Meat and antibiotics

Portraits in Ottawa

Quite a while ago, I wrote about connections between human disease and the factory farming of animals. Recently, some new observational data has supported the link between the two. In the Netherlands, a new form of the superbug MRSA has emerged. It is strongly resistant to treatment with tetracycline antibiotics: a variety heavily used on livestock. The animals need the drugs because they are kept in such appalling conditions (unhygienic and constrained) that they would get infections too easily otherwise.

Xander Huijsdens and Albert de Neeling found that 39% of pigs and 81% of pig farms in the Netherlands were hosts to the potentially lethal antibiotic resistant bacteria. People who came into contact with pigs were 12 times more likely to contract this form of MRSA than members of the ordinary population; those who come into contact with cattle are 20 times more susceptible. The strain has since been found in Denmark, France, and Singapore. A study conducted by the University of Guelph found the strain in 25% of local pigs and 20% of pig farmers.

Maintaining the effectiveness of antibiotics for the treatment of people is highly important for human welfare. Antibiotics are one of the major reasons why modern medicine is valuable: they help people die dramatically less often after childbirth and surgery than was the case before their development. They have also helped to make diseases that would formerly have been probable death sentences treatable. The fact that we are allowing farms to deplete their value so that they can produce meat more cheaply (by forcing more animals closer together in less clean conditions) seems profoundly unwise. In Pennsylvania, legislators have even banned farmers who produce hormone and antibiotic milk from saying so on their packaging – on the grounds that it would make consumers unduly worried about the other milk on offer.

Author: Milan

In the spring of 2005, I graduated from the University of British Columbia with a degree in International Relations and a general focus in the area of environmental politics. In the fall of 2005, I began reading for an M.Phil in IR at Wadham College, Oxford. Outside school, I am very interested in photography, writing, and the outdoors. I am writing this blog to keep in touch with friends and family around the world, provide a more personal view of graduate student life in Oxford, and pass on some lessons I've learned here.

54 thoughts on “Meat and antibiotics”

  1. Guelph Researchers Find MRSA in Pigs

    November 08, 2007 – News Release

    Pigs can now be added to the list of potential carriers of the drug-resistant “superbug” methicillin-resistant Staphylococcus aureus (MRSA).

    A tale of pigs, people and germs

    “A lot of these bacteria are going to be washed off into the waterways, into the environment, and we just don’t know what it really means,” said Margaret Mellon of the Union of Concerned Scientists.

    There was one piece of good news from the Canadian study: Neither the pigs nor the people got sick from the MRSA.

    That’s to be expected with the pigs, who make for good carriers precisely because the germ usually doesn’t make them ill.

    People, though, aren’t always so lucky.

  2. I have some questions,

    Are humans who are getting this infection dropping dead? Or are there other antibiotics to treat it?

    You said 20% of those who come into contact with cattle are getting it, but you don’t otherwise mention cows having it. Do cows get it?

    What are the risks for consumers, eating this meat?

  3. Will Nalgene bottles no longer symbolize health and enviromental engagement?

    Mountain Equipment pulls water bottles off shelves
    Country’s largest specialty outdoor-goods retailer cites concern over possible health risks


    From Friday’s Globe and Mail

    December 7, 2007 at 3:00 AM EST

    Mountain Equipment Co-op, the country’s largest specialty outdoor-goods retailer, says it has pulled most food and beverage containers made of polycarbonate plastic from its shelves, citing concern over possible health risks.

    The plastic in question is made mostly from bisphenol A, which mimics estrogen and is derived from petrochemicals.

  4. Are humans who are getting this infection dropping dead? Or are there other antibiotics to treat it?

    MRSA Morbidity and mortality


    You said 20% of those who come into contact with cattle are getting it, but you don’t otherwise mention cows having it. Do cows get it?

    Staphylococcus aureus freuqently lives on the skin and in the noses of many animals.

    “S. aureus may occur as a commensal on human skin (particularly the scalp, armpits, penis and vagina); it also occurs in the nose (in about 25% of the population) and throat and less commonly, may be found in the colon and in urine. The occurence of Staph. aureus under these circumstances does not always indicate infection and therefore does not always require treatment (indeed, treatment may be ineffective and re-colonisation may occur). It can survive on domesticated animals such as dogs, cats and horses, and can cause bumblefoot in chickens. It can survive for some hours on dry environmental surfaces, but the importance of the environment in spread of S. aureus is currently debated. It can host phages, such as the Panton-Valentine leukocidin, that increase its virulence.”

