Pediatric practice tests to delabel patients with mislabeled antibiotic allergy

Thursday, Dec 14, 2023 5:00 AM Updated Thursday, Dec. 14, 2023 11:29 AM

About 10% of people are said to be allergic to penicillin; the real number is closer to 1%

Amanda Harrison, a nurse and practice administrator at Pediatric Partners of the Southwest, collects vitals information from Gabriel Lucero, 11, while his brother Luciano Lucero, 8, looks on. The two brothers were both tested for an amoxicillin allergy as a part of the practice’s “delabelling clinic.” (Reuben M. Schafir/Durango Herald)

Reuben M. Schafir

The first time two of Taylor Lucero’s children were prescribed amoxicillin, they developed bad rashes.

“It was horrible,” she said.

Luciano Lucero, 8, and his older brother Gabriel, 11, are two of an estimated 5 million children in America who are labeled as allergic to penicillin, a family of antibiotics that includes amoxicillin.

About 10% of Americans are labeled as allergic to the antibiotics because of reactions, typically rashes first reported by parents, after taking amoxicillin. But a growing body of work indicates that the true number of allergic patients could be quite smaller.

Amoxicillin is the antibiotic that Dr. Kelly Miller prescribes the most, she said, because it is effective and inexpensive.

“Most of the time, the rash is more from the virus than it probably was from the amoxicillin,” she explained to the Luceros on Monday at the Pediatric Partners of the Southwest clinic.

Although antibiotics do not treat viral infections, they are sometimes prescribed in response some viruses to treat underlying bacterial infections.

Luciano “Lucky” Lucero, 8, takes a dose of amoxicillin as a part of the Pediatric Partners of the Southwest’s “delabelling clinic.” (Reuben M. Schafir/Durango Herald)

Reuben M. Schafir

On Monday, Taylor Lucero took her two boys out of school and brought them to the clinic, where they were given a single dose of amoxicillin. Then, they sat in room, watched “The Grinch” and waited.

“You’re going to hang out here for an hour … I’ll come look at you in 15 minutes. We’ll do another set of vitals after the hour and then hopefully it’s all well and we say, ‘You’re not allergic anymore,’” Miller told the family. “The next time either of them needs amoxicillin for anything – strep throat, sinus infection, whatever – we’ll have them get it for real, not just the one dose.”

The test is what physicians call a drug challenge. And PPSW is hosting a series of clinics for current patients to take the challenge in an effort to delabel patients who have an incorrectly assigned penicillin allergy.

“The overlabeling of antibiotic allergy is a liability that leads to unnecessary long-term health care risks, costs and antibiotic resistance,” one recent study on the matter said.

The Lucero brothers are among about 300 PPSW patients who qualify as “low risk,” meaning their previous reaction took place more than 24 hours after starting the antibiotic regime and they reacted only with either a rash, hives or gastrointestinal symptoms.

Although patients who had swelling, anaphylaxis or immediate reactions don’t qualify for the challenge, doctors still have Benadryl and epinephrine ready just in case a patient does have a severe reaction.

Gabriel Lucero, 11, downs a dose of amoxicillin before staff members at Pediatric Partners of the Southwest monitored him over an hour for an allergic reaction as a part of the clinic’s “de-labelling clinic.” (Reuben M. Schafir/Durango Herald)

Reuben M. Schafir

The next clinic will take place Jan. 10, and the practice expects to hold them quarterly going forward. Although it is only for patients of the practice, Miller said anyone questioning their allergy could consider talking to their physician or an allergist about getting tested.

Of the 10% of people who are labeled as having a penicillin allergy, physicians estimate the actual number with an allergy is closer to 1%.

As it turned out, Luciano and Gabriel Lucero were in the 9% of patients incorrectly labeled with an allergy. They left the clinic after an hour without any reaction and an updated medical file.

rschafir@durangoherald.com

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China Quietly Rebuilds Secretive Base for Nuclear Tests

In the remote desert where China detonated its first atom bomb nearly 60 years ago, a drilling rig recently bored a deep vertical shaft that is estimated to plunge down at least a third of a mile. It is the strongest evidence yet that Beijing is weighing whether to test a new generation of nuclear arms that could increase the lethality of its rapidly expanding missile force.

A large drill rig hidden in the eastern hills of the Lop Nur site.

The New York Times; satellite image by Maxar

For years, U.S. government reports and independent experts have expressed vague concerns about the old base, Lop Nur. The reports point to possible preparations for year-round operations and a “lack of transparency.”

Now, however, waves of satellite images reveal that the military base has newly drilled boreholes — ideal for bottling up firestorms of deadly radiation from large nuclear blasts — as well as hundreds of other upgrades and expansions.

