Antibiotics are the wonder drugs of modern medicine. They've allowed doctors to save and extend life by killing infection and enabling ground breaking surgery. But imagine a world where antibiotics don't work - that would be a place dominated by superbugs, bacteria that don't respond to antibiotics. Scientists say this would end many modern medical procedures and they claim the threat is greater than we realise.

Next on Four Corners reporter Geoff Thompson looks at the rise of superbugs, visiting the hot spots around the world where the misuse of antibiotics is creating a breeding ground for these bacteria and he tells the horrific stories of those who've contracted infections that can't be controlled. He also reveals that Australian health officials are making decisions that could open the way for a deadly superbug to infect Australians living in the far north of the country.

"...Every time we take an antibiotic we're giving the bug a chance to become a superbug ... the more of us that take antibiotics inappropriately, the greater the chance in the community a superbug will come."

And that's exactly what's happening in India, where antibiotics are not restricted in their use. As a result a new superbug, New Delhi metallo-beta-lactamase or NDM-1, has evolved. Not only is it deadly in its own right, it's also capable of genetically modifying other bacteria to make them superbugs.

Superbugs like this have infected people who've been injured in accidents while travelling overseas. In other cases, apparently healthy people return from abroad only to discover that a simple medical procedure effectively unleashes the bug. In one instance, a healthy middle-aged man went for a prostate biopsy. The procedure was done successfully but one day later he became desperately ill. A superbug, possibly contracted while travelling overseas, had moved from his bowel into his bloodstream making him critically ill.

In the Western Province of Papua New Guinea, close to the Australian border, the misuse of antibiotics has contributed to the rise of a superbug form of Tuberculosis. For seven years the Queensland and Federal Governments funded TB clinics for PNG nationals in the Torres Strait. These clinics were the last line of defence that could stop the superbug coming to the Australian mainland. But the closure of these clinics in June this year has left the job of treating TB patients with the PNG Government , funded by AusAID. This could increase the risk of superbug TB coming to Australia.

"Rise of the Superbugs", reported by Geoff Thompson and presented by Kerry O'Brien, goes to air on Monday 29th October on ABC 1 at 8.30 pm. It is replayed on Tuesday 30th October at 11.35 pm. It can also be seen on Saturday at 8.00 pm on ABC News 24, ABC iview and at abc.net.au/4corners.

Transcript

RISE OF THE SUPERBUGS - Monday 29 October 2012

KERRY O'BRIEN, PRESENTER: We've been warned about the rise of superbugs for more than 20 years. We either act now or face a frightening future.

Welcome to Four Corners.

Antibiotics delivered one of the great breakthroughs in medical history. We're now at risk of blowing it.

It's a sobering thought - or should be - that every time we take an antibiotic we're giving the bug we're trying to kill a chance to do the opposite, become a super bug.

That chance increases if we don't complete the prescribed course of treatment.

Already there are horror stories of what mayhem and suffering superbugs are capable of inflicting. It's a process of bacterial resistance that began with the very first use of penicillin. That was okay up to a point - for as long as scientists continued to find new antibiotics to replace the ones for which bugs had developed a resistance.

But now the tide has turned in favour of the bugs for various reasons. As a result, some superbugs have evolved that are so powerful, they're capable of defeating every antibiotic available.

And Australia is in a region that is particularly vulnerable. We're also one of the highest users of antibiotics in the developed world, with 22 million scripts a year.

We now face the grim prospect of a return to the pre-antibiotic era when often the only way to defeat infection was to remove it surgically.

This report from Geoff Thompson.

(Shot of a very crowded city street in Asia)

GEOFF THOMPSON, REPORTER: The human race has always been at war with bacteria.

But the development of antibiotics in the 1930s and 40s gave us the upper hand over the bugs that were killing us.

Suddenly we were superhuman.

PROFESSOR LINDSAY GRAYSON, AUSTIN HOSPITAL: Prior to that they were used to bacterial meningitis 100 per cent mortality; bad pneumonia, 30 per cent mortality; appendicitis or ruptured bowel, 100 per cent mortality, unless you had surgery.

The only cure really was surgical intervention to cut the infection out.

PROFESSOR DAVID PATERSON, UQ CENTRE FOR CLINICAL RESEARCH: Antibiotics allowed us to do things that no-one could've dreamed of doing historically. They've allowed us to transplant organs, they've allowed us to undergo chemotherapy, they've allowed us to receive therapy in intensive care units when we're critically ill.

Without antibiotics none of those advances in human medicine would be possible.

PROFESSOR MATT COOPER, UQ INSTITUTE OF MOLECULAR BIOSCIENCE: We've still got the upper edge. Clearly antibiotics still work, but it's the speed of change that concerns me.

Twenty years ago this wasn't an issue. Today it's a real issue. You know, infectious disease kills more people than cancer. TB kills 5,000 people a day.

So if we don't start to act soon and start to put our pedal on the gas pretty soon, within another 20 years we could be in serious trouble.

GEOFF THOMPSON: We've deployed our antibiotic defences far and wide while the bacteria have kept up their counter-attack.

They adapted and evolved.

(Petri dishes squirming with illuminated bacteria)

Now even our last precious antibiotics are surrendering to the rise of the superbugs.

JOEL BECLU: I was feeling good, no problem, no symptoms, no nothing. I was feeling really great!

GEOFF THOMPSON: As his 60th birthday approached Joel Beclu was feeling fit and enjoying semi-retirement.

His career in Australia as a stage technician was winding down in favour of travel through Europe and spending a year in Bali with his partner Roseann Schoch.

During a brief return to Australia he thought he'd better get a check-up.

JOEL BECLU: Getting 60, you think better to have a good checkup, so I did, went to a doctor and among the checkup was the prostate checkup, and felt a hard lump there and said 'You better to go to urology'.

And I went to urology and they say, 'Oh you better to have a biopsy done'.

GEOFF THOMPSON: It's procedure undertaken by tens of thousands of Australian men every year.

(Animation of the taking of a prostate sample)

A special device passes a thin needle through the wall of the rectum to take a prostate sample.

To prevent infection antibiotics are taken.

It's usually over within an hour.

JOEL BECLU: The procedure was on Friday morning. By Saturday to Sunday night, two o'clock, that's when I started to shiver. And so I thought 'Okay, well I've got the infection, better to go to hospital'.

