Ebola, the highly lethal hemorrhagic fever that can cause people to bleed out of their eyes and ears, is sweeping through West Africa. The current strain is unrelated to those which caused previous outbreaks in Uganda and Congo, meaning health officials are dealing with a new source, which is likely a bat or ape or some other wild animal. But the real root cause may be deforestation, or rather the activities and proximities to wildlife that accompany it.
The current Ebola outbreak has caused over 500 deaths, making it the largest outbreak on record and prompting an official with Doctors Without Borders to call the epidemic “out of control.” The disease is spread easily through touch, and the best way to limit its spread is to quarantine the sick. But Ebola’s early symptoms are similar enough to other tropical diseases like malaria that patients often aren’t quarantined quickly enough.
The Associated Press reports:
“We’re under massive time pressure: The longer it takes to find and follow up with people who have come in contact with sick people, the more difficult it will be to control the outbreak,” said Anja Wolz, emergency coordinator for the group, also referred to by its French name Medecins Sans Frontieres.
Quarantining the sick, though, doesn’t necessarily limit the possibility of future outbreaks. Strains of the virus are carried in bats, apes, and other wild animals. As Africa’s frontier regions develop, more and more people are brought into closer contact with the carriers. Unlike smallpox, diseases can’t be eradicated just by treating humans alone, and finding all non-human carriers is so large a task as to be untenable.
Terrence McCoy, reporting for the Washington Post:
Researchers behind the article in the Onderstepoort Journal of Veterinary Research found deforested regions where locals hunted, dug for gold and farmed were most susceptible to an outbreak. The findings landed upon some dismal conclusions: The activities locals depend on the most are also what puts them at the most risk of contracting Ebola.
Ebola isn’t the only disease that’s associated with people living closer to wildlife—yellow fever, Lyme disease, chikungunya, and others are also prevalent at the wildland-urban interface. While Ebola is contained in Africa for the time being, mosquito-borne chikungunya is sweeping the Americas, with over 350,000 suspected cases (pdf). For more on chikungunya, check out NOVA Next contributor Carrie Arnold’s riveting read on the peripatetic virus’s travels around the globe.
How eating bats, washing victims’ bodies, and a lack of doctors are all contributing to the worst Ebola outbreak of all time.
The worst Ebola virus outbreak ever is ravaging Liberia, Sierra Leone, and Guinea. So far, the disease has killed 670 people and infected more than 1,000, including an American doctor and aid worker.
One reason why Ebola is so terrifying is that there’s no cure, and the fatality rate is roughly 60 to 90 percent. Those who catch it and don’t get treated early will very likely die. Since 2008, past outbreaks of Ebola have killed a few dozen people at most.
So, what makes this one so much worse?
Past outbreaks of the virus have been linked to people hunting gorillas and chimps for food, or eating dead apes they find in the jungle. There are no gorillas in West Africa, so specialists think this outbreak is linked to fruit bats. In 2007 in Uganda, an Ebola outbreak was traced to “a couple of kids playing with fruit bats in a cave. They came home with two dead fruit bats and the mothers cooked them,” said Dr. Estrella Lasry, a tropical medicine advisor to Doctors Without Borders.
Researchers still don’t know the exact cause of this particular outbreak, but it might have to do with the local practice of eating bats for food, according to Jonathan Epstein, an epidemiologist at EcoHealth Alliance. “It’s unclear whether it occurred due to butchering a bat, exposure to bat bodily fluids, or eating some food or fruit that was contaminated by saliva, urine, or feces from the bat, which may contain Ebola virus,” he said. Pig farms in Africa also often attract bats, which also may have been a cause.
Once the infected person begins to show symptoms—flu-like aches, nausea, and vomiting—local customs continue to play a big role. There aren’t enough doctors or supplies available to treat all the Ebola patients in the area, but even if there were, many locals are suspicious of Western medicine.
“In this outbreak, there’s been intense mistrust of Western health care workers,” Epstein said. “You’re battling a lot of perceptions and convictions. There are local remedies that people have trusted. They will turn to a local witch doctor in the village.”
If the person dies, tradition holds that the body should be washed by the family, which inadvertently creates new opportunities for exposure. The family member might then prepare a meal for the rest of the funeral party, further increasing the odds that infection will spread.