    What are the risks for consumers, eating this meat?

    MRSA does not survive proper cooking, though the antibiotics in the meat can contribute to the development of resistant strains in people.

    See also: Antibiotic resistance: Role of animals

    “Currently, it is estimated that greater than 55% of the antibiotics used in the US are given to food animals (e.g. chickens, pigs and cattle) in the absence of disease. Antibiotic use in food animal production has been associated with the emergence of antibiotic-resistant strains of bacteria including Salmonella, Campylobacter, Escherichia coli and Enterococcus, among others. There is substantial evidence from the US and European Union that these resistant bacteria cause antibiotic-resistant infections in humans. The American Society for Microbiology (ASM), the American Public Health Association (APHA) and the American Medical Association (AMA) have called for substantial restrictions on antibiotic use in food animal production including an end to all non-therapeutic uses. The food animal and pharmaceutical industries have fought hard to prevent new regulations that would limit the use of antibiotics in food animal production.”

  5. On the Nalgene front, I certainly hope bisphenol A turns out to be fairly harmless. I have lots of stuff that probably includes it.

  6. Are antibiotics given to animals exclusively because it lets them live in less clean circumstances, or are there other motivations as well?

  7. There’s sh*t in the meat
    NYT on the surge in E. coli outbreaks
    Posted by Tom Philpott at 1:19 PM on 07 Dec 2007

    “I have a better idea. E. coli 0157:H7 can’t thrive in cows that feed primarily on grass. So end the confinements and raise animals outside, replacing as much of their current rations with grass as possible.

    That would detoxify the shit; but how to keep it out of the meat? Let’s try deindustrializing the slaughterhouses. Instead of a few enormous ones, why not have hundreds of small and mid-sized ones all across the country?”

  8. Meat Processors Look for Ways to Keep Ground Beef Safe

    “In the last decade, Tyson Fresh Meats has transformed its slaughterhouse here to combat a potentially deadly type of food poisoning, adding huge chambers to scald carcasses and wash them in acid, steam vacuums to suck away microbes and elaborate gear to test hundreds of meat samples a day.”

  9. “After each cut is made to remove the hide, a worker follows behind with a steam vacuum to kill and suck away microbes. The carcass, pulled along on an overhead rail, is then sent into a cabinet with pivoting nozzles that soak it with water at about 185 degrees.

    After the head is removed and before the animal is gutted, the carcass is sprayed with a mild acid wash, again to reduce the level of microbes. Besides removing the hide, one of the most critical steps to prevent E. coli 0157:H7 comes when the animal is eviscerated and its internal organs are removed.

    The workers who remove the organs are careful not to cut the bowel, which could spread manure, and a worker looks over the internal organs to make sure the intestines are intact. The carcasses are then sawed in half, and the cut line is steam vacuumed.”

  10. Recently there a news report here in Houston about a study done on drug-resistant bacteria in the border communities in Texas and Mexico. Many antibiotics are available over the counter in Mexico. The researchers openly admitted they expected there to both be more types of resistant bacteria in Mexico and more incidence of drug-resistant infections. They found the opposite.

  11. @JesusChristHimself

    What are you arguing? Can you provide a source on that study?

  12. 11 slaughterhouse workers ill, inhaled pig-brain matter suspected

    By Mark Frauenfelder

    Inhaling aerosolized pig brains could be hazardous to your health.

    In the slaughterhouse floor at Quality Pork Processors Inc. is an area known as the “head table,” but not because it is the place of honor. It is where workers cut up pigs’ heads and then shoot compressed air into the skulls until the brains come spilling out.

    But now the grisly practice has come under suspicion from health authorities.

    Over eight months from last December through July, 11 workers at the plant in Austin, Minn. — all of them employed at the head table — developed numbness, tingling or other neurological symptoms, and some scientists suspect inhaled airborne brain matter may have somehow triggered the illnesses.

  13. Hmm.. inhaling aerosolized pig brains is hazardous?! I guess my patent on pig-brain sensual body spray is useless now.

