>> Today's call is being recorded.
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I would now like to turn the conference
over to your host for Laura Murrell.
Thank you.
You may begin.
>> Thank you, Sarah.
Good afternoon, everyone.
My name is Laura Murrell, and I work in the One Health Office
at the National Center for Emerging
and Zoonotic Infectious Diseases at the Centers
for Disease Control and Prevention.
On behalf of the One Health Office,
I'm pleased to welcome you to the month Zoonoses
and One Health updates call on December 4 2019.
ZOHU Call content is directed to epidemiologists, laboratorians,
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animal health officials,
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Before we begin today's presentation,
Dr. Casey Barton Behravesh,
Director of CDC's One Health Office will share some news
and updates with you.
>> Hi, everyone.
Thank you for joining us for today's ZOHU Call and welcome
to all of our new call participants.
The ZOHU Call audience continues to grow,
and we have subscribers representing professionals
from government, non-governmental organizations,
industry, and academia, including students.
We really appreciate your help spreading the word
about the ZOHU Call.
So, please continue to share the ZOHU Call website link
with your colleagues from human, animal, environment,
and other relevant sectors.
The site includes links to past call recordings,
information on free continuing education for a variety
of professionals, and also a link to subscribe
to the ZOHU Call email list.
To begin today's call, I'd like to share some highlights
from the One Health News from CDC included
in today's ZOHU Call email newsletter.
First, CDC's 2019 Antibiotic Resistance Threats Report is
available online.
We'll have a presentation about this report on today's call.
The Council to Improve Foodborne Outbreak Response invites public
comment on the third edition of its guidelines
for foodborne disease outbreak response.
And CDC's new Typhus fact sheet is available in six languages.
There are some upcoming webinars of interest
that includes CDC's Updated Guidance for the Use
of Intravenous Artesunate to Treat Severe Malaria
in the United States on December 10th
and the National Association of County
and City Health Officials will present Leveraging One Health
Collaborations to Enhance Investigation Capacity
on December 12th.
We've shared links to recent publications on several topics,
including Genomic Epidemiology as a Public Health Tool
to Combat Mosquito-Borne Virus Outbreaks, a Multistate Outbreak
of Salmonella Infections Linked to Raw Turkey Products
in the US, Botulism Type E After Consumption of Salt-Cured Fish
in New Jersey, and the December EID Journal has a
zoonoses theme.
Regarding outbreaks, new outbreaks have been posted
for E.coli infections linked to romaine lettuce
and hepatitis A virus infections linked to fresh blackberries.
Updates have been posted for outbreaks of listeria
and an outbreak of salmonella infections linked
to ground beef.
There's a selected list of ongoing and past US outbreaks
of zoonotic diseases, as well as information on staying safe
and healthy around animals, available on CDC's Healthy Pets,
Healthy People website.
And as always, the complete current CDC outbreak list,
including foodborne outbreaks,
is available at cdc.gov/outbreaks.
If you would like for us to share news
from your organization, or if you want
to suggest presentation topics, or even volunteer
to present yourself, please contact us
at ZOHU Call at cdc.gov.
Again, thank you so much for supporting the ZOHU Call
and for joining us today.
We've got an exciting lineup of speakers and topics.
I'll now turn the call back over to Laura.
>> Thank you.
Today's presentations will address one or more
of the following objectives, describe two key points
from each presentation, describe how a multisectoral One Health
approach can be applied to the presentation topics,
identify an implication for animal and human health,
identify One Health approach strategy for prevention,
detection, or response to public health threats,
and identify two new resources from CDC partners.
Questions for all presenters will be taken
at the end of the call.
Call 1-800-857-9665 and enter participant pass code 6236326,
press star 1 and give the operator your name
and affiliation.
Please name the presenter or topic
at the beginning of each question.
You'll find resources and links for all presentations
on our website and in today's ZOHU Call email.
Our first presentation,
One Health in Veterinary Education Advancing Career
Opportunities that Address Societal Needs will be given
by Dr. Michael Lairmore.
Please begin when you're ready.
>> Thank you, and I'd like to thank all of those
at the National Center for Emerging and Zoonotic Diseases
and One Health Office for this opportunity
to present One Health in educational opportunities.
