Several bloggers are raising concerns about the FBI’s case against Dr. Bruce Ivins, who was suspected of carrying out the 2001 anthrax attacks and who died from an acetaminophen overdose hours before he was supposed to meet with government officials about the case. In particular, Revere explains why the anthrax tracing and medical report explanations are fishy, and Glenn Greenwald criticizes the way both the FBI and the mainstream press have addressed the case.
Since other bloggers are already tackling the troubling questions about the investigation, I wanted to focus on an issue that Andrea Seabrook raised on NPR’s All Things Considered yesterday in a conversation with David Kestenbaum. Seabrook noted that all mail sent to Congress is still being irradiated, at a great cost to taxpayers; Kestenbaum responded that, indeed, some critics of government’s security priorities are pointing out that we have no evidence Al Qaeda is trying to spread anthrax through the mail.
If we’re going to spend $8 billion on biopreparedness next year, which Kestenbaum says is likely, there are bigger threats than anthrax attacks. An article in the latest issue of the New Yorker highlights one threat that could use more attention.
Jerome Groopman begins his article “Superbugs” with a description of an outbreak of multi-drug-resistant Klebsiella pneumoniae in a New York hospital. Healthy people can harbor Klebsiella without experiencing problems, but it can produce serious infections in compromised patients, like those in intensive care units. Dr. Roger Weatherbee, an infectious-disease expert who responded to an outbreak at New York University’s Tisch Hospital, found that the bacteria was only sensitive to one drug (colistin, which had been largely abandoned due to its potential for causing sever kidney damage) and that bleach seemed to be the only cleaning agent capable of destroying it.
Intensive ICU decontamination and stringent hygiene procedures eventually stopped the outbreak, but 34 patients contracted Klebsiella infections and nearly half of them died. Tisch Hospital has experienced no more outbreaks, but resistant Klebsiella has appeared in hospitals in New York, New Jersey, Ohio, and Missouri.
MRSA (methicillin-resistant Staphylococcus aureus), is a better-known resistant bacteria. It’s still responsive to several drugs, but can often be deadly: According to the CDC, MRSA causes more than 94,000 life-threatening infections and nearly 19,000 deaths each year in the U.S. Dr. Robert Moellering, a professor at Harvard Medical School and expert on antibiotic resistance told Groopman that until about 10 years ago, “virtually all cases of MRSA were either in hospitals or nursing homes … Now we see it in a whole bunch of other populations.”
Groopman explores two likely causes of bacteria’s quick development of antibiotic resistant. Over-prescription of antibiotics is one problem:
Before the development of antibiotics, the threat of infection was urgent: until 1936, pneumonia was the No. 1 cause of death in the United States, and amputation was sometimes the only cure for infected wounds. The introduction of sulfa drugs, in the nineteen-thirties, and penicillin, in the nineteen-forties, suddenly made many bacterial infections curable. As a result, doctors prescribed the drugs widely—often for sore throats, sinus congestion, and coughs that were due not to bacteria but to viruses. In response, bacteria quickly developed resistance to the most common antibiotics. The public assumed that the pharmaceutical industry and researchers in academic hospitals would continue to identify effective new treatments, and for many years they did. In the nineteen-eighties, a class of drugs called carbapenems was developed to combat gram-negative organisms like Klebsiella, Pseudomonas, and Acinetobacter. “They were, at the time, thought to be drugs of last resort, because they had activity against a whole variety of multiply-resistant gram-negative bacteria that were already floating around,” Moellering said. Many hospitals put the drugs “on reserve,” but an apparent cure-all was too tempting for some physicians, and the tight stewardship slowly broke down. Inevitably, mutant, resistant microbes flourished, and even the carbapenems’ effectiveness waned.
And then there’s the problem of routine use of antibiotics in livestock. Low doses of antibiotics can keep animals – who are often crowded together in unclean areas – from getting sick, and also speed their growth. Selling antibiotics for livestock is profitable, and author Michael Pollan tells Groopman that 70% of the antibiotics administered in this country go to livestock. It’s not really surprising that recent studies have found poultry workers and people exposed to pigs and cows to have high rates of carrying antibiotic-resistant bacteria. MRSA has been found in U.S. pigs and Canadian pork, too – but our federal agencies aren’t rushing to check meat for the bacteria.
Here’s where Groopman connects the problem to anthrax:
Since September 11, 2001, significant funding has been directed toward the study of anthrax and other microbes, like the one that causes plague, which could be used as bioweapons. Although there is little concern that Klebsiella or Acinetobacter might be weaponized, the basic science of their mutation and resistance could be useful in helping us to understand these threats. [National Institute of Allergey and Infectious Diseases Director Dr. Anthony] Fauci hopes to make the case that funds for biodefense should be used to study the ESKAPE bugs [Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumanni, Pseudomonas aeruginosa, and the Entero-bacter], but, for now, he is quick to point out the challenge posed by a lack of resources. “The problem is, it is extremely difficult to do a prospective controlled trial, because when people come into the hospital they immediately get started on some treatment, which ruins the period of study,” he said, referring to research into the treatment of common infections. “The culture of American medicine makes a study like that more difficult to execute.”
The 2001 anthrax attacks killed 5 people; MRSA kills 19,000 each year. There are differences between the two, of course; the anthrax was deliberately mailed out by a malicious individual, and such individuals can be arrested and stopped. But individuals also contribute to antibiotic resistance, and with some effort we can curb the damaging behaviors of doctors who write antibiotic prescriptions for viral illnesses and livestock owners who routinely dose their animals with drugs that should be reserved for treating actual illnesses. (Of course, this will also require educating patients to stop expecting a prescription for every health complaint and cheap meat for every meal.) Better infection-control practices in hospitals, nursing homes, and other healthcare sites are also essential, since many of the resistant infections still originate in healthcare settings.
There are also things we can do that will help out with many different kinds of health threats, whether they come from terrorism, bacteria, viruses, or disasters. In June, the American Association for the Advancement of Science and the Congressional R&D Caucus organized a Capitol Hill briefing on President Bush’s proposed FY2009 biodefense budget. Dr. Eric Toner of the Center for Biosecurity at the University of Pittsburgh Medical Center pointed out that hospital emergency rooms were overwhelmed during the anthrax attacks, because thousands of patients needed to be assessed; he said that hospitals have improved their planning and communication since then, but the number of hospital beds and emergency departments is declining.
Alan Pearson of the Center for Arms Control and Non-Proliferation noted that Bush’s proposed budget would reduce hospital preparedness funding by 15% and sate and local capacity-building efforts by 18% – while adding what amounts to a 39% increase for bioweapons, prevention, and defense.
Maybe Bush the members of Congress who support such lopsided biosecurity spending do so because they’d rather be seen as fighting terrorism than strengthening public health. Putting more money into drug-resistant bacteria research and emergency departments might not be the best thing for their “tough on terrorism” images, but it’s important for our health.