    I am always disheartened when my doctor prescribes antibiotics for an infection (or potential infection) that could be easily cured with a pile of vitamin C, and an abundance of water to clear out your system. I get throat infections fairly often, (whenever I catch a cold) and I’ve been prescribed antibiotics for a sore throat that is easily salved by gargling some table salt and water.

    It’s almost as if the pharmaceutical companies have something to gain by pushing the superfluous usage of antibiotics! Something like .. oh, huge profit margins.

  14. Hillary and Big Meat

    By Tom Philpott

    “A lot of pig shit is one thing; a lot of highly toxic pig shit is another. The excrement of Smithfield hogs is hardly even pig shit: On a continuum of pollutants, it is probably closer to radioactive waste than to organic manure. The reason it is so toxic is Smithfield’s efficiency. The company produces 6 billion pounds of packaged pork each year. That’s a remarkable achievement, a prolificacy unimagined only two decades ago, and the only way to do it is to raise pigs in astonishing, unprecedented concentrations.”

    — Jeff Tietz, “Boss Hog,” Rolling Stone, Dec. 14, 2006

  15. In 2005, Human Rights Watch — which usually finds its services most useful in dictatorships and war-torn regions — saw fit to issue a blistering report on the wretched working conditions in the meatpacking industry.

  16. Our Decrepit Food Factories
    By: Michael Pollan

    “The first story is about MRSA, the very scary antibiotic-resistant strain of Staphylococcus bacteria that is now killing more Americans each year than AIDS — 100,000 infections leading to 19,000 deaths in 2005, according to estimates in The Journal of the American Medical Association. For years now, drug-resistant staph infections have been a problem in hospitals, where the heavy use of antibiotics can create resistant strains of bacteria. It’s Evolution 101: the drugs kill off all but the tiny handful of microbes that, by dint of a chance mutation, possess genes allowing them to withstand the onslaught; these hardy survivors then get to work building a drug-resistant superrace. The methicillin-resistant staph that first emerged in hospitals as early as the 1960s posed a threat mostly to elderly patients. But a new and even more virulent strain — called “community-acquired MRSA” — is now killing young and otherwise healthy people who have not set foot in a hospital. No one is yet sure how or where this strain evolved, but it is sufficiently different from the hospital-bred strains to have some researchers looking elsewhere for its origin, to another environment where the heavy use of antibiotics is selecting for the evolution of a lethal new microbe: the concentrated animal feeding operation, or CAFO.”

  17. “The Union of Concerned Scientists estimates that at least 70 percent of the antibiotics used in America are fed to animals living on factory farms. Raising vast numbers of pigs or chickens or cattle in close and filthy confinement simply would not be possible without the routine feeding of antibiotics to keep the animals from dying of infectious diseases. That the antibiotics speed up the animals’ growth also commends their use to industrial agriculture, but the crucial fact is that without these pharmaceuticals, meat production practiced on the scale and with the intensity we practice it could not be sustained for months, let alone decades.”

  18. “A European study found that 60 percent of pig farms that routinely used antibiotics had MRSA-positive pigs (compared with 5 percent of farms that did not feed pigs antibiotics). This month, the Centers for Disease Control and Prevention published a study showing that a strain of “MRSA from an animal reservoir has recently entered the human population and is now responsible for [more than] 20 percent of all MRSA in the Netherlands.”

  19. Then, sometime in the 1990s, MSRA cases began to pop up among folks who had never gone near a hospital. Around the same time, the pork industry was undergoing a massive wave of consolidation — more and more hogs crammed into tighter and tighter spaces. And since hogs raised under such conditions essentially cede their immune systems, the only way to keep them alive was , you guessed it, by dosing them liberally with antibiotics.

    Can anyone guess what happened next?

    Evidently, FDA and USDA regulators couldn’t. As MRSA cases — and deaths — piled up, these folks looked the other way, Schneider reports. And they remain slack-jawed and flummoxed, even as evidence mounts of a link between the deadly bacteria and industrial pork production.

  20. “Recently, though, a researcher at the University of Iowa decided to do what U.S. authorities have avoided: test U.S. CAFO-grown pigs for MRSA. Evidently, it wasn’t t that hard. Schneider reports that assistant professor of epidemiology Tara Smith and her team of graduate students merely “swabbed the noses of 209 pigs from 10 farms in Iowa and Illinois.”