I would like to begin by emphasizing the concept
of One Health as an approach which intersects animals,
people, and the environment, and this approach requires.
This approach requires the interaction across disciplines,
ranging from veterinary medicine, public health
to engineering and ecology and a cooperative spirit and knowledge
and skills to appreciate how multiple disciplines view a
societal issue.
Viewed from the perspective of the AVMA and AVMC Council
of Education which accredits veterinary colleges and schools
in the US, we can see elements of the One Health
within the curriculum standards, and these include an emphasis
on central biological principles,
understanding the natural history of disease
and principles of the relationship of animals
and the environment, including public health.
Studies such as the National Research Council's report
on the workforce needs
in veterinary medicine were published in 2013,
have identified the value of the One Health approach
to address complex global problems including
food security.
We also know from the NIH Physician-Scientists Workforce
Working Group report of 2014
that veterinary sciences are considered a unique workforce
in biomedical research
and in understanding the emerging epidemics,
but are a relatively small workforce in the overall field.
The Association of American Veterinary Medical Colleges
works to engage member institutions and faculty
in the One Health initiatives underway in federal
and international agencies, including the NIH,
World Health Organization, CDC, and others.
This includes sponsorship of the consortium of the university
as a global health, which has developed an interest group
on global environmental health and One Health and will be part
of the 2020 meeting focused on global health at a time
of worldwide political change.
Viewed from the global perspective, we find the need
for One Health approach at the interface of animals,
livestock, and wildlife health.
This intersection often involves increased contact
between humans, livestock, and wildlife, as well as cycles
of factors that influence outcomes related
to disease transmission, such as economic pressures and land use.
The United Nations' sustainable goals include many One Health
indicators of the ability of food systems to withstand shock,
whether natural or manmade as part
of the sustainable global food security and the need
for government policies to preserve the environment
and natural resources and sustain ecosystems.
At UC Davis, we found in bringing real world examples
of the One Health approach
into the classroom is a compelling way
to educate students.
These include examples from international projects
such as the Health for Animals and Livelihood Improvement,
the HALI Project,
a collaborative One Health based program in Tanzania
and the Gorilla Doctors Program based in Rwanda.
Inspired by these case studies and using pilot courses,
we've created a new undergraduate major called
Global Disease Biology in collaboration
with our colleagues at the UC Davis College of Agriculture
and Environmental Sciences.
This major, which is one of the fastest growing on campus,
allows students to study disease and its relationship
to the health of people, animals, and plants,
as well as the environment in a global context
and uses an interdisciplinary approach
to advance the understanding of diseases, societal impact,
as well as the evolution of prevention of disease.
We've also started supported important extracurricular
experiences for our students, including participation
in the Veterinary Students Day at the Centers
for Disease Control and Prevention.
We've also found that One Health approach excites our students
to work in underserved communities.
These communities include Knights Landing, California,
which is an economically underserved community
with a large migrant population.
The goal of the project is to improve health
at the community level.
This can be extended to One Health experiences globally,
which is sponsored by our Office of Global Programs
and supports students to work across discipline boundaries
and the interconnectedness of humans and animals,
but in this context, globally,
to provide community-based services.
One of the projects is RX for One Health, which provides a
"prescription" for advanced students
and early career professionals to prepare them
for immediate engagement in global health careers
that will demand the effective problem-solving skills
in a cross disciplinary manner and solid foundations
in field and laboratory work.
In Tanzania and Nepal, a recent poultry project showed the
important role of veterinarians
and extension agents in their communities.
They found that school children collecting data
on household poultry production produced a more accurate result
than research staff visiting the households.
At UC Davis, the One Health Institute has been integral
in global surveillance of zoonotic diseases
and capacity building through its leadership
of the PREDICT program, a project aimed to define
and find viruses before they spill over into humans.
Last year, the PREDICT Project announced the discoveries
of new viruses, a new Ebola virus' closely related cousin
Marburg virus in bats in Sierra Leone.
Dr. Brian Bird is a recent example
of a veterinary scientist trained in One Health
that helped lead the CDC Ebola field laboratory
in Sierra Leone in 2015.
He's now a faculty member at UC Davis,
continuing his One Health work.
