2950. The Bugs Are Winning

By Jerome Groopman, The New York Review of Books, June 28, 2018

Penicillium Chrysogenum 3D model

I never knew my aunt, Pessimindle. As a teenager in the early 1900s, she developed appendicitis and rapidly succumbed to the infection. At the time, there were no antibiotics. When I was growing up, my father contrasted the loss of his sister with the advent of penicillin that saved many of his fellow soldiers in the waning days of World War II. I was taught that medicine could create miracles, which should never be taken for granted.

Penicillin was serendipitously discovered when the researcher Alexander Fleming went on vacation in the summer of 1928. He returned to his laboratory at St. Mary’s Hospital, London, to find that a petri dish with bacteria had been left open and had become contaminated by a relatively rare strain of airborne mold, Penicillium notatum, its spores likely drifting in through the window. The growth of the bacteria in the dish was inhibited by the mold. Its inhibitory substance, termed penicillin, was produced in scant quantities and was laborious to purify. A worldwide search was launched to find other strains of Penicillium that produced higher concentrations; promising samples were obtained in Cape Town, Mumbai, and Chongqing, but the best came from an overripe melon bought at a fruit market in Peoria. Pharmaceutical companies scaled up production of the antibiotic and, beginning with the D-Day landings in 1944, it was widely available to Allied troops.

Fleming recognized not only the opportunity afforded by the open petri dish, but also the peril from misusing the drug. In his speech accepting the 1945 Nobel Prize in Physiology or Medicine he said:

The time may come when penicillin can be bought by anyone in the shops. Then there is the danger that the ignorant man may easily underdose himself and by exposing his microbes to non-lethal quantities of the drug make them resistant. Here is a hypothetical illustration. Mr. X has a sore throat. He buys some penicillin and gives himself, not enough to kill the streptococci but enough to educate them to resist penicillin. He then infects his wife. Mrs. X gets pneumonia and is treated with penicillin. As the streptococci are now resistant to penicillin the treatment fails. Mrs. X dies. Who is primarily responsible for Mrs. X’s death? Why Mr. X, whose negligent use of penicillin changed the nature of the microbe. Moral: If you use penicillin, use enough.

Fleming’s advice to use the antibiotic properly was widely disregarded, not by “the ignorant man” but by “negligent” medical professionals. Prescriptions of penicillin in suboptimal dosages led to the emergence of bacteria resistant to it.

This is because bacteria reproduce at an astonishing rate. E. coli, commonly found in our colon, has a generational interval of about twenty minutes. Homo sapiens has an average generational interval of thirty years. So, over two and a half years, E. coli goes through the same number of generations as we do in two million years. As DNA is copied to spawn the next generation, random errors (mutations) occur, and the more copying, the more random mutations. If an antibiotic is used in suboptimal concentrations, then bacteria with random mutations that confer some level of resistance to the drug are more likely to survive and over many generations become impervious to it.

Researchers thus play leapfrog with bacteria that are resistant to one antibiotic by searching for a new one that is effective. William Hall, Anthony McDonnell, and Jim O’Neill in their lucid and thoughtful book Superbugs recount that for several decades, this strategy succeeded. But now we are running out of options. Potent antibiotics that were mainstays in the clinic over the four decades that I’ve practiced medicine, like ampicillin, ceftazidime, and imipenem, typically fail to eradicate many of the bacteria that currently cause infections.

Bacteria that have developed immunity to a large number of antibiotics are termed “superbugs.” The best known is methicillin-resistant Staphylococcus aureus, or MRSA. It originally appeared in intensive care units, among surgical patients. In this setting, MRSA primarily causes pneumonia and bloodstream infection from catheters. But over the past two decades, the resistant microbes have spread outside hospitals to the larger community. At the end of the 1990s this superbug infected children in North Dakota and Minnesota, then was found among men who have sex with men and in prisons among prisoners. A widely publicized outbreak occurred among the St. Louis Rams football team, transmitted by shared equipment. Other MRSA outbreaks were reported among religious groups in upstate New York, Hurricane Katrina evacuees, and people who have received tattoos without proper sanitary precautions. Resistant forms of so-called gram-negative bacteria—characterized by cell walls that protect them from many antibiotics—have also emerged, like Klebsiella and Acinetobacter, which often cause death. Recently, resistant strains of gonorrhea have been detected in Asia.1

Superbugs only briefly reviews the science of bacterial resistance; its focus is on the societal consequences. While there are no exact data on the total number of people dying each year from resistant microbes, the authors calculate it to be at least 1.5 million. This number outstrips deaths from road accidents (1.2 million) and approximates the number of deaths from diabetes (1.5 million).

