When Jeanne Marrazzo was announced as director of the US National Institute of Allergy and Infectious Diseases (NIAID) last year, she became one of the leading public health decision-makers in the world. Replacing Anthony Fauci, whose tenure during the covid-19 pandemic made him a household name, the stakes have never been higher for the agency’s newest boss.
Having spent decades working across HIV prevention and sexually transmitted diseases, as well as overseeing therapeutic interventions for covid-19, Marrazzo is now in charge of NIAID’s $6.6 billion annual budget – and the future of the US response to infectious disease.
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That involves working with the institute’s 21 laboratories across the country, leading the fight against ebola and HIV and spearheading efforts to develop new vaccines, therapies, diagnostics and technologies.
At the top of Marrazzo’s to-do list is tackling antimicrobial resistance (AMR), or drug-resistant superbugs, which are predicted to cause 10 million deaths per year by 2050 at an annual cost of $1 trillion to the global economy. In May, the UK’s former chief medical officer warned that the rise of these pathogens could make the pandemic look “minor” and that the issue is more acute than climate change.
Our warming world is partly responsible for increasing rates of AMR, with shifting climate conditions around the globe helping bacteria such as Salmonella and cholera-causing Vibrio to survive – and evade our current antibiotic weaponry completely. Here, Marrazzo outlines the things we should perhaps fear most, as well as some promising developments on the horizon.
Charlotte Lytton: In what ways is the climate fuelling the problem of AMR?
Jeanne Marrazzo: When it comes to bacteria, climate change is affecting so many things on a macro scale. It has an impact on the health of livestock, which are often totally overfed with antibiotics and are a huge reservoir of antibacterial resistance. People are relocating more because of the heat – increased human mobility has been linked with greater AMR. And climate change has been linked with more natural disasters, which are particularly concerning because they disrupt clean water supplies and so we see more outbreaks of AMR bacteria in the gut.
On top of that, there are more diseases transmitted from animals to humans. So I think it all sets a stage where we’re less and less able to predict even where outbreaks are going to happen – and when they do happen, it becomes harder to respond to them because infrastructure is threatened.
Some 1.2 million people are killed by antimicrobial-resistant bacteria each year. Did covid-19 make things worse?
I would say the pandemic effect can’t be underestimated. For one thing, we know that AMR infections in hospitals increased during the pandemic, and that was probably due to a variety of factors.
One is that there were so many ill people who were at risk of hospital-acquired infections and so got treated with a lot of antibiotics. Sometimes they didn’t need them, sometimes they really did. The proportion of people I saw who clearly had covid-19 but came in being treated with steroids and antibiotics on the outpatient side was, I would say, 95 per cent.
The other thing is we weren’t examining patients as much. The isolation procedures were really very tough, so people often didn’t get diagnosed and treated in a timely fashion.
How have things changed in the past decade?
I would have expected to see more antibiotics come through the pipeline into clinical trials in the past decade. But it’s very expensive. The return on investment for these products is very, very low.
The other thing I think that we don’t talk about enough is the role of biofilms [thin layers of bacteria that gather on hard surfaces]. Biofilms, in particular, are a great place for bacteria to hide, and while you can treat people with antibiotics to kill the bacteria, you often can’t penetrate bacteria that are hiding in biofilms. They’re often in catheters, intravenous things, valves, so we don’t have a lot of ways to eradicate potential stealthy bacteria in those settings. And that’s a good place for them to continue to evolve.
Will the situation get worse?
I am worried about antimicrobial resistance. We’ve had outbreaks, but most of the time we have been able to contain them, whether it’s in an institution or in a small population. But what if there’s something that was really easy to spread that, say, spread through the water supply? Especially in systems that are disrupted during conflict. You can say “oh, pasteurisation is great”, “oh, we have great sewage systems” – unfortunately, that isn’t the case in many parts of the world.
Which treatments do you consider to be the most promising?
Phages [bacteria-killing viruses] are very good. I think that’s important. I’m also hopeful about the AI models we’re using to look at synthesis of new drugs and what compounds might be adapted from products we already know work.
Given the scale of the problem, why isn’t there more investment in developing solutions?
The easiest answer is that there’s almost no return on investment in these products compared with something like weight loss drugs or cancer drugs. Those are huge markets where people are making billions and billions of dollars. Antibiotics aren’t cash cows. There is legislation in the US that is aimed at creating some incentives for pharmaceutical companies to come on board. I’m hopeful that will change things, but it isn’t a great scenario.
The more we use antibiotics, the more chances bacteria have to become resistant to them. Do you think that the public fully understands the dangers of antibiotic overuse?
I don’t think they do, because you talk to people who have a cold and they say “this is so bad, I finally got antibiotics and it went away”. The reality is it probably would have gone away anyway because it wasn’t bacterial to start with. There is this feeling that it can’t hurt, but it can hurt. It really does hurt to overuse these antibiotics.
Has it become harder to communicate public health information since covid-19?
We’re still suffering a lot from the pandemic and from the clear examples of misinformation and disinformation that occurred. The whole thing comes back to trust, right? Who can you trust to give you valid, helpful health information? During covid-19, we heard so much contradictory and so much argumentative dialogue about what was good, what wasn’t good, who was studying this, where this was in the pipeline, how this was going, that it was really hard to separate the noise from what I think most of us in the traditional scientific field were trying to do.
Scientists don’t agree. We review papers, we review grants and we argue – that’s what we do. But all of a sudden, it was very much on the outside, and people were seeing that. And I think that paradoxically undermined trust. That unsettled a lot of people who just didn’t understand that’s how we operate. I don’t think we’ve gotten over that yet.
Aside from AMR, what are the biggest public health concerns coming down the track?
I’m obviously worried about influenza, and respiratory viruses in general. Coronavirus and influenza – they’ve struck twice now, big time, in our relatively recent memory.
The signals for the current situation with influenza in dairy cattle, other mammals and wild birds is really concerning, because the more you see mixing and the more you see cross-species transmission, the more opportunity you have for mutations that are going to favour the ability to infect humans.
Would we be equipped for another pandemic?
We have vaccines ready to scale up. But I’m worried, given how quickly covid-19 spread and the toll it took, that we are going to be challenged if this happens again, especially with all the conflict right now. So many people are vulnerable, whether it’s for socioeconomic reasons or war. That’s what keeps me up at night. I never want to sound too alarmist, but I do think vigilance is really important or we’re going to get caught flat-footed again.
Charlotte Lytton is a freelance writer based in London
