Superbugs; Germs as an expression of political ideology

MRSA – methicillin resistant staphylococcus aureus

VRE – Vancomycin Resistant entercooccus

The previous blog spoke to the huge initial Canadian success, followed by a near complete collapse of the efforts to contain antimicrobial resistant organisms (AROs). One remnant of the antimicrobial resistance (AMR) surveillance system in Canada that remains is the Canadian Nosocomial Infection Surveillance  Program -  or at least their reports.   MRSA in Canada 2007 , VRE in Canada 2006 .  An effort of multiple hospitals that report identification of certain microbial agents in Canada.  A second effort that focuses on antimicrobial resistant organisms is Safer Healthcare Now – Safer Healthcare Now    A great initiative, albeit focused only on institutional efforts at reducing negative patient outcomes in hospital – not about improving health.   Finally there is a collaborative known as the Canadian Antimicrobial Resistance Alliance (CARA) that was lunched in 2007 and hidden in that site are some data that are not readily recoverable. CAR-A home.  Not surprisingly, the stated audience has a huge emphasis on institutional based services. 

Perhaps you see a trend? the superb efforts focused broadly during the 1996-2006 time period have faded and been replaced by focused hospital based efforts.   Who says politics doesn’t impact health? I’m sure it was merely coincidental that the Conservative government was first elected in 2006, around the time the community based infrastructure began crumbling.  

The last public reports on admission rates for MRSA were from 2003, and rates have gone upwards since with BC reporting that almost 25% of patients admitted to a hospital show evidence of MRSA before requiring hospitalization. The bigger question is why now is it so difficult to find these rates in the public domain? Hospital based (nosocomial) infections are a failure of infection control practices to adequately protect persons needing hospital care from becoming more ill during their hospital stay.  The risk in 2007 for MRSA was just under 1% of persons admitted to hospital, and 0.1% for VRE - and the trends for both were headed upwards. Some provincial data is available, and I would welcome links to others

The only relatively current data that seems locatable at as provincial level is in BC from 2010 BC AMR 2010 report. This appears to be an excellent report and certainly needs replication nationally and within each of the provinces.   (Please send links to other recent data so that it can be shared).

Superbugs – Canadian superheroes, then a national shame

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There are three good reasons why public health will be an enduring vocation;  Humans continue to innovate and create new technologies which have potential harmful effects; Humans are capable of choosing, and sometimes do not make the healthiest choices; and germs that can make humans sick evolve very quickly.

Things that we can’t see, hear, touch, smell or taste, and have the potential to make us very sick are very capable of instilling disabling fear.   Relatively normal people become walking phobias.  You may have had a sense of the fear during pandemic influenza fears, SARS, or some new emerging organism that you don’t know enough.   Topping the list of dreaded bugs are the aptly names superbugs. 

The job of a microorganism, just as all species,  is to survive and multiple.  The strength of their success is in shear numbers.   Their key to survival are creative ways of adapting to their environment.  When you take an antibiotic for some infection, the drugs often effectively kill off most of the invading bacteria and allow your body the chance to finish off the job.   In its efforts to survive, bacteria and viruses can adapt to the changed environment – one now designed to kill it – by some simple tricks for survival.  First is that while the process of multiplying through cell division is superb – it is not perfect.  Small errors in replication called mutations, can provide a daughter cell with differing characteristics.  Mutated cells that survive better in a hostile environment, can carry this mutation into their daughters as well – merely survival of the fittest. 

In a second common method for developing protection, bacteria that are already able to survive because of existing protection, may merge some of their protection with different bacterial species endowing them with already effective protective mechanisms. 

As such, some bacteria have developed a series of mutations or shared solutions that lead to resistance to some antibiotics – those that have adapted to almost all the weapons in the human arsenal have become dubbed “superbugs”.

While man has been creative in developing new antibiotics, the germs seem to have responded in an even faster fashion.