We took the ambulance to the hospital and discovered that the preventative antibiotic didn't work and infection was spreading in my body.

GEOFF THOMPSON: The infection spread from Joel's prostate to his shoulder, spine and hip.

JOEL BECLU: The first pain was in the collarbone. That was the very first one I noticed. Then the lower back pain started to come and the hip - right in the hip joint, ah very, very strong pain. The pain was really horrible.

GEOFF THOMPSON: Standard antibiotics had no effect.

Joel had a superbug.

JOEL BECLU: I think within ten days the pain in my collarbone was so bad that they decided to operate, to do a scraping of the abscess in the collarbone. And then I basically lost touch with reality for about a month, because of the painkillers.

GEOFF THOMPSON: Joel spent three months in a hospital bed on rare antibiotics imported from overseas.

His body wasted away.

Now he's trying to regain his strength while fighting off the last of the infection.

JOEL BECLU: Obviously it has been a progress because I'm standing up and I can talk to you and whatever, which I wouldn't have been able to do a mere month ago. A month ago I was in pain and screaming in my bed, so it has been a big progress.

GEOFF THOMPSON: Somewhere in his travels, Joel had consumed a virulent strain of E. coli bacteria.

It survived harmlessly inside his gut until it was unleashed by the prostate procedure.

(Joel Beclu and Roseanne Schoch looking at photos of when he was in hospital)

ROSEANNE SCHOCH: I knew that it was a strain of E. coli they hadn't dealt with before and that they were trying their very best to try and find something that it would respond to and that would have an effect.

But I wasn't sure at times whether it was going to work, or that his organs would cope with the bacteria and the antibiotics and everything else, and that he would come through it, actually.

GEOFF THOMPSON: Did you fear for his life?

ROSEANNE SCHOCH: Yes. At times I didn't know that he was going to to make it or not.

PROFESSOR LINDSAY GRAYSON: Now we know that people who've returned from overseas in some of these hotspots where resistance is very common and it's in the food supply and it's in the water supply - because of misuse of antibiotics, mostly, in those countries - that we've had a whole string of men after their prostate biopsy now getting superbugs into their bloodstream cause it's- we've introduced it into their prostate not knowingly and it's then spread into their blood and then they've got incredibly sick.

(Plane taking off from a busy airport)

GEOFF THOMPSON: With one billion people now travelling the world each year, bacteria are more mobile than ever before.

And so are superbugs.

They are born when we abuse antibiotics - and we're doing that across the globe.

PROFESSOR MATT COOPER: Every time we take an antibiotic we're giving the bug a chance to become a superbug. So if you think about you in the community, you know, the more of us that take antibiotics inappropriately, the greater the chances in the community a superbug will come.

PROFESSOR LINDSAY GRAYSON: Australia I think out in the community is pretty bad. It rates seventh in the world for overuse of antibiotics per capita. Australia's like many of the other developed countries.

We saw development and wealth equaling ability to use antibiotics, and we lost the plot in terms of realising well, most sore throats are due to viruses. They're not going to respond to antibiotics but 'I want my antibiotics', you know?

GEOFF THOMPSON: It's the Indian subcontinent which is proving to be a superbug's perfect petri dish.

Antibiotic abuse is rampant here.

DR ABDUL GHAFUR: Yes, in India, also, antibiotic overuse is a serious problem. There's no antibiotic policy in the country...

And but of course there are many countries where there is no antibiotic policy, but I'm concerned about my country and there is no antibiotic policy.

GEOFF THOMPSON: India mass produces antibiotics and sells them cheaply. The drugs are available over the counter without prescription.

(Scenes of rubbish dumps near polluted rivers in India)

Waterways and even the soil are contaminated by waste from antibiotic manufacture.

On top of poor sanitation and chronic overcrowding, it's fertile ground for antibiotic resistance.

PROFESSOR DAVID PATERSON: There is a general principle in treatment of infections - the more we use any antibiotic, the quicker the bacteria are going to become resistant to it.

So if we have a situation where antibiotics are used in agriculture, where they're available over the counter, where in hospitals there's very little control over their use, clearly in that environment there's going to be a more rapid spread of resistance.

GEOFF THOMPSON: When more and more patients in Indian hospitals began dying from untreatable infections, local microbiologists began to ask why.

Working with international researchers they identified one of the most dangerous superbugs the world has ever seen.

They called it New Delhi metallo-beta-lactamase or NDM-1.

It's a gene that can turn bacteria once easily destroyed into untreatable killers.

PROFESSOR LINDSAY GRAYSON: The NDM bug is really scary because when you only have to drink one or two of those bugs. And they don't have to multiply in themselves, they just have to spit out the little bits of genetic material that make them superbugs and then they convert all your healthy bacteria into superbugs.

So it's a bit like putting a red t-shirt into the washing machine of white shirts. And the t-shirt itself doesn't have to multiply, it just has to leach out this stain and it changes all your white shirts into red shirts and converts them into you know, a superbug.

GEOFF THOMPSON: India's researchers were shunned at home for bringing the country into disrepute and threatening a multi-billion dollar medical tourism industry.

Chennai-based Dr Abdul Ghafur is one of the few Indian doctors prepared to speak out.

DR ABDUL GHAFUR: We need wartime measures. We can't wait and watch. What we need is, we need urgent wartime measures to rationalise the antibiotic in all countries.

Government should take initiative and ask the medical community to use the antibiotics very sensibly. The government should bring in strict laws to rationalise the antibiotics in countries, there must be strict antibiotic policies on one end. On the other end, governments should talk to pharma industries to stimulate the research on antibiotics.

DAVID RICCI: The drugs that they were treating me with seemed worse than the infection because the infection I didn't even know it was there unless they told me. But apparently it was so dangerous that they had to go to that extreme levels of treatment.

GEOFF THOMPSON: David Ricci travelled to India last year to volunteer in the slums of Calcutta.

A walk to an orphanage one morning changed his life forever.

(A train depot in India)

DAVID RICCI: Me and my group kind of stayed like a single file line and I was in back of it and so we didn't hear the train coming. And it like hooked my right sleeve and kind of through me in front of the train and hit me, ran me over and my leg got caught under the wheel.

So I'm directly underneath the train kind of head first. It pulled me probably about thirty metres or so before it stopped.