When the infected person dies in a medical tent, meanwhile, the body is usually disinfected and buried or burned, not returned to the family. This causes enormous agony for the families—“it enhances grief if people aren’t allowed to perform the rituals that are important to them,” Epstein said. “So if someone dies, they’ll secret the body away.”
Then there’s the fact that because Ebola is so deadly, those who enter a Western-established medical tent might never come back. That heightens fears among locals that Western doctors might be worsening the outbreak. People start to hide their sick relatives, who bleed out at home and infect others. One Sierra Leone woman fled a hospital after testing positive for the Ebola virus. Other communities are preventing doctors from entering entirely.
“So why don’t people avoid the bats in general?” I asked.
“Eating wildlife is a generational practice,” Epstein said. “It’s something people have done forever. There isn’t necessarily an association with the animals they’re hunting or killing and getting sick. Even if they’re told by local doctors that bushmeat is making them sick, there’s a strong belief that the illness is due to black magic or spiritual power.”
It’s tempting to blame local customs, but less so when you realize that Ebola is an extremely rare virus, and food options in the bush can be extremely scarce. One might eat five or 10 or 100 bats and be fine, but the 101st might be lethal.
Think of it this way: “We know there’s mad cow disease, but does that stop you from eating hamburger?” said Sarah Olson, a wildlife epidemiologist at the Wildlife Conservation Society.
“They’ve probably never seen Ebola, and they’re balancing that against a need to feed their family,” she added. “The risk of contracting it is very low, but when you multiply that across many interactions, occasionally it’s going to happen.”
It’s the Hamptons’ dirty little secret: Dozens of children and adults are being diagnosed with Lyme disease each day as officials mount a campaign to battle ticks.
The problem has gotten so bad that Southampton Hospital launched the Tick-Borne Disease Resource Center to help residents bugging out over the tiny blood-suckers.
One physician, Dr. Blake Kerr, told The Post he treats 100 patients a week for Lyme disease.
“It’s an epidemic,” said Kerr, who runs Wainscott Walk-In Medical Center and last summer contracted Lyme and two other tick-borne illnesses simultaneously.
Pediatrician Dr. Nadia Persheff of Hampton Pediatrics in Southampton sees as many as four children a day for Lyme disease and 20 for tick bites — including one 3-week-old baby who came in with four ticks on his back.
“You have to check every kid and every baby,” Persheff said. “We’re much busier than last summer. I’ve never seen it like this.”
Suffolk County was ground zero for Lyme disease in 2012, leading the state with 689 reported cases, data show. In 2013, the number of reported cases dropped to 566, according to state data.
Still, locals believe the ticks — and tick-related illnesses — are growing every year. The culprits are often deer ticks, which carry Lyme or malaria-like diseases such as babesiosis and — at the size of a poppy seed — are much smaller than common wood ticks.
Lyme disease, a bacterial illness with symptoms of skin rash, headache and fatigue can cause neurological damage and other serious problems if left untreated. Early treatment typically includes a single dose of antibiotics.
Brian Kelly, owner of East End Tick and Mosquito Control, said he has fielded frantic calls from out-of-towners who want him to remove ticks from their bodies.
“People are realizing they’re everywhere — you can’t even go to the beach without getting a tick,” Kelly said.
As 67 new Ebola virus disease (EVD) illnesses in Sierra Leone and Liberia pushed the outbreak total to 1,048 cases, the United Nations Food and Agriculture Organization (FAO) warned about the risk of virus transmission from wildlife, especially fruit bats.
Along with new infections, 19 more deaths were reported in Sierra Leone and Liberia, raising the fatality count to 632, according to a Jul 19 update from the World Health Organization (WHO) that covers new cases reported from Jul 15 to Jul 17.
The WHO said the outbreak shows a decline in Guinea, which was the first country hit by the outbreak, the biggest and deadliest one of its kind so far. The country reported no new cases or deaths during the reporting period.
However the country’s neighbors Sierra Leone and Liberia reported a steady rise in cases at a level that the WHO said was serious.
Sierra Leone situation
Sierra Leone reported 45 new illnesses and 9 deaths, lifting the country’s total so far to 442 cases, 206 of them fatal. The country has for the first time more cases than Guinea, which has logged 410.
