MERS Virus: Pandemic or Hype?

MERS Virus: Pandemic or Hype?

Posted May 31, 2014 at 8:00PM

Courtesy of JonBarron.org.

I used to think that Halloween came in October, complete with scary jack-o-lanterns, ghosts, and witches on broomsticks. Apparently I was wrong, and it now also comes in the spring. How else to explain all the scary headlines about MERS (Middle East Respiratory Syndrome) in the media over the last few weeks? You would think the world was about to come to an end, that MERS was on the verge of wiping out millions of people in the days ahead. Then again, we seem to see headlines like this every couple of years. We saw them for SARS, for bird flu, and for swine flu. And for each of those, I told you that they were worth watching carefully, but were unlikely to ever become major pandemics…and they didn't. And now we're seeing the same kind of shock headlines for MERS, and to cut to the chase, MERS too is unlikely to become a major pandemic. Nevertheless, many pundits are doing the best to scare the bejeebers out of you. For example, here are some actual headlines taken from the news:

  • MERS Experts Fret About Deadly Virus' Great Unknowns1

  • Deadly MERS Virus Arrives in US2

  • The deadly MERS virus is spreading at a terrifying rate3

  • MERS outbreak hits 30% death rate as pandemic spreads in Saudi Arabia4

If you were so inclined and took these headlines to heart, you might think we were approaching the End Times. But if you thought that, you would be wrong. In truth, these headlines are yellow journalism scaremongering, plain and simple. The media knows people love to be scared. Last year, for example, The Conjuring grossed $137 million at the box office.5 And they're playing to your desire to get a good scare at the movies--or in the media headlines in this case.

In truth, MERS is little changed since I first reported on it last July. At that time:

  • There were 90 cases with 45 deaths, which worked out to a 50% mortality rate.

  • The vast majority of cases were in Saudi Arabia, although a few cases had appeared in Jordan, Qatar, Tunisia, and the United Arab Emirates, as well as Britain, France, Germany, and Italy. However, almost all of these cases came from people who had traveled to Saudi Arabia and then returned home.

  • No one knew where it came from (although bats were suspected), which meant that no one knew where it was hiding in nature. This is important, because if you can't root it out at the source, it can keep reappearing even if you eliminate all human cases.

  • And most important of all, cases had occurred in clusters--that is, in families and health facilities, indicating a limited capacity to spread among people in close contact with an infected person. In other words, there was no evidence that MERS had crossed the "sustainability" threshold when it comes to human-to-human transmission; it didn't seem to transfer easily from one person to the next.

So what's changed in the last 10 months? As it turns out, not much.

  • The total now is 621 cases and 128 deaths. That works out to 30 new cases and 10 new deaths a month--hardly pandemic numbers. That means that MERS hasn't "hit" a 30% death rate as some headlines claimed, but rather that it has dropped to a 30% death rate from what was previously a 50% death rate. Again, the headlines are scaremongering, plain and simple!

  • The vast majority of cases, approximately 84%, are still in Saudi Arabia. Yes, there was a recent spike in the number of cases over the last two months, but that was largely, but not exclusively, due to poor hospital isolation procedures that infected a number of healthcare workers and hospital patients--including some who had no direct contact with the MERS patients. And yes, cases have recently appeared in Egypt and the US, but we're talking about one person in Egypt and three in the U.S. Three of these people actually contracted the disease while working with MERS patients in Saudi Arabia. The fourth acquired a very mild form of it after meeting several times with one of the patients who brought the disease back from Saudi Arabia. Again, hardly pandemic numbers.  Those patients in Egypt and America immediately were put in isolation wards in hospitals, and there is no indication as yet that the disease has gone beyond the isolated individuals. Incidentally, one of the U.S. patients made the news with multiple variations of the following headline: "Florida MERS patient sat in busy ER for hours."6 One TV station in their promo for the evening news added the extra tidbit to that headline by referring to MERS as "highly contagious"--obviously trying to scare with the one-touch, one-contact scenario from the movie Contagion

But this is stuff and nonsense. The bottom line is that when it comes to full-blown MERS, we are NOT talking about one-touch, one-contact transmission. This is not Contagion. To repeat, at this point in time, full-blown MERS requires extended, close contact for transmission--NOT one touch, one contact. In fact, MERS has already passed the Hajj test, which we will talk more about in a bit. Now, if you’ve been paying attention, you probably noticed that several times I’ve referred to “full-blown” MERS. It appears that it is possible to contract a lesser form of the virus, one that presents with mild cold-like symptoms or no symptoms at all, with somewhat less contact. In fact, in some cases the only way you’d know you’d even had this mild form is with a blood test that showed your immune system had generated some antibodies for MERS. Otherwise, you’d never know. But even this mild form is not one touch, one contact. This will become clearer when we talk further about the Hajj.