They had to back the train back over my leg 'cause it was kind of stuck up in the wheels kinda.

And they pulled me out and something punctured my lower abdominal region and it was probably about, you know, yay long. And there was a lot, a lot of internal bleeding. And my femoral artery in my thigh started spraying and gushing blood all over me and stuff and I was in shock, obviously, instantly.

GEOFF THOMPSON: Miraculously, a passerby managed to stop the bleeding.

David Ricci was bundled into a cycle rickshaw and taken to a local clinic.

DAVID RICCI: They started just putting water all over my leg and just kind of washing off all the dirt and the filth. Because when they pulled me out of the train, they set me in the trash because that was kind of the only place not on the tracks that they could put me.

And so, you know, I was just covered in filth and this this black gunk all over me. And so they were washing all that off and then he took out like a big leather bundle of knives and untied it and pulled out like a big medical knife and just started cuttin' my leg off.

(Excerpt of report from King 5 Television, showing David in recovery)

GEOFF THOMPSON: David was in so much pain those first few days that he didn't want to live.

Within a few weeks he was in a hospital back in the United States.

Blood tests confirmed he still faced a danger even greater than being hit by a train and losing his leg.

DAVID RICCI: A couple of days later they came in, you know, all suited up and they're like 'Uh sorry, we kind of need to quarantine you 'cause you have a lot of dangerous infections that we haven't seen before and uh we need to figure out how to treat this before we can do anything else'.

GEOFF THOMPSON: David was infected with several types of NDM-1 bacteria.

PROFESSOR MATT COOPER: So what's happened with NDM-1 is this particular gene has been able to jump around very, very quickly.

It likes to get out and about, if you like - so it's jumped from one bacteria to another, it's jumped from one country to another very, very quickly. And that's why it's quite a dangerous bug, the NDM-1 gene that's in all these different bacteria.

The other key thing, of course, is there's only really one antibiotic left now that can kill this NDM-1.

GEOFF THOMPSON: To date, Australia has dealt with fewer than 10 cases of infection by NDM-1 type bacteria.

The superbug is kept inside tightly secured laboratories like this one at the University of Queensland.

PROFESSOR MATT COOPER: When you look at one of the superbugs, it's the same type of bacteria but this one has acquired those genes, the NDM-1 gene. What you can see now is these powerful antibiotics that were being used before just aren't working at all.

(Indicating five bacteria cultures in a square petri dish)

The bacteria's just ignoring them and growing quite happily in the presence of antibiotics.

The one in the middle here is the only one we've got left, Colistin, which can kill this particular superbug.

GEOFF THOMPSON: So will this superbug eventually defeat that antibiotic too?

PROFESSOR MATT COOPER: Yes it will. We haven't seen that in Australia yet, but overseas there are some cases where this particular bacterium is resistant to all antibiotics, including this one in the middle.

GEOFF THOMPSON: So you're only really buying some time?

PROFESSOR MATT COOPER: Yes, we are.

GEOFF THOMPSON: Colistin was the only drug that worked for David Ricci. It was abandoned decades ago because it was too toxic.

DAVID RICCI: I was only able to be on it for so long before my kidneys and my white blood cell count and everything started dropping and they had to they had to pull me off right before you know most of my organs were unretainable.

And so at that point they figured that it had worked because they didn't see any signs of infection - there was no fever, no irritation around the site and so they figured that, 'Well I guess the infection's gone'.

But they left a track open in my leg which we cleaned out every day and it was just causing extreme pain like, like it was worse than India. It was a ten out a ten pain and I would just scream every single morning.

CHERYL RICCI, DAVID'S MOTHER: You would just see every day, he would just go down you know downhill and very pale and lethargic. And at times I felt like I was losing him but it was from the antibiotics. And they didn't even know if they were gonna work.

So it was it was a hard time, really hard time.

(Still photo of David and one of his doctors)

DAVID RICCI: And you know my doctors were like alright 'He shouldn't still be in this much pain, what's going what's going on in there?'

So they surgically went in and looked and it was all black and infected. So they're like 'Oh, well it's back'.

GEOFF THOMPSON: The tenacity of infections like NDM-1 threaten not only individuals but the very future of modern medicine.

PROFESSOR DAVID PATERSON: I think the worst nightmare for a hospital would be that not only is there an outbreak of these particular infections, but they become entrenched, they're an ongoing problem for decades to come.

That really changes the whole game in terms of ability to deliver high quality medical services, to deliver transplantation or chemotherapy or intensive care medicine.

GEOFF THOMPSON: Melbourne's Austin Hospital faced this challenge last year when it agreed to accept a patient infected with a superbug.

Nick Komilionis picked it up while holidaying in his native Greece.

NICK KOMILIONIS: I've been in the last five years, three times to Greece. I have beautiful time, beautiful country for holiday, nice weather.

I enjoy myself 80 days, the last ten days I come sick.

GEOFF THOMPSON: Nick ruptured his bowel and required urgent surgery. He was soon overcome by infection.

NICK KOMILIONIS: I feel tired. Outside 38, 40 degrees - hot. I like to be, to put me five, ten blankets.

PROFESSOR LINDSAY GRAYSON: In the end he was in hospital in Greece for six months, three different hospitals, multiple operations to save his life and ended up with lots of abscesses inside his abdomen, but was finally stable enough.

I mean, Nick is- he's a tough nut you know and uh he was well enough to get airlifted back to Australia. We knew that he had these superbugs in his bowel but also in all these abscesses. Essentially, they were untreatable.

GEOFF THOMPSON: At the Austin, Nick was kept in strict isolation.

NOULA SETTINELLI, NICK'S DAUGHTER: There was precaution taken and it was a harsh time for the family. Dad was quite, you know, isolated and was in quarantine for the length of time he did stay at Austin which the family felt- we felt for him.

GEOFF THOMPSON: Doctors struggled to find a combination of antibiotics which could kill Nick's superbug without killing Nick.

Just like NDM-1, this superbug was sharing its antibiotic resistant gene with other bacteria.

PROFESSOR LINDSAY GRAYSON: Now what's interesting is, this is a strain also from the patient. And this is a different bug, it's called an E. coli, and previously this was sensitive and you can see in this case that it's also growing quite well - just carefully look.

You can see it's pink though.