The economic burden on our health care systems is considerable. People with resistant infections spend more time in the hospital, require more care from doctors and nurses, are treated with more expensive drugs, and often have to be isolated from other patients. In the United States, it costs an average of $16,000 to treat a patient with Staphylococcus aureus that is susceptible to the antibiotic methicillin, with an 11.5 percent chance of death; if the bacteria are resistant, the cost jumps to $35,000 and the chance of the patient dying more than doubles. A study from the European Medicines Agency in the European Union, which includes England, estimated the cost to EU healthcare  systems at €900 million ($1.06 billion)

The impact of bacterial resistance on economic productivity is also significant. The Centers for Disease Control and Prevention in the United States have estimated that resistance costs the American health care system about $20 billion per year, to which productivity losses add a further $35 billion. Using the American estimates, the authors of Superbugs extrapolate the total costs of antimicrobial resistance worldwide to about $57 billion for health systems, with the reduction in world productivity valued at $174 billion.

Based on these economic calculations, Superbugs provides a set of policy prescriptions, framed in pragmatic terms meant to motivate self-interested politicians:

Governments might not want to invest in solutions, but they will ultimately pay either way. Any money not spent now will result in substantial costs in the future—not to mention many lost lives. Serious damage to economic productivity (which by extension threatens governments’ tax incomes) coupled with the higher costs of health care (which is largely government funded) should provide the impetus to deal with this crisis now.

Investment to combat superbugs begins with identifying new antibiotics. Almost all antibiotics are still derived from natural compounds, like Fleming’s penicillin. Although researchers at the Rockefeller University have recently devised advanced methods to facilitate the search, it is unclear how many antibacterial agents are left to discover.2 The most prudent approach is to rely not on discovery but on conservation. “We need to think of our current antibiotics as nonrenewable natural resources,” Hall, McDonnell, and O’Neill write.

Long before we discovered the environmental damage caused by burning hydrocarbons, we were keenly aware that one day the world would run out of coal and oil and that not only should we not waste them, but we should develop renewable resources.

This in part has been the focus of Environmental Protection Agency (EPA) regulations:

Both government and industry plan for the exhaustion of rare earth metals that are needed in electronics and elsewhere. This is not to say that we will never find any new antibacterial compounds…. However as it is unclear how many more drugs can be found in the future, we should work hard to protect the ones we have, as well as new ones that we find.

They provide a concise overview of the logistics of new drug development. It normally takes ten to fifteen years to bring a new therapy to market, at a cost of more than a billion dollars. Intellectual property rights give the company a monopoly over the drug for some twenty years, depending on the country. After that, low-cost generic manufacturers typically jump in to sell it at a reduced price. Much of those twenty years is spent testing the drug in clinical trials, so investment costs are recouped over only about a decade. The company generally makes no significant profit after the patent expires. Still, high sales usually mean that patented drugs end up making a profit.

Antibiotics, the authors show, are paradoxically different in the marketplace when properly prescribed:

If an excellent new antibiotic is effective against infections caused by drug-resistant bacteria, most public health officials would want to protect it for use in the most extreme circumstances and would discourage it from being sold worldwide. To get the maximum benefit from the drug and prevent the development of resistance, it is important that people not use it frequently.

This makes eminent sense from a public health point of view, in effect safeguarding a precious social resource:

When asked what she would do with a useful new antibiotic, the chief medical officer for England, Sally Davis, said that the drug “would need a stewardship program”—that is, that systems would have to be in place to make sure that the antibiotic was only prescribed when absolutely necessary. Indeed, limiting unnecessary use is essential to keep bacteria from becoming resistant to new antibiotics, and thus essential for our continued health.

While this is a cogent strategy, it doesn’t coincide with the marketing goals of the drug industry: “When a really useful new antibiotic is found, the company that invests in it cannot rely on high sales for return on investment.”

