Antibiotic-resistant infections kill 23,000 people in the US and sicken two million each year, and the problem is getting worse, warns a new report from the Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2013 ranks several strains of bacteria according to their current and projected health and economic impacts. It describes 18 microorganisms whose threat levels are “urgent,” “serious,” or “concerning.”
CDC identifies three bacteria as urgent threats: Clostridium difficile, Carbapenem-resistant Enterobacteriaceae (CRE), and Drug-resistant Neisseria gonorrhoeae. C. diff is included on the list even though most infections from it aren’t resistant to typical treatments, because most of these infections “are directly related to antibiotic use and thousands of Americans are affected each year.” (The fact that C. diff infections often arise after a course of antibiotic treatment has prompted a few clinicians to treat persistent cases with “fecal transplants” — essentially, trying to repopulate patients’ guts with a mix of normal bacteria that can keep C. diff in check.) CDC’s report offers snapshots of each of these bacteria:
- Clostridium difficile causes life-threatening diarrhea, and mostly infects hospitalized or recently hospitalized patients who’ve recieved antibiotics. A stronger strain of the bacteria emerged in 2000, demonstrating resistance to fluoroquinaolone antibiotics (a common treatment for other infections). C. diff causes 250,000 infections, 14,000 deaths, and $1 billion in excess medical costs each year.
- Carbapenem-resistant Enterobacteriaceae (CRE) include Kleibsella and E. coli bacteria that are resistant to carbapenams, which are often used as antibiotics of last resort. The bacteria are resistant to all or nearly all of the antibiotics available, and nearly half of hospital patients who get CRE bloodstream infections (a minority of healthcare-associated CRE cases, at the moment) die. CRE causes 9,000 infections and 600 deaths each year.
- Drug-resistant Neisseria gonorrhoeae causes the sexually transmitted disease gonorrhea, which is the second most commonly reported notifiable infection in the US, and is showing resistance to the antibiotics normally used to treat it, including tetracycline and cefixime. Out of an estimated 820,000 US gonorrhea cases in 2011, 246,000, or nearly one-third, were resistant to at least one antibiotic.
The 12 “serious” threats include multidrug-resistant Acinetobacter, drug-resistant Campylobacter, Vanomycin-resistant Enterococcus (VRE), and the poster bug of antibiotic resistance, Methicillin-resistant Staphylococcus Aureus (MRSA).
CDC recommends four core actions to address these threats:
- Preventing Infections, Preventing the Spread of Resistance: Avoiding infections in the first place reduces the amount of antibiotics that have to be used and reduces the likelihood that resistance will develop during therapy;
- Tracking: CDC gathers data on antibiotic-resistant infections, causes of infections and whether there are particular reasons (risk factors) that caused some people to get a resistant infection;
- Improving Antibiotic Use/Stewardship: Perhaps the single most important action needed to greatly slow the development and spread of antibiotic-resistant infections is to change the way antibiotics are used;
- Development of Drugs and Diagnostic Tests: Because antibiotic resistance occurs as part of a natural process in which bacteria evolve, we will always need new antibiotics to keep up with resistant bacteria as well as new diagnostic tests to track the development of resistance.
Maryn McKenna’s Superbug blog is always the first place I go for expert analysis of bacteria-related news, and she has two great posts about the report: “CDC Threat Report: ‘We Will Soon Be in a Post-Antibiotic Era’” summarizes the report’s findings and the pace of progress to address the threats; “CDC Threat Report: Yes, Agricultural Antibiotics Play a Role in Drug Resistance” highlights the report’s many references to the role of large-scale livestock operations in antimicrobial resistance. Perhaps most striking is the report’s graphic on the development of antibiotic resistance:
McKenna also notes, “Out of the 18 drug-resistant organisms the report highlights as alarming, four are foodborne organisms that become drug-resistant as the foods that carry them are produced or grown: Campylobacter (p. 61), E. coli (p. 65), Salmonella (p. 70) and Shigella (p. 75).”
The report lists action steps CDC, states and communities, healthcare leaders and providers, and patients and their families can take to reduce the development of antimicrobial resistance and the spread of resistant bacteria. In addition, Congress could pass the Preservation of Antibiotics for Medical Treatment Act, and FDA could collect and publish better data on use of antibiotics in livestock and restrict livestock operations’ use of antibiotics to therapeutic purposes (i.e., let producers give antibiotics to infected animals but not routienly dose the whole herd for growth promotion). The decisions we all make today will determine how quickly we recover — or die — from infections in the future.
