DDP Newsletter July 2018 Vol. XXXIV, No. 4

According to the Centers for Disease Control and Prevention (CDC), infections caused by microbes resistant to antibiotics are increasingly prevalent and can spread like wildfire. Many of these are bred in hospitals, which give bacteria selected by heavy use of antibiotics the opportunity to share genes conferring resistance.

“Nightmare bacteria” (carbapenem-resistant Enterobacteriaceae, or CRE) were isolated more than 200 times in 2017 (https://tinyurl.com/yb2n9qzq). Half the patients infected with this organism die. It is resistant to all antibiotics available in the U.S. The most common medical care-associated  infection is probably  Clostridium difficile (“C diff”), which affects about 500,000 patients each year and is the direct cause of about 15,000 deaths (https://tinyurl.com/ycfbrcpd).  Other threats include resistant Staphylococcus aureus, streptococci, and Pseudomonas. Now a hypervirulent form of Klebsiella pneumoniae (“Klebsi”), widespread in Chinese hospitals, has apparently combined with CRE. Highly contagious, it can kill healthy young adults. NPR calls it the triple threat new pneumonia (https://tinyurl.com/y8nh72us).

These germs may lurk in the hospital bed itself. A study of all identified cases of nosocomial (hospital-acquired) infections in four New York hospitals from 2006-2012 found that the odds of cases having been exposed to a prior bed occupant with the same organism were 5.83 times that of controls (95% confidence interval [CI], 3.62–9.39), and the odds of cases having been exposed to a roommate with the same organism were 4.82 times that of controls (95% CI, 3.67–6.34) (Infect Control Hosp Epidemiol, May 2018, https://tinyurl.com/y7aa4utp). Patients can acquire C diff from the mattress even if the previous patient had been asymptomatic, despite standard “terminal cleaning” methods in use by hospitals. Use of a launderable mattress barrier cover can reduce the C diff infection rate by 50% (https://tinyurl.com/y7bo9ge2).

Hospitals ignore the risk because they’re rushed to turn over rooms, writes Betsy McCaughey. They need to adopt high-tech cleaning methods to rapidly disinfect the whole room, including mattresses (IBD 4/11/18, https://tinyurl.com/ycbrpyhm).

The advent of antibiotics in the 1930s stopped research on other antimicrobial methods; with the emergence of resistance, interest is reviving. Copper was recognized as the first metallic antimicrobial in 2008 by the Environmental Protection Agency (EPA). But it has been used since ancient times. Egyptian and Babylonian soldiers would sharpen their bronze swords (bronze is an alloy of copper and tin) after a battle, and place the filings in their wounds to reduce infection and speed healing.

Copper alloys kill microbes on contact: bacteria, viruses, and fungi are all affected. With routine cleaning, when copper alloy is used on regularly touched surfaces in busy wards and intensive care units, there is up to a 90% reduction in the numbers of live bacteria on their surfaces. This includes bed rails, chair arms, call buttons, over-bed tables, IV poles, and door handles. Studies in three hospital intensive care units in the U.S. also showed a remarkable 58% reduction in infection rates. Copper alloy touch surfaces are now being deployed worldwide in airports, trains, train stations, busses, restaurant kitchens, and gyms. The payback time for installing copper fittings in hospitals is estimated to be only 2 months. Copper is no more expensive than stainless steel. The latter may look shiny and clean, but it has no antimicrobial properties and has tiny crevices where microbes can escape cleaning (https://tinyurl.com/y8lnwblv).

Copper can also be used in particle form, or as nanoparticles. For example, no infectious viral particles were recovered from copper oxide-impregnated face masks after 30 min, unlike with control masks. Bacteria have some survival mechanisms, but no complete resistance to prolonged exposure to copper has been found.

Copper has great public health potential, as against rapidly mutating influenza virus, or against norovirus, which is not killed by hand sanitizers.

Doctors frequently name silver as a metal with antimicrobial properties, but it does not work as a protective surface coating when dry (https://tinyurl.com/yalp98dt).

A MEASURE OF DESPERATION?

