Maryn McKenna

Journalist and Author

Turning grief into action: Moms and antibiotic misuse

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In December 2007, I flew to Chicago to meet the team of researchers who spotted the first known cases of community-associated MRSA in the US in the mid-1990s, and who have been agitating ever since for recognition and action to beat back the rising tide of antibiotic resistance. It was grey and snowy outside their shabby suite of offices, carved out of University of Chicago’s long-replaced children’s hospital. I sat in a green-tinged conference room piled with stacks of articles while Everly Macario — a Harvard-trained ScD in public health, the daughter and sister of physicians — described how MRSA killed her toddler son Simon in less than 24 hours.

“We have no idea where he got it,” she told me. “We have no idea why he was susceptible.”

Simon Sparrow was 17 months old in April 2004, a big, sturdy child with no health problems except a touch of asthma. The day before he died, he woke up feverish and disoriented, startling his parents with a cry unlike anything they had heard from him before. It was a busy morning — his older sister had a stomach virus — but they got him to the pediatric ER, got him checked, and brought him home when doctors found nothing unusual going on.

A few hours later, Everly was working at home, watching both kids, and Simon’s breathing changed. Her husband James, a history professor, had driven a few hours away to give a speech. She called a friend who is a pediatrician, held the phone up to Simon’s nose and mouth so she could hear, and then got back on the line.

“Hang up,” her friend said. “Call 911.” [Read more…]

The biggest foodborne-disease threat may not be addressed by the new food-safety law

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So if we wanted to reduce the danger of pathogens passing to people via food — not just drug-resistant bacteria, which are an increasingly significant problem, but all disease-causing ones — where to start?

Formulating a strategy is more difficult than it seems. In the US, policing food safety is divided among several federal agencies: the FDA, USDA and CDC. The FDA has responsibility for most of the food supply, including seafood, produce, processed food and fresh eggs. The USDA’s Food Safety and Inspection Service (FSIS) regulates fresh meat and poultry and egg products. The CDC surveys the illnesses that result from any of them, estimating most recently that one in six US residents, or about 48 million people, get sick each year, 128,000 are hospitalized and 3,000 die.

But most of those illnesses are never investigated, because a substantial portion of them occur individually or in small clusters, not in major outbreaks. Many of them have long-term consequences that are never recorded by any federal counting mechanism. And there’s currently no surveillance system that links pathogens and food — which means there’s no way to target which foods, or food-raising practices, pose the greatest risks.

The new food-safety bill, signed in January, addresses at least some of those barriers, by requiring a risk-based approach to foodborne illness — meaning, you look at what is causing the greatest problem, and aim your efforts and funding in that direction. But the bill — which certain Congressmen have threatened to starve of funding — covers primarily the FDA. And a new analysis suggests that’s not where the greatest problems lie. [Read more…]

Multi-Drug Resistant Staph in 1 in 4 Meat Samples

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Much of the contentious debate over abuse of antibiotics in farming boils down to a couple of simple questions: Whether resistant organisms that arise on farms because of antibiotic use leave the farm, and whether, once they do, they reach human beings.

A piece of research due to be released this morning in the journal Clinical Infectious Diseases helps answer both those questions. (I received an advance copy under embargo; I’ll put up the link when the journal posts it. here’s the link to the full-text pdf.)

A team of researchers from Arizona bought meat and poultry in five cities across the United States, tested them for bacteria, and found this: 47 percent of the samples contained the very common pathogen Staphylococcus aureus, and 96 percent of those isolates were resistant to at least one antibiotic. Of more concern: 52 percent of those staph isolates were resistant to at least three antibiotics that are commonly used in both veterinary and human medicine.

That is: Roughly one in four packages of meat and poultry from across the United States contained multidrug resistant staph. [Read more…]

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?

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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…]

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…]

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.

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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)



Superbugs in Canadian chicken? Yes, and US too

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CBC News, the Canadian national TV network, has caused a stir in the food-blog world with the results of a nationwide investigation that found antibiotic-resistant bacteria contaminating supermarket chicken. In its words:

Chicken bought at major supermarkets across Canada is frequently contaminated with superbugs — bacteria that many antibiotics cannot kill — an investigation by CBC TV’s Marketplace has found.

