Maryn McKenna

Journalist and Author

World Health Day: Time to tackle resistance

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Tomorrow, Thursday, is World Health Day, an annual observance that the World Health Organization uses to focus attention on some critical global-health issue. This year, they’ve chosen antimicrobial resistance as the issue that most needs highlighting. Noting the choice, the Lancet editorialized: “Resistance has joined the front rank of global health concerns.”

On the day, the WHO and some other agencies and organizations will be announcing plans and strategies. I’ll cover those tomorrow. For today, a scene-setter: Why you should care.

Having spent the last couple of years immersed in antibiotic resistance (because, you know, I wrote a book about it), I’m often puzzled why it doesn’t excite more alarm. I’ve concluded our situation is similar to the overused analogy of the frog in the slowly warming water: We don’t realize how bad things have gotten, even when we’re in imminent danger of death.

So here’s a round-up to remind us, drawn just from recent news.

In hospitals: Very large hospital systems are using more broad-spectrum last-resort drugs. Last weekend, representatives of the Veterans Health Administration disclosed that over 5 years, vancomycin use has gone up 79 percent, and carbapenem use, 102 percent. Vancomycin is the only affordable drug of last resort for MRSA; carbapenems are the drugs of last resort for gram-negative infections such as Klebsiella. The use of those drugs is growing because organisms are becoming multi-resistant to less-powerful drugs, but they are becoming resistant to the big guns too. Carbapenem resistance in Acinetobacter, a bacterium that afflicts ICU patients and gravely wounded military members, rose from 5 percent of isolates in US hospitals in 2000 to 40 percent in 2009. Israeli scientists reported this month that carbapenem-resistant Klebsiella pneumoniae (CRKP, subject of my Scientific American article this month) caused a nationwide outbreak in 2007 and 2008, sickening 1,275 patients in 27 hospitals before it was brought under control. [Read more…]

Polio eradication: Not over for a while yet and why

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The news on polio eradication — the almost 30-year up-and-down struggle to make polio the second human disease, after smallpox, to be eradicated from the planet — recently has been wonderful. The case numbers are seesawing — fewer in the four countries where the disease remains endemic, more in the countries where has recently crept back — but overall much lower than just a few years ago. The game-changer has been the entry into the eradication fight of the Gates Foundation, which has declared polio one of its major priorities. That infuses a huge bolus of cash into an effort that was always short of funds, but even more it shines a spotlight of international attention on a mostly neglected disease. Where Gates goes, governments and the media follow.

But before expectations of success rise too high, it is important to say that there is a largely unexplored and difficult end-game to polio eradication. It is smartly captured in an essay by Debora MacKenzie of New Scientist, who reminds us that ending all cases of wild-type polio will only be the end of the beginning — because we will still have to protect the world from the virus that we have been using all these years in the vaccine. [Read more…]

The Enemy Within: A new superbug, KPC/CRKP

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Remember NDM-1, the “Indian supergene” that created a media furor last fall and then fell below the news horizon? This is worse.

I have a story in the April Scientific American (“The Enemy Within,” just previewed online) about a new and very troubling form of antibiotic resistance: Carbapenem resistance, spreading through Gram-negative bacteria such as Klebsiella (above, from the CDC) and E. coli.

Carbapenems are drugs of last resort for Gram-negatives, which include many of the bacteria that cause potentially deadly infections in debilitated ICU patients and frail elderly in nursing homes. Gram-negatives have been becoming ever-more resistant to antibiotics, but the carbapenems remained reliable drugs of last resort for even the most serious cases. Then, in 1996, researchers at the Centers for Disease Control and Prevention spotted the first signal that carbapenems were under threat: A single bacterial sample, found in a patient in a North Carolina hospital, that was resistant to the carbapenems and could only be treated by a few remaining drugs that were much less effective or so toxic that medicine had put them on the shelf years ago.

By 2000, that same resistance pattern surfaced in hospitals in Manhattan: first one, then another, then a third and fourth. Then it began to spread to cities where New Yorkers vacation, and then to countries where they travel. Now, more than a decade later, it has reached at least 37 states and at least a dozen countries around the world.

It is spreading much faster than drugs to combat it could be developed — if there were such drugs. One of the difficulties, indeed tragedies, of carbapenem resistance is that there are very few such drugs left — because, for reasons I’ve explored before, drug development in the United States has ground to a halt. For resistant Gram-negatives, there are almost no drugs left, and none on the immediate horizon. If that scares you, well, it should.

Here’s a quick snip from the article:

The end of the antibiotic miracle is not a new theme. For as long as there have been antibiotics, there has been antibiotic resistance: The first penicillin-resistant bacteria surfaced before penicillin was even released to the marketplace in the 1940s. And for almost that long, doctors have raised the alarm over running out of drugs, sparked by the global spread of penicillin-resistant organisms in the 1950s and followed by methicillin resistance in the 1980s and vancomycin resistance in the 1990s.

This time, though, the prediction of post-antibiotic doom comes from a different part of the microbial world. The genes that confer carbapenem resistance have appeared over the past decade or so in a particularly challenging grouping of bacteria called gram-negatives.

Gram-negative bacteria are promiscuous: They facilely exchange bits of DNA, so that a resistance gene that arises in Klebsiella, for example, quickly migrates to E. coli, Acinetobacter and other gram-negative species. Gram-negative germs are also harder to dispatch with antibiotics because they have a double-layered membrane that even powerful drugs struggle to penetrate, and possess certain internal cellular defenses as well. In addition, fewer options exist for treating them. Pharmaceutical firms are making few new antibiotics of any type these days. For the protean, stubborn gram-negatives, they have no new compounds in the pipeline at all.

