A New Twist on Germ Warfare: The U.S. Government’s Pathogen Predators Program

The context is new but we’re familiar with the theory: The enemy of your enemy is your friend.

Using germs to fight germs is the idea behind the Pathogen Predators program of the US Defense Advanced Research Projects Agency (DARPA), which began last May. It’s based on the way bacteria behave in nature. As they compete for resources such as food and living space, bacteria fight a war against each other and have been doing so since their inception – 4 billion years ago. Those that survived have evolved ways of attacking other bacteria. In response, the defenders with stronger protections were favored, and the assailants, in turn, evolved even better weapons, and so on.

This digitally colorized electron micrograph shows your immune system in action: A white blood cell (blue) attacking MRSA (yellow). But when the immune system fails – the usual case with resistant germs - and antibiotics continue to loose their effectiveness - then what?

This digitally colorized electron micrograph shows your immune system in action. A white blood cell (blue) is attacking MRSA (yellow). But when the immune system fails – the usual case with resistant germs  like MRSA – and antibiotics continue to loose their effectiveness , then what?

Studying that arms race and picking and choosing what may work for us is the focus of the research. For example, Bdellovibrio bacteriovorus, is found in the soil. It attacks prey bacteria by embedding itself between the host’s inner and outer cell membranes, and begins to grow filaments and replicate. The host bacterium eventually explodes and releases more B. bacteriovorus into the environment. In another case, a team has engineered the gut bacterium Escherichia coli to produce peptides that kill Pseudomonas aeruginosa, a microbe that causes pneumonia.

But researchers warn that the enemy of your enemy isn’t always your friend. Some of these predators will attack you too, just as MRSA does. So they have to tease out which ones are toxic to us, and which pathogens (prey) the predators are effective against.

One more thing. From the perspective of bacteria, antibiotics, most of which come from the soil, are simply another front in their battle against one another. We tend to think of ourselves as Lords of the Universe, but when it comes to germ warfare we are relative newcomers dating back mere decades to the advent of the era of antibiotics in the 1940s. In other words, in this war, our ‘enemy’ has had a 4 billion year head start. So by using our know-how to harness theirs, DARPA wants to treat not just battlefield infections, but especially those that are stubbornly resistant to antibiotics – a problem that concerns all of us.

 

 

 

 

 

 

 

 

The Placebo Effect

Uh-oh: more strange news about Humans – apparently we’re very placebo-susceptible.

According to Jerome Groopman, MD, Chair of Medicine at Harvard Medical School, in his New Yorker piece, “The Most Notable Medical Findings of 2015,” (there are seven), placebos - placebos – are very real, very powerful, and, he says, may change how we think about medicine. For example, when it comes to taking an inert sugar pill – something that should have zero effect — research tells us otherwise:

Placebo effect“In most cases, the larger the pill, the stronger the placebo effect. Two pills are better than one, and brand-name pills trump generics. Capsules are generally more effective than pills, and injections produce a more pronounced effect than either. There is even evidence to suggest that the color of medicine influences the way one responds to it: colored pills are more likely to relieve pain than white pills; blue pills help people sleep better than red pills; and green capsules are the best bet when it comes to anxiety medication.”

Which may explain why 97 per cent of UK doctors admit to administering ‘impure’ placebos. These are unproven treatments including antibiotics for suspected viral infections, such as the cold or flu, on the basis that they “clearly believe that placebos can help patients.” Of course, technically speaking, there is a downside to this: the spread of antibiotic resistance which is predicted to kill more people than cancer.

But placebos don’t really help infected patients do they? Well, according to this study, the antibiotic amoxicillin is no better than a placebo for most sinus infections. Not only that, the placebo comes without side effects!

So where does this leave us? Since it’s the day before New Year’s Eve we’ll turn to a well-known home remedy – humor. The New Yorker just published “Our Fifteen Most-Read Blog Posts of 2015.” The best of the bunch may be courtesy of humorist Andy Borowitz with his little gem: “Scientists: Earth Endangered by New Strain of Fact-Resistant Humans,” best read in its (brief) entirety here.

