Deadly Fungus-Related Disease Has the CDC Concerned

New Jersey Has Had the Third Most Cases in the United States
By RICK MELLERUP | May 22, 2019

Surf City — Forget lions and tigers and bears. Viruses, bacteria and fungi pose a much bigger threat in the United States.

Fungi? There’s a new drug-resistant fungus, discovered in Japan only in 2009, that has become a major public health threat. It is called Candida auris, and according to the Centers for Disease Control and Prevention there had been 613 confirmed cases of disease caused by the fungus reported in the United States as of March 31, the latest figures available. New Jersey accounted for 106 of those cases, making it the state with the third highest number of confirmed cases, behind only New York and Illinois.

Candida auris is a killer. According to the National Center for Biotechnology Information, patients with a delayed diagnosis of C. auris – and delayed diagnoses are common – had a mortality rate of 35.2 percent.

Before launching into a discussion of fungi in general and Candida auris in particular, it might be worth some time to quickly review the world of pathogens, microscopic organisms that cause disease. There are five main types – viruses, bacteria, fungi, protozoa and worms. Even though protozoa and worms can be debilitating and, yes, killers – malaria is caused by a protozoa – let’s focus in on viruses, bacteria and fungi.

Viruses – which have been described as “organisms on the edge of life” because although they possess genes, they do not have a cellular structure and require a host cell to reproduce – are notorious because they can’t be killed by the use of antibiotics. Ebola provides a good example.

Just the word ebola is enough to rapidly spread panic through a community, and for good reason. According to the CDC, “There is currently no antiviral drug licensed by the U.S. Food and Drug Administration to treat EVD (Ebola Virus Disease).” So treatment can only be “supportive” in nature, such as providing fluids and electrolytes via intravenous infusion, offering oxygen therapy to maintain oxygen status, using medication to support blood pressure, reduce vomiting and diarrhea and to manage pain and fever, and treating secondary infections if they occur. Ebola can be defeated only by a victim’s own immune system; the World Health Organization says the average EVD case fatality rate is around 50 percent.

Vaccines, however, have been developed for some viruses. At this time there is no Ebola vaccine that has been approved for clinical use in humans, but polio and measles provide good examples of diseases with vaccines that are extremely effective.

Polio, according to the WHO, has not been eradicated worldwide, but thanks to vaccines it has been greatly reduced. “Polio does still exist, although polio cases have decreased by over 99 percent since 1988 (when WHO launched the Global Polio Eradication Initiative) from an estimated more than 350,000 cases to 22 reported cases in 2017.” The situation is even better in the U.S. According to the CDC, “Since 1979, no cases of polio have originated in the United States. However, the virus has been brought into the country by travelers with polio. The last time this happened was in 1993.”

But, of course, people have to get their shots to prevent outbreaks of preventable viral diseases. Many Americans, due to religious beliefs or because of fear produced by the anti-vaccination movement, have failed to have their children immunized against measles. That’s the reason why the CDC reported on Monday that 839 cases of measles have been confirmed from Jan. 1 to May 10 this year, the greatest number of cases in the U.S. since 1994. New Jersey accounted for 14 of those cases as of April 23 and Ocean County witnessed a major outbreak in Lakewood in the autumn and winter of 2018.

Let’s move on to bacteria.

It appeared that the deadly reign of bacteria, which had killed untold numbers of humans over the course of history (bubonic plague, for example, is caused by a bacterium), would come to a close starting in 1942 when the life of a woman named Anne Sheafe Miller was saved by a new drug, penicillin. Since then Scottish chemist Alexander Fleming’s discovery (by accident in 1928) has saved an estimated 80 million to 200 million people. And penicillin is just one of the “wonder drugs” in the modern medical arsenal that includes over 100 antibiotics.

But bacteria have fought back since the very beginning of the age of antibiotics. Simple one-cell organisms, they reproduce quickly by dividing. According to Microbiology Online, “When conditions are favorable such as the right temperatures and nutrients are available, some bacteria like Escherichia coli can divide every 20 minutes. This means that in just seven hours one bacterium can generate 2,097,152 bacteria.”

Every time a cell divides, the risk of mutation raises its ugly head. If a mutation gives a bacterium an advantage, such as resistance to an antibiotic, it thrives while its microbiological relatives are killed.

The risk of antibiotic resistance was recognized early on. In fact, Fleming himself, the father of antibiotics, warned of the danger in his remarks made at the ceremony where he collected his Nobel Prize for Medicine in 1945.

Now, according to the CDC, antibiotic resistance has become a huge problem. “Each year in the U.S., at least two million people are infected with antibiotic-resistant bacteria, and at least 23,000 people die as a result. ... If antibiotics lose their effectiveness, then we lose the ability to treat infections and control public health threats.”

Unfortunately, drug resistance isn’t limited to bacteria.