Carbapenem resistance has already brought hospital-acquired infections to the brink of untreatable. The imagined future that keeps health authorities awake at night is the undetected dissemination of carbapenem resistance genes into organisms that cause everyday maladies—such as E. coli, which is responsible for most of the millions of urinary tract infections in the U.S. every year.

Carbapenem resistance in Klebsiella — which is sometimes called KPC or CRKP for short — got a spike of attention last week just as my piece hit the web. Coincidentally, the article posted just as the Los Angeles County Department of Public Health released results of a survey showing 356 cases just between June and December 2010 just in LA County medical facilities.

This SciAm piece is the first that we know of to tell the whole tangled, troubling story. I hope you’ll take a look.

And while you’re there, please read SciAm’s brave and cogent editorial against antibiotic overuse in industrial-scale agriculture. It’s marvelous.

CDC Public Health Image Library

China pig crisis: Drug residues in pork

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In China, more than 2,000 tons of fresh pork and pork products — at a minimum, 4 million pounds — have been recalled because the meat has tested positive for clenbuterol, a stimulant that is illegal in food-producing animals not only in China but in Europe and the United States. Another 1.6 million pigs are being tested.

The story has been unfolding for the past week without much notice from Western media, but it has been heavily covered in China, even in English-language media there.

Clenbuterol, which lingers in muscle tissue for months and concentrates in some organs, is hazardous to humans because of its stimulant properties: It revs up the heart and gives you the shakes, and can be especially dangerous for pregnant women. (Here’s the data sheet from the Food Safety and Inspection Service.) If it sounds familiar, that’s because its stimulant qualities also make it a performance enhancer — and thus a banned drug for elite athletes, including a listing on the World Anti-Doping Agency’s Prohibited List. Tour de France winner Alberto Contador was temporarily banned from cycling this year after a positive clenbuterol test, and US Olympic swimmer Jessica Hardy was found positive for the drug in 2008 (a finding she blamed on an allegedly tainted supplement). Clenbuterol’s a common subject on body-building forums (here’s one example) for its perceived ability to build lean muscle while diminishing fat.

And that may have been the motivation in China: putting lean weight, inexpensively, on pigs.

Here’s what’s known:

On March 17, the Chinese TV network CCTV reported that 19 pigs at a slaughterhouse in Henan province, part of a lot of 689, had tested positive for clenbuterol in their urine. About 20 people — farmers, middlemen, quarantine inspectors and a buyer for the processing company, Jiyuan Shuanghui Food Co., Ltd. — were arrested.

On March 18, Xinhua News reported that the number of positive tests had grown to 52 pigs out of 1,512, on nine farms tested, and the number of people in police custody had grown to 30. Plus, the scandal had spread to a second province, Jiangsu, after 20 randomly picked pigs out of 264 from Henan tested positive at a slaughterhouse in Nanjing. Concern over the brewing scandal drew the central government’s Ministry of Commerce into the issue; the agency urged the company where the tainted pork was first found — which happens to be a subsidiary of China’s largest meat processor — to suspend production and start an internal investigation.

On March 19, the central government convened an emergency meeting of pig farmers, meat processors and food retailers, and two days later ordered provincial authorities to start a crackdown that extends to checking backyard pigs.

And on March 25, the government released its annual food safety plan and put special emphasis on banning clenbuterol and tracking down illegal users.

Notably, the more-free parts of the Chinese media are pushing the government to do more. China Daily editorialized on Thursday:

Why can’t quarantine workers go to pig farms in a random way to check the pigs? Why do they have to wait for the pig urine sent by pig raisers? Why aren’t pigs randomly checked immediately before they are butchered? What is both funny and sad is the fact that a local bureau of animal husbandry in central China’s Henan Province checked a problematic pig farm and 98.8 percent of the pigs tested were passed safe on March 15. But an investigation by reporters after the check found that the farm still feeds pigs clenbuterol, which was banned nine years ago.

The revelation that pigs are being fed growth hormones that are considered harmful to humans so the animals develop more muscle and less fat has shaken consumers’ confidence in pork, just as the melamine scandal did with milk. Anyone involved, whether pig raisers or quarantine checkers, must be brought to justice…

The general public wants to be told how problematic pigs can pass a series of tests before they are butchered and how the meat containing harmful substances can go through a series of tests and still end up in the mouths of consumers.They also want to know whether the culprits, including pig raisers who have fed pigs harmful chemicals and those who took money to turn a blind eye to the problematic pigs and meat will get the punishments they deserve.

This isn’t the first time clenbuterol has been found in pork in China. In 2009, 70 people in Guangdong province were hospitalized for stimulant poisoning after eating organ meats from contaminated pigs; in 2006, more than 300 people in Shanghai were sickened. In January, two months before this scandal surfaced, the AP’s Alexa Olesen wrote a prescient long takeout on the complexity of controlling clenbuterol abuse, especially in rural areas.

Here’s a question: Activism for safe food in the United States was arguably ignited by Upton Sinclair’s The Jungle, a novel that served as an expose of the contamination and filthy conditions he witnessed working undercover in Chicago’s meatpacking plants. There was such a public outcry at his revelations that the Pure Food and Drug Act of 1906, the first US food-safety legislation, was written and passed in the same year the book came out. The Jungle was so influential that, 105 years later, it is still in print.

I wonder: Who will write a Jungle for China? And given the repression that seems to be practiced against whistleblowers there, if anyone did, would it see print?

Flickr/JulianPTan/CC

Tuberculosis: Forgotten but not gone

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It’s World TB Day: 129 years ago today, Robert Koch announced the identification of the tuberculosis bacillus. It must have looked, back then, as though solving TB — effectively the AIDS of the 19th century, the disease that took leading artists and writers in the prime of their creative lives and inspired novels, poems and operas of loss — was tantalizingly close at hand.