“All the evidence points to China making preparations that would let it resume nuclear tests,” said Tong Zhao, a nuclear expert at the Carnegie Endowment for International Peace.

Siegfried S. Hecker, a former director of the Los Alamos weapons laboratory in New Mexico, described Lop Nur’s rebuilding as unusual. “The Russians and Americans have continued activity at their test sites,” he said, “but nothing like this.”

Analysts say the activity at Lop Nur signals a wide modernization of China’s nuclear establishment, warning that it could speed arms buildups and spark a new age of atomic rivalry.

They add that China’s moves, along with those of other nuclear powers, could undermine the global test ban that began in 1996. The world’s atomic powers signed it after the Cold War as a way to curb a costly nuclear arms race that was spinning out of control.

The new evidence at Lop Nur was uncovered by Renny Babiarz, a former analyst at the National Geospatial-Intelligence Agency, an arm of the Pentagon. An expert on satellite reconnaissance as well as Beijing’s nuclear program, Dr. Babiarz says that detonations in the deep shafts could accelerate an effort to perfect new types of nuclear arms for the country’s fast-growing arsenal. Independent experts who have examined the satellite imagery and Dr. Babiarz’s analyses share his concerns.

The activity at Lop Nor comes at one of the most sensitive moments in U.S.-China relations. President Biden has said he’s trying to “stabilize” an increasingly contentious relationship and, at a summit meeting last month with Xi Jinping, China’s leader, sought a measure of accord.

American intelligence officials say they’ve followed Lop Nur’s revival for years. While the construction is obvious, they say, its purpose is not. China could be preparing for a nuclear test, they concede. But they add that Mr. Xi may not intend to move ahead unless the United States or Russia go first. The officials say Mr. Xi could be hedging his bets, drilling the deep vertical shafts so that, if necessary, China can act quickly.

On Monday, the Foreign Ministry in Beijing responded to questions about upgrades at Lop Nur, dismissing them in a statement as “clutching at shadows, groundlessly whipping up a ‘China nuclear threat.’” It called such claims “utterly irresponsible.”

The ministry also emphasized Beijing’s commitment to observing the nuclear test ban — a position, it added, that “has won high praise from the international community.” China, it said, will spare “no effort to realize the noble aspiration of comprehensively banning and totally eradicating nuclear weapons.”

Dr. Babiarz, the former intelligence analyst, wrote his doctoral thesis on the roots of China’s nuclear program. He now runs the operational arm of a company that analyzes civilian satellite imagery, teaches a course on geospatial analysis at Johns Hopkins University and recently co-wrote a textbook on the interpretation of satellite images.

Renny Babiarz at his home in Vermont.

John Tully for The New York Times

Since leaving government service, Dr. Babiarz has spent much time analyzing images of Lop Nur. In assessing the base, he has looked at not only the most up-to-date imagery but earlier views that provide a visual history of the site’s development.

In a report this year, he documented a new test area covering roughly 10 square miles. The barren site possesses deep boreholes, Dr. Babiarz said, as well as new roads, power lines, an electrical substation and a support area with multiple buildings.

A probable new underground test area in the eastern part of Lop Nur.

The New York Times; satellite image by Maxar

“The overall indications are that they’re preparing to test,” he said in an interview.

Lop Nur is a sprawling military base, roughly the land mass of Virginia, in the arid Xinjiang region of China’s far west. Chinese accounts say the area was chosen for nuclear tests because it was so barren and isolated, without any permanent residents. But the broader Xinjiang region is home to the Uyghurs, a largely Muslim ethnic group that has recently endured mass detentions and pervasive security controls.

The Uyghurs have long protested health threats from nuclear tests at the site, which began in 1964 after Mao decided to build the bomb. The early tests were capped by mushroom clouds and radioactive fallout. China conducted its first underground nuclear test in 1969.

At first, Beijing used shallow horizontal tunnels. It was a relative latecomer to drilling vertical shafts that were deep enough to reliably contain the deadly radiation, especially for large blasts. Its first such shaft test occurred in 1978.

Mao famously disparaged the bomb as a “paper tiger.” China thus built a nuclear arsenal smaller than the combined atomic forces of France and the United Kingdom. After the Cold War, the Lop Nur test site ended its large blasts and became a relative backwater.

That began to change after 2012, when Mr. Xi came to power. The Chinese leader saw the Rocket Force, which he created in late 2015, as one of his glories. The elite organization, the custodian of China’s nuclear weapons, embodied Mr. Xi’s ambitions to elevate his country as a respected, and feared, great power ready to stand up to the United States.