GEOFF THOMPSON: And that agar is full of antibiotics as well?

PROFESSOR LINDSAY GRAYSON: Full of antibiotics.

GEOFF THOMPSON: It's become a superbug?

PROFESSOR LINDSAY GRAYSON: So what's happened is that this klebsiella strain has transferred its resistance strain to normally sensitive E.coli and turned this into a superbug and this is from the same patient.

GEOFF THOMPSON: In the end the infection could not be stopped.

The only cure available was from a time when antibiotics did not exist.

Nick's bowel was removed.

PROFESSOR LINDSAY GRAYSON: We were still not able to get on top of all his abscesses and so in the end, there was a long discussion with the surgeons to say 'Look, maybe we should go back to the pre-antibiotic way of doing things and just cut it all out'.

In the end, we said to him 'Look, there's a 50 per cent chance you're going to die on the table, on the operating table. If you don't have the surgery you probably- you're dying in pieces'.

And, mean my view was he had maybe a 3 per cent chance of living for another six months. And this was this was just for him, let alone all the risk to the greater community, you know.

So essentially we had to take a pre-1940s approach to cure him.

But that's an example of where we're headed. Unless we do something about this, there'll be more of him for sure.

NICK KOMILIONIS: Now I feel like before, exactly. I can tell you - more better. Now I not for nothing, I do everything. I see the doctor sometime in hospital. I can say 'thanks, you saved my life'.

NOULA SETTENELLI: It can happen to anyone. It happened to my dad, it certainly can happen to anyone that travels or that's away from home, and, yeah, it is a scary thing. And if surgery wasn't an option, then we'd have nothing and we wouldn't have my father today.

So it's a worry and it's scary, yep.

GEOFF THOMPSON: At the beginning of the 20th century, tuberculosis was Australia's biggest killer.

(Photo of an Australian city street at the turn of the 20th century and hospital wards)

Antibiotics helped bring it under control.

Today Australia's rate of this bacterial infection is one of the lowest in the world. Indeed, it's easy for us to believe that TB is a disease of the past.

But here in Papua New Guinea - right on Australia's doorstep - not only is TB thriving, but Superbug TB has already crossed the border.

(Exterior of Cairns Base Hospital)

Most Australians wouldn't know it, but superbug TB bacteria are living here at Cairns Base Hospital.

They're surviving inside the lungs of this young woman from Papua New Guinea.

CATHRINA: How I got this TB, like it's an airborne disease and like people you talk with... like, you stand with somebody and talk, like you don't know that the person got sick.

GEOFF THOMPSON: Cathrina is currently Australia's only known case of Extensively Drug Resistant Tuberculosis or XDR-TB.

CATHRINA: There's many people for TB and some are dying for TB.

GEOFF THOMPSON: It's her fifth month inside this isolation room which she's very rarely allowed to leave.

Negative air pressure keeps the disease contained.

Anyone entering must wear a mask.

NURSE (speaking to Cathrina): So these here are the tablets...

DR STEPHEN VINCENT, THORACIC SPECIALIST: She's on medication at the moment, pretty stable but unsure as to what the outcome's gonna be in the next months and years, as the cure rate is fairly low and there's about a 40 per cent chance of death from this disease despite treatment.

GEOFF THOMPSON: Dr Stephen Vincent is a TB specialist based in Cairns.

DR STEPHEN VINCENT: We've got a lot of cases of drug-resistant TB in Papua New Guinea and now we've got Extensive Drug-Resistant TB - which wasn't even around 10 years ago and now it's worldwide. And Australia has a case currently up here in Cairns and also there was a case I think two years ago.

And I believe it's about three or four cases of Extensive Drug-Resistant TB in Papua New Guinea at the moment, so if you don't get onto these early and it gets into the population, that's, that's the disaster.

GEOFF THOMPSON: To understand why Cathrina came to be receiving treatment in an Australian hospital, we went to Papua New Guinea.

The rate of TB infection here is about 50 times greater than Australia's.

About 3,000 people die from TB in PNG every year - around one every three hours.

(Scenes of busy streets in Daru)

We travelled to the island of Daru - the dirt poor capital of PNG's Western Province.

GEOFF THOMPSON: This is the father of the woman in Cairns?

GUIDE: Yes.

GEOFF THOMPSON: It's here we found Cathrina's father Abraham.

ABRAHAM: So I was really upset. So I was really worried about her. She was losing weight fast.

At my own expense I had to take her to Saibai. It cost me a lot of money and... just because I love my daughter and I want her to get better. So I had to take her to Saibai.

GEOFF THOMPSON: At their closest points, the Australian islands of Saibai and Boigu are only 5 kilometres away from mainland PNG - a ten minute ride in a speedboat.

(A map showing the islands of Saibai and Boigu)

Unfettered two-way travel is permitted for locals under the terms of the Torres Strait Treaty.

DR STEPHEN VINCENT: People don't realise but there's about 50,000 movements back and forward between Torres Strait Islanders and the PNG nationals due to traditional purposes.

So there's no gate there. It's a porous border.

GEOFF THOMPSON: For the past seven years Australian doctors have staffed TB clinics on the islands.

(A doctor treating a patient from PNG in an island clinic)

They treated infected people from Papua New Guinea.

But in June this year the clinics were controversially closed. With help from AusAID, PNG is now trying to manage its TB patients on its own.

DR RENDI MOKE: I would say that we are doing much better now than it was before

GEOFF THOMPSON: Daru Hospital is the main centre for TB treatment in PNG's Western Province. Dr Rendi Moke is the chief physician.

DR RENDI MOKE: We are more than confident that we can take on board all the patients that have been handed to us, and the current patients on the ground.

We have the capacity with very good support from people, our stakeholders, very good support from AusAID, very good support from World Vision.

(Dr Rendi Moke greets patients as he walks down the hospital corridor)

GEOFF THOMPSON: Built in 1963, Daru Hospital is badly rundown and always busy.

Dr Moke leads us through to the outpatients clinic, where suspected TB sufferers are first diagnosed.

DR RENDI MOKE: Any patient we suspect may have TB and is coughing, we isolate them and give them a mask to prevent transmission to our staff as well as other patients.

GEOFF THOMPSON: So this is the first line - when people first come to the hospital they come here?