Gambia has sent a team of 11 healthcare workers to help Sierra Leone with its outbreak response, based on a call for regional collaboration made at an early July health minister’s meeting in Accra, Ghana. The WHO added that the team will help with critical human resource needs, but the mission will also help boost preparedness in Gambia.
Meanwhile, Sierra Leone’s religious leaders have criticized the government’s management of the outbreak response, noting that a lack of information is fueling rural community resistance to medical help, Reuters reported today.
Bishop John Yambasu, head of the United Methodist Church of Sierra Leone and chair of an interfaith task group, said he was disappointment that the government hasn’t declared a public health emergency, which he said would increase resources for outbreak response, according to Reuters. He accused the government of being too concerned about the political ramifications of declaring an emergency.
The country’s health minister has said the outbreak is serious but hasn’t reached emergency levels, Reuters said.
Meanwhile, Liberia reported 22 more infections and 10 deaths to the WHO. The numbers boost the country’s total to 196 cases, which includes 116 deaths.
The WHO said it, Liberia’s health ministry, and its other health partners are assessing the outbreak response in each country to identify challenges and help set priorities.
A recently completed assessment in Liberia identified a number of gaps, including low coverage of contact tracing; persistent denial about the disease and resistance to response activities in the community; weak data management; inadequate infection and control practices, especially in outlying health facilities; and weak leadership and coordination at the subnational level.
The WHO said some of the challenges are driven by a lack of financial resources and human technical capacity. The agency added that authorities are mapping out the financial, logistics, and human resources needs as part of a national operational plan to battle the EVD outbreak.
Similar assessments are under way for Guinea and Sierra Leone, as well, the WHO said.
In other developments, elected officials in Liberia have voted to ask the country’s president to declare a health emergency due to the country’s EVD outbreak, the Daily Observer, a newspaper based in Monrovia, reported on Jul 18.
A motion passed by the country’s Senate on Jul 17 orders its leadership to join with the country’s House of Representatives in requesting the health emergency and asks that the government free up $1.5 million to help the health ministry battle the disease.
FAO caution singles out fruit bats
The FAO said today that although curbing human-to-human EVD transmission is the most important focus, it is working closely with the WHO to raise awareness about transmission risks from wildlife among rural communities that hunt bush meat to supplement their diets and income.
The agency said the communities risk future spillover from species that carry the virus, including fruit bats, some primates, and duikers—small antelopes native to sub-Saharan Africa.
Juan Lubroth, DVM, the FAO’s chief veterinary officer, said in a statement that the group isn’t suggesting that people stop hunting, because that wouldn’t be realistic. “But communities need clear advice on the need not to touch dead animals or to sell or eat the meat of any animal that they find already dead.”
He added that people in rural communities should also avoid hunting animals that are sick or behaving strangely.
The FAO, however, said fruit bats should be avoided altogether, because they are the most likely reservoir for the virus and can carry it without showing signs of disease. In West Africa, fruit bats are usually eaten dried or in a spicy soup, the group added.
Several governments in the region have tried to ban the sale and consumption of bush meat, but bans have been impossible to enforce and have prompted suspicion from rural populations, the FAO said.
Katrinka de Balough, DVM, FAO veterinary public health officer and Ebola focal point, said in the statement that mistrust, myths, and rumors are among the challenges in controlling the disease. She added that concerns are growing about the impact the outbreak might have on food security in some parts of the region, with some farmers afraid to work in their fields and some markets shut down.
The FAO said it has committed resources and has been working with partners to improve information about the disease using existing networks that include rural radio and agricultural extension services. It also added that it will work with governments to set up wildlife surveillance systems to more quickly detect the virus.
“Rural communities have an important role to play in reporting unusual mortality in the animal population, which is another reason that their collaboration is so crucial,” de Balogh said.
Another step will be to assess the role of hunting, with an eye toward identifying healthier, more sustainable livestock production options that can provide more protein and income sources, the FAO said.
Canada’s only flu vaccine production plant, owned by GSK, has received word from a Health Canada inspection that 10 issues need to be addressed to meet required standards, according to a Canadian Press article today. GSK has until Aug 4 to submit a plan to fix the problems.
Health Canada posted a summary of its inspection findings late yesterday. Some major findings related to two new vaccines being made at the plant that are licensed in Canada but not yet sold there. The regulatory agency said GSK has to give 90 days’ notice before resuming production of the vaccines to allow further inspections and action as necessary.
