The total number of antibiotics used in agriculture is continuing to grow

Op-Ed Contributor - Cows on Drugs - NYTimes.com

"More than 30 years ago, when I was commissioner of the United States Food and Drug Administration, we proposed eliminating the use of penicillin and two other antibiotics to promote growth in animals raised for food. When agribusiness interests persuaded Congress not to approve that regulation, we saw firsthand how strong politics can trump wise policy and good science.

Even back then, this nontherapeutic use of antibiotics was being linked to the evolution of antibiotic resistance in bacteria that infect humans. To the leading microbiologists on the F.D.A.’s advisory committee, it was clearly a very bad idea to fatten animals with the same antibiotics used to treat people. But the American Meat Institute and its lobbyists in Washington blocked the F.D.A. proposal....

But the total number of antibiotics used in agriculture is continuing to grow. According to the Union of Concerned Scientists, 70 percent of this use is in animals that are healthy but are vulnerable to transmissible diseases because they live in crowded and unsanitary conditions.

In testimony to Congress last summer, Joshua Sharfstein, the principal deputy commissioner of the F.D.A., estimated that 90,000 Americans die each year from bacterial infections they acquire in hospitals. About 70 percent of those infections are caused by bacteria that are resistant to at least one powerful antibiotic.

That’s why the American Medical Association, the American Academy of Pediatrics, the American Pharmacists Association, the Infectious Diseases Society of America, the American Public Health Association and the National Association of County and City Health Officials are urging Congress to phase out the nontherapeutic use in livestock of antibiotics that are important to humans.

Antibiotic resistance is an expensive problem. A person who cannot be treated with ordinary antibiotics is at risk of having a large number of bacterial infections, and of needing to be treated in the hospital for weeks or even months. The extra costs to the American health care system are as much as $26 billion a year, according to estimates by Cook County Hospital in Chicago and the Alliance for the Prudent Use of Antibiotics, a health policy advocacy group.

Agribusiness argues — as it has for 30 years — that livestock need to be given antibiotics to help them grow properly and keep them free of disease. But consider what has happened in Denmark since the late 1990s, when that country banned the use of antibiotics in farm animals except for therapeutic purposes. The reservoir of resistant bacteria in Danish livestock shrank considerably, a World Health Organization report found. And although some animals lost weight, and some developed infections that needed to be treated with antimicrobial drugs, the benefits of the rule exceeded those costs...."

Donald Kennedy, a former commissioner of the United States Food and Drug Administration, is a professor emeritus of environmental science at Stanford.

Fight Disease With Soap and Water - Wash your hands

Fight Disease With Soap and Water - WSJ.com:

"Wall Street Journal, May 12, 2009

Put Up Your Dukes: Fighting Disease With Soap and Water

Fear of swine flu is fading, but there are still plenty of reasons to wash your hands frequently.

The list of infections that can spread via unwashed hands reads like the Biblical plagues, including staph, strep, salmonella, E. coli, hepatitis, MRSA (methicillin-resistant Staphylococcus aureus), colds, flu and norovirus -- the infamous cruise-ship bug.

The importance of hand washing has been known since 1847, when a doctor named Ignaz Semmelweis suspected that maternity patients were dying in his Vienna hospital because med students treated them right after working on cadavers. When he instituted hand-cleaning, the deaths fell sharply.

The Centers for Disease Control and Prevention says hand washing is the most effective way to stay healthy. But many people don't do it often enough, or long enough, to be effective. Here's a guide:

The swine flu headlines have brought attention to the importance of hand-washing. Health columnist Melinda Beck describes the best way to wash off germs and protect against sickness.

When to do it. Wash your hands every time you use the bathroom. Every surface presents an opportunity for germs to hitchhike out. "Who thinks to clean the latch on the inside of the stall door? Try nobody," says Jim Mann, executive director of the Handwashing for Life Institute, which advises food-service providers around the world on best hand-hygiene practices.

