WHO Releases New Guidelines to Curb Antibiotic Overuse, Resistance
By David Wallinga, MD
As antibiotic resistance spreads worldwide, the calls get more urgent to stop squandering our most precious medicines, in both human medicine and in livestock. Just released Tuesday are new recommendations from the World Health Organization (WHO)—the leading international public health authority—on how the medically important antibiotics given to food animals can be used better. They're especially timely, given that next week is Antibiotic Awareness Week.
Resistance is largely a numbers game: The more we use antibiotics, the faster resistance spreads. Already, at least two million Americans suffer drug-resistant infections every year, and more than 23,000 die as a result. And the numbers will keep rising without urgent action. Curbing antibiotic overuse is critical.
Experts warn that antibiotic overuse in livestock contributes significantly to the spread of drug-resistant bacteria. With livestock and poultry production expanding in the U.S. and worldwide, that threat will continue to mount. Many livestock antibiotics—perhaps a large majority—are not for treating sick animals. They're given routinely to healthy flocks or herds to promote faster growth or to compensate for crowded or unsanitary conditions. Routine antibiotic use on farms, in other words, is avoidable.
Here in the U.S. about 70 percent of all medically important antibiotics are sold for use on livestock and poultry. Just since 2009, those numbers have increased more than 26 percent. They includes penicillins, tetracyclines, erythromycins and cephalosporins—used to treat things like pneumonia—as well as antibiotics of last resort from the fluoroquinolone class, which can be used when all other antibiotics fail.
The worldwide epidemic in antibiotic resistance is what motivated the World Health Organization to develop and release today their new Guidelines on Use of Medically Important Antimicrobials in Food-Producing Animals.
The guidelines may be a game-changer in this fight. It calls for fairly significant changes to how many of the world's biggest food-animal producers now operate, including the U.S. Some of its major recommendations for global livestock and poultry production include the following:
- First, use of medically important antibiotics in food animals should be reduced, overall;
- Second, use of these precious medicines for growth promotion and so-called "disease prevention" (i.e. compensation for unsanitary living conditions) in healthy animals should no longer be allowed;
- Third, the subset of medically important antibiotics previously identified by WHO as being "critically important for humans" (fluoroquinolones, colistin, some cephalosporins, erythromycins) should be greatly restricted in terms of their use for treating or controlling disease in sick animals.
As important as these guidelines are, they are just that—guidelines. To help curb resistance, individual companies and/or countries actually have to take action on them. A policy brief released alongside the guidelines has WHO's vision for how the recommendations can be implemented
By our estimates, close to half of U.S. chicken producers now raise birds with responsible antibiotics use practices, or are under a pledge to do so within the next few years. Changing consumer demand, translated via changing chicken policies at the nation's biggest restaurant chains, has been a key element, as was described in our latest Chain Reaction report.
The chicken industry can't do it alone, however, and leadership in the U.S. pork and beef sectors to reduce antibiotic use has been largely absent. No major pig or cattle producer has made a commitment to stop the use of medically important antibiotics in hogs or cattle that aren't sick, e.g. for disease prevention—as the WHO now recommends.
Stronger leadership at the federal level could change that picture. Sec. Sonny Perdue at the U.S. Department of Agriculture (USDA) recently acknowledged the need to address the resistance crisis, according to Politico Agriculture: "We need to move faster, we need to be quicker, we need to move more aggressively in attacking this issue so that we don't have the kind of outbreaks" that could spread fear across the country, he said.
We hope Sec. Purdue will put his words into action. A good start would be for the USDA to set a concrete goal for reducing the overall use of medically important antibiotic sales/use across the major food animal species—in pork and beef, as well as in chicken and turkeys. A modest goal of shrinking current use of these precious antibiotics in animal agriculture by 25 percent would mean a rollback to antibiotic use at 2009 levels.
We know this level of reduction is very doable. Since 2009 the Netherlands, an important European livestock producer, has reduced its overall use of agricultural antibiotics by 64 percent.
Anyone who has ever needed antibiotics should be concerned about the overuse of antibiotics in our food supply. Let's hope the strong new WHO guidelines spur more companies and more countries to take the actions that need to happen. Before it's too late.
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To hear many journalists tell it, the spring of 2020 has brought a series of extraordinary revelations. Look at what the nation has learned: That our health-care system was not remotely up to the challenge of a deadly pandemic. That our economic safety net was largely nonexistent. That our vulnerability to disease and death was directly tied to our race and where we live. That our political leadership sowed misinformation that left people dead. That systemic racism and the killing of Black people by police is undiminished, despite decades of protest and so many Black lives lost.
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After sustained declines in the number of COVID-19 cases over recent months, restrictions are starting to ease across the United States. Numbers of new cases are falling or stable at low numbers in some states, but they are surging in many others. Overall, the U.S. is experiencing a sharp increase in the number of new cases a day, and by late June, had surpassed the peak rate of spread in early April.