But not. In 2011, the World Health Organization reports, tuberculosis is stubbornly persisting, and the twin problems of multidrug-resistant and extensively drug resistant TB — MDR and XDR — are growing worse. [Read more…]

Diseases and borders: Potatoes and St. Patrick's Day

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Beannachtai lá le Pádraig, constant readers — or, for you English-speaking lot, Happy St. Patrick’s Day.

In Irish, the way to say “Once upon a time” is O fadó fadó — “Long, long ago…” So, for St. Patrick’s Day, an Irish story:

Long, long ago — or, by the calendar, in 1824 — the territory know as Peru broke Spain’s last hold on the New World. The nascent Republic needed trade relationships, and quickly: It had borrowed heavily from banks in Europe to finance its 3-year war of independence. But after 300 years of colonization, all it had to offer, bluntly, was crap.

No, really, crap. Bat and seabird crap, otherwise known as guano. In the centuries before the establishment of the chemical industry, guano was a precious commodity, a potent natural fertilizer packed with nitrate and phosphates. There were enormous deposits of guano on the Andean coast and offshore islands; they provided the currency that Peru’s new government leveraged into a web of trade relationships with England, the United States, and France. Guano quickly became Peru’s leading export and the basis of its entire economy. In 1841, the government nationalized the guano deposits, selling the stuff to its European and American partners in hundreds of shiploads — tens of thousands of tons — per year. [Read more…]

Brief promo: SUPERBUG on BoingBoing and JoanneLovesScience

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As I told you a few weeks ago, my book SUPERBUG (Free Press 2010) is out in paperback. Mark Frauenfelder of BoingBoing.com has very kindly put up an interview and podcast about it. And Joanne Manaster, AKA @ScienceGoddess, has done one of her excellent and charming book review videos, calling it “not for the faint of heart or someone incessantly worried about their health.” (Heh.) I’m grateful to both.

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Drug-Resistant Bacteria: To Humans From Farms via Food

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You have to love a scientific commentary that starts this in-your-face:

“Show us the science that use of antibiotics in animal production is causing this antibiotic resistance,” Dave Warner of the National Pork Council told the Washington Post back in June 2010, responding to a Food and Drug Administration (FDA) guidance document advising against the sub-therapeutic use of antibiotics in livestock.

Well, here’s some.

To be clear: That’s the paper’s language, not mine. The gut-punch challenge comes from an editorial that is only on the web so far but is scheduled for publication in the journal Clinical Microbiology and Infection. It accompanies a research article that makes an important claim:

Chickens, chicken meat and humans in the Netherlands are carrying identical, highly drug-resistant E. coli — resistance that is apparently moving from poultry raised with antibiotics, to humans, via food. [Read more…]

Ag antibiotic use: Risky — but also sloppy and wasteful

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So, antibiotics. Given to farm animals. (Yeah, that again.) How does that work, anyway? Pills? Injections? Daily massage with specially compounded creams?

Not quite. Farm animals overwhelmingly get antibiotics in their feed. (You knew that.) And a new paper in the journal Environmental Health Perspectives explains what a bad idea that is: Animals that are given “free choice medicated feeds” (FCMF, in the jargon) can overdose or under-dose themselves, leading not only to the creation of antibiotic-resistant bacteria but to the accumulation of antibiotic residues in their flesh that can persist past slaughter.

There are two issues hidden in this. The first is the practice of giving tiny doses of antibiotics as “growth promoters,”  a use that dates back to the late 1940s. Despite a fair amount of study, there are still competing explanations for how this actually works, but the results are clear: Give animals micro-doses of antibiotics, and they put on weight faster, meaning they get to market size and can be sold — and replaced by another batch to whom the same thing happens — more quickly than if the drugs were not being used. The second is using treatment-sized doses in feed to take care of any illnesses among animals, as well as to protect animals who might pick up those illnesses in the close quarters of confinement agriculture.

If you view animal raising as an industrial-style process, the equivalent of making widgets on a production line, then medicated feed appears to make economic sense, because it offers a substantial return for little forward investment of money or labor. But as this paper picks apart, medicated feeds are not the bargain they seem. [Read more…]

Some hospital infections sharply reduced. Others, not.

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Important news from the CDC Tuesday: A particularly deadly kind of hospital-acquired infection, CLABSIs — central line-associated bloodstream infections — was sharply suppressed across the 2000s. There were an estimated 43,000 in intensive-care unit patients in 2001 and an estimated 18,000 in 2009, a drop of 58 percent. That’s excellent: Up to one out of four patients who contracts a CLABSI dies as a result of it. According to the CDC report, the numbers represent — just in 2009 — 6,000 lives saved and and $414 million in healthcare costs that didn’t have to be spent. Across the decade, the lives saved might go as high as 27,000, and the total savings, $1.8 billion.

But the news is not uniformly good. CLABSIs are still prevalent outside of ICUs, in general in-patient care, and especially in outpatient care such as dialysis. In 2009, there may have been 23,000 CLABSIs in hospitals but outside of ICUs, and 37,000 in dialysis-clinic patients. [Read more…]

Lie Down With Dogs, Get Up With Fleas. And Plague

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Do you let your dog sleep on your bed? You do, don’t you? Once you read this story, you might want to rethink that.

There were only two cases of bubonic plague in humans in the United States last year. They were two people, unidentified except for their ages  — 17 and 42 — who lived in the same household in the high desert country of Lake County, Oregon. In August, they both came down with high fevers and hard, lumpy swellings in their groins. The older one, a woman, was very sick, was hospitalized with low pulse and blood pressure, and went into kidney failure.

Physicians couldn’t figure out what was wrong. In her blood, they found a rod-shaped bacterium. Four different diagnostic labs took a crack at identifying it. The first said it was Acinetobacter lwoffii. The second suggested it was Pseudomonas luteola. The third guessed Yersinia pseudotuberculosis.

