Last May, an elderly man was admitted to the Brooklyn branch of Mount Sinai Hospital for abdominal surgery. A blood test revealed that he was infected with a newly discovered germ as deadly as it was mysterious. Doctors isolated him quickly in the intensive care unit.
The germ, a fungus called Candida auris, attacks people with weakened immune systems and is spreading silently throughout the world. In the last five years, he has hit a neonatal unit in Venezuela, swept a hospital in Spain, forced a prestigious British medical center to close its intensive care unit and established itself in India, Pakistan and South Africa.
Recently, C. auris came to New York, New Jersey and Illinois, leading the Federal Centers for Disease Control and Prevention to add it to a list of germs considered "urgent threats."
Everything was positive – the walls, the bed, the doors, the curtains, the phones, the sink, the whiteboard, the posts, the bomb. The mattress, the bed rails, the canister holes, the blinds, the ceiling, everything in the room was positive.
– Dr. Scott Lorin, in C. auris
The man at Mount Sinai died after 90 days in hospital, but C. auris did not. Tests showed that he was everywhere in his room, so invasive that the hospital needed special cleaning equipment and had to uproot some of the floors and floors to eradicate it.
"Everything was positive – the walls, the bed, the doors, the curtains, the phones, the sink, the whiteboard, the posts, the bomb," said Dr. Scott Lorin, president of the hospital. "The mattress, the bed rails, the box holes, the window blinds, the ceiling, everything in the room was positive."
C. auris is so tenacious, in part, because it is impervious to major antifungal medicines, becoming a new example of one of the most intractable health threats in the world: the emergence of drug-resistant infections.
For decades, public health experts warned that overuse of antibiotics was reducing the effectiveness of drugs that prolonged life expectancy by curing bacterial infections, since they are fatal. But lately, there has also been an explosion of resistant fungi, adding a new and frightening dimension to a phenomenon that is undermining a pillar of modern medicine.
"It's a huge problem," said Matthew Fisher, a professor of fungal epidemiology at Imperial College London, who co-authored a recent scientific review of the emergence of resistant fungi. "We depend on being able to treat these patients with antifungal."
A new breed of fungi
Simply put, fungi, like bacteria, are evolving the defenses to survive modern medicines.
Even so, world health leaders called for more moderation in prescribing antimicrobial drugs to fight bacteria and fungi – convening the United Nations General Assembly in 2016 to manage an emerging crisis – their glutted overuse in hospitals, clinics and agriculture continued.
Resistant germs are often called "superbugs," but this is simplistic because they do not usually kill everyone. Instead, they are more lethal for people with immature or compromised immune systems, including newborns and the elderly, smokers, diabetics, and people with autoimmune disorders who take steroids that suppress body defenses.
Cancer versus superbug
Scientists say that unless new, more effective drugs are developed and unnecessary use of antimicrobial drugs is drastically reduced, the risk will spread to healthier populations. A study by the British government funded projects that if policies were not put in place to delay the rise of drug resistance, 10 million people could die in the world of all those infections by 2050, eclipsing the eight million who died that year due to cancer.
In the United States, two million people contract resistant infections annually and 23,000 die from them, according to the official CDC estimate. This number was based on 2010 numbers; recent estimates by researchers at the University of Washington School of Medicine point to the death toll at 162,000. Deaths worldwide caused by resistant infections are estimated at 700,000.
Antibiotics and antifungals are essential for fighting infections in people, but antibiotics are also widely used to prevent diseases in farm animals, and antifungal drugs are also applied to prevent agricultural plants from rotting. Some scientists cite evidence that the unrestrained use of fungicides in plantations is contributing to the emergence of fungi resistant to drugs that infect humans.
However, as the problem grows, it is poorly understood by the public – in part because the very existence of resistant infections is often cloaked in secrecy.
With bacteria and fungi, hospitals and local governments are reluctant to disclose outbreaks for fear of being seen as centers of infection. Even the CDC, under its agreement with the states, is not allowed to make public the location or name of the hospitals involved in outbreaks. In many cases, state governments have refused to publicly share information but acknowledge that they have had cases.
Meanwhile, germs are easily spread – transported in hands and equipment inside hospitals; transported in plants fertilized with meat and manure from farms; transported across borders by travelers and in exports and imports; and transferred by nursing home patients to the hospital and back.
C. auris, which infected man at Mount Sinai, is one of the dozens of dangerous bacteria and fungi that have developed resistance. However, like most of them, it is a virtually unknown threat to the public.
The problem in question
Other prominent strains of Candida fungus – one of the most common causes of bloodstream infections in hospitals – have not developed significant drug resistance, but more than 90% of C. auris infections are resistant to at least one drug and 30% are resistant to two or more drugs, the CDC said.
Lynn Sosa, a state deputy epidemiologist in Connecticut, said she now considers C. auris as the leading threat among resistant infections. "It's practically unbeatable and difficult to identify," she said.
