Emerging Diseases
Speaker: Dr. Stephen Ostroff
Primetime Summit 1

Transcript of Proceedings
June 4, 1999

DR. OSTROFF: Sonny asked me to talk about what keeps me up at night worrying about various things that are going on in the world of infectious diseases. As Sonny said, it's not Ebola, it's not Marburg, because I think you're absolutely correct, I think most people who live in Nebraska or Los Angeles don't have to worry that tomorrow they're going to get exposed to the E Bola virus. Let us at CDC worry about that. You have a lot of other things to worry about.

I'm sure that there are a lot of people in the LA basin who have lost a lot of sleep over anthrax in the past six months. As many of you know, there's been this string of anthrax hoaxes that have occurred from one end of the country to the other. We're almost at the point of saying, with the FBI, that it's become the bomb scare of 1999. If you want to cause a little bit of mischief and trouble, tell somebody that you put anthrax into the courthouse in Van Nuys, or tell somebody that you put anthrax in the air system of the rave party, somewhere down in Riverside or San Bernardino. You'll get a pretty vigorous response to that. And so, if you want to get some attention, that's how people are doing it these days. Unfortunately, they do it a lot of times at midnight and one o'clock in the morning, and then my beeper goes off, and I get awakened. We've really hyped these very bizarre, peculiar diseases, like anthrax. I mean, it's all you hear about these days. I don't know quite how to ratchet down that hysteria. But we've had probably 200 to 250 of these anthrax hoaxes, um, in the past six months, and they're really very, very problematic for us in terms of trying to approach these. They've gotten into the middle of the abortion wars. One week it'll be a series of envelopes going to abortion clinics all around the United States saying, when they open up the envelope, you've just been exposed to anthrax. This is a form of psychological terror, another type of terror for these poor people who work in these clinics. Then, the next week, it's just the opposite. The pro-abortion forces send them to the anti-abortionists, and Catholic schools, and places like that and then we have the scares in the other direction. They're using this, because they know about it and because it's a fad.

But, setting that aside, there are a lot of things that sort of keep me up at night and keep me concerned that are the emerging infectious diseases that we can do something about. Worry about doing the things that you can do to reduce the risk of being the victim of one of these emerging infectious diseases that are right there, on your plate, in your neighborhood, with the person sitting next to you on the subway. And what are they? Let me just start with a little list. One of them is vaccines, immunizations. There are a lot of really problematic illnesses that cause a lot of disease in the United States, like influenza, pneumonia, for which we have very effective vaccines. The problem is, that even in the best of circumstances, with the groups that we attempt to target to get these vaccines our success rate, even in the best of circumstances, is maybe 50 or 60 percent. Despite the fact that we try to get our message out there we can't do any better than that.

Influenza is a disease that every year in the United States, even in the best of circumstances, kills maybe 15 or 20,000 people a year. There's a great vaccine out there. Why can't we get some messages across to those that we target to get this vaccine to make sure that they can do what's necessary to protect themselves from getting influenza. The same with the pneumonia vaccine, which is directed against an organism called the pneumococcus. It's a wonderful vaccine. You only have to get it once, or maybe once every six years or so. In this country, fewer than 20% of the targeted population receives this particular vaccine, particularly elderly individuals. And for the life of us, we can't figure out strategies to try to increase the amount of vaccine that's used in the populations that should receive it. We need to think creatively with you about how we can put messages out there about the positive beneficial effects of getting these vaccines.

When I think about what could reverse many of our successes that we've had in the United States and elsewhere in combating infectious diseases, the problem is antibiotic resistance. This is an emerging phenomenon that we've been seeing increasingly for the past maybe 30 years or so which is tremendously picking up speed now in the 1990s. It's happening not only in the hospital environment, but it's also happening out there in the community. We know, as an example, that everyday in this country there are about five million doses of antibiotics that are prescribed in the outpatient setting. In the hospitals, there are about 190 million doses of antibiotics that are administered everyday in the United States.

That's a tremendous force that's just pushing and pushing and pushing and pushing and pushing all of these bugs to become resistant to the antibiotics that we need when people really need them. We've rapidly seen the pneumococcus, which is the most common reason for bacterial pneumonia in the United States very rapidly acquiring resistance to all of the major antibiotics that we have available to us. And for any of you who have young children having ear infection after ear infection after ear infection after ear infection that doesn't seem to respond to antibiotics, it's the cause of about seven to eight million cases of middle-ear infections in the United States every year. And it's the most common cause of meningitis in this country.

In the most severe cases of meningitis, we're basically down to one antibiotic, which is Vancomycin. Vancomycin is also the last antibiotic that we have available to treat what is the most common of the hospital-acquired infections, staphylococcus aureus. And, just within the past couple of years, we've now started seeing strains of staph aureus that are acquiring resistance to Vankomycin. When they become fully resistant to Vankomycin, we will have nothing left to be able to treat the most common hospital-acquired infection. It's a real problem. Now, why do we have so much of a problem with antibiotic resistance? People tend not to think of behavior so much in association with infectious diseases. But antibiotic resistance is probably our best example of a behavioral disorder leading to an infectious disease problem. And we like to talk about it as sort of being three legs of the stool, because there are three different entities that are sort of pushing the problem of antibiotic resistance.