    The results were unsettling: they “found MRSA in 70 percent of the porkers.” Stunningly, this apparently marked the first-ever publicly released test of U.S. hogs for MRSA. “

  21. In the presence of drugs, pathogens have evolved sophisticated mechanisms to inactivate these compounds (e.g. by pumping out compounds, mutating residues required for the compound to bind, etc.), and they do so at a rate that far exceeds the pace of new development of drugs. Examples include drug resistant strains of Staphylococcus aureus, Klebsiella pneumonia, and Pseudomonas aeruginosa, and Mycobacterium tuberculosis (TB) among bacterium and HIV-1 among viruses. Indeed, no new antibiotics have been developed against TB in thirty years. Efforts to develop new antibiotics by the pharmaceutical industry by large-scale screens of chemical libraries which inhibit bacterial growth have largely failed, and new tetracycline and sulfanilamide analogs will likely engender resistance and will quickly be rendered useless.

  22. If [the pasture] system is so sensible, you might ask, why did it succumb to Confined Animal Feeding Operations, or CAFOs? In fact there is nothing inherently efficient or economical about raising vast cities of animals in confinement. Three struts, each put into place by federal policy, support the modern CAFO, and the most important of these — the ability to buy grain for less than it costs to grow it — has just been kicked away. The second strut is F.D.A. approval for the routine use of antibiotics in feed, without which the animals in these places could not survive their crowded, filthy and miserable existence. And the third is that the government does not require CAFOs to treat their wastes as it would require human cities of comparable size to do. The F.D.A. should ban the routine use of antibiotics in livestock feed on public-health grounds, now that we have evidence that the practice is leading to the evolution of drug-resistant bacterial diseases and to outbreaks of E. coli and salmonella poisoning. CAFOs should also be regulated like the factories they are, required to clean up their waste like any other industry or municipality.

  23. Our Pigs, Our Food, Our Health
    Published: March 11, 2009

    The federal Centers for Disease Control and Prevention reported that by 2005, MRSA was killing more than 18,000 Americans a year, more than AIDS.

  24. Op-Ed Columnist
    Pathogens in Our Pork

    Published: March 14, 2009

    We don’t add antibiotics to baby food and Cocoa Puffs so that children get fewer ear infections. That’s because we understand that the overuse of antibiotics is already creating “superbugs” resistant to medication.

    Yet we continue to allow agribusiness companies to add antibiotics to animal feed so that piglets stay healthy and don’t get ear infections. Seventy percent of all antibiotics in the United States go to healthy livestock, according to a careful study by the Union of Concerned Scientists — and that’s one reason we’re seeing the rise of pathogens that defy antibiotics.

    These dangerous pathogens are now even in our food supply. Five out of 90 samples of retail pork in Louisiana tested positive for MRSA — an antibiotic-resistant staph infection — according to a peer-reviewed study published in Applied and Environmental Microbiology last year. And a recent study of retail meats in the Washington, D.C., area found MRSA in one pork sample, out of 300, according to Jianghong Meng, the University of Maryland scholar who conducted the study.

  25. As MRSA gets worse, the FDA discovers antibiotic abuse on factory farms [UPDATED]

    Posted 1:55 PM on 17 Jul 2009
    by Tom Philpott

    A bill now circulating in the House, sponsored by Rep. Louise Slaughter (D.-NY), would limit the amount of antibiotics that can be used on factory animal farms.

    There’s good news and bad news on that front. The bad news: “The farm lobby’s opposition makes its passage unlikely,” The New York Times reported Monday. The farm lobby’s opposition is like that. But The Times should be more precise: it’s really the agribusiness lobby—representing a few large companies—that wields power.

    Ok, now to the good news: Obama’s FDA has come out in support of restricting antibiotics. FDA official Joshua Sharfstein testified at a hearing sponsored by Slaughter that the agency will seek to limit antibiotic use on factory farms.

  26. The Superbug in Your Supermarket

    A potentially deadly new strain of anti-biotic-resistant microbes may be widespread in our food supply. Protect your loved ones with Prevention’s Special Report.

    By Stephanie Woodard , Stephanie Woodard is a New York City-based writer who covers food, gardening, health, and human rights, among other subjects.

