’m happy to engage offline.

I may post on what you send, or I may not. But it will be my post, not someone else’s cloaked advertising. Just so we’re clear.

Sermon over. Donuts and coffee, anyone?

Maybe we just build them better? (But who pays?)

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OK, campers, I know I’m tossing crumbs here, but I drove 6 hours today and am now, umm, well, not in any major metropolitan area, that’s for sure. But I’m visiting a very interesting hospital program tomorrow. And my chain motel is smack-dab between a Denny’s and a Waffle House. Just think of the breakfast options. (And imagine my arteries clogging. OK, don’t.)

Skittering back to the reason why we’re here: Via the LA Times, an intriguing article about the possibilities of reducing hospital-acquired infections by designing hospitals better: single rooms, improved airflow, more sinks, etc.

“Private rooms are the most important design element that reduces the spread of infection between patients,” says Richard Van Enk, director of infection control and epidemiology for Bronson Methodist Hospital in Kalamazoo, Mich. Bronson is a pioneer of evidence-based design and was among the first hospitals in the United States to build a facility with all private patient rooms.
The hospital’s new design also incorporates two sinks in each patient room, one of which is dedicated for the exclusive use of the healthcare worker. Many easily cleaned surface materials such as water-based low VOC (volatile organic chemical) paint, plastic counter coverings and linoleum floorings with antimicrobial properties were also used throughout the hospital. (Byline: Lisa Zamosky)

It sounds plausible to me. Superbug Spouse is an expert in human-factors design, and we both do photography and web design (he’s better), so issues like this – which way do your eyes go? what button do you naturally want to push? – get tossed about a lot in our house. And just yesterday I listened to an infection-control nurse describe the difficulty of getting healthcare workers to use sinks in older rooms in which the sinks are within the bathrooms; the HCWs perceived the bathrooms as the patients’ private space, not as accessible to all. So there may be something to this.

But retrofitting is expensive. And the bill will be paid by… ??

Limiting prescriptions – can it be done, will it help?

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I’m on the road reporting for two weeks, which makes keeping up with MRSA news fairly challenging. (Hangs head in shame, promises to do better in August when I will be chaining myself to my computer in vain hope of meeting a manuscript deadline.)

Meanwhile, here is a tidbit of news on the MRSA front, from the UK. As our international readers will know (oh yes, we have them, Google Analytics makes a very nice map – hi, London! say hello, Rotherham!), MRSA has been a ferocious hospital pathogen in the UK, but community strains have been less problematic there until recently.

The National Institute for Health and Clinical Excellence, an agency that does cost-benefit analysis on behalf of the National Health System, has asked doctors to limit prescribing antibiotics for most of the upper-respiratory infections they see in private practice on the assumption that most URIs will be viral and therefore not helped by antibiotics anyway.

…Doctors in the state’s health system should not prescribe antibiotics for most cases of sore throats, colds, bronchitis or other types of respiratory infections, the National Institute for Health and Clinical Excellence, or NICE, said.
They should also delay writing such prescriptions and reassure people the drugs are not needed immediately and would make little difference because most respiratory infections are viral, the new guidelines said. …
The drugs watchdog said a quarter of people in England and Wales visit the doctor because of respiratory tract infections, which account for 60 percent of all antibiotic prescriptions in general practice. (Reuters, byline Michael Kahn)

Note that this is a guideline, which is to say voluntary — though because it is promulgated by a regulatory body within a single-payer health system, may well have more force than similar guidelines that have been promulgated in the US by professional societies such as the Infectious Diseases Society of America. This article from IDSA from last April captures how effective guidelines have been here. Answer: Overall, not much, because they are a matter of asking, not compelling.

I’m interested in hearing from any readers who have experience with antibiotic stewardship programs at the society level or in institutions: Do they work, what does it take to implement them, how draconian do you have to be? If anyone can offer thoughts, please comment or send me a private email to the address in the right-hand column.

On to North Carolina.

Please route to the Dept. of Unintended Consequences.

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Via the open-access Journal PLoS One, an unnerving report of Canadian researchers finding fluoroquinolone resistance in E. coli in a group who are vanishingly unlikely to have ever taken a quinolone: indigenous Indians in isolated villages in the Guyanese rainforest.

