Reflecting on the past year in infectious disease and global health news, these were some of the stories that particularly grabbed my attention. Antibiotic resistance Milken Institute School of Public Health at GWU Antibiotic use in agriculture is a huge driver of antibiotic resistance Antibiotic resistance continues to be a huge problem prompting many of my consults on hospitalized patients. Because of resistance—and sometimes from incorrectly claimed drug allergies by patients—we are forced to use more toxic antibiotics than would otherwise be needed. This is also more costly, usually requiring placement of a long-term IV catheter (aka PICC line), which has its own risks, such as blood clots and additional infection. Overall, news is pretty grim on this front, as more resistant bacteria are spreading globally and the antibiotic pipeline is dismal. There have been glimmers of good news, however. A dozen antibiotic resistance experts, supported by the Antibiotic Resistance Action Center at GWSPH and the Natural Resources Defense Council, issued recommendations in Combating Antibiotic Resistance: A Policy Roadmap to Reduce Use of Medically Important Antibiotics in Livestock. The focus on livestock is because “70% of medically important antibiotics sold in the U.S.(i.e. those identical or belonging to the same class as antibiotics used in human medicine) are sold for use in food-producing animals, not people.” Further, the OneHealth concept is gaining attention, as “6 out of every 10 infectious diseases in people are spread from animals.” This is a recurrent message to keep in mind as we look at links between outbreaks—such as Yellow Fever and Ebola—and environmental destruction that places people in closer proximity to animal hosts. There was recently a bit of good news from the FDA’s report on the Animal Drug User Fee Act (ADUFA)—there has been a marked decrease in antibiotic use for chicken, according to Michael Hansen at Consumer Reports and Lance Price at Milken Institute School of Public Health at GWU. Unfortunately, antibiotic use for beef and pork lag ways behind and is still high. Mounting pressure from consumers have led to the changes from the (fast-)food industry. Let’s keep it up. Sexually transmitted diseases STDs are likely to explode. Related to antibiotic resistance, and on the bad news front, is the rise in syphilis and gonorrhea. More than half of state and local STD programs have been cut, and in 2012 alone, 21 STD clinics closed. Public health spending was 10% lower in 2013 than in 2009. Yet Congress just voted to further slash public health funding. With Congress letting the Children’s Health Insurance Program (CHIP) expire, 9 million poor children and pregnant women have lost health coverage. This will no doubt increase the toll of syphilis and life-long problems for affected children and their families. The American Public Health Association noted the recent tax legislation would include “the complete elimination of the Prevention and Public Health Fund and other mandatory spending over the next 10 years. The fund currently makes up 12 percent of the entire Centers for Disease Control and Prevention budget, and its elimination would cripple the public health workforce’s ability to respond to infectious disease outbreaks and continue critical prevention programs. APHA executive director Georges Benjamin observed, "Like a game of high-stakes poker, Congress is gambling with public health by undercutting our ability to protect against infectious disease, stop the opioid crisis and tackle chronic conditions that are making Americans sick.” The Trust for America’s Health also explained the importance of the Prevention Fund, including strict performance measures for grants. More than 500 signatories—ranging from the TFAH and public health organizations to patient advocacy groups, universities and local health departments sent a letter imploring Trump not to gut this essential program. The CDC outlined the impact of cuts, including on childhood immunization and lead poisoning prevention, noting that in FY 2016, PPHF accounted for over 12 percent of CDC’s total program funding. They also outlined the cost-effectiveness of the PPHF program, demonstrating that this cut is really not about saving money. Zika Speaking of children, CHIP, and public health disasters…didn’t anybody learn anything about the need for sound public health from the Ebola and Zika outbreaks? Ebola was well-controlled in the U.S. through scientific, evidence-based, sound public health policy. Without that, there would have undoubtedly been far more panic and cases. Think back to then Governor Christie irrationally and needlessly quarantining Kaci Hickox, violating her civil rights. She subsequently sued Christie, with help from the ACLU. That suit was settled this summer. According to the Bangor Daily News, with an agreement outlining when and how quarantines can be imposed. When there is a resurgence of Zika, it will be far more of a problem than before for several reasons—poverty and worsening infrastructure, as well as a warming climate, will likely lead to more mosquito-borne outbreaks in coming years. Public health funding is being devastated. While ineffective abstinence-only programs are being promoted instead of comprehensive sex ed, and anti-abortion laws are increasing, one does not need a crystal ball to see that there will be more babies born with microcephaly in future outbreaks. Poor women and women of color will be disproportionately affected and left in the lurch, given cuts in funding for CHIP and Medicaid. With CDC and NIH reportedly being told that controversial words like “fetus” will be flagged and the censorship at government agencies growing (a clear message, whether or not the