Mr. Xi’s political rise, it turns out, coincided with Lop Nur’s rebirth. The secretive activity was publicly disclosed by means of a new kind of open surveillance.

The most powerful civilian imaging satellites that orbit the Earth can distinguish objects on the ground as small as a foot in diameter. From hundreds of miles up, the spacecraft and their telescopes can discern people, types of vehicles and even aircraft tail numbers, analysts say.

Dr. Babiarz’s analyses of civilian imagery over several years tell the story of Lop Nur’s upgrades. By 2017, an old site with a handful of buildings had turned into a slick, ultramodern complex ringed by security fences. Its new structures included a bunker protected by earthen berms and lightning arresters, making it ideal for handling high explosives.

A high-security facility at Lop Nur, possibly for explosive storage or nuclear device preparation.

The New York Times; satellite image by Maxar

The site was suspicious but ambiguous. Nuclear arms use conventional explosives to start their chain reactions. But so do subcritical tests — lesser experiments that a global test ban treaty allows. Conservatively, Dr. Babiarz called the complex a possible site for the preparation of atomic devices.

By 2018, the next big project at Lop Nur was the rapid expansion of a giant air base whose main runway was three miles long. Satellite images showed a dozen large buildings under construction.

Taklamakan air base, near the southern edge of the Lop Nur site.

The New York Times; satellite image by Maxar

In parallel, the Trump administration declared in 2018 that “the United States must remain ready to resume nuclear testing.” In 2019, the Chinese Foreign Ministry criticized the U.S. as undermining not only the test ban but “global strategic security and stability.”

Even so, senior Trump officials in May 2020 discussed the merits of an atomic restart. News of the meeting leaked. Soon after, Republicans on the Senate Armed Services Committee approved spending $10 million to reduce the time it would take to conduct an atomic test.

Amid the heightened tensions, Dr. Babiarz discovered that China had begun to revamp and expand Lop Nur’s test zones — initially, its horizontal tunnels. Fairly close to the surface, they had shaken with modest test explosions during the Cold War. A 2020 satellite image showed a main tunnel undergoing extensive new digging and construction, its entrance surrounded by trucks, bulldozers and piles of excavated dirt.

Recent excavation and construction in one of the horizontal tunnels at Lop Nur. This area was previously used for relatively small nuclear tests.

The New York Times; satellite images by Maxar

Like the high-security site, however, the tunnels were ambiguous. Their rocky depths could be used to bottle up blasts from small atom bombs or large subcritical tests.

Then, unexpectedly, the clues turned more troubling. Early in 2021, Dr. Babiarz was examining new Lop Nur imagery when he noticed large pieces of road-making equipment: a grader and a front-end loader.

“They were out in the middle of nowhere,” he recalled.

Dr. Babiarz noticed road-making equipment and a new road leading to a concealed drill rig.

The New York Times; satellite image by Maxar

Dr. Babiarz followed the new road. Over a dozen miles, it led from a flat zone used decades ago for vertical shaft detonations to a hilly region undergoing fast development.

In a labyrinth of canyons he found, to his surprise, a large drilling rig being set up. It was almost 90 feet tall. That was July 2021. Next month, he obtained a new image showing not only the derrick but a stack of drill pipes and an adjacent pit of lubricating fluid for keeping the drill bit moving ever deeper. From the clues, Dr. Babiarz estimated that the borehole was meant to go down at least a third of a mile.

A large drill rig hidden in the eastern hills of the Lop Nur site.

The New York Times; satellite image by Maxar

In comparison, the maximum depth of a vertical shaft at the U.S. government’s Nevada test site is 2,500 feet, or about a half mile. So the estimated depth of China’s borehole appears to fall within the American range.

Unlike Lop Nur’s flat areas, the new zone’s rugged terrain provided good concealment for large gear. Despite this, Dr. Babiarz found a second drill site last year. It “was tucked deeper into the hilly terrain,” he said, and the rig’s support gear had been meticulously covered.

A second drill site hidden in the eastern hills of the Lop Nur site.

The New York Times; satellite image by Maxar

To atomic experts, the deep holes seemed to have been designed to contain large nuclear tests. “We never did subcritical tests in vertical shafts,” said Patrick Rowe, a former director of drilling operations at the Nevada test site. “It didn’t make sense because drilling the holes was so expensive.”

The surprise discovery of the drill rigs prompted Dr. Babiarz to look wider. Recently, he zeroed in on a sprawling support base. By examining its historical imagery, he found that more than 30 of its buildings were major renovations or new construction.

More than 30 buildings at the Malan support base have been renovated or added since 2017.