Marketplace researchers — along with their colleagues at Radio-Canada’s food show L’Epicerie — bought 100 samples of chicken from major grocery chains in Vancouver, Toronto and Montreal… The 100 samples were sent to a lab for analysis. Two-thirds of the chicken samples had bacteria. That in itself is not unusual — E. coli, Salmonella and Campylobacter are often present in raw chicken.

What was surprising was that all of the bacteria uncovered during the Marketplace sampling were resistant to at least one antibiotic. Some of the bacteria found were resistant to six, seven or even eight different types of antibiotics.

“This is the most worrisome study I’ve seen of its kind,” said Rick Smith, the head of Environmental Defence, a consumer advocacy group.

I haven’t had time to watch the full program, but no question I think this kind of reporting is worth doing. Nothing brings the threat of agricultural antibiotic use home to people like showing them that resistant bacteria are living on the meat they might have brought home last night.

One important point, though: Don’t think for a moment this is just a Canadian problem.

Last month, a team from the University of Ioannina in Greece analyzed in Foodborne Pathogens and Disease 428 samples of various retail meats they bought in northwest Greece over three years:

E. coli from chicken exhibited high rates of resistance to ciprofloxacin (62.5%) followed by lamb/goat (10.9%), pork (15.7%), and beef (27.9%) meat. Resistance to nitrofurantoin dominated in the lamb/goat isolates (60%). Resistance to tetracycline predominated in pork (68.2%) and chicken (62.5%), and resistance to aminoglycosides dominated in lamb/goat meat isolates. S. aureus resistance to clindamycin predominated in lamb/goat isolates (50%), whereas resistance to ciprofloxacin predominated in the pork strains, but no resistance to methicillin was observed. Of the enterococci isolates 21.1% were resistant to vancomycin. High resistance to ampicillin (96%) was observed in Y. enterocolitica and all of the C. jejuni isolates were resistant to ampicillin, cephalothin, and cefuroxime. These results indicate that meat can be a source of resistant bacteria, which could potentially be spread to the community through the food chain.

Last year, a team from the University of Iceland found fluoroquinolone-resistant E. coli passing from chickens to humans there (the drug Cipro is a fluoroquinolone, and the human isolates were Cipro-resistant), a multi-institution team from Canada found resistance to third-generation cephalosporins in Salmonella enterica spreading from chicken meat to humans, and the Irish quasi-governmental group SafeFood released a long report (and hosted a conference) on “The Problem of Antimicrobial Resistance in the Food Chain.” And of course MRSA ST398, the strain of drug-resistant staph that arose in food animals, has now been found in retails meats across the EU.

Oh, but none of those countries are the United States, you say. Then take a look at these:

Those graphics come from a little-read report put out every year by the US Food and Drug Administration as part of its participation in NARMS, the National Antimicrobial Resistance Monitoring System that’s shared by the FDA, USDA and CDC. The FDA handles the part of NARMS that looks for resistant bacteria in meat (CDC does human illnesses, USDA does live animals), and the figures above show the percentages of Salmonella and enterococci that were found in retail chicken breasts between 2002 and 2008 (the most recent report) and were resistant to various drugs. The bar along the bottom of each figure shows the major drug classes. So in 2008: 45% of Salmonella on chicken were resistant to tetracycline and 30% to penicillins; among enterococci (common gut bacteria, and therefore common contaminants of meat during slaughtering), 65% resistant to tetracycline and more than 90% to lincosamides, which include the everyday drug clindamycin.

In the narrative portion of the report, the FDA said:

38.2% of chicken breast Salmonella isolates were resistant to ≥ 3 antimicrobial classes in 2008 compared to 51% in ground turkey, an increase in both from previous years. From 2002–2007, multidrug resistance to ≥ 3 antimicrobial classes ranged from 20–34.4% among chicken breast and 20.3–42.6% for ground turkey. More than 15% of chicken breast and ground turkey isolates showed resistance to ≥ 4 classes in 2008.