The work from the PREDICT grant form the basis
of a new consortium to enhance global health security the
university networks and member institutions in Africa
and Southeast Asia by developing training programs
and using the One Health approach.
The education of the One Health Workforce
through interdisciplinary research provides clear examples
of how this approach serves
to address complex health issues at this interface.
Dr. Chris Parker and colleagues have developed a CDC funded
Center of Excellence
that involves multiple universities and agencies.
The Pacific Southwest Regional Center of Excellence
in Vector-Borne Diseases includes these partners
with approaches and surveillance, vector control,
genetics, and methodological tools, but importantly also
to train public health professionals
and other scientists.
One Health approaches are used by the Western Institute
of Food Safety and Security and Cooperative Extension Research
to investigate and identify solutions to complex challenges
in agriculture, from food safety and disease surveillance
to biotechnology and animal welfare.
These field-based examples are then utilized
to create food safety educational materials
for stakeholders in government agencies, such as the FDA.
These programs have assisted in the implementation
of the Food Modernization Act
and context large food producing systems.
These agriculture-based One Health courses support the goals
of Homeland Security and national preparedness systems
as well and are tailored for people specifically
in rural regions of the United States.
Across the country,
linked through the National Animal Health Laboratory Systems
are laboratory systems
that utilize the One Health principles to protect the health
of our nation's food supply.
A recent example was the effort in California with the USDA
to detect and form an eradication program
against exotic Newcastle disease.
Antimicrobial resistance, as you'll hear about,
is a major threat to the health of the world's population
and future economies in many countries.
A collaborative project co-sponsored by the AAVMC
and the Association of Public and Land-grant Universities,
APLU, helped form the National Institute
of Antimicrobial Resistance at Iowa State University.
The institute uses a One Health approach to address the problem
and will serve as a national resource for coordinating
and focusing the efforts of various stakeholders,
organizations, and institutions from academia,
government, and industry.
We must not forget that the One Health educational approaches
are equally critical in small scale farming
and emerging trends in urban agriculture.
These markets have been recognized by the USDA,
which is funding One Health approaches
to determine disease risk and educational needs
for the stakeholders involved.
The parallels of naturally occurring diseases
between humans and animals provides multiple examples
of how One Health approaches are being used to apply to education
and research approaches at the interface
of human and animal health.
The Clinical and Translational Science Award One Health
Alliance is a consortium of 15 veterinary schools partnered
through the NIH Clinical Translational Science
Award Network.
It leverages the expertise of physicians, research scientists,
veterinarians, and other professionals
to accelerate translational research.
Recent examples in non-human primate models
of inherited retinal disease provide great examples
of therapeutic testing grounds for gene replacement.
A recent discovery in a genetic mutation
across dog breeds that's responsible
for chondrodystrophy provided fundamental knowledge
of the importance of a retro gene in dwarfism in humans.
Another example was the efficacy of multi-mesenchymal stem cells
to treat chronic gingivostomatitis in cats,
which is similar to human oral lichen planus.
We also see examples
in hypertrophic cardiomyopathy parallels between the feline
and the human in a study designed
to look at new therapeutics.
Comparative oncology using the One Health principles that led
to new discoveries in cancer treatment
and also recent examples of proof of mechanism
of new inhibitors that highlight the value
of the NCI Comparative Oncology Program.
These results in clinical trials at multiple institutions,
and these One Health approaches to advance the standard of care
of veterinary and human medicine
through these organized trials has received great attention
across the country.
These clinical trials have proved a dual benefit
of advancing human health with animal health,
but also adding data that shortened time
for the approval of human drugs.
One Health approach is often applied to wildlife conservation
in ecosystem health perspectives.
A clear example was the elucidation of toxoplasmosis,
a major cause of sea otter mortality off the coast
of California.
Greater attention in the patterns of emergence
of wildlife cancer has offered interesting and novel insights
into potential unique non-age-related mechanism
of carcinogenesis across the country.
As we look to the future, One Health approaches will need
to be considered how information technology
and data science will be used to identify effective ways
of machine learning telemedicine
and telecommunication in this context.
A recent example from Dr. Titus Brown's group used existing data
with new tools to more accurately identify trends
across datasets.
One Health approaches will be needed
as we interpret data science in context to animals,
environmental, and human health.