Canada and most countries have developed national responses to antimicrobial resistance.  Canadian integrated program for antimicrobial resistance surveillance.  One can glance through annual reports and quickly note that the focus is on the agri-food sector specifically.   The Canadian Committee on Antimicrobial Resistance which led the Canadian charge for the late 90’s and early 2000’s, was disbanded in 2009 through a lack of funding.   CCAR obituary  The Canadian Bacterial Surveillance Network is still active but seems to have  fallen off in activity CSBN however does provide antimicrobial resistance patterns through 2009.  Likewise the industry finance National Information Program on Antibiotics fell to the side in about 2004 though the website remains alive NIPA .   Just try to find recent data on antimicrobial use in Canada - please post the link if you do.  The data are owned by a private consortium and the inaccessability of drug use data at a national level is another national shame. 

In 1996, the visionary leadership of Dr. John Conly led Canada on a great success story that has gone untold.  For about 10 years, Canada successfully resisted antimicrobial resistance.  Inappropriate prescribing practices were reduced and antimicrobial stewardship became a professional standard.   Most importantly, the rates of superbug infections in Canada stayed much lower than our neighbours to the south.  While not formally analyzed, the costs savings to the Canadian health care system would be in the hundred’s of millions of dollars.  

But, as is typical in Canada, money saved through public health efforts is not counted as a success. The collective efforts of the organizations have fallen out into the shadows.  Despite assurances from the Public Health Agency of Canada that antimicrobial resistance “coordination at the federal level would be better suited to move this complex issue forward”, the issue remains without a home and without a plan.   Not surprisingly, the superbugs are marching forward relentlessly and Canadian rates have been climbing. 

And who says bugs aren’t smart?  Though perhaps it doesn’t take much brains to outsmart some governments.

Organic foods - Consumer choice and caveat emptor.

The latest and greatest food fad is organic production.   I call it a fad only in that it has its great proponents and zealous followers.  Organicity has certain value in attempting to reduce chemical use  - which should be a good thing.  It is a movement that has agriculturists rethinking some long standing less than sustainable practices - which is a great thing.  

It is not a practice without some risks or costs.   The E. Coli outbreak in Germany that killed at least 44 and caused illness in nearly 4000 was associated with organic farming. Not that most organic farming is associated with such terrible outcomes.   While costs for pesticides and antibiotics may be reduced, there may be a higher cost for labour,  and more animal losses during production, all of which lead to increases in per unit production costs.  The cost to the consumer is increased, sometimes partially attributed to reduced costs through subsidization of regular food production. 

There is little evidence either way whether the quality, taste or nutrient value of organic foods is superior or not to non-organically produced foods.  Nor is there definitive evidence that organic foods reduce other health related risks. I am sure that stating the facts may disappoint some people.  I’m also sure there are many in the industry that would like to tout such claims.  

So,  we have less than definitive evidence that either organic or non-organic is safer, healthier, tastier or more nutritious.  We do know they cost more, and the environmental footprint required to produce equivalent amounts of food is more. Seems the consumer is left to make the choice, and the public health role is to ensure that they can make an informed choice. 

Organic food practices are overseen in Canada by the Canadian Food Inspection Agency (CFIA) and through national regulations CFIA Organic Products information .  The value in this is knowing that false claims cannot be made -  something claiming to organic needs to be able to demonstrate that it is organic (there are further graduations of “organicity” that are not enshrined in regulation and are voluntary in nature so claims can be stretched).

On this issue, it is the buyer’s call.  Decisions may be based on values other than health and safety.  Just be an informed consumer as the added cost will come from your wallet.

Food irradiation - is it a nuclear debate or a missed opportunity?

Potentially dangerous things that we can’t see, smell or sense fuel fears. Seems that nothing fuels these fears more than the words "nuclear" or "radiation".  A little knowledge can ease the mind - slightly. 

Probably more sensitive that GMO foods is the issue of using irradiation on foods foods.  We seem to know that exposure to radiation may cause cancer, so it doesn’t take much of a leap to conclude that exposure to irradiated foods would also cause cancer.  That is not the case, but in the absence of good education and communication, lingering fear will dominate. 

Irradiation can be a good technology for certain food processes, and in some situations may be the best technology. It potentially has value and purpose.  The controversy exists because organized groups have mounted aggressive campaigns opposing the use of irradiation that have affected political processes - particularly south of the border and in Europe. Political decisions are often made on the basis of lobbying and not based on scientific rigour. Policy need not exclusively consider science, but should at least acknowledge its contribution to the debate and not offhandedly dismiss the evidence.