It wasn’t until 25 days had passed, and the woman and teen had recovered, that the isolate got handed up to the regional health district laboratory, part of the state health department. Then someone identified it for what it was: Yersinia pestis, the bacterial cause of plague.

That rang all kinds of alarm bells. Plague is a Category A bioterrorism agent, the highest ranking of three: It causes severe illness and can pass from person to person. Also, it triggers what planners bluntly term “public panic and social disruption”: For centuries, plague has been something we are very, very scared of.

It also makes people very, very sick. On average in the United States — where there are only a few cases per year — one out of seven people who contract plague die of it. If bubonic plague goes untreated, the death rate goes up to one out of two.

So a case of plague makes public health investigators, and bioterrorism responders, come running. And as recounted by the CDC Friday morning, they ran to Oregon — and found no sign that this rural household had been subjected to a bioterror attack or involved in anything nefarious. But they did find dogs. One of the dogs slept on the bed of one of the humans. They checked the dog, which looked healthy, and in its blood they found evidence that, at some earlier point, the dog had been infected with Y. pestis too.

Where did it come from? The natural hypothesis is fleas.

Rodents — rats, but also mice, chipmunks, prairie dogs, ground squirrels — are a natural reservoir for Y. pestis. Fleas on shipboard rats were the vector that carried the plague from Asia to Europe in the 14th century, eventually killing one-third of the population of the Western world. Fleas from wild rodents are the source of the 10 to 20 cases of human plague in the United States every year. And fleas, apparently, had bitten this dog.

Imagine it: A loved dog, probably a big dog, racing through a dog’s perfect landscape: flat, wild, open, full of things to chase and smell and stick its nose into. Running after chipmunks. Tearing through prairie dog burrows. Romping home happily to flop on the bed and dream, while the fleas that jumped onto it hop off again, from the dog to the quilt, from the quilt to the pillow, from the pillow to the owner sleeping unknowingly alongside.

Imagine that, for a minute. And then go buy a flea collar.

Cite: Centers for Disease Control. “Notes from the Field: Two Cases of Human Plague — Oregon, 2010,” MMWR [Morbidity and Mortality Weekly Report], Feb. 25, 2010.

KeokiSeu/Flickr/Creative Commons

Food safety: Needs speed, technology — and funds

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Perhaps you remember the Great Tomato Scare of 2008.

It started in mid-May, when the New Mexico Department of Health told the Centers for Disease Control and Prevention that it had identified a  Salmonella cluster: four people who were infected with an identical, uncommon strain called Salmonella Saintpaul, and another 15 who seemed to be part of the same outbreak but whose infections hadn’t been characterized enough for authorities to be certain. Then there were cases in Texas, and then more cases in the Navaho Nation. By June 9, 2008, there were at least 150 cases nationwide; by July 1, the count was 869. By the time the outbreak ended in late August, there would be 1,499 victims — almost certainly an undercount — in 43 states. Two people died.

The outbreak was chaotic. On June 3, based on some early studies, the Food and Drug Administration warned people in New Mexico and Texas against eating certain types of raw tomatoes; on June 7, the FDA expanded the warning to nationwide. Investigators were puzzled by tomatoes causing an outbreak so early in the season, and hypothesized that they must have been grown in a warm climate area — maybe California, Florida or Mexico. Then they were troubled by how widely the outbreak spread. Because tomatoes can come from so many different places, they wondered whether the source of the contamination wasn’t the growing fields, but rather a packing house or a wholesaler where fruit from many different farms came together.

Consumers were just as confused. The FDA said raw red plum, red Roma and red round tomatoes were no-gos, but cherry tomatoes, grape tomatoes and tomatoes sold on the vine were OK. People were unsure what was safe to eat and from where it was safe to buy. The entire enormous tomato industry — 8 billion pounds per year in the US — ground to a halt.

There was just one problem: The cause of the outbreak wasn’t tomatoes at all. [Read more…]

News break: Slaughter will reintroduce PAMTA (and cites data from this blog)

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Rep. Louise Slaughter (D-NY), Congress’s only microbiologist, said late today that she plans shortly to reintroduce PAMTA, the Preservation of Antibiotics for Medical Treatment Act, a timely move given the collapsing antibiotic market (see this morning’s post) and continuing reports of resistance moving off farms (as in this post).

PAMTA would direct the FDA to re-examine its approvals of veterinary antibiotics that are close analogs of ones used in humans, because they can stimulate the development of resistant organisms. When those organisms move off the farm, as research shows they do, they then cause illnesses that cannot be treated by the functionally identical human drugs.

The Union of Concerned Scientists said in 2008 about an earlier version of the bill:

The FDA is aware of the problem of antibiotic resistance due to overuse in animal agriculture, but the agency’s process for reviewing and withdrawing drugs from the market is far too slow and cumbersome. A recent effort to withdraw an antibiotic from use by poultry producers due to concerns about human antibiotic resistance lasted for more than five years, costing millions of taxpayer dollars. And while the judicial proceedings dragged on, disease-causing bacteria continued to outwit antibiotics.

While some producers and retailers of meat products have announced policies that take steps to curb antibiotic use, private-sector initiatives to reduce antibiotic use in animal agriculture are relatively rare, limited in scope, and difficult to verify. Federal action is needed to achieve comprehensive reductions and create a level playing field for all producers and retailers.

Passage of PAMTA is critical to keep antibiotics working for human health. In addition to averting the harmful effects of antibiotic overuse on human health, curtailing animal use of antibiotics will encourage producers to raise animals in better living conditions that are less conducive to disease.

Parenthetically, it is flattering to see Slaughter reference new data on the amount of antibiotics used in animals in the United States — almost 29 million pounds — and the percentage of the total market antibiotic market that represents: 80 percent. Those pieces of news were broken over the Congressional break by myself, here at SUPERBUG, and by Ralph Loglisci at the blog of the Center for a Livable Future.

