Journalist and Author
Lung tissue containing the original SARS coronavirus (CDC, 2003)
There’s lots of news to catch up with regarding the new coronavirus that emerged last summer in the Middle East and has been causing concern to international health authorities all autumn: additional cases, additional deaths, and new lab evidence that is more than a little concerning.
Lung tissue containing the original SARS coronavirus (CDC, 2003)
(This post has been updated; read to the end.)
Holidays. It never fails.
Today, while the United States has been largely off-line following our Thanksgiving holiday (and while Northern Europe was on its way to the pub for Friday evening revelry), the World Health Organization announced four new cases of the novel coronavirus that caused a great deal of worry immediately before the October hajj season. (Earlier posts here and here.)
In its bulletin, released by the WHO’s Global Alert and Response team (GOAR), the agency said:
Lung tissue containing the original SARS coronavirus (CDC, 2003)
Have we dodged a bullet? Or is the other shoe yet to drop?
The uncertainty over the novel coronavirus that was recognized last month is captured in a research report and editorial just released this evening by the New England Journal of Medicine. (I believe these are the first peer-reviewed papers on the new organism, though it has several times been written up in the European CDC’s bulletin, EuroSurveillance.) The papers are a treatment report and analysis of the first known case, the 60-year-old Saudi man who died in June, and an examination of the larger issues raised by this case and the second known one, which occurred in Qatar and London in September.
Short summary of the situation from the second paper, co-authored by the former chief of the division of viral diseases at the US CDC:
Since there has been no evidence of human-to-human transmission or virus transmission to healthcare workers, [the novel virus] is not currently a public health risk. (NEJM Anderson 2012)
Lung tissue containing the original SARS coronavirus (CDC, 2003)
On Feb. 21, 2003, a 65-year-old physician who lived in the Chinese province that abuts Hong Kong crossed into the territory surrounding the city and checked into a hotel in Kowloon. He was given a room on the ninth floor. Sometime during his stay — no one has ever fully traced his path — he encountered roughly a dozen other people; most of them were hotel guests whose rooms were on the same floor, but some were staying on other floors, and some were visitors to events there. The physician had been sick for a week with symptoms that had started like the flu, but were turning into pneumonia, and the next day, he checked out of the hotel and went to a Hong Kong hospital. Before the end of the day, he died.
In the next few days, the people who had crossed paths with the physician left the hotel. Most of them were visitors to the special administrative region: Hong Kong is not only a port and transit hub, but a business and shopping destination for much of the Pacific Rim. They went to Vietnam, Singapore, Canada, and Ireland. As they traveled, some of them started to feel as though they had picked up the flu.
I was off-line for a week with family issues, and while I was gone, news broke out. (It senses your absence, news does. This is the real reason why coups and major foodborne outbreaks happen in August.)
So while I dive into the bigger stories that seem to be happening — and get some fun summer stuff lined up — here’s a quick recap of things worth noticing:
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:
The data-dense graphic above may be too reduced to read (here’s the really big version), but its intricacy masks a simple and fairly dire message: The global trade in food has become so complex that we have almost lost the ability to trace the path of any food sold into the network. And, as a result, we are also about to lose the ability to track any contaminated food, or any product causing foodborne illness.
The graphic, and warning, come from a paper published last week in PLoS ONE by researchers from the United States, United Kingdom, Hungary and Romania. The group used United Nations food-trade data — along with some math that I do not pretend to understand — to describe an “international agro-food trade network” (IFTN) with seven countries at its center, but a dense web of connections with many others. Each of the seven countries, they find, trades with more than 77 percent of all the 207 countries on which the UN gathers information.
As a result, they say: “The IFTN has become a densely interwoven complex network, creating a perfect platform to spread potential contaminants with practically untraceable origins.”
So, these deadlines: They’ve been intense. (I know, I said last week I thought I was done. I was wrong. But now I think I’m done — though chairing a conference for the rest of the week, so still busy.) While I’ve been underwater, there has been literal tons of news on this blog’s core topics, all of which I need to get back to. But while I’m getting re-oriented, here’s an intriguing piece of news that I stashed last month for consideration. It’s worth thinking about, if you’re planning exotic travel.
TL;DR: If you’re going somewhere where you run the risk of being exposed to a disease that your doctors back home might not recognize, and you can take simple steps to prevent it, you should. Really. Wear your bug repellent, stay out of the stagnant water, keep your skin covered, take your pills. [Read more…]
On the heels of the news of totally drug-resistant (TDR) TB being identified in India — and disavowed, unfortunately, by the Indian government — the World Health Organization has released an update on the background situation of drug-resistant TB around the world.
The news is not good. Drug-resistant TB is at the highest rates ever recorded.