So, just to underline: Multi-drug resistant superbugs aren’t only on chicken in Canada; if you buy chicken in the United States, they are more than likely on your chicken too.

And whatever country they are occurring in, the solution is the same. Drug-resistant bacteria in food won’t diminish until we reduce the amount of drugs that food animals receive while they are raised.

Update: At Grist’s Meat Wagon, Tom Philpott very kindly points out that I actually broke the news of the latest NARMS report, which I didn’t realize (it was a busy day; see my next post for why). Apparently the report was posted to the FDA web site on Dec. 17, but neither of us can find any evidence that it was publicized, such as a press release on the FDA’s press site. His larger point is important:

We find out from the report that the FDA has been monitoring the situation since 2002 — and finding plenty of antibiotic-resistant strains on meat sold directly to consumers. And they’ve been sharing the information with other leading regulatory/public health agencies — but not so much to the people they’re supposed to be protecting and informing: i.e., us. … six weeks since the FDA report and a year since Sharfstein’s testimony [in 2010, promising scrutiny by the Obama adminsitration – m.], policy hasn’t moved at all. Where are the loud public statements from the FDA trumpeting the fact that our factory farms are cooking up superbugs that make their way to our meat? Where’s the USDA on this topic, which is supposed to protect the public from tainted meat? Where’s CDC?

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Opposing industrial-scale pig farming — in Europe

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Well, wow. National legislators stand up to oppose the use of tax revenues to subsidize large-scale confinement pig farms out of concern for food safety and antibiotic resistance, declaring that they are “going to war in defense of pigs.”

In Europe, though.

At the European Parliament today, three national representatives — Janusz Wojciechowski of Poland, José Bové of France and Dan Jørgensen of Denmark — declared their opposition to industrial-scale swine agriculture, positioning themselves for a fight over the European Union’s Common Agriculture Policy, which is up for revision this summer.

Jørgensen represents the country that has done the most to place controls on agricultural antibiotic use; Bové is a farmer and political organizer who famously destroyed a McDonald’s by driving a tractor through it; and Wojciechowski is the son of pig farmers who wrote on his blog today:

Chcemy poruszyć sumienia posłów i doprowadzic do likwidacji tego typu “fabryk miesa” w Unii Europejskiej, no czywiscie takze w Polsce, gdzie takich fabryk jest juz ponad sto.
Chcemy doprorowadzic do tego, aby wielkie fermy nie były wspierane środkami europejskimi, aby wstrzymać lokalizacje nowych obiektów, po czym stopniowo likwidować te, które już istnieją.
Chcemy, żeby na miejsce fabryk miesa powróciła normalna hodowla świń.
We want to move the conscience of members and lead to the liquidation of this type of “meat factories” in the European Union, also in Poland, where such plants are already over a hundred.
We want to ensure that large farms are not supported by the European funds to stop the locations of new facilities, then gradually eliminate those that already exist.
We want “meat factories” returned to normal breeding of pigs. (via GoogleTranslate)

As I’ve written before (long archive here and here),the MRSA strain ST398 arose on Dutch pig farms in 2004, among pigs that had been given prophylactic doses of antibiotics, especially tetracycline. It has since spread through the EU, Canada and the United States, affecting not only farm workers and veterinarians, but also hospital patients with no connection to agriculture.

(Self-promotion alert: This may be a good time to tell you that my book SUPERBUG: The Fatal Menace of MRSA, which tells the full story of the emergence and spread of ST398, has just been released in paperback.)

In advance, this morning the trade paper Farming UK wrote this about the planned European Parliament announcements:

(Members of the European Parliament) will hear evidence that European taxpayers’ money is being used by the European Bank for Reconstruction and Development, together with Common Agriculture Policy payments, to subsidise industrial pig farming even though there is increasing concern over the impact on human health. With a vote this summer over reforms to the Common Agricultural Policy, MEPs will come together to take a stance against the crisis in agriculture with critically low prices for pork, poor labelling, and widespread disregard for animal welfare laws.

