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Statement on Antimicrobial Resistance: Solutions to a Growing Public Health Threat by David Satcher, M.D., Ph.D.
Assistant Secretary for Health and Surgeon General
U.S. Public Health Service
U.S. Department of Health and Human Services

Before the Senate Committee on Health, Education, Labor, and Pensions, Subcommittee on Public Health
February 25, 1999

Good morning. I am Dr. David Satcher, Assistant Secretary for Health, Department of Health and Human Services and Surgeon General. I want to thank you, Mr. Chairman and members of the Subcommittee, for your invitation to testify at this important hearing on "Antimicrobial Resistance: Solutions to a Growing Public Health Problem." I will briefly address issues related to resistance, discuss the associated public health problems, and describe the targeted public health messages for the public and medical community. In addition, you have asked me to describe the President's FY 2000 budget for public health initiatives, which I will highlight at the end of my statement.

Emerging infectious diseases are a continuing threat to the health of U.S. citizens and people around the world. They cause suffering and death and impose an enormous financial burden on society. Antimicrobial drugs have saved the lives of millions of people. However, the emergence of drug resistance in bacteria, parasites, viruses, and fungi is threatening to reverse medical progress of the past 50 years.


Tremendous strides have been made in medicine and science to combat infectious diseases. The development and widespread use of antibiotics and vaccines, coupled with earlier improvements in urban sanitation and water quality, have dramatically lowered death and disability from infectious diseases. Progress had been so great that three decades ago some experts predicted we would soon see the end of infectious diseases as a significant problem.

However, our optimism, though understandable, was premature. Today, we see a global resurgence of infectious diseases, including the identification of new infectious agents, the reemergence of old infectious diseases such as tuberculosis and the rapid spread of antimicrobial resistance. As we approach the 21st century, many important drug choices for the treatment of common infections are becoming increasingly limited and expensive and, in some cases, non-existent.

In 1995, I had the honor of chairing a working group on emerging infectious diseases for a Committee of the National Science and Technology Council (NSTC), which was charged with conducting a government-wide review of our ability to protect our citizens from emerging infectious diseases. The NSTC Committee -- the Committee on International Science, Engineering and Technology (CISET) -- was staffed by the Department of State. The issue of emerging infectious diseases was regarded as urgent by many U.S. agencies, and more than 20 agencies ultimately participated in the working group.

In September 1995, the Committee issued a report which concluded that existing mechanisms for surveillance, response to, and prevention of outbreaks of new and reemerging infectious diseases were inadequate, both at home and abroad. The report described the seriousness of infectious diseases and problems of antimicrobial resistance in the United States and made specific recommendations that became the basis of a 1996 Presidential Decision Directive (PDD) that established a new national policy. The Directive called for a coordinated U.S. government response to address the growing health threats posed by infectious diseases including those caused by pathogens that are resistant to antimicrobial drugs.

The PDD calls for the establishment of an Emerging Infectious Diseases (EID) Task Force, which I co-chaired with Dr. Kerri-Ann Jones, the former Associate Director for National Security and International Affairs of the White House Office of Science and Technology Policy (OSTP). The President charged the EID Task Force with implementing the PDD. The lead agencies on the Task Force include three agencies within the Department of Health and Human Services (DHHS): the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA) and the National Institutes of Health (NIH); as well as the U.S. Agency for International Development (USAID) and the Department of Defense (DOD). The U.S. Department of Agriculture (USDA) has also played an increasingly important role. In addition to OSTP, the Department of State, the National Oceanic and Atmospheric Administration (NOAA) of the Department of Commerce, the National Aeronautics and Space Administration (NASA), and the Department of Veterans Affairs are also active participants. In working toward the goals of the Task Force, USAID, CDC, and other agencies are also supporting the efforts of the World Health Organization to improve communications networks and build regional centers for surveillance of and response to infectious diseases.

Agency Collaboration

From the beginning, the basic principles of the EID Task Force and the work group on emerging diseases have been collaboration and coordination. We know that the challenge ahead outstrips the means available to any one agency or organization, and various DHHS agencies' missions are relvant to the issues of antimicrobial resistance.

CDC addresses antimicrobial resistance as a major focus area in its plan, Preventing Emerging Infectious Diseases: A Strategy for the 21st Century. CDC's programs include activities that focus on working with other Federal agencies, State and local health departments, academic centers, health care providers and networks, international organizations, and other partners to conduct surveillance and identify infectious disease problems. CDC combines its strengths in epidemiology and laboratory sciences to solve problems that cannot be solved by either discipline alone, such as developing new laboratory tests to improve the timeliness and accuracy of detecting antimicrobial resistance and developing and disseminating practical recommendations and guidelines for the prudent use of antimicrobial drugs.