Lost in the irradiation debate is the value of potential reductions in toxic chemical use, physical processes that can affect food products, and sometimes the lack of alternatives.  The result can be decisions to not import/export certain foods and indefensible trade barriers.  Fruits in particular,  can have shelf lives extended through irradiation making longer distance transport and providing greater healthy food options.

Unlike with GMOs,  there are few strong proponents for the use of irradiated foods as alternate options do exist.   Food distributors can recognize the added value and potential cost savings, however the costs and risks of approval and conditions for use are a deterrent to the needed initial investments.  Radiation is not subject to patent protection,  and processes can be readily modified for unique commercial application thus avoiding patent infridgements.  As such, there is no big money behind supporting irradiated foods.  In the absence of big money there is limited research undertaken to truly test food irradiation safety and dangers.  

There may be legitimate safety issues. Following rigorous scientific methodology will answer such questions.  As with other non-patent protected solutions to health problems, there is an inherent bias against exploration as there is limited public or private money for developmental research.   In the end, we may just be missing a simple and cost-effective way of solving many food production problems for unwarranted fears.  If there are dangers, they can be documented rather than merely speculated.

As with GMO foods, in Canada foods that are irradiated undergo regulatory review, something that should make Canadians feel safer  CFIA irradiation fact sheet  .  On top of this is that foods with more than 10% irradiated components require labelling (unlike GMO foods where industry has successfully argued against labelling).   That the regulatory environment does not treat the issues in a parallel fashion is perhaps the good indicator of what money can buy.

I'd be interested in your thoughts - which would you prefer GMO foods, irradiated foods - or do you sit in the organic food camp that will be discussed next?   Leave a comment for all to ready, or contact me at drphealth@gmail.com   

GMO foods - a reality show with a really bad plot

Private comments or suggestions for topics - you can reach me at drphealth@gmail.com

There are several food related debates that increase passion and confusion:  Genetically Modified (organisms[GMO]) Foods, radiation sterilization of foods, and organic production make for a nice controversial week of possible blogs.  The news front for public health has been relatively quite.   The premature and sad death of Jack Layton is a blow to health advocates across the country -  that however is a digression.

You might think the GMO debate would make a tremendous movie.  It pits those struggling to address global hunger through improving food production,  against the unknown threats of genetic manipulation, with right wing pundits looking at patent production, left wingers claiming money grabs, and just to spice up the plot - a really bad guy in the form of a well known corporation (that produces pesticides and seed products).   Okay, perhaps the audience wouldn’t be so enthralled, but then who would ever have thought that a movie about big tobacco would be produced?  

Our monoculture approach to food production is rife with the vulnerability of crops to specific threats from pests.  GMO approaches attempt to bolster crop defences through several means, and just like many interventions, those means may have very different impacts and threats.  There are some 70 or so GMO foods that are routinely utilized, and when  you sit down at your dinner table, you will likely find one of them being served without your explicit knowledge. 

One of the most notable defences to the use of some GMO foods, is that after literally millions of person years of consumption, that no adverse effects have been noted.  The caution, is that while the initial GMO modifications focused on insect, virus, drought and herbicide resistance, more recent modification looks to enhance the food quality, and certainly the most controversial, is modification for the purposes of patent protection (affecting plant sterility).

Prior to direct genetic manipulation, man has selectively been genetically modifying plant and animal species through breeding programs including interspecies breeding efforts. Hence the more recent debates about GMO perhaps are a bit exaggerated.

Of course the debate about GMO would likely be restricted to science if approaches to patent protection and intellectual property rights did not shroud the evaluation process in secrecy, adding to the mystique and perceived danger.   The “bad guy” tactics of big agri-farming giants further fuel the scepticism. 

Canada does maintain a regulatory approach to GMO Health Canada fact sheet on GMO which is worth becoming familiar with.  Those that support GMO innovation will likely be impressed with the rigour, those that oppose may choose to stop eating any foods.  

In the meantime, consider donating to the Somalian drought situation.   We may currently have enough food globally to support everyone, regrettably however the food is not distributed equitably and an estimated 925 Million people are undernourished, (roughly 15% of the global population).  Our Somalian brothers and sisters are amongst the worst affected right now.

Maternal-infant care - a great public health success story.