MEPs and NGOs will condemn the overuse of antibiotics in factory farms which has led to the emergence of antibiotic-resistant bacteria such as MRSA and ESBL E. coli. A recent report by the Dutch Food Standards Agency estimated that one third to one half of all antibiotic resistance in human diseases in the Netherlands derives from farm antibiotic use. American scientists recently found that flies and cockroaches from intensive pig farms carry bacteria resistant to the same antibiotics routinely used in pig farming, and warned that the insects were likely to be able to spread the disease from the farms to local people.

The event was co-organized by Tracy Worcester, who is both a British aristocrat and director of a documentary, Pig Business, that has not yet been shown in the US. Here’s its trailer:

[HTML1]

In both medicine and agriculture, Europe has been ahead of the US in addressing concerns about antibiotic resistance. This morning’s announcements are yet more evidence of just how far ahead they are.

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Disease v. culture: Botulism in the Arctic

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What if there were a food whose consumption carried a predictable risk of contracting a  fatal illness?

What if consumption of that food were so deeply embedded in a culture that there was no chance of stopping people from eating it?

That’s not a hypothetical. It’s the dilemma facing Arctic indigenous communities and health authorities over the risk of botulism from traditional foods — raw fish, whale, seal, walrus or beaver — that are “cured” by being wrapped, buried and left to rot. Alaskan Natives and Canadian First Nations members have eaten them since some lost time in their history: They’re full of minerals, vitamins and beneficial fatty acids, fresh-food nutrients that are in short supply when the world is frozen over and dark.

(I hear you gagging. So: Who eats country ham? Fish sauce? Roquefort? Products of rot, all of them. We’ll move on, shall we?)

The traditional foods aren’t fermented, strictly speaking; they’re decayed in an airless environment. That makes them friendly breeding grounds for Clostridium botulinum, the organism that produces botulism toxin. Since 1947, according to two new papers in Clinical Infectious Diseases, there have been 317 cases (159 small outbreaks) of foodborne botulism just in Alaska, as tracked by the Indian Health Service and the Alaska Division of Public Health. Out of the 317 individual cases in those records, 8.2 percent died of the paralysis of botulism poisoning.

Measured against the population, the rate of botulism in Alaska is 836 times what it is in the Lower 48. It’s such a persistent problem that the Alaska division spends scarce funds to maintain a 24-hour botulism emergency line.

There’s something interesting hidden in those numbers: Since the 1970s, the incidence of foodborne botulism has been increasing. That’s roughly coincident with the point at which Native communities began a transition that must have looked like a good idea, from

placing meat and fat tissues into skin bags … which are sewn shut and aged for weeks or months under rocks or buried under gravel

to

us(ing) either plastic bags or buckets, metal barrels, or glass containers in place of the skin pouch. (Austin and Leclair)

It turns out that something in the modern materials may have increased the possibility of C. botulinum growth: maybe the temperature differential, since they are more likely to be kept above ground; maybe the lack of contact with soil microorganisms. (A hypothesis-generating experiment showed that salmon heads kept for 17 days in a plastic container produced botulinum toxin, but salmon heads buried in a moss-lined pit did not.) One of the papers notes:

Among outbreaks for which a preservation process was described, 67% (56 of 84) were associated with storage of food in sealed plastic or glass containers, 23% (19 of 84) with storage in wood or cardboard containers, 6% (5/84) with storage in sealed metal containers, 4% (3/84) with storage in moss- or tundra-covered holes, and 1% (1/84) with storage in a sealskin bag. (Fagan et al.)

The cured foods are so intricately tied to family, tribe and place that repeated rounds of public health education haven’t dislodged them from Inuit culture. One paper notes, rather wistfully:

…an educational botulism video was distributed to all rural schools and medical facilities in Alaska, but 1 year after distribution, only 38% of Alaska Native adults had seen the video, and no behavior changes were noted that might reduce risk for botulism. (Fagan et al.)