A clear example in the Center for Animal Disease Modeling
and Surveillance provides coordinated multidisciplinary
ongoing research efforts to model disease
and predict future disease and also the risk
of disease entering the US
and evaluating alternative strategies for mitigation.
Undoubtedly, finally, One Health trained scientists will be drawn
to the concept of planetary health
that has emerged subsequent to the One Health movement.
This newer concept has foundations in One Health
and emphasizes the application of interdisciplinary research,
knowledge to improve human health with respect
to the integrity of natural systems.
I'd like to thank you for listening and for your support,
all of you listening, and the support of One Health.
Thank you.
>> Thank you.
Our next presentation, Zoonotic Mycobacterium bovis Disease Deer
Hunters in Michigan 2002 to 2017 is by Dr. James Sunstrum.
Please begin when you're ready.
>> Hello and thank you for inviting us
to present this interesting topic.
This was published in MMWR on September 20th
and involves a multidisciplinary group I represent,
Michigan Department of Health and Human Services.
We've got involvement from the School of Public Health
at University of Michigan, from the Michigan Department
of Natural Resources, from the USDA,
and from a local hospital system in northern Michigan,
which diagnosed a recent case
of Mycobacterium bovis in a deer hunter.
This article in -- it was a brief report in MMWR
and generated quite a bit of attention.
And the MMWR site lists the metrics with 22,000 views.
It also made the front page of the Detroit Free Press related
to hunting-related tuberculosis, and the figure in this report,
and I'll spend a little bit of time going over it,
it starts on the right-hand side with a figure of a human being
with pulmonary TB in red.
This was the case that was diagnosed two years ago
in northeastern Michigan, along the shores of Lake Huron.
And this was an older gentleman, 77 years old,
who had been a deer hunter for many, many years.
He was a little bit immune suppressed, and he was found
to have pulmonary tuberculosis,
and it surprised the local doctors
when it turned it was identified as Mycobacterium bovis.
This was quickly appreciated at the State Health Department,
because this patient resided in an endemic area
with enzootic Mycobacterium being present
in wild deer and cattle.
And as a result, his isolate underwent whole genome
sequencing, and the purpose of this tree is to show
that his isolate was very closely related
to an isolate in M. bovis.
This is the dark grey circle from 2007,
that was a culture obtained from a deer
that was analyzed in that same area.
And the patient's isolate had only one snip difference
from the deer that was recovered many years earlier.
Tuberculosis has a very low mutation rate,
and this suggests the patient was exposed
to Mycobacterium bovis that was circulating close
to that time period.
These whole genome sequences
in veterinary isolates are all stored at USDA,
and they have a library of 900 or 1,000 isolates.
And they also show that it was closely linked
to the blue circle, which was isolated
from a cow in that same region.
So, we were very interested in this single human isolate
that was closely linked to circulating M. bovis
in northern Michigan, and I'll show you a map in a second.
What we did then was go back to two archived cultures
of Mycobacterium bovis that had been published several
years ago.
They were identified in deer hunters,
and the middle case was another pulmonary case,
which dates back to 2002.
When we analyzed whole genome sequencing there,
there was a one snip difference between five deer in grey
in that circle in the middle and also three cattle in blue.
And then you can see there's some light grey circles
where it spills over into some other dead-end animals,
such as coyotes, raccoons, or opossum.
So, this was a one snip difference, again,
a very tight molecular epidemiological linkage.
The third case, which has also been published previously,
was a case of cutaneous tuberculosis due to M. bovis
on the finger of a deer hunter.
In that case, the patient's whole genome sequence had a
perfect match, because we could identify exactly
which deer he had shot, and that was a perfect molecular match.
So, this'll give you some background
on this enzootic issue that's going on.
This has been going on in northern Michigan.
It was diagnosed about 25 years ago,
where it was recognized there had been spillover
of Mycobacterium bovis from cattle into wild deer.
And currently, this photograph is what you would see today
at the DNR Wildlife Disease Laboratory in Lansing, Michigan.
Every day, several hundred deer heads are being submitted
for analysis of their lymph nodes for evidence
of Mycobacterium bovis,
and there is remarkable veterinary epidemiology
in the deer population in northern Michigan,
going back 20 years or more.
