Bad news from California

Constant readers, some of you may be aware that one major nexus of MRSA infection gets very little attention, though I've tried to raise it here periodically. That's MRSA in jails and prisons: Thanks to poor hygiene and extraordinary overcrowding, jails and prisons are hotbeds of the bug, and it is very common for people to develop an infection after they are incarcerated, and then to be unable to shake it because they cannot keep up with hygiene, cannot get access to a doctor, etc.

Some commenters, here and elsewhere online, have suggested that this is no more than prisoners deserve. This seems to me both extraordinarily uncompassionate and epidemiologically foolish. In case no one has noticed, prison overcrowding is so serious that many prisoners don't stay in prison for their sentenced time. And when they come out, and come back to their communities, they bring MRSA with them. That's not even to mention the risk to the very large numbers of people who are not themselves incarcerated, but go in and out of jails and prisons every day: correctional officers, cooks, medical staff, and on and on.

All of which makes the news from California on Friday more than usually depressing.

Prison medical care in California has been so bad (see Gov. Arnold Schwarzenegger's 2006 emergency declaration) that it is no longer under control of the state, but rather administered by a court-appointed receiver, who said in 2007:

Across the board we see delays in diagnosis and access to care and needed tests; misfiled, incomplete or illegible medical records; lack of space, sanitation and staffing; botched hand-offs of medical information during inmate transfers; failures by clinicians to recognize and evaluate "red flag" symptoms, follow published guidelines, perform basic physical examinations or respond to patient complaints; abdication of responsibility for patient care and lack of critical thinking or requests for help in difficult cases.

The prevalence of MRSA in California prisons is an important part of that picture : Correctional officers have sued over MRSA they acquired at work. (And yes, you can read all about it in SUPERBUG.)

Now, you may also know that California is in the midst of a gruesome budget crunch — and on Friday, the push for better prison medical care and the deficit in the state budget collided, and the deficit won. According to the Associated Press and the San Francisco Chronicle, the Schwarzenegger administration backed off an agreed-upon plan that would have ended the receivership and returned control of the medical system to the state at a cost of $1.9 billion, one-fourth of what was originally thought to be needed.

Schwarzenegger said in a statement Thursday that California cannot afford the additional cost.
"We cannot agree to spend $2 billion on state-of-the-art medical facilities for prisoners while we are cutting billions of dollars from schools and health care programs for children and seniors," he said.
Schwarzenegger and lawmakers are considering eliminating or significantly reducing education, state parks and core social programs to address the $24.3 billion budget shortfall. (AP, byline Don Thompson)

The Chronicle story makes clear that the prison spending would not have made the deficit any worse, because the money was coming from new bonds, not from the state's general fund. Its online commenters don't seem to have paid attention to that, as they hit the same familiar themes:

• "Why should the public have to babysit them for the medical problems they brought on themselves... Let them rot."
• "In my opinion bad medical services in prison should be only one of the deterrents that keeps one from wanting to go to jail. "
• "Prison should be a place that is so intolerable, that no sane person would ever want to go there."

It's easy to moralize. It's much harder, as we know here, to control the continuing spread of a microbe that has already gotten a solid foothold in the community. California's decision to not improve medical care in its prisons — and therefore not address the threat of MRSA to its prisoners and staff — is practically a guarantee that the state's already substantial community MRSA problem is going to get much worse.

Food and ag policy sites: New in the blogroll

Folks, when I was writing the last post (regarding Scott Weese's blog), I had to stop and look up several sites. In mid-click, I realized how silly that was, because they are sites I visit all the time — and you should too, if you're concerned about the veterinary, zoonotic, agricultural and food-policy issues that we discuss here so frequently.

So I've created a new category in the blogroll to the right, showcasing food and ag-policy sites that I think are worth reading. Among them you'll find:

• Extending the Cure and the Center for a Livable Future
• the excellent group food-policy blog Ethicurean
• Grist magazine's coverage of food policy
• the amusing and cogent Fair Food Fight
• the nonprofit research organizations Trust for America's Health and the Pew Commission on Industrial Farm Animal Production
• the Union of Concerned Scientists, on the case for antibiotic use in animals longer than almost anyone
• and the Soil Association, the British nonprofit who have done the most to bring MRSA in meat to public attention.