    About 2 years ago, dozens of workers at a large chicken hatchery in Arkansas began experiencing mysterious skin rashes, with painful lumps scattered over their hands, arms, and legs. “They hurt real bad,” says Joyce Long, 48, a 32-year veteran of the hatchery, where until recently, workers handled eggs and chicks with bare hands. “When we went and got cultured, doctors told us we had a superbug.” Its name, she learned, was MRSA, or methicillin-resistant Staphylococcus aureus. This form of staph bacteria developed a mutation that resists antibiotics (including methicillin), making it hard to treat, even lethal. According to the CDC, certain types of MRSA infections kill 18,000 Americans a year–more than die from AIDS.

  27. Superbug

    Research, strategies and stories from the struggle against methicillin-resistant Staph aureus (MRSA)

    This blog is the virtual whiteboard for my new book, SUPERBUG, coming in March 2010 from Free Press. Whether you’re a MRSA researcher or a MRSA victim — or simply a major disease geek — I’m interested in your leads, thoughts, comments and stories. Watch this space for drafts and details as SUPERBUG moves forward.

  28. Big Meat, that new report on antibiotics doesn’t say what you say it says

    Posted 12:59 PM on 21 Oct 2009
    by Tom Laskawy

    The American Academy of Microbiologists (“the world’s oldest and largest life science organization”), just issued a major report on antibiotic resistance which, among many recommendations, calls for decreasing or eliminating the use of antibiotics in animal production. The report adds more support for the Preservation of Antibiotics for Medical Treatment Act (PAMTA), Rep. Louise Slaughter’s (D-N.Y.) bill before Congress that would end sub-therapeutic doses on antibiotics for livestock.

  29. Pingback: DDT and evolution
  30. Emerging infectious diseases that affect livestock and man alike are a threat to health and prosperity. International researchers in Delhi this week met to discuss how new agricultural practices, notably in livestock, affect public health. Livestock not only pass on new diseases to other species, including man, but also help spread existing diseases to new places.

    Scientists spot a new disease roughly every four months. Most are trivial but a minority, such as HIV, bird flu and SARS are grave threats. Animals seem to be the main source of new infectious disease in man: in general around 60% of human pathogens are transmissible from animals; among new diseases, the rate is about 75%.

    As rural populations in India and elsewhere expand, grow richer and eat more protein, backyards where a few chickens or pigs once scratched have become densely packed smallholdings of several dozen animals. These bring owners more wealth, but also hygiene and veterinary problems. One symptom is the poor quality of meat traded in markets. A 2009 study of pork sold in Nagaland, in the north-east of India, where smallholdings have been flourishing (Christians, fond of pork, are prevalent there), found that 9% of meat contained tapeworm cysts. More than half the customers said that they had seen such cysts in their meat at some time.

  31. Q. Well, that’s certainly not what you’d expect from the media reaction to the paper. How did you reach that conclusion?

    A. There is one particular type of resistance found by the researchers that is a big red flag for the influence of farm antibiotics, and that is resistance to the antibiotic tetracycline.

    Let’s back up. When someone gets an infection, you give them a drug. Maybe it’s not the right dosage and the bacteria become more resistant to that drug. If the bacteria are never exposed to the drug, it’s unlikely they’ll become resistant.

    Yet lots and lots of the bacteria that were analyzed in this study were resistant to tetracycline. And doctors haven’t historically given tetracycline to humans with MRSA infections. It’s not one of the major drugs. But animals get lots of tetracycline. The MRSA strain in livestock that was first identified back in 2004 that went from pigs to humans was tetracycline-resistant. In fact, that form of resistance was a big arrow pointing back to the drugs given to the pigs.

    And indeed, when you look at all the bacteria samples that the Iowa team analyzed you see tetracycline resistance in lots of them. [Whereas] the human strains of MRSA found on the meat were probably put there by a slaughterhouse worker or a butcher or someone handling it in the supermarket.

    These results turn this paper on its head. What it says is not, “Oh, farm antibiotics aren’t having that big an effect.” The prevalence of tetracycline resistance in all forms of MRSA tell us that farm antibiotics are a much bigger deal than anybody realized.

  32. Finally, a smoking gun connecting livestock antibiotics and superbugs

    How does the livestock industry talk about antibiotics? Well, it depends on who’s doing the talking, but they all say some version of the same thing. Take the National Cattlemen’s Beef Association; they say there is “no conclusive scientific evidence indicating the judicious use of antibiotics in cattle herds leads to antimicrobial resistance in humans [MRSA].”