So let’s review: we are not a fact-susceptible, placebo-resistant species. Nope. With us, it’s the other way around.

And so with that – Happy New Year!

 

 

 

“If these patients were our loved ones, would we still not … take proper precautions?”

People don’t have to die or become disabled anywhere near as much as they do. We can smoke less, exercise more, eat better, pass appropriate gun safety laws, and so on. But what’s less understood and really quite surprising is that this also applies to cancer. Doctors, apparently, know how to reduce deaths by cancer by as much as 100,000 patients a year in the U.S., yet fail to do so. That’s the point of a new book, The Death of Cancer, by Vincent DeVita, Jr, MD, who is a professor of medical oncology at the Yale School of Medicine and former head of the National Cancer Institute.

It's time to move on

It’s time to move on

Devita is “one of the critical figures in twentieth-century oncology [who] unloads a lifetime of frustration with the … closed-mindedness of his profession,” writes Malcolm Gladwell in his review of the book for The New Yorker.

That “closed-mindedness” is in part due to the “incredibly promising therapies not used to their full potential,” but DeVita’s core criticism of his profession, says Gladwell, is reserved for its inert bureaucracy that refuses to be flexible and adapt to the ever-changing world of cancer medicine.

A case in point is the downside of treatment guidelines: those protocols and standards of practice that treatment providers must follow. Devita believes that “Guidelines are backwards looking. With cancer, things change too rapidly for doctors to be able to rely on yesterday’s guidelines for long. These guidelines need to be updated frequently, and they rarely are, because this takes time and money . . . . Reliance on such standards inhibits doctors from trying something new.” All to the detriment of the patient.

It’s that very inability to try something new that betrays not only cancer patients but patients of infectious disease as well. For example, hospitals typically don’t treat someone who’s colonized by methicillin-resistant Staphylococcus aureus (MRSA), thus increasing their risk of acquiring a serious infection.

And the risk is a big one: Studies estimate that between 1 in 4 and 1 in 7 people who are colonized by MRSA go on to become infected. Once infected, you’re looking at multiple hospital admissions, infection-related complications, surgery, the need for care in an ICU, and even death. Moreover, you can give your MRSA to others.

The merits of decolonization have once again been confirmed, this time by a 4-year study published this week in the journal Antimicrobial Resistance and Infection Control. It says that with proper decolonization protocols MRSA infection rates can be drastically reduced and in some cases brought down to zero.

Given that in the U.S. alone over 11,000 people die each year from MRSA and over 80,000 more become seriously infected by it, the failure to adopt this effective preventive measure is puzzling. Whether, in the words of Dr. DeVita, this is another case of an “incredibly promising therap[y] not used to [it’s] full potential,” either because of the “closed-mindedness” of the profession or because the new measure would take “time and money” to implement, is best left for others to judge.

We do, however, have a suggestion about how to make that judgment a wise and humane one. It comes from Arlene Wilgosh, a former frontline nurse and CEO of the Winnipeg Regional Health Authority, in her address last year to a packed house at “Bug Day,” the national conference on infectious disease held annually at Winnipeg’s Health Sciences Centre. Lamenting the fact that hospitals know what to do to prevent these infections yet fail to follow through with proven protocols, she posed this question to the audience: “If these patients were our loved ones, would we still not … take proper precautions?”

With respect to another area of human concern it has been said that “The path ahead is not just about politics [and policy], it is a change of heart and mind that starts with each and every one of us.”

It seems to us that that is exactly what Ms. Wilgosh and Vincent DeVita are calling for.

And we commend them for it.

Northern Exposure: Climate Change and the Migration of Infectious Disease

Lindsay Lohan didn’t have to go to French Polynesia to catch the once tropical-only virus chikungunya (pronounced chicken-goon-ya). Florida, as of last year, would have done just fine, according to the US Centers for Disease Control and Prevention.