Also wash your hands whenever you change a diaper, pick up animal waste, sneeze, cough or blow your nose; when you take public transportation, insert or remove contact lenses, prepare food, handle garbage and before eating. Few people are as conscientious as they should be. Mr. Mann recalls being in meetings to discuss hand hygiene: "Everybody shakes hands. You finish the talk, and everybody runs for the food line. Nobody washes their hands."

How to do it. Soap and water is the gold standard. In a recent study in the journal Clinical Infectious Diseases, researchers in Australia doused the hands of 20 health-care workers with human H1N1 flu virus. Soap and water removed slightly more virus than three alcohol-based hand rubs. When volunteers didn't clean their hands, most of the virus was still present an hour after exposure.

It's the mechanical process of washing that's so effective. Soap molecules surround and lift the germs, friction from rubbing your hands loosens them, and water rinses them down the drain.

Experts recommend using warm water -- mainly for comfort, so you'll wash longer. Use liquid soap if possible. Bar soaps can harbor germs, though they'll likely rinse off with water.

Use enough soap to build a lather. Lace your fingers together to cover all the surfaces. Rub the fingertips of one hand into the palm of the other, then reverse. Keep rubbing for as long as it takes to sing "Happy Birthday" twice. (Some experts prefer "Row, Row, Row Your Boat." But any tune will do as long as it lasts at least 15 seconds.)

"The typical 'splash and dash' that most people do doesn't do anything," says Mr. Mann.

Rinse thoroughly. Residual soap can make hands sore. Leave the water on while you grab a paper towel and use it to shut off the faucet. Take it with you to use on the door handle as well.

Drying lessons. Many hand-hygiene experts are down on hand dryers -- chiefly because few people have the patience to dry completely and end up wiping their hands on their clothes. "That's fine -- unless your pants have been down around your ankles in the stall," Mr. Mann says.

Air dryers can also blow remaining germs as far as six feet away.

Antibacterial soap? In 2005, a Food and Drug Administration panel voted 11-to-1 that antibacterial soaps are no more effective at keeping people healthy than regular soap. There may be some downside too. Some antibacterial ingredients like triclosan leave a residue on the skin that continues killing some bacteria. Critics worry that the remaining bacteria could become resistant, not only to soap but also to antibiotics. "To our knowledge, it's not happened, but it's theoretically possible," says Elaine Larson, a professor in the schools of nursing and public health at Columbia University. Another problem with antibacterial soap, she says, is that it gives people a false sense of security. "People think, 'Ah -- it's antibacterial. So the germs are gone.' That's a false perception," Dr. Larson says.

Hand sanitizers. It's not often that a personal-care product gets a presidential endorsement. Some drug stores sold out after Barack Obama echoed the CDC's recommendation that people use alcohol-based hand sanitizers when soap and water aren't available to help stop the spread of swine flu.

Experts say they must be at least 60% alcohol to kill germs. "Alcohol ruptures their cell membranes -- it causes them to explode," says Dr. Larson, although she notes that if your hands are visibly dirty, soap and water is much preferable.

Curiously, the FDA does not allow over-the-counter hand sanitizers to claim they kill viruses. The CDC's recommendations are based on information published since the FDA ruling, showing that alcohol-based sanitizers are effective at killing viruses, specifically the H1N1 strain, says Nicole Coffin, a CDC spokeswoman.

Can you overdo handwashing? Yes. "Try to strike a balance between being obsessive-compulsive and being reasonable," says Dr. Larson. "And if there is some kind of outbreak like with the flu or SARS, then there is reason for more caution.""

Do Everybody a Favor - Take a Sick Day

Cases - Do Everybody a Favor - Take a Sick Day - NYTimes.com:

"New York Times, May 12, 2009

Do Everybody a Favor: Take a Sick Day

By ANNE MARIE VALINOTI, M.D.

My patient was a 25-year-old man. He sat on the examination table, the picture of misery, coughing, red-eyed and shivering. His fever was 103. An interview and an examination suggested influenza (the rapid diagnostic test for flu wasn’t available at that time), but there was little I could offer him, other than ibuprofen and some homespun advice.

