infectious diseases

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Ebola Tipping Point? Dispelling Myths And, Possibly, Less Hysteria Over Virus

A World Health Organization worker trains nurses on how to use Ebola protective gear in Freetown, Sierra Leone. (AP)

A World Health Organization worker trains nurses on how to use Ebola protective gear in Freetown, Sierra Leone. (AP)

Has the national hysteria over Ebola peaked? Who knows. Maybe. There seem to be fewer front page headlines screaming about it; a new national poll finds most Americans are “positive” about the response by public health authorities; and today’s news is that more than 40 Dallas residents (all who had been in contact with the Liberian man who died of Ebola) were declared virus-free.

Still, education is the antidote to hysteria, so it’s worth reiterating some of the facts. Many of them can be found in this must-read commentary in the London Review of Books by Paul Farmer, the rock star Harvard infectious disease doctor and leading advocate for global health equity in the world’s most impoverished regions. Farmer, who is also a co-founder of the Boston non-profit Partners in Health, writes that despite some of the truly scary aspects of the virus, an Ebola diagnosis is not necessarily a death sentence:

The Ebola virus is terrifying because it infects most of those who care for the afflicted and kills most of those who fall ill: at least, that’s the received wisdom. But it isn’t clear that the received wisdom is right….

…the fact is that weak health systems, not unprecedented virulence or a previously unknown mode of transmission, are to blame for Ebola’s rapid spread. Weak health systems are also to blame for the high case-fatality rates in the current pandemic, which is caused by the Zaire strain of the virus. The obverse of this fact – and it is a fact – is the welcome news that the spread of the disease can be stopped by linking better infection control (to protect the uninfected) to improved clinical care (to save the afflicted). An Ebola diagnosis need not be a death sentence. Here’s my assertion as an infectious disease specialist: if patients are promptly diagnosed and receive aggressive supportive care – including fluid resuscitation, electrolyte replacement and blood products – the great majority, as many as 90 per cent, should survive.

And he adds this:

I’ve been asked more than once what the formula for effective action against Ebola might be. It’s often those reluctant to invest in a comprehensive model of prevention and care for the poor who ask for ready-made solutions. What’s the ‘model’ or the ‘minimum basic package’? What are the ‘metrics’ to evaluate ‘cost-effectiveness’? The desire for simple solutions and for proof of a high ‘return on investment’ will be encountered by anyone aiming to deliver comprehensive services (which will necessarily include both prevention and care, all too often pitted against each other) to the poor. Anyone whose metrics or proof are judged wanting is likely to receive a cool reception, even though the Ebola crisis should serve as an object lesson and rebuke to those who tolerate anaemic state funding of, or even cutbacks in, public health and healthcare delivery. Without staff, stuff, space and systems, nothing can be done.

If you want to become more educated on Ebola and find out what you can do to support the global effort, Partners In Health/Engage and Harvard are sponsoring an Ebola teach-in Wednesday night in Cambridge with a panel of practitioners and public health experts. Continue reading

Opinion: Why America’s Ebola Fears Are Dangerously Misplaced

Cpl. Zachary Wicker demonstrated the use of a germ-protective gear in Fort Bliss, Texas on Tuesday. (Juan Carlos Llorca/AP)

Cpl. Zachary Wicker demonstrated the use of a germ-protective gear in Fort Bliss, Texas on Tuesday. (Juan Carlos Llorca/AP)

By Richard Knox

At the memorial service last weekend for the only person to have died of Ebola on American soil, the Liberian clergyman who eulogized his countryman Thomas Eric Duncan posed a question we all should be thinking hard about right now.

“Where did Ebola come from to destroy people — to set behind people who were already behind?” Methodist Bishop Arthur F. Kulah wondered.

Here’s the reality: Until the world (and especially the United States of America) refocus on the “people who were already behind” in this battle of virus-versus-humanity, no one can rest easy.

Ebola is an animal virus that has sporadically caused local human outbreaks in Africa for at least 38 years. But now it has crossed into people who live in densely populated African nations with barely functioning health systems and daily jet connections to the rest of the planet.

“It’s like you’re in your room and the house is on fire, and your approach is to put wet towels under the door.”
– World Bank chief Jim Yong Kim

This is entirely predictable, as scientists who watch emerging diseases have long known. They just didn’t know which virus would be the next to terrorize the world. (SARS and HIV showed how it can happen, remember?)

Those of us who, like me, report on global public health have a sense of inevitability as we watch the Ebola crisis unfold. We always knew it would mostly affect, as Bishop Kulah so aptly puts it, “people who were already behind.”