The National Institutes of Health funds a diverse portfolio of grants and contracts to study antimicrobial resistance in major viral, bacterial, fungal, and parasitic pathogens. This support includes investigator-initiated and solicited research on microbial pathogenesis and host-pathogen interactions, molecular mechanisms responsible for drug resistance, as well as research to develop and evaluate new or improved products for disease diagnosis, intervention, and prevention. Numerous genome projects seek to identify new gene targets for the development of drugs and vaccines. Pathogens that have developed resistance and are being studied include: HIV and other viruses; nosocomial bacteria such as staphylococci, enterococci, and E. coli; bacteria that cause respiratory diseases such as pneumonia and tuberculosis; foodborne bacteria such as Salmonella and Campylobacter; organisms that cause sexually transmitted diseases; Candida and other fungi; and parasites of international importance such as Plasmodium falciparum, a cause of malaria.

Other NIH sponsored activities with relevance to antimicrobial resistance include physician and research training and education and the conduct of workshops and symposia. The National Institute of Allergy and Infectious Disease has a lead role in many of the resistance-related activities but numerous other agencies also support and participate in these activities. Expanded research on microbial changes influencing disease emergence, such as the evolution of drug resistance, was a major emphasis of the 1996 Research Agenda for Emerging Infectious Diseases of the National Institute of Allergy and Infectious Diseases.

The FDA also has a critical role in addressing the growing public health problem of antimicrobial resistance and has been working with CDC, NIH, and industry to help meet this threat. FDA is committed to the development and approval of new drugs and vaccines to treat or prevent antimicrobial resistant infections and to the appropriate labeling, promotion, and use of approved antimicrobials for both humans and food animals in order to protect the safety and efficacy of these antimicrobials and the public's health. Examples of recent or ongoing FDA activities include devising plans to include information on antibiotic resistance and prudent use of antimicrobials in product labeling and exploring other options for encouraging appropriate use of antimicrobials, such as working with industry to include messages about appropriate antibiotic use in their consumer advertising campaigns.

There is growing scientific evidence that certain uses of antimicrobials in food-producing animals can lead to antibiotic resistance in intestinal bacteria that are then transmitted to people, causing treatment-resistant illness. Recent FDA actions in response to these concerns include proposing a new framework for antimicrobial drug use in food-producing animals in order to protect human health and prolong the period of usefulness of antimicrobials; working with the American Veterinary Medicine Association to develop and implement educational programs for the judicious veterinary use of prescription antimicrobials; implementing and interagency coordination of the National Antimicrobial Resistance Monitoring System for Enteric Bacteria, (NARMS:EB), to monitor antimicrobial resistance in man and other animals for specific pathogens that are predominantly acquired from food-producing animals; and research to understand the mechanisms of resistance development in food-producing animals in order to better address human health concerns.

Overview of Antimicrobial Resistance

Drug resistance is a serious clinical and public health problem in the United States and globally. Although we have been using antibiotics for more than 50 years, the extent of resistance is much greater than ever before, and the number of new drugs in the late stages of testing is limited. In past years serious problems of drug resistance tended to involve a small number of pathogens, and new drugs were continually being developed and replacing drugs that were no longer effective because of resistance. But today, the frequency of drug resistance is increasing in virtually all hospital- and community-acquired pathogens. In part, this is because resistance is a consequence of the selective pressure exerted by widespread antimicrobial drug use. Antimicrobial drugs kill the sensitive pathogens, but the resistant ones survive, and with time the resistant ones become predominant. Antimicrobial drugs have been used extensively and often inappropriately, with little concern about resistance as an adverse effect. We now face the consequences.

The Public Health Problem

In a report released last year, "Antimicrobial Resistance: Issues and Options Workshop Report" from its Forum on Emerging Infections, the Institute of Medicine (IOM) noted that while the phenomenon of antimicrobial resistance is neither surprising nor new, it is newly worrying because the problem is spreading rapidly. In some areas of the United States , up to 30 percent of infections with Streptococcus pneumoniae, the most common cause of bacterial pneumonia, meningitis, and ear infections, are no longer susceptible to penicillin. Many of these infections are resistant to other common antibiotics as well. For some pathogens, we have reached the point where there are virtually no available drugs left to treat them, such as vancomycin-resistant enterococci acquired by patients in U.S. hospitals.

Data from intensive care unit patients in the United States indicate that more than 25 percent of the bacteria that most frequently cause hospital-acquired infections are resistant to the preferred antibiotic for treatment. One organism of particular concern is Staphylococcus aureus, the most common cause of hospital-acquired infections. Approximately 35 percent of S. aureus infections acquired in United States hospitals are resistant to the drug methicillin, and the rate of resistance to this drug has risen 15 fold in the last 20 years. Serious infections caused by resistant S. aureus frequently require treatment with vancomycin, which is the last uniformly effective available drug against S. aureus, and some strains of S. aureus with diminished susceptibility to vancomycin have been identified recently.