If you have other recommendations, please send them!

Restricting antibiotics in animals: Start by restricting access

Constant readers, those of you who follow the pressing issue of MRSA in animals will know the work of J. Scott Weese, DVS, associate professor of pathobiology at the University of Guelph in Ontario and supervising author of many crucial papers on MRSA in food and companion animals, including the first finding of MRSA in pigs and pig farmers in North America.

You may not know that Weese and his postdoc Maureen Anderson publish an excellent blog on veterinary and zoonotic diseases called Worms and Germs (in the blogroll at right). This weekend they have an important post that deserves wider attention: Antibiotics: A Dose of Common Sense. In it, they propose that one way to reduce the overuse of drugs in food animals is to make animal antibiotics prescription-only. It's worth taking the time to read it.

Those of you in the cities may not know this, but out here in the Great Flyover, antibiotics for veterinary use are surprisingly easy to buy (as I discovered when I stumbled into a farm-related store in search of a Carhartt jacket against the Minnesota winter). They're not even over-the-counter — they're on the shelf, or stacked on the floor with the implements and feed, or blended into the feed itself. And as Weese points out in this post, they are also available without prescription over the Internet (as human antibiotics are too).

It's a potentially controversial proposal: I don't think I have any farming readers, but I would imagine their response would start with an objection to the extra cost of hiring a veterinarian to assess whatever situation might require the drugs. And since most farmers (NB: not the overarching ag-biz companies, but the farmers themselves) exist on razor-thin economic margins, they would have a point. But as we know from the excellent work of Extending the Cure and the Center for a Livable Future, unnecessary antibiotic use comes with a cost as well — one that is borne by all of us when antimicrobial resistance prevents antibiotics from working.

200th post! with thanks

Constant readers: Funny how one loses track. According to the dashboard, this is my 200th post at SUPERBUG. I'm thrilled and humbled that we've been able to build this solid community in support of more attention to this very under-appreciated disease. You are the ones that make it happen, and I am very grateful.

MRSA legislation in Congress

Readers, on Monday, Rep. Jackie Speier (D-CA, 12th District) introduced a bill: HR 2937, the MRSA Infection Prevention and Patient Protection Act.

It requires:

• hospitals to screen all patients entering high-risk units for MRSA infection
• adoption of best practices including contact precautions among health care professionals to prevent MRSA’s spread within hospitals.
• patients testing positive for MRSA be informed of the result and given instructions on how to prevent the spread of their infection when discharged.
• hospitals to report the number of cases of hospital-acquired MRSA that occur within their facilities.

In other words, it seeks to enact nationally what advocates such as Jeanine Thomas, Carole Moss, Michael Bennett and others have done in individual states. (Find their organizations in the right-hand column.)

Speier's announcement is here and the text of the bill is here.

MRSA and pets

It's been a while since we've focused on the presence of MRSA strains in pets, and the complications that can cause for the pets' human owners/custodians/companions (or, in the view of my own two cats, abject servants. No, I will not post their pictures. I have some shreds of pride).

The problem with MRSA and pets is not the same as the problem of MRSA ST398 in food animals. Rather, pets tend to carry human strains, passed to them by their owners. The carriage is usually asymptomatic, but not always; there are cases in the medical literature of cats and dogs suffering serious skin and soft-tissue infections from community-strain MRSA, usually USA300. But the emerging consensus seems to be that pets carry the bug transiently — not long, but long enough to reinfect the person who passed the bacterium to the pet in the first place. (This can be, but is not always, the source of recurrent infections in humans: The human takes antibiotics and recovers, but the animal holds onto the bug long enough to pass it back to the now-clear human.)

For anyone who needs to go deeper on this, the current issue of Lancet Infectious Diseases has a good overview of the problem that community MRSA strains pose to pets and their humans. There's a thorough review of the major papers:

• Cefai, 1994: hospital outbreaks traced to two nurses and through them to their dog
• Simoons-Smit, 2000: household epidemic of three humans, one cat, one dog
• Manian, 2003; dog is source for owner's recurrences
• Vitale, 2006: owner is (apparently) source of cat's MRSA.