But modernity might yet prove the cure, in two dimensions. First, the mortality rate from botulism is going down, to less than 4 percent in recent years, probably because cases are recognized and antitoxin distributed faster than in decades past. Second, and probably more important in the long run, the taste for traditional foods may be passing from Native culture. Of those 317 cases,

Overall median age was 45.0 years (range, 5–93 years). Incidence was associated with age group; age group–specific incidence was greatest among Alaska Natives aged ≥60 years. … Patient age increased from 1970–1979 (median age, 39.0 years) to 2000–2007 (median age, 49.5 years). (Fagan et al.)

If younger generations of Inuit no longer care for traditional foods, the risk of botulism will naturally diminish: no anaerobically rotted salmon heads, no Clostridium, no deaths. It ought to be something to rejoice in. I wonder though. There’s something especially compelling about foods tinged with risk; think of foraged mushrooms, or puffer fish. Inuit foods — which, I confess, I can’t quite imagine eating — must have offered deliciousness and danger, and comfort, and memory. It would have been a potent, and poignant, combination; for all its harms, a sad thing to lose.

Cites:

Austin JW and Leclair D. Botulism in the North: A Disease Without Borders. Clin Infect Dis. (2011) 52 (5): 593-594. doi: 10.1093/cid/ciq256

Fagan RP et al. Endemic Foodborne Botulism among Alaska Native Persons—Alaska, 1947–2007. Clin Infect Dis. (2011) 52 (5): 585-592. doi: 10.1093/cid/ciq240

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Farm antibiotics, human illness and what connects them. (It has legs.)

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When it comes to the impact of farm antibiotics on human health, there’s a data gap.

That the use of antibiotics on conventional/confinement farms provokes the emergence of drug-resistant bacteria really isn’t in dispute; it’s been proven, over and over again, for about 30 years now. (Here’s a long bibliography from the Pew Charitable Trusts that lists the major pieces of research.) And there’s good research as well that those bacteria move off farms via animals, farm workers, groundwater and air currents. (Another long bibliography here, from the Center for a Livable Future.)

But proving the links between resistant farm bacteria and human illness is trickier. Among the reasons: When an individual person who is sick with a foodborne illness goes to the doctor, that doctor does only enough testing to figure out how to treat them. The kind of subtyping you would need to do on a foodborne organism to prove its farm-drug link isn’t useful to a primary-care physician, and the equipment isn’t accessible either; it’s found in academic medical centers and state public health labs. But the public health system isn’t filling the data gap either. The CDC’s main foodborne outbreak-tracking program, FoodNet, monitors the prevalence of 10 illness-causing organisms, but doesn’t test for antibiotic resistance. And the joint federal program that does monitor resistance, NARMS (for National Antimicrobial Resistance Monitoring System, shared by the CDC here, USDA here and FDA here) uses randomized anonymized samples from humans, animals and retail meat, so it can’t illuminate whether resistant bacteria are causing outbreaks.

So are resistant bacteria from farms causing outbreaks of human illness? The Center for Science in the Public Interest says yes. In a white paper published this week, the group documents 35 outbreaks between 1973 and 2009 for which epidemiologic and microbiological links are clear. Quoting from the report:

  • Reporting of outbreaks due to antibiotic-resistant bacteria has increased in each decade since the 1970s, with 40% (14 out of 35) occurring in the last decade … Outbreaks were most common in dairy products (34%) and ground beef (26%). Two outbreaks each were linked to poultry, pork, produce, and seafood, and one outbreak each was linked to eggs and multi-ingredient foods. The food vehicle was unknown in four of the outbreaks.
  • A total of 19,897 people were sickened from these 35 outbreaks, resulting in 3,061 hospitalizations and 26 deaths.
  • For the 31 outbreaks for which antibiotic-resistance patterns were determined, the responsible bacteria displayed resistance to a total of 14 different antibiotics … Of those antibiotics, seven are classified by the World Health Organization (WHO) as ‘critically important’ to human medicine and eight as ‘highly important’ to human medicine. Bacteria showed resistance to tetracycline in 30 outbreaks. Resistances to streptomycin and ampicillin, both classified as critically important antibiotics, were the next most common. Bacteria associated with 19 outbreaks were resistant to at least five antibiotics. Fifteen of those occurred between 1990 and 2009.

