By MITCHELL J. SCHWABER AND YEHUDA CARMELI
In March of this year an epidemic of H1N1 influenza virus, otherwise known as swine flu, began in Mexico. It spread to the United States within weeks and has since affected over 100 countries. Between the start of the outbreak and the end of July, a total of 1,154 people worldwide had died of the virus, about one-third of them in the U.S.
The World Health Organization and other public-health agencies have responded to the epidemic with appropriate urgency. International organizations have disseminated information and guidelines and coordinated with public authorities across the globe to ensure an effective response. The pharmaceutical industry is developing antiviral agents and vaccines and producing them on a mass scale.
The U.S. also has responded rapidly and forcefully. Just two weeks after the report of the first case on American soil, President Barack Obama asked Congress to allocate $1.5 billion to fight the virus.
Compare this response to the scant media and political attention that have been given to several silent but no less deadly outbreaks of disease in recent years caused by antibiotic-resistant bacteria. Most such outbreaks are treated as the poor stepsisters of pandemic influenza, even while they have killed far more people than swine flu over the same period.
Bacterial infections were once big killers. Before the advent of the antibiotic era some 70 years ago, pneumonia, meningitis, gangrene and bloodstream infection were almost uniformly fatal. But with antibiotics, they suddenly became treatable.
Unfortunately, the era of easily treated infections is proving to be short-lived, as bacteria develop increasingly sophisticated mechanisms of resistance to antibiotics.
Antibiotic-resistant bacteria typically do not threaten healthy people at first. Rather, they generally appear initially among hospitalized patients and only later spread to the community at large. But they are deadly. In the same period as the swine flu outbreak, antibiotic-resistant bacterial infections have killed thousands of people in the U.S.
In contrast to the flu, most of these infections receive little or no public attention. The only exception has been methicillin-resistant Staphylococcus aureus (MRSA). This microbe is now receiving significant public attention—but this attention has come some three decades after its spread in the U.S. first began. That delay allowed MRSA to spread uncontrollably, and more than 18,000 people are now estimated to die each year in the U.S. from this bug, according to the Journal of the American Medical Association.
Initially, MRSA was confined to hospital wards and affected primarily the elderly and chronically ill. It therefore remained outside of the headlines and off political agendas. MRSA entered the spotlight only after it began to affect healthy people living outside of hospitals.
Have we learned our lesson? A more recent outbreak of resistant bacteria, widespread in New York City since the beginning of the decade, has now spread to areas outside of New York and even outside of the U.S. The bacteria involved are from the family of microbes that live in the human gut, called Enterobacteriaceae. They are the most frequently identified bacteria in human disease and are resistant to the carbapenem group of antibiotics, the drugs of last resort in combating resistant bacteria of this type.
In the four-month period since it entered the U.S., swine flu has killed 436 people in this country. During this same period, more than 100 people are estimated to have succumbed to carbapenem-resistant Enterobacteriaceae in the New York City area alone, and more have undoubtedly died outside of New York.
Yet the spread of these and other resistant bacteria has met with almost no coordinated effort to fight them in the U.S. Very few resources have been allocated to combat antimicrobial resistance. Last fiscal year, for example, the U.S. government budgeted just $16.9 million for the Centers for Disease Control and Prevention to spend fighting antibiotic resistance, about 1% of the total funding requested for swine flu.
Can a campaign be effective in containing the spread of resistant bacteria? Yes. In England, national intervention has led to a greater than 50% decrease in MRSA bloodstream infections since 2004. Similarly, in Israel, where there has been a nationwide outbreak of a strain of carbapenem-resistant Enterobacteriaceae since 2006, a coordinated effort at every level of public health has succeeded in containing the spread of the bacteria.
In both England and Israel, extensive media exposure led to widespread public awareness of the problem. That led the national government in both countries to make outbreak containment a top priority. England and Israel executed centralized, professionally-directed public health interventions that included setting targets, implementing new regulations, measuring outcomes, and accountability. These efforts successfully curtailed the outbreaks and demonstrate that the battle against infections with antibiotic-resistant bacteria can and should be waged.
The ongoing spread of resistant bacteria must not be viewed as inevitable. The existence, extent and severity of the epidemic of antibiotic resistant bugs need to be immediately recognized by the government, the media and the public at large. The pharmaceutical industry should also be encouraged to develop new antibiotics to fight resistant bacteria.
The response to the swine flu outbreak has been impressive. This response should be seen as a blueprint for how we fight other deadly outbreaks.
Dr. Schwaber is director of the National Center for Infection Control of the Israel Ministry of Health. Dr. Carmeli is director of the Division of Epidemiology and Preventive Medicine at Tel Aviv Medical Center and is affiliated with the Division of Infectious Diseases at Beth Israel Deaconess Medical Center in Boston.
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