Journalist and Author
I get this a lot: “I understand that the things you write about are important — but they’re so depressing. Couldn’t you write some, you know, good news, for a change?”
So here you go: a solutions post for once, instead of another problem. (But I can’t promise to make a habit of it.)
As I said Wednesday would happen, I participated in a Twitterchat today about antibiotic-resistant foodborne illnesses arising as a result of agricultural antibiotic use. This is the subject of my investigative piece in the June issue of SELF Magazine. Chat participants were me and blogger and cancer survivor Lisa Bonchek Adams, with many constant readers checking in. And because I’m sure you were all busy, but I want you to know what we talked about, I made a Storify for you. You’re welcome.
Image: KaptainKobold/Flickr
The World Health Organization has weighed in on the growing threat from antibiotic-resistant gonorrhea, saying in a statement this morning (emailed, and apparently not online):
Millions of people with gonorrhoea may be at risk of running out of treatment options unless urgent action is taken, according to the World Health Organization (WHO). Already several countries, including Australia, France, Japan, Norway, Sweden and the United Kingdom are reporting cases of resistance to cephalosporin antibiotics — the last treatment option against gonorrhoea. Every year an estimated 106 million people are infected.
The statement arrived as an adjunct to the launch of the WHO’s new global action plan for controlling the spread of resistant gonorrhea.
If you’ve been reading here for a while, the problem of resistant gonorrhea won’t be new to you. (Here are some past posts on data from the CDC and a call to action in the New England Journal of Medicine, along with a piece I wrote in Scientific American and a separate post by my SciAm editor Christine Gorman.) But in case you’ve just come in:
I have a new story up at SELF Magazine, where I’m privileged to do a long and often investigative piece about once a year. This one is close to my heart: It took two years to complete, and in that time I conducted 37 interviews and reviewed several hundred scientific papers.
Here’s what it says: The misuse of antibiotics in agriculture, particularly in livestock-raising, is creating antibiotic-resistant foodborne illnesses that are taking victims and their doctors by surprise.
We talk pretty often here about drug-resistant bacteria arising as a result of farm antibiotic use, and moving off the farm in a variety of ways. There is a lot of dispute, of course, about whether farm-caused antibiotic resistance has much effect on human health, or whether the various resistant illnesses that people contract arise instead from antibiotic misuse in daily life or in hospitals and health care.
But in this case, the illnesses are being caused specifically by classic foodborne bugs that have become resistant and are making people sick when the food is handled or eaten. The evidence is not 100 percent — no evidence ever is — but to me, these illnesses demonstrate the most direct link yet between antibiotic use on farms, and human illness far away from farm areas.
There’s been another development in the continuing court battle to get the US Food and Drug Administration to exert some control over agricultural use of growth-promoter antibiotics — and it arrives accompanied by some remarkably direct language from the US magistrate judge hearing the case.
In a Memorandum of Opinion and Order that was filed last Friday afternoon — which I extracted from the PACER system and stashed in my Scribd account — Judge Theodore Katz addresses the FDA’s denial of two citizens’ petitions regarding ag antibiotic use. I’ll explain the details below, but here is the key language:
… the Court finds the Agency’s denial of the Petitions to be arbitrary and capricious. For over thirty years, the Agency has been confronted with evidence of the human health risks associated with the widespread sub-therapeutic use of antibiotics in food-producing animals, and, despite a statutory mandate to ensure the safety of animal drugs, the Agency has done shockingly little to address these risks.
Whew. OK, the details:
When medicine runs out of effective antibiotics, what does it do?
It turns to the uneffective ones. And patient care suffers.
People on the front lines of antibiotic resistance — infectious-disease physicians and nurses, and the patients sick or unlucky enough to contract a resistant infection — have been insisting for a while that this is happening. Their alarm has not been much-noticed. A paper published this evening might change that. (Link fixed from earlier.)
If you’ve been reading me for a while, you may remember Everly Macario and her son Simon Sparrow: I told their story in my 2010 book Superbug and blogged about them in 2011. Everly is a public health researcher in Chicago and the sister and daughter of physicians. Yet despite all her own knowledge, and all the knowledge resident in her family, she was unable to protect 17-month-old Simon from the MRSA infection that killed him in 24 hours in 2004.
Simon, as I wrote about him last year, was:
[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.”
She did, and then she called her husband, who reversed course and began tearing back to the city. At the hospital, Simon failed rapidly: His heart raced, his blood pressure crashed, his lungs filled with fluid. His skin darkened with pinpoint hemorrhages. He died the following morning.
Simon Sparrow. Photo: Courtesy Everly Macario
if I were starting this blog today, I’d be tempted to name it the Department of Unintended Consequences. So much of what I write about seems to belong in that zone: Send U.N. troops to Haiti, start a cholera epidemic. Aim to eradicate wild polio, clear the way for the vaccine-derived kind. Drive down the price of producing animal protein, ramp up antibiotic resistance.
Now add to the list: Develop cheap rapid tests for detecting sexually transmitted diseases, and lose the ability to track that those diseases are becoming resistant to the last antibiotics that work reliably against them.