I should mention that many
of these deer heads are also being evaluated
for chronic wasting disease, which is causing great anxiety,
and that's in a different part of Michigan.
But so, this lab is a dual purpose laboratory.
This is one of the largest negative pressure air rooms
in the United States.
And this is a picture of the DNR veterinarian Dan O'Brien,
who was on our publication,
and he's holding a very grossly diseased lung from an animal,
from a deer diseased with Mycobacterium bovis.
This is unusual to find this much disease.
Often, it's confined to cervical lymph nodes,
which is the main organ to do surveillance on.
And Dan O'Brien has provided this chart going back to 1995,
showing that every year there have been culture positive deer
specimens obtained, and you can see that if you look at 2018,
there were 26 deer that were analyzed
with positive lymph node cultures
for Mycobacterium bovis.
This is out of a huge number of deers analyzed,
35,000 last year, that the number
of deer being analyzed has risen considerably, but that's mainly
because of the concerns about chronic wasting disease.
This season, deer hunting season, has just wrapped up.
It's in full force right now, and they've identified seven,
I believe, culture positive deer so far on the --
and these are all confirmed by acid fast culture.
This map is to show you that this is confined
to a relatively small area in northern Michigan.
The yellow area involves four counties where the bulk
of Mycobacterium bovis has been identified in deer.
And then the red area is the more concentrated higher
intensity area, which is called a deer management unit,
where there's been more aggressive interventions,
and it's been confined to that that area.
There are a few other colored circles elsewhere in the state,
where there's been scattered herds with evidence
of Mycobacterium bovis unrelated to deer,
and those are usually cattle herds that had M. bovis brought
in from outside of the state.
And so, all the efforts of the Department of Natural Resources
and the Department of Agriculture
in northern Michigan are focused
in this concentrated four county area.
It's quite rural.
It's heavily forested, where there's a lot of deer,
and then there's also a lot of cattle farms mingled in.
There's lots of opportunities for interaction
between wild deer and cattle.
So, this slide shows the zoom in on the four county area.
This is showing the location of culture positive deer in red
that were identified last year.
You can see that almost all of them are
within that tighter deer management unit,
and that's really where a lot of efforts are being made to try
and deal with this situation.
Now, the next slide is showing more the interaction of deer
with cattle farms, and I will explain this slide,
because it's presenting the infected deer
as squares or rectangles.
So, a culture positive deer would either be a red square
or a crosshatch square, and you can see they're scattered
across this area.
But the purpose of this slide is to show the yellow dots,
which identified farms
with previously infected cattle herds.
So, there's clearly close proximity
where deer have been shot with very close proximity
to cattle farms, which have been affected by Mycobacterium bovis.
There are 120 cattle farms in this four county area,
and there's been very intensive efforts to work
with cattle producers and with deer hunters in this area.
Every year in -- and this is in the State of Michigan.
In 2016, this graph shows there were three cattle herds
in that area that were found to have evidence
of M. bovis infection.
You can see that this has been an ongoing issue
with continued evidence of spread
from wild deer into herds.
In this part of the state, there are highway signs with this kind
of information where all cattle have to be tagged
with an electronic identification device,
and they cannot be moved outside of this region,
unless they have documentation of a negative bovine TB test.
This issue has resulted in Michigan being identified
as having a modified accredited zone status for restriction
of movement of cattle.
And I'm not a big expert on how that's performed,
but this has put significant restrictions on movement
of cattle in this area.
There are quite a few efforts now
at enhanced wildlife biosecurity, in other words,
restricting the ability of deer to get onto farms either
by building better fences,
by making sure gates are properly closed,
and trying to reduce the interactions of wild deer
with cattle in the area.
Now, just as our case was being accepted for publication,
we received notice from the Health Department
in northern Michigan that they had identified a taxidermist
with a chronic finger infection.
This started about last November or December and had no response
to broad spectrum antibiotics.
It was a chronic festering finger infection.
They did a biopsy of this taxidermist's finger
and found granulomas,
and Mycobacterium bovis was identified in culture.
The isolate is known to be resistant to pyrazinamide,
which can be used as an indirect marker for this organism.
The patient did have a positive IGRA blood test.
We're presently sending this patient's isolate to the USDA
in Ames, Iowa for comparison
of his isolate's whole genome sequencing
with the veterinary library.
