In the Year 2036...Hepatitis C Will be Rare

I've written before about how the advent of new therapies for hepatitis C, with their promise of increased cure rates and compliance, could change the face of hepatitis C. Now, some of my colleagues at the University of Pittsburgh Graduate School of Public Health (led by Mina Kabiri) have shown just that with mathematical modeling in an important paper published in the Annals of Internal Medicine. 

As this viral infection, which exists in the over 3 million individuals,  progresses and  viral damage accrues, cirrhosis and need for transplantation will ensue. Hepatitis C is currently the leading cause of liver transplantation, liver cancer, and end stage liver disease. Anything that can diminish the disease burden of hepatitis C would be a huge boon. 

Kabiri and coauthors constructed a mathematical model that simulated the US hepatitis C population from the years of 2001 through 2050. Varied treatments were placed into the model based on what the standard of care treatment was in a given year, culminating with our modern regimens. 

The major finding of this study is that, using current treatment regimens coupled to universal screening, hepatitis C could become rare by 2036!

This study really provides a substantial quantitative basis to justify the excitement over newer hepatitis C regimens--regimens I believe are truly priceless, pathbreaking, and have the ability to alter the landscape of disease.

Attenuating the Zombie Apocalypse Warning

Today has seen many developments in the unfolding Ebola outbreak. Some highlights include further details of the experimental therapy provided to the two surviving American patients, the identification of a patient in New York City that has some risk factors for exposure, and nearly continual media coverage.

This has been an interesting summer for someone (like me) who is focused on the threat of emerging infectious diseases. First MERS, then chikungunya, and now Ebola. 

One of the tasks I take very seriously is to emphasize the importance of preparedness for these events at the individual, hospital, and larger levels. With the Ebola outbreak, I am kind of finding this preparedness emphasis to be somewhat of a 2-edged sword. While, I thought it was clever to talk to individuals about "zombie" preparedness in order to get them to think about the threat of newly emerging infectious diseases, I wonder if it went a little too far. (Disclosure: I proudly bought one of the t-shirts myself).

Preparedness has to be based on sound risk analysis. How contagious is a disease? How does it spread? Are there countermeasures? How are similar diseases handled in this country? These are the questions the answers to which should condition one's response. 

If these questions have unequivocal answers and those answers aren't integrated into response plans, the plan will be faulty.

One aspect of the current scenario that I find particularly challenging is being able to fully convince individuals of the difference between an infectious disease (which Ebola is) and a highly contagious infectious disease (which Ebola is not). I don't fully know how Ebola developed the mystique it has acquired but it clearly has to do with its portrayals in fiction, something I said in this interview. 

Some important pieces to read with respect to the general sentiment I am expressing include this piece by Faye Flam and this one by (one of my favorites) Maryn McKenna.

Tomorrow's news will likely bring a slew of new developments. One thing is for certain though, infectious disease and the microbes that cause them won't take a break, so we shouldn't either.

Castle, Caves, & Mummy Tombs: Microbes, not Curses, Lurk Within

I was recently watching an old episode of Castle, a great TV show focused on the exploits of a detective and detective fiction-writer who team up to solve murders in New York City, in which dengue fever was mentioned. 

The context was an investigation of a murder involving a museum exhibit of Mayan mummies. In recounting the bad luck of those who interacted with the mummy, it was mentioned that many had died suddenly. One of the deceased was said not to have died from a mystical course, but from dengue fever.

The incident provoked some thinking on my part regarding the old cliche of ancient tombs being cursed. Thinking of what pathogens can grow in remote dark dank caves led me to focus on a few:

• Histoplasmosis: a fungal infection related to a fungus found in bat droppings
• Aspergillosis: a fungus that is ubiquitous and can cause infection in immunocompromised individuals
• Cryptococcus: another fungus associated with bats and caves
• Ebola and Marburg: given their association with bats (see Kitum Cave in Kenya)
• Staphylococcus and Pseudomonas bacteria

What most of these pathogens have in common is bats. Bats are one of the most numerous mammalian species on the planets and have a major role in the transmission of several diseases. In addition to the above, bats are major reservoirs for rabies, Hendra virus, SARS, (likely) MERS, and Nipah virus.

As for dengue, since it is transmitted by Aedes mosquitoes, I don't believe it poses a major risk within caves or to mummy aficionados--unless they are exploring in mosquito-laden environments.

Hopefully, however, dengue will be something of the past as a promising vaccine is moving toward licensure.

Walking with Ebola

It's very reassuring that the nation's 1st Ebola patient, Dr. Kent Brantly, walked into Emory's hospital.

The fact that he was ambulatory suggests several things that include:

• He is hemodynamically stable: Dr. Brantly's cardiovascular system is intact enough to allow him to support his own blood pressure and stand upright
• His respiratory system is intact: No requirement for mechanical ventilation is present
• He is able to follow commands: There doesn't appear to be any delerium

Important questions that remain to be answered include will include what role the convalescent serum he received has played in his recovery, how his immune system may differ from others, and what type of supportive care he received prior to therapy.

Also, though this may be the first Ebola patient in the US, it is important to remember that Ebola, the virus, is studied in several laboratories in this country--a point well made by Dr. Tara Smith in this blog post.

A Celebrity, Shigella, and an Airplane

With all the (mostly sensationalized) talk of individuals harboring Ebola traveling to the US from West Africa, I thought of an odd incident involving a sick celebrity traveler I recently heard about.

David Duchovny, the star of The X-Files (a show I predictably loved),  was recently on The Late Late Show and was recounting the story of a trip he had taken to Thailand. During that trip, he contracted a Shigella infection. 

Shigella causes dysentery--a fancy word that means diarrhea that contains pus. Often people with shigellosis will have fevers and chills as well. Shigella is a pathogen that is highly infectious as only a few organisms are required to cause disease. Fortunately, barring antibiotic resistance, Shigella is something that can be treated with antibiotics.

The story that Duchovny related (at about 3:50 in this clip) included him making so many trips to the bathroom that flight attendants suspected him of being a drug mule, prompting a full body inspection upon arrival in the US. Such an inspection of someone with explosive diarrhea is clearly a scenario ripe for contagion.

One of the fascinating aspects of Shigella is that the US military has shown interest in using bacteriophages (viruses that infect and can kill bacteria) as nutritional supplements for troops stationed in areas with a high incidence of Shigella infections. Phages are an elegant, totally targeted, therapy that avoid the issues inherent with broad spectrum antibiotics. There will be more to come on bacteriophages in the future.

As for Duchovny, I'm sure the customs inspectors found out, possibly in an unpleasant manner, that the truth was in there.