Seven day rolling average of number of people confirmed to have COVID-19, per day (not including today). This chart gets updated once per day with data by Johns Hopkins. Johns Hopkins university doesn't provide reliable data for March 12 and March 13. Johns Hopkins CSSE Get the data
To Have a Second Wave, the First Wave Needs to End.<p>A wave of an infection describes a large rise and fall in the number of cases. There isn't a precise epidemiological definition of when a wave begins or ends.</p><p>But with talk of a <a href="https://www.theguardian.com/world/2020/jun/27/new-covid-19-clusters-across-world-spark-fear-of-second-wave" target="_blank">second wave in the news</a>, as an <a href="https://www.american.edu/cas/faculty/mhawkins.cfm" target="_blank">epidemiologist and public health researcher</a>, I think there are two necessary factors that must be met before we can colloquially declare a second wave.</p><p>First, the virus would have to be controlled and transmission brought down to a very low level. That would be the end of the first wave. Then, the virus would need to reappear and result in a large increase in cases and hospitalizations.</p><p>Many countries in <a href="https://doi.org/10.1038/s41562-020-0908-8" target="_blank">Europe and Asia have successfully ended the first wave</a>. <a href="https://www.theguardian.com/world/2020/jun/08/new-zealand-abandons-covid-19-restrictions-after-nation-declared-no-cases" target="_blank">New Zealand</a> and <a href="https://www.newyorker.com/magazine/2020/06/08/how-iceland-beat-the-coronavirus" target="_blank">Iceland</a> have also made it through their first waves and are now essentially coronavirus-free, with very low levels of community transmission and only a handful of active cases currently.</p>
Different States, Different Trends<p>Looking at U.S. numbers as a whole hides what is really going on. Different states are in <a href="https://www.nytimes.com/interactive/2020/us/coronavirus-us-cases.html" target="_blank">vastly different situations right now</a> and when you look at states individually, four major categories emerge.</p><ol><li>Places where the first wave is ending: States in the Northeast and a few scattered elsewhere experienced large initial spikes but were able to mostly contain the virus and substantially brought down new infections. <a href="https://www.nytimes.com/interactive/2020/us/new-york-coronavirus-cases.html" target="_blank">New York</a> is a good example of this.</li><li>Places still in the first wave: Several states in the South and West – see <a href="https://www.nytimes.com/interactive/2020/us/texas-coronavirus-cases.html" target="_blank">Texas</a> and <a href="https://www.nytimes.com/interactive/2020/us/california-coronavirus-cases.html" target="_blank">California</a> – had some cases early on, but are now seeing massive surges with no sign of slowing down.</li><li>Places in between: Many states were hit early in the first wave, managed to slow it down, but are either at a plateau – like <a href="https://www.nytimes.com/interactive/2020/us/north-dakota-coronavirus-cases.html" target="_blank">North Dakota</a> – or are now seeing steep increases – like <a href="https://www.nytimes.com/interactive/2020/us/oklahoma-coronavirus-cases.html" target="_blank">Oklahoma</a>.</li><li>Places experiencing local second waves: Looking only at a state level, <a href="https://www.nytimes.com/interactive/2020/us/hawaii-coronavirus-cases.html" target="_blank">Hawaii</a>, <a href="https://www.nytimes.com/interactive/2020/us/montana-coronavirus-cases.html" target="_blank">Montana</a> and <a href="https://www.nytimes.com/interactive/2020/us/alaska-coronavirus-cases.html" target="_blank">Alaska</a> could be said to be experiencing second waves. Each state experienced relatively small initial outbreaks and was able to reduce spread to single digits of daily new confirmed cases, but are now all seeing spikes again.</li></ol><p>The trends aren't surprising based on how states have been dealing with reopening. The virus will go wherever there are susceptible people and until the U.S. stops community spread across the entire country, the first wave isn't over.</p>
What Could a Second Wave Look Like?<p>It is possible – though at this point it seems unlikely – that the U.S. could control the virus before a vaccine is developed. If that happens, it would be time to start thinking about a second wave. The question of what it might look like depends in large part on everyone's actions.</p><p>The <a href="https://dx.doi.org/10.1086%2F592454" target="_blank">1918 flu pandemic</a> was characterized by a mild first wave in the winter of 1917-1918 that went away in summer. After restrictions were lifted, people very quickly went back to pre-pandemic life. But a second, deadlier strain came back in fall of 1918 and third in spring of 1919. In total, <a href="https://www.cdc.gov/flu/pandemic-resources/1918-commemoration/1918-pandemic-history.htm" target="_blank">more than 500 million people were infected</a> worldwide and upwards of <a href="https://theconversation.com/compare-the-flu-pandemic-of-1918-and-covid-19-with-caution-the-past-is-not-a-prediction-138895" target="_blank">50 million died</a> over the course of three waves.</p><p>It was the combination of a quick return to normal life and a mutation in the flu's genome that made it more deadly that led to the horrific second and third waves.</p><p>Thankfully, the coronavirus appears to be much more <a href="https://doi.org/10.1016/j.meegid.2020.104351" target="_blank">genetically stable</a> than the influenza virus, and thus less likely to mutate into a more deadly variant. That leaves human behavior as the main risk factor.</p><p>Until a <a href="https://theconversation.com/what-needs-to-go-right-to-get-a-coronavirus-vaccine-in-12-18-months-136816" target="_blank">vaccine or effective treatment is developed</a>, the tried-and-true public health measures of the last months – <a href="https://theconversation.com/this-simple-model-shows-the-importance-of-wearing-masks-and-social-distancing-140423" target="_blank">social distancing,</a> <a href="https://theconversation.com/masks-help-stop-the-spread-of-coronavirus-the-science-is-simple-and-im-one-of-100-experts-urging-governors-to-require-public-mask-wearing-138507" target="_blank">universal mask wearing</a>, frequent hand-washing and avoiding crowded indoor spaces – are the ways to stop the first wave and thwart a second one. And when there are surges like what is happening now in the U.S., further reopening plans need to be put on hold.</p>
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