(This is a good place to say that this entire history, including personal stories of human and animal infection, is covered in a chapter of SUPERBUG. Publication date coming soon!)

The Lancet paper incorporates reminders of some powerful and troubling trends. As with MRSA ST398, one thing can distinguish MRSA that has been in an animal is a resistance pattern that is slightly different from what we expect but that has arisen because the animals receive different drugs. In the case of pigs and ST398, the intriguing marker is tetracycline resistance; humans don't usually get tetracycline for MRSA, but pigs do. In the case of companion animals, it tends to be fluoroquinolone resistance; pets are more likely to get that class of drugs for a skin/soft-tissue infection. But, the authors caution, that may mean that pets serve as a breeding ground for multi-drug resistant MRSA, with their fluoroquinolone treatment adding another resistance factor into the bug's already potent arsenal.

The authors also remind us that MRSA can come from animals much more directly than through silent carriage: that is, in a bite. Both dog and cat bites have been found infected with MRSA, due to bacterial contamination of the wound either from the pet or from colonization on the human's skin.

The cite is: Oehler RL et al. Bite-related and septic syndromes caused by cats and dogs. The Lancet Infectious Diseases, 9(7):439 - 447, July 2009. doi:10.1016/S1473-3099(09)70110-0.

H1N1 and MRSA - first disclosed case

Readers, once again there's a lot of MRSA-related news piling up, and I'll try to roll some of it out over the next few days. But first, today we have to deal with an event that many of us have been anticipating, though not with any pleasure: the first known report of a MRSA death secondary to H1N1 "swine" flu infection.

We've talked about this possibility for weeks, because bacterial pneumonia, especially due to MRSA, is a known and frequently deadly follow-on to flu infection. (Archive of posts here.) With swine flu so common, CDC has said several times that they have been looking for post-flu bacterial pneumonia, but had not seen it. And commenters to this blog have relayed rumors — or, to be more precise, stories with no names attached — of flu patients so ill with MRSA that they have to be put on an ECMO, what we used to call a "heart-lung machine," and sometimes do not come off.

Today, however, the Buffalo News carries the story of a New York State teen's death from MRSA pneumonia as a sequela of flu:

Matthew Davis was a healthy Buffalo teenager who participated in sports before complaining of headaches June 13.
Within a few days, the 15-year-old student at Harvey Austin School 97 on Sycamore Street arrived seriously ill at Women & Children’s Hospital and then died Saturday, making him the first known fatality in Erie County caused by swine flu, officially known as novel H1N1 influenza.
... By the time Matthew entered the hospital, he was seriously ill with the flu, as well as co-infected with a type of bacteria known as methicillin-resistant staphylococcus aureus, or MRSA, according to health officials. (Byline Henry L. Davis)

Under normal circumstances — as in, during the past flu season — the public health advice has been to protect against MRSA pneumonia by getting a flu shot, which by preventing flu prevents the microtrauma to the lungs that allows MRSA and other bacteria to gain a foothold. In this case, though, with no H1N1 vaccine available, ir's not clear what protective actions could have been taken.

Still, it's terribly sad.

Antibiotics in water supplies

Via the journal Environmental Health Perspectives comes an important, comprehensive review article by scientists from Environment Canada and the Universite de Montreal on the presence of antibiotics in water supplies and waste water.

The news is not good. If you are concerned about the possibility that antibiotic residues in the environment create another setting in which resistance can develop, it is worth reading. It is long (10 pages in pdf) but has a comprehensive bibliography. Also, it's open-access.

Where do these antibiotic residues come from? From us, in some cases: We urinate out up to 90% of some drugs, wash off topical formulations, flush old prescriptions down the toilet. Sometimes from industrial residues, or from leaky hospital sewage, or from sewage treatment plants, or — of course — from industrial-scale agriculture administration and run-off.

And where do they go? According to the paper, over more than 20 years of research, 126 different antibiotics and anti-infectives have been identified in processed waste water, natural surface water and groundwater, and drinking water supplies. Among them are all the antibiotics that we are concerned about here: the drugs that MRSA is already resistant to (beta-lactams, lincosamides, macrolides) and the drugs that still work, for community MRSA at least (sulfonamides, trimethoprim, tetracycline).

