As if the COVID-19 pandemic were not threat enough, another pandemic is creeping slowly but steadily across the globe, killing people in the tens of thousands and threatening to surpass cancer as a cause of mortality over the next few decades.
The slow-moving pandemic is antibiotic resistance, an evolutionary process recognized 75 years ago that has weakened the life-saving power of the revolutionary drugs that transformed medicine around the time of World War II.
Dr. Jake Scott, an infectious disease physician at Stanford Health Care - ValleyCare in Pleasanton, spoke last week about both threats: the COVID-19 pandemic that dominates today’s news and activities, and the slower acting pandemic that looks to have far greater consequences in future.
Scott was originally scheduled to speak to a live audience at Livermore’s Bankhead Theater as part of the ValleyCare Speaker Series, a collaboration of the Livermore Performing Arts Center and the ValleyCare Charitable Foundation. With restrictions on large public gatherings, his talk was changed to an online format.
Scott chose to discuss antibiotic resistance first, particularly the threat of so-called “superbugs” resistant not just to one or two, but to many antibiotics.
As dominant as the COVID-19 pandemic seems to be today in today’s health picture, there was a grim medical logic to speaking first about microbes that are multidrug resistant, or MDR.
Some world health experts estimate that some 700,000 people die from MDR infections every year, a number projected to rise to 10 million by 2050.
Economically, MDR infections are anticipated to cost the world $100 trillion in lost productivity by 2050, with a 2 to 3.5% drop in global gross domestic product by then.
Scott said he saw evidence of the MDR “epidemic” during his medical residency in 2011.
Along with other physicians who treat patients suffering from MDR infections, he recognized the crisis has been building for decades, hiding in plain sight.
The rise of antibiotic resistance was predicted by Sir Alexander Fleming, the British physician credited with discovering penicillin, during his Nobel Prize acceptance speech in 1945. That was the dawn of the era of antibiotics, which saved countless lives during the final years of World War II and would save countless more in the decades to follow.
Fleming, however, foresaw that “negligent use” would lead to the proliferation of deadly bacteria that survive inconsistent or inadequate doses of the antibiotic.
Many different antibiotics have been developed since then, but even with proper dosing, they do not eradicate all suspect microbes.
“Every time a patient takes antibiotics, some bacteria in or on them may survive,” Scott explained. “These then adapt and multiply.”
He also cited an amplifying factor – the ability of bacteria to exchange genes with one another. Like victorious soldiers passing fighting skills on to their comrades, bacteria that survive a dose of penicillin may pass their genes to neighboring bacteria, making them resistant as well.
To Scott, this is an inevitable part of the reality of living in a world of microbes, which “have been around for billions of years.” They have survived and adapted to countless changes in their environment.
The introduction of antibiotics some 75 years ago is only one more speed bump for the world’s most abundant life forms.
In a future world that no longer has effective antibiotics, he said, today’s routine hospital procedures like hip and knee replacements could become way too dangerous because of the risk of infection.
Other medical experts have pointed to chemotherapy, cesarean sections and appendectomies as examples of common procedures that will become unsafe.
Even everyday cuts and scrapes could lead to dangerous infections in a future world that Sally Davies, then England’s Chief Medical Officer, described as an “antibiotic apocalypse.”
Scott urged two approaches to fighting the rise of antibiotic resistance. One is to develop new antibiotics to take the place of those that are becoming ineffective. The other is to use fewer antibiotics, both in human medicine and in agriculture.
“Basically, we use antibiotics too much,” he said, citing surveys showing that only about half of the antibiotic doses given hospitalized patients are actually necessary.
Outside hospitals, the Centers for Disease Control estimates that about 47 million courses of antibiotics are given every year for illness like colds and flu, for which they are useless. That’s about one-third of the prescriptions written overall.
An even greater area of overuse is in agriculture, where antibiotics are used in larger quantities than they are in human medicine.
Antibiotics are given to animals to stimulate growth, as well as to prevent and cure disease. They find their way into the food we eat, as well as into soil and groundwater, Scott said.
There, they have their inevitable effect, discouraging the growth of some bacteria and making it easier for others to thrive. Some of those that prosper are inevitably noxious to humans.
About one in five antibiotic resistant infections in humans are caused by microbes, such as salmonella and campylobacter, that come from animals, according to the Centers for Disease Control.
In the meantime, the development of new antibiotics proceeds too slowly to make up for the buildup of resistance to existing ones, Scott said.
Under our medical system, there is relatively little economic incentive for a pharmaceutical company to develop new antibiotics, he noted.
Compared to drugs for chronic conditions like diabetes and high blood pressure, antibiotics are taken for limited periods. In addition, a powerful new antibiotic would likely be “kept on the shelf to minimize the development of resistance.”
Companies that do produce antibiotics often fail to thrive, he said. He cited the bankruptcy of the South San Francisco pharmaceutical company Achaogen, despite developing the successful antibiotic plazomycin.
Shifting his focus to the COVID-19 pandemic, Scott pointed out that until recently, the medical world thought of coronaviruses as relatively harmless, the second most frequent cause of common colds after rhinoviruses.
That changed after a severe flu spread from Guangdong Province on China’s southern coast in late 2002. By April 2003, researchers had identified the agent as a previously unknown coronavirus.
The medical community characterized the disease as a severe acquired respiratory syndrome, or SARS, and that became its official name.
Aggressive public health efforts blocked the further spread of what might have become a deadly pandemic. The SARS mortality rate was estimated at 9 to 12%, Scott said.
COVID-19 is closely related, sometimes called SARS-2. It appears to have originated in Hubei Province, about 450 miles north of Guangdong. To Scott, as to many medical experts, the disease is still evolving, so information has to be offered with caution.
“There is more that we don’t know than we do know,” he said.
For weeks, state and local health departments have been circulating advice and sometimes regulations covering protective measures: wash hands frequently, avoid joining or forming crowds, stay at least 6 feet apart and wear masks.
Scott reiterated these precautions. He also noted that someone coming down with COVID-19 can pass the virus to others days before symptoms appear, making spread extremely difficult to control.
“Some estimates say that 40 to 50% of cases may come from people who don’t have symptoms,” he said.
At the beginning of his talk, Scott emphasized that he would not discuss politics or conspiracy theories.
It was clear, however, that unlike some in the political sphere, including the president, Scott does not have a rosy view of the future in which the pandemic suddenly goes away.
He quoted Harvard epidemiologist as saying, “We’ve managed to get to the life raft, but I’m really unclear on how we’ll get to shore.”
He was not aware of solid medical evidence for drugs that can cure COVID-19 infection. He was politely skeptical of hopes that an effective vaccine can be distributed widely in the coming year or 18 months.
Average vaccine development time is around 20 years, he said, with the fastest on record, the mumps vaccine, taking four years.
In answer to a question, he said that testing will be essential to learn whether people have the disease or have developed antibodies to it, but also noted that many tests are unreliable. FDA regulation of tests only began about a week ago.
He said he believes in a “social contract” in which people work together and “take personal responsibility” for their actions.
“It’s most important that we recognize the need to support each other and those who are most vulnerable,” he said.