Can The Bunny stop Botulism?

Today during  a lecture I delivered on botulism, the topic of ultra high temperature (UHT) pasteurization of milk came up. 

Specifically, I was discussing the vulnerability--at multiple points--of the US milk supply to intentional botulism contamination, the subject of a famous paper.

While milk pasteurization is an OK (~70% effective) preventative, UHT pasteurization is much better and essentially reduces the vulnerability to zero. However, as audience members attested, the taste of UHT pasteurized milk is a big drawback. Additionally, certain groups oppose UHT pasteurization for various reasons (nutritional concerns, etc).

I wonder if NesQuik (strawberry or chocolate) makes it taste better? If so, it could be touted as a resiliency-enhanced measure!

2013 Eradication Final Score: Polio 8 countries, Guinea Worm 4

Since I work on a daily basis with DA Henderson, the man who led the only successful effort to eradicate smallpox from the planet (see his excellent book), the eradication of other infectious diseases are always something I track. 

Since smallpox, only the cattle disease rinderpest has been eradicated. 

Two major eradication efforts are currently underway with varying degrees of success. One is focused on polio, the other on guinea worm disease. Polio remains in 8 countries; guinea worm disease (dracunculiasis) in 4.

To eradicate polio is actually a tripartite task,  as the disease is caused by three types of poliovirus. Poliovirus type 2 was eliminated in 1999 and type 3 is likely on the verge of eradication. Type I is a different story, however, and has proven difficult to extinguish and has been abetted by social and political developments conducive to its spread. 

In 2013, polio cases increased by approximately 62% (from 2012) largely as a result of importation of cases to countries from which it had been previously driven out (Cameroon, Kenya, Somalia, Ethiopia, and Syria).

Polio remains endemic in 3 countries: Afghanistan, Pakistan, and Nigeria. In Afghanistan and Pakistan there have been several reports of violence directed against vaccinators by the Taliban. There is also an excellent book on the topic of polio in Pakistan detailing the structural problems involved there.

Guinea worm disease, on the other hand, experienced a 73% decline in cases from 2012 and remains in South Sudan, Ethiopia, Mali, and Chad.

As the new year unfolds, it will be fascinating to track the progress--and setbacks--of these two programs. For a good overview of eradication in general, see this book. 

Mom, Apple Pie, Handwashing, and Influenza Vaccination

The recent news story regarding a pregnant healthcare worker refusing a flu vaccination has generated much controversy prompting her firing by the hospital, I  decision which I fully support.

A few points, most of which I have made in response to the HHS plan for influenza vaccination of health care workers and some other places (Today's Hospitalist, ACEP News): 

• Employers have the right to set the conditions of employment, including what vaccines they require be received by employees
• Employees are free to refuse such vaccinations and face the consequences which could include being asked to wear a mask, refrain from patient contact, or termination
• Influenza vaccine, thought not a panacea with its ~60% effectiveness, is the only preventative countermeasure we have against this virus
• The influenza vaccine is unequivocally safe, as it is in all demographic subgroups, for pregnant women and, in fact, pregnant women are at elevated risk for severe influenza which can lead to miscarriage, among other things

As a physician, I view the influenza vaccine as part of my professionalism as well as a patient safety issue. While I respect the right of individuals to abstain from the vaccine--at their own peril--employers should not countenance such behavior, especially healthcare facilities.

Jane Eyre, Louse Dodger

I recently watched the 2011 movie version of Jane Eyre. Since it has been about 20 years since I read the novel in high school some of the plot details had become somewhat hazy (pun intended for the really nerdy), including the multiple instances in which the infectious disease typhus is mentioned.

In the novel, typhus runs rampant at Lowood, the boarding school to which Jane is sent, and Jane's wicked aunt falsely reports Jane's death from typhus to another relative. Jane herself never contracts the disease.

Typhus, not to be confused with typhoid, is caused by Rickettsia prowazekii and carried by the human body louse.  The word is derived from the Greek work typhos, which means hazy or smokey, a reference to the dazed mental state characteristic of the disease. Because of the relationship between cleanliness, the body louse, and the typhus microbe, this disease has a special place in history--one of my favorite aspects of infectious disease.

Epidemic typhus was considered a major health threat for most of history and remains so for certain parts of the world today. The use of epidemic typhus as a bioweapon is also a concern.

Probably the greatest role typhus has taken on is in thwarting Napolean's invasion of Russia, the subject of The Illustrious Dead. Typhus was also responsible for the death of President Franklin Pierce's son. Today, the disease occurs in situations enticing to lice such as in refugee camps. 

One of the other reasons I like typhus is because one of its foremost researchers was Hans Zinsser, who delivered my favorite quote regarding infectious disease, capturing the entire allure of the discipline:

Infectious disease is one of the few genuine adventures left in the world. The dragons are all dead and the lance grows rusty in the chimney corner. ... About the only sporting proposition that remains unimpaired by the relentless domestication of a once free-living human species is the war against those ferocious little fellow creatures, which lurk in dark corners and stalk us in the bodies of rats, mice and all kinds of domestic animals; which fly and crawl with the insects, and waylay us in our food and drink and even in our love.

The Amalgamation of Critical Care & Infectious Disease

When I decided, upon the completion of my infectious disease fellowship in 2009, to pursue another year of training in critical care medicine, I was perceived crazy given the rigor of such a fellowship and the fact that I was (and still am) an ID addict. (Plus, I had also completed a combined residency in Internal and Emergency Medicine).

My answer to those who questioned my motives was that I didn't want to be an ID physician who steps back once the patient becomes critically ill and requires ICU care. Critical care physicians are trained to be adept at almost everything and often need little to no consultative help from other sub-specialists, leaving the ID physician with little to add. The ICU is also the place where infectious disease often reach their culmination--particularly infections I am very interested in such as emerging infectious diseases and influenza--and I like the unique challenges of managing all aspects of the patient's care, which is the role of a critical care physician. I have a similar sentiment regarding Emergency Medicine, where all these diseases initially present. 

Last night in the ICU served to reinforce my sentiment.

Overnight I admitted two patients with severe infectious diseases, one of which required extraordinary interventions to keep alive. That patient, transferred from a rural hospital with likely influenza pneumonia, progressed throughout the night from requiring moderate amounts of ventilator support to ultimately, after a series of rescue interventions, being placed on ECMO. Trying to halt the onslaught of the infection and the resultant failure of multiple organ systems was extremely challenging.

It is these challenges, inherent in working in an ICU, where the melding of infectious disease and critical care medicine reaches its apotheosis and its what I like to do.