Moreover, the trend is expected to get worse, the authors warn: because of increased urbanization; because many urban areas are consciously setting water-saving policies, reducing the volume of wastewater and therefore increasing the concentration of drugs in the water that remains; and because, well, CAFOs aren't exactly going away right now, are they? As they say:

...even if our results show that high concentrations ... of anti-infectives in these waters are more the exception than the rule, the existence of a few locations where these concentrations can be reached are enough to contribute to the global spreading of anti-infective resistance. Given that large populations of bacteria are being exposed to a selective pressure, environmental waters and especially wastewaters become ideal settings for the assembly and exchange of mobile genetic agents encoding for resistance in bacteria. ... Anti-infectives, the miracle drugs of the 20th century, have become environmental contaminants of emerging concern in the 21st.

The cite is: Segura PA et al. Review of the Occurrence of Anti-infectives in Contaminated Wastewaters and Natural and Drinking Waters. Environmental Health Perspectives, 117 (5) May 2009.

H1N1 flu and swine surveillance - more relevance for MRSA

Constant readers, you probably know that yesterday the World Health Organization declared the first flu pandemic in 41 years. I want to point out for you a side issue in the H1N1 story that has great relevance for MRSA, especially ST398.

As described in this article I wrote last night for CIDRAP, three medical journal articles have now pointed out that the virus, or its major components, could have been recognized in swine months to years ago. We missed it, though, because there is so little regular surveillance in pigs for diseases of potential importance to humans. As the authors of the most recent article, in Nature, said yesterday: "Despite widespread influenza surveillance in humans, the lack of systematic swine surveillance allowed for the undetected persistence and evolution of this potentially pandemic strain for many years."

This is important for our purposes because we know that we are in the same situation with MRSA ST398: The strain was first spotted in France, and has been a particular research project in the Netherlands, but has been found pretty much wherever researchers have looked for it, throughout the European Union, in Canada, and most recently in the United States. All told, though, the scientists concerned with it are still a small community; there is no broad surveillance looking for this bug.

And that's a problem, for MRSA, for influenza, and for any number of other potentially zonotic diseases: We cannot anticipate the movement of pathogens from animals to humans if we don't know what's in the animals to start with. That's the argument behind the "One Health" movement, which has been arguing for several years now for including veterinary concerns in human health planning. (The human health side would probably say that the animal health side just wants more money. This is also true, which does not make it unimportant.)

To understand the need to look at animal health in order to forecast threats to human health, you can't do better than the map I've inserted above (because Blogger, annoyingly, won't let me put it below). It has appeared in various forms in various publications for about 10 years but originates I think from the IOM's Emerging and Reemerging Diseases report in the early 90s. (This iteration comes from the One Health Initiative website.) It depicts the movement of new diseases from animals to humans over about 30 years. It's up-to-date through SARS and through the 2003-05 movement of H5N1 avian flu around the world. I'm sure H1N1 will be added soon. How many of those outbreaks could we have shortcircuited if we had been warned of their threat in good time?

Farm animals and antibiotics - a new campaign

I was gobsmacked to discover today, a few days late, that the Pew Campaign on Human Health and Industrial Farming (authors of the report discussed here) have launched a marvelously in-your-face series of ads in Washington DC, aimed at bringing the issue of antibiotic use in farm animals to people who might not think about it.

The ads have been placed in the Capitol South and Union Station Metro stops, which are the stops that bracket Capitol Hill, and in Metro cars on the red and blue/orange line trains, which are the main commuter trains down to the Hill. In other words, they've been made to be the morning reading of the people most engaged in the health reform debate right now — and if you think those folks are not thinking about healthcare spending and the growth of antibiotic resistance, well, umm, oh never mind.

