Jade Patel, Alyssa Schmidt, Sam Shames, Chandlyr Mickan, Aman Barekzai, Emergency Management, Health, and Hazards (EMH2) Team
Week of Monday, July 26, 2021
A Candida Auris (C Auris) fungus outbreak has been identified in care facilities across the United States (US), specifically in Washington DC, Texas, and Florida. Whilst this type of fungus is usually common, this specific outbreak is being classed as a superbug given the bacteria's resistance to medications making it highly transmissible. Since February 2021, 123 people have been infected across all three states, with more cases likely over the coming months. The survival rate of those infected is dependent on demographics and health status and has a 30%-80% fluctuation of recovery. Without preventive measures and efforts to decrease transmission, more people will likely become infected and could result in fatalities.
Description of Pathogen
Candida Auris is a fungus that grows as yeast and is one of the few species of the genus Candida that causes an infection in humans known as candidiasis. Symptoms of this infection can include fever, redness and swelling, and chills. The fungus is commonly found in healthcare facilities and can cause severe illness in hospitalized patients, and/or those with weakened immunities. In some cases, this yeast enters the bloodstream of the patient and can spread throughout the entire body, resulting in serious invasive infections. This type of yeast does not respond to commonly used antifungal drugs, making it difficult to treat and prevent. Because of this, it is likely that those infected will have longer-lasting and worsened infections caused by Candida Auris. Long infection from Candida Auris could leave the infected individual(s) with long-term symptoms and discomfort. As the symptoms for Candida Auris are common to that of a flu-like, seasonal cold, one major health risk is not identifying the fungus in time to prevent an outbreak. The transmissibility of Candida Auris means that it can spread rapidly before the infection is diagnosed and can lead to an influx of infected individuals in a short period. Patients who have been hospitalized in a healthcare facility for a long duration and/or who are permanently residing in a care setting are at higher risk of this yeast infection, along with those who have a central venous catheter, or other lines or tubes entering their body. There are also studies to suggest that those who have previously received antibiotics or antifungal medications are more likely to be at risk of developing antibiotic-resistant infections.
According to recent CDC research, patients with C Auris shed the fungus onto high touchpoints such as bed rails and other parts of the hospital environment which is the likely cause of transmission. The pathogen can survive for several weeks on objects despite cleaning, as standard disinfectants are not effective in removing the fungus. As other people then touch the infected surface the pathogen can then spread, and continue transmitting. The mortality rate of C Auris differs but is likely to impact individuals with underlying or existing suppressed immunities. For at-risk individuals, it can have up to an 80% mortality rate, reducing the chances of survival significantly. C Auris has not been found to follow a seasonal pattern, which means that the outbreak is likely to continue until transmission can be contained. Efforts to stop the spread may be long-term, as the fungus has proved itself able to resist common antibiotics and antifungal medicines.
The fungus has been identified in care facilities within the US, specifically in Washington DC, Texas, Michigan, and Florida. The high transmissibility of the fungus makes it likely that other states could record infections if containment measures are unsuccessful. Transmission could occur if people are actively visiting the infected care facilities and socially interacting, along with discharging or transferring infected patients to other health facilities, nationwide.
C Auris is thermotolerant, meaning it can survive in high temperatures and optimizes between 37°C and 42°C. The pathogen is also salt tolerant and cells develop into large, difficult to disperse clusters, which heavily promotes the fungus persistence in a hospital setting. Weather increases within the US and the general care environment are likely the reason why the outbreak has occurred in facilities. With the pathogen being challenging to control, these circumstances are likely the reason for the high transmissibility within the US across multiple states. As the heatwaves continue in parts of the US, this creates the perfect environment for C Auris to continue spreading and is likely to impact the increase of cases over the summer season.
The most challenging response to combating the C Auris outbreak fungus is its resistance against antifungal medications. According to researchers, the five patients located in Texas and Washington, D.C., did not respond to any of the three major anti-fungal treatments available. Since C Auris Fungus is difficult to treat, it is highly likely that this outbreak could spread even further, infecting more individuals.
In addition to the C Auris fungus being multidrug-resistant, it is also very difficult to identify, contain, and prevent. According to the Brown Institute for Media Innovation at Columbia University, C Auris has an affinity for skin and can persist on various surfaces in healthcare facilities for an extended time. With standard disinfectants not effective against C Auris, there is a high chance that health facilities will experience more outbreaks. This may become a problem because if health facilities report more outbreaks, they will likely be forced to close or reduce their capacity to conduct disinfectant operations. This has the potential to spread the C Auris fungus since patients will be transferred to other healthcare facilities. It is likely that confirmed cases of C Auris may go undetected, which makes it difficult for state and local health departments to contact trace.