Commercial imperatives also work against societal needs in the use of antibiotics in animal husbandry. This is partly a result of the sheer number of animals being reared yearly to feed the world’s seven billion–plus people. Antibiotics were introduced into agriculture in the 1950s, when it was discovered that regular low doses of them made farm animals grow faster and larger. Consumers could purchase meat at lower prices, since the drugs reduce production costs for farmers. Globally, more antibiotics are estimated to be used today for animals than for humans. For example, “over 70 percent of medically important antibiotics in the United States, by volume, are sold for use in farm animals.” Hall, McDonnell, and O’Neill note that

antibiotics are more effective growth promoters when used for animals kept in cramped, dirty, unregulated conditions than for animals living in cleaner, more open, more controlled environments. Under suboptimal conditions, the growth promoters are for all practical purposes a substitute for good infection prevention and control.

The effects of antibiotics on growth are not fully understood. They may alter the animal’s microbiome—the bacteria in the gut—as well as prevent infection, so less energy is expended on fighting microbes.

Our environment is becoming contaminated with antibiotics and their residues in several ways. The first is a result of body waste—from both animals and humans. According to Hall, McDonnell, and O’Neill, “Studies suggest that as much as 75 to 90 percent of antibiotics may be excreted from animals without being metabolized. This waste goes into the soil and is then washed into the water systems.” Second, when pharmaceutical factories dump their untreated waste that contains the active ingredients of antibiotics into the water supply, they save money on expensive disposal. Such practices encourage the development of antibiotic resistance, since we are thus exposed to low and varying amounts of the drugs, as Fleming warned.

Hall, McDonnell, and O’Neill argue that “antibiotics provide a backbone to the entire healthcare system,” essential in everything from hip surgery to cancer treatment to organ transplantation. Thus developing effective antibiotics should be recognized as a “public good.” This justifies governmental intervention with incentives for the creation of new drugs. But such incentives have not been forthcoming, partly, in the authors’ view, because “electoral cycles encourage short-term thinking.” This kind of thinking has become particularly acute with the economic and social upheavals of the recent elections in the United States and Europe:

If a prime minister or president invests government resources to curtail drug resistance, they are unlikely to get huge rewards from the electorate. People generally do not vote on how well the government is dealing with a future problem, and they do not have enough knowledge of the early stages of research to make judgments. As a result, the political incentives have not been sufficient to pressure governments into action.

To overcome these barriers, they recommend a public innovation fund that covers early-stage research, as well as “non-cutting edge research that has societal benefit but little commercial attractiveness”; enhanced collaboration among companies in conducting clinical trials; harmonization of new drug regulation to reduce the costs of development; and “market entry rewards” that will compensate a company for creating useful products.

In agriculture, the authors write, methods are needed to rear animals without antibiotics. But “progress on an international scale will be a challenge because many meat-producing countries have a financial interest to continue antibiotic use.” Still, farming practices can be profitably improved, as occurred in Denmark, where farmers significantly reduced use of antibiotics while sustaining productivity; the country is one of the largest exporters of pork in the world. This has been possible despite regulations to limit the use of antibiotics, in part because of improved infection control procedures, which lowered infection rates and reduced the need for drugs. Denmark also improved the monitoring of antibiotic sales and use, which enabled the government to intervene if farmers were disregarding the law. It did this through what was called a “‘yellow card system’—pig farmers using the most antibiotics were sent warnings that they might face penalties.”

Given this evidence of economic competitiveness despite the regulation of antibiotic use in livestock, Hall, McDonnell, and O’Neill propose international agreements as a first step toward remedying the urgent issue of superbugs. “A combination of taxation, regulation, and subsidies for alternatives to antibiotics should be developed.”

But regulation is needed not only in farming. When we are treated for bacterial infection, we excrete unmetabolized antibiotics that enter our water systems. As the authors write, “A wastewater system that eradicates all traces of antibiotics does not yet exist, partly due to the high cost of development.” This issue is especially prominent in hospital waste, since patients are more likely to have antibiotic residues in their feces, in addition to drug-resistant bacteria. “This combination has the potential to create hotspots of resistance.”

Yet another obstacle is found where antibiotics are often manufactured, in India and China, where production costs are minimal. There is often poor quality control of the content of the antibiotic pills manufactured in these countries. They also often contain less of the active drug than advertised.3 Again, as Fleming noted, undertreatment with suboptimal doses of antibiotics fosters bacterial resistance.

