I’ve never been terribly good at philosophy but I’m going to have a go, because this is a conversation that we need to have, especially as we see the re-emergence of measles. This post has been inspired by a fascinating opinion piece in the Lancet Microbe called “Embracing the monsters: moving from infection control to microbial management”. I think the ideas are crystallised into something like this: it’s futile to aim for “pathogen eradication” – “microbial management” is a better approach to juggling our resources to get to the best overall population health outcomes.

This idea of “pathogen eradication” is perhaps best illustrated by the now-infamous pronouncement of the US Surgeon General General William H. Stewart at a conference in 1969 that it was time to “close the book on infectious diseases” and to “shift national resources to such chronic disease problems as cancer and heart disease”. There were a couple of good reasons for this wave of optimism that William Stewart reflected. The ‘golden age’ of antibiotics was in full swing, with a very healthy and productive new antibiotic pipeline. For every new resistance mechanism, there was seemingly a rapidly available solution. Also, smallpox was moving towards global eradication, and antivax sentiments didn’t really become an established movement until the 1970s or 80s, so population levels of immunity to infectious diseases seemed to be rising inexorably. So, at the time, he had a point!

But now, looking back, both the statement and the sentiment seem laughable. Especially as we exit the COVID-19 pandemic, with the trail of destruction in its wake.

It’s worth a discussion about our prevention strategy for antibiotic-resistant bacteria. It is now clear that we can’t “eliminate” antibiotic-resistant bacteria. It’s not an issue that we will ever be able to “close the book on”. Antibiotic-resistant bacteria are co-evolving with us and so rather than trying to eliminate them (much as we’d like to), “microbial management” is the way to go. Sure, there will be some scenarios where antibiotic-resistance can be reversed, and we must not lose hope that our actions can make a real difference. But our future will include managing antibiotic-resistant infections.

Our approach to preventing the spread of SARS-CoV-2 is perhaps another example of this principle in action. SARS-CoV-2 isn’t a virus that we can eliminate. It is now endemic in the human population and so our role is to find the best management of our resources to mitigate impact and prevent harms. For me, this includes the uncomfortable concept of not implementing maximal protection against SARS-CoV-2 infection due to conflicting priorities (especially access to healthcare) – as we have done for decades with other pathogens.

Another example of microbial management is our developing understating of curation of the human microbiome to reduce disease and optimise health. The impact of faecal microbiota transplantation in reducing the risk of recurrent Cdiff infection is nothing short of spectacular. And this is just the start of what we can do to take care of the microbiome to reduce the risk of infection and improve health.

Perhaps an exception to this idea of “microbial management” set against “pathogen eradication” is vaccine preventable infectious diseases. Here, I think we really can aspire towards pathogen eradication. And the desperately sad re-emergence of measles is the latest example where slippage in population immunity levels due to reduced vaccination update cause real clinical issues.

Generally speaking, I think the idea of “microbial management” is a helpful lens through which to view infection prevention and control, and is a concept that can be adapted to range of existing and emerging microbial threats (in a way that “pathogen eradication” can’t).