And those results are still pending, but we suspect
that he was inoculated when he was cleaning deer heads
with wire brushes.
It does not appear that he can recall a specific specimen
that looked different or looked diseased.
So, we may not have the source for that.
These cases have generated a lot of discussion
about what could be done next, because there's always concern
about ongoing transmission to humans.
So far, we've only seen diseased and Mycobacterium bovis disease
in deer hunters or people who handled deer carcasses.
So, we think that education
of hunters is going to be necessary.
The DNR does put some education
in their hunting brochure every year about Mycobacterium bovis
and chronic wasting disease.
But I think emphasizing the use of gloves for field dressing
of animals would be a very easy thing to do.
It is very, very unknown whether airborne protection would be
feasible for the tens of thousands or hundreds
of thousands of deer hunters who go up to Michigan every fall.
But -- so we just say
that recommendation remains controversial,
but two of our cases were pulmonary cases.
We can speculate that those hunters got infected
from a brief, intense exposure to aerosols
when they were field dressing the carcass out in the woods.
We would like to proceed with IGRA blood testing for hunters
who submit diseased deer heads, and that's a project
that we're actively working on getting going.
We would also like to simultaneously be doing IGRA
screening of cattle producers, who have affected herds.
We feel that this area represents a unique location
to study the zoonotic transmission of bovine TB
between wild animals
and domesticated animals and human beings.
This topic is now gaining recognition around the world
that global zoonotic tuberculosis is really being
recognized, that this was launched
at a 2017 tuberculosis conference, saying that control
of human TB around the world cannot be accomplished
without control of zoonotic tuberculosis.
This topic has been very foreign for the TB community at large,
but just earlier, a month ago, in Hyderabad, India,
there were four major sessions on zoonotic TB working
to advance understanding of this topic.
Thank you.
>> Thank you.
Our final presentation,
CDC's 2019 Antibiotic Resistance Threats Report is
by Michael Craig.
Please begin when you're ready.
>> Hello all, and thanks for listening, and we're excited
to give you an overview of CDC's AR Threats Report.
You probably saw some of the releases in the middle
of November in the news, and I just want to walk
through some of the pieces.
I'm happy to give an overview, and it's, in particular,
something that's very important to us, because it is
such a important One Health issue.
And I think the report actually puts some finer points on that
in ways that we haven't been able to before, and so thanks
for the opportunity to share it with you.
So, I want to just highlight that some of the data pieces
in the report, importantly,
CDC put out the 2013 AR Threats Report,
and we used the best data available that we had
at the time, but that was really pre-investment
from the Congress in this topic.
And so, CDC put out our estimate,
but we also caveated it pretty significantly
when we put it out, and we've talked about it in --
with caveats ever since then and ever since we've sort
of released our new report.
And the big caveat was that we really had conservative
estimates, because we didn't have better data to be able
to assess the burden for all the different pathogens
in the report.
And looking at the slides here and just advancing,
so you can see this, we used new data this time, and the new data
that we used from primarily electronic health record data
from three different electronic health record vendors,
we pulled that together and really had data from millions
of different patients across the spectrum of healthcare.
And we're able to really get data specifically,
that not only highlighted the current burden of AR Threats
in the United States, but also gave us data that went back
in time to when we released the first report.
And it allowed us to actually recalibrate,
re-estimate what the burden of AR was
with these better estimates.
And as you can see here with this slide,
the two million was underestimated, and it was more
like 2.6 million infections.
And the deaths notably were underestimated pretty
significantly, and they went from 23,000 to 44,000,
which is an important point, as I note where we are today.
These are the numbers, as you can see here, about where we are
with the burden of antibiotic resistant infections
and the pathogens that we highlight in the report today.
Notably, we're at over 2.8 million infections.
An important piece though is
that the deaths number has actually declined,
from 44,000 to just a little below 36,000.
And that decline is largely due to success that we've had
in preventing resistant infections
in hospitals in particular.
The data that we had really focused on hospital settings
versus community settings,
and provided information specifically
about the differences there.
And so, I would highlight here that the success that we've seen
in the declines overall in deaths and mortality,
over this period of time from roughly 2012 to 2017,
is attributed to a lot of the interventions and things
that we have put in place in the United States
over the last decade to improve patient safety
and health care quality in hospitals.