A new report is out from the federal collaboration that monitors antibiotic resistance in animals, retail meat and people, and the news is not good.
The full title is the 2010 Retail Meat Report from the National Antimicrobial Resistance Monitoring System. This report is issued by the Food and Drug Administration; the humans one comes from the Centers for Disease Control and Prevention and the animals one from the US Department of Agriculture. It reports the results of testing on 5,280 meat samples collected in 2010 in California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, Tennessee, and Pennsylvania. (Those are sites of state labs participating in a federal surveillance network, FoodNet, plus one volunteer lab, Maryland.)
The report — which is broken down first by foodborne organism and then by meat type — notes a number of instances where either the percentage of bacteria that are antibiotic resistant, or the complexity of the resistance, is rising. Quoting from the report:
A fantastic pair of producers named Ernie Park and Michael Graziano, who jointly make up a company called Uji Films, are working on a documentary about antibiotic resistance called, appropriately, Resistance. (Among their previous works: the fantastic Lunch Line about the U.S. School Lunch Program.) They asked if I would be taped for it, I was thrilled, and here’s a rough-cut sneak peek.
In the summer of 2004, a 6-month-old girl who lived in the southeastern part of the Netherlands — prime, intensive hog-farming country — went in for surgery for a birth defect of her heart. As is routine in the Netherlands, which has excellent hospital infection control, she was checked before surgery for MRSA, the drug-resistant bacterium that can live on the skin without causing infections and can be unwittingly transmitted from one patient to another. The girl was carrying MRSA, which was a surprise — but the bigger surprise was that her MRSA strain did not render any results on the standard identification test, PFGE.
Looking for a source for the mysterious strain, the hospital epidemiologists where the girl was being treated asked to check her family: father, mother, school-age sibling. They were carrying it. They asked to check the family’s social circle; some of them were carrying it too. Then, flailing about for an answer — the Netherlands has such low rates of MRSA that these persistent findings were really rather odd — the epidemiologists asked what the family and their friends all did for a living, and received the answer that they were all pig farmers. So they checked the pigs, and the pigs were carrying the MRSA strain as well. And if a new MRSA strain in humans was odd, then a MRSA strain in pigs was very odd — because swine have their own varieties of staph, and are not supposed to get S. aureus, the usually human strain that accounts for the “SA” in MRSA.
That summer of detective work (which is told in full in my book Superbug) provided the first sighting of what would come to be called MRSA ST398, or in Europe CC398: a strain which was not quite like hospital MRSA, and not quite like community MRSA, and which carried a distinctive signature of resistance to tetracycline, a drug that is not much used for human MRSA but is routinely used in confinement-style farming. From its first identification, ST398 spread rapidly through Europe, and then into Canada, and then to the United States, being found first in pigs and pig-farm workers, and then in retail meat, and then in people with no connection to farming at all.
The only mystery was where it had come from.
It’s astonishing what you can not know about the place where you live. Me, for instance: I live mostly in Atlanta. I’ve lived here twice, once for 10 years as a newspaper reporter, and now — after a four-year break — for 15 months so far as a writer (and trailing spouse, which is how I got back here). Between working for one of the (formerly) largest papers in the country, liking long drives, and regularly indulging my ungovernable curiosity, I thought I knew Georgia pretty well.
I was wrong. Here’s what I learned about Georgia on Thursday:
One hundred years and some months ago — on March 16, 1911 — a publication called the Boston Medical and Surgical Journal printed a description of the treatment of 20 men at Walter Reed General Hospital in Washington, D.C. The men were members of the U.S. Army. Because medical privacy rules were a lot looser 100 years ago, we know most of their names, because the journal gave them: Cornwell, 22 years old; Smith, 24; Randall, 29; Simerly, 27; Brown, 23; Davis, 26; Waits, 22; Allen, 19; Kimmitt, 27; Megee, 29; Laird, 40; Brinson, 34; Franklin, 29; Clements, 34; Johnson, 24; Lorah, 23; and Crabbe, 27.
The men were in Walter Reed, which we now know as Walter Reed Medical Center, because they all had the sexually transmitted disease syphilis. A century later, it seems absurd to be hospitalized for an STD — but in the years before antibiotics, syphilis and gonorrhea were fantastically destructive of productivity. The men’s records, excerpted by the journal, capture that: They had arthritis, ulcerated skin, heart-valve failure, necrosis of the skull. Cornwell had been “on sick report” — unable to report to duty — for 4 months and 10 days; Simerly, for 5 months and 23 days; Kimmitt, for 11 months; Johnson, for 1 year.
A paper released recently, by the University of Iowa team that is the lone US research group tracking “pig MRSA” ST398, caused a ripple. (It came out while I was at ScienceOnline and it’s taken me a while to catch up.) The paper compares the occurrence of MRSA, drug-resistant staph, on various cuts of retail pork from pigs that were raised either conventionally in confinement, with routine use of antibiotics, or in an alternative rearing scheme with no antibiotics. (NB: Not “organic,” despite what some headlines said; that’s a separate issue of USDA licensure.) The team found that both conventionally raised and antibiotic-free meat carried MRSA, both the human-associated kind and the pig-adapted kind.