One of them is the patient themselves, the second is the health-care provider, and the third is the pharmaceutical industry. Let's go through each of these separately. Let's look at the patient. One of the things that we know, people love antibiotics. I mean, they absolutely love antibiotics for every cold, for every runny nose, for every scratch, they want an antibiotic. And they go to their health care provider, and they demand an antibiotic. And if they don't get them from one health-care provider, they'll go down the street to another health-care provider until somebody gives them the antibiotic. I will point out, if you go to the developing world, it's even worse, because you don't have to go to a health-care provider. You just go to a store and you buy them. So patients really demand antibiotics. And then what happens once they get them? Well, if the prescription says take it three times a day for seven days, or take it three times a day for 10 days, what do they do? I mean, we're all guilty of it. You take it three times a day for a couple of days, and then you start feeling better, and maybe you take it once a day, maybe twice a day, and then after a couple more days, you stop it. And what you've done by doing that is kind of kill off all the weak ones and left behind all the more resistant ones, so that you then are in a position to transmit those more resistant bugs to somebody else.

The other question is, what do you do with those leftover pills? Well, you put them in the medicine cabinet. I could probably go into half the medicine cabinets of people's homes in this room, and I'll find lots of antibiotics sitting up there on the shelf. What happens is, the next time you get sick, or the next time somebody else in your family gets sick, you pull them off the shelf and you give them to them.

Whether they work or not. That's a behavioral problem. Somehow we have to convince people, not only doesn't it work, but it has really negative consequences for sort of the larger community, not only in Los Angeles, but the larger community of microbes, because it just pushes and pushes and pushes us towards the more resistant microbes.

Let's look at the physician, or the health-care community in the United States. Physicians love to prescribe antibiotics, because they don't see any down side to prescribing antibiotics. All they know is it gets the patient out of their office. In these days of managed care you can't afford to be wrong. Maybe they all know that this particular cold or this particular scratch might not be responsive to antibiotics, but maybe it's the one in a thousand that would be. And I don't want to be the one to get it wrong. If you come back a day or two later, no better, then it's an extra charge and I don't get reimbursed for that, or I don't want to have a malpractice suit or whatever it happens to be. So they give them the pills. They're the second part of the problem. Patients love them, and physicians love to give them.

The third part of the problem is the pharmaceutical industry, because they don't want you to prescribe amoxicillin, or they don't want you to prescribe doxycycline. They want to prescribe the razzle-dazzle new, hot drug on the market that costs 10 times what these simpler ones do. They are much more powerful and kill off a whole variety of different bugs.

By doing that, what they do is they drive the organisms to become much more resistant to these newer antibiotics, and it's kind of the tortoise and the hare. What we do is every once in a while, we come up with a new antibiotic, and we leap ahead of the bugs once more. But the bugs are relentless. They have nothing else to do but sort of wait and wait and wait for their opportunity, and they do it. Unfortunately, they're winning this race. Most of us don't remember that antibiotics really only came around in the 1930s and '40s. We hate to think that in the coming years we'll be back where we were in 1910 with some of these organisms, which is basically nothing that we can do to treat them. And that worries us a lot. More than anything else, that has the potential to drive us backward from the successes that we've had with emerging infectious diseases.

I hope that there would be some opportunities to incorporate messages wherever possible about the importance of not demanding antibiotics, the importance of taking them the way they're prescribed, and the importance of using the appropriate antibiotics.

We know, for instance in the hospital that's one of the main ways that bugs will go from one patient to another. It's certainly one of the main ways that flu bugs and various respiratory viruses go from one person to another. It's a really simple message, and it's a very effective message. We know that we can do something about 20 to 30 percent of the bugs that cause respiratory infections in the winter. We don't need to use all this razzle-dazzle antibiotic impregnated high chairs and all these anti-bacterial soaps that are available and things like that. All we need to do is get people to wash their hands. There are a lot of really very simple messages that over the long term will do a tremendous amount to reduce the risks, from having their kid develop terrible kidney failure because of eating an undercooked hamburger to preventing somebody from getting one of these highly drug-resistant staph aureus infections.

We know that there's a wonderful vaccine out there that will prevent many of our elderly individuals from getting a very bad pneumonia with an organism that we can't treat with antibiotics anymore. We just need somehow to be able to figure out how to get those messages across to people. And I hope that there is really an opportunity to dialog and try to get some of these messages very simply into the programs that you do such a wonderful job writing and directing and producing everyday. I look forward to the opportunities to work with you. We have enough shows on Ebola. The good part of it is to try to get these messages across to the public so they don't do things like eat raw hot dogs, or they don't do things like not wash their hands, or they don't do things like not get their kids vaccines. Thanks for your attention.