Human health implications of antimicrobial use in livestock production

Why use in this sector matters for the public

Christopher D. Heaney, PhD, MS Environmental Health Sciences & Epidemiology

Johns Hopkins Bloomberg School of Public Health Director, Johns Hopkins Environmental Health Microbiology and Immunology Laboratory

Room W7033B (443) 287-4989

http://www.jhsph.edu/departments/environmental-health-sciences/faculty-research/heaney/ cheaney1@jhu.edu

GOAL 1: Slow the emergence of resistant bacteria and prevent the spread of resistant infections

Goal 1.2 Eliminate the use of medically-important antibiotics for growth promotion in food-producing animals and bring other agricultural uses of antibiotics, for treatment, control, and

prevention of disease, under veterinary oversight.

Goal 1.3 Identify and implement measures to foster stewardship of antibiotics in animals.

GOAL 2: Strengthen national one-health surveillance

efforts to combat resistance objectives

Challenge: Global meat consumption

http://www.npr.org/blogs/thesalt/2012/06/27/155527365/visualizing-a-nation-of-meat-eaters

US average annual meat consumption per person (lbs)

http://www.npr.org/blogs/thesalt/2012/06/27/155527365/visualizing-a-nation-of-meat-eaters

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US antimicrobial use

80% Food animal use

20% Human use

07-M145

Beef Cows - Inventory: 2007

1 Dot = 2,500 Beef Cows

U.S. Department of Agriculture, National Agricultural Statistics Service

United States Total

32,834,801

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http://www.agcensus.usda.gov/Publications/2007/Online_Highlights/Ag_Atlas_Maps/Livestock_and_Animals/

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07-M161

Number of Broilers andOther Meat-Type Chickens Sold: 2007

1 Dot = 1,000,000 Broilers

U.S. Department of Agriculture, National Agricultural Statistics Service

United States Total

8,914,828,122

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http://www.agcensus.usda.gov/Publications/2007/Online_Highlights/Ag_Atlas_Maps/Livestock_and_Animals/

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07-M162

Number of Turkeys Sold: 2007

1 Dot = 100,000 Turkeys

U.S. Department of Agriculture, National Agricultural Statistics Service

United States Total

295,793,159

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http://www.agcensus.usda.gov/Publications/2007/Online_Highlights/Ag_Atlas_Maps/Livestock_and_Animals/

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07-M149

Hogs and Pigs - Inventory: 2007

1 Dot = 20,000 Hogs and Pigs

U.S. Department of Agriculture, National Agricultural Statistics Service

United States Total

67,786,318

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http://www.agcensus.usda.gov/Publications/2007/Online_Highlights/Ag_Atlas_Maps/Livestock_and_Animals/

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What quantities of antimicrobials are being used to produce food animals in US?

11 http://www.fda.gov/downloads/ForIndustry/UserFees/AnimalDrugUserFeeActADUFA/UCM338170.pdf

http://www.fda.gov/downloads/ForIndustry/UserFees/AnimalDrugUserFeeActADUFA/UCM440584.pdf

Why focus on North Carolina?

Industrialization of hog production in NC

Adapted from Wing et al., 2000. Env. Hlth. Persp. 14

Hog CAFO waste management practices in North Carolina

Humans Animals

Soil/Sand

Human Waste

Animal Waste

Receiving Water

Air

Antibiotic Use

Environmental Reservoirs

of Resistance Elements

Human Exposures

Humans

Food Products

Recreational Waters

Drinking Waters

Antibiotics

Naturally Occurring Resistance

Complex exposure dynamics

Where to start looking in such a complex microbial system…? Fecal microbes & source tracking markers in surface

waters proximal to hog CAFO lagoon waste spray fields

Association between living proximal to swine CAFO waste land application crop fields and human MRSA infection but…

…what about risks to workers inside the facilities?

Challenge: Vulnerability of livestock production workers in NC

Rural eastern North Carolina: • Diverse population, low-income, predominantly African-American and Latino

• Is a high distrust of health/medical research

• Little industry/employer cooperation with health research (lack of access to

workplace) • No unions or other representation for livestock workers

• Livestock workers tend to lack access to healthcare and health insurance

• In vulnerable position Challenge: How can we engage livestock workers to improve knowledge about questions transmission dynamics and persistence of antimicrobial resistant bacteria carriage and infection?

