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Nation Unprepared for Microbial Threats, IOM Reports

Donna Young

Just as the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) were alerting the world in mid-March to a new public health threat—severe acute respiratory syndrome (SARS)—the Institute of Medicine (IOM) warned that the United States was inadequately prepared to prevent, detect, and control emerging and resurgent microbial threats to residents’ health.

Infectious diseases pose a global threat that requires a global response, said the authors of an IOM report released on March 18.

In its report, “Microbial Threats to Health: Emergence, Detection, and Response,” IOM said that the rapid transport of humans, animals, foods, and other goods through international travel and commerce can lead to the broad dissemination of pathogens and their vectors throughout the world.

In today’s highly interconnected and readily traversed global environment, said Margaret A. Hamburg, vice president for biological programs for Nuclear Threat Initiative in Washington, D.C., and cochair of the committee that wrote the report, “one nation’s problem soon can become every nation’s problem.”

Infectious diseases traverse geographic and political boundaries, therefore every nation and every person is at risk, the IOM report said.

For up-to-date information on severe acute respiratory syndrome, go to the Web sites for the World Health Organization and the Centers for Disease Control and Prevention.
When WHO issued its global alert to health care workers and the public about SARS on March 12, there were 167 confirmed cases of the infection and 4 reported deaths. WHO’s emergency travel advisory, issued three days later, did not restrict travel and only warned travelers and airline workers to be aware of symptoms associated with SARS. 

Three weeks later, WHO reported that SARS had rapidly spread to 15 countries and had infected more than 2220 people, killing almost 80.

WHO issued a recommendation on April 2 that persons traveling to Hong Kong and Guangdong province of China—places where some of the first cases of SARS were identified and the infection had continued to spread—should consider postponing all but essential travel.

The warning was issued after at least nine people—travelers, tourists, and businessmen from China, Taiwan, and Singapore—had been diagnosed with SARS after visiting Hong Kong, said David Heymann, executive director of communicable diseases for WHO, at an April 2 press briefing.

The first WHO officer to identify the outbreak of SARS in Vietnam, Carlo Urbani, a physician and an expert in communicable diseases, died of SARS on March 29 in Hanoi, Vietnam, after treating an American businessman who had the disease.

“Individuals travel to the other side of the planet in less time than it takes to manifest symptoms of disease, potentially infecting anyone they encounter along their route,” IOM warned in its report.

SARS is a “perfect example” that the globalization of infectious diseases “is no longer a theoretical risk,” said Marianne Billeter, clinical pharmacy specialist in infectious diseases at the Ochsner Clinic Foundation in New Orleans, Louisiana.

Billeter was recently named to an expert panel convened by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to assess its infection control standards.

JCAHO announced in January that accredited health care organizations must conduct a root cause analysis whenever a patient dies of or is seriously harmed by a nosocomial infection.

Illnesses such as West Nile encephalitis and hantavirus pulmonary syndrome have emerged in the United States in recent years, killing hundreds of Americans. Other diseases, including measles, tuberculosis, and malaria, have reappeared, IOM said.

Billeter noted that IOM’s report highlighted the lack of development of new antimicrobials and vaccines and periodic shortages of certain vaccines.

Too little has been done to resolve this issue, IOM said, warning that the world, not only the United States, faces “a serious crisis with respect to vaccine development, production, and deployment.”

IOM recommended that the U.S. Secretary of Health and Human Services ensure the formulation and implementation of a national vaccine strategy for protecting the nation’s population from endemic and emerging microbial threats.

Also, the federal government should work closely with industry and academia to ensure the rapid development and deployment of vaccines that protect against naturally occurring or man-made microbial threats to national security.

Billeter said the Bush administration has focused more attention on theoretical threats, such as smallpox, rather than active threats like influenza and other diseases.

In recent years, there have been shortages of several childhood vaccines, she noted.

Production and dissemination of the influenza vaccine in 2001 was delayed, resulting in many people not being immunized that year.

But Billeter noted that, even when vaccines, such as those for pneumococcal disease and influenza, are available, many adults are not getting vaccinated.

“The bottom line is, we have the vaccines, but we are not using them,” she said, adding that hospitals need to develop and implement inpatient influenza and pneumococcal immunization programs.

“This is where pharmacy has a big role,” she stated.

Billeter’s hospital identifies, during the initial assessment at admission, patients needing vaccinations, she said. If a patient indicates that he or she would like to be vaccinated, the hospital’s admission system generates an automatic order that is sent to the pharmacy.

Many essential antiinfectives are also in short supply, IOM noted in its report, and the development of new ones has been severely curtailed.

In the past two decades, the report said, only two new classes of antiinfectives have been developed, and resistance to one class, which IOM did not identify, emerged even before the drugs entered the commercial market. There were only four pharmaceutical companies in 2002 that had antiinfective research programs, according to IOM, and relatively few antivirals are available or in development.

The federal government should take an active role in creating incentives and even regulations for pharmaceutical companies to stimulate research and development of antiinfectives, said Russell Lewis, assistant professor for the University of Houston College of Pharmacy.

Pharmaceutical companies “recognize that, for an antibiotic, you are asking somebody to make medications that people take for 10 days, versus if you develop a lipid therapy or hypertension [therapy], you have medicines that people are on for the rest of their lives,” he said. “You can see why [the companies] are moving away from antibiotics. That’s not a moneymaking area.”

According to IOM, a steady global increase in the number of microbes resistant to available therapies has made it difficult to treat infections.

Pharmacists play a large role in helping to educate the public and other health care professionals about the inappropriate uses of antiinfectives, Lewis said.

Billeter said azithromycin, prepackaged in three- and five-day regimens, is one of the most inappropriately used drugs because physicians can conveniently prescribe a short course of the relatively nontoxic antimicrobial to satisfy patients. Other antiinfectives inappropriately prescribed by physicians include amoxicillin for children and fluoroquinolones for adults.

About 50% of prescriptions for antimicrobials are inappropriate, Lewis stated, referring to findings by CDC.

Billeter said pharmacists should discuss with patients the indication, dosage, and duration of therapy of prescribed medications.

Pharmacists should also actively educate and counsel patients about the importance of finishing all of a prescribed antiinfective, Lewis added.

IOM suggested that the United States also take a leadership role in promoting the implementation of a comprehensive surveillance system to globally track infectious diseases.

Current surveillance systems in the United States are fragmented and have not kept up with technological advances. IOM said that CDC should implement a national electronic reporting system that links to state health department clinical laboratories.

In addition, IOM noted, the federal government has neglected the infrastructure of public health. Upgrading public health capacities will require considerably increased and sustained investments.

The United States must also do a better job of educating its health care professionals on how to properly identify and report infectious diseases, IOM said.

“The knowledge and skills needed to confront microbial threats must be better integrated into the training of all health care professionals to ensure a prompt and effective response to any and all infectious disease threats, whether naturally occurring or maliciously introduced.”