“Go home and get to bed,” I told him.

He looked at me. “Bed? I’ve got to get back to work.” He put on his jacket and power tie and headed back to Wall Street.

I was appalled. Work in that condition? How could he even think straight with that fever? Whom else would he infect along the way?

Still, a tiny part of me was filled with admiration. Here was a tough guy. No reason to let minor delirium keep him from doing his job.

I had recently finished my residency, three years immersed in the culture of house officer training. Of all the sins an intern or resident could commit, the worst was to call in sick, for it meant somebody else would have to do your work — extra patients to admit, phone calls to make, IVs to insert, emergencies to deal with.

As a resident, my greatest pride was in never having missed a day for illness. I’d drag myself in and sniffle and cough through the day. Once, I’m embarrassed to admit, I trudged up York Avenue to the hospital making use of my own personal motion sickness bag every few blocks while horrified pedestrians looked on.

Now, though, I see the foolishness of this bravura. And I confront it almost daily in my primary care practice. No one can miss a day — a minute, even — of work, carpooling, volunteering, vacation, anything. “I don’t have time to be sick!” my patients wail. Everyone must soldier on, leaving sick days to those with less important things to do.

And many patients aren’t satisfied with sympathy and friendly advice. They have come to the office for that little piece of blue paper, the antibiotic prescription. “I would never ask for this under normal circumstances,” I’m told — except (pick one) I’m getting married tomorrow; leaving for a month in the Amazon; having 25 houseguests for the weekend.

Never mind that antibiotics are useless in treating colds and viral illnesses, and that they have their own dangers and side effects. Some doctors will write the prescription just to get on with their day.

I have done this and know plenty of other physicians who have — much as we may resent being bullied and feel we’ve failed in our duty to “first, do no harm.” In fact, we may very well be doing harm. Beyond the possible side effects and allergic reactions, the nonchalant use of antibiotics in the community has helped lead to the rise of the drug-resistant bacteria known as superbugs.

“Clearly, the overprescribing of antibiotics in doctors’ offices, clinics and other community settings contributes to the problem of antibacterial drug resistance,” Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Disease, told me in an e-mail message. “Because most bacteria multiply rapidly, they can quickly evolve and develop resistance to antimicrobial drugs. Overusing or misusing antibiotics can make resistance develop even faster.”

If the swine flu epidemic ever swings into full gear, I will be prepared for the onslaught of ill patients. I will educate them about the appropriate use of antibiotics. I will provide symptomatic relief when I can. And I will let them know it’s O.K. to be sick. It’s O.K. to stay home from work, pull up the covers and drink gallons of hot tea all day. Maybe for an entire week.

And believe me: if you show up to work sick these days, you are not going to earn anyone’s admiration."

Anne Marie Valinoti is an internist in northern New Jersey.

Babies Know - A Little Dirt Is Good for You

Personal Health - Babies Know - A Little Dirt Is Good for You - NYTimes.com:

"In studies of what is called the hygiene hypothesis, researchers are concluding that organisms like the millions of bacteria, viruses and especially worms that enter the body along with “dirt” spur the development of a healthy immune system. Several continuing studies suggest that worms may help to redirect an immune system that has gone awry and resulted in autoimmune disorders, allergies and asthma.

These studies, along with epidemiological observations, seem to explain why immune system disorders like multiple sclerosis, Type 1 diabetes, inflammatory bowel disease, asthma and allergies have risen significantly in the United States and other developed countries.

Training the Immune System

“What a child is doing when he puts things in his mouth is allowing his immune response to explore his environment,” Mary Ruebush, a microbiology and immunology instructor, wrote in her new book, “Why Dirt Is Good” (Kaplan). “Not only does this allow for ‘practice’ of immune responses, which will be necessary for protection, but it also plays a critical role in teaching the immature immune response what is best ignored.”

One leading researcher, Dr. Joel V. Weinstock, the director of gastroenterology and hepatology at Tufts Medical Center in Boston, said in an interview that the immune system at birth “is like an unprogrammed computer. It needs instruction.”

