A Biosecurity Lesson Courtesy of Castle

The plot of the latest episode of Castle was ripped right from a bioterrorism scenario and was well worth watching. The episode weaved together various elements that are all very real concerns including:

• The theft of a deadly pathogen from a laboratory
• The deliberate infection of someone via a novel device
• The anticipation of that person spreading the pathogen
• Stockpiling of vaccines

To fill in the blanks, a vial of H5N1 avian influenza goes missing, a man is infected via his asthma inhaler, individuals on the subway with this man are exposed, and stockpiled vaccine is administered to contacts.

I was pleasantly surprised that most of the science was right and there was an acknowledgment of the realm of biosecurity on such a popular television show, illustrating that the general public has not only understanding of these issues but also an appreciation. 

A Hepatitis C Lesson Inspired by Ice Cube

I have a serious obsession with infectious diseases and constantly search for references everywhere. My latest find: the movie Ride Along. This comedy is about a police officer (played by Ice Cube, who I once saw in concert) and an aspiring police officer (played by Kevin Hart). The infectious disease reference occurs in a scene in which the police officer questions the neophyte's resolve asking him how he would react if he were stuck with a hepatitis C needle. 

Hepatitis C is and injection drug use are indelibly linked: 90% of new infections are due to this risk factor. Needle exchange programs are the cornerstone of hepatitis C prevention and it is unfortunate, that despite the unequivocal evidence that supports them, political opposition exists. In Pittsburgh, we are luck to have an organization called Prevention Point Pittsburgh, whose board I serve on, that provides needle exchange and disposal services. Pennsylvania also allows needles to be sold without a prescription, another key component to hepatitis C prevention. 

Clean needles lead to a lowering of hepatitis C incidence and prevalence. This translates into a lower chance that a discarded needle will be contaminated with hepatitis C. 

Until a vaccine is developed for hepatitis C clean materials with which to inject drugs, coupled with extensive testing, are the primary means of prevention. 

Ebola in Semen: A Worry for Nymphomaniacs, Not A Basis for Detention

Countries all around the globe are now conducting some sort of entry screening of travelers from Ebola-afflicted nations. These processes will involve temperature checks and a survey of symptoms coupled to a risk-assessment based on the person's activities. It is non-invasive and if suspicion is aroused, more testing is performed. Individuals who are flagged may be escorted to a room that has the requisite medical equipment present. 

Right now, I am trying to imagine the case of the man in India who was taken to a room that, perhaps, was strewn not with thermometers, but with Playboy magazines as part of an "enhanced" screening program that must be in place there.

The man in question had survived Ebola in Liberia but is now under detention. He is not under this order because of the presence of any lingering symptoms of Ebola, however. He clearly passed exit screening when he embarked on his trip and had not developed any new symptoms upon arrival. 

He is being detained because his semen tested positive for Ebola -- something that we know can occur for up to 3 months after infection. Such a condition is remedied by safe sex counseling and is not a basis for isolation or detention.

I can't imagine the protocol details that are in place that are used to elicit the requisite body fluid or what the rationale for detention may be (unless it is only used for nymphomaniacs).

Hopefully, he gets to keep his "reading" material for it may be months before his semen tests negative. 

Such actions divert important resources and feed the irrational panic surrounding this virus.

Tetanus Vaccine: Making Rusty Nails Less Scary

When I was a child I was scared to death over tetanus, chiefly because my babysitter would "entertain" me with horrific stories of one of the severe complication of tetanus, "lockjaw". Although I was fully vaccinated, rusty nails became the rattlesnakes in my backyard and it was hard for me to fathom that someone would not be vaccinated against tetanus.

This all came back to mind when I read about the recent events in Kenya where the vaccine is being erroneously labeled by the Catholic Church there as a population control scheme.

If there was genuine concern for reproductive matters in Kenya it would be tetanus--not the tetanus vaccine--that would be recognized as the real threat. Maternal and neonatal tetanus claim over 100,000 lives per year in Africa and the vaccine is literally life-saving. I have seen exactly zero cases of tetanus due to the high penetration of the vaccine here in the US.

If one were to contemplate nefarious population control mechanisms, infectious diseases would be first on the list; indeed, throughout most of human history they have served in this role. It is only after the technological breakthrough that brought us vaccines, that the human race has been able to flourish into old age. 

The anti-vaccine movement, in all of its incarnations, represent the return of the primitive.

Familiarity Should Not Breed Complacency with Influenza

There is a deadly infectious disease about to pounce on the US populace and I have already seen some early cases, yet no alarm bell has sounded. As you can probably guess, the disease I am referring to is influenza. 

A few weeks ago, during one of my occasional shifts in my hometown ED, I diagnosed a case of influenza B in a patient with shortness of breath using the poorly sensitive rapid antigen test that is widely available. The patient was admitted and placed on Tamiflu (oseltamivir). This season, I have sent several rapid antigen tests all of which were negative on similar patients. This fact likely means that many flu cases are not being diagnosed because the rapid test is just not good enough to detect all cases. CDC data suggests that 6% of tests are positive at this time and, thus far, there has been one pediatric death from flu in North Carolina.

At the start of the flu season stutters and sparks herald the first exploits of the virus in the current season and, judging by the experience of the Southern Hemisphere, we may have another severe season. 

In the ICU portion of my career, I have been involved with the management of individuals who present with fevers, cough, chills, and muscle aches and end up in the ICU because of severity. Such individuals clearly fit the case definition and hence should be appropriately tested. While the more sensitive PCR test results are pending in those with severe symptoms or comorbidities--especially pregnancy (or if rapid antigen tests are used) Tamiflu should be started empirically.

While people are clamoring over Ebola and many are being ruled out for this infection, the familiar--but by no means tame--influenza virus may go undetected because it is not tested for with enough frequency or is tested for using obsolete technology. To compound the problem, Tamiflu is woefully underused despite its capability to lessen severity as is the influenza vaccine.

As the current flu season evolves, familiarity should not breed complacency.