Having exhausted new, toxic, expensive antibiotics that have been approved after extensive randomized, double-blind controlled trials, might doctors try an old, nontoxic, cheap, but unapproved remedy, possibly risking medical staff privileges or their license? Vitamin C has been discussed here (July 2003, November 2005). After Dr. Paul Marik reported a case series of sepsis patients treated with a cocktail of intravenous vitamin C, hydrocortisone, and thiamine, more than 50 medical centers are said to be using his protocol. While some experts may call vitamin C “as effective as healing incantations,” nurses treating the patients do not share this  skepticism. Of the more than 150 patients he has treated with his cocktail, only one has died of sepsis. Previously, 19 of 47 sepsis patients had died. More than 1 million of Americans fall ill with sepsis each year, and between 28% and 50% die (Smithsonian.com 6/27/17, https://tinyurl.com/y9rgqdrt).

Cures of a wide variety of human conditions by high-dose vitamin C have been reported (Thomas Levy, Curing the Incurable: Vitamin C, Infectious Diseases, and Toxins). Harri Hemilä of the Department of Public Health, University of Helsinki, has reviewed human studies and 148 animal studies of vitamin C in diverse infections (Nutrients 2017 9:339, https://tinyurl.com/yct5swx9). Infectious agents included tuberculosis, other bacteria, viruses, Candida albicans, and protozoa. Vitamin C was also protective against tetanus toxin, diphtheria toxin, and endotoxin.

In children aged 1 to 12 years with tetanus in Bangladesh, there were no deaths in the group receiving 1 g/day of intravenous vitamin C, whereas there were 23 deaths in the control group (p = 10^-9). Five controlled trials showed significant benefit in pneumonia.

There is a paucity of data, but no large-scale controlled trials have shown  ineffectiveness. Hemilä attributes loss of interest and the low level of  acceptance in the medical community to the success of antibiotics and to misconceptions and prejudice. Vitamin C has been placed in the category of “alternative medicine” by the National Institutes of Health and the Cochrane collaboration. Goodwin and Goodwin described the “tomato effect” (JAMA 5/11/1984): “If the treatment bypasses the medical establishment and is sold directly to the public…the temptation in the medical community is to accept uncritically the first bad news that comes along.”

With antibiotic-resistant superbugs, why should an “alternative” treatment without known serious adverse effects be a last resort, instead of the first thing tried, along with meticulous isolation and control measures?

DDP Newsletter May 2018 Vol. XXXIV, No. 3

Deadly diseases once thought to be controlled are re-emerging globally, invading or re-invading new territory. The number of infectious disease outbreaks worldwide and in the U.S. has steadily increased, from fewer than 1,000 in a 5-year period 1980-1984 to more than 3,000 in 2005-2009. Human-specific diseases, zoonoses such as Salmonella, vector-borne and non-vector-borne infections have all increased.

Rapid urbanization, travel, mass migration, failures in sanitation, poor building design, and a surge in vector populations contribute to turning the nation into a “crowded, germ-trading global market” (Scientific American, May 2018).

A number of cities, including Detroit and San Diego, have experienced severe epidemics of hepatitis A. Rates of hepatitis C have nearly tripled over the past 5 years.

About 19–21 million Americans are sickened with waterborne infections each year, estimates Kelly Reynolds of the University of Arizona School of Public Health, from taps, swimming pools, hot tubs, and showers. Many drinking-water distribution pipes are old; up to 20 percent of the water from the utility leaks out, and “where water leaks out, contaminants can leak in.” Energy-conservation measures that decrease water flow allow microbial biofilms to build up on pipe surfaces.

In Baltimore, some 65% of rats are infected with leptospirosis, which people and pets can catch from rat urine. Few cases are diagnosed because doctors don’t test for it.

“Neglected tropical diseases” are probably far more widespread than recognized in the U.S. The Centers for Disease Control and Prevention (CDC) estimates 300,000 cases of Chagas disease, with up to 45,000 cases resulting in heart failure each year, and 1,000 hospitalizations annually with neurocysticercosis, a brain tapeworm.

More than 300 people in a huge Hong Kong apartment complex came down with severe acute respiratory distress syndrome (SARS) after an infected visitor had diarrhea and flushed a toilet, because of the plumbing and ventilation arrangements. This accounted for 20% of cases in the 2002-2003 outbreak. If rooms are poorly ventilated, microbes in exhaled air or the stool droplets that permeate the air during a toilet flush become more concentrated over time. In 2016, University of Hong Kong researchers studying the dynamics of an influenza outbreak concluded that ventilation rate had a strong influence on the outbreak dynamics. “Opening a window, they noted, can reduce infection rate as much as getting vaccinated” (ibid.).

