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Commentary: With Candida Auris, Worry About Transparency, Not Infection

U.S. News & World Report logo U.S. News & World Report 7/16/2019 Carol A. Heimer
This undated photo made available by the Centers for Disease Control and Prevention shows a strain of Candida auris cultured in a petri dish at a CDC laboratory. On Tuesday, April 25, 2017, New York state health officials provided new details about a continuing outbreak of the infection. The count is 44 now, up from a half dozen last fall. The fungus is a harmful form of yeast that was first seen in a patient in 2009, in Japan. Scientists say it can be hard to identify with standard lab tests, and more cases are being reported as doctors are looking harder for it. (Shawn Lockhart/CDC via AP) © (SHAWN LOCKHART/CDC VIA AP IMAGES) This undated photo made available by the Centers for Disease Control and Prevention shows a strain of Candida auris cultured in a petri dish at a CDC laboratory. On Tuesday, April 25, 2017, New York state health officials provided new details about a continuing outbreak of the infection. The count is 44 now, up from a half dozen last fall. The fungus is a harmful form of yeast that was first seen in a patient in 2009, in Japan. Scientists say it can be hard to identify with standard lab tests, and more cases are being reported as doctors are looking harder for it. (Shawn Lockhart/CDC via AP)

In any other year, it seems, this would be big news: A drug-resistant yeast is spreading around the world, behaving like a cross between a fungus and a bacterium. It lodges itself so tenaciously in hospital environments that cleanups can resemble demolitions. It can't be easily identified with standard laboratory methods, and it kills 30% to 60% of the people it infects.

The yeast, Candida auris, "is a creature from the black lagoon," according to Dr. Tom Chiller, who heads the Mycotic Diseases Branch of the U.S. Centers for Disease Control and Prevention. At the 20th Congress of the International Society for Human and Animal Mycology in Amsterdam in 2018, he also noted that C. auris is "more infectious than Ebola." Indeed, by the end of May C. auris had been reported in more than 30 countries, according to the CDC.

This sounds like the stuff of nightmares, or material for an update to the 2011 medical action thriller, "Contagion."

To make matters worse, some hospital administrators and state and local governments appear to be stonewalling. No need to frighten patients or potential patients or ruin the hospital's reputation by discussing the matter, some argue.

Although the CDC has the data, under its agreement with the states, the CDC is prohibited from releasing information about the locations and names of hospitals experiencing outbreaks. Hospitals in England and Spain have been equally secretive.

For those of us who study how societies cope with emerging infectious diseases, the mixture of uncertainty and fear are familiar. What is unfamiliar is the indifference to, or even endorsement of, secrecy.

Surprisingly, Chiller seems unperturbed about the secrecy, stating that C. auris "is not something I want the general public to go home and be concerned about."

Others seem to agree that the general public should not be worried. Although these microbes are everywhere, healthy people rarely become infected. And although C. auris has spread around the world, there still aren't many cases; the latest U.S. case count, issued in June, was 687.

More than 15 years ago, China was criticized for keeping secrets both from its citizens and from the rest of the world about the emergence of a new infectious disease there.

For four months, China failed to tell the World Health Organization about Severe Acute Respiratory Syndrome, which had turned up in Guangdong Province. Without official information, only tidbits were picked up by ProMed-mail and the Global Public Health Intelligence Network, the global health "rumor mills," as alarmed citizens and care-providers shared what they knew and sought information.

By the time China made its report in February 2003, SARS had begun its march around the world, ultimately reaching 30 countries, infecting over 8,400 people and killing about 10% of them before the epidemic was fully controlled in July 2003. Had China shared information sooner, the disease might have been confined to China with many infections and deaths prevented.

Now Americans are keeping critical health secrets. Although some public health experts seem untroubled by the secrecy, the rest of the world should be. Everyone needs to worry more about systemic problems than individual health.

A remedy requires three parts: following closely how global public health information is tracked, monitoring how cross-sector threats are managed, and making certain citizens have adequate information to watch the watchdogs.

Yes, the news on the adequacy of global public health tracking is generally good. The World Health Organization and the International Health Regulations, the treaty that governs global health surveillance, have become more robust and more comprehensive. In 2002-2003 when the SARS epidemic occurred, countries were required to report on only three diseases. That means China's failure to report SARS was not technically a violation of its treaty obligation.

Since then, the rules have changed. The most recent revision of the IHR mandates reporting on any "public health emergency of international concern" and tells countries how to determine whether a health problem has reached that level of severity.

And because the WHO is now empowered to draw on additional sources of information, it is less often hamstrung by countries' wishes to protect trade and tourism by denying disease outbreaks.

That global public health experts consider antimicrobial resistance to be an urgent problem is clear from the title of the United Nations report, "No Time to Wait," released in April along with recommendations on drug-resistant infections and clear evidence that 35 percent of human infections are drug-resistant.

Still, C. auris itself is not seen as rising to the level of being a "public health emergency of international concern" and therefore countries are not required to report these cases to the WHO, even though information has been shared with the World Health Organization and the CDC. C. auris cases are regularly reported to the CDC and to WHO's Global Antimicrobial Resistance Surveillance System.

Indeed the CDC was pro-active, circulating information about C. auris even before it arrived on American soil. At the same time, though, information has sometimes moved slowly, reaching the public as much as 18 months after an outbreak and then without identifying specific healthcare organizations.

Antimicrobial resistance is not just about how antimicrobials are used in healthcare settings. Unless policy makers, administrators, researchers, experts and health care officials tackle the overuse of antibiotics in animal husbandry and antifungals in agriculture, there is no hope of winning the battle against drug-resistant infections in humans.But governance of agriculture and human health are lodged in different bodies, making tracking and coordination difficult and regulation nearly impossible.

This is why transparency is critical. When Chiller and others argue that the general public doesn't need to be concerned about C. auris, they are drawing a distinction between concerns of public health and matters of personal health. Obviously these are different, but they are also linked.

Secrecy in medicine has a long and sordid history, including the familiar scandals around experimentation, mistakes and malpractice, and price gouging. Healthcare, pharmaceutical, and agricultural organizations, ever sensitive to their reputations and the bottom line, respond to public pressure.

Under the revised rules since SARS, the WHO can use unofficial sources of information to pressure states to report on health emergencies. If such unofficial leverage is effective in inducing more timely compliance by public bodies, citizen pressure is surely a resource during a health crisis that "threatens a century of progress in health" and is on track to kill 10 million people a year by 2050.

Copyright 2019 U.S. News & World Report

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