#ahcj11 Report: Food Safety, or Lack Thereof?

I was reminded last week of the Tom Lehrer admonition, “just don’t drink the water and don’t breathe the air.” That lead to the other Lehrer song, “Who’s next?”

In this week’s episode, the doom and gloom comes from food safety, brought to you by #ahcj11. The first panelist, Michael Taylor, deputy commissioner for food, Food and Drug Administration, set the stage, explaining the magnitude of the problem. The U.S. has 12 million shipments imported from150 countries. He explained that the FDA's role is to set standards to ensure accountability for both domestic and international products, but he placed the primary responsibility for ensuring safety squarely on industry. Unfortunately, the FDA’s efforts to improve safety standards are being stymied by budget cuts, as well as politics and the bizarre fragmentation of responsibilities.

Scott Faber, J.D., vice president, federal affairs, Grocery Manufacturers Association, countered that the new Food Safety bill provides some increased protection for consumers—for example, by giving the FDA access to industry records as well as the authority to require 3^rd party auditors. The bill also gives the FDA the power to issue mandatory recalls.

Erik D. Olson, director, Food and Consumer Product Safety Programs, The Pew Charitable Trusts, stole the show, however, with his clear outline of the problems and the mixed improvements coming via Food Safety Bill:

1. Inspections now only occur ~every 10 years. The frequency is to increase to every 3 years. (This seems unlikely to occur, given the budget cuts, and still leaves huge gaps).
2. Appallingly, the FDA has not previously had the authority to issue mandatory recalls.
3. 80% of our seafood is imported. While the FDA was only checking 1% of imports, they only now are being given authority to block imports at the border.
4. There is no requirement that industry test their products for contaminants; this is still a gap despite the new bill.
5. Historically, the FDA has been almost entirely reactive. Under the Food Safety Bill, the focus will be prevention based.
6. U.S. food legislation has changed little since 1906, when it was revised after Upton Sinclair’s “The Jungle” exposed the unsanitary meat packing industry; there was a small update—most recently—in 1938.
7. Why change? There are ~48 million foodborne illnesses in U.S. per year—about 1 per 6 people, with 127,000 hospitalizations and 3,000 deaths.
8. FDA previously was not able to see any internal industry records; now they can.
9. There have been no rules regarding produce safety—e.g., water quality or contamination by manure. Proposals to address this will now be required in 2012 (but who knows how long industry will have to implement changes after that).
10. The FDA will still not have any enforcement of penalties without going to court. (and look at BP’s penalties—tax breaks and bonuses to execs).

Similarly, schools have somehow seemed oblivious to many recalls, and not complied, per GAO reports.

Taylor, the FDA deputy commissioner for food, spoke positively of Administration support for food safety in the budget; unfortunately, some in Congress—you can guess who—want to unimplement the Food Safety bill.

There are still many logistical hurdles to be overcome including better ability (let alone, authority) to conduct tracebacks. They are cumbersome and time-consuming, but have worked for items with one ingredient, like produce or meat. But there is no good system for tracking products with multiple ingredients. This is giving more impetus for food manufacturers to work with the FDA more cooperatively, a risk sharing arrangement.

One of the most shocking things I learned—there is huge hole in the system—meat and poultry are regulated by the USDA, not the FDA, and therefore are not included in improvements in the Food Safety bill. How irrational is that?

And 60% of produce and 80% of seafood is imported, with little oversight.

I’ve always enjoyed the CDC outbreak investigation reports and marveled at the ability to do tracebacks. Given the magnitude of the problem, their success is even more amazing.

I’ve reassured myself somewhat about food safety from the early polio studies, that showed that children from more affluent families were disproportionately affected.

Unlike many other illnesses, David M. Oshinsky notes “in the past, polio had been a disease of cleanliness.” Poor kids, from less sanitary environments, actually fared better, presumably from having built up some immunity.

(Photo by Judy Stone; Luang Prabang, Laos--suggest you enlarge)

So, while the Food Safety bill offers some hope, there are still huge gaps, especially with such a fragmented system. What’s a mother to do? I guess I’ve gotten much more fatalistic. Try to eat organically, at least where the most pesticide-laden crops are concerned. If you can, support local farmers who don’t use antibiotics or hormones, and who support free-range animals. Otherwise, if you think it will help, pray or lobby, whichever suits your beliefs, or assume an ostrich-like stance.

#ahcj11

This past week I attended my first conference of the Association of Health Care Journalists, aka #ahcj11. I was initially drawn to the meeting by seeing that some of my favorite bloggers—Maryn McKenna, Pharmalot, Scott Hensley—were moderating panels. The conference far exceeded my expectations. While neither my fingers nor my mind have the agility to live tweet, here were some of the highlights for me:

Workshop: Mapping and charting health in your area

Introduced me to neat mapping that can be done with Google’s Fusion Tables. I’m a visual person, so love the ability to display reams of data visually, such as global patterns in TB. Later, I was also impressed by esri’s GIS mapping capabilities.

Workshop: What are your criteria in reporting on health care research?