There’s still a data gap, of course: Exactly how are the organisms getting from the animals or their manure into the guts of humans? Via meat, or milk, is the logical assumption. But an article also published this week suggested the organisms might have help — from cockroaches and flies.

Researchers from Kansas State University and North Carolina State University scooped up house flies and German (common) cockroaches on conventional confinement farms in both states, and also scooped up poop from the pigs being grown on the farms. They tested all three for the presence of resistant forms of the common gut bacteria Enterococci. Almost all — 89 percent of the pig-manure samples, 94 percent of the cockroach guts and 98 percent of the flies’ guts — contained Enterococci. Of the Enterococci, at least 90  percent of those found in each species were resistant to tetracycline; from 50 percent to 70 percent were resistant to erythromycin; and from 10 percent to 40 percent were resistant to ciprofloxacin and streptomycin — NB, all drugs used in essentially identical forms in humans as well as livestock. PFGE analysis of the Enterococci from the pigs and the insects showed they were carrying the same bacterial clones.

The researchers write:

Organic wastes in and around animal production
facilities including swine farms provide excellent habitats for house flies and German cockroaches. Several features of house flies and cockroaches, including their dependence on live microbial communities, active dispersal ability and human-mediated transport, attraction to places where food is prepared and stored, developmental sites, and mode of feeding/digestion make these insects an important “delivery vehicle” for transport of bacteria including antibiotic resistant enterococci from reservoirs (animal manure), where they pose minimal hazard to people, to places where they pose substantial risk (food)…

High frequency of resistance to tetracycline, erythromycin, streptomycin, kanamycin, and
ciprofloxacin in our study likely reflects use of tetracyclines, macrolides, aminoglycosides and
fluoroquinolones as feed additives for swine in the USA… The source of antibiotic resistant
enterococci in house flies and cockroaches in this study was the swine manure due to very high
prevalence of antibiotic resistant enterococci in all three sources.

Cite: Ahmad, A et al. Insects in confined swine operations carry a large antibiotic resistant and potentially virulent enterococcal community. BMC Microbiology, 26 January 2011, 11:23doi:10.1186/1471-2180-11-23

Food bin Flickr/j_bongio/CC; Fly face Flickr/e_monk/CC

Farm worker infections with MRSA — the first numbers

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Since the first identification in 2004 of MRSA ST398, also known as “pig MRSA” or livestock-associated MRSA (archives of posts here and here), that drug-resistant organism has been found being carried asymptomatically by farm workers and veterinarians, and causing illness in health care workers, hospital patients, and people with no known ties to agriculture. One of the persistent data gaps, though, has been whether farm workers themselves have been made sick by it.

It’s a difficult question to answer for a nested set of reasons: First, in most of the states, MRSA (methicillin-resistant Staphylococcus aureus, or drug-resistant staph) is not a reportable disease; that is, a doctor who diagnoses it in a patient is under no obligation to tell any public health authority about that patient’s case. And second, the testing required to distinguish livestock-associated MRSA from community-acquired or hospital-acquired is not something that primary-care medical personnel have access to; you have to go to a state laboratory or an academic medical center to do the appropriate molecular typing. Those tests are expensive to perform, and their results primarily are useful to public health, not to individual medical practitioners. So finding out where that nascent epidemic is going has been unusually challenging.

Comes now a team from the University of Iowa — the same team that first identified ST398 in pigs and pig-farm personnel in the United States — to start to fill the gap. [Read more…]

Disease detectives and the 12th blue man

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Pretty much every disease-detection geek — which includes me, since I wrote a book about disease detectives — has read, at some point, the story “Eleven Blue Men” by Berton Roueche. Roueche was a journalist who worked for the New Yorker for almost 50 years, and for most of that time, he was responsible for the column “The Annals of Medicine,” which was created for him. “Eleven Blue Men” was the first installment. It ran June 5, 1948. It begins like this:

At about eight o’clock on Monday morning, September 25, 1944, a ragged, aimless old man of eighty-two collapsed on the sidewalk of Dey Street, near the Hudson Terminal. Innumerable people must have noticed him, but he lay there alone for several minutes, dazed, doubled up with abdominal cramps, and in an agony of retching. Then a policeman came along. Until the policeman bent over the old man, he may have supposed that he had just a sick drunk on his hands; wanderers dropped by drink are common in that part of town in the early morning. It was not an opinion that he could have held for long. The old man’s nose, lips, ears, and fingers were sky-blue.