All that being said, it's important to note though,
that if you add up the burden of the resistant threats along
with the burden of C. diff, which is the companion pathogen
that we include in the report, because it's driven
by antibiotic use, you get over three million infections
and nearly 50,000 deaths, which is a lot of sick people
and a lot of deaths that we have to deal
with in the United States.
And frankly, it's too many, and it's something that we need
to do even more about in the United States to address.
The report also does categorize pathogens and,
compared to the last report, would highlight for you
that we have the three categories of urgent, serious,
and concerning, and last time, in the highest category
of threat, we had three pathogens.
And this time we have five pathogens,
and as you can see here with the categories,
there were two major changes to that urgent category list.
And that is that we added a pathogen, Candida auris,
which folks, I think, have probably heard about.
This is the multidrug resistant fungus
that we really didn't know about the last time we put
out the threats report, but has since emerged
and really circumnavigated the globe
and is really wreaking havoc
in healthcare facilities especially,
where it becomes colonized and where it becomes prevalent.
And so, this is one where given its resistance,
given the challenges that we face both in the United States
with this pathogen, as well as overseas,
and given how readily it's been transmitted and really moved
across the globe, we put it and added it
to this highest category.
We also added Acinetobacter to the urgent list,
and this is somewhat of a slight definition change.
In the last report,
we had multidrug resistant Acinetobacter.
This time we changed it
to carbapenem-resistant Acinetobacter
because of specific concerns we've been seeing to --
specific concerns
to the resistance we're seeing to carbapenems.
And when we looked at that, and when we redefined it
and evaluated and compared it to those other urgent threats,
we saw that it was warranted to be in that higher category.
I would note for you that even though we added Candida auris,
the 2013 report and the 2019 report have the same number
of pathogens, 18.
As we categorized, we actually removed VRSA and combined it
with MRSA, given the low prevalence of that
and given the relationship between the two.
One thing we note with the threats report,
and I think it's particularly important to this group is
that we spend a lot of time and a lot of hard work with folks
across the agency, trying to come up with new infographics
that talk about the different aspects
of antibiotic resistance and, in particular,
talk about the challenges, the One Health challenges
of antibiotic resistance and do so in a way
that is more accessible to a variety of audiences.
This infographic is emblematic of that, and you can see this
in greater detail in some of our online material
or in the print version.
And it -- we really --
you really can't zoom in on different aspects of this to try
and understand some of the relationships.
So, we really, you know, had twin goals
of conveying a high level scientific information,
but packaging it in a way
where multiple audiences could understand the One Health nature
of antibiotic resistance and how it touches on really any
and every aspect of human life.
And this is one, in particular, that we're proud of,
because we can zoom in on some of these different parts
and highlight the aspects that relate to human healthcare
that relate to agriculture in the farm, the use of antibiotics
as pesticides, but can also relate to what we deal
with in our homes and in our communities day in and day out.
So, there's a lot of new infographics.
There's a lot of new resources both for healthcare providers
with note that we worked with the One Health Office as well
as our partners at AVMA to have a sheet
on what veterinarians can do to address antibiotic resistance.
For a long time, we've had companion materials
on the human health side about what doctors
and healthcare providers can do.
But the report this time launched some other new elements
like our fact sheet on what veterinarians can do.
And we're proud to sort of bring that approach
and improve upon how we message and how we talk
about antibiotic resistance as a One Health threat.
I would highlight here, these are some
of the more specific data that I noted at the beginning
about the success that we've seen
in preventing resistant infections, as well as driving
down the number of deaths.
And this has been the success that's really related
to the hospital prevention and the hospital successes.
And so, you can see some
of the most prominent resistant infections in the report,
we have seen decreases over this period
of time, from 2012 to 2017.
And for things like CRE, we have them on this as a success,
because we do consider having a stable level of CRE,
given it is an urgent threat and given
that we have seen it spread in other countries,
significantly maintaining that at the level that we're at,
when we sort of expected that it would grow,
we consider that a public health success.
And I think it shows the emblematic of the success
that we've had in implementing things
like the containment approach and our support to state
and local health departments in identifying these emerging forms
of resistance and responding to them in real time.