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• Community-based participatory research (CBPR) – Overcoming barriers together to build the evidence base

• Rural Empowerment Association for Community

Help (REACH) Duplin County, North Carolina • www.duplinreach.org

“Hog capitol of the world”

• In addition to environmental health education,

REACH provides diverse social and community-building services for industrial hog operation workers and other community members in rural eastern North Carolina 24

How to build the evidence base? Partner with community organizations

REACH partners at NC Legislature

Timeline of studies in partnership with REACH

2014 Cross-sectional study of drug-resistant S. aureus carriage prevalence among children (<7 years) of IHO workers compared to a referent group of children and workers in the same communities

2013-2014 Longitudinal study of IHO worker S. aureus carriage persistence over 4-months

2012 Pilot longitudinal study of industrial hog operation (IHO) worker S. aureus carriage persistence

Showed persistent carriage of drug-resistant S. aureus among IHO workers over 14 days

2011 Cross-sectional study of NC livestock worker drug-resistant S. aureus carriage

Showed higher drug-resistant S. aureus prevalence in industrial vs antibiotic-free livestock operation workers

2009-2011 Surface water studies

Found pig-specific fecal bacteria & drug-resistant S. aureus (Staph) in streams near hog CAFOs in Duplin County, NC

CAFO exposure group

Antibiotic-free livestock operation exposure group

Rinsky et al., PLOS ONE 2013.

Who else is contributing to the US evidence base about livestock worker carriage of drug-resistant S. aureus?

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Who is studying the persistence of livestock-associated S. aureus

carriage?

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Why should we care?

Persistent S. aureus carriage over 14 days Even with up to 4 days off

Persistent livestock-associated S. aureus carriage

Persistent livestock-associated multidrug-resistant S. aureus (MDRSA) carriage

“This study, while small, is important because it shows

the persistence of this bacteria for the first time in the

U.S. setting”

What do we still not know…?

• What is transmission potential of livestock-associated S. aureus:

– IHO worker households?

– Communities with high densities of IHOs?

– Beyond?

• Is livestock-associated S. aureus carriage associated with health outcomes?

Acknowledgements

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• Johns Hopkins University – Trish Perl, Barbara Detrick, Alan F. Scott, David Mohr, Karen Carroll, Kenrad Nelson, Nora Pisanic, JHU

Center for a Livable Future, JHU NIOHS ERC

• Rural Empowerment Association for Community Help, Duplin County, NC – Dothula Baron, Devon Hall, Victor Smith, Norma Mejia, Jennifer Hall, Ronald Hall, Cliff Smith

• North Carolina Environmental Justice Network – Naeema Muhammad

• North Carolina Riverkeepers & Waterkeepers – Rick Dove, Larry Baldwin

• UNC Depts. of Epidemiology & Environmental Sciences and Engineering – Steve Wing, Alice Ammerman, Jill Stewart, Jessica Rinsky, Maya Nadimpalli, Sarah Hatcher, Alan Kinlaw,

Rachel Kauffman, Kevin Chu, Jessica Richardson, Courtney Sanford, UNC NIOSH ERC

• UNC Hospitals & School of Medicine – Melissa Miller, David Weber, John Schmitz, Stan Lemon

• George Washington University – Lance Price

• Statens Serum Institut – Robert Skov, Jesper Larsen, Marc Stegger

This research was made possible by support from the Sherrilyn and Ken Fisher Center for Environmental Infectious Diseases, Division of Infectious Diseases of the Johns Hopkins University School of Medicine; NIOSH K01; Pilot Awards from the Johns Hopkins NIOSH ERC & UNC NIOSH ERC; Thrasher Research Fund; Center for a Livable Future Directed Research Grant; NSF Ecology and Evolution of Infectious Disease Program

Thank you.

Questions?

Photo credits: Schmidt CW 2009. Swine CAFOs & Novel H1N1 Flu: Separating Facts from Fears. Environ Health Perspect 117:A394-A401. http://dx.doi.org/10.1289/ehp.117-a394 Gillings Sustainable Agricultural Project, UNC Gillings School of Global Public Health. http://gillingsproject.wordpress.com/about/ Definition of MRSA, Centers for Disease Control and Prevention. http://www.cdc.gov/mrsa/definition/index.html Neuse River Foundation, North Carolina.