DR RENDI MOKE: Yes, this is the point of entry, if you like, to the hospital

GEOFF THOMPSON: So far AusAID has spent about one and half million dollars improving this hospital.

It's part of an 11 million-dollar aid package over four years aimed at boosting TB services in the Western Province.

(Dr Moke indicates the chest area of an illuminated X-Ray)

DR RENDI MOKE: So this is typical of a TB chest X-Ray...

GEOFF THOMPSON: The money has helped pay for a new X-Ray machine and training to use it.

DR RENDI MOKE: This is our GeneXpert machine. It has four slots...

GEOFF THOMPSON: Within two hours this new machine can determine resistance to one of the six types of TB antibiotics.

But it still takes months before multi or extensive drug resistance can be confirmed by a laboratory in Brisbane.

DR RENDI MOKE: Yeah, well it may take yup more than two months before we can know that. But it's a control because these patients that we diagnose here, we take them and we isolate them while we initiate treatment.

They are given a face mask and we isolate them in our TB wards so it reduces the chances of transmission and right then they are commenced on drugs.

GEOFF THOMPSON: Dr Moke showed us around Daru Hospital's TB wards.

DR RENDI MOKE (to patients): Wear your masks, please. Wear your masks.

GEOFF THOMPSON: Here the concept of isolation is a loose one.

(Patients wearing masks)

DR RENDI MOKE: We encourage them to wear masks for these patients and they are expected to wear masks when they are in the ward to prevent cross-transmission.

And we also encourage our staff to wear the masks as well. We discourage guardians from coming here. If they are to come, they are to come with masks

GEOFF THOMPSON: So everyone here's meant to wear- wears a mask?

DR RENDI MOKE: Yes, we expect them to wear masks, okay? TB patients. By wearing masks it prevents infection by 50 per cent...

GEOFF THOMPSON: That's a big difference?

DR RENDI MOKE: Makes a big difference, yes.

GEOFF THOMPSON: Outside, Dr Moke explained the very beginnings of the hospital's brand new TB ward.

It's also being paid for by AusAID and is expected to be finished next year.

DR RENDI MOKE: It will be 22 bed space ward and it will be six isolation for drug resistant TB, including MDR TB and XDR TB, and 16 bed will be general TB, those sensitive TB.

GEOFF THOMPSON: When Dr Moke left we returned to the TB ward.

Most patients were now unmasked and the special isolation room for extensively drug resistant patients was suddenly empty.

SISTER KONGA, NURSE: From the 16th month of her treatment...

GEOFF THOMPSON: From the Sister in charge we learned that one woman in this multi-drug resistant ward was actually suspected of having Extensively Drug Resistant TB.

So which one of these girls is XDR?

SISTER KONGA: Antonia.

GEOFF THOMPSON: Antonia is XDR?

SISTER KONGA: Yes, suspected.

GEOFF THOMPSON: And why is she in the MDR ward ?

SISTER KONGA: Because in the isolation room we've got only four beds available in the isolation room...

GEOFF THOMPSON: Is that a bad idea for infection?

SISTER KONGA: Of course it is because if she's confirmed XDR then she can spread it to the other patients.

GEOFF THOMPSON: Anton Narua is the deputy president of the region's local government.

He's just learnt that two of his nieces are here with TB. One of them is Antonia - the girl with suspected XDR-TB.

ANTON NARUA: That's why I'm saying they're all going to die. They should separate them but they're all mixed up together.

I know my two girls are going to die. They're definitely going to die.

There is something wrong which I can't- I can't- I can't explain. It happened to a lot of people. My two girls are going to die.

GEOFF THOMPSON: Anton Narua is also concerned about the fate of villagers living far away from Daru, along PNG's southern coast.

He took us to meet the people of Sigabaduru. It takes two hours and the fuel costs $350.

That's way beyond the means of people used to making quick trips to islands like Saibai, where Australia's TB clinic has shut its doors.

COUNCILLOR KEBEI SALEE: Over there is Saibai, just only about four nautical miles from here - sea nautical miles.

GEOFF THOMPSON: It's very close. And how long does it take you to get there each day?

COUNCILLOR KEBEI SALEE: It takes me only 10 minutes across by 60 horsepower outboard motor.

GEOFF THOMPSON: AusAID has provided a sea ambulance to help bridge the distance between outlying villages and TB services in Daru.

It cost about half a million dollars.

It's meant to travel up and down the coast dispensing TB drugs and checking on the sick.

Since it was delivered in May, Sigabaduru's villagers say it's only visited them twice.

VILLAGER: I'm Mr Duri (phonetic) from Sigabaduru (inaudible) community and I would like to raise a concern on a shutdown of the TB clinic on Sabai island.

GEOFF THOMPSON: The community of Sigabaduru is not happy about the closure of Saibai's TB clinic or the service it's getting from the new sea ambulance.

VILLAGER: Only twice. Since then it has completely stopped it. But we would like this one to continue.

GEOFF THOMPSON: The new TB strategy in Western Province relies on health workers living in these local villages.

They depend on Daru.

GOIGA ANU: There is no patient that has been taken to Daru. All the patients are here, even those who are on treatment.

GEOFF THOMPSON: Goiga Anu has been Sigabaduru's health worker for 15 years.

When was the last visit you got from the sea ambulance from Daru bringing drugs to the village?

GOIGA ANU: In June... June 27 - that was the last visit and they said that they were going to come on August 3 but they never did. We are still waiting.

GEOFF THOMPSON: Have people here with TB run out of drugs?

GOIGA ANU: Yes they have run out of drugs and they are still here in the village.

(Geoff Thomson talking to villagers)

GEOFF THOMPSON: TB sufferer Sabdu Samai got her drugs from the Australian clinic on Sabai island.

She's since run out.

GOIGA ANU: Yes, the last drugs were supplied at Saibai. And the last clinic, the speedboat came to visit the patients and they advised her that on August 3 they will come again and check the patient. But then they never did and patient's medicine's finished but she's still waiting for doctor's review.

GEOFF THOMPSON: So you need to see a doctor?

SABDU SAMAI: Yes.

GEOFF THOMPSON: And when did you last take drugs for TB?

SABDU SAMAI: September 1.

GEOFF THOMPSON: About a month?

SABDU SAMAI: Yeah.

DR RENDI MOKE: This is a concern. We really want these patients to continue their treatment.