Fungi All Around:

Some 120,000 Species

Fungi are so common that they are classified as a kingdom, the second-highest level in taxonomy, the science of naming, defining and classifying biological organisms on the basis of shared characteristics. They belong to the domain (the top classification group in taxonomy) Eukaryota, organisms whose cells have a nucleus enclosed within membranes, a domain that also includes the animal and plant kingdoms.

There are about 120,000 species of fungi that have been identified, but estimates of the total number of fungi species run as high as 2.2 million to 3.8 million!

The public often associates fungi with their most obvious representatives, mushrooms. But yeasts, mildews and molds, along with rusts and smuts that cause plant diseases, are also fungi. So it shouldn’t be surprising that the spores – asexual reproductive units that are usually microscopic – of fungi can be found by the trillions or more in water, soil and the air. Indeed it is estimated that humans inhale between 1,000 and 10 billion spores on an average day. Luckily, most fungi are harmless to humans thanks to our incredible immune systems, but certainly not all.

Fungi have long been known to cause human diseases. According to the CDC, fungal nail infections, vaginal candidiasis, a.k.a. vaginal yeast infection, ringworm and Candida infections of the mouth, throat and esophagus, also known as thrush, are the most common. But there are more-serious diseases caused by fungi, such as Pneumocystis pneumonia (PCP), mucormycosis and aspergillosis.

There’s not time to explain the aforementioned diseases. But they, as do many other fungi-caused diseases, have a common thread. Remember the earlier mention of the remarkable human immune system? Well, our immune systems mostly fight off fungi-caused diseases, so such diseases are usually found in persons with weakened immune systems. PCP, for example, was quite common in people with HIV/AIDS before the development of antiretroviral therapy.

Drug-Resistance

And Secrecy

If our own immune systems provide the first line of defense against fungi-related infections, three classes of drugs called antifungal agents – azoles, polyenes and allylamine/thiocarbamates – constitute the second. What makes Candida auris so frightening is that it has developed resistance to those drugs.

“Antifungal medicines commonly used to treat Candida infections often don’t work for Candida auris,” says the CDC. “Some C. auris infections have been resistant to all three types of antifungal medicines.”

Have no doubt about it, Candida auris is dangerous.

“C. auris can cause bloodstream infections and even death, particularly in hospital and nursing home patients with serious medical problems,” says the CDC. “More than one in three patients with invasive C. auris infection, for example, an infection that affects the blood, heart, or brain, die.”

Candida auris is difficult to identify. According to the CDC, it “can be misidentified as other types of fungi unless specialized laboratory technology is used. The misidentification might lead to a patient getting the wrong treatment.”

Finally, C. auris can spread in hospitals and nursing homes. “C. Auris has caused outbreaks in healthcare facilities and can spread through contact with affected patients and contaminated surfaces or equipment,” says the CDC. “Good hand hygiene and cleaning in healthcare facilities is important because C. auris can live on surfaces for several weeks.”

The CDC says, “C. auris is still rare in the United States.” But it also says the disease is “becoming more common.” “Although C. auris was just discovered in 2009, it has spread quickly and caused infections in more than a dozen countries.”

The CDC was right in saying that hand hygiene and cleaning are important in healthcare facilities. “Universal precautions” have been the rule in hospitals and other healthcare facilities for decades. But cleaning up after Candida auris is a labor worthy of Hercules.

Matt Richtel and Andrew Jacobs of The New York Times showed how difficult ridding a healthcare facility of C. auris can be in an April 6 article. They recounted the experience of the Brooklyn branch of Mount Sinai Hospital after an elderly man was admitted for abdominal surgery and a blood test revealed the germ in the patient:

“The man at Mount Sinai died after 90 days in the hospital, but C. auris did not. Tests showed it was everywhere in the (isolated) room, so invasive that the hospital needed special cleaning equipment and had to rip out some of the ceiling and floor tiles to eradicate it.

“‘Everything was positive – the walls, the bed, the doors, the curtains, the phones, the sink, the whiteboard, the poles, the pump,’ said Dr. Scott Lorin, the hospital’s president. ‘The mattress, the bed rails, the canister holes, the window shades, the ceiling, everything in the room was positive.’”

How did Candida auris become drug-resistant? Scientists have long blamed drug-resistance in bacteria on overuse, both over-prescribing by doctors for things such as colds (a virus, so antibiotics would be useless), and widespread prophylactic use on farms. Some scientists blame the latter for the Candida auris situation, saying the rampart use of fungicides on crops is contributing to the surge in drug-resistant fungi infecting humans.

Another problem, as reported by Richtel and Jacobs, is a culture of secrecy within the medical establishment.

“With bacteria and fungi alike, hospitals and local governments are reluctant to disclose outbreaks for fear of being seen as infection hubs. Even the CDC, under its agreement with states, is not allowed to make public the location or name of hospitals involved in outbreaks. State governments have in many cases declined to publicly share information beyond acknowledging that they have had cases.”

— Rick Mellerup

rickmellerup@thesandpaper.net

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