The TL;DR over the past week has been: There’s just as much resistant bacteria on drug-free meat as there is on conventional meat, so why spend the money — or raise the alarm over farm antibiotic use?
My interpretation is a little more nuanced. But my takeaway is that, in its underlying data, the study proves what campaigners against ag antibiotic use keep saying: that once you use antibiotics indiscriminately and drive the emergence of resistant organisms, you have no way of predicting where that resistance DNA will end up.
An update to the news two weeks ago of totally drug-resistant tuberculosis, TDR-TB, being identified in India (and earlier in Italy and Iran): The Indian government has announced that it doesn’t exist, and is putting pressure on the physicians who identified it to say they made a mistake.
Because, of course, that’s going to keep a disease from spreading.
There was a lot of interest in in TDR-TB Friday; both The Leonard Lopate Show on WNYC and Science Friday kindly asked me to be on to talk about it. While I was waiting for the phone link to Science Friday to become live, an alarming bulletin arrived in my e-mail. The early-warning list ProMED reported that the existence of two additional cases of TDR-TB have been disclosed, in Bangalore, 600 miles from Mumbai where the first known Indian cases were identified. The patients, a 56-year-old man and a 29-year-old woman, had been coming to a hospital for directly observed administration of their TB for more than two years; they were initially recognized as MDR-TB patients, with disease that was highly resistant but not untreatable, but were not getting better. For the past two weeks, though, the man has not shown up, and no one appears to know where he is.
A follow-up to Monday’s post on the recognition in India of totally drug-resistant tuberculosis, TDR-TB: The fantastic early-warning list ProMED points out that the earliest recorded cases of TDR were not the current 12 known cases in Mumbai or the 15 cases in Iran in 2009, but rather two women from Italy who died in 2003 after being sick for several years.
It’s a sad story that was briefly recounted in 2007 in the journal EuroSurveillance, published by the European Centre for Disease Prevention and Control (ECDC).
Well, this is a bad way to start the year.
Over the past 48 hours, news has broken in India of the existence of at least 12 patients infected with tuberculosis that has become resistant to all the drugs used against the disease. Physicians in Mumbai are calling the strain TDR, for Totally Drug-Resistant. In other words, it is untreatable as far as they know.
News of some of the cases was published Dec. 21 in an ahead-of-print letter to the journal Clinical Infectious Diseases, which just about everyone missed, including me. (But not, thankfully, the hyper-alert global-health blogger Crawford Kilian, to whom I hat-tip.) That letter describes the discovery and treatment of four cases of TDR-TB since last October. On Saturday, the Times of India disclosed that there are actually 12 known cases just in one hospital, the P. D. Hinduja National Hospital and Medical Research Centre; in the article, Hinduja’s Dr. Amita Athawale admits, “The cases we clinically isolate are just the tip of the iceberg.” And as a followup, the Hindustan Times reported yesterday that most hospitals in the city — by extension, most Indian cities — don’t have the facilities to identify the TDR strain, making it more likely that unrecognized cases can go on to infect others.
Here’s a bookend to the Food and Drug Administration’s disappointing Christmas Eve notice that it will cease trying to regulate the largest classes of growth-promoter antibiotics. Today, the agency announced that it is forbidding certain uses of a different class of drugs, cephalosporins.
To those who are concerned about antibiotic overuse in agriculture, though, this is good news — though it may be more good news-bad news-bad news-good news.
The dialectic looks like this:
The use of antibiotics and sulfonamide drugs, especially in growth promotant and subtherapeutic amounts, favors the selection and development of single and multiple antibiotic-resistant and R-plasmid-bearing bacteria.
Animals that have received either subtherapeutic and/or therapeutic amounts of antibiotic and sulfonamide drugs in feeds may serve as a reservoir of antibiotic resistant pathogens and non-pathogens. These reservoirs of pathogens can produce human infections.
The prevalence of multi-resistant R-plasmid-bearing pathogenic and nonpathogenic bacteria in animals has increased and has been related to the use of antibiotics and sulfonamide drugs.
Organisms resistant to antibacterial agents have been found on meat and meat products.
If you give the text above a close read, you might think it was written by Mark Bittman or Tom Philpott or Tom Laskawy, or me — or any of the small number of journalists who focus on the safety and policy perils of giving scarce antibiotics to confinement-raised farm animals. After all, what it says is what any of us would say: Routine administration of antibiotics to livestock spurs the emergence of drug-resistant bacteria that move through the food chain, threaten human health, and lend their DNA to yet other bacteria, increasing the reservoir of resistance in a dangerous and untracked manner.
As it happens, though, the text above wasn’t written by any of us. It was written by the Food and Drug Administration, the FDA.
Yes, the FDA — the federal agency that, as I wrote last Friday, has just backed off a 34-year attempt to assert regulatory control over “growth promoter” antibiotic use, opting instead for voluntary self-policing by the agricultural and pharmaceutical industries.