And we knew the people least affected by this scourge — privileged denizens of wealthier countries — would overreact out of misplaced fear for themselves, rather than a reasoned and compassionate understanding about what needs to be done.

So we see the freaked-out, wall-to-wall, feedback-loop media coverage we’re experiencing now. Schools closing down in Ohio for completely unnecessary disinfection. Recriminations against hapless health workers who suddenly find themselves dealing with an exotic new threat. Continue reading

Enterovirus D68: Good News, Bad News, What To Do

(CDC)

(CDC)

Pick your viral anxiety: Do you want to focus your media-fueled jitters on Ebola or on enterovirus D68?

Personally, even with today’s news of the first U.S. death from Ebola, I pick the enterovirus every time. For one thing, it’s actually around; it’s not a single case in Texas. But I’d prefer no anxiety at all, and the best antidote tends to be knowledge. So here are some data points:

The Massachusetts Department of Public Health fact sheet on enterovirus D68 is here and the CDC’s here. At a news conference last week, Dr. Alfred DeMaria, the department’s medical director for the Bureau of Infectious Disease, told reporters that enterovirus D68 had probably been “the predominant cause of respiratory illness over the last four weeks.”

Mostly, that meant colds, he said, and he thinks he even had the bug himself. But reports of lung ailments have “decreased significantly over the past couple of weeks,” he said, so “enterovirus 68 seems to be going away.”

Let’s hope. But what the heck? Here & Now reports that the enterovirus has been connected to five deaths nationwide, most recently of a 4-year-old in New Jersey. Of course, we know that viruses can sometimes lead to deaths by unleashing bacterial infections; flu has been known to kill dozens of American children in a bad year. But still, what to make of all the coverage of this unfamiliar virus?

I asked Dr. Ben Kruskal, chief of infectious diseases at Harvard Vanguard Medical Associates. My takeaway: Yes, this is quite a bit like flu, only it’s drawing attention because it’s a virus that’s acting atypically, surprisingly. Our conversation, edited:

There are so many viruses around; why are we even hearing about this one and what should we make of the coverage?

We’re hearing about it because it is not just a strain of a virus we don’t see very often but because it’s causing unusual manifestations, and manifestations that have enough impact for us to pay attention to. It’s actually in 30 or 40 states now, and we don’t really know how widespread it is because it’s clinically not terribly distinctive. It’s a respiratory virus that looks like a lot of other respiratory viruses, including the flu and the cold viruses and a whole bunch of others. And the reason we’re paying attention is not just the fact that it’s an unusual strain — then it would be a sort of laboratory curiosity — but because it’s actually on a more severe end of the spectrum for some people.

So it’s been confirmed that it’s here in Massachusetts, and it sounds like we have had more kids being hospitalized for respiratory trouble than usual in recent weeks, right? For example, Tufts Medical Center tells us that they’ve had 54 hospital admissions of kids with repiratory problems this year, compared to 27 admissions by this date last year, and they’re tending to stay in longer and need more treatment.

I understand from Dan Slater, who’s the director of pediatrics here at Harvard Vanguard, that we went months without having to admit any kids with asthma to the hospital, and in the last few weeks we’ve had quite a few admissions.

So what’s your public health message then at this point? What do you say to parents?

It’s reasonable to think of this outbreak in most respects as being like a sort of a nastier flu season. The timing is different from the flu season but in terms of how it manifests itself, it’s pretty similar to a severe flu. Remember that the flu and this virus — like any infectious agent — have a spectrum of severity. So even though this one is on average more severe, there are still lots of people who will get just a regular old cold. And there are some people who will get kind of a nasty cold. And there are some people who will get more severe things, including asthma-like illness in people who don’t have pre-existing asthma or an exacerbation of underlying asthma in people who do.

So are there telltale symptoms to watch for? Continue reading

CDC: Record-Breaking Year For Measles Due To Travel, Non-Vaccinated Residents

Back of female with measles/ Wellcome Library, London. Wellcome Images/flickr

Back of female with measles/ Wellcome Library, London. Wellcome Images/flickr

Measles, one of the most contagious diseases in the world, was officially eliminated from the U.S. in the year 2000.

Nevertheless, we’re in the midst of a record-breaking year for measles in this country, according to a new report from the Centers for Disease Control and Prevention, with 288 confirmed cases so far.

There are two main reasons for the spike, said Anne Schuchat, M.D. (RADM, USPHS) assistant surgeon general, United States Public Health Service and director of the CDC’s National Center for Immunization and Respiratory Diseases, speaking at a telebriefing for reporters today.