The New York Times; satellite image by Planet Labs

Unexpectedly, he also found what appeared to be a training site for the shaft drillers. The biggest rig seemed similar to the tall one he had observed a hundred miles away in the new test zone.

Drill rigs of different sizes, probably used for training, at the support base.

The New York Times; satellite image by Maxar

“The bottom line is that it’s quite active,” Dr. Babiarz said of the military base.

Nuclear experts say they see no signs of an imminent Chinese test and argue that Beijing may do nothing. The rebuilding of the military base could simply be a warning to the West, they say. Chinese experts have suggested as much.

Xi Jinping, center, replaced the Rocket Force’s top leaders in July 2023.

Li Gang/Xinhua

Whether China conducts a nuclear test might also depend on what its rivals do. Signals sent recently by Russia and earlier by American administrations may worry Beijing.

Richard L. Garwin, a prominent nuclear physicist who has often visited China and met with its top scientists, said Lop Nur’s rebuilding represents a technological hedge. “They don’t want to be caught flat-footed in case somebody else goes first,” he said.

Dr. Zhao of the Carnegie Endowment agreed: “China feels it needs to prepare for the worst-case scenario.”

Stephen M. Younger, a former director of Sandia National Laboratories, said it was not inconceivable that China would unilaterally conduct a test to make a statement.

Some analysts argue that China may not be planning large blasts but instead ramping up its program of subcritical experiments, which stop short of producing self-sustaining chain reactions. Both Russia and the United States use them to assess their existing arms.

Other analysts disagree, arguing that China’s fleets of new bombers, submarines and missile silos herald a push for new armaments.

China could field 1,500 nuclear warheads by 2035 at its current pace of force expansion, the Pentagon has projected. That figure would be a fivefold increase from the “minimum deterrent” that China possessed for more than half a century.

American experts say Chinese scientists are now planning the particular arms they see as best suited for that buildup and may learn much from test explosions — unlike Moscow and Washington, which detonated far more blasts during the Cold War.

“I know they believe they’re behind,” said Terry C. Wallace, a former Los Alamos director who has long studied China’s program of nuclear experimentation. “They may feel that they’re so far behind in testing knowledge that they want to do something exotic.”

Nuclear testing allows scientists to uncover flaws and fine-tune new weapon designs. During the Cold War, China conducted 45 test explosions. In comparison, France set off 210, Russia 715 and the United States 1,030.

The test ban treaty, though signed by 187 nations, never entered into force because China, the United States and six other nations failed to ratify it. Even so, analysts have long argued that it favors Washington because it bars pact-abiding rivals from making their nuclear arms more advanced.

What China wants most, experts say, is miniaturization. With new, more accurate missiles that pinpoint targets, its scientists can reduce the power, size and cost of warheads.

“They have perfectly serviceable nuclear weapons,” said Dr. Garwin, who is credited with designing the world’s first hydrogen bomb. “But they might want to make them smaller.”

Experts say miniaturization could make China’s submarine missiles far more deadly. They’re judged to be carrying up to three warheads each. In contrast, the main American submarine missile, the Trident II, carries up to eight.

Miniaturization could also aid China’s development of hypersonic warheads that would zig and zag to evade U.S. defenses. According to the Pentagon, Beijing wants to give the weapons a nuclear edge.

This fall, global civil society leaders warned of “growing threats” to the test ban and suggested ways to reinforce the taboo against experimental blasts.

While Chinese officials are quick to deny any testing plans, they’re even faster to criticize Washington.

“If you truly care” about the test ban, the Foreign Ministry said in its statement, “you should pay serious attention to the position of the United States.” For instance, Chinese experts accuse Washington of a double standard in backing the global ban while seeking technologies that can sidestep its prohibitions.

Last year, American scientists announced a fusion breakthrough that was hailed as a step toward abundant clean energy. The next day, Global Times, China’s nationalistic Communist Party tabloid, highlighted a little-known fact about the giant laser: Its main job is to advance nuclear arms development.

Of late, China has pointed to the W93 — the first new American nuclear warhead since the Cold War, now in development — as an example of U.S. nuclear strides. The military says the innovative weapon will require no test detonations.

Even so, Chinese experts cast the threat of test resumption as coming from the United States. In September, the military affairs channel of China’s state television network ran a program in which Teng Jianqun, a former military officer, said Washington was “trying to break through the restrictions.”

American experts, in contrast, cast Lop Nur’s modernization as a sign of just how far the Chinese may be willing to go.

“We have to realize that they had a conservative posture,” said Dr. Wallace, the former Los Alamos director. “That’s changing.”