At the 2016 G7 meeting, chaired by Japan, world leaders recognized how market forces mitigate against new drug development and called on international institutions to rectify the problem. While these leaders recognized the importance of increased access to antibiotics for their underserved populations, they also highlighted the need for stewardship in use of the drugs for both patients and animal husbandry.

The authors assert that political will is needed to find the funds for implementing incentives. They estimate that an investment of $40 billion over ten years is required for the world to avoid a $100 trillion cost by 2050. They argue that “the potential to prevent an increase from 1.5 million to 10 million deaths per year should make every one of us stand up and take note.”

But I am not hopeful that such pragmatism will prevail. Superbugs was written before the sharp shift in our politics, notably Brexit and the election of Donald Trump. The withdrawal of the United States from both the Paris Climate Accord and the Trans-Pacific Partnership has been followed by a declaration of trade wars, which the president tweets are “good” and “easy to win.” This absurd delusion fits with his view that all deals are binary, with “winners and losers” rather than agreements that may benefit both parties in the negotiation.

Such brute nativist thinking undermines global cooperation, which is needed for the proposals of Hall, McDonnell, and O’Neill. If the recent lifting of salutary regulations by Trump’s EPA on the chemical and mining sectors are any indications of disregard for the environment, there is scant hope that measures to limit factory dumping of antibiotic waste will be pursued. Still, some within the administration are trying to address the threat of superbugs in the defense budget, where research on antibiotic resistance may be cloaked under the aegis of national security.4 But such singular measures will ultimately fall short without a comprehensive and coordinated plan of cooperation among nations.

1. 1
   For greater detail on the science of bacterial resistance, see my “Superbugs: The New Generation of Resistant Infections Is Almost Impossible to Treat,” The New Yorker, August 11, 2008; and “Sex and the Superbug: The Rise of Drug-Resistant Gonorrhea,” The New Yorker, October 1, 2012. See also Ellie Kincaid, “New Study Raises Specter of More Bacteria Resistant to Last Line Antibiotics,” The Wall Street Journal, January 16, 2017. This April the Centers for Disease Control and Prevention released an update on multidrug-resistant microbes in the United States. Bacteria that were believed to be rare proved more common than previously thought, with unusual resistance making them impervious to most available antibiotics. See Kate Russell Woodworth et al., “Vital Signs: Containment of Novel Multidrug-Resistant Organisms and Resistance Mechanisms—United States, 2006–2017,” Morbidity and Mortality Weekly Report, Vol. 67, No. 13 (April 6, 2018). ↩
2. 2
   Bradley M. Hover, Zachary Charlop-Powers, Sean F. Brady et al., “Culture-Independent Discovery of the Malacidins as Calcium-Dependent Antibiotics with Activity Against Multidrug-Resistant Gram-Positive Pathogens,” Nature Microbiology, February 12, 2018.  ↩
3. 3
   Patricia McGettigan, Peter Roderick, Abhay Kadam, and Allyson Pollock, “Threats to Global Antimicrobial Resistance Control: Centrally Approved and Unapproved Antibiotic Formulations Sold in India,” British Journal of Clinical Pharmacology, February 21, 2018.  ↩
4. 4
   Ike Swetlitz, “Drug Makers Lobby for Antibiotic Incentives in Pandemic Preparedness Bill,” STAT+, February 27, 2018. ↩

1669. ‘Superbugs’ Kill India’s Babies and Pose an Overseas Threat

By Gardiner Harris, The New York Times, December 3, 2014

NDM-1 Super Bacteria found in Indian hospitals

AMRAVATI, India — A deadly epidemic that could have global implications is quietly sweeping India, and among its many victims are tens of thousands of newborns dying because once-miraculous cures no longer work.

These infants are born with bacterial infections that are resistant to most known antibiotics, and more than 58,000 died last year as a result, a recent study found. While that is still a fraction of the nearly 800,000 newborns who die annually in India, Indian pediatricians say that the rising toll of resistant infections could soon swamp efforts to improve India’s abysmal infant death rate. Nearly a third of the world’s newborn deaths occur in India.

“Reducing newborn deaths in India is one of the most important public health priorities in the world, and this will require treating an increasing number of neonates who have sepsis and pneumonia,” said Dr. Vinod Paul, chief of pediatrics at the All India Institute of Medical Sciences and the leader of the study. “But if resistant infections keep growing, that progress could slow, stop or even reverse itself. And that would be a disaster for not only India but the entire world.”