GEOFF THOMPSON: Is that how you develop MDR and XDR?

DR RENDI MOKE: Certainly. MDR and XDR do... do develop through the non-compliance

GEOFF THOMPSON: Australian doctors who worked at the Sabai clinic say Sabdu Samai's case was referred to Dr. Moke for further treatment.

DR RENDI MOKE: I'm not sure which patient you're talking about but we are well aware of our drug resistant TB patients on the ground at the moment. So those are the ones we have on the list and we are following up on that.

GEOFF THOMPSON: I guess this is what to point out, it's difficult to do, but is there a danger of not maintaining?

DR RENDI MOKE: No, the system is doing what it's supposed to be doing and this is the... we just started a year ago. These are the initial phases, okay?

As I've said, we are very much aware of our challenges. We are very much aware of our shortfalls but we are working on it. We are not neglecting that. We are not ignoring it.

GEOFF THOMPSON: Without faith in their own TB treatments, more Papua New Guineans like Cathrina may seek care in Australian hospitals.

She was diagnosed with Multi-Drug Resistant TB in Saibai in 2010.

With relatives in Cairns, she chose to travel here for her check-up rather than remain in Daru.

CATHRINA: From Daru, I flew to Port Moresby with my medication and I stayed there for three months until, while waiting for my visa, I ran out of medication and by the time I flew here, I got sick.

GEOFF THOMPSON: Her Australian doctors now believe that three month break from treatment may have led to her developing Extensively Drug Resistant TB.

(Dr Stephen Vincent showing a range of pharmaceuticals)

DR STEPHEN VINCENT: Here we have one that's called Pyrazinamide, one that's called...

GEOFF THOMPSON: Treating XDR TB requires a toxic drug cocktail.

DR STEPHEN VINCENT: ...his one here can cause severe psychosis in 20 per cent of patients...

GEOFF THOMPSON: If she survives, the cost of Cathrina's treatment could reach $1 million.

DR STEPHEN VINCENT: And this one here can cause a lot of arthritis.

The majority of the medications are in tablet form and there's one of them that's through a drip, which she'll probably need to be on for at least 12 months. So that's 12 months in hospital, away from her family and friends, and at the moment she's still considered infectious, so she's in isolation.

GEOFF THOMPSON: So her treatment might cost a million bucks?

DR STEPHEN VINCENT: Yep.

GEOFF THOMPSON: And she could still die?

DR STEPHEN VINCENT: Yeah.

GEOFF THOMPSON: The Australian TB services on Saibai and Boigu islands cost about $600,000 a year.

DR LINDSAY GRAYSON: The cost of those clinics up there was nothing so economically it makes no sense.

If Papua New Guinea's got big problems with TB, which it does, and increasingly now with not only MDR, multi-drug resistant, but XDR-TB, why wouldn't you nip it in the bud by running clinics on those islands to stop it getting into the Queensland population?

New York City struggled with XDR-TB. You know, they had a bunch of docs and nurses die from XDR-TB. Even throwing the best resources they could at it, people still got infected and couldn't be cured even just by having parts of their lung cut out.

So it's a- it's a worry.

DR STEPHEN VINCENT: We're going to get to an era when there's the phenomenon called Totally Drug-Resistant TB and this is where it comes to telling these people that we have nothing to offer you, we can't treat you.

And the unfortunate thing is that while they're dying from that disease, they're probably going to infect others. So on a public health point of view, it's better off not treat them and they go off and die alone.

It sounds harsh but unfortunately we're going to be dealt with this phenomenon probably in the next decade or so.

GEOFF THOMPSON: Pharmaceutical companies aren't about to save the world from total drug resistance.

They have little financial incentive to produce new antibiotics.

PROFESSOR MATT COOPER: Not so long ago, there were 18 pharmaceutical companies developing new antibiotics; there are now four.

And the reason is that antibiotics are fantastic drugs, you take them for two weeks and you can cure the infection. And they basically don't make much money for pharmaceutical companies.

If you take Lipitor, a cholesterol hypertension agent, you take it for the rest of your life. It's a very profitable drug. So the economics are wrong.

That's why here, we are stepping up. If industry isn't going to look at new antibiotics it's really up to institutes like universities and research institutes to start to take that fight to the superbugs.

GEOFF THOMPSON: The few new drugs in the pipeline are refinements of antibiotics we've already discovered.

PROFESSOR DAVID PATERSON: These new antibiotics, which I expect will become available in the next two or three years, are completely inactive against the NDM producers, the very bacteria that we're likely to see in Australia because of our geographic proximity with Asia and the Indian subcontinent.

GEOFF THOMPSON: What are the implications of that?

PROFESSOR DAVID PATERSON: So the implications are basically we will have no antibiotics left at all to treat some patients.

Therefore it really rests on us to do surveillance for those infections and for us to put into place very strict infection control measures to prevent person-to-person spread within our hospitals.

PROFESSOR LINDSAY GRAYSON: In some form or another, we need a central reporting system for these superbugs.

You need to go back to basics: improved hand hygiene, proper cleaning, bleach cleaning of hospitals.

You know bleach is a wonderful product. It kills HIV, it kills all viruses, it kills everything.

In fact, when we introduced bleach cleaning to the hospital here one of my professors said 'Lindsay, you know, do you mean the hospital's going to smell like it used to in 1980?'

And I said, 'Yeah, like before we ever had superbugs, you know?'

So proper cleaning. We need proper hospital design - one bum per toilet - and we need a set of national guidelines for invasive procedures to stop those superbugs getting into our bloodstream.

GEOFF THOMPSON: Defence may be our only offence in a world where antibiotics no longer work.

PROFESSOR DAVID PATERSON: If we've got no antibiotics left, we've only got one option if we're going to save the person's life - and that is to eradicate the source of infection, to eradicate that area of infection. And that means radical surgery, and clearly that's going to impact many people's lives.

They're going to be amputees, they're going to have had significant scars from major surgery, in situations where previously we would've used an antibiotic and those measures wouldn't have been necessary.

GEOFF THOMPSON: Since he was hit by a train in India, David Ricci has had five operations - each of them has cut away a bit more tissue.

It's now been almost a year since his last infection.

CHERYL RICCI: They've always said that it could come back and it could even be lying dormant right now so you know, it could come back at any time.

