Infectious diseases make more resistant comeback

Complacency has fueled rise of resistant pathogens

Controlling new and re-emerging infectious diseases throughout the United States and the world is an ongoing and costly battle that consumes the time and resources of public health officials.

"Despite all the progress we are making, disease still seems to have the upper hand," said Sen. William Frist, MD (R-TN), during his keynote address at the International Conference on Emerging Infectious Diseases, held July 16-19 in Atlanta. "New diseases keep emerging and old diseases are making a comeback, stronger and more resistant to treatment than ever before."

Frist was one of several speakers who opened the second annual conference sponsored by the Atlanta-based Centers for Disease Control and Prevention that drew some 2,500 scientists and clinicians from around the world.

Jim Hughes, MD, director of the Atlanta-based National Center for Infectious Diseases and a second keynote speaker, said many scientists believed that the middle of the 20th century marked the end of one of the most important social revolutions in history with the virtual elimination of infectious diseases as a significant factor in social life.

"But a complacency has developed, which explains why we have gotten behind in dealing with infectious diseases," Hughes said. More than 30 new infections have been identified in the past 20 years.

Spread of disease creates desperate situation

The results of that complacency are all too familiar, said Frist, who recently returned from a second medical mission to Africa where he experienced first-hand poverty, infectious diseases, and a lack of hope among villages of people who live in unhealthy circumstances.

"My job in the Congress and yours on the front lines of science is not merely to see the world as it is, but the world as it could be if we do nothing to counter the consequences of disease," he told conference participants. "This medical mission to Africa reinforced everything we know and fear about infectious disease."

Sudan is a classic example of what has come to be known as "humanitarian warfare," a type of aggression characteristic of the post-Cold War era. This type of warfare, Frist said, deliberately seeks to inflict pain and suffering on civilian noncombatants by denying them vital human necessities.

Unlike other wars, where collateral damage is unintentional, "humanitarian warfare" uses starvation, forced migration, and the manipulation of medical resources and food supplies as an integral part of its military strategy, Frist said. "This is the place where health and national security really intersect."

It has been reported widely in recent months that the spread of HIV/AIDS in Africa is threatening the national security of the United States and that of other countries. And while infectious diseases are considered diseases of poverty, they also present obstacles to growth and development, said David Heymann, MD, executive director of communicable diseases for the Geneva-based World Health Organization. In low-income countries, about 45% of deaths are due to infectious diseases.

Goodbye to smallpox; hello to HIV

Just as one disease is eradicated, another often surfaces, particularly in developing nations, said Heymann. This is the case with smallpox, which has cost the world millions in lives and dollars. In the early 1980s, smallpox came under control worldwide at the same time AIDS became a threat.

Throughout sub-Saharan Africa, more than 23 million adults and children are infected with HIV. With an overall infection rate of about 8%, as compared to 1.1% worldwide, almost 14 million Africans have died from AIDS. "And this is the only region in the world where women are infected at a higher rate than men," Frist said. "About 55% of the HIV-positive adult population are women, and girls and young women are particularly at risk, with an infection rate of 15% to 23%."

As a result, 600,000 infants also have become infected through mother-to-child transmissions, either at birth or through breast feeding, causing eight million children to have lost one or both parents due to AIDS.

But AIDS is not the only infectious disease threatening Africa and other parts of the world, including the United States. Tuberculosis, the great killer of the 19th century, has re-emerged "with a vengeance, stronger and more resistant to drugs than ever before," Frist said. "It claims a million African lives each year, and today there are 16 million cases of TB worldwide. Of those, at least 1% to 2% are multidrug-resistant," he added.

Yet another re-emerging disease is malaria, which kills more than one million people each year — mostly children. Resistance to chloroquine, the former treatment of choice, is now widespread in 80% of the 92 countries where malaria is a major killer, Frist said. "It doesn’t take a surgeon to understand the threat of infectious disease, whether locally grown or borne on silent wings from a far-off corner of the world," he said. "It is a threat that is real and growing. And when you couple it with the potential that exists for our adversaries to deliberately target Americans through bioterrorist attack, the enormity of the problem becomes alarmingly apparent. Bioterrorism is not a question of if, but when." (See Hospital Infection Control, March 2000, pp. 29-39.)

Meeting the challenges of the threats

Research and drug development are necessary to meet the growing challenges emerging infectious diseases pose. As a senator, Frist has the ability to help obtain funding necessary to fight diseases.

To help stop the spread of HIV/AIDS, TB, and other infectious diseases, Frist proposed the Global AIDS and Tuberculosis Relief Act of 2000, an amendment that would provide $460 million for HIV/AIDS. Of that money, $300 million would go toward prevention and education, testing and counseling, medications to prevent transmission, and care for those living with HIV and AIDS.

In an effort to both improve the public health infrastructure and address the growing threats of antimicrobial resistance and bioterrorism, Frist recently introduced the Public Health Threats and Emergencies Act of 2000. "The bill reflects many of the recommendations presented to us by the CDC and many of the national groups and state and local representatives," he said.

If passed as submitted, the bill will:

• Strengthen public health departments and labs by enhancing the CDC’s ability to improve core capacities for basic surveillance technologies in labs at the federal, state, and local levels.

• Combat antimicrobial resistance by expanding National Institutes of Health research for the development of improved diagnostics tools and therapies for resistant pathogens.

• Help prepare the United States for a bioterrorist attack by strengthening its ability to detect and respond to the public health and medical consequences of bioterrorism.