For most people the most familiar quinolone is likely to be ciprofloxacin (Cipro), a very valuable antibiotic in the arsenal because it works against a broad array of Gram-positive and Gram-negative organisms and is off-patent and therefore relatively inexpensive. (Cipro became a household word in the US during the anthrax attacks — it is given prophylactically on suspicion of exposure to inhalational anthrax — and was recently given a “black box” warning by the FDA because of an association with tendon ruptures.)

Quinolone resistance has certainly been recorded: In 2003, a team found 4.0 percent of E. coli in US intensive care units were resistant to cipro. The Canadians — 20 volunteer medical personnel from Ontario — found 5.4 percent among the Guyanese. That’s in a setting where there is no selective antibiotic pressure, because no one is taking antibiotics.

Aha: But they are taking malaria prophylaxis, including the extremely common and cheap antimalarial chloroquine. The team theorizes that chloroquine is sufficiently chemically similar to the quinolones to provoke the development of resistance. If correct, this is very bad news: Malaria is a major killer especially of children, so no one is about to stop prescribing a cheap, effective antimalarial in a highly malarious area. In fact, the WHO and other agencies are preparing a new antimalarial program called ACT (for “artemisin combination therapy”; artemisin is a botanical) that includes a drug family called quinolines that are chemically similar to chloroquine.

Controlling malaria is an important public health goal, but so is controlling antibiotic resistance, especially resistance to effective drugs that poor countries can afford. As one of the authors, Michael Silverman of Oshawa, Ont. warned as the study was releasing:”Chloroquine use for malaria may make the fluoroquinolones less effective for many common tropical diseases such as typhoid fever, diarrheal illnesses, and possibly also tuberculosis and pneumonia in the developing world.”

The cite is: Davidson RJ, Davis I, Willey BM, Rizg K, Bolotin S, et al. (2008) Antimalarial Therapy Selection for Quinolone Resistance among Escherichia coli in the Absence of Quinolone Exposure, in Tropical South America. PLoS ONE 3(7): e2727. doi:10.1371/journal.pone.0002727

Of course we would never have thought of that.

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A new paper in the Annals of Internal Medicine suggests an astounding technique for figuring out whether patients experienced an adverse event while in the hospital:

Asking them.

No, really.

The study by Massachusetts researchers (from University of Massachusetts, Brown, Harvard, Massachusetts Department of Public Health and Massachusetts Hospital Association) looked back at the experience of more than 2,600 patients in 16 Massachusetts hospitals during 6 months in 2003. The researchers started from the assumption that the medical-records review done by many hospitals to spot adverse events was not capturing enough information — and that the interviews that some hospitals do with patients after discharge were asking the wrong questions because they focus only on satisfaction.

So the team did a 20-minute phone interview 6 to 12 months after discharge for 2,600 patients, asking about “negative effects, complications or injuries,” and also reviewed the medical records of 1,000 patients who agreed to their charts’ being released for review. For each arm of the study, two physician-reviewers checked results to be sure what was scored as an adverse event actually qualified as one.

And they found: That twice as many adverse events were uncovered when patients were asked about their experience. Among the interviewees, 23 percent reported an adverse event; when records were reviewed, only 11 percent of patients were judged to have experienced one.

Now, let’s be clear: I’m very glad these researchers had the courage to do this study. Anything that supports better care, more transparency in care and more responsiveness to the patient’s experience is a good thing and I support it.

But when I think of the dozens of hospital patients and family members who have told me about their experiences with poor infection control — lack of hand-washing, lack of housekeeping, bloody gauze on floors — and with being completely unable to get anyone in those hospitals to pay attention, it just makes me want to beat my head against a wall. Coming up with the idea of asking the patients about their experience… this is so hard?

As one of the co-authors, Saul Weingart of Dana-Farber Cancer Institute in Boston, said in an accompanying press release: “It’s pretty clear that they can teach us important things about improving patient safety, if only we ask them.”