Chikungunya isn’t alone among northern migrants. Dengue fever has moved into Florida and south Texas; and typhus, Chagas disease, West Nile virus, Lyme disease, and others are also moving into new and newly warmer territory.

Once an Evergreen forest

Once an Evergreen forest

The explanation is straightforward enough: as the planet warms, animals and insects that carry disease are able to survive in places where they previously didn’t or can thrive longer than they were able to before.

The trend isn’t limited to “imports.” Our warming climate also enables the rise of domestic pathogens. For example, a study that looked at seasonal variation in hospital admissions found that for every 10-degree Fahrenheit rise in temperature, there was a corresponding rise in infections: MRSA rose 2.2 %, E. coli infections rose 12.2 %, Pseudomonas, a cause of bloodstream infections, rose 28.1 %, and Ancinetobacter, associated with urinary tract infections, rose by 51.8 %.

The extent of the forest destruction

The extent of the forest destruction

While the explanation for warming temperatures and disease increase may be straightforward it’s not necessarily persuasive. To really see the connection we can to turn to an analogous – and dramatic – example: the relationship between warming temperatures, the northern migration of the mountain pine beetle, and their destruction of millions of acres of forests.

The sickly-looking brownish-red trees in the picture above are Evergreens. They are supposed to be green, as their name implies. But they have fallen victim to pine beetles that used to be controlled by bitterly cold winters where temperatures used to fall to 40 degrees below zero in the mountains every few years, killing off many beetles. However, that just doesn’t happen anymore and so as the climate warms the pines of the northern and central Rockies are dying off from Arizona up to the Canadian border.

Here’s a fuller discussion of climate change and its effect on the forest and our lives:

Let’s Talk Turkey

In this era of antibiotic resistance and foodborne illness, getting Thanksgiving right means more than just deciding who to invite for dinner. These days, it means proper preparation and cooking of the turkey to prevent food poisoning. The good news is that it can be easily accomplished; but first, some background.

Outbreaks of food poisoning occur most often in November and December. Meat and poultry account for 92% of outbreaks with an identified single food source – and turkey has become one of the usual suspects.

Turkey 2For example, just last month a report came out that found MRSA in 3 out of 10 turkey farms: and 5 of 11 farmers on those 10 farms were MRSA-positive, as well as 2 of 32 family members, and 15 of 49 samples from the home residences. Worse still, is a report by CBS that dangerous bacteria were found on 90% of ground turkey.

Now for the good news: proper preparation and cooking of our Thanksgiving turkey will virtually eliminate problems with these pesky pathogens; so says the US Centers for Disease Control and Prevention, who recommend this 4-step plan:

  1. Thawing the turkey. No, not on the counter silly! Because when the turkey is left out at room temperature for more than two hours, its temperature can creep into the danger zone between 40°F and 140°F, where bacteria can grow rapidly. Ergo, thaw thy turkey in the fridge!
  2. Handling the turkey. Thoroughly wash your hands, utensils, and work surfaces to prevent the spread of bacteria to your food and family. Okay, that’s easy.
  3. Stuffing the turkey. Do it just before Use a food thermometer to make sure the stuffing’s center reaches 165°F. Bacteria can survive in stuffing that has not reached 165°F, and possibly cause food poisoning. So, remember 165°F because it will come up again!
  4. And finally – Cooking the turkey. Set the oven temperature to at least 325°. To make sure the turkey has reached a safe internal temperature of 165°F, check by using a food thermometer inserted into the center of the stuffing and the thickest portions of the breast, thigh, and wing joint.

Of course, the CDC aren’t the only ones to consult for our Thanksgiving dinner. This one seems particularly yummy:

Quiz Time!

The World Health Organization needs our help.

Here’s the issue: “The rise of antibiotic resistance is a global health crisis, and governments now recognize it as one of the greatest challenges for public health today. It is reaching dangerously high levels in all parts of the world,” says Dr. Margaret Chan, WHO Director-General, in a statement released on Monday.