Related past posts:
Study: Industrial food-animal workers test positive for livestock-associated MRSA
Chicken, UTIs, and a long-festering antibiotic problem
How meaningful is FDA’s latest move on antibiotics in livestock?
On World Health Day, Confronting the Menace of Antimicrobial Resistance
Senator Kirsten Gillibrand introduced last week the Safe Meat and Poultry Act (S. 1502). The bill would require USDA’s Food Safety Inspection Service (FSIS) to take new steps to decrease foodborne pathogens, including authority to compel producers to recall contaminated meat and poultry.
The legislative text is 73 pages long, but one short paragraph caught my eye: a provision addressing the serious health and safety hazards to which meat and poultry workers are exposed. It’s an issue that we’ve written about many times (e.g.. here, here, here, here, here, here, here, here, here). It remains in the forefront because USDA Secretary Tom Vilsack continues to insist on a plan to “modernize” poultry slaughter. In it, poultry producers will be able to significantly increase line speeds posing an even greater risk to the health of workers employed in their processing plants.
S. 1502 will do a little to address that problem. Section 402 provides for an ongoing assessment of occupational health for workers in meat and poultry plants. In particular, it would require USDA to cooperate with CDC’s National Institute for Occupational Health & Safety (NIOSH) and OSHA, to prepare a biennial report which includes:
- information on trends in occupational health and safety in federally inspected meat and poultry establishments;
- recommendations for improving the work environment for both the employees of the plants, as well as federal inspectors who also work day-to-day in these plants; and
- findings and recommendations for an appropriate maximum line speed in establishments that slaughter and process meat and poultry, to ensure, in the Secretary of Labor’s determination, worker safety.
In 2009, Nebraska Appleseed issued its report “The Speed Kills You: The Voice of Nebraska’s Meatpacking Workers.” In a survey of 455 workers from five Nebraska communities excessive line speed was the most commonly expressed concern about the safety of their workplaces. Similarly, a report released this year by the Southern Poverty Law Center (SPLC) and Alabama Appleseed, “Unsafe at these speeds: Alabama’s poultry industry and its disposable workers,” described the findings of interviews with 302 poultry workers. The punishing speed of the production lines was the workers’ greatest concern. More than three-quarters of the workers said line speed made their work dangerous and was the dominant factor for them in developing musculoskeletal disorders. The authors note:
“If the line seems to move at a pace designed for machines rather than people, it should come as no surprise. Plant workers, many whom are immigrants, are often treated as disposable resources by their employers. Threats of deportation and firing are frequently used to keep them silent.”
The authors of those reports and the meatpacking and poultry processing workers they represent reacted this way to Senator Gillibrand’s bill:
“We’re very happy to see that Senator Gillibrand has brought attention to important and often-overlooked consumer and worker safety issues,” remarked Tom Fritzsche with SPLC. “The information sharing and recommendations that this legislation would produce are a step in the right direction, but should not be the only step. America’s meat and poultry workers need action to slow down lines now.”
Earlier this month, SPLC, Nebraska Appleseed and other workers’ rights groups filed a petition with USDA and OSHA urging the agencies to issue a regulation on line speed. They eagerly await the agencies’ response.
Earlier this week, Michigan Governor Rick Snyder signed legislation that accepts the Affordable Care Act’s Medicaid expansion for his state, and Pennsylvania Governor Tom Corbett has signaled his intention to do so if the federal government approves his proposed program changes. Wonkblog’s Sarah Kliff notes that if Pennsylvania does expand its Medicaid program, that will mean the majority of the states have adopted one of the main aspects of the Affordable Care Act. This is good news for the millions of low-income uninsured US residents who will gain health coverage from Medicaid.
Another recent headline comes from a study, published in the journal Women’s Health Issues, reporting that nearly half of all US births (48%) in 2010 were covered by Medicaid. (Disclosure: Three of the study authors are from the George Washington University School of Public Health, where I work.) This is up from a previous estimate of 45% of all births, and it emphasizes the importance of Medicaid’s role in public health. The authors (Markus et al) note, “As states expand coverage to low-income women, women of childbearing age will be able to obtain coverage before and between pregnancies, allowing for access to services that could improve their overall and reproductive health as well as birth outcomes.” I hope governors and legislators in the 24 states that haven’t yet accepted the expansion will keep this in mind as they consider the future of their Medicaid programs.
