Children are hooked up to IV drips on the stairs at a children’s hospital in Beijing on Nov. 23.

Authorities are covering up the spread of antibiotic-resistant pneumonia.

Article initially published by Foreign Policy on November 28, 2023 and written by Annie Sparrow

In Beijing and other megacities in China, hospitals are overflowing with children suffering pneumonia or similar severe ailments. However, the Chinese government claims that no new pathogen has been found and that the surge in chest infections is due simply to the usual winter coughs and colds, aggravated by the lifting of stringent COVID-19 restrictions in December 2022. The World Health Organization (WHO) has dutifully repeated this reassurance, as if it learned nothing from Beijing’s disastrous cover-up of the COVID-19 outbreak.

There is an element of truth in Beijing’s assertion, but it is only part of the story. The general acceptance that China is not covering up a novel pathogen this time appears reassuring. In fact, however, China could be incubating an even greater threat: the cultivation of antibiotic-resistant strains of a common, and potentially deadly, bacteria.

Fears of another novel respiratory pathogen emerging from China are understandable after the SARS and COVID-19 pandemics, both of which Beijing covered up. Concerns are amplified by Beijing’s ongoing obstruction of any independent investigation into the origins of SARS-CoV-2, the virus that causes COVID-19—whether it accidentally leaked from the Wuhan lab performing dangerous gain-of-function research or derived from the illegal trade in racoon dogs and other wildlife at the now-infamous Wuhan wet-market.

Four years ago, during the early weeks of the COVID-19 outbreak, Beijing failed to report the new virus and then denied airborne spread. At pains to maintain their fiction, Chinese authorities punished doctors who raised concerns and prohibited doctors from speaking even to Chinese colleagues, let alone international counterparts. Chinese medical statistics remain deeply unreliable; the country still claims that total COVID-19 deaths sit at just over 120,000, whereas independent estimates suggest the number may have been over 2 million in just the initial outbreak alone. Now, Chinese doctors are once again being silenced and not communicating with their counterparts abroad, which suggests another potentially dangerous cover-up may be underway.

We don’t know exactly what is happening, but we can offer some informed guesses.

The microbe causing the surge in hospitalization of children is Mycoplasma pneumoniae, which causes M. pneumoniae pneumonia, or MPP. First discovered in 1938, the microbe was believed for decades to be a virus because of its lack of a cell membrane and tiny size, although in fact it is an atypical bacterium. These unusual characteristics makes it invulnerable to most antibiotics (which typically work by destroying the cell membrane). The few attempts to make a vaccine in the 1970s failed, and low mortality has provided little incentive for renewed efforts. Although MPP surges are seen every few years around the world, the combination of low mortality and difficult diagnostics has meant there is no routine surveillance.

Although MPP is the most common cause of community-acquired pneumonia in school children and teenagers, pediatricians such as myself refer to it as “walking pneumonia” because symptoms are relatively mild. Respiratory Syncytial Virus (RSV), influenza, adenoviruses, and rhinoviruses (also known as the common cold) all cause severe inflammation of the lungs and are far more common causes of emergency-room visits, hospitalization, and death in infants and young children. Why should MPP be acting differently now?

One contributing factor to the severity of this outbreak may be “immunity debt.” Around the globe, COVID-19 lockdowns and other non-pharmaceutical measures meant that children were less exposed to the usual range of pathogens, including MPP, for several years. Many countries have since seen rebound surges in RSV. Several experts agree with Beijing’s explanation that the combination of winter’s arrival, the end of COVID-19 restrictions, and a lack of prior immunity in children are likely behind the surging infections. Some even speculate that that substantial lockdown may have particularly compromised young children’s immunity, because exposure to germs in infancy is essential for immune systems to develop.

In China, MPP infections began in early summer and accelerated. By mid-October, the National Health Commission had taken the unusual step of adding MPP to its surveillance system. That was just after Golden Week, the biggest tourism week in China.

Infection by two diseases at the same time can make things worse. The usual candidates for coinfection in children—RSV and flu—have not previously caused comparable surges in pneumonia. One difference this time is COVID-19. It is possible that the combination of COVID-19 and MPP is particularly dangerous. Although adults are less susceptible to MPP due to years of exposure, adults hospitalized for COVID-19 who were simultaneously or recently coinfected by MPP had a significantly higher mortality rate, according to a 2020 study.

Infants and toddlers are immunologically naive to MPP, and unlike COVID-19, RSV, and influenza, there is no vaccine against MPP. It seems implausible that no child (or adult) has died from MPP, yet China has not released any data on mortality, or on extrapulmonary complications such as meningitis.

Most disturbing, and a fact being downplayed by Beijing, is that M. pneumoniae in China has mutated to a strain resistant to macrolides, the only class of antibiotics that are safe for children less than eight years of age. Beyond discouraging parents to start ad hoc treatment with azithromycin, the most common macrolide and the usual first-line antibiotic for MPP, Beijing has barely mentioned this fact. Even more worrying is that WHO has assessed the risk of the current outbreak as low on the basis that MPP is readily treated with antibiotics. Broader azithromycin resistance in MPP is common across the world, and China’s resistant strain rates in particular are exceptionally high. Beijing’s Centers for Disease Control and Prevention reported macrolide resistance rates for MPP in the Beijing population between 90 and 98.4 percent from 2009 to 2012. This means there is no treatment for MPP in children under age eight.

Fears over a novel pathogen are already abating. After all, MPP is rarely lethal. But antimicrobial resistance (AMR) is. Responsible for 1.3 million deaths a year, AMR kills more people than COVID-19. No country is immune to this growing threat. Since China, where antibiotics are regularly available over the counter, leads the world in AMR, it is inconceivable that this issue hasn’t yet come up, particularly during WHO’s World AMR Awareness week, from Nov. 18 to Nov. 24.

Any infectious disease physician would want to know: Did WHO asked China the obvious question—what is the level of azithromycin resistance of M. pneumonia in the current outbreak—and include the answer in its risk assessment? Or did it ask about resistance to doxycycline and quinolones, antibiotics that can be used to treat MPP in adults? Even if WHO did ask, China isn’t telling, and WHO isn’t talking.

China’s silence isn’t surprising. Its antibiotic consumption per person is ten times that of the United States, and policies for AMR stewardship are predominantly cosmetic. While surveillance is China’s strong point, reporting is not.

Despite Spring Festival, the Chinese celebration of the Lunar New Year and another peak travel period, approaching in February 2024, WHO hasn’t advised any travel restrictions. It should have learned the danger of accepting Beijing’s statements at face value. Four years ago, Beijing’s delay enabled more than 200 million people to travel from and through Wuhan for Spring Festival. That helped COVID-19 go global. Since China’s AMR rates are already so high, importing AMR from other countries isn’t a major concern for China. Export is the issue, and China’s track record in protecting other countries is abysmal.

Rather than repeating the self-serving whitewashing coming from Beijing, WHO should be publicly pressing China about the threat of mutant microbes. Halting AMR is essential. Before antisepsis and antibiotics, surgery was a treatment of last resort. Without antibiotics, we lose 150 years of clinical and surgical advances. Within ten years, we are at risk of few antibiotics being effective. It may not be the novel virus that people were expecting, but the next pandemic is already here.

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