Margaret Chan, MD: We need the public in on this

Margaret Chan, MD: We need the public in on this

The thing is, when we hear such statements from on high we think there isn’t anything we can do. To the contrary, says Dr. Chan: “There’s an urgent need to improve our understanding of antibiotics and how our misuse of them contributes to the rising plague of antibiotic resistance.”

In kicking off World Antibiotic Awareness Week, which runs November 16 – 22, the WHO has released its just-completed worldwide survey that identifies four areas where we, the public, need to change our behavior:

1. This is the Big One: 64% of respondents believe antibiotics can be used to treat colds and flu, despite the fact that antibiotics have no impact on viruses.

2. 43% think it is acceptable to insist that your doctor give you the same antibiotics, if you are sick and antibiotics helped you get better when you had the same symptoms before.

3. 32% of people surveyed believe they should stop taking antibiotics when they feel better, rather than completing the prescribed course of treatment.

4. 25% of respondents across the 12 countries included in the survey think it is acceptable to use antibiotics that were given to a friend or family member, as long as they were used to treat the same illness.

Now for the fun part. To help explain these issues the WHO has put together a neat little 6-question quiz. As we enter cold and flu season it makes for timely lunch time office conversation. Be sure to click on “Check your answers” to get helpful user-friendly explanations that tell you everything you need to know about using antibiotics the right way. Cheers:

It Takes a Village: Herd Immunity, Contagious Disease, and the Duty to Vaccinate

Should health care workers be required to have a flu shot as a condition of their employment?

That was the question posed by Eric Bow, MD, in his presentation to a province-wide audience of HCWs at Bug Day, Winnipeg Health Sciences Center’s annual conference on infectious disease.

Underlying the question is the principle of herd immunity, i.e., since vaccine’s prevent illness, the more people in a community who are immune through vaccination the less people will get sick, therefore the smaller the risk that those who are not immune – because they didn’t vaccinate – will come into contact with an infectious individual.

Herd Imm 1

 

The reason herd immunity matters is that for medical reasons a whole lot of people cannot be vaccinated. These are people with weak immune systems; for example, infants, the elderly, cancer patients, and those with HIV/AIDS – in other words, the very people you find in hospitals. Hence the issue of whether hospital workers should be required to be vaccinated against the flu.

The issue, however, goes beyond the hospital and reaches each one of us. Take, for example, the measles outbreak at Disneyland in California last December where, as of February 11 this year, a total of 125 measles cases had been confirmed among U.S. residents in an ongoing outbreak, 45% of whom were unvaccinated.

But here’s the interesting thing: the December measles virus wasn’t confined to California. A few children and adults from the small religious community of L’esprit Saint in Quebec went to Disneyland last Christmas. Unknowingly, they brought the virus back to their community – where no one was vaccinated. The result: the virus infected 119 children and adults, and counting, as of this past March.

The root principle at work in herd immunity is that we have a duty to protect others. That duty is at its highest with HCWs because they are entrusted with the care of our most vulnerable. The singular importance of this principle is why herd immunity has been broadened to mean we have an ethical duty to undertake any affirmative action – such as vaccination – to prevent the spread of disease. So for example, with highly contagious MRSA, hospitals have an affirmative duty to provide a clean and sterile environment by mandating best practices for hand hygiene and decolonization protocols. As we wrote in these pages a year ago:

Changing how we conceptualize the colonization issue may help as well. For example, we vaccinate healthy people all the time so they don’t run the risk of catching a disease, some a lot less serious than what a MRSA infection can do to you. So why not think of a policy of decolonization as a kind of “vaccination,” a way of preventing the risk of serious harm?

The primacy of prevention in medicine is why “Prevention is the Cure” is the title of Part Four of The Emperor of All Maladies, Dr. Siddhartha Mukherjee’s 2010 Pulitzer Prize-winning book on the history of cancer. It’s the same idea advanced by Hillary Clinton in her 1996 book, It Takes a Village: And Other Lessons Children Teach Us. She believes that people and institutions outside the family – schools, community centers, hospitals, and so on – also determine a child’s well-being.