The cite is: Weissman, JS et al. Comparing Patient-Reported Hospital Adverse Events with Medical Record Review: Do Patients Know Something That Hospitals Do Not? Ann Intern Med 2008; 100-108.

Antibiotic resistance in food animals all across Europe

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Via a journal that’s new to me — the Acta Veterinaria Scandinavica, the open-access journal of the Veterinary Associations of the Nordic Countries — comes an amazing review of the prevalence of antibiotic resistance in cattle in 13 European countries. Based on 25,241 isolates collected over three years, Denmark, Britain, the Netherlands, Norway, Sweden and Switzerland do well, but “many isolates from Belgium, France, Italy, Latvia and Spain were resistant to most antimicrobials tested.“

Most resistant pathogen: E. coli. MRSA is present as well:

Of major concern is the level of resistance to oxacillin and 3rd generation cephalosporins (i.e. ceftiofur) in S. aureus. The prevalence of oxacillin resistance in Spain (3.7%) and France (8.3%) and the resistance towards cephalosporins in Spain (0.9% in 2004) and France (4.2% in 2002; 1% in 2003) indicate the presence of methicillin resistant S. aureus (MRSA) in these two countries.

The authors ascribe the differences among countries to different patterns of antimicrobial use by veterinarians and stress that it is time for veterinarians to begin using measurements of local resistance patterns (in human medicine, an “antibiogram”) before prescribing. Cite coming when the Acta site is updated. UPDATE: The paper is here; cite is: Hendriksen, RS et al. Prevalence of antimicrobial resistance among bacterial pathogens isolated from cattle in different European countries: 2002-2004. Acta Veterinaria Scandinavica 2008, 50:28doi:10.1186/1751-0147-50-28.

I wasn’t aware that this same set of authors (Hendriksen, RS et al.) just a few weeks ago published a similar review of antimicrobial resistance in pigs in Europe. It looks at several bacterial species in pigs, but unfortunately for our purposes, no S. aureus.

MRSA colonization – the long-term risk

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One of the ongoing puzzles of MRSA’s behavior is the significance of colonization, that situation of MRSA living on the skin — or in the nostrils or other locations close to the body’s external surface — without causing illness. It’s not known how frequently MRSA colonization occurs, for one thing: The long-standing estimate of 1% of the population has been challenged by a number of recent studies.

Another persistent question has been whether the risk of illness and death changes as colonization continues. It has been established that up to one-third of newly colonized carriers will become seriously ill within a year of their acquiring the bug (Huang, SS. et al., Society for Healthcare Epidemiology of America Annual Meeting 2006, abstract 157 – not online that I can find)— but what happens beyond that? Does the risk of illness persist or decrease?

In Clinical Infectious Diseases, the same team that defined the risks of recent colonization report that there are significant risks to long-term carriage as well: 27% of invasive illness in the second year and 16% thereafter, based on a review of 281 patients who were followed for at least one and up to four years at Brigham & Women’s Hospital, a Harvard Medical School teaching hospital. These patients become very ill, and in addition use a significant amount of health-care resources:

At our hospital, there are 2–3 times as many hospital admissions involving patients previously known to harbor MRSA than there are hospital admissions of individuals who are newly detected as MRSA carriers each year.

What is the precipitating event that tips MRSA carriage over into MRSA illness? It may be health care. In other words, the long-term carriers do not become ill with MRSA disease and then come to the hospital. Instead, they come to the hospital for some other reason, and the surgery, IV placement, dialysis etc. they receive allows their MRSA strain to slip past the protective barrier of their skin and begin an invasive infection.

We submit that these high risks of MRSA infection among culture-positive prevalent carriers are not only preferentially detected because of hospitalization but may, in fact, be incurred because of the device-related, wound-related, and immunologic declines associated with a current illness.

This raises the question of whether any admitted patient found to be colonized should undergo the routine known as decolonization before any other procedures are performed — and whether institutions and insurance companies will be open to the additional hospital days and drug costs that will represent.

The cite is: Datta, R. and Huang, SS. Risk of Infection and Death due to Methicillin-Resistant Staphylococcus aureus in Long-Term Carriers. Clinical Infectious Diseases. 2008 47:176-81.