None of the issues raised pose a critical risk to public health, but 7 of the 10 fall into the major observation category, says the story.
The plant has contracts to produce 53% of Canada’s seasonal flu vaccine for next season and “also holds a 10-year contract to produce pandemic for vaccine for Canada when needed,” the story notes.
It is also scheduled to provide 23 million flu vaccine doses for the United States for 2014-15. The US Food and Drug Administration (FDA) issued a warning letter to the plant Jun 21 saying that 21% of the upcoming season’s product had unacceptable bacterial counts and could not be used.
Health Canada inspects the plant, which is in Ste. Foy, Quebec, every 2 years. The plant is reportedly cooperating with both Health Canada and the FDA on resolving the issues, the story said.
A cross-disciplinary team is calling for public discussion about a potential new way to solve longstanding global ecological problems by using an emerging technology called “gene drives.” The advance could potentially lead to powerful new ways of combating malaria and other insect-borne diseases, controlling invasive species and promoting sustainable agriculture.
Representing the Wyss Institute for Biologically Inspired Engineering at Harvard University, Harvard Medical School, Harvard School of Public Health, the Massachusetts Institute of Technology (MIT), Boston University, the Woodrow Wilson Center, and Arizona State University, the team includes scientists working in disciplines ranging from genome engineering to public health and ecology, as well as risk and policy analysis.
Engineered gene drives are genetic systems that circumvent traditional rules of sexual reproduction and greatly increase the odds that the drive will be passed on to offspring. This enables the spread of specified genetic alterations through targeted wild populations over many generations. They represent a potentially powerful tool to confront regional or global challenges, including control of invasive species and eradication of insect-borne diseases such as malaria and dengue.
The idea is not new, but the Harvard-based researchers have now outlined a technically feasible way to build gene drives that potentially could spread almost any genomic change through populations of sexually reproducing species.
“We all rely on healthy ecosystems and share a responsibility to keep them intact for future generations,” said Kevin Esvelt, PhD, Wyss Institute Technology Development Fellow and lead author of two papers published this week. “Given the broad potential of gene drives to address ecological problems, we hope to initiate a transparent, inclusive and informed public discussion—well in advance of any testing—to collectively decide how we might use this technology for the betterment of humanity and the environment.”
Following discussion of the technology’s widespread implications at an NSF-sponsored workshop organized by the Woodrow Wilson Center and MIT in January 2014, the team wrote two related papers. The first, published in eLife, describes the proposed technical methods of building gene drives in different species, defines their theoretical capabilities and limitations, and outlines possible applications. The second, featured in Science, provides an initial assessment of potential environmental and security effects, an analysis of regulatory coverage and recommendations to ensure responsible development and testing prior to use.
The new technical work in eLife builds upon research by Austin Burt of Imperial College London, who, more than a decade ago, first proposed using a type of gene drive based on cutting DNA to alter populations. The authors note that the versatile gene editing tool called CRISPR, which was recently co-developed by some of the same researchers at Harvard and the Wyss Institute and makes it possible to precisely insert, replace and regulate genes, now makes it feasible to create gene drives that work in many different species.
“Our proposal represents a potentially powerful ecosystem management tool for global sustainability, but one that carries with it new concerns, as with any emerging technology,” said Wyss Core Faculty member George Church, PhD, a coauthor on both publications. Church is also a professor of genetics at Harvard Medical School, and professor of health sciences and technology at Harvard and MIT.
Esvelt noted that the genomic changes made by gene drives should be reversible. The team has outlined in the eLife publication numerous precautionary measures intended to guide the safe and responsible development of gene drives, many of which were not possible with earlier technologies.
“Many different groups and the interested public will need to come together to ensure that gene drives are developed and used responsibly,” said James P. Collins, PhD, an evolutionary ecologist at Arizona State University and senior author of the Science paper. Collins was formerly the assistant director for biological sciences at the National Science Foundation.
“Understanding how populations and ecosystems will respond to different alterations and addressing potential security concerns will require sustained multidisciplinary work by teams of biological engineers, ecologists, instrumentation specialists, social scientists and the public,” Collins said. “The eLife and Science articles provide a model for the next steps that need to be taken.”