First, she said, travelers are importing measles into the U.S. from other parts of the world, including Europe, Asia, Africa and the Pacific, notably the Philippines, which has been experiencing a large measles outbreak. In addition, Schuchat said, the imported measles is spreading within communities of non-vaccinated people.

CDC: It's a record-breaking year for measles

CDC: It’s a record-breaking year for measles

From the agency’s weekly Morbidity and Mortality Report:

Most of the 288 measles cases reported this year have been in persons who were unvaccinated (69%) or who had an unknown vaccination status (20%); 30 (10%) were in persons who were vaccinated. Among the 195 U.S. residents who had measles and were unvaccinated, 165 (85%) declined vaccination because of religious, philosophical, or personal objections, 11 (6%) were missed opportunities for vaccination, and 10 (5%) were too young to receive vaccination.

When asked if the non-vaccinated U.S. residents who contracted measles had declined shots due to widely discredited information linking autism to the MMR vaccine, Schuchat said no, public health officials don’t believe that to be true.

Her bottom line message was clear, however: “This year we are breaking records for measles,” Schuchat said. “And it’s a wake up call. Measles may be forgotten but it’s not gone.” Continue reading

NIMBY Disease: Yes, U.S. Residents, You’re Vulnerable To Parasites Too

Photo by CDC/Jim Gathany: An adult triatomine, or kissing bug, with eggs. Triatomines transmit the parasite that causes Chagas disease.

Photo by CDC/Jim Gathany: An adult triatomine, or kissing bug, with eggs. Triatomines transmit the parasite that causes Chagas disease.

Just in time for outdoor-frolicking season, yet another thing to worry about: parasitic disease.

You may think this topic should be filed under: “no cause for concern;” indeed many people believe that illnesses transmitted by parasites are primarily a problem of the developing world, something you might pick up on an exotic trip, but never here at home.

Think again, says the CDC.

In a special supplement to the American Journal of Tropical Medicine and Hygiene, CDC scientists offer abundant detail on the health dangers of parasites.

Here’s the news release from the public health agency:

…parasitic infections also occur in the United States, and in some cases affect millions of people. Often they can go unnoticed, with few symptoms. But many times the infections cause serious illnesses, including seizures, blindness, pregnancy complications, heart failure, and even death. Anyone—regardless of race or economic status—can become infected.

CDC has targeted five neglected parasitic infections (NPIs) in the United States as priorities for public health action based on the numbers of people infected, the severity of the illnesses, or our ability to prevent and treat them. These NPIs include Chagas disease, cysticercosis, toxocariasis, toxoplasmosis, and trichomoniasis.

Parasitic infections affect millions around the world causing seizures, blindness, infertility, heart failure, and even death,” said CDC Director Tom Frieden, M.D., M.P.H. “They’re more common in the US than people realize and yet there is so much we don’t know about them. We need research to learn more about these infections and action to better prevent and treat them.” Continue reading

Opting-Out Of Vaccines; Dipping Below Herd Immunity

Graphic Credit: Jan Willem Tulp http://tulpinteractive.com

Graphic Credit: Jan Willem Tulp http://tulpinteractive.com

With more and more families opting out of vaccinating their kids, one of the most sacred of public health goals, the concept of herd immunity, is being threatened.

A recent piece in Scientific American featured tantalizing graphics — on view above — illustrating this scary trend.  According to this analysis, the vaccination rates in some states — Oregon, West Virginia and Colorado, for instance, are shockingly low. So low, in fact, that they’ve dropped below the “herd immunity” levels (or what is thought to be the safe threshold) for MMR (measles, mumps and rubella) and DTP (diphtheria, tetanus and pertussis).

So what’s the deal with herd immunity?  According to the CDC, a population has reached herd immunity when a sufficient proportion is immune to a particular infectious disease.  Immune population members get that protection either by being vaccinated or by having a prior infection.

The epidemiological concept is based on this logic: Continue reading

As Of Today In Mass., You Can Just Say Yes To The HIV Test

Dr. Paul Sax (Courtesy of BWH)

As of today in Massachusetts, you can get an HIV test without having to sign a written consent form. That means you can also skip that potentially embarrassing walk down to the lab to hand over your consent paperwork. You can just say yes.

Massachusetts is a leader in HIV care and research, but it is the last — yes, the very last — state to switch from written to verbal consent for HIV tests, said Dr. Paul Sax, clinical director of the Infectious Disease Department at Brigham and Women’s Hospital.