  • Scientists now think they know a major piece of the puzzle as to where the virus comes from. It looks like it's camels, not bats. A study published several weeks ago in the journal Eurosurveillance, found that the virus lives in camels, and the version of the virus in camels is genetically indistinguishable from the version that infects humans.6 On the other hand, we don't know how camels were infected with the disease -- which is not dangerous to them. Even more significantly, the disease had been present in camels for a long time before the first human cases were detected in 2012. Although the infection rate from camels to humans is likely very low, this is important because it means that even if you eliminate the virus in people, it can keep reappearing in those who work closely with camels. They can then spread it to family members and healthcare workers--in other words, perpetually keeping the virus in play--albeit at a very low level. That means that if you're not sleeping with camels or personally taking care of a MERS patient, your risk appears to be infinitesimal. It also means that, at least for the foreseeable future, MERS is likely to stay in countries with large camel populations.

  • And again, most importantly of all, the vast majority of new cases have occurred either in close family members or in health care workers working closely with MERS patients in hospitals that did not have effective isolation procedures--both involving extended close contact with people who already had the disease. Again, with MERS we seem be talking about the antithesis of one touch, one contact. Keep in mind, as I mentioned earlier, the first two cases of MERS in America that have been all over the news the last couple of weeks, were in people who had been involved in healthcare in Saudi Arabia, contracted the disease there, and then travelled to the U.S. The first person, who incidentally has recovered and been released from the hospital, also had underlying medical conditions, which seems to be a factor in being susceptible to the disease, as many MERS patients seem to suffer from pre-existing health issues, which means having a compromised immune system may play a role contracting the disease.

    It should also be noted that the MERS passed the Hajj test last fall. As we said in our previous newsletter on MERS, the October Hajj was a concern when it came to MERS. The Hajj is one of the five pillars of Islam. It is the Muslim pilgrimage to Mecca that takes place in the last month of the year (Islamic calendar). It is a religious duty that must be carried out by every able-bodied Muslim who can afford to do so at least once in their lifetime. In 2012, the Hajj placed 1.75 million foreign pilgrims in contact with 1.4 million Saudi pilgrims, and there were concerns that such contact during the October 2013 Hajj could prove a deadly mix for a disease that had, at least up to that point, largely been contained within Saudi Arabia. To be sure, fears about MERS caused attendance to drop. For foreign pilgrims, numbers were down about 21 percent to 1.37 million from 188 countries. And even more significantly, the number of pilgrims from within Saudi Arabia were estimated be down about 50%. It's true that's a big drop off, but you're still talking about 1.37 million visitors from foreign countries mixing in close contact with 700,000 Saudi's for 10 days…and there was no notable spike in the numbers of cases of MERS in countries outside of Saudi Arabia in the weeks following the Hajj.

    The bottom line is that MERS does not transmit easily from one person to another. It requires prolonged intimate contact such as seen with immediate family members and healthcare workers who do not observe isolation protocols. For this reason, it requires a reservoir outside of people to keep on going. Camels, then, seem to be a key part of the equation. In other words, if you're not living in a country where camels are a fundamental part of the infrastructure and if you're not intimately involved with a MERS patient, the,n statistically, your chances of winning the mega lotto literally appear to be better than your chances of contracting MERS--much better, in fact.

A Surprising Side to MERS

Now, let’s talk for a moment about that third case of MERS in the U.S. since it occurred in someone who had never travelled to the Middle East. What happened is that an American in Illinois who had contact with one of the two healthcare workers returning to the U.S. from Saudi Arabia was found to have the disease--though he had no symptoms and didn’t require medical care.

The man had extended face-to-face contact with the MERS infected healthcare worker from Indiana twice after he had returned from Saudi Arabia. The Illinois “patient” was first tested for MERS on May 5—not because he was sick in any way, but merely because he had been in contact with the Indiana patient. This test, called a PCR, is run on a patient's respiratory secretions and reveals any active illness. The results of the test were negative. A subsequent test, however, which looked at a blood sample from the patient to see if there were any antibodies for MERS (which would indicate a prior exposure to the virus at some point in the past) turned up positive on May 16. The crucial fact here, though, is that the man never reported feeling sick, never displayed any symptoms, and is still “feeling well,” according to the CDC.