In visits to neonatal intensive care wards in five Indian states, doctors reported being overwhelmed by such cases.

“Five years ago, we almost never saw these kinds of infections,” said Dr. Neelam Kler, chairwoman of the department of neonatology at New Delhi’s Sir Ganga Ram Hospital, one of India’s most prestigious private hospitals. “Now, close to 100 percent of the babies referred to us have multidrug resistant infections. It’s scary.”

These babies are part of a disquieting outbreak. A growing chorus of researchers say the evidence is now overwhelming that a significant share of the bacteria present in India — in its water, sewage, animals, soil and even its mothers — are immune to nearly all antibiotics.

Newborns are particularly vulnerable because their immune systems are fragile, leaving little time for doctors to find a drug that works. But everyone is at risk. Uppalapu Shrinivas, one of India’s most famous musicians, died Sept. 19 at age 45 because of an infection that doctors could not cure.

While far from alone in creating antibiotic resistance, India’s resistant infections have already begun to migrate elsewhere.

“India’s dreadful sanitation, uncontrolled use of antibiotics and overcrowding coupled with a complete lack of monitoring the problem has created a tsunami of antibiotic resistance that is reaching just about every country in the world,” said Dr. Timothy R. Walsh, a professor of microbiology at Cardiff University.

Indeed, researchers have already found “superbugs” carrying a genetic code first identified in India — NDM1 (or New Delhi metallo-beta lactamase 1) — around the world, including in France, Japan, Oman and the United States.

Anju Thakur’s daughter, born prematurely a year ago, was one of the epidemic’s victims in Amravati, a city in central India. Doctors assured Ms. Thakur that her daughter, despite weighing just four pounds, would be fine. Her husband gave sweets to neighbors in celebration.

Three days later, Ms. Thakur knew something was wrong. Her daughter’s stomach swelled, her limbs stiffened and her skin thickened — classic signs of a blood infection. As a precaution, doctors had given the baby two powerful antibiotics soon after birth. Doctors switched to other antibiotics and switched again. Nothing worked. Ms. Thakur gave a puja, or prayer, to the goddess Durga, but the baby’s condition worsened. She died, just seven days old.

“We tried everything we could,” said Dr. Swapnil Talvekar, the pediatrician who treated her. Ms. Thakur was inconsolable. “I never thought I’d stop crying,” she said.

A test later revealed that the infection was immune to almost every antibiotic. The child’s rapid death meant the bacteria probably came from her mother, doctors said.

Health officials have warned for decades that overuse of antibiotics — miracle drugs that changed the course of human health in the 20th century — would eventually lead bacteria to evolve in a way that made the drugs useless. In September, the Obama administration announced measures to tackle this problem, which officials termed a threat to national security.

Some studies have found that developing countries have bacterial rates of resistance to antibiotics that are far higher than those in developed nations, with India the global focal point.

Bacteria spread easily in India, experts say, because half of Indians defecate outdoors, and much of the sewage generated by those who do use toilets is untreated. As a result, Indians have among the highest rates of bacterial infections in the world and collectively take more antibiotics, which are sold over the counter here, than any other nationality.

A recent study found that Indian children living in places where people are less likely to use a toilet tend to get diarrhea and be given antibiotics more often than those in places with more toilet use. On Oct. 2, the Indian government began a campaign to clean the country and build toilets, with Prime Minister Narendra Modi publicly sweeping a Delhi neighborhood. But the task is monumental.

“In the absence of better sanitation and hygiene, we are forced to rely heavily on antibiotics to reduce infections,” said Ramanan Laxminarayan, vice president for research and policy at the Public Health Foundation of India. “The result is that we are losing these drugs, and our newborns are already facing the consequences of untreatable sepsis,” or blood infections.

Some health experts and officials here say that these killer bugs are largely confined to hospitals, where heavy use of antibiotics leads to localized colonies.

But India’s top neonatologists suspect the large number of resistant infections in newborns in their first days of life demonstrates that these dangerous bacteria are thriving in communities and even pregnant women’s bodies.

“Our hypothesis is that resistant infections in newborns may be originating from the maternal genital tract and not just the environment,” Dr. Paul said in an interview.