In 153 blocks of downtown San Francisco, including popular tourist spots, schools, and major hotels, the NBC Bay Area Investigative Unit found 41 blocks dotted with needles and 96 blocks sullied with piles of feces. The contamination is worse than in communities in Brazil, Kenya, or India, stated Dr. Lee Riley, an infectious disease expert at the University of California, Berkeley. He noted that feces becomes airborne when dry, and spreads infection (https://tinyurl.com/y7x77rgn).

Disease cases spread by insect vectors have tripled over the past 13 years in the U.S., with more than 640,000 cases reported between 2004 and 2016. These diseases include West Nile, dengue, chikungunya, Zika, and malaria (mosquito-borne); Lyme, ehrlichosis, babesiosis, and Rocky Mountain spotted fever (tick-borne); and bubonic plague (flea-borne), according to CDC (https://tinyurl.com/y8rrz2mr).

Malaria remains one of the world’s top killers. According to CDC, there were an estimated 216 million cases worldwide in 2016 and 445,000 deaths, mostly African children. About 1,700 cases of malaria are diagnosed in the U.S. each year.

While some expressed hope of a malaria-free southern Africa by 2018, cases tripled in 2017 (https://tinyurl.com/ya8jg6rt).

Climate change is accelerating the spread of vectors, according to Scientific American. A consortium of medical organizations, among other advocacy groups, claims that failure to limit CO₂ emissions will “reverse 50 years of public health gains” (https://tinyurl.com/ycz7exq6, Climate Change IQ Question 10).

While speculative reports note the coincidence of increased disease incidence with warmer temperatures in recent decades, “climate has not consistently changed in the right way, at the right time, and in the right places to account for the recorded epidemiology of VBPs [vector-borne pathogens].” Trade, travel, land-use changes, poverty, and conflict are driving factors, while “climate change has played and will play a minor part (Lancet 12/1/12, https://tinyurl.com/yce2szho). A study of mosquito populations over the past century in North America showed almost no correlation with temperature. An up- to-tenfold increase in mosquito populations is correlated with increasing urbanization and with decreasing environmental concentrations of DDT. In NY, it took nearly 40 years for mosquito populations to reach pre-DDT levels (Nature Communications 2/16/16, tinyurl.com/y942jp3l).

Just after malaria deaths in Africa reached an all-time high in 1999, the campaign for an international ban on the world’s best anti-malaria tool, still being used with dramatic success in some areas (see tinyurl.com/ydyoh4z6), was joined by 260 environmental groups, including Physicians for Social Responsibility. For the amount of DDT once used on a cotton field, all the high-risk residents of a small country can be protected from malaria by indoor residual spraying (BMJ 12/2/2000, https://tinyurl.com/yd9nzl8n).

The main substitute for DDT, pyethroids (which are twice as expensive), in use since 1977, may be failing because of mosquito resistance. DDT and pyrethroids work by similar mechanisms, so mosquitoes may be resistant to both. Resistance to the immediate killing effects may not render DDT ineffective, as mosquitoes may still be repelled from entering houses. And their lifespan may be shortened, so malaria parasites may not have the needed 14 days to mature. Judicious use of pesticides—as by rotating the use of different chemical classes—is key. But political resistance to use of the least toxic pesticide—turning the Precautionary Principle upside down—has killed millions.

PLANETARY HEALTH

The “sustainable” Agenda 2020 touted by Politico misrepresents its own sources in blaming the spread of insect vectors on warming temperatures (tinyurl.com/yacxp45r). It calls for massive increases in “social spending,” comprehensive central planning, and a “post-carbon economy” (tinyurl.com/y9nb7mpz): things like “green, efficient buildings” (translated as “stack and pack” and cram into public transportation). Is “homelessness” the root cause of the hepatitis epidemic, because people can’t afford housing (NEJM 1/18/18)? How about social policy such as rent control that creates shortages, or expensive mandates such as California’s solar panel mandate, expected to add $8,000 to the cost of a new home? Where is the evidence measuring the outcome of human well-being?