Isolation: Doesn’t work if healthcare workers contaminate themselves afterward

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In the new Emerging Infectious Diseases, there is a small but very smart study that ought to get wider play. It was done by a PhD candidate at University of North Carolina, Chapel Hill named Lisa Casanova, with the help of faculty and the local health department.

Background: In certain highly infectious environments — including in-hospital isolation — healthcare workers wear what is usually known as “personal protective equipment” or PPE. PPE generally includes gloves, gown and an eye shield, goggles or face-splash guard (also called “barrier precautions”) as well as a mask or a respirator (“respiratory protection”). PPE protects the healthcare worker while he or she is in the patient’s presence, but it poses a problem when the worker leaves that environment, because the PPE is likely to be carrying the disease organism on its surface. If the worker doesn’t doff the PPE very carefully, he or she might contaminate himself/herself and become infected or colonized, or spread the organism further in the healthcare environment.

This accidental contamination was a significant problem in the 2003 SARS epidemic — so after SARS was over, the Centers for Disease Control and Prevention came up with a recommended procedure for taking off PPE (on this page, half-way down). Casanova decided to test how well the protocol actually works.

Answer: Not so much. She had 10 volunteers (men and women, left- and right-handed) dress in PPE, contaminated the equipment in certain spots (“front shoulder of gown, back shoulder of gown, right side of N95 respirator, upper right front of goggles, and palm of dominant hand”) with a benign virus, had the volunteers take off their PPE, and then tested them for the virus’s presence. Results:

Transfer of virus to both hands, the initially uncontaminated glove on the nondominant hand, and the scrub shirt and pants worn underneath the PPE was observed in most volunteers.

Casanova recommends changes: additional PPE; different PPE and doffing protocols, such as are used in surgical suites; or PPE impregnated with antimicrobials. (#1 and #3 of course would be more costly; #2 would require procedural change but not necessarily additional garments).

She also raises a vital ongoing issue for MRSA infection control: that healthcare workers may not be punctilious about hand hygiene because they believe that gloves are adequate protection. Only, as this study demonstrates, they are not:

This study also indicates the need for continued emphasis on hand hygiene. A barrier to improving hand hygiene compliance rates is the belief that gloves make hand hygiene unnecessary (14). This is contradicted by our study and others showing that organisms can spread from gloves to hands after glove removal (15). Even if double gloving is incorporated into protocols for PPE use, it is not a substitute for proper hand hygiene.

The cite is: Casanova L, Alfano-Sobsey E, Rutala WA, Weber DJ, Sobsey M. Virus transfer from personal protective equipment to healthcare employees’ skin and clothing. Emerg Infect Dis. 2008 Aug; [Epub ahead of print]

The “vicious cycle” of HA-MRSA

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In the new issue of Lancet Infectious Diseases there’s a marvelous analytical review of the complex relationship between hospital overcrowding and understaffing and the rise of hospital-acquired MRSA.

You can feel intuitively that these phenomena must be linked:

  • If a hospital has more patients, its staff will be more stressed;
  • If they are more stressed, they may neglect handwashing and other infection-control measures;
  • If budget shortfalls cause staff cuts, the remaining staff will be more stressed still;
  • If infection control is neglected, more patients will acquire MRSA;
  • Since MRSA patients are sicker and stay longer, more beds will be full;
  • Since there are more patients, staff will be more stressed;
  • Since MRSA patients are more costly, budgets will be more stressed.

And so on. Because it is a review article it is also an excellent guide to the medical literature on this aspect of the MRSA problem, with 140 cites.

The citation is: Clements, A. et al. Overcrowding and understaffing in modern health-care systems: key determinants in meticillin-resistant Staphylococcus aureus transmission. The Lancet Infectious Diseases 2008; 8:427-434.

Great post elsewhere on antibiotic use in animals

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There will be a bit of a blog break, as I’m traveling for a week. But here as a walk-off is an excellent post from the marvelous public-health blog Effect Measure about the complexities (to be kind) of food companies declaring antibiotic use in food animals.