In a continuing study in Delhi at several government-run hospitals that has so far included more than 12,000 high-risk newborns, and was made available to The New York Times, about 70 percent of the babies’ infections were found to be immune to multiple powerful antibiotics, confirming the results of earlier and smaller studies.

Doctors interviewed in hospitals across India said that a large number of the infections they found in newborns were resistant to many antibiotics. Awareness of the problem has begun to grow, with Indian medical associations calling for efforts to reduce unnecessary antibiotic use. But there is keen sensitivity here to any alert to the dangers. A 2010 discovery of a New Delhi “superbug” caused intense controversy because of fears that publicity would threaten India’s profitable medical tourism industry. Government officials have stopped some studies of the problem, Dr. Walsh said.

The effects of antibiotic-resistant bacteria on treating disease in India could be enormous. Tuberculosis is just one example of the challenges doctors face. India has the world’s largest number of cases, and recent studies using the latest genetic tests have shown that as many as 10 percent of untreated patients in places as far apart as Mumbai and Sikkim have resistant infections. These patients are catching resistant bugs at home, not hospitals, making the epidemic very difficult to control, Dr. Soumya Swaminathan, director of the National Institute for Research in Tuberculosis, said in an interview.

“It’s startling and very worrying,” Dr. Swaminathan said. Unless the government makes profound and drastic changes, tuberculosis in India may soon become untreatable, she said.

Although resistant bugs are everywhere here, hospitals have become factories for untreatable “superbugs.” A government program that pays women to have babies in hospitals has in 10 years more than doubled the share of hospital-born babies to 82 percent, but the government did little to increase hospital capacity to deal with the crush. Maternity wards often have two and three women in each bed, allowing infections to spread rapidly.

Besides being desperately crowded, many hospitals are unhygienic, allowing the bugs to flourish. A Unicef survey of 94 district hospitals and health centers in Rajasthan last year found that 70 percent had possibly contaminated water and 78 percent had no soap available at hand-washing sinks, while 67 percent of toilets were unsanitary.

Doctors across India have responded to the sanitation crisis in hospitals by giving antibiotics freely.

In Haryana, for instance, almost every baby born in hospitals in recent years was injected with antibiotics whether they showed signs of illness or not, Dr. Suresh Dalpat, deputy director of child health in the state of Haryana, said in an interview. “Now, with proper training, we are bringing that down.”

All those drugs create resistant bacteria that find their way into hospital sewage, which is mostly dumped untreated into rivers, canals and pits in the surrounding community where pregnant women can become infected.

The most frequent causes of resistant newborn infections in India are bacteria like Klebsiella and Acinetobacter, which are found in untreated human waste. Such bacteria rarely infect newborns in developed nations, said Dr. Paul.

India and other developing nations are by no means alone in threatening the future of antibiotics. Overuse of the drugs in chicken, hog and cattle farms in the United States has led to the rise of resistant strains there, and research has shown that as much as half of antibiotic prescriptions in the United States are unnecessary.

The Centers for Disease Control and Prevention estimated last year that two million people are sickened by resistant bacteria every year in the United States and 23,000 die as a result. But efforts to crack down on inappropriate antibiotic use in the United States and much of Europe have been successful, with prescriptions dropping from 2000 to 2010. That drop was more than offset, however, by growing use in the developing world.

Global sales of antibiotics for human consumption rose 36 percent from 2000 to 2010, with Brazil, Russia, India, China and South Africa accounting for 76 percent of that increase. In India, much of that growth has been driven by private doctors who deliver about 90 percent of care here and are often poorly trained. Much of these doctors’ income comes from drug sales.

Just as worrisome has been the rapid growth of India’s industrialized animal husbandry, where antibiotics are widespread. Most large chicken farms here use feed laced with antibiotics banned for use in animals in the United States. A New Delhi science group recently found antibiotic residues in 40 percent of chicken samples tested.

But the effects in children are perhaps the most heart-wrenching. After her baby’s death a year ago, Ms. Thakur, 21, was soon pregnant again. She gave birth on Sept. 21 to a baby girl. On a visit shortly after the baby’s birth, Ms. Thakur was shivering from a severe infection while staying in a home with no toilet or running water. She nursed her tiny infant, Khushi, under a small shrine with pictures of Durga and Krishna.

Nearly two months later, she reported that she and the baby were fine.