An independent monitoring board convened by the worldwide polio-eradication initiative has delivered a report on the global effort that is striking for its brutally frank and even frustrated tone.
Among its findings, just in its first few pages: “Case numbers are rising”; “unwelcome surprises continue”; “as many milestones are being missed as are being met”; and “the (eradication) Programme is not on track for its end-2012 goal, or for any time soon after unless fundamental problems are tackled.”
Possibly the biggest problem, the board concludes, is a get-it-done optimism so ingrained in the 23-year effort that it cannot acknowledge when things are not working:
We have observed that the Programme:
Is not wholly open to critical voices, perceiving them as too negative – despite the fact that they may be reporting important information from which the Programme could benefit.
Tends to believe that observed dysfunctions are confined to the particular geography in which they occur, rather than being indicative of broader systemic problems.
Displays nervousness in openly discussing difficult or negative items.
If some of this sounds familiar, that is because the board hit similar notes in its last report in July, in which it declared that the international effort “is not on track to interrupt polio transmission as it planned to do by the end of 2012.” I get the sense, reading the latest, that the board does not believe it was heard.
It’s been more than a year since the “Indian superbug” NDM-1 — not actually a bacterium, but a gene that directs production of an enzyme — hit the news. The enzyme, whose acronym is short for New Delhi metallo-beta-lactamase-1, disables almost all antibiotics directed against it, leaving the bacteria in which the gene appears vulnerable to only two imperfect and sometimes toxic drugs.
The enzyme and its gene, blaNDM-1, were first identified in 2008 in people who had traveled in India or sought medical care in South Asia. Hence its name: Many beta-lactamases, enzymes that denature the very large class of everyday antibiotics known as beta-lactams, are named for countries and cities where they were first identified. Since its identification, NDM-1 has been discovered in patients in more than a dozen countries and has also been found to be widely harboured outside hospitals in India, and in surface waters and sewage there.
The unveiling of NDM-1 clearly caused embarrassment for India, and media and lawmakers there struck back, throwing around intemperate language and claiming the naming of the enzyme was a plot to derail the subcontinent’s medical-tourism industry — even though the Indian doctors had attempted to raise the alarm earlier and had been ignored.
So it seemed like a promising signal of openness when an international conference on antibiotic resistance opened in New Delhi a week ago. But in its wake, just what is going on in India — and whether its government is willing to face up to what might be an international crisis — is less clear than ever.
Very bad news from China, as reported by Xinhua and confirmed by the World Health Organization: For the first time in 12 years, polio paralysis has surfaced in China. Four children, the oldest 2 years old, were diagnosed with polio in mid-July. They all live in Hotan prefecture in Xinjiang province (by weird coincidence, also the site of the latest Chinese food-safety scandal).
The generally accepted math, in polio detection, is that one verified case of polio paralysis represents up to 200 cases of silent infection. Those 200 undetected cases may not experience symptoms, but they can pass on the disease to others. As a result, one case of polio in an area that has been considered polio-free is an emergency. Four cases, as you can imagine, is much worse. [Read more…]
Over the weekend, I sat in an airport in the midwestern United States for a 12-hour stretch, trying to get a standby seat. Time after time, the goal was in sight — the customer service agents and the video screen hanging from the ceiling all told me I was No. 1 on the waitlist — but every time a flight opened up to boarding, a few higher-priority customers popped up at the last minute and slid onto the list in front of me. The possibility of my getting a seat dangled just out of reach: never impossible, but despite the exhausting wait, never quite achieved.
I suspect this is what polio eradication feels like.
The long effort to wipe the paralyzing disease from the planet, begun in 1988 by a coalition of the World Health Organization, the Centers for Disease Control, UNICEF and the service organization Rotary International (recently joined by the Bill and Melinda Gates Foundation), has several times missed its goal of interrupting all transmission of wild virus — first in 2000, then in 2002 and then again in 2005. The hoped-for date has been moved again, to the end of 2012 this time.
But last week, an independent assessment bluntly warned that the international effort “is not on track to interrupt polio transmission as it planned to do by the end of 2012” and likely will miss that goal as well.
Warner Brothers has released the first trailer for CONTAGION, a Steven Soderbergh bio-thriller about an influenza strain gone virally rogue that will open Sept. 9. Quoting from the movie’s website:
“Contagion” follows the rapid progress of a lethal airborne virus that kills within days. As the fast-moving epidemic grows, the worldwide medical community races to find a cure and control the panic that spreads faster than the virus itself. At the same time, ordinary people struggle to survive in a society coming apart.
Delicious exchange from the trailer (zinger response from Laurence Fishburne):
“Is there anyway someone could weaponize the bird flu?”