Very short version of the story: Massive chicken producer Tyson advertised its chickens as being “raised without antibiotics”; the chicken eggs were actually being treated with gentamicin before hatch (therefore technically not being “raised”; the US Department of Agriculture objected, then backed down, then objected again after Tyson’s competitors acted on their own.

Tyson announced it is “voluntarily” withdrawing the label. Which is more than the USDA did, apparently, its hand having been forced by Tyson’s competitors organized into the Orwellian-named Truthful Labeling Coalition (including Perdue Farms Inc., Sanderson Farms Inc. and Livingston, California-based Foster Farms). Perdue and Sanderson had sued over a label they considered “clearly false and misleading,” and a federal judge agreed, ordering Tyson to stop them from running any advertisements with the claim last month. Now, belatedly, the USDA is acting.

The entire post is worth reading, as is Effect Measure (which is running on a “summer schedule” and therefore posting only once a day, thus making us all look bad. Hmm, perhaps a Public Health Blog Truthful Labeling Coalition is in order…)

Closing the loop: meat, meat-eaters, health-care workers

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A posting on the international disease-alert mailing list ProMED led me to a scientific abstract presented at a European meeting this spring on the ST 398 MRSA strain. It adds another, quite unnerving piece to the emerging interplay of MRSA in pigs, humans who have close contact with pigs, humans who have contact only with pig meat, and health-care workers who treat those humans.

Brief precis: About a year ago, Dutch health authorities discovered that a patient who had come in for surgical debridement of a diabetic foot ulcer had an unrecognized MRSA strain in that ulcer. Subsequently, they discovered that four other patients and five health-care workers in the same institution were carrying the same strain. None of the patients reported any contacts with pigs (or calves, which have also been found to carry the strain). One of the health-care workers lived on a farm that raised pigs, but said that she had no contact with the animals in her daily life; nor did her partner.

The authors conclude:

While the source is not fully established it could be the HCW living on a pig farm. This outbreak makes clear that transmission on a larger scale can occur, even with NT-MRSA.

(Hat-tip to Helen Branswell of the Canadian Press for telling me about the ProMED report. And a note to loyal readers: The “MRSA in meat” story is being picked up by some US newspapers. Doesn’t it feel good to know you’ve been reading about the issue here for months? And if you’re a reader of Helen’s work, months more? Of course it does.)

New blog on animal health including MRSA

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Dr. J. Scott Weese of the Ontario Veterinary College (author of many important papers, discussed in many posts here, on MRSA in food and companion animals) has started a blog on animal-health issues. Here is a recent post on tracking down the source of a MRSA infection when there is a pet in the house.

The blog is called Worms and Germs and I’ve added it to the blogroll at right.

One more on MRSA in meat

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It turns out that European governments — in contrast to the United States — are taking very seriously the emergence of MRSA in food animals and its potential for transfer to humans. (For background, posts here, here, here and here.)

How seriously? They’re doing a sampling survey of pigs on farms across the European Union, at a cost of about $3 million in EC funds, with matching funds expected from each government.

The MRSA survey piggybacks (sorry) on a year-long survey of Salmonella incidence that the EC called for in September 2007. But in December, following publication of several significant papers about the ST 398 MRSA strain in pigs and pig farmers, the EC Directorate-General for Health and Consumer Protection pushed for an addition to the Salmonella study: a same-time sampling for the presence of MRSA strains in pig operations across 29 countries.

The sampling is taking place from January to December of this year, with results mandated by mid-2009, though individual country authorities may release data earlier if they choose. (In the wake of the finding of three ST 398 cases apparently caused by retail meat in the UK, the Soil Association has called on the British government to release whatever data it has ASAP. Before the EC decision, the UK government had refused to test its pigs; cf. these House of Lords minutes.)

Of note: The Soil Association is pressing the argument that ST 398 has developed in the setting of widespread use of antibiotics in food animals, and contends the strain’s arising in the Netherlands is especially alarming because they have some of the lowest animal-antibiotic use rates in the EC it illustrates the difficulties that even a society conscientious about antibiotic overuse can have keeping track of veterinary applications. The Netherlands has been successful limiting overuse in humans, but has found controlling veterinary use much more of a struggle. (Thanks to the Soil Association for correcting my misunderstanding!)