Needless to say, the press has had a field day with this case promoting the fact that the Illinois man had contracted MERS after casual contact with the Indiana patient—again, the Contagion scenario.

But in fact, there may be another way of looking at this particular case that paints an incredibly optimistic scenario for MERS moving forward. Consider:

  • The contact, although not as extended as with other cases, was not casual. We’re still not talking about one touch, one contact. The man in question had two extended face-to-face meetings with the MERS carrier that may have included hugging both in greeting and farewell.

  • The man was never sick and displayed no symptoms.

  • This means that full-blown MERS may not be the only form of MERS being transmitted, but rather, the only one being documented since only sick people go to hospitals, and if someone is sick with MERS, you never have to go beyond the PCR test. In fact, it may be quite likely that symptomless MERS is far more prevalent than full-blown MERS since it seems to require less intimate contact for transmission, which would mean:

    • The mortality rate for MERS could actually be far, far less than 30%. In fact, it might be negligible, depending on how widespread symptomless MERS actually is.

    • And if symptomless MERS is widespread and people are carrying it out of Saudi Arabia en masse into the world at large (think Hajj), then the world is now undergoing a massive program of natural MERS self-inoculation, which will eventually render it safe from any possible MERS pandemic in the future. 

I’m not saying that this scenario is a proven reality, but it would behoove world health authorities to start running the MERS antibody test on large numbers of people who attended the last Hajj to see if they carry the MERS antibodies in any substantial numbers. In any case, when it comes to full-blown MERS, it really did pass the 2013 Hajj test in which several million people mixed together in close quarters over 10 days…and there was no spike in full-blown MERS cases in the days and weeks following. That’s the real story, and it’s not that scary.

To sum things up, MERS appears to be of the same impact as SARS, bird flu, and swine flu. In other words, it is not the 1918 flu pandemic revisited. To use a line I coined about swine flu (which later went global with someone else's name attached), we are not talking about "black-plague carts being hauled through the streets piled high with dead bodies." It doesn't mean that MERS can't become something nasty, but at this point in time, we would have to say that MERS is unlikely to ever become the terrifying global pandemic that we are all holding our breath for--and that someday will come. It certainly bears watching, but there is little reason to be panicked.

What you should be worried about?

So, if MERS isn't actually that scary at the moment--unless you're living with camels--what disease should you be worried about? What can we use as a mid-year Halloween jack-o-lantern to get our adrenaline going? I would suggest, if you're looking for something "moderately" scary, then you take another look at antibiotic resistant infections.

Back in 2005, in a newsletter entitled Why Antibiotics and Antivirals Fail, I introduced you to the concept of drug resistant bacteria. We explored how each antibiotic is a single compound and one dimensional in its approach so it's not that hard for microbes to "evolve" around them. The newsletter also explained how bacteria swap genes like politicians swap favors, which meant that not only are bacteria programmed to "evolve" defenses against antibiotics, but once they produce such a defense, they are also programmed to rapidly share that defense with other bacteria -- thus rapidly spreading the resistance.

Antibiotic resistance to manmade drugs is almost impossible to stop since it is the result of some simple rules of evolution. Any population of organisms, bacteria included, naturally includes variants with unusual traits -- in this case, the ability to withstand a particular antibiotic's attack. When said antibiotic is used and kills the defenseless bacteria, it leaves behind those bacteria that can resist it. These renegade variants then multiply, increasing their numbers a million fold in a single day, instantly becoming the dominant variant. In other words, the very act of using an antibiotic creates the opportunity for strains resistant to it to flourish.

And this problem has been compounded and the whole process accelerated by the use of antibiotics in farm animals. In fact, as we discussed just last fall, most of the antibiotics in circulation in the U.S.--up to 80 percent as it turns out--get fed to animals. Farmers add antibiotics to animal feed to prevent and treat disease because when animals are packed close together as in large-scale industrial farming, diseases breed and spread lightning fast, and the farmers want to prevent problems before they develop. They also use the antibiotics to spur rapid growth, along with added hormones. This literally turns industrial animal farms into breeding grounds for drug resistant pathogens…on a Biblical scale.

Unfortunately, our chickens now have come home to roost--all puns intended.