    A study in the journal mBio, published by the American Society for Microbiology, shows how an antibiotic-susceptible staph germ passed from humans into pigs, where it became resistant to the antibiotics tetracycline and methicillin. And then the antibiotic-resistant staph learned to jump back into humans.

    “It’s like watching the birth of a superbug,” says Lance Price of the Translational Genomics Research Institute, or TGen, in Flagstaff, Ariz.

  33. MODERN FARMER / The Abstinence Method by Maryn McKenna

    “Oosterlaken is in the midst of a high-stakes, government-mandated experiment: Can large-scale meat production succeed without routine use of antibiotics?”

  34. ‘Disturbing’ drug-resistant superbug gene has been detected in Canada
    The alarming drug-resistance gene MCR-1 that was first detected in China in November has been found in meat sold in Ontario in 2010, the Star has learned. The gene grants bacteria like E. coli resistance to colistin, a powerful antibiotic of last resort.

    An alarming new superbug gene that makes bacteria resistant to a last-resort antibiotic has been detected in Canada, the Star has learned.

    The gene, called MCR-1, produces an enzyme that makes bacteria invincible to colistin, a highly toxic antibiotic used only when all other drugs have failed.

    MCR-1 was first reported in November by scientists in China, who published a paper in The Lancet that set off alarm bells across the globe. Analyzing bacterial samples in southeastern China, researchers found 260 samples of E. coli with the MCR-1 gene on meat, hospital patients and farm animals — the likely source of this new superbug, the paper suggests.

    Colistin is still rarely used in human medicine because doctors want to conserve the antibiotic’s effectiveness. But polymyxins are often given to livestock animals to prevent infections and promote growth — especially in China, one of the world’s highest users of colistin in agriculture. (While colistin isn’t used in agriculture in Canada, polymyxin B — a similar compound that creates the same resistance problems as colistin — is.)

    In 2015, the global market for colistin in agriculture reached nearly 12,000 tonnes and is expected to rise to 16,500 tonnes by 2021, according to the Lancet paper. “That’s insane,” said Dr. Gerry Wright, a microbiologist with McMaster University and expert in antibiotic resistance.

  35. Resistance is not only encouraged and spread in medical settings. In many places, more antibiotics are given to farm animals than to people. In America 70% of those sold end up in beasts and fowl. Some of this is to treat disease; most is not. For reasons only dimly understood, many animals put on weight faster when fed these drugs. A lot of these drugs pass into the soil and watercourses, where they further encourage resistance. The bacteria that become resistant this way are unlikely to be human pathogens. But their resistance genes can quite easily get into bugs that are.

    Some of the antibiotics farmers use are those that doctors hold in reserve for the most difficult cases. Colistin is not much used in people because it can damage their kidneys, but it is a vital last line of defence against Acinetobacter, Pseudomonas aeruginosa, Klebsiella and Enterobacter, two of which are specifically mentioned on the CDC watch list. Last year bacteria with plasmids bearing colistin-resistant genes were discovered, to general horror, in hospital patients in China. Agricultural use of colistin is thought to be the culprit.

    The cost of banning antibiotics as growth enhancers would not be great: an American government study suggests it might reduce the bottom line of those who currently use them by less than 1%. The European Union has already enacted such a ban. Despite practical difficulties—the difference between a growth-enhancing dose and a veterinarially defensible prophylaxis may often be in the eye of the beholder—more should follow.

    Lord O’Neill favours such prohibitions. He also likes the idea of using more vaccination to head off the need for treatment, both in livestock and in people. Hospital hygiene is another focus; there is some evidence that staff are more careless about cleanliness than they were in pre-antibiotic days, when they saw deaths like Albert Alexander’s on a more regular basis.

  36. The Meat Industry Refuses to Track Drugs on America’s Farms—and It’s Making Superbugs Worse

    Alternatives to antibiotics exist, but farmers have no way to know when to use them.

    Growth-promoter antibiotic dosing was disallowed in the United States as of January 1 under a set of measures known as Guidances. Disease prevention and treatment are now allowed only with a veterinarian supervising.

    The FDA took those steps because antibiotics given to meat animals contribute to the development of antibiotic-resistant bacteria and thus contribute to the 700,000 deaths and millions of illnesses caused each year by drug-resistant infections.

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