“Someone doesn’t have to weaponize bird flu. The birds are doing that.”
Here’s the trailer. You are made of stern stuff if it doesn’t make you want to wash your hands. (I’ll be over here in the corner, rubbing mine together in scary-disease glee.)
[HTML1]
A number of years ago, I was in New Delhi, at the end of an exhausting 18 hours in which I had torn around the city to watch a National Immunization Day. On those days — like a national holiday, with flags and banners and kids let out from school — tens of millions of children line up to stick out their tongues and receive the sugary drops that contain the vaccine that should protect them against polio.
The Indian government, along with the Centers for Disease Control, the World Health Organization and the volunteer ground troops of Rotary International, has been organizing these days now for most of two decades, always coming closer to the goal of eradicating polio, never quite getting there. On this day, which occurred close to the end of weeks I had spent embedded with a WHO “STOP Polio” team, 135 million children were expected to queue in cities and suburbs and rich neighborhoods and slums. I spent the day with the team I had been observing, racing in a battered turquoise Tata from neighborhood to neighborhood, trying to understand where the campaign’s message was working and where its earnest persuasions had failed. (You can read my account of the day here.)
The latest news from the European Centre for Disease Prevention and Control, the EU’s CDC, suggests that the massive outbreak of E. coli O104 is declining. The number of new cases being discovered has fallen, and the most recent onset of illness among confirmed cases was June 27. The toll is now 752 cases of hemolytic uremic syndrome and an additional 3,016 cases of illness in 13 countries, for a total of 3,768 illnesses including 44 deaths. (The EU adjusted that total to remove 161 cases that were suspected but not lab-confirmed. It also did not include the five confirmed cases, one suspect case and one suspect death in the United States.)
But a simultaneous report from the European Food Safety Authority (EFSA) reveals that, despite the epidemic curve’s trending down, the outbreak can’t be considered over. The ultimate source — the contaminated seeds from which salad sprouts were grown — has been so widely distributed that no one really knows where they have gone or for how long they might remain for sale. One prediction, based on the probable package labeling, is that they could remain on shelves for three more years.
So if we agree that the untrammeled rise in antibiotic resistance is a bad thing — and given the unexpected World Health Day news that an incredibly resistant bacterium is in New Delhi’s water supply, I think many do agree — what do we do next?
How about charging everyone who buys an antibiotic a user fee?
That’s one of the surprisingly nervy proposals that surfaced Thursday during World Health Day, a refreshing change from the somber but predictable rhetoric put forward by the WHO and CDC. It comes from a comprehensive set of policy recommendations released Thursday by the Infectious Diseases Society of America in the journal Clinical Infectious Diseases and at a press event in Washington DC.
The direct language in the recommendations’ introduction indicates their tone:
The availability of effective antibiotics is not a ‘‘lifestyle’’ issue, and the lack of availability of these agents is not theoretical. Society worldwide is facing a public health crisis due to stagnation in the antibiotic drug pipeline combined with rapidly spreading, deadly antibiotic-resistant pathogens. The lack of effective antibiotics already is resulting in deaths and maiming of patients and the problem will only continue to worsen until Congress and the Administration act. The time for debate about the problem has passed. Immediate action is critically needed now.
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…]
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…]
…And does paying it keep them poor?
That’s the provocative question that underlies a report released Thursday by the World Health Organization: Working to overcome the global impact of neglected tropical diseases.
What’s a “neglected tropical disease,” or NTD for short? In the WHO’s definition, there are 17; they are bacterial, viral and parasitic, and include dengue, rabies, trachoma, leprosy, Chagas, sleeping sickness, leishmaniasis, river blindness and Guinea worm. They not only have different causes, they affect different organs of the body and even occur in different climate zones. But in a hard-hitting speech delivered Thursday in Geneva, WHO director Dr. Margaret Chan underlined what links them all: They are diseases of the devastatingly poor, those who exist on $2 or less per day, and thus until now have largely been ignored. Chan said:
What brings these diseases together is our collective failure as an international community to do a better job of reducing poverty and addressing the diseases that are bred by poverty.
The neglected tropical diseases form a group because of one shared feature: all occur almost exclusively among very poor people living in tropical parts of the world. All thrive in impoverished settings, where housing is often substandard, safe water and sanitation are scarce, environments are filthy, and insects and other vectors are abundant.
Together, these diseases blind, maim, disfigure, disable, and otherwise impair the lives of an estimated 1.2 billion people. Less visibly, they damage internal organs, cause anaemia, retard the growth of children, impair cognitive development, and compromise pregnancy outcomes.
The significant damage to health is frequently compounded by the misery of stigma and social exclusion, especially for women and girls. In many societies, this is a fate worse than death.