So whether it’s measles or MRSA, promoting child development or arresting cancer, our best and brightest agree that the best medicine is to act preemptively. And as the case of herd immunity teaches us, it takes all of us working together – it takes a village.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NFL Player Daniel Fells Seems to Have Overcome MRSA. But That Doesn’t Mean it’s Over

You can be in your physical prime, as strong as they come, have access to the best of medical care in the country, and still be hit hard – real hard — by methicillin-resistant Staphylococcus aureus (MRSA). That’s the case right now with New York Giants tight end Daniel Fells.

On Oct. 2, Fells, 32, appeared in an emergency room with a 104-degree temperature. Doctors diagnosed a MRSA infection in his ankle and admitted him to hospital. He was immediately given antibiotics but they couldn’t control it. The concern, therefore, was that the MRSA would spread. Not just to the bone and tissue in his foot, which would then require amputation; but if it got into his bloodstream it could be fatal. So Fells was transferred to the ICU and underwent a series of five surgeries to save his foot and his life.

Daniel Fells

Daniel Fells

So far so good – sort of. Daniel Fells is still in hospital but he is out of ICU. His foot seems to have been saved from amputation but he may require further surgeries. And the NY Daily News is reporting that his football career is likely over because of the extensive damage to his foot.

Fells is not alone among athletes with his MRSA. A 2007 ESPN report, MRSA Has Sidelined Careers, Even Caused Deathsays MRSA is endemic in professional sports and mentions several high profile athletes who contracted it including Grant Hill of the Orlando Magic, Junior Seau of the New England Patriots, Paul Pierce of the Boston Celtics, Drew Gooden of the Cleveland Cavaliers, and Braylon Edwards of the Cleveland Browns. Since the ESPN report came out there’s been further outbreaks in the NFL in Cleveland and Washington, and in Tampa where MRSA has recently ended the careers of Buccaneer players Carl Nicks and Lawrence Tynes.

And there’s this: One in 4 patients discharged from the hospital after being treated for MRSA will have to go back, often more than once, to the ICU and require further surgery. That’s because MRSA is easily spread to most surfaces you’ve had contact with and so you can easily pick it up again. That’s why the Giants, for example, hired infection specialists to clean their facilities. But Daniel Fells wasn’t taken to the ER from the team facilities, he was taken there from his home. Where, recent science also tells us, among households with people recently treated for it, MRSA is regularly found and spread to the other people who live there.

Daniel Fells lives with his wife and 2 young children.

Britain Unveils its Back-to-School Plan to Fight Antibiotic-Resistant Infections

It’s suppertime. And you’re going to do the right thing: skip that fast food joint too-conveniently located around the corner and prepare that healthy homemade pizza everyone loves. As you’re congratulating yourself on your choice in walks your 10-year old who politely asks if you have washed your hands. Not quite willing to fess up that you haven’t you try an artful dodge: Um, why do you ask, young lady? To which you get something like:

child drBecause germs on your hands can spread to Daddy and me through the food you’re touching. And if a bad bug gets in your bloodstream it’s serious. I even know how it works:

“Each microbe has special markers or antigens on their surface which is special to just that microbe. Specific white blood cells see these microbes and their antigens. And make specific antibodies to attach to that particular antigen. These antibodies lock onto the microbe with the corresponding antigen. The antibodies then mark the harmful microbe for destruction. And stay in the bloodstream to fight that antigen should it ever return.”

No, your 10-year-old probably wouldn’t put it that way. However, those are the exact words used in the computer animation “Counter Attack,” which is 1 of 14 computer games designed for British school children, ages 7 – 11. That’s not a typo: this stuff is for kids. It’s part of the new British health authority guidelines released this week aimed at teaching students, age 7 though university, about drug-resistant bugs. In addition to games, the e-Bug website has home science experiments, quizzes, a disease fact file (explaining MRSA, for example), and a Fact of the Week: “Scientists believe that there are more bacteria in your body than the actual number of cells in your body.”