Flickr/net_efekt/CC

Running out of antibiotics — and other drugs too

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Last night, the Journal of the American Medical Association posted ahead of print an editorial by Dr. James Hughes, former director of the National Center for Infectious Diseases at the CDC and now a professor of medicine and global health at Emory University. It’s a blunt and eloquent plea for attention to a problem that many people haven’t yet faced up to: We’re running out of antibiotics.

Antimicrobial agents have saved millions of lives and improved the outcomes for countless patients since these drugs were introduced in the early 1930s. However, the effectiveness of these lifesaving resources is at risk. Many medical advances that physicians and patients take for granted—including cancer treatment, surgery, transplantation, and neonatal care—are endangered by increasing antibiotic resistance and a distressing decline in the antibiotic research and development pipeline. (JAMA Hughes)

Drug resistance is a biologic inevitability — but in the 83-year history of the antibiotic miracle, starting from Fleming’s first recognition of natural penicillin, whenever resistance made one drug useless, another drug came along to save us. Those days are over. [Read more…]

Giant pig farms: Antibiotic resistance is not the only problem

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When I talk about farming, I usually focus on antibiotic over-use and the way that it stimulates the emergence of drug-resistant organisms. That’s part of what my recent book is about, and to me, it’s the critical piece in the entire discussion of industrial-scale agriculture. If we didn’t use antibiotics in such vast quantities, confined animal-feeding operations, CAFOS, couldn’t exist: Animals couldn’t survive in those conditions without them.

But so many other negatives come from CAFOs — not just antibiotic resistance, but air and water contamination, and chronic human diseases caused by effluent and pollution. I’m grateful to be reminded of that via a webinar hosted this afternoon by the Institute for Agriculture and Trade Policy, which threw a sharp light on the impact of industrial-scale hog farming in North Carolina.

The webinar took a close look at new research by University of North Carolina associate professor Steven Wing. His paper, just published on the website of the journal Epidemiology, details the acute physical symptoms experienced by North Carolina residents who live in areas near very large hog farms: eye irritation, wheezing, chest tightness, shortness of breath, sore throat and nausea.

Emerging from the farms, Wing said, are “dust, and particles from dried feces, as well as spraying of waste that aerosolizes that material. There are several important gases such as ammonia and hydrogen sulfide… as well as bioaerosols, which include endotoxin from dead bacteria. Some of these materials… are allergenic and can cause respiratory problems.”

(See Wing’s image above of manure spraying, and dead-pig disposal, outside a North Carolina hog farm.)

To get that data, Wing and colleagues at UNC and Mount Sinai School of Medicine collaborated with residents of eastern North Carolina, especially the Concerned Citizens of Tillery, in a project dubbed Community Health Effects of Industrial Hog Operations (CHIEHO). They recruited 101 adults in 16 communities who agreed to sit outside for 10 minutes twice a day, every day for two weeks, and to log their symptoms and also measure their lung function with a flow meter. Separately, the team measured ambient air pollution with continuous monitors that were parked in each community.

Overall, between September 2003 and 2005, they received 2,900 responses about people’s symptoms in the previous 12 hours, 2,600 about symptoms that were provoked by those episodes of sitting outdoors, and 1,900 error-free measurements of lung function. And — no surprise for anyone who knows what these farms look like and smell like — the symptoms tracked with the air pollution measurements.

Wing asked: “Is it fair to tell anyone they can’t go outside their own home because it is too polluted to be there?”

Here’s why conditions outside those eastern North Carolina houses are so bad. Within two miles of each of the communities that contributed to the research, there was an average of 42,000 hogs. Within North Carolina as a whole, there are more than 10 million hogs on more than 2,400 farms. The distribution looks like this:

The spots where the dots cluster most densely are Duplin and Sampson counties. Duplin contains 45 hogs for every resident; Sampson, 32. Something else those areas have in common, mentioned during the webinar by Naeema Muhammad, from Concerned Citizens of Tillery:

Most of those operations are in eastern North Carolina, and eastern North Carolina is where you have your predominantly African-American communities, …other communities of color and also your highest rates of poverty. Looking at that map, we are able to use the phrase “environmental racism.”

Wing and colleagues add in their paper:

…in low-income communities of color… there is more potential for exposure to outdoor air pollutants due to older homes that are not air tight and have no air conditioning. Many residents also lack the financial resources to travel and choose activities that could help them avoid high pollution. Exposure to air pollution from hog operations is an environmental injustice in rural areas hosting facilities that supply pork to populations spared the burdens of its production.

IATP said today they will subsequently post a recording of the webinar along with its slides; I’ll update when it goes live.

Cite: Schinasi, L et al. Air Pollution, Lung Function, and Physical Symptoms in Communities Near Concentrated Swine Feeding Operations. Epidemiology 2011;22: 208–215. DOI: 10.1097/EDE.0b013e3182093c8b

Images: Dead pigs and manure spraying at a North Carolina farm/Institute for Agriculture and Trade Policy + S. Wing, UNC; map of North Carolina hogs farms/IATP + S. Wing, UNC (adapted from Wing et al. 2001)



The dangers of ticks: Not just Lyme disease

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I have a story in the forthcoming March issue of SELF Magazine that has just been put up online: The Rising Dangers of Ticks. It’s a long look at the under-appreciated other diseases that can be transmitted by tick bites — that is, not the Lyme disease that most people associate with ticks, but babesiosis, erlichiosis, anaplasmosis, and others. From the story:

“We’ve seen pretty dramatic increases,” says Jennifer McQuiston, an epidemiology team leader in the vector-borne disease division of the Centers for Disease Control and Prevention in Atlanta. “We’re told to get out and exercise and enjoy nature, so we need to be aware.” Most people have heard of Lyme disease, which appeared among residents of that town in Connecticut in the mid-1970s and now affects more than 35,000 Americans per year. Most Lyme cases occur in the Northeast and upper Midwest; if you don’t live there, you might be safe from Lyme but still at risk for other diseases. Cases of a tickborne illness known as ehrlichiosis grew from 200 to 957 nationwide—a 378 percent jump—between 2000 and 2008, according to the CDC. The infection anaplasmosis nearly tripled in the same period, and Rocky Mountain spotted fever quintupled. The new disease STARI (southern tick-associated rash illness) has spread across the South, and strains of an infection called rickettsiosis have hit the Gulf and Pacific coasts.