First, some background: The Affordable Care Act, also known as Obamacare, has two main mechanisms to help those who are uninsured get affordable health insurance. First, it expands eligibility for Medicaid to citizens and legal residents of 5+ years who have incomes of up to 133% of the federal poverty level, and the federal government will cover 100% of the costs of this expansion initially and no less than 90% in all future years. (Generally, the federal government covers 50 – 75% of Medicaid beneficiaries’ healthcare costs; percentages vary depending on states’ economic circumstances.) Second, the ACA establishes state health insurance exchanges, or marketplaces, where all legal US residents can buy individual coverage and those with incomes of 100-400% FPL can get sliding-scale subsidies toward premiums. The Supreme Court made this all a lot more complicated when it decided that the Medicaid expansion portion of the law would be optional for states.
People eligible for coverage under the Medicaid expansion are far from wealthy: In 2013, the federal poverty level is $11,460 for a one-person family (133% is $15,282), and $23,550 for a four-person family (133% is $31,322).
Medicaid and women of childbearing age
In order to get federal funds for their Medicaid programs, states have long been required to cover certain populations, including pregnant women and children up through age five with family incomes of up to 133% of the federal poverty level, children ages 6 – 18 with family incomes of up to 100% FPL, and low-income adults with dependent children (income cutoff limits for this group vary by state). Many states have expanded eligibility beyond the federal minimums; in the case of pregnant women, 19 states and the District of Columbia will enroll women with incomes of up to 185% FPL; 15 states have cutoffs of 200 – 299% FPL, and Iowa and Wisconsin allow pregnant women with incomes of up to 300% FPL to enroll in Medicaid. All women who become eligible for Medicaid based on pregnancy status retain the coverage for 60 days after giving birth.
Before becoming pregnant and after 60 days post-partum, though, it’s often hard for non-disabled low-income women under age 65 to get Medicaid coverage. Only eight states and the District of Columbia offer full Medicaid coverage to childless adults, and income cutoffs for parents of dependent children have a median of 61% for working parents and 37% for non-working parents. Several states have used Medicaid waivers and federal Title X funds to offer family-planning services and pre-conception or inter-conception care to low-income women, and some states have used waivers to extend Medicaid coverage to women who lose it after a baby’s birth or an increase in family income.
The ACA’s Medicaid expansion does not address the health of undocumented immigrant women or those who have been in the US legally for fewer than five years, who are ineligible for Medicaid coverage. Strict requirements for proof of legal status can also pose a barrier to enrollment for women who are eligible but have difficulty obtaining the required documentation. Some states use their own funds to cover women who do not meet federal requirements for immigration status or documentation.
Women’s health and birth outcomes
It’s in states’ interest to cover pregnant women, so that they can have access to prenatal care that can contribute to healthy babies — but women’s health and healthcare prior to conception also matters. “Rising rates of maternal mortality, stagnant rates of infant mortality, high proportions of preterm and low birthweight births, and continuing disparities in pregnancy outcomes in the United States have prompted a number of states to increase their focus on the health risks faced by women of childbearing age,” reports Kay Johnson in a 2012 Commonwealth Fund issue brief. These risks include chronic health conditions such as diabetes and hypertension; smoking and heavy alcohol use; and depression, all of which disproportionately affect low-income women and women of color, Johnson notes. Treating these conditions prior to conception can improve pregnancy outcomes, as well as women’s overall health.
Birth spacing is another important factor in birth outcomes. Short intervals between pregnancies are associated with increased risks for preterm birth and for low birthweight in babies, and for preeclampsia in mothers. The 2020 Healthy People goals include reducing the number of pregnancies occurring within 18 months after giving birth, and recent research has found short birth spacing to be strongly linked to unintended pregnancies. Ensuring that women have access to contraception and medical guidance can allow for birth spacing that’s favorable to the health of both mothers and children.
In 2006, the Institute of Medicine sounded the alarm about the growing public health problem of preterm births (those occurring before 37 weeks of gestation). Preterm babies are at higher risk for health and developmental problems than their full-term counterparts, and the IOM committee estimated that costs for medical care and disability associated with US preterm births top $26 billion per year. Reducing preterm births could result in substantial savings as well as improved quality of life.
Ideally, everyone would have access to the healthcare services they need to be in optimum health; given limited healthcare dollars, though, it makes sense to target them at women whose health will most directly influence the health of the next generation. And given that nearly half of all US pregnancies are unplanned, the best way to ensure that women have access to healthcare services prior to conceiving is to ensure that all women of childbearing age have access to healthcare.