This session, on critically reviewing stories, was excellent. Th-e session and the accompanying book, “Covering Medical Research,” taught more about how to evaluate articles than I received throughout my medical training, sadly enough. Gary Schwitzer’s Health News Review uses this approach, and is a valuable resource. Schwitzer’s point about differentiating stenography from journalism is broadly applicable and well taken.

Later sessions included a briefing by Donald Berwick, an overview of nanotechnology in cancer, and Francis Collins’ perspective on NIH research. Given my own clinical research background, I found the talks on problems in drug development, detecting fraud in medical research, and James Wilson’s lessons from gene therapy trials (Jesse Gelsinger) gave valuable perspectives.

Overall, the knowledge of many of the speakers and of the journalist questioners was impressive, with many perceptive, pointed questions being addressed to the panelists.

I even felt comfortable enough with the group to raise questions of my own.

One of the most provocative sessions was that on food safety. I’ll have more on that in my next post.

Photo courtesy Pia Christensen, ahcj

Like horror flicks? Read this…

I used to worry about MRSA…then I started seeing multi-resistant Gram negative bacteria in the hospital, like the carbapenem resistant (KPC) Acinetobacter I mentioned in my last post, usually infecting nursing home or chronic ventilator patients. That pales in comparison to the impending wave of infections caused by bacteria carrying the NDM-1 gene. NDM-1 stands for New Delhi Mettalo-beta-lactamase, an enzyme that chews up the “beta-lactam” ring, which is the backbone of many antibiotics, rendering them useless. NDM-1 was first described in a patient from India in 2008. Last year, a cluster of cases was described in 180 patient isolates. A common denominator was that most of the patients had received medical care in India or Pakistan.

As I’m preparing to go to India with a group of students next month who want to study public health, I was particularly struck by this week’s unsurprising news that the NDM-1 carrying bacteria had been identified in Delhi tap water and in standing water in the city—I said unsurprising, having seen some of the lack of sanitation first-hand.

What makes NDM-1 scarier than other recent superbugs is its ability to transfer its genetic material more readily. Part is because the transmission occurs via plasmids, small extra-chromosomal bits of DNA. Another part is that the transmission between bacteria can occur at water temperature, facilitating the spread in sewage-contaminated water. India also has a high rate of people without access to good sanitation or clean water, diarrheal disease, and access to over-the-counter antibiotics, all of which serve as enhanced breeding grounds for transfer. Even worse, the NDM-1 resistance gene is able to transfer to common bacterial pathogens there, such as cholera, typhoid, and the ubiquitous E. coli.

On my first trip to India, as the train approached the station in Delhi, I was rather shocked to see men lined up along the river like this:

Now take a look at this graph of antibiotic drug development from IDSA, to commemorate World Health Day:

Scary, isn't it?

Until CA-MRSA (community acquired MRSA), superbugs were fairly predictably associated with ill people and healthcare associated infections.

But now, this NDM-1 has now been isolated throughout the environment in one of the world’s most densely populated cities...and will soon spread globally.

Add to that the way antibiotics are squandered, irresponsible detailing by pharma and misuse by agribusiness…and you understand the insomnia...

A minor hope—may the student’s trip remain academic, and not become an experiential study.

(photo from drmuir.wordpress.com)

Superbugs and Seasons

Besides MRSA, other superbugs are now vying for our attention. A few months ago, NDM-1, from India, was creating a furor. A new article, by Maryn McKenna, focuses attention on Carbapenem resistance in Klebsiella pneumonia and clearly outlines how this form of resistance occurs. But there is one element fueling this growing problem of resistance that is not often touched upon—that of the public’s unreasonable expectations about care.

For example, I saw another patient last month who was minimally responsive, with little likelihood of recovery. This patient was colonized with a carbapenem resistant Acinetobacter baumanii which, like the KPC, was susceptible only to colistin, a highly toxic antibiotic. Years ago, when I started practice, families understood when doctors said, “Nothing can be done.” Patients were allowed to die in peace, with the emphasis being on comfort. Now, many families appear to believe in the immortality of their loved one and want “everything” done—no matter the cost in money, pain for the patient, or the danger to others. In the current U.S. environment, families have a sort of magical thinking in the ability of technology to prolong life, and an inability to accept death as a part of life. This leads to their demands for care beyond what seems reasonable for both the patient and from a public health perspective. And all of this is fueled by conservative religious groups. These demands—based on wishfulness—contribute to the increasing bacterial resistance to antibiotics, which in turn is putting the viable segment of our population at risk for unnecessary death from multi-resistant bacteria.

While some might be shocked at the idea of “rationing” antibiotics, or feel that we might head down a slippery slope to euthanasia, I would suggest that consideration be given to the public health aspects of squandering antibiotics on what is widely agreed to be futile care. Is it reasonable to continue antibiotic treatment of such end-stage patients, who have no likelihood of recovery, knowing that they are a breeding ground for multi-resistant organisms that threaten the community? How else might this be addressed? Keep in mind that there are almost no antibiotics in development; many pharmaceutical companies, such as Pfizer, have forsaken antibiotic research as not being adequately profitable. After all, who needs antibiotics when you can have Latisse or Viagra?