Early warnings appeared a number of years ago, such as the 2005 report that appeared in the Archives of Medical Research that said, "In recent times new mechanisms of resistance have resulted in the simultaneous development of resistance to several antibiotic classes creating very dangerous multidrug-resistant (MDR) bacterial strains, some also known as "superbugs". The indiscriminate and inappropriate use of antibiotics in outpatient clinics, hospitalized patients and in the food industry is the single largest factor leading to antibiotic resistance."7 Needless to say, no one paid any attention to the early warnings.

In September of last year, the warnings had a stronger edge to them when the director of the CDC stated at a press briefing announcing the release of a landmark report about drug-resistance threats in the United States that "If we are not careful, we will soon be in a post-antibiotic era. And for some patients and for some microbes, we are already there."8

Just two months later, Dr. Arjun Srinivasan, Associate Director of the CDC, stated in an interview with PBS, "We have reached the end of antibiotics, period. We're in the post-antibiotic era.  There are patients for whom we have no therapy, and we are literally in a position of having a patient in a bed who has an infection, something that five years ago even we could have treated, but now we can't…"9

And most recently, on April 30th of this year, the World Health Organization released its first global report on antibiotic resistance. In its press release, the WHO echoed the CDC's warnings of a post-antibiotic era and stated that global antibiotic resistance "is no longer a prediction for the future, it is happening right now in every region of the world and has the potential to affect anyone, of any age, in any country."10

So what kind of impact are we talking about?

In total, over the last couple of years, MERS has killed a total of about 128 people worldwide. Antibiotic resistant infections, on the other hand, using the most conservative estimates possible, now kill about 23,000 people each and every year in the United States alone.11 That means that each year, just in the U.S., antibiotic resistant infections kill more people than SARS, bird flu, swine flu, and MERS have killed, all together, in total, throughout the entire world…ever. And that's just in the U.S. Add in the death toll in Europe, and you're probably looking at about double that number. And if you add in the numbers from Asia and Africa, who knows?

We're talking about drug resistant diseases now killing people throughout the world in scary numbers that include MRSAXDR TBClostridium Difficile, and Klebsiella Pneumoniae, just off the top of my head.

And remember, as I said, these are the most conservative numbers possible--a fact acknowledged by the CDC itself. This was by design according to Dr. Steven L. Solomon, the director of the C.D.C.'s office of antimicrobial resistance.12 Researchers were instructed to be conservative and to base their calculations only on deaths that were a direct result of a drug-resistant bacterial infection. To quote Dr. Solomon, "This is a floor. We wanted the cleanest number, the least subjective number."

So, if you're looking for something in the spirit of a mid-year Halloween, and for those of you who like a good scare, this is a real and immediate threat, not a distant vaguely possible threat like MERS. But even at that, the post-antibiotic age is unlikely to be quite as devastating as many would have you believe. Even this very real threat is unlikely to produce death carts hauling away millions of dead bodies and flesh eating zombies wandering the streets feeding on the living.

Conclusion

When taken at face value, the end of antibiotics is a frightening prospect--even for those into alternative health. Although people who are health conscious try and avoid antibiotics as much as possible, there are times you truly need them. And when you need them, you really, really need them to work. If they don't, the potential for death rates from infection climbing through the roof is a very real possibility. As mentioned above, we're already talking conservatively of 23,000 deaths a year in the U.S. alone, but some less conservative estimates say the number is closer to 100,000, which would already make drug resistant bacteria and viruses the sixth leading cause of death in the U.S.13 Then, once you eliminate the effectiveness of the remaining antibiotics and antivirals we still have in our arsenal over the next several years, you can easily see drug resistant infections occupying the number three spot, or even higher.

This is absolutely something to be concerned about. However…

How fast that day actually arrives is up to us. Like the melting of the Antarctic ice cap, we've crossed the point of no return. Can't go back, and we will have to deal with the consequences moving forward. Can't change the end of the age of antibiotics no matter what we do. However, what we do in the near term does influence how soon we will have to face the day of reckoning--and that matters big time.