The C Auris fungus is unlikely to create difficulty with traveling. If individuals have recently been in the hospital or are traveling for a medical procedure, they are more likely to be susceptible to this infection. No vaccinations have been created to cope with this outbreak. There are no foods that have been known to increase the spread of C Auris. Since the world is dealing with an increase of COVID-19 cases alongside this infection, it is important to continue to follow precautions and for people with weakened immune systems to be diligent when going to medical facilities. No research suggests that any specific transportation will increase the spread of C Auris; however, if individuals have recently been at a hospital, they should monitor their symptoms to ensure that they are healthy.
Political Effects/Effects on Terrorism
The type and nature of the outbreak do not pose a direct terror threat. However, as cases increase in care facilities, this could require aid from governmental organizations such as Federal Emergency Management Agency (FEMA) and the Centers for Disease Control and Prevention (CDC) are monitoring the outbreak. If more cases are discovered and the outbreak continues, emergency management practices may need to be revised to control the spread of the fungus. With multiple incidents occurring throughout the US, alongside the accelerated C. Auris cases, necessary interventions from these organizations may cause vulnerabilities in security or counterterrorism efforts. The outbreak is very unlikely to cause political instability unless the fungus was to mutate or equally become uncontrollable which is less likely given the number of cases over a multiple month span. Candida Auris is also unlikely to create new opportunities for terror groups. The primary environment that this fungus is identified is not likely to present itself as an attractive weapon or target for extremists.
Recommendations for AOCs
The major challenges with Candida Auris are its rapid spread and drug resistance, making it difficult to contain and treat. Since a majority of current cases are being detected in long-term care facilities (LTCF) and acute care homes, these organizations must work with local public health departments to establish C. Auris protocols. Symptoms of C. Auris are similar to those of other infections and staff at hospitals and LTCFs must be made aware of recent outbreaks so that proper testing can be run on patients. Due to the rapid spread of C. Auris, early detection and reporting to local public health labs are extremely crucial in containing the fungus. Public health departments should continue using Whole Genome Sequencing (WGS) to improve early detection and also to determine how cases at different facilities and regions are potentially connected. Additionally, these healthcare facilities should enhance infection control measures such as personal hygiene and increased vigilance for disinfecting patients’ rooms and medical equipment. Increased personal protective equipment (PPE) such as gowns and gloves may be useful in preventing the spread of the fungus, and instituting lockdowns at affected facilities will greatly reduce transmission. Hospitals in regions with C. Auris outbreaks should expect an increase in the number of patients requiring critical care. With many states experiencing surges in COVID-19 cases and hospitalizations, this will likely create competition for hospital beds. As a result, continued efforts to decrease hospitalizations from COVID-19 will also help with freeing up beds for potential increases in patients infected with C. Auris.
________________________________________________________________________ The Counterterrorism Group (CTG)
 What Is Candida Auris?, Very Well Health, October 2020, https://www.verywellhealth.com/candida-auris-4692475
 Antifungal Resistance, CDC, July 2021, https://www.cdc.gov/fungal/antifungal-resistance.html
 Infection Prevention and Control for Candida auris, Centers for Disease Control and Prevention (CDC), July 2021, https://www.cdc.gov/fungal/candida-auris/c-auris-infection-control.html
 Rare, often deadly Candida auris fungal infection identified in Oakland County man, Detroit Free Press, July 2021, https://eu.freep.com/story/news/local/michigan/oakland/2021/07/29/candida-auris-michigan/5392638001/
 Candida auris Outbreak in a COVID-19 Specialty Care Unit — Florida, July–August 2020, Centers for Disease Control and Prevention (CDC), January 2021, https://www.cdc.gov/mmwr/volumes/70/wr/mm7002e3.htm
 Candida auris: What Have We Learned About Its Mechanisms of Pathogenicity?, NCBI, December 2018, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6315175/
 Outbreaks of Untreatable, Drug-Resistant Fungus Spread in 2 Cities, NY Times, July 2021, https://www.nytimes.com/2021/07/23/health/superbug-fungus-cdc.html
 'Superbug' fungus Candida auris found in 76-year-old Oakland County man, WXYZ, July 2021, https://www.wxyz.com/news/superbug-fungus-candida-auris-found-in-76-year-old-oakland-county-man
 Candida auris: A Drug-resistant Germ That Spreads in Healthcare Facilities, CDC, December 2018, https://www.cdc.gov/fungal/candida-auris/c-auris-drug-resistant.html