[Read more…]

Update: Farm Animals Get 80 Percent of Antibiotics Sold in U.S.

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Two weeks ago, I broke the news of a new FDA report that estimated for the first time the amount of antibiotics sold in the United States every year for use in agriculture: 28.8 million pounds.

That long-awaited report didn’t answer a crucial question: What volume of antibiotics are sold in the United States each year for human use. It’s a crucial question because, in answer to concerns about antibiotic resistance arising on farms, the answer has always been that human medicine is equally culpable because it uses similar volumes of antibiotics.

The only research that has attempted to answer that question is contained in a decade-old report by the Union of Concerned Scientists that put the proportion of antibiotics going to animals at 70 percent of the U.S. total.

That UCS report and estimate are a decade old not because no one has cared about the topic, but because accurate updated figures have been so hard to get. So we owe a special holiday thank-you to the researchers at the Center for a Livable Future, who decided the release of the FDA report justified another attempt to get the numbers straight. They succeeded.

The proportion of antibiotics sold in the United States each year that go to animals turns out to be not 70 percent, but rather 80 percent. Here’s CLF’s Ralph Loglisci, who got the confirmatory numbers from the FDA:

In accordance with a 2008 amendment to the Animal Drug User Fee Act, for the first time the FDA released last week an annual amount of antimicrobial drugs sold and distributed for use in food animals. The grand total for 2009 is 13.1 million kilograms or 28.8 million pounds. I … contacted the FDA for an estimate of the volume of antibiotics sold for human use in 2009. This is what a spokesperson told me:

“Our Office of Surveillance and Epidemiology just finished an analysis based on IMS Health data. Sales data in kilograms sold for selected antibacterial drugs were obtained as a surrogate of human antibacterial drug use in the U.S. market. Approximately 3.3 million kilograms of antibacterial drugs were sold in year 2009. OSE states that all data in this analysis have been cleared for public use by IMS Health, IMS National Sales Perspectives™.”

3.3 million kilograms is a little over 7 million pounds. As far as I can determine, this is the first time the FDA has made data on estimates of human usage public.

At its blog, CLF lays out the math for each major drug class as sold for animal use and human use, with a long discussion of the significance of the different drug classes. Here’s the CLF table summing up the math, but please go over to CLF’s blog for its discussion.

Most important to note: Most of the drugs used in animal agriculture and in human medicine are functionally identical. That’s one reason why the overuse of antibiotics in animals is such a concern: When organisms become resistant on the farm to drugs used on livestock, they are becoming resistant to the exact same drugs used in humans. (One major drug category used in animals, ionophores, do not have a direct human analog. But use of them on farms is still a concern, because resistance factors can move freely between species of bacteria. That’s a discussion for another day.)

Loglisci’s conclusion is also worth underlining:

The next battle, which industry has already begun, is defining what non-therapeutic use will constitute. Producers are already claiming that the use of antibiotics for growth promotion has decreased, maintaining current low-dose usage is aimed at disease prevention. Regardless, all low-dose usage of antibiotics can lead to a significant increase in antibiotic resistance.

Image: Flickr/Epsos

The food safety bill and the long cost of foodborne illness

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In a nailbiter ending tonight, the US House of Representatives passed the long-stalled, almost-lost, back-from-the-dead FDA Food Safety Modernization Act, a decades-overdue piece of legislation that will equip the US Food and Drug Administration with enforcement tools to help it prevent and track foodborne illness outbreaks.