Nearly half of the patients who get C. auris die within 90 days, according to the CDC. However, experts in the world have not discovered where they came from in the first place.
"It's a creature from the black lagoon," said Dr. Tom Chiller, who heads the fungal branch at C.D.C., who is leading a global detective effort to find treatments and prevent propagation. "It's bubbled up and now it's everywhere."
"No need" to tell the public
In late 2015, Dr. Johanna Rhodes, an infectious disease specialist at Imperial College London, received a panicked call from Royal Brompton Hospital, a British medical center outside London. C. auris had taken root some months ago and the hospital was unable to release him.
"We have no idea where it's coming from. We've never heard of it. It's spread like a fire, "Rhodes said. She agreed to help the hospital identify the genetic profile of the fungus and clean it out of the rooms.
Under his direction, hospital employees used a special device to spray aerosolized hydrogen peroxide around a room used for a patient with C. auris, the theory was that the steam would scour each corner and nook. They left the unit for a week. Then they put a "stabilization plaque" in the middle of the room with a gel in the bottom that would serve as a location for any surviving microbe to grow, Rhodes said.
Only one organism grew back. C. auris.
It was spreading, but the news of it was not. The hospital, a center specializing in lungs and heart that attracts wealthy patients from the Middle East and Europe, warned the British government and told infected patients but made no public announcement.
"There was no need to launch a press release during the outbreak," said Oliver Wilkinson, a hospital spokesman.
This silent panic is occurring in hospitals all over the world. Individual institutions and national, state and local governments have been reluctant to disclose outbreaks of resistant infections, arguing that there is no reason to scare patients – or prospective ones.
Dr. Silke Schelenz, a specialist in infectious diseases at Royal Brompton, called the government's and hospital's lack of urgency in the early stages of the outbreak "very, very frustrating."
"They obviously did not want to lose their reputation," Schelenz said. "It did not impact our surgical results."
By the end of June 2016, a scientific paper reported "an ongoing outbreak of 50 cases of C. auris" at Royal Brompton, and the hospital took an extraordinary step: it closed its first penny. during 11 days, transferring the intensive care patients to another floor, again without prior notice.
Days later, the hospital finally recognized a newspaper that had a problem. A headline in The Daily Telegraph warned: "The Closed Intensive Care Unit After the New Deadly Superdegenerate Emerges in the UK" (Research later reported that there were 72 cases in total, although some patients were only carriers and were not infected by the fungus ).
However, the issue remained little known internationally, while an even larger outbreak had begun in Valencia, Spain, at the Hospital Universitario i Politecnico La Fe, with 992 beds. There, without the public's knowledge or unaffected patients, 372 people were colonized – meaning they had the germ in their body, but they were not sick – and 85 developed infections in the bloodstream. An article in the journal Mycoses reported that 41% of infected patients died within 30 days.
A statement from the hospital said that it was not necessarily C. auris that killed them. "It is very difficult to discern whether patients die from or with the pathogen, since they are patients with many underlying diseases and in a very serious general condition," the statement said.
As in Royal Brompton, the hospital in Spain made no public announcement. Not yet.
An article author in Mycoses, a hospital doctor, said in an e-mail that the hospital did not want him to speak to reporters because he "is concerned about the hospital's public image."
Stealth rages against patient advocates who say people have the right to know if there is an outbreak so they can decide whether to go to a hospital, particularly when dealing with a non-urgent issue such as elective surgery.
"Why the hell are we reading about an outbreak almost a year and a half later – and do not you have front page news the next day?" Said Kevin Kavanagh, a Kentucky physician and chairman of Health Watch USA, a nonprofit patients. "You would not tolerate this in a restaurant with an outbreak of food poisoning."
Health officials say the outbreak spread scares patients of a situation they can not do anything about, particularly when the risks are unclear.
"It's already difficult enough with these agencies for health care providers to get their heads around that," said Dr. Anna Yaffee, formerly C.D.C. outbreak investigator who dealt with resistant outbreaks of infection in Kentucky in which hospitals were not publicly disclosed. "It's really impossible to send messages to the public."
Authorities in London alerted the CDC to the outbreak of Royal Brompton while it was taking place. And C.D.C. I realized that I needed to get the word out to American hospitals. On June 24, 2016, C.D.C. criticized a national alert for hospitals and medical groups and created an e-mail address, [email protected], for field visits. Dr. Snigdha Vallabhaneni, a key member of the fungus team, should receive a drop – "maybe a message every month."
Instead, within a few weeks, her inbox exploded.
Coming to America
In the United States, 587 cases of people who contracted C. auris, concentrated at 309 in New York, 104 in New Jersey and 144 in Illinois, were reported according to C.D.C.
Symptoms – fever, aches and fatigue – are apparently common, but when a person is infected, particularly someone who is not healthy, these common symptoms can be fatal.