The campaign says:

The American Medical Association, the American Academy of Pediatrics and other leading medical groups agree that the growth of bacterial infections resistant to antibiotic treatment is a looming public health challenge. The groups also agree the misuse of antibiotics on industrial animal farms plays a significant role in this crisis. While antibiotics are prescribed to people for short-term disease treatment, these same critically important drugs—like tetracycline, erythromycin and ciproflaxin—are fed in low doses to large herds or flocks daily, often for the lifespan of the animal. This creates ideal conditions for the breeding of new and dangerous antibiotic-resistant bacteria.

For statistics and arguments, along with more images — cows! chickens! pills! — go to the site of the commission's campaign, Save Antibiotics.

MRSA in pig-farm workers - very high rates

Let's go back for a moment to what I think of as the "third epidemic" of MRSA: ST398 and the other strains that reside in animals and cross to humans. (In my personal taxonomy, the first and second epidemics are hospital-acquired and community-associated.)

Via Emerging Infectious Diseases, the open-access journal published by the CDC (Do I have to keep telling you to read it? It's free. It's good. Your tax dollars pay for it.), comes a report of surveillance for MRSA colonization of pig-farm workers, conducted in Belgium by researchers from Erasmus Hospital of the Free University of Brussels, and the Veterinary and Agrochemical Research Centre of Brussels. The group persuaded 127 farm workers on 49 farms to be tested for colonization, or asymptomatic carriage, of MRSA; at the same time, they tested 30 randomly selected pigs on each farm.

They found very high rates of colonization, higher than have been found in patients in hospitals or residents of nursing homes: 38% of the farm workers carried MRSA ST398, the pig strain (plus, an additional 17% carried various strains of MSSA, drug-susceptible staph). There was a clear association between colonized farmers and colonized pigs: Out of 1500 pigs sampled, 44% carried ST398 — and half of the workers on farms with colonized pigs were colonized also, compared to only 3% of workers on farms where pigs did not carry the bug.

In a bit of good news, the researchers found only one farm worker who had suffered any MRSA disease from ST398, a man with a lesion on his hand. There was no invasive disease, though ST398 has been associated in the past with pneumonia and endocarditis.

Workers were more likely to acquire the bug if they had regular contact with pigs, dogs or horses, which makes intuitive sense. But in an odd finding, their odds of acquiring ST398 did not go down if they wore protective clothing — which is to say, aprons, gloves and masks did not protect them from picking up the bug, leading the researchers to wonder whether airborne spread or contaminated surfaces are playing a role in transmission.

So what does this mean? The lack of invasive disease in this population must be good news; and it's consistent with a number of papers that have reported low rates of disease from ST398 even when colonization is present. But to me, the high rate of colonization must be bad news. The more of this bug there is (and every researcher who looks for it seems to find it), the more chance there is of the bug adapting in an unpredictable — potentialy more resistant, potentially more virulent — way. If that did happen, it could well go undetected for a while — because as swine flu has been teaching us, disease surveillance in animals is patchy at best, and new pathogens can and do arise and ciruclate for years before being detected.

For more on the paucity of surveillance in animals, see my CIDRAP colleague Lisa Schnirring's story here. For a complete archive of posts on "pig MRSA" ST398, go here.

The cite is: Denis O, Suetens C, Hallin M, Catry B, Ramboer I, Dispas M, et al. Methicillin-resistant Staphylococcus aureus ST398 in swine farm personnel, Belgium. Emerg Infect Dis. 2009 Jul; [Epub ahead of print] DOI: 10.3201/eid1507.080652.

Infections rise, but hospital budgets - and infection control - shrink

Bad news from the Association of Professionals in Infection Control and Epidemiology (APIC): In a survey of almost 2,000 of their 12,000 members, 41% say that their hospitals' infection-prevention budgets have been cut due to the down economy.

According to the survey, conducted March 2009 and released Tuesday morning:

Three-quarters of those whose budgets were cut experienced decreases for the necessary education that trains healthcare personnel in preventing the transmission of healthcare-associated infections (HAIs) such as MRSA and C. difficile.
Half saw reductions in overall budgets for infection prevention, including money for technology, staff, education, products, equipment and updated resources.
Nearly 40 percent had layoffs or reduced hours, and a third experienced hiring freezes.