Care from community health centers
Being insured isn’t necessarily synonymous with having access to healthcare, although in the US people with health insurance have better health outcomes than those without. Community health centers – also known as federally qualified health centers, or FQHCs – have long been a source of high-quality, affordable primary healthcare for low-income and uninsured individuals. In a 2008 article in Women’s Health Issues, Sara Wilensky and Michelle Proser describe how health centers deliver preconception care and how their low-income patients have better birth outcomes than low-income US women as a whole:
Almost 60% of health center patients are women, about half of whom are women of childbearing age. In addition, health centers provide care for >17% of low-income births in the United States. Most health centers offer their patients preconception services, such as HIV/AIDS screening and treatment, weight management, nutrition counseling, and smoking cessation programs, in addition to comprehensive primary care services. Three quarters of health centers provide mental health services and half provide substance abuse treatment services onsite; the rest provide these services in partnership with other providers. Health centers also participate in a number of community-based programs focused on improving women’s health and providing preconception care services.
… Low socioeconomic status (SES) women seeking care at health centers experience lower rates of low birth weight (LBW) babies compared with all low-SES mothers (7.5% vs. 8.2%), a trend that holds for each racial/ethnic group. This is particularly noteworthy for African American women of low SES who are especially at higher risk for adverse pregnancy outcomes. If the LBW black–white disparity seen at health centers could be achieved nationally, there would be 17,100 fewer LBW black infants annually (Shi et al., 2004).
Health centers are also a major source of primary care for Medicaid beneficiaries; in 2012, 40% of health center patients had Medicaid or CHIP coverage. Another 36% were uninsured. Health centers receive federal grants that help cover the cost of caring for uninsured patients, but they also rely heavily on Medicaid revenue. In recognition of the comprehensive care health centers provide (including nutritional counseling, case management, and translation services), health centers receive higher Medicaid payments than other providers. States’ decisions about accepting the Medicaid expansion will greatly affect the finances of their health centers – which in turn affects low-income women’s access to high-quality preconception and prenatal care.
The states that have not yet accepted the Medicaid expansion need to keep in mind that their decisions affect not only the health of their poorest residents, but of the next generation.
Earlier today, Secretary of Labor Thomas Perez announced that the Department of Labor has finalized a rule extending minimum-wage and overtime protections to home care workers. Starting on January 1, 2015, the wage and overtime provisions of the Fair Labor Standards Act will apply to home health aides, personal care aides, and other direct care workers employed by agencies. The agencies will have to pay workers minimum wage ($7.25/hour in those states that haven’t adopted higher minimum wages) and 1.5 times their regular wage for hours worked above 40 per week. In addition, workers who travel between multiple clients’ homes in the course of a workday must be paid for time spent traveling between those sites.
Home care workers had been exempt from these federal requirements because they were considered to fall into the “companions for the elderly” category of work, which is exempt from FLSA protections. Fifteen states (Colorado, Hawaii, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota, Montana, Nevada, New Jersey, New York, Pennsylvania, Washington, and Wisconsin) already extend minimum wage and overtime protection to home healthcare workers, and six states (Arizona, California, Nebraska, North Dakota, Ohio, and South Dakota) and DC extend minimum-wage, but not overtime, protection. For specifics on the state laws, as well as the federal regulations, see the National Employment Law Project’s report Fair Pay for Home Care Workers: Reforming the U.S. Department of Labor’s Companionship Regulations Under the Fair Labor Standards Act.
As I wrote back in March 2012, when DOL was accepting comments on their proposed rule, DOL’s economic analysis suggests that Medicare and Medicaid together cover 75% of payments for home healthcare services, and private insurers pay another 12%. The remainder includes families paying out of pocket for home health services. In the 29 states that don’t already extend minimum wage to home care workers, costs to all payers may increase. For some families, higher costs to hire agency workers may result in greater burdens for unpaid family caregivers, many of whom already face substantial hardships. DOL also anticipates that home-care agencies will shoulder more than half of the additional costs, in the form of reduced profits.
Thousands of home care workers currently receiving less than minimum wage or lacking overtime and travel-time pay can expect to see their paychecks grow starting in 2015. That’s welcome news in an industry where around 40% of workers rely on public assistance like food stamps or Medicaid, to the tune of $14,800 per worker receiving assistance for her family. Low-income workers tend to spend most of their pay, so higher earnings for home care workers can translate to more economic activity in home care workers’ communities.