Given enough time, drug manufacturers can probably find one or two new antibiotics to help buy us some more time. But the big ace in the hole--and don't fall out of your seats--is genetic engineering. Despite what you might think about genetically modified foods, and not to mention the fact that genetically engineered plants and animals may have actually played a major role in directly promoting antibiotic resistance,14 genetic engineering is actually the future when it comes to fighting bacteria and viruses. (By the way, genetic engineering is already involved in manufacturing most of the vitamin B2, B12, E, and C that you find in health store supplements.)  What genetic engineering is likely to produce in the post-antibiotic era promises to be far, far more effective than today's antibiotics, and far more targeted. Today's antibiotics are essentially a blunt weapon. Yes, they kill the bad guys, but they also kill the good bacteria in your body--bacteria that are essential for your health. The post-antibiotic age has the potential to be far healthier.

You need to understand that the use of genetic engineering when it comes to antibiotics is far from new. While most manufacturers now simply make their antibiotics in the lab, for several decades, a number of antibiotics were manufactured from genetically engineered bacteria. For example, manufacturers made erythromycin commercially through fermentation using the soil bacteria Saccharopolyspora erythraea and E. coli.15,16 But our new-found ability to quickly unravel the genetic code of bacteria, has opened the door to an entirely new world of infection fighting. It seems that almost weekly now, the genetic code of yet another bacterium has been revealed.17

The future lies in using a particular bacterium's genetic code against it by locating its particular vulnerabilities and then modifying other bacteria to produce agents that target those particular vulnerabilities--and nothing else. This would mean that we could fight both bacterial and viral infections far more effectively and with virtually no side effects--and with the ability to counter any workarounds the pathogens develop as fast as they develop them. One of the most interesting strategies involves directing specific counterattacks at the infectious agents' resistance weapons--as revealed through genetic decoding. Treatments could then be devised that combine an antibiotic that might currently be ineffective with a second drug that has little antibiotic effect but possesses the power to disarm a bacterial or viral defense molecule. Other hybrid treatments could be devised using compounds that impair the invading pathogen's ability to pump the antibiotic component out of the bacterial cell.

This is coming. The only question is time. Do we get to roll relatively seamlessly from antibiotics of diminishing effectiveness into targeted, genetically engineered, infection-fighting drugs, or do we have an extended gap in which deadly bacteria have free reign and kill millions of people before we plug that gap.

Unfortunately, two things stand in the way of plugging that gap quickly.

  • Getting new antibiotics into the pipeline is not going to be easy. Pharmaceutical companies have little incentive to develop new antibiotics because they're not very profitable. Most people only need antibiotics for just a few times in their lives--and then only for a few weeks until they get better.  Compare that to a new statin drug that requires people to stay on them every day for the rest of their lives. For this reason, there has been a 75% decline in the development of new antibiotics since 1983. And the development process is lengthy. If a pharmaceutical company decided today to develop a new antibiotic, it would be ten years hundreds of millions of dollars before that drug would be available to patients. And then, thanks to the ability of pathogens to quickly evolve around them, they only remain effective for a couple years. Unless governments decide to subsidize their development, we're unlikely to see many stop gap antibiotics. In other words, we're pretty much stuck with what we have unless governments totally transform their mindsets--which is another way of saying we're stuck with what we have.

  • The time we have left for using the antibiotics now in place is likely to get exponentially shorter. If physicians stopped prescribing unnecessary antibiotics, if patients actually finished their course of antibiotics instead of stopping the moment they felt better, and most important of all, if large commercial farms abandoned all use of antibiotics in the raising of their beef, pork, poultry, and farmed fish, then the whole process would slow down, and we would have more time before new methods for fighting infection would need to be in place. But nothing in modern human history says that even one of those things is likely to happen--at least in time to make any difference.

Natural alternatives

So what do you do to protect yourself while waiting for science to come to your rescue?

  • Keep your immune system optimized so that you don't get sick in the first place

  • And keep a supply of natural pathogen destroyers on hand to give yourself a fighting chance against any infection you might get. And be sure and start using the anti-pathogen all out the moment there is any indication that you have come down with something. Remember, it is far easier to defeat an infection during its incubation phase then after it has taken hold.

Then, having done what you can, hunker down and wait for the coming miracle of genetic decoding/genetic engineering to break the back of infectious diseases once and for all. It's coming…if you can survive long enough.

And if you're looking for a good fright, you probably need to keep your eyes open for the next horror film to hit the theaters…or just wait for Halloween.

*Post courtesy of Jon Barron.org.

Founder and Director of the Baseline of Health® Foundation, Jon Barron has been at the forefront of much of the pioneering work in the study of nutrition and anti-aging for the last 45 years. He is editor and publisher of the Baseline of Health® Newsletter and the Barron Report, which are both read by thousands of doctors, health experts, government health ministers, and nutrition consumers in over 100 countries. For more information, visit http://www.jonbarron.org.