He said that public health measures like cleaning up contaminated water and food have saved the lives of countless children, but they “also eliminated exposure to many organisms that are probably good for us.”

“Children raised in an ultraclean environment,” he added, “are not being exposed to organisms that help them develop appropriate immune regulatory circuits.”"

Antibiotics may not help sinus infections

Antibiotics may not help sinus infections

A study comparing the use of a placebo with the drug treatment finds little difference. Patience and over-the-counter remedies are recommended.

By Jia-Rui Chong
Los Angeles Times Staff Writer

December 5, 2007

The widespread use of standard antibiotics to treat sinus infections does not help cure patients and may harm them by increasing their resistance to the drugs, according to a study released Tuesday.

The researchers found that the percentage of patients who recovered in 10 days was about the same whether they took an antibiotic or a placebo.

"With a little bit of patience, the body will usually heal itself," said Dr. Ian Williamson, a family medicine researcher at the University of Southampton in England and lead author of the paper published today in the Journal of the American Medical Assn.

The results showed that patients should be more willing to forgo antibiotics, although they should still check with their doctors when a cold worsens into a sinus infection, he said.

Dr. Daniel Merenstein, a family physician at Georgetown University in Washington, who was not involved in the study, said the report was more evidence of the overuse of antibiotics, which has caused enormous problems with drug resistance.

More than 80% of American physicians prescribe antibiotics for sinus infections, he said. Recent studies also have shown that antibiotics are unnecessary for treating ear infections and bronchitis.

"Doctors and patients get into habits and use antibiotics," Merenstein said. "Now people know . . . we should just give supportive care," such as pain relievers and saline nasal mists.

Sinusitis is an inflammation of the sinuses that commonly develops as a complication from a cold.

Allergies can also cause sinusitis, but researchers in this study focused on cases likely to be caused by bacteria.

Bacterial cases often lead to localized pain in the face and to thick discharges from the nose, with more coming from one nostril.

In the latest study, which was funded by the British government, Williamson and his group looked at about 200 sick adults from family practice offices around southwestern England.

Of the 100 patients who took the antibiotic amoxicillin, 29% had symptoms lasting 10 or more days. Of the 107 patients taking a placebo, about 34% of patients had symptoms of a similar length. Researchers deemed the difference statistically insignificant.

Williamson surmised that the antibiotic was ineffective because it had trouble penetrating pus-filled sinus cavities. Though the researchers did not test other antibiotics, he said, they probably would fare no better because amoxicillin is considered the most appropriate drug for sinusitis.

The researchers also tested the efficacy of a nasal steroid spray called budesonide because it was thought to reduce inflammation.

The proportion of patients in the steroid group and the placebo group who had symptoms lasting 10 or more days was the same at 31%.

The researchers found that the nasal spray helped a subset of patients with milder symptoms who reported feeling less ill by day 10. Williamson said the spray probably helped in milder cases because it wasn't washed away as quickly as it was in sicker patients with more nasal discharges.

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FDA Questions Use of Antibacterial Soaps

FDA Questions Use of Antibacterial Soaps

FDA Questions Use of Antibacterial Soaps

Hearing Will Probe Possible Link To Drug-Resistant Bacteria; No Clear Benefit Over Plain Soap?
By JANE ZHANG, Staff Reporter of THE WALL STREET JOURNAL, October 18, 2005; Page D1

The Food and Drug Administration is questioning the use of popular antibacterial cleansers, which critics say may not only provide little benefit for healthy consumers but could carry environmental and public-health risks.

In documents made public yesterday, the agency raised concerns about the use of antibacterial soaps, wipes and washes, a class of products that includes everything from some Dial soaps to Pfizer Inc.'s Purell hand sanitizer. This Thursday, the FDA will bring the issue to an outside committee of experts, which will examine whether the agency needs to limit their use by consumers. The FDA could, for example, recommend labels that would limit the circumstances in which some products would be used, which would also restrict how they could be marketed.