DAVID RICCI: I wouldn't say it's all the way out of the woods but I definitely have experienced that feeling of recovery. You know, I'm walking on my prosthetic. I'm going back to school finally, which is something I've been wanting to do since India.

I'm just kind a living my life and if the infection comes back it comes back.

PROFESSOR MATT COOPER: There isn't an infinite number of antibiotics, just like there's not an infinite amount of rainforest or coral reef. It is a very precious natural resource.

It's getting tougher. There are fewer companies in the race to discover them and in the meantime the superbugs are going up and up.

So this is what we call the perfect storm, and if we don't start to take action very soon, the problem's just going to get worse until we go back to the pre-antibiotic age.

KERRY O'BRIEN: Obviously the facts of this story throw up serious questions, not least why so few recommendations from an expert government panel's report were ever implemented.

In the Senate tomorrow, the Greens will push for a further inquiry into public policy on antibiotic resistance.

Good luck on the outcome.

That's Four Corners for this week. Join us again next Monday but for now, good night.

END

Background Information

STORY UPDATE

Sadly Four Corners has learned that Catherina Abraham died at Cairns Base Hospital on Thursday March 7, 2013. She spoke to us for the "Rise of the Superbugs" program while being treated for extremely drug resistant tuberculosis or XDR-TB. Respiratory physician Stephen Vincent said that the 20 year old Papua New Guinean's death was not unexpected. "We had her on every medication we could think of. She failed to respond to the 1st world treatments". He says the region is only one step away from totally drug resistant tuberculosis. "If we have problems treating her, I can't imagine what sort of problems PNG are going to have...Housing, sanitation, overcrowding, sewerage and water - if you don't address those issues you can throw as much money as want at it and it won't make a difference".Read more here...

REPORTS AND RESEARCH

Executive Summary of the Risk Analysis of TB in the Western Province | AusAID | Oct 2012 - This risk analysis was conducted by Dr Emma McBryde, Head of Epidemiology at the Victorian Infectious Diseases Service, on behalf of the PNG Government. The report finds that the burden of TB in the Western Province is 'very high' and 'well above' current WHO estimates. [PDF 2.5Mb]

Tuberculosis Control in the Torres Strait Region: What's Needed and Why? Report Following a Public Forum | Social Science Research Network | 1 Aug 2012 - Recently, there has been increasing focus and concern regarding transmission of tuberculosis (TB) in the Papua New Guinea (PNG)-Australia cross-border region. In particular, there is growing recognition that preventing the emergence and spread of drug resistant TB is of vital importance to both PNG and Australia. This paper discusses the way forward for sustainable, long-term tuberculosis control in the region.

Summary of TB cases in PNG | WHO | 2011 - Health Observatory Data from the World Health Organization. [PDF 25Kb]

Summary of TB cases in Australia | WHO | 2011 - Health Observatory Data from the World Health Organization. [PDF 24Kb]

RELATED NEWS AND MEDIA

Antibiotic Awareness Week 12-18 November 2012 | National Prescribing Service - NPS is asking all Australians to become 'resistance fighters' and join in the fight against antibiotic resistance. Antibiotic Awareness Week is a global health initiative to reduce the spread of dangerous antibiotic-resistant bacteria. Australia has one of the highest rates of antibiotic use in the world. We must change the way we use these medicines now or risk a return to the pre-antibiotic era by 2030. Find out how you can join the fight against antibiotic resistance this November.

Audio: Superbugs posing a serious health risk | ABC Bush Telegraph | 29 Oct 2012 - Deadly superbugs are emerging undetected in Australia, posing a serious health risk. Listen to this report, featuring featuring Lindsay Grayson and Professor Peter Collignon.

Explainer: what are antibiotics? | The Conversation | 29 Oct 2012 - Today, take a course of antibiotics and most of time you'll be completely fine. But just what is an antibiotic, and how does it work? And what's all this talk about antibiotic resistance and superbugs? By Matt Cooper, UQ Institute of Molecular Bioscience.

TB clinics made things 'worse' | The Australian | 29 Oct 2012 - The controversial shutdown of Queensland-run tuberculosis clinics on the Torres Strait has been backed by new research that claims the centres made the situation "much worse".

Audio: Papua New Guinea's tuberculosis crisis | Radio National Breakfast | 23 Oct 2012 - A leading Australian epidemiologist says the spread of tuberculosis in Papua New Guinea's western province is five times worse than official figures suggest.

MRSA on the Loose | The Scientist | 22 Oct 2012 - Wild animals harbor and transmit the most infamous and life-threatening drug-resistant germ, methicillin-resistant Staphylococcus aureus (MRSA), according to a study published this month in the Journal of Wildlife Diseases, which identified the deadly superbug in two wild rabbits and a shorebird.

Deadly superbug hits Australia | Brisbane Times | 17 Oct 2012 - A deadly superbug that has killed people in Europe and North America has arrived in Australia, but experts fear it is being missed because of inadequate testing. Brisbane Times talks to Thomas Riley, a professor of Microbiology at the University of Western Australia.

'Superbug' stalked NIH hospital last year, killing six | The Washington Post | 23 Aug 2012 - As a deadly infection, untreatable by nearly every antibiotic, spread through the National Institutes of Health's Clinical Center last year, the staff resorted to extreme measures. They built a wall to isolate patients, gassed rooms with vaporized disinfectant and even ripped out plumbing.

MRSA deaths fall fourth year in a row | The Guardian | 22 Aug 2012 - Hospital superbug killed 364 patients last year compared with 485 in 2010, while C difficile deaths fall from 2,704 to 2,053.

Audio: Tuberculosis emerges in Queensland | Radio National Breakfast | 3 Aug 2012 - A rare and deadly strain of tuberculosis has emerged in Far North Queensland. There are ongoing concerns that the highly infectious and extremely drug resistant disease will take hold in the Torres Strait.

Audio: Superbugs in food | Life Matters | 13 Jun 2012 - Antibiotic use in farm animals is producing resistant strains of bacteria which put human health at risk. American science journalist Maryn McKenna believes we urgently need to reduce antibiotic use in food production to preserve life-saving antibiotics in the treatment of common diseases.

Video: Doctors warn of dangerous TB outbreak | 7.30 | 7 Jun 2012 - Queensland Health doctors are warning that the Torres Strait is vulnerable to a dangerous, drug-resistant form of tuberculosis.