Sources:

  • 1.Joshua Hersh "MERS Experts Fret About Deadly Virus' Great Unknowns." 05/04/2014. Huffington Post. (Accessed 7 May 2014.) http://www.huffingtonpost.com/2014/05/04/mers-virus_n_5263502.html

  • 2.Brian Williams. "Deadly MERS Virus Arrives in US." NBC News. May 2, 2014. (Accessed 7 May 2014.) http://www.nbcnews.com/nightly-news/deadly-mers-virus-arrives-us-n96121

  • 3.ISHAAN THAROOR "The deadly MERS virus is spreading at a terrifying rate." April 24, 2014. The Washington Post. (Accessed 7 May 2014.) http://www.washingtonpost.com/blogs/worldviews/wp/2014/04/24/the-deadly-mers-virus-is-spreading-at-a-terrifying-rate/

  • 4.Mike Adams. "MERS outbreak hits 30% death rate as pandemic spreads in Saudi Arabia." April 28, 2014. Natural News. (Accessed 7 May 20114.) http://www.naturalnews.com/044903_mers_outbreak_saudi_arabia_infectious_disease.html

  • 5.http://www.the-numbers.com/market/2013/top-grossing-movies

  • 6.N Nowotny. "MIDDLE EAST RESPIRATORY SYNDROME CORONAVIRUS (MERS-COV) IN DROMEDARY CAMELS, OMAN, 2013." Eurosurveillance, Volume 19, Issue 16, 24 April 2014 (Accesses 7 May 2014.) http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20781

  • 7.Alanis AJ. "Resistance to antibiotics: are we in the post-antibiotic era?" Arch Med Res. 2005 Nov-Dec;36(6):697-705. http://www.ncbi.nlm.nih.gov/pubmed/16216651

  • 8."CDC Telebriefing on today's drug-resistant health threats." CDC September 16, 2013. (Accessed 15 May 2014.)  http://www.cdc.gov/media/releases/2013/t0916_health-threats.html

  • 9."Dr. Arjun Srinivasan: We've Reached 'The End of Antibiotics, Period'." PBS. 22 October 2013. Accessed 15 November 2013. http://www.pbs.org/wgbh/pages/frontline/health-science-technology/hunting-the-nightmare-bacteria/dr-arjun-srinivasan-weve-reached-the-end-of-antibiotics-period/

  • 10."WHO's first global report on antibiotic resistance reveals serious, worldwide threat to public health." WHO 30 April 2014. (Accessed 15 May 2014.) http://www.who.int/mediacentre/news/releases/2014/amr-report/en/

  • 11."Antibiotic / Antimicrobial Resistance." CDC 2013 (Accessed 12 May 2014.) http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf

  • 12.SABRINA TAVERNISE "Antibiotic-Resistant Infections Lead to 23,000 Deaths a Year, C.D.C. Finds." New York TimesSeptember 16, 2013. (Accessed 12 May 2014.) http://www.nytimes.com/2013/09/17/health/cdc-report-finds-23000-deaths-a-year-from-antibiotic-resistant-infections.html

  • 13."Leading Causes of Death." CDC (Accessed 16 May 2014.) http://www.cdc.gov/nchs/fastats/lcod.htm

  • 14.Chen J, Jin M, Qiu ZG, Guo C, et al. "A Survey of Drug Resistance bla Genes Originating from Synthetic Plasmid Vectors in Six Chinese Rivers." Environmental Science & Technology 2012, 46, 13448-54. http://www.ncbi.nlm.nih.gov/pubmed/23215020

  • 15.Dawn Levy. "Genetic engineering speeds development of new antibiotics." Stanford News Service 3/1/01. (Accessed 16 May 2014.) http://news.stanford.edu/pr/01/khosla37.html

  • 16."Erythromycin A produced in E. coli for first time: Biosynthetic breakthrough paves way for other pharmaceuticals."ScienceDaily 26 Nov 2010. (Accessed 16 May 2014.) http://www.sciencedaily.com/releases/2010/11/101124124020.htm

  • 17."Human microbe study provides insight into health, disease." ScienceDaily. March 18, 2013. (Accessed 16 May 2014.) http://www.sciencedaily.com/releases/2013/03/130318151641.htm

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