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Which is the Bigger Public Health Threat—Tuberculosis or Candida auris? A Public Health Showdown

Which Is the Bigger Public Health Threat—Tuberculosis or Candida auris? A Public Health Showdown

By Donna Campisano, specialist, Communications, APHL

Tuberculosis (TB) and Candida auris (C. auris) are two potentially deadly infectious diseases that deserve attention, action and advocacy. But when all things are considered, which is the more concerning public health threat?

Two prominent public health laboratory professionals took to the podium at the APHL 2024 Annual Conference on May 9 in Milwaukee, Wisconsin to debate the matter—but in an unconventional way. Each was tasked with relaying the history and impact of the disease as well as waxing poetic about it with a haiku and even using elements of the infections to develop a cocktail recipe.

The debate was separated into rounds, with the winner determined by the volume of the crowd’s applause.

How did the two stack up? Read on to find out.

Team Tuberculosis

Marie-Claire Rowlinson, PhD, bureau chief of the Florida Bureau of Public Health Laboratories, took the stage to argue the case for tuberculosis.

She pointed out that tuberculosis, an airborne infectious disease, has been around for three million years, has gone by a variety of names, including the ominous-sounding white plague and consumption, and, in 2022, affected roughly 10 million people worldwide (nearly 10,000 in the US alone).

“In 2022, tuberculosis was the second-leading cause of death from an infectious agent after COVID-19, and it causes almost twice as many deaths as HIV,” reported Rowlinson, who also noted that tuberculosis is difficult to grow in the lab and is resistant to many antibiotics, the mainstay of treatment. “None of this makes diagnosing or treating tuberculosis easy,” she said.

After sharing a haiku written by the 19th century Japanese poet Masaoka Shiki, who himself lived with and died from tuberculosis, Rowlinson enumerated the many tuberculosis references in art, music and literature (including Puccini’s “La Boheme” and Edvard Munch’s “The Sick Child”). She also shared her recipe for a cocktail she dubbed the “Tuberculini,” which included throat-soothing honey and cough syrup as well as “smoky mescal.”

In her final arguments, Rowlinson compared tuberculosis’ widespread impact to the more limited reach of C. auris.

Candida auris is a healthcare-acquired infection,” she said. “You have a specific, captive population at risk. But anyone who breathes has a risk of getting TB. We’re talking millions versus thousands of cases. Candida auris has been seen in 36 states, but eight of those states have only one individual case. I could also ask, has anyone sang or written or drawn about Candida auris? I’ll finish by saying that Candida auris is not going to be the last of us.”

Candida auris Contingent

Mark Pandori, PhD, director of the Nevada State Public Health Laboratory, painted a grim picture of the relatively new and primarily healthcare-associated fungal infection Candida auris, noting that when it seeps into the bloodstream a person has a one-in-three chance of surviving.

“It’s naturally drug resistant and very easy to spread, forming biofilms that are quite viable,” Pandori said. As if those details weren’t chilling enough, he went on to add that the fungus—which really took off during COVID-19 when hospitals were bursting at the seams—is difficult to kill, even with hospital-grade disinfectants, and hard to identify in the lab, making detection tricky.

When it came time for the haiku portion of the debate, Pandori charmed the crowd with his Dr. Suess-style compositions. An example?

A cat in the hat
With Candida auris
That cat dead now, yo

As for a cocktail, Pandori settled on the cloudy-looking Nigori sake, saying it was the same color as Candida auris and has its origins in Japan, where the fungus was first isolated in 2009. “But Nigori saki is not a cocktail by itself. So, what if you chase it with Everclear? That will put you on your ear,” said Pandori, who reminded the audience that the fungus was first discovered in the ear canal of an elderly patient.

In summation, Pandori emphasized the seriousness of C. auris in the brief time it’s been around.

Candida auris has only been in the human population for 15 years, yet we’re one step away from pan-resistance [resistance to all microbial drugs],” Pandori said. “And those 15 years have been during the time of modern medicine, with all the weaponry, skills, information, diagnostic tools and sequencing we have. In a mere 15 years, C. auris has established itself as what might be the most dangerous healthcare-acquired infection in world.”

The Winner

By the end of the session, both Team Tuberculosis and the Candida auris Contingent were neck- and-neck. As a tiebreaker, moderator Sara Vetter, PhD, interim director at the Minnesota Department of Health Public Health Laboratory, invited the audience to step forward and recite their own haikus devoted to either TB or C. auris. There were a variety of offerings, some generated by AI and others by the creativity of the participants. Ultimately, tuberculosis eked out the win, but not before one audience member decided to give both pathogens their due:

Candida auris
Why not enjoy both?

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