Public health has its roots in communicable disease control (actually in ‘biological’ warfare in biblical times).  Then it wandered into occupational health issues in the mid 1800’s.  The turn of the 1900’s saw a growing interest in maternal and child health.  At that time about 1 in 200 births resulted in the death of the mother and one in ten the death of the infant before their first birthday.  Today, those numbers are 1 in 11,000 mothers and 5.1 infant deaths per 1000 live births.

Incredible improvements - due mostly to the simple public health interventions of improved nutrition and better hygiene.

Today there rightly remain concerns for the thriving growth of the infant.  Death is not the only health outcome of concern and issues like attachment in the first hours to year of life are receiving more attention as they relate to our health as adults. 

There is also a “quality of birth experience” that has driven change to the birthing experience for some mothers and at times can be at a odds with increasing risks to the baby.  On the other hand, formal health care services are not yet always aligned with ensuring a good quality of experience while maximizing the reduction in risk.   

There is a good recent Canadian set of surveys and studies on the maternity experience at http://www.phac-aspc.gc.ca/rhs-ssg/survey-eng.php  

Notably, Caesarean section rates continue to increase and often exceed 1/3^rd of births.  This was considered acceptable until 2009 when new guidelines now stress that C-sections should only be provided when there is a threat to infant or mother http://www.sogc.org/guidelines/documents/gui221PS0812.pdf.  Rates have yet to  not come down yet, nor has promotion of the new guidelines received much attention.     

Good news - breastfeeding initiation rates are in the 90% range.  Continuation through 6 months is much lower than needed to promote the health of infants. More good news is the routine circumcision is decreasing and now about 1/3^rd of male infants.   Two more public health success stories.

Midwifery is reinvigorating the health system approach to normalizing the birth process,  this is a great thing.  Many physicians have shied away from continuing obstetrical practice.  While specialization in managing only one component of our health care has some value, it undermines the primary health care relationship that should form the foundation of personal health care.  Collaboration between health care providers is essential, and with this the sharing of information referenced in the previous blog on electronic health records. 

Lacking in many parts of the country is a dedicated focus to maternal child health based on public health principles.  Replacing this are specific approaches driven by philosophy and often in competition.  The undermining of the public health approach to maternal-child health is perhaps something only to be mourned now - and hopefully without the need to mourn mothers or children who suffer because of the change.

Electronic health records - information is power AND possibly lifesaving

Private comments or suggestions for topics - you can reach me at drphealth@gmail.com
We are all individuals.  Our genetic make-up varies.  What we eat and drink forms part of what we are.   What we are exposed to can affect our bodies.   It should not be surprising that when a battery of “tests” are done, that unlike machines that operate in a specific fashion, that each of us ‘operates’ differently.  Thank goodness for physicians and others that interpret these differences, determine when we are operating incorrectly and recommending ways to function better.

All that takes information.  What is happening today is important. What has changed is often the most critical information when something goes wrong.   The Star Trek tricorder concept of a quick scan misses that the story is usually about the change.  How can a physician who doesn’t know you, figure out what you need if they don’t know your information?  

Health system users expect that their information is readily available to anyone working in the health system.   A small minority are concerned that their “privacy” is compromised.  In our often libertarian driven policy environment, the privacy concerns have won out.  This perception is likely fuelled by health care workers that recognize that information is power,  and to not share information, means keeping control.

Unlike Facebook where nearly half of Canadians are willing to post intimate details of their personal life,  your medical information is usually so tightly wrapped up that hospitals do not have information from your family doctor. Even you would be challenged to amass all the health information into a single location if you tried. You have the right to access your medical records, but you are not the owner of the record.  It is this problem that contributed to the demise to Google Health. How can you populate your record, if there are barriers to you collecting the information (physicians may charge for copies, hospitals may require written requests and can charge to review the record for sensitive information before you can look at it, and can charge for anything that is copied)  

While there are attempts being made to integrate health information together, the inadequacy of the efforts should scare us all.  Our bodies and mind tell an important story.  Time to share it with those that are involved in helping us care for it.   This won’t happen until the public demands it – and that is more often something critical in an emergency, not when we are well.   In the meantime, propagating the information inefficiency requires more workers, and at risk is your wellbeing.