In other states that switched to verbal consent, experience has borne out the rationale for making HIV testing easier, he said: More people get tested, so more people know their HIV status, and those who find out they’re positive can get treatment and avoid spreading the virus to others.

How will the new Massachusetts law play out in the clinic? Dr. Sax says that typically, a medical staffer recommends an HIV test to a patient — “For example, you could say, ‘The CDC recommends everyone in the US get at least one HIV test, so I recommend you get one.'” Then the clinician should ask if the patient has any questions about accuracy or other implications of the test. If the patient says yes to the test, that should be noted in the medical record.

(Speaking of the CDC, how cool is this little tool? They have the public-health equivalent of a storefinder: You type in your zipcode and it gives you the addresses of clinics where you can get tested for HIV and other sexually transmitted diseases in your area. It’s here.)

Why is Massachusetts so late on this when we’re normally out front on public health? Dr. Sax theorizes that the existing law also included privacy protections that no one wanted to lose. Testing and privacy were “very entangled, and it was very hard to change one without changing the other.” All previous privacy protections have in fact been preserved.

Why Not To Demand Antibiotics For Your Post-Christmas Crud


You drag into your doctor’s office for help after a week of a ruthless, chest-ripping cough. “Doc, I think it’s lung cancer,” you say.

“Okay,” your doctor says. “I’ll write you out a prescription for the chemo drug methotrexate.”

Not exactly a realistic scenario, is it? So then why, when you’ve got garden-variety winter phlegm, might you push your doctor to do your bidding and write you an order for antibiotics?

That’s a point paraphrased from a recent talk by Dr. John Powers, a physician and researcher at the George Washington University School of Medicine, and formerly the lead medical officer for antimicrobial drug development and resistance initiatives at the FDA.

I share it now because it’s the season of bugs and crud, and chances are you’ve been kissing and hugging a lot of people who were sharing their germs along with their cheer. That means you may soon be tempted to demand a nice little course of a “-cillin” or a “-mycin” from your doctor — but hold on a minute:

Antibiotics remain tremendously valuable treatments when prescribed appropriately for bacterial infections, but the reasons to avoid using them unnecessarily have been multiplying of late, and the information below might tip you a bit toward restraint.

‘Up to about 10% of antibiotic prescriptions can cause some adverse effects.’

Personally, I just got over a cough so violent that each spasm threw me backward like the recoil of a rifle. Friends told me to get a lung X-ray and to ask for antibiotics, but under the influence of Dr. Powers and others like him, I decided to just wait and see. The message had finally started to penetrate that if an upper respiratory infection is likely to be a virus — and yes, my children had just been through one — time might be the best cure. (It was.)

No question, antibiotics can work wonders. But they’re also hugely over-used, particularly for coughs. A study last month in the journal “Pediatrics” found that American pediatricians order unnecessary antibiotics at least 10 million times a year, for conditions the drugs do not affect such as asthma and flu.

Health authorities say that what doctors and patients alike need to aim for is the sweet spot known as “judicious use” of antibiotics. But where is it? And how do we get there when we tend to focus on the wonder-drug aspects of antibiotics rather than the downsides?

I asked Dr. Ben Kruskal, director of infection control at Harvard Vanguard Medical Associates and director of infectious disease at Atrius Health, who has worked on “judicious use” campaigns both within Harvard Vanguard and as part of a statewide project. (The CDC works on the issue at the federal level; its”Get Smart” materials are here.) Continue reading

Radio Boston Today: Equalizing Hospital Rates, And ‘Pox’ History


Tune in to Radio Boston at 3 today for a health coverage bonanza:

Meeting in the middle:
Doctors and hospitals in Massachusetts charge vastly different rates for the same services—that’s the big finding of a recent Patrick administration report. But buried within that report was another finding: the state could save hundreds of millions of dollars a year if all health care providers met in the middle and charged the median rate for procedures. Blue Cross Blue Shield Foundation president Sarah Iselin says that would be a hard sell, as it would require the government setting the prices for providers.

Fascinating vaccine history:
An interview with Brandeis professor Michael Willrich, author of “Pox: An American History.” He tells riveting tales of the Draconian vaccine policies during the smallpox epidemic at the turn of the 20th century. From WHYY’s Fresh Air: “There were scenes of policemen holding down men in their night robes while vaccinators began their work on their arms. Inspectors were going room to room looking for children with smallpox. And when they found them, they were literally tearing babes from their mothers’ arms to take them to the city pesthouse [which housed smallpox victims.]”