All of these non-Lyme tick diseases attack victims in a similar way, bringing on fever, headache, and muscle and joint pain—making it easy to misdiagnose them as anything from flu to meningitis, says [Gary P. Wormser, M.D., the chief of infectious diseases at Westchester Medical Center and New York Medical College and head of a team researching tick diseases]. If the patient remembers finding a tick, or develops a rash, that’s a big clue. If not, “it is somewhat common for these to be missed. The symptoms resemble so many other common viral infections,” says Gregory A. Storch, M.D., a pediatric infectious-disease specialist at Washington University in St. Louis, which created a multidisciplinary tickborne-disease research team because cases have surged there.

…[B]ecause medical awareness has not kept up, patients have been overlooked, undertreated and taken by surprise when their enjoyment of the outdoors—a hike, a run, a round of golf, their own backyard—turns into a life-altering threat.

Sometimes these infections can be transmitted by a tick bite at the same time as Lyme, making them what physicians and Lyme patients call “co-infections.” Sometimes they are mistaken for Lyme. Some of them require different drugs to treat, so if they are not diagnosed correctly, people will not be treated properly and the diseases can linger.

That’s especially important for one of them, babesiosis, because it is caused not by a bacterium but by a parasite that lives in red blood cells much as malaria does — in fact, one researcher described it to me as “American malaria.” Because many people don’t show obvious symptoms, babesiosis isn’t always detected and treated. As a result, it is spreading, both from women to their children prenatally, and also, troublingly, through the blood supply. Babesiosis is currently the No. 1 cause of infections transmitted through blood transfusion in the United States. Unlike other infections that are potentially passed by blood, such as HIV and West Nile virus, there is no test for babesiosis that blood banks can use.

In 2007, in a case that rang alarm bells, a cancer patient in California arrived at the hospital weak and throwing up blood. Tests revealed babesiosis: He had been infected by blood from a man who had donated in Maine, say Van P. Ngo and Rachel Civen, M.D., epidemiologists at the Los Angeles County Department of Health who investigated the case. The FDA has since reported that over the past 10 years, babesiosis has infected more than 100 Americans via transfusions—and 11 of them have died.

These are tiny numbers compared with the more than 5 million people who receive transfusions in the United States each year. But there are almost certainly more cases than there would be if blood banks could effectively check for the parasite. Right now, donors merely complete a questionnaire that asks whether they have had babesiosis or unexplained fever. In one study in Connecticut, 1 out of every 100 donors who passed that screening was shown to be potentially infectious.

These infections aren’t often deadly, but sometimes “deadly” isn’t the point: For many of the women (and men) who have had them, they are life-interrupting and sometimes life-changing, requiring tough drug treatment and long recovery times. A number of women who suffered from babesiosis and erlichiosis generously shared their stories with me, and two are featured in SELF. I hope you’ll take a look.

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Drug residues and drug resistance in water: Not good

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When we talk about the emergence of antibiotic resistance, two factors usually get the blame: the overuse of antibiotics in human medicine and in agriculture. In both cases, the drugs’ presence exert selective pressure on bacteria, encouraging them to develop or acquire resistance genes that will protect them.

But there’s another way that bacteria are exposed to antibiotics. It’s through wastewater: residues from antibiotic manufacturing, retail drugs dumped because they are expired or no longer needed, and sewage — because a percentage of the drugs we take (and give to animals) pass through our bodies unused, and also pass intact through municipal wastewater treatment when it exists.

I wrote about this a bit last September, just after this blog launched, in the context of how difficult it can be to get rid of prescription drugs that you no longer need or want. (Plea: Don’t flush them.) But a new paper in PLoS One underlines that this problem is much bigger than the bottles cluttering your medicine cabinet.

For several years, faculty from several universities in Sweden have been tracking the content of wastewater flowing into a river near Hyderabad in India, a city that is a center of generic drug manufacturing. (For a sense of how saturated the local environment is with pharma firms — more than 90 — check the map at right.) Previously, they had found levels of fluoroquinolones  high enough to kill fish and permeating drinking-water wells in villages. (For humans, the most familiar fluoroquinolone is Cipro.) For this paper, researchers looked specifically at bacteria living in parts of the river where that industrial pharma effluent is flowing, to see whether they were developing resistance in response to that exposure.

Answer: Oh, yeah. Using a method called “multiplexed massively parallel pyrosequencing” (which I love just saying out loud), the team analyzed the bacterial DNA and found it loaded with resistance genes that would confer protection to multiple classes of antibiotics: fluoroquinolones, aminoglycosides and sulfonilamides. At three sites downstream of the key wastewater plant that processes the effluent, known resistance genes accounted for 1.7% of all the DNA they analyzed. Along with those genes, they also found two previously unknown plasmids that contained genes conferring resistance to fluoroquinolones (qnrD) and sulfa drugs (sul2).

It’s important to say that the bacteria in the river that were harboring these resistance genes were not disease-causing bacteria. It’s also important to say that is only minimally relevant. Once resistance factors arise, they move with surprising speed between bacteria and also across bacterial species. In the downstream samples, they also found abundant integrons and transposons that would allow the genes to move, reinforcing the case that resistance was evolving at these spots because of the antibiotic-laden effluent.