Audio: AusAID $8m package to tackle tuberculosis in PNG | ABC PM | 17 May 2012 - Papua New Guinea - with Australian help - has taken a big step towards tackling drug-resistant tuberculosis. Mark Colvin reports.

Antibiotics binge helping superbugs spread | The World Today | 30 Apr 2012 - Experts believe Australia's overuse of antibiotics may be contributing to the rampant spread of dangerous superbugs like E. coli.

Frog skin protein may help fight superbugs | ABC Science | 19 Mar 2012 - Proteins secreted by frog skin could one day help in the design of new antibiotics to fight superbugs, say researchers.

Media release. New data shows how often hospital staff wash their hands | Department of Health | Mar 2012 - Doctors and nurses will be given more information about how they can continue to protect their patients from the spread of infectious diseases with the release of new national data on how often hospital staff wash their hands.

Nanotech filters 'could boost superbugs' | ABC Science | 13 Mar 2012 - The rise of antibiotic-resistant "superbugs" could result from an increased dependence on nanomaterials in water treatment, Chinese researchers say.

Greek Doctors Battle Hospital Superbug as Crisis Depletes Budget | Businessweek | 21 Feb 2012 - Greek doctors are fighting a new invisible foe every day at their hospitals: a pneumonia-causing superbug that most existing antibiotics can't kill.

How Using Antibiotics In Animal Feed Creates Superbugs | NPR Blog | 21 Feb 2012 - A study in the journal mBio, published by the American Society for Microbiology, shows how an antibiotic-susceptible staph germ passed from humans into pigs, where it became resistant to the antibiotics tetracycline and methicillin. And then the antibiotic-resistant staph learned to jump back into humans.

BACKGROUND READING

Transcript: Antimicrobial resistance in the European Union and the world | WHO | 14 March 2012 - Keynote address by Dr Margaret Chan, Director-General of the World Health Organization, at the conference on Combating antimicrobial resistance: time for action.

Antimicrobial Resistance | WHO - Antimicrobial agents are considered "miracle drugs" that are our leading weapons in the treatment of infectious diseases. Antimicrobial resistance is the ability of certain microorganisms to withstand attack by antimicrobials, and the uncontrolled rise in resistant pathogens threatens lives and wastes limited healthcare resources. More from the World Health Organization.

Infectious diseases | WHO - Infectious diseases are caused by pathogenic microorganisms, such as bacteria, viruses, parasites or fungi; the diseases can be spread, directly or indirectly, from one person to another. Zoonotic diseases are infectious diseases of animals that can cause disease when transmitted to humans. Read more research and information from the World Health Organization.

Tuberculosis management in Western province, PNG | AusAID - AusAID support to the Government of PNG to manage TB in the Western Province of PNG is leading to better detection, treatment and management of TB. With AusAID's assistance TB mortality rates have been dramatically reduced in Western Province - from 25 per cent to just 5 per cent in the past year.

Severe infection with Clostridium difficile PCR ribotype 027 acquired in Melbourne | MJA | 2011 - We report the first recognised case of infection with Clostridium difficile PCR ribotype 027 acquired in Australia. This pathogen has caused significant morbidity and mortality in widespread hospital-based outbreaks in the northern hemisphere.

100 million Indians could be carrying NDM-1 | The Times of India | 9 Oct 2011 - Extrapolating the data from our environmental study undertaken in New Delhi and combining this with the recent study of NDM-1 carriage from Pakistan, we estimate that the carriage rate of NDM-1 in India is between 100 and 200 million, which means that NDM-1 has become a very serious public health issue.

Communicable Diseases Surveillance | Department of Health - Introduction to the work undertaken by the Health Protection and Surveillance Branch, Office of Health Protection, Australian Government Department of Health and Ageing.

Interactive: Clostridium difficile | The Guardian - A brief explainer about the superbug Clostridium difficile.

MRSA Interactive | The Guardian - Find out more about the MRSA bacteria.

LINKS

Austin Health is the major provider of tertiary health services, health professional education and research in the northeast of Melbourne. www.austin.org.au/

Australian Institute of Health and Welfare - www.aihw.gov.au/

Australasian Society for Infectious Diseases - ASID is an independent organisation, whose aim is to advance postgraduate education in infectious diseases in Australasia and internationally. www.asid.net.au/

Australian Society for Antimicrobials - ASA is an Australian-based association of members, from a wide variety of professions, involved in the study of antimicrobials. www.asainc.net.au/

Asia Pacific Foundation for Infectious Diseases - APFID was founded on the belief that inernational collaboration for research on infectious diseases and antimicrobial resistance is essential for improvement of public health in the Asia Pacific region. www.ansorp.org/

Alliance for the Prudent Use of Antibiotics: Australian Chapter - The most urgent antibiotic resistance problem identified by members of APUA Australia is the lack of surveillance of antibiotic use and resistance. This leads to challenges in treating infectious diseases that are prevalent in Australia such as acute respiratory infections. www.tufts.edu/med/apua/intl_chapters/australia

Advisory Committee on Prescription Medicines | TGA - The ACPM advises and makes recommendations to the TGA on prescription medicines. www.tga.gov.au/.../committees-acpm

Antibiotics and Food | Food Standards Australia New Zealand - Farmers use antibiotics to keep their animals healthy and as a result low residues of antibiotics may be present in some of the foods we eat. Read more. www.foodstandards.gov.au/consumerinformation/antibioticsandfood

National Residue Survey | Department of Agriculture, Fisheries and Forestry - The NRS is a vital part of the Australian system for managing the risk of chemical residues and environmental contaminants in Australian food products. www.daff.gov.au/agriculture-food/nrs

UQ Centre for Clinical Research (UQCCR) | The Royal Brisbane and Women's Hospital - Focused on improving people's lives through patient-orientated research, UQCCR offers state-of-the-art facilities and brings together leading health professionals, clinicians and scientists from around the globe. www.uqccr.uq.edu.au/

The Institute for Molecular Bioscience | The University of Queensland- The IMB's mission is to decipher the information contained in the genes, proteins and molecules of humans, animals and plants. www.imb.uq.edu.au/

Victorian Infectious Diseases Reference Laboratory - www.vidrl.org.au/

World Health Organization - www.who.int/