What Has New Orleans to do with Monrovia?

By coincidence today, I finished Dr. Sheri Fink's Five Days at Memorial: Life and Death at a Storm-Ravaged Hospital. In this remarkable book, Dr. Fink--whom I am looking forward to see lecture in Pittsburgh--details the events that occurred at Memorial Hospital during Hurricane Katrina. Specifically, she focuses on the gut-wrenching decisions physicians and nurses had to make as the hospital appeared to become increasingly non-functional and rescue prospects thought to be dim. 

It was in this setting, and without any framework to apply in such an austere situation, that several doctors and nurses found themselves. Faced with the grim choices of which patients could be moved, which couldn't, and in what order to prioritize them decisions were made. As is widely known, allegations of euthanasia surfaced leading to a formal criminal investigation.

To me the theme of the book is that hospitals and other facilities must diligiently prepare for disasters and ensure that during a disaster full situational awareness (e.g. what the true prospects of rescue are, what the conditions are in the entire complex, etc.) is strived for. Also, guidance for physicians that is transparent and widely disseminated--prior to events--must be available for aid in decision-making, especially when conditions call for the rationing of scarce resources. 

Fortunately, since Katrina (and because of it) such a need has been recognized and guidance on Crisis Standards of Care have been developed. 

Now, to put this in today's context, think of how this might apply and is being applied in West Africa. In more than one sense Ebola can be thought of as a hurricane unleaded on the populations of Guinea, Liberia, and Sierra Leone. Bereft of experience in dealing with Ebola--this is their first outbreak--these nations are akin to the doctors in Katrina and, like them, they are confronted with stark choices. 

Who to treat? Who to admit? Who to give IV fluids to? Who to give personal protective equipment to? These are the decisions being contemplated right now in what can only be described as a situation in which extreme crisis standards of care are the norm. 

Reading Dr. Fink's book with the context of Ebola in mind shows how widely applicable her astute observations are.

Emerging Infectious Diseases & Closing the Book on Infectious Diseases

In advance of the expected remarks by the President on Ebola tomorrow during his CDC visit, I have done a few interviews, including this one with NPR, speculating upon what he might propose. 

Whatever is proposed, one thing is certain: this won't be the last time the world faces the threat of an emerging infectious disease.

Reflecting upon this fact I wrote, in Forbes, about how I believe that this and future emerging infectious disease responses should be handled--namely with a high level emerging infectious disease/biosecurity coordinator coupled to a prioritization of the core (i.e. infectious disease) missions of both the CDC and US Surgeon General. 

How wrong was Surgeon General William Stewart when he declared in 1969 that “we can now close the book on infectious diseases." 

Our microbial world guarantees that this book will be open forever but with proper preparation, response and situational awareness we can get it at least shut it partway.

The Flu Vaccine: Love the One You're With--But Don't Stop Thinking About Tomorrow's Vaccine

So today I went through one of my favorite rituals and it wasn't a Buffy the Vampire Slayer marathon; it was my annual flu vaccination.

This year I got the quadrivalent version of the vaccine, at my place of appointment, and it was much easier to find than last year when I basically had to cold-call several pharmacies to find it. 

I want to make couple of points to make about the annual flu vaccination.

1. Getting the vaccine early is advisable. Though there is some decrement in the level of immunity as the season progresses, being immunized at the start of the season is the best way to avoid the flu. Remember it takes about 2 weeks for the vaccine to induce immunity so it's ideal to be vaccinated prior to the start of the season.

2. The quadrivalent vaccine should be the preferred vaccine for almost everyone with the exception of the elderly who should receive the high dose trivalent formulation (hopefully soon to be quadrivalent).

3. Children between 2 and 8 years of age should receive the nasal live-attenuated version given the high efficacy it shows in this population

4. I anticipate a rough flu season this year based on what is going on in the Southern Hemisphere's current season (which runs opposite to ours).

The ordinary vaccine is about 60% effective (assuming a good match with circulating strains) at preventing the acquisition of flu and, for the vaccinated who contract flu, it can decrease the chances of having a severe case.

Though we are still years away from the Holy Grail--a game-changing universal vaccine that does not require one to be revaccinated each year and provides near-sterilizing immunity (like other vaccines)--for now, we've got to love the one we're with.

In the Land of the Unvaccinated, The Immune is King

I've recently been drawn to the television dramedy Castle and have been making my way through prior seasons. Yesterday, I watched an interesting episode from season 5.

In this episode, entitled "Swan Song", Beckett and Castle investigate the murder of a man whose blood shows the absence of antibodies against polio and tetanus. Later on in the episode it is revealed that he had not been vaccinated because he belonged to a religious cult which forbade vaccinations.

The plot of this episode prompted me to think of how paradoxical it is to be part of a large community of individuals who are not vaccinated. Their isolation from society, rather than protecting them, strikes me as akin to bleeding in a tank full of great white sharks. In such a conglomeration of chum, all it takes is one individual exposed to, say, measles to set off an outbreak that could have deadly consequences.

If I were in an unvaccinated cult I would get vaccinated because, in the land of the unvaccinated, the immune is king.

A Back to School Victim-Finding Spree for Enterovirus 68

There are multiple reports today of a large outbreak of respiratory illness in the Midwest and, no, it's not Ebola or MERS.

It's Enterovirus D68. You might recall a few months earlier a big scare with this virus causing a polio-like paralytic disease in California, but this virus (which bears Jaromir Jagr's number, for Pittsburghers) is well known as a cause of respiratory illness.

A few points about this outbreak:

• Seems very large: 300 kids in Kansas City, MO (other states are reporting too) but this is likely not the full extent of infection as most cases are likely asymptomatic
• High degree of ICU admission: 15%
• Hospitals are limiting visitation of the hospitalized children

Enteroviruses, in general, are a ubiquitous group of viruses that number over 100 and cause a wide variety of illnesses from meningitis to upper respiratory tract infection. Each year over 10 million cases of infection with this group of viruses occur. However, the vast majority of these infections are without symptoms (but are still contagious). 

This new outbreak could reflect a number of things.

1. Better diagnostics: Many hospitals are moving to PCR-based testing of respiratory illness and what may have been an undifferentiated cluster of illness is now able to be named.

2. The start of school: It is widely known that schools function as viral exchange centers and this virus is likely benefiting from the school year (a sort of back to school victim finding spree for the virus).

The next steps will be to determine the true burden of this virus, understand it's full spectrum of illness, given its now proven ability to cause severe infection, and assess whether a vaccine against it (like is being developed against Enterovirus 71) is warranted.