The ramifications of antimicrobial resistance are becoming more serious for a wider range of diseases. Resistance has become a serious problem for pathogens that cause tuberculosis, AIDS, salmonellosis, gonorrhea, malaria, and other common infections. Individuals infected with resistant pathogens may experience more and longer hospital stays due to resistance, and mortality rates are estimated to be more than twice as high for these patients than those with antimicrobial-susceptible infections.

Economic Costs of Drug Resistance

A recent study conducted in New York City by the Lewin Group estimated that resistant infections due to Staphylococcus aureus cost an additional $2500 per infected patient, or $7 million annually in New York City alone. A 1995 Office of Technology Assessment (OTA) report, "Impacts of Antibiotic-Resistant Bacteria," estimated that the emergence of antimicrobial resistance among six common bacteria in hospitals adds approximately $661 million per year in hospital charges. This estimate does not include indirect costs or costs of infections caused by other resistant pathogens. OTA also noted that as the spread of resistance continues, these costs can be expected to increase. This points to great potential for economic savings from preventing resistance and the resulting infections.

Public Health Messages

As is the case with most public health issues, effective prevention programs will require strong linkages between public health practitioners and those involved in clinical practice. One approach to preventing the spread of drug resistance is developing and disseminating practical public health messages to the medical community and the public regarding the scope of the problem and the prudent use of antimicrobial drugs. CDC estimates that more than 100 million courses of antibiotics are provided by office-based physicians each year. Based on preliminary analysis, many of those are unnecessary, being prescribed for colds, coughs, and other viral infections such as influenza against which antibiotics are not effective. Prudent use of antibiotics is the key to decreasing, or even reversing, the spread of resistance. Although the solution to the problem of antibiotic resistance is complex, we do know that when communities have decreased antibiotic use, they also have decreased resistance.

One important tool in decreasing antibiotic use is assuring that people at greatest risk of influenza and pneumonia, including the elderly and those with chronic illnesses, are vaccinated against those diseases. Unfortunately, many of these at-risk adults do not receive an annual influenza vaccine, and most adults at risk for pneumonia have not received pneumococcal vaccine. If they did, it could not only prevent serious illness and save lives, but also greatly reduce the use of antibiotics otherwise needed to treat pneumonia.

Physicians should prescribe antimicrobial drugs only when they will be beneficial and, when possible, prescribe drugs that are specific for the bacteria causing the infection. The public needs to be aware that antimicrobial drugs offer no benefit for colds, the flu, most sore throats, and other illnesses caused by viruses. If a patient takes an antibiotic when it is not necessary, such as for a cold, there is an increased risk of developing an infection caused by antibiotic-resistant bacteria. Infections caused by resistant bacteria may be difficult or impossible to cure with antibiotics and could even spread to others. Patients should avoid requesting their doctors to prescribe antibiotics; however, when an antibiotic is prescribed, it should be taken exactly as directed. The public should be made aware of the appropriate use for antibiotics so that infections remain treatable and antimicrobial drugs remain effective for as long as possible. Preventing and controlling antimicrobial resistance is not just a problem for doctors and scientists; we all must do our part.

Additionally, the pharmaceutical industry has an important role to play in developing new drugs that will treat strains of bacteria that have become resistant to conventional antibiotics. Pharmaceutical companies have an important educational opportunity to include messages about antibiotic resistance and to discourage unneeded or inappropriate use of their products.

Global Implications

In order to be successful, efforts to address antimicrobial resistance must be undertaken on a global scale, since resistant organisms can spread quickly in our global village. Drug resistance is an emerging problem throughout the world--not only for the infections that are common in the United States and other developed countries, but also for others such as malaria and typhoid fever that are becoming increasingly difficult to treat in many countries due to drug resistance. CDC is working with the US Agency for International Development, the World Health Organization, the Pan American Health Organization, the European Union, and many other partners to improve global coordination, offer technical assistance, training, and assist in developing surveillance and prevention and control measures internationally.

Tuberculosis provides a striking example. In this decade, we have had to aggressively combat a resurgence of TB in the United States . We have made extraordinary progress, with the number of cases declining dramatically.

New York City was among the hardest hit by the resurgence of TB. Although cases are down in New York City, in 1997, a majority of new TB cases were found among the city's foreign born population - among people who were exposed elsewhere, emphasizing the need to work globally to sustain further declines in U.S. TB cases.

Overview of the FY 2000 Budget Request for Public Health Initiatives

When I was invited to appear before the Subcommittee today, I was asked to provide an overview of the President's fiscal year 2000 budget with respect to federal initiatives to improve our public health infrastructure. The following overview highlights several of our most important activities.