This Indian river is a hot spot because of the concentration of manufacturing along it — but it’s not the only offender. Last year, Chinese scientists reported on very high levels of oxytetracycline stimulating bacterial resistance in a river in China. In January, British scientists reported similar results for a river in Cuba. And as I said last fall, the US Geological Survey has found pharmaceutical residues in 80% of the 139 US streams they sampled in 2002.

National and international health agencies, and medical societies and NGOs, have programs that seek to reduce the overuse of antibiotics in human medicine. There’s increasing pressure, as we talk about here all the time, to push back against the overuse of antibiotics in farming. But the thought that antibiotics are spreading freely in groundwater, lakes and rivers is truly disturbing. Curbing that will require a whole different level of effort.

Cite: Kristiansson E, Fick J, Janzon A et al. 2011 Pyrosequencing of Antibiotic-Contaminated River Sediments Reveals High Levels of Resistance and Gene Transfer Elements. PLoS ONE 6(2): e17038. doi:10.1371/journal.pone.0017038

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In Defense of Science Blogs (yes again)

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Two days ago, the acclaimed British science journalist and blogger, Ed Yong, published a post titled I think you have all you need for a blog.  This detailed an e-mail exchange with a public information officer who’d been approached for, surprisingly enough, information for a story.

The PIO was – let’s say – reluctant to help. He explained that after 15 years as a journalist, he was able to judge who needed in-depth details and, apparently, it wasn’t a blogger.  The PIO in question – later identified as Aeron Haworth of the University of Manchester – went on to assert that Yong was only a “journalist wannabe.” This latter – let’s say – exercise in poor judgment appeared in the comment section of another blog post, this one from another notable journalist/blogger, Ivan Oransky, a health editor at Reuters, titled How to demonstrate you’re not about transparency and piss off reporters – as a PIO.

As Oransky noted, Haworth was refusing to share information about a study that was, in fact, already widely available. That angle was picked up by another outstanding journalist/blogger, Maryn McKenna, in a post titled How Not to Publicize Science: A Sad and Cautionary Tale (Bring Popcorn). In fact, the Haworth debacle was promptly picked up as “please don’t do this” example by David Harris, who writes the savvy blog, The Enlightened PIO.

Myself, I want to pick at another point, found in that remark: “I think you have all you need for a blog.” Italics mine. Haworth critics have justly pointed out that his fumble began with not being clued in enough to know that Ed Yong, who writes award-winning blog, Not Exactly Rocket Science, for Discover, is justly regarded as one of best science writers working today. The other two science bloggers I cited are also at the top of the game. Oransky (an MD) is executive health editor for Reuters; McKenna is author of the influential book on emerging infections, Superbug. My point is not to emulate Who’s Who here; my point is that the world of science blogging is populated with some of the best journalists I know.

And my particular complain is not that Haworth wasn’t  sharp enough to know who Ed Yong is –  its that he wasn’t sharp enough to recognize just how good – and how influential – the world of science blogging has become. Or that bloggers are starting to set new standards in excellence regarding how we share information about research.

“I was a journalist for 15 years, which included being a newspaper reporter and a magazine publisher” Mr. Haworth says, explaining why he knows that a blog isn’t worth his time. Well, not to date myself too much, but I was a newspaper staff writer for 22 years, during which time I won a Pulitzer Prize and began president of the National Association of Science Writers (USA).  So I also feel somewhat qualified to judge meaningful journalism.

And what I’ve come realize, despite my print background, despite my abiding love for the science  journalism I practiced at a traditional newspaper, is that science blogs offer some of the best, most illuminating, most intelligent communication of science out there today.  I’m not telling you that I admire all blogs any more than I would claim to admire all newspapers. I am telling you that it’s a mistake to let a newspaper background blind one to the sometimes amazing work being done online.

I blog myself – obviously – at the network hosted by the Public Library of Science (PLoS) and I’ve done work I’m proud of here. But sometimes, seriously, I am humbled by my fellow bloggers (and I wish I could list all them) – the incredible reporting done by Emily Anthes in her piece, Real, Live Practice Babies, the almost physically beautiful writing of Steve Silberman in posts like this one; the wonderfully smart work of John Rennie. If I could be as smart and funny as John, I am positive I would have won that second Pulitzer that I’ve always coveted. (No, I am never satisfied.)

But I am smart enough to recognize a blaze of talent and good journalism when I see it.  I acknowledge that we’re still in an evolutionary period in journalism – painful for many of my generation. It’s not only public information officers who dismiss – or angst about – bloggers. Last October, as you may remember, the editor of the journal Analytical Chemistry went off into a rant about blogs and the future of science education and communication.

I suspect these miscues and rants are simply part of the process of change. But they offer opportunity as well as irritation. As is now ongoing, we dissect the mistakes. And we use the moment to illuminate the increasing professionalism of science blogging.  Eventually, I hope, this leads us to a time in which whether it’s an Ed Yong or a Tim Oleson, one of my science journalism students at the University of Wisconsin, who blogs about geology, the response is the same.

And it goes like this: “So glad you contacted me. How can I help?”

How not to publicize science: A sad and cautionary tale. (Bring popcorn.)

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There’s an ingrained perception that journalists and public-affairs or public-information officers (PIOs for short) loathe each other, with reporters always pushing for more and PIOs always wanting to limit access. In my experience, it’s a mostly false impression: Smart and experienced reporters understand that PIOs can be useful translators for the institutions they represent, and are often the most direct or only way of reaching scientists and bureaucrats for interviews.