For people who don’t know the regulatory landscape of food in the United States, it comes as a shock that FDA (which regulates both drugs used in food production and much of the food produced in the US, except for meat and poultry which are under USDA) has so little power. Until now, the FDA could not compel a food recall; it could only ask for a problematic or dangerous food to be recalled, and the food producer could demur. That was, if the FDA even associated a particular food with a foodborne outbreak, which was unlikely given its lack of surveillance resources or inspectors. (A remarkable number of foodborne outbreaks are solved not by the feds but by the Minnesota Department of Public Health, which is well-funded by the state it represents.) The last time food-safety legislation was updated in the US was 1938. [Read more…]

"Pig MRSA": New human infections in France

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It’s one of the touchiest topics under the broad category of antibiotic resistance: Whether the drug-resistant organisms that emerge on farms as a result of antibiotic use stay on farms, or pose a risk to humans who have no connection to agriculture.

That drug resistance emerges under any selective pressure is basic biology: Resistance is an inevitable process. That they emerge on farms when antibiotics are used broadly — that is, in growth-promoting or prophylactic ways, not to treat disease in individual animals — really isn’t in dispute any more. It’s now a question of economics and politics, not science. (See this bibliography, stretching back to 1969; and the news I broke yesterday of FDA’s estimate of US farms using almost 29 million pounds of antibiotics last year.)

So the argument over farm antibiotic use now tends to focus on whether the resistant organisms that emerge on farms are only an issue within a farm’s confines, or rather pose a broader human health threat — and that’s where the continuing story of the “third epidemic” of MRSA becomes so important. Recapping, this is a strain known as MRSA ST398 that emerged in pigs and passed to pig farmers in the Netherlands in 2004, subsequently spread across the European Union, and crossed to Canada and then to the United States. (Key posts on ST398: here, here, here and this archive at my old site. Yes, it will be moved soon, promise.)

Most of the identifications of MRSA ST398 in humans, including those first identifications above, were colonizations, the term for symptomless carriage of staph in the nostrils and on the skin; in other words, it wasn’t making people sick. News of actual illnesses has been rare — especially illnesses among people who have no contact with farming, such as the post-surgical infections found in Canada earlier this year.

But they’re getting a little less rare, as demonstrated by a letter just posted ahead-of-print to the journal Clinical Infectious Diseases. It recounts the finding, via annual surveys of bloodstream infections, of four cases of ST398 in four different hospitals in France. One may have been due to animal exposure. Three were hospital-acquired.

Examination of patient histories revealed exposure to animals in 1 case, a fatal idiopathic community-acquired bloodstream infection in an 84-year-old man who lived on a farm at which 1 pig was being raised. The remaining cases were hospital-acquired and included 1 case of catheter-associated infection observed in a 58-year-old man with advanced multiple myeloma, 1 case following elective digestive tract surgery in a 69-year-old woman, and 1 case following cardiac surgery in a 68-year-old man.

There’s an especially interesting thing about these cases. In Europe and the US, ST398 has particular characteristics: It is resistant to tetracycline (the drug most commonly given to pigs) and does not manufacture the toxin Panton-Valentine leukocidin or PVL, which is suspected to be a cause of community-strain MRSA’s uncommon virulence. (See this story, from the book SUPERBUG, of how PVL-positive pneumonia almost killed a toddler.) The strain in the French cases, though, does manufacture PVL, and shares some virulence characteristics with the dominant community strain, USA300. It is less like the European strain of livestock-associated MRSA and more like a livestock-associated strain that appears to be emerging in China, ST9 (more on that here).

The argument against the significance of these cases is likely to be that they are, again, just one data-point, and may be just rare and random. That is worth considering. But it is also worth considering that they continue to be found.

And, also, that the community epidemic of MRSA was first flagged in a discovery of 25 cases in children in Chicago back in 1998, a finding that was also dismissed at the time as rare and random — and that grew into an epidemic of millions of cases a year.

(H/t to constant reader Pat Gardiner for flagging this paper for me.)

Cite: van der Mee-Marquet N et al. Emergence of Unusual Bloodstream Infections Associated with Pig-Borne–Like Staphylococcus aureus ST398 in France. Clin Infect Dis. (2011) 52 (1): 152-153. doi: 10.1093/cid/ciq053

Image via Flickr user johnmuk under CC