“They work hard and play by the rules and they should see that work and responsibility rewarded,” President Obama said of the nation’s nearly two million home care workers when announcing the proposed rule in December 2011. Today’s news release emphasizes the role home care workers play in US healthcare:
“Many American families rely on the vital services provided by direct care workers,” said Secretary of Labor Thomas E. Perez. “Because of their hard work, countless Americans are able to live independently, go to work and participate more fully in their communities. Today we are taking an important step toward guaranteeing that these professionals receive the wage protections they deserve while protecting the right of individuals to live at home.”
“Direct care workers play a critical role in ensuring access to high-quality home care that many people need in order to remain healthy and independent in their communities, and they should be compensated fairly for this important work,” said Secretary of Health and Human Services Kathleen Sebelius. “We will continue to engage with consumers, states, advocates and home care providers in the implementation of this rule to help people with disabilities, older adults and their families receive quality, person-centered services.”
DOL’s economic analysis of the proposed rule also predicted that agencies would respond to the rule change by spreading work among more employees to avoid paying overtime. Limiting overtime can reduce fatigue and other negative impacts on workers, and that can translate into higher-quality care for clients.
Implementation of this rule will not be without hardship, and additional policy changes are necessary to ensure that all elderly and disabled people get appropriate, high quality care and that family caregivers have the support they need. With today’s announcement, though, DOL takes a welcome step to correct a long-standing injustice, and that’s worth cheering for.
A fourth official formerly associated with Massey Energy was sentenced to 3 ½ years in prison for conspiring to thwart federal mine safety laws. David C. Hughart, 54, appeared this week before U.S. District Judge Irene Baker for his sentencing hearing. Hughart plead guilty in February 2013, following charges brought by the U.S. Department of Justice (DOJ).
U.S. attorney Booth Goodwin’s staff have been investigating former Massey Energy personnel (the firm was purchased by Alpha Natural Resources in 2011) as part of DOJ’s criminal investigation related to the April 2010 Upper Big Branch (UBB) disaster. The coal dust explosion at the West Virginia coal mine killed 29 miners and caused permanent disabling injuries to another worker.
Hughart worked for Massey Energy for more than 20 years, but as Ken Ward, Jr. of the Charleston (WV) Gazette reminds us:
“Hughart did not work at Upper Big Branch, and his plea involved crimes he has admitted between 2000 and 2010 at Massey Energy’s White Buck operations.”
But in the big scheme of things, the fact that Hughart never worked at UBB doesn’t really matter. As Ken Ward, Jr. reported in May, Hughart implicated Massey Energy’s Don Blankenship as leader of the conspiracy to deceive mine inspectors. Blankenship was Massey’s CEO and is the big fish in DOJ’s sight.
Besides Hughart, three other individuals have been prosecuted and have, or are, serving their sentences. Thomas Harrah, a foreman at UBB falsified his coal mine foreman’s license, a certification required in West Virginia. He also lied about his fake certificate to investigators, earning him 10 months in jail.
Hughie Stover, 61, a security director—-and sometimes chauffeur for Don Blankenship—-is serving 3 years in prison also for lying to investigators. Stover also destroyed documents in the wake of the disaster when federal and state mine safety investigators were just beginning their work.
The most senior former Massey Energy official to be convicted to-date is Gary May, 44. May was a superintendent at UBB and directly involved in its day-to-day operations. He plead guilty in March 2012 to DOJ’s criminal charges of conspiring to deceive mine inspectors about serious hazards at UBB. Judge Berger sentenced him to pay at $20,000 penalty and serve 21 months in jail. U.S. Attorney Booth Goodwin noted that May has been cooperating with DOJ’s criminal probe.
The Governor’s Independent Investigation Panel, of which I was a member, concluded that the UBB disaster:
“was not something that happened out of the blue, an event that could not have been anticipated or prevented. It was, to the contrary, a completely predictable result for a company that ignored basic safety standards and put too much faith in its own mythology.”‘
That mythology was the brain child of Massey’s CEO.
The massive coal dust explosion at UBB was not caused by a technical glitch, and it certainly wasn’t an “accident.” The 29 men who died on April 5, 2010 were the victims of a man-made disaster. I hope DOJ is successful getting the man in the man-made, who was at the top of the corporate ladder.