The relationship is never perfect: The two sides’ interests are not perfectly aligned, a reporter may be sloppy, a PIO may be a control freak. But in my unnervingly long experience as a journalist, my dealings with PIOs have been far more positive than negative. There are plenty of stories in my archives that only happened because a PIO took the initiative to point out an interesting piece of research I had missed, and plenty of times when a PIO assigned to me spent hours with me on the scene of a story — sometimes overnight, sometimes for days at a time.

But every once in a while, it goes so badly wrong. And for the past 48 hours or so, the science-writing blogosphere has been agog over a vast and expanding trainwreck of wrong.

It started like this. Ed Yong, proprietor of the Discover blog Not Exactly Rocket Science, related on his Posterous on Sunday that he had had an odd exchange with a PIO. Ed, in his telling, wanted to speak to the author of an embargoed journal article rather than relying on a press release, and the PIO, after supplying the article, refused to help any further. In fact, after lecturing Ed about the PIO’s former experience as a journalist, the PIO shut down the conversation, telling him: “I think you have all you need for a blog.”

To understand the full impact of that, you have to know a bit about Ed. First, he’s British, with the politeness that (usually) implies. Second, he is incredibly hardworking, publishing posts that usually run at least 1,000 words, and usually at night, after his day job ends. And, third and not least, he’s extremely smart, very skilled, unusually humble, and extremely generous to fellow bloggers in his own blog and on Twitter.

(Not to mention that last year he was awarded the Keck Futures Initiative Communication Award of the National Academies, which carries not only enormous prestige, but also a $20,000 check. So it’s not only fellow bloggers who think well of him.)

In his Posterous, Ed discreetly did not name the PIO or institution, in part to avoid breaking an embargo on the article itself. But at the blog Embargo Watch — which inquires into the barriers that embargoing the release of research put in the way of good journalism — co-founder Ivan Oransky, MD (in his day job, executive editor of Reuters Health) decided to look a little further. He put up a post Monday morning that explained why this episode was the latest in a series of bad decisions regarding embargoes that demonstrate how little good they accomplish: The press release that Ed had received, though embargoed, was describing a paper in the Lancet that had been released two days earlier. (Note, Ivan and I are friends and both serve on the board of the Association of Health Care Journalists, which on Monday formally objected to a new embargo policy at the FDA.) He also named the institution, the University of Manchester, and the PIO, Aeron Haworth.

And at that point, the wheels came off.

The discussion in the comments — which at this point is up to 145 166 and still climbing — began civilly enough, but took fire when Haworth replied to Ivan’s original post:

I have spent the past three days supplying information to journalists across the world about this story. It is only Mr Yong that appears to have taken issue. If he wasn’t so patronising towards PIOs then perhaps he would have received more cooperation.

This was bizarrely defensive, and also inaccurate, given that the original exchange with Ed shows him being respectful until taunted (and after that, still more civil than I would have been).

Now, one way to guarantee the attention of journalists is to attack one of us, especially unfairly. Senior science writers — Carl Zimmer, David Dobbs, Bora Zivkovic and John Fleck among others — commented. So did NYU professor and new-media god Jay Rosen; leading PIOs and communication consultants such as Ruth Seeley, Denise Graveline, and William Raillant-Clark; and a number of scientists (including some from the University of Manchester, one pleading “We’re not all that bad.”).

So far — posting under his real name and the name of his institution (British science writer and physician Ben Goldacre says he confirmed Haworth’s identity in an email exchange) — Haworth has called Ed Yong a “jumped-up arrogant journalist wannabe,” called a fellow PIO “a doormat,” threatened a PR consultant with a defamation suit, mocked the editor of a major science blog network, and joked, “At least none of you lot will ignore my next press release!”

The flame-out has — so far — been picked up by MediaBistro, the Gawker-network site i09.com, and Nature.com, which notes that Haworth is scheduled to conduct a “Top tips if you come face-to-face with a journalist” workshop on March 11.

Meanwhile, still at Embargo Watch — where the comments continue, though it’s late at night now in the UK — people have begun begging Haworth to stand down on behalf of his institution’s relationships with science journalists, standing in the new-media world, and identity, and his own reputation as well. Natural historian Chris Clarke of California pleaded, late this afternoon:

Aeron, I have been both a PIO and a journalist, and I’m also a bit long in the tooth, and I am telling you as one caring human being to another: for god’s sake, man, stop digging. You failed to recognize one of the UK’s top science writers, condescended to him, and are now compounding your error – for the entire world to view – by becoming more and more defensive. I’m not certain what sort of contract you have with your current employer: if it doesn’t run right up until you plan to retire, I would stop now, offer Ed an cordial apology for your initial mistake, and let the entire world move on. Otherwise, the name “Aeron Haworth” will become Google-synonymous with “doesn’t keep up with who’s writing in his field” and “needlessly unconstructive and insulting.”

Any comment, Manchester?

Update: David Harris, who was one of the commenters at Embargo Watch and operates (among other sites) the very smart The Enlightened PIO, collected the parallel Twitter convo over this trainwreck in a Storify. When you look at it, pause to consider: How many followers do all those commenters have? That’s how far this story spread.

Update 2: About 12 hours after I posted above, Ed Yong said (in the comments below and in this tweet) that Haworth has apologized to him privately. PIOs, PR consultants, is that sufficient?

Update 3: About 5 hours after the private apology, Haworth posted a public one, on Embargo Watch. Excerpt:

This morning, I apologised to Ed Yong, which he graciously accepted. I have been somewhat mortified by the comments above but, I guess, this is to be expected when you post knee-jerk, overly defensive comments on a blog site after a few glasses of wine. Never a good idea!

I work hard to promote science to the public and, you may have seen today, another story in the papers about the north-south health divide, which I have been dealing with for the past few days.

I’m a fairly private person, so this episode has upset me quite a lot. My own silly fault.

Anyway, if you don’t mind, I’d like to get back to my day job. Thanks for all your comments. I’ve taken them on board.

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