As we know here, there are (by CDC estimate) 1.7 million hospital-acquired infections and 99,000 deaths as a result of them, each year. These are numbers we are supposed to be trying to reduce. That is going to be less likely if less money flows toward what may already be an underfunded goal:

A third of survey respondents say that cuts in staffing and resources have reduced their capacity to focus on infection prevention activities.
A quarter of respondents have had to reduce surveillance activities to detect, track and monitor HAIs.

Disturbingly, at a time when electronic health records are such an important part of the health-reform debate, "Only one in five respondents have data-mining programs – electronic surveillance systems that allow infection preventionists to identify and investigate potential infections in real time." (APIC press release)

The full report is here.

10 years but little progress on patient safety

Constant readers, I've been away for a week — trying to get my breath back now that the chaos of the novel H1N1/swine flu is diminishing — and so I've missed a lot of news. Over this week, I'll try to catch you up on it.

First up: Some of you know that, 10 years ago, the nonpartisan, Congressionally-chartered Institute of Medicine (IOM) published a groundbreaking report called To Err is Human (html here, pdf here) that jump-started examination of medical quality in the United States. That report said:

Health care in the United States is not as safe as it should be--and can be. At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented...
Preventable medical errors in hospitals exceed attributable deaths to such feared threats as motor-vehicle wrecks, breast cancer, and AIDS. ...
Beyond their cost in human lives, preventable medical errors exact other significant tolls. They have been estimated to result in total costs (including the expense of additional care necessitated by the errors, lost income and household productivity, and disability) of between $17 billion and $29 billion per year in hospitals nationwide. (To Err is Human, executive summary)

The report prompted a huge groundswell of legislative interest and patient advocacy that led, years later, to the successful passage of state laws insisting on public reporting of hospital infections and more recently on disclosure of hospital-acquired MRSA.

And yet: Despite all that scrutiny and activism, we are nowhere near as far as we should be in reducing medical errors. Just in the area of hospital infections, which is our greatest interest here, there is not mandatory reporting in all states, and there is no nationwide reporting.

So says the Safe Patient Project of Consumers Union, which has produced an update to the IOM report called To Err is Human — To Delay is Deadly. They conclude:

Ten years later, we don’t know if we’ve made any real progress, and efforts to reduce the harm caused by our medical care system are few and fragmented. With little transparency and no public reporting (except where hard fought state laws now require public reporting of hospital infections), scarce data does not paint a picture of real progress.
Based on our review of the scant evidence, we believe that preventable medical harm still accounts for more than 100,000 deaths each year — a million lives over the past decade. This statistic by all logic is conservative. For example, the Centers for Disease Control and Prevention (CDC) estimates that hospital-acquired infections alone kill 99,000 people each year.

The project finds that many of the reforms recommended by the IOM in 1999 have not been created:

• Few hospitals have adopted well-known systems to prevent medication errors and the FDA rarely intervenes.While the FDA reviews new drug names for potential confusion, it rarely requires name changes of existing drugs despite high levels of documented confusion among drugs, which can result in dangerous medication errors. Computerized prescribing and dispensing systems have not been widely adopted by hospitals or doctors, despite evidence that they make patients safer.
• A national system of accountability through transparency as recommended by the IOM has not been created. While 26 states now require public reporting of some hospital-acquired infections, the medical error reporting currently in place fails to create external pressure for change. In most cases hospital-specific information is confidential and under-reporting of errors is not curbed by systematic validation of the reported data.
• No national entity has been empowered to coordinate and track patient safety improvements.Ten years after To Err is Human, we have no national entity comprehensively tracking patient safety events or progress in reducing medical harm and we are unable to tell if we are any better off than we were a decade ago. While the federal Agency for Healthcare Research and Quality attempts to monitor progress on patient safety, its efforts fall short of what is needed.
• Doctors and other health professionals are not expected to demonstrate competency.There has been some piecemeal action on patient safety by peers and purchasers, but there is no evidence that physicians, nurses, and other health care providers are any more competent in patient safety practices than they were ten years ago.

The entire report is well worth reading. Its lamentable but well-supported conclusion:

We give the country a failing grade on progress on select recommendations we believe necessary to create a health-care system free of preventable medical harm.