Saudi Arabian researchers have detected genetic fragments of Middle East Respiratory Syndrome coronavirus (MERS-CoV) in the air of a barn holding a camel infected with the virus. The work, published this week in mBio®, the online open-access journal of the American Society for Microbiology, indicates that further studies are needed to see if the disease can be transmitted through the air.
MERS, a serious viral respiratory illness caused by the coronavirus, has been identified in 699 people as of June 11, according to the World Health Organization; 209 people have died from the condition. An additional 113 cases occurring between 2012 and 2014 were reported by the Saudi Arabian Ministry of Health on June 3.
For the study, researchers on three consecutive days last November collected three air samples from a camel barn owned by a 43-year-old male MERS patient who lived south of the town of Jeddah, who later died from the condition. Four of the man’s nine camels had shown signs of nasal discharge the week before the patient became ill; he had applied a topical medicine in the nose of one of the ill camels seven days before experiencing symptoms.
Using a laboratory technique called reverse transcription polymerase chain reaction (RT-PCR) to detect gene expression, they found that the first air sample, collected on November 7, contained genetic fragments of MERS-CoV. This was the same day that one of the patient’s camels tested positive for the disease. The other samples did not test positive for MERS-CoV, suggesting short or intermittent shedding of the virus into the air surrounding the camels, said lead study author Esam Azhar, PhD, head of the Special Infectious Agents Unit at King Fahd Medical Research Center and associate professor of medical virology at King Abdulaziz University in Jeddah.
Additional experiments confirmed the presence of MERS-CoV-specific genetic sequences in the first air sample and found that these fragments were exactly identical to fragments detected in the camel and its sick owner.
“The clear message here is that detection of airborne MERS-CoV molecules, which were 100% identical with the viral genomic sequence detected from a camel actively shedding the virus in the same barn on the same day, warrants further investigations and measures to prevent possible airborne transmission of this deadly virus,” Azhar said.
“This study also underscores the importance of obtaining a detailed clinical history with particular emphasis on any animal exposure for any MERS-CoV case, especially because recent reports suggest higher risk of MERS-CoV infections among people working with camels,” he added.
Meanwhile, he said, mounting evidence for camel-to-human transmission of MERS-CoV warrants taking precautionary measures: People who care for camels or who work for slaughterhouses should wear face masks, gloves and protective clothing, and wash their hands frequently. It is also important to avoid contact with animals that are sick or have tested positive for MERS-CoV. Those who visit camel barns, farms or markets should wash hands before and after contact with animals. In addition, pasteurization of camel milk and proper cooking of camel meat are strongly recommended.
Study reveals promising information for developing an alternative to antibiotics
Research published today in PLOS Pathogens reveals how viruses called bacteriophages destroy the bacterium Clostridium difficile (C. diff), which is becoming a serious problem in hospitals and healthcare institutes, due to its resistance to antibiotics. The study, by scientists at the European Molecular Biology Laboratory (EMBL) in Hamburg, Germany, could help bring about a new way of fighting this and other bacteria.
“Our findings will help us to engineer effective, specific bacteriophages, not just for C. diff infections, but for a wide range of bacteria related to human health, agriculture and the food industry,” says Rob Meijers from EMBL, who led the work.
C. diff infections, which can be fatal, are currently very difficult to treat, as the bacterium is particularly unresponsive to many antibiotics. A possible solution would be not to use antibiotics, but instead employ bacteriophages – viruses which infect only bacteria. Scientists know that these viruses hijack a bacterium’s DNA-reading machinery and use it to create many new bacteriophages. These then start demolishing the bacterium’s cell wall. Once its wall begins to break down, the bacterial cell can no longer withstand its own internal pressure and explodes. The newly formed viruses burst out to find new hosts and the bacterium is destroyed in the process.
To harness the power of bacteriophages and develop effective therapies against bacteria like C.diff, scientists need to know exactly how these viruses destroy bacterial cell walls. The viruses’ demolition machines, endolysins, are known, but just how these enzymes are activated was unclear – until now.
“These enzymes appear to switch from a tense, elongated shape, where a pair of endolysins are joined together, to a relaxed state where the two endolysins lie side-by-side,” explains Matthew Dunne who carried out the work. “The switch from one conformation to the other releases the active enzyme, which then begins to degrade the cell wall.”