I want to highlight though that this is not just a
"mission accomplished," but there's a lot more to do,
and the challenges that we see, and the challenges
that we highlighted in the report, of course,
are that the numbers are much bigger
than we previously estimated.
The other issues are, of course, though, that outside
of hospitals, we're not seeing the same level of success.
And when we defined community here,
we defined healthcare facilities,
that non-hospital healthcare facilities
in that community bucket as well as true community.
So, in those -- both of those areas
in the non-hospital healthcare settings, like nursing homes,
ambulatory surgery centers, dialysis settings,
we're not seeing the same level of prevention
of infections and deaths.
And we need to really make sure that the gains that we've had
in hospitals are maintained and that we carry those successes
over to other healthcare settings.
Moreover, we're seeing some increases in the true community
and for infections that are driven in community settings,
like drug resistant gonorrhea, would highlight
for you here the ESBL-producing Enterobacteriaceae,
in particular.
That is one that -- these are largely drug resistant urinary
tract infections that disproportionately affect women.
This is an area that needs more exploration to see all
of the reasons, and we do think
that there are multifactorial reasons
that are driving these increases up here.
But these are serious.
These are urinary tract infections
that previously would've been treated
with an outpatient antibiotic prescription,
but because of the resistance issues,
folks are unfortunately having
to be hospitalized to be treated.
And in some cases, if those urinary tract infections proceed
to the bloodstream, they can be deadly.
I'd also highlight for you, and we do more work in this
to highlight the fact
that antibiotic resistance is a global phenomenon
and a global challenge.
While this is a report that is focused on the United States
and the threats that we face in the United States, we do note
and that this is one of the only pieces of data that we have
around the globe about the burden
of antibiotic resistance in a country.
So, we have good data from the US.
We have good data from European countries.
Outside of those two spheres, we don't have the same level
of data, and we don't have the same level of understanding
of the burden of resistance.
We don't have a good understanding
of the emerging forms of resistance.
Sometimes we are identifying emerging forms of resistance
for the first time when we see them in the US,
even though they may not have originated here.
And that's a big challenge for us in a big area, where we feel
like there's a lot more that the global community can do
and a lot more that CDC can play a role in,
in supporting other countries of the world
to address those infections.
The Threats Report also had a new addition,
which was the watch list.
The watch list was a little different
than the other categories of threats that we had
for the other pathogens, in that these three pathogens are ones
that we don't have good data on.
We don't have data on burden or deaths related to these threats,
but there are things that, and in fact, for some of them,
they may have extremely low incidence
or negligible incidence in the United States.
But there are things that we're seeing either in other parts
of the world or things that are poorly understood in the US,
and we need to have a better understanding of it and move
that forward for these pathogens.
I want to highlight
in particular azole-resistant Aspergillus fumigatus,
they're the first one.
This is one that we highlighted in the report and note
that this is a particular One Health threat and one
that we should be aware of.
Azoles are one of the main drugs and an important drug
for treating fungal diseases.
They're also used very widely around the world as a pesticide,
and what we're seeing in parts of Europe and the US is
that the use of those azoles as a pesticide is creating forms
of resistance that are then being inhaled
to immune compromised patients in the US and Europe
and likely other parts of the world.
And they are coming down with these azole-resistant
Aspergillus fumigatus infections,
and this is something
that I think we're paying close attention to and want
to learn more about some of the relationships here and figure
out how we can minimize these risks and how we can figure
out the best way to address these problems that we see
in both our plants as well as in people.
The report does also highlight the road ahead
and highlights the areas that we feel at CDC are where we need
to be moving with the our next action plan.
Folks may be aware that we are in the final year of the CARB,
Combating Antibiotic Resistant Bacteria action plan.
It runs from 2015 to 2020, and a new action plan is currently
under development across the US Government.
These are areas that we, at CDC, feel are critically important,
and they're not just the public health areas, but they're things
that we feel like need to be done across the spectrum
of both public health as well as academics, private industry
and greater engagement really from all stakeholders
from around the world.
Of course, all of this we sort of see
through a One Health approach, and we're taking that approach,
as we move forward with the new CARB 2.0 action plan,
which we hope to be released early next calendar year.
And with that, I will stop.
>> Thank you.
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