The committee is looking at the use of these products by healthy consumers, as opposed to their use by those -- such as health-care providers and food-service employees -- where the benefits may more clearly outweigh the risks. The FDA documents state that it "often is not clear what contribution consumer antiseptics make relative to washing with plain soap and water."

Any moves by the FDA could affect hundreds of products that are on store shelves: Manufacturers have introduced 253 antibacterial products in the U.S. so far this year. Last year, there were 322 new products, according to Datamonitor's Productscan Online, a new-products database. Antibacterial products generally cost about the same as their conventional counterparts, though prices can sometimes vary widely.

Some doctors have recommended against the widespread use of antibacterial products for years, arguing that they can lead to the emergence of bacteria that resist antibiotics. In 2000, the American Medical Association recommended that the FDA "expedite its regulation" of antibacterial consumer products that have been linked to resistant bacteria.

The FDA's concerns come against a backdrop of heightened awareness about the potential for drug-resistant bacteria. The incidences of deadly bird flu in Asia, for example, have increased anxiety about infectious diseases overall. Earlier this year, the FDA for the first time banned an antibiotic used in chickens and turkeys because of evidence that its use might lead to pathogens that could withstand drugs used to fight human illness.

In the documents released yesterday, the FDA said it found no medical studies that showed a link between a specific consumer antibacterial product and a decline in infection rates. Indeed, one major study found little difference between washing with soap and using an antimicrobial product. However, the agency said that the data about links to resistant strains of bacteria are "conflicting and unclear." The worries raised by researchers center largely on triclosan, an ingredient in a number of antibacterial products.

The agency also raised concerns about the environmental impact of some antibacterial cleansers, which may hurt some algae and fish and break down into a harmful contaminant. Another potential fear -- which the FDA said was "controversial" -- was that using too many antibacterial products may prevent people from being exposed to routine bacteria, weakening the development of their immune systems and leading to asthma and allergies.

Makers of the antibacterial products strongly defended them in filings to the agency. Manufacturers said that the cleansers' effects on the environment are limited, and there is no solid evidence that their products lead to resistant bacteria in real-world conditions. Moreover, they said, monitoring systems are in place to pick up such problems if they arise.

Manufacturers also stood by their individual products. "We're not aware of any evidence linking the use of Safeguard to drug resistance in bacteria," said Laurie Steuri, a spokeswoman for Procter & Gamble Co., which makes the Safeguard line of antibacterial soaps. A spokeswoman for Pfizer, which markets Purell to consumers, said, "We definitely believe there is benefit to consumers."

Still, many medical experts disagree. Stuart Levy, a researcher at Tufts University and president of the Alliance for the Prudent Use of Antibiotics, says products with alcohol and bleaches aren't worrisome, but chemicals that don't quickly evaporate or break down -- including triclosan -- are. Triclosan, he says, has been linked to antibiotic-resistant bacteria in lab tests. Use of such products by healthy households should be limited, he says, unless their manufacturers can prove concrete health benefits.

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Deadly immunity

Deadly immunity

"Deadly immunity

When a study revealed that mercury in childhood vaccines may have caused autism in thousands of kids, the government rushed to conceal the data -- and to prevent parents from suing drug companies for their role in the epidemic.

By Robert F. Kennedy Jr., Salon.com, June 16, 2005

In June 2000, a group of top government scientists and health officials gathered for a meeting at the isolated Simpsonwood conference center in Norcross, Ga. Convened by the Centers for Disease Control and Prevention, the meeting was held at this Methodist retreat center, nestled in wooded farmland next to the Chattahoochee River, to ensure complete secrecy. The agency had issued no public announcement of the session -- only private invitations to 52 attendees. There were high-level officials from the CDC and the Food and Drug Administration, the top vaccine specialist from the World Health Organization in Geneva, and representatives of every major vaccine manufacturer, including GlaxoSmithKline, Merck, Wyeth and Aventis Pasteur. All of the scientific data under discussion, CDC officials repeatedly reminded the participants, was strictly 'embargoed.' There would be no making photocopies of documents, no taking papers with them when they left."

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