Meijers and collaborators discovered the switch from ‘standby’ to ‘demolition’ mode by determining endolysins’ 3-dimensional structure, using X-ray crystallography and small angle X-ray scattering (SAXS) at the Deutsches Elektronen-Synchrotron (DESY). They compared the structures of endolysins from two different bacteriophages, which target different kinds of Clostridium bacteria: one infects C. diff, the other destroys a Clostridium species that causes defects in fermenting cheese.
Remarkably, the scientists found that the two endolysins share this common activation mechanism, despite being taken from different species of Clostridium. This, the team concludes, is an indicator that the switch between tense and relaxed enzymes is likely a widespread tactic, and could therefore be used to turn other viruses into allies in the fight against other antibiotic-resistant bacteria.
The work was performed in collaboration with Arjan Narbad’s lab at the Institute of Food Research in Norwich, UK, who tested how engineering mutations in the endolysins affected their ability to tear down the bacterial cell wall.
Bushmeat, the use of native animal species for food or commercial food sale, has been heavily documented to be a significant factor in the decline of many species of primates and other mammals.
However, a new study indicates that more than half of the species being consumed are birds, particularly large birds like raptors and hornbills.
“By surveying not only the meat made available for sale but the meat that is being eaten inside the forest by hunters and brought to villages for consumption, we noted a significant percentage attributed to bird species,” said Bethan Morgan, head of the Central African Program for the San Diego Zoo Institute for Conservation Research. “The significant use of large birds like eagles, vultures and hornbills as bushmeat poses a new side to this conservation challenge.”
The study indicates that more than half of meat surveyed was of avian origin, with the larger species like birds of prey forming a significant portion of the whole. Documenting the effects of bushmeat use and trade on endangered species in Africa is part of the work being done in the proposed Ebo Forest National Park under the auspices of San Diego Zoo Global. The bushmeat trade is not only a conservation challenge, as species are eradicated through consumption, but has also been highlighted as a significant human health concern linked to several zoonotic disease outbreaks globally.
The new study, funded jointly by San Diego Zoo Global and The Peregrine Fund, is presented in the July issue of the academic journal “Oryx.”
The San Diego Zoo Global Wildlife Conservancy is dedicated to bringing endangered species back from the brink of extinction. The Conservancy makes possible the wildlife conservation efforts(representing both plants and animals) of the San Diego Zoo, San Diego Zoo Safari Park, San Diego Zoo Institute for Conservation Research, and international field programs in more than 35 countries. The important conservation and science work of these entities is supported in part by The Foundation of the Zoological Society of San Diego.
Washington, DC, July 28, 2014 – “Fist bumping” transmits significantly fewer bacteria than either handshaking or high-fiving, while still addressing the cultural expectation of hand-to-hand contact between patients and clinicians, according to a study published in the August issue of the American Journal of Infection Control, the official publication of the Association for Professionals in Infection Control and Epidemiology (APIC).
In this study from the Institute of Biological, Environmental, and Rural Sciences at Aberystwyth University in the United Kingdom, researchers performed trials to determine if alternative greetings would transmit fewer germs than the traditional handshake. In this experiment, a greeter immersed a sterile-gloved hand into a container of germs. Once the glove was dry, the greeter exchanged a handshake, fist bump, or high-five with a sterile-gloved recipient. Exchanges randomly varied in duration and intensity of contact.
After the exchange, the receiving gloves were immersed in a solution to count the number of bacteria transferred during contact. Nearly twice as many bacteria were transferred during a handshake compared to the high-five, and significantly fewer bacteria were transferred during a fist bump than a high-five. In all three forms of greeting, a longer duration of contact and stronger grips were further associated with increased bacterial transmission.
“Adoption of the fist bump as a greeting could substantially reduce the transmission of infectious diseases between individuals,” said corresponding author, David Whitworth, PhD. “It is unlikely that a no-contact greeting could supplant the handshake; however, for the sake of improving public health we encourage further adoption of the fist bump as a simple, free, and more hygienic alternative to the handshake.”
This study expands on the recent call from the Journal of the American Medical Association (JAMA) to ban handshakes from the hospital environment.
Healthcare providers’ hands can spread potentially harmful germs to patients, leading to healthcare-associated infections (HAIs). HAIs are among the leading causes of preventable harm and death in the United States. The U.S. Centers for Disease Control and Prevention estimates that one in 25 hospitalized patients develops an HAI and 75,000 patients with HAIs die during their hospitalization each year.