precise language has been confirmed), how will evidence-based research to ensure the health of fetuses continue? Who will care for these children with devastating birth defects? CDC/Entomological Society of America Counties with Aedes aegypti mosquitos that commonly transmit Zika Also, the CDC noted a 21% increase in A. aegypti, the main Zika vector, which also transmits Chikungunya and dengue viruses and also A. albopictus, a lesser source of zika, dengue, Chikingunya, West Nile, Japanese and Eastern equine encephalitis in counties where they are present. Who will continue to do surveillance and education with funding cuts and misplaced priorities? CDC Range of disease bearing mosquitoes Vaccine preventable diseases - Measles and Polio We have been tantalizingly close to eradicating polio, but several problems sabotage successes. Perhaps most tragically are the assassinations of polio workers. In part, we can thank the CIA for this legacy of mistrust from their using a hepatitis vaccination program to help track down Osama Bin Laden in 2011. Additional rumors that the polio vaccine is being used to sterilize Muslims contributes to the mistrust in the countries where polio persists—Pakistan, Afghanistan, and Nigeria. The result? Vaccine workers are routinely murdered and polio continues, as vaccinations were banned by the Taliban in Afghanistan and Pakistan. Similarly, using an HIV prevention workshop as a pretense in 2014, the U.S. Agency for International Development sent young people undercover to Cuba to incite anti-government activism. At that time, Congresswoman Barbara Lee, co-chair of the Congressional HIV/AIDS Caucus, aptly noted, “This blatant deception undermines U.S. credibility abroad and endangers U.S. government supported public health programs which have saved millions of lives in recent years around the world.” Fallout from these poorly conceived programs has continued, with similar mistrust fueling the Ebola epidemic, with attacks on health care workers in 2014. A more recent problem with polio is the growing number (now 84) of cases of circulating vaccine-derived poliovirus cases, outnumbering the wild (natural) type. The oral polio is a very weakened but still live vaccine, which can be shed in stool. There have been a few cases of infection from this vaccine, especially in non-endemic countries. Most recently, this occurred in Syria and the Democratic Republic of the Congo, each with one case of paralysis. But without vaccination, the world remains threatened by a possible resurgence of polio. Measles was eliminated from the U.S. in 2000, but had since made a large comeback because of vaccine refusers. Nearly 70 percent of the people with measles from January 2001 through December 2015 were unvaccinated. Per the CDC, 79% claimed personal belief exemptions rather than a medical contraindication. The public health cost to the rest of taxpayers for these people’s “personal beliefs”? $2.7-5.3 million. There were several large outbreaks, one at Disney, one among the Amish in Ohio, and, most recently, an outbreak among the Somali community in Minneapolis. Many Somalis were dissuaded from vaccination by people pushing the long-debunked assertion that vaccines cause autism. That our tax-dollars, paid to ICE, fueled an epidemic in Arizona through a for profit prison, is particularly infuriating, as was their refusal to cooperate with local public health officials. Measles is not a mild childhood rite of passage. Keep in mind that a number of children who are too young for the shots or are immunocompromised and cannot be vaccinated can be killed or disabled for life because of an infection. The argument over vaccinations for highly communicable diseases shows why we generally opt to do things for the good of the society; it’s why we have basic laws an norms. It’s why most people support regulations to protect our communities from infections, pollution, and gun violence, understanding that individual “liberties” shouldn’t trump other people’s rights to a safe existence. Shock and septic shock I’ll end on this bit of good news, about Angiotensin II for treatment of shock. Severe shock has a mortality of ~50% despite all efforts to improve care over decades, and sepsis is a common cause. This ATHOS-3 study was small, but a “gold-standard” design, being multinational, double-blind (neither investigator nor patient knew which treatment they were receiving), randomized, controlled trial. This study showed that Angiotensin II, aka Giapreza, (La Jolla Pharmaceutical Company, NASDAQ: LJPC) was better than saline for improving blood pressure in these critically ill patients. It was given in addition to standard treatments with catecholamines (norepinephrine, or Levophed—known cynically as “leave-em-dead” or vasopressin , which have many nasty side effects, with a goal of reducing the dose of these toxic drugs that have to be used now. It did not result in a higher mortality or more frequent adverse events than the saline placebo. Note that while this study had limited endpoint—an elevation of blood pressure after three hours—it is an important start in finding an effective treatment for a deadly condition. Conclusion It’s been a mixed year in infectious disease news. We have made a bit of progress on antibiotic use in agriculture, particularly in chickens. Outbreaks of various plagues—Yellow fever, Plague in Madagascar, Zika— have cropped up, but have been fairly well-controlled or have burnt themselves out. We’ll face more challenges in the coming years due to recent legislative funding priorities. One potentially good thing coming is the formation of HHS Federal Tick Borne Disease Working Group, though they have a very difficult task ahead of them. More on that in the coming year. Source