We saw this coming. Last year, Prime Minister David Cameron warned the public that “We are in danger of going back to the Dark Ages of medicine to see infections that were treatable not be treatable and you would see many thousands of people potentially die from these infections.”

Following that announcement his government released a report at Christmastime predicting drug resistant infections will kill an extra 10 million people a year worldwide – more than currently die from cancer – by 2050 unless action is taken. And so the health guidelines released Tuesday constitute, in part, that action.

So if you’re having trouble convincing your 10-year-old that hand washing before meals is important, I suggest the interactive e-Bug game “Soapy Soakers”(click on “Horrid Hands”). You’re shrunk down to microbe size and placed onto an unwashed hand. Armed with a soap gun and confronted with gnarly-looking bugs, your job is to knock’em dead. Can you figure out how to chase the critter, jump in the air and shoot him, all at the same time? So cool!

 

 

 

 

 

 

 

Are We As Smart As We Think?

A popular story in the New York Times this week is No, You Don’t Have to Drink 8 Glasses of Water a Day. It says that contrary to conventional wisdom it’s not true that you have to drink that much water; there’s just no science behind it. In fact, it turns out to be a myth that traces back to a 1945 Food and Nutrition Board recommendation that said people need about 2.5 liters of water daily. But everyone forgot the sentence that followed: “Most of this quantity is contained in prepared foods.”

smartAnother interesting myth is that we only use 10% of our brain: not so again; recent evidence tells us we use pretty much all of it.

While these myths seem relatively harmless, there are a number of “truths” floating around in the field of infectious disease that do cause harm.

For example, we generally believe hospitals to be safe places. Yes, they’re staffed by dedicated professionals and we only go there when we have to, but hospitals are not as safe as we think. Incredibly, twice as many people die of preventable hospital deaths every week in the US – some 8,400 people — than died in all of the Iraq War. And about 25% of these deaths occur because of infections you contract at the hospital.

Perhaps the biggest misconception we adhere to is that antibiotics cure sore throats, runny noses, chest colds, and pneumonia’s. For the most part antibiotics don’t work on these things because they’re caused by viruses and antibiotics only kill bacteria.

And when you use antibiotics inappropriately you inadvertently create another problem for yourself: you increase your chance of getting an infection. That’s because most antibiotics kill ALL bacteria, the “good” and the “bad.” Your good bacteria operate in conjunction with your immune system to protect you from disease. So if you knock them out with an antibiotic and are then exposed to a disease-causing germ, the chance of that germ making you sick goes up – way up. As one specialist puts it: “Has any health-care professional ever told you that taking antibiotics would increase your susceptibility to infection?”

Then there’s the myth that we’ve conquered diseases that we actually haven’t. Take for example the biggest contagion in human history – the Black Death, also known as the Bubonic Plague, or simply the Plague, that in the 14th C knocked off as many as 200 million people.

Since April of this year 11 people in the US have become infected with the Plague and 3 have died, which is about triple the normal rate.

We don’t hear much about the Plague because with early intervention antibiotics can treat it. But there’s a catch: we’re approaching what the World Health Organization and others call a post-antibiotic era where, increasingly, these drugs just aren’t working anymore. So much so that a recent UK government report predicts that antibiotic resistant infections will cause more deaths – about 10 million a year — than cancer by the year 2050.

Which brings us to our final myth: given the looming peril these huge numbers indicate we’ll now give antibiotic resistant disease the attention it deserves – or maybe not. Because psychologists tell us that just the opposite happens: “When the numbers [of dead or injured] go up, the amount of sympathy people feel goes perversely down. And with it goes the willingness to donate money or time to help.” Psychologists call this the “collapse of compassion.” It means that “when people see multiple victims, they turn the volume down on their emotions for fear of being overwhelmed.” Put another way: The death of one person is a tragedy; the death of a million is a statistic.

The trick, of course, is to make sure that we don’t fall into that statistic.

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