As we enter the 21st century, new threats to our public health are continually emerging. From the challenge of confronting infectious diseases, to the possibility of a bioterrorist attack and the ongoing problems of foodborne illness, we must constantly be vigilant. The only way to successfully combat the public health problems of tomorrow is by investing today in the necessary medical research and public health and disaster response infrastructure.

International trade, commerce, and tourism have truly created a global village. Because infectious diseases do not recognize borders, it is increasingly necessary to protect the health and safety of American citizens by investing in a global public health strategy.

Working in partnership with the WHO, and providing the necessary resources, we can develop the global strategy that is critical to protecting our citizens and people around the world.

Terrorism represents a serious threat to the peace and prosperity of our nation. While terrorist attacks can take numerous forms, the threat posed by bioterrorism is particularly deadly, because it can affect a large population, remain undetected for some time, and cause secondary illness or death if the agent is communicable. As the lead federal agency responsible for preparing for and responding to the medical and public health consequences of a bioterrorist event, we are mounting a comprehensive public health effort to combat this deadly threat.

The President's Budget includes $230 million for the Department to undertake a coordinated, four-pronged initiative to prepare for the medical needs and health consequences resulting from a potential terrorist use of biological weapons. First, our budget invests in the infectious disease surveillance infrastructure needed to detect the occurrence of a bioterrorist attack and to determine its cause, including improvements in case reporting, epidemiological and laboratory capacity, and the development of information technology to allow coordination among Federal, State and local public health officials. Second, it funds the purchase of a stockpile of the vaccines needed to treat the most likely biological agents. Third, the budget invests in developing the medical response capability at the local level to respond to an outbreak by training local health providers and supporting the creation of 25 Metropolitan Medical Response Systems. Finally, it provides funds for research and development activities to develop and expedite review of new vaccines and therapeutics and new rapid screens for diagnosing chemical agents.

Our nation needs a high quality surveillance system to collect and analyze epidemiologic information if we are to be able to respond effectively to a future outbreak of disease. The President's budget proposes to strengthen our surveillance system by providing a total of $65 million to support the implementation of a National Electronic Disease Surveillance Network Initiative (NEDSNI) at the Centers for Disease Control and Prevention. This Initiative would integrate electronic communications related to surveillance for the Emerging Infectious Diseases ($15 million), Bioterrorism ($40 million), and Food Safety ($10 million) programs and will establish communication links with the public health and medical communities to enable them to furnish timely information on outbreaks of communicable diseases to State and local public health departments and assure better communications among public health entities. It will also help address problems such as the emergence of drug resistance.

Surveillance is just one of the keys to fighting outbreaks of foodborne illness. Food-related hazards are responsible for as many as 33 million illnesses and up to 9,000 deaths each year. To combat these outbreaks, the budget seeks $29.5 million for the CDC, a $10 million increase, to expand the PulseNet network of health labs which perform DNA "fingerprinting" of disease causing bacteria. In addition, FDA is seeking $188 million to support its food safety efforts.

Biomedical research has been the foundation of the unprecedented gains we have made in improving the health of both Americans and the world. Last year, the President made a commitment to increase the budget for the National Institutes of Health, the world's largest and most distinguished organization for biomedical research, by nearly 50 percent over five years, and Congress responded by passing an increase of almost $2 billion. This year's budget continues the President's commitment and keeps us on the path set last year with an investment of $15.9 billion, an increase of $320 million. The FY 2000 request, combined with last year's 14 percent increase, represents a 17 percent increase over two years. This year's request will enable NIH to fund over 30,000 research projects grants, the highest total in history.

Along with his commitment to increase funding for biomedical research, the President last year also made a commitment to ensuring that scientific advances are translated into better health care for the American people. The President's budget honors this commitment as well, providing an increase of $35 million for the Agency for Health Care Policy and Research. These funds will be spent on health care research that will enhance knowledge about how to improve outcomes and quality of medical treatment and how to best translate research results into daily practice to improve health care for all Americans.


While issues of antimicrobial resistance are multifaceted, complex, and serious, much work is being done by the various agencies of the Public Health Service to develop and implement prevention initiatives to address the problem. There is much more to accomplish. Combating resistance requires that antimicrobial drugs are used only when necessary, that new drugs and vaccines are developed, and that infection control measures are used appropriately in hospitals, day care centers, and long-term care facilities. Combating resistance will also require Federal leadership, outreach and partnerships in the public and private sectors, both domestically and internationally, and collaboration between public health and medical care sectors.

The rapid spread of resistance demands an aggressive response, and the challenges ahead demand our continued attention. By collaboratively addressing the issues, we can prolong the effectiveness of currently available drugs and reduce the threat of resistance for patients today and in future generations. Our goal is to ensure that we are able to protect ourselves and the global community from emerging pathogens and emerging resistance to antimicrobial drugs whenever and wherever they may arise.

Thank you for the opportunity to testify before the Subcommittee. I will be happy to answer any questions you may have.

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