Dressed Down by the Captain of the Men of Death (Again)

The bacterium Streptococcus pneumoniae or the pneumococcus was labeled the "Captain of the Men of Death" by Sir William Osler because of its extreme prowess at killing. Today we are fortunate that the availability of pneumococcal vaccines has diminished the burden of invasive pneumococcal disease but it still causes approximately 3500 deaths per year. Those with the bacteria in their bloodstream succumb to the infection in 15% of cases--a figure that is thought not to have improved for decades despite myriad improvements in critical care. 

In my career I've taken care of several patients with severe pneumococcal infections and each time I am astounded by its deathly abilities. Last night, I unfortunately saw pneumococcus in action once again in a cirrhotic patient (who I don't believe was vaccinated).

There's a concept in treating patients with septic shock known as decompensation. Human physiology can hold out for so long and then, the deluge. Once decompensation occurs, it becomes a Herculean task to counteract the derangements induced by the infection, which soon become irreversible, and maintaining a blood pressure can become near impossible.

Pneumococcal vaccines, a life-saving technology developed by Dr. Robert Austrian, have the ability to make these types of occurrences a remnant of the past but if only if we avail ourselves of their benefits. For in those unlucky individuals in whom severe pneumococcal sepsis ensues, to rescue them requires beating back the devil.

The Dog Gave Me Plague

The recent detailing of the 4-person cluster of plague cases that occurred in Colorado in 2014 is a fascinating look at how plague, in the modern age, can still cause substantial morbidity. 

People forget that plague is endemic in parts of the US that are west of the "plague line" and we have a handful of cases each year in the US. What was special about this cluster was the involvement of a dog and possible human-to-human transmission in one instance. Additionally, half of the cases of pneumonic plague were mild and didn't require hospitalization, a fact that calls into question the common conception of plague as a universally severe illness.

The index mammal in this outbreak was a dog who was euthanized for an illness that caused bloody-tinged cough. This was subsequently diagnosed as plague and the property on which he lived had inactive prairie dog burrows and rabbits--known means for how the dog may have acquired its fatal affliction.

Didn't realize there was a movie with this title, unfortunately its anti-vivisection.

What happened next illustrates the concept of One Health, an approach to medicine and public health in which animal and human health issues are integrated, perfectly: 3-4 contacts of the dog became ill with plague. Of the 4 human cases, 3 had very close contact with the ailing dog and the remaining patient had some contact with the dog but also close contact with the dog's owner, raising the prospect that human-to-human transmission occurred--a phenomenon that hasn't occurred in the US for 70 years.

So, it's time to add spreading plague to the long litany of things, including their favorite pastime of eating homework, to blame on dogs 

Understanding Ebola in West Africa Through Laurie Garrett's Lens on Kikwit

The WHO announced yesterday that the decline in Ebola cases which has been occurring has halted. This is ominous news as it highlights the very real fact that unless every Ebola case is run down, a new transmission chain can commence, reigniting the epidemic in West Africa. 

To understand why the West African Ebola epidemic is so recalcitrant to the public health measures that have been employed to stop all the prior instances of Ebola, it is instructive to examine prior outbreaks. After the 1st outbreak of the most virulent Zaire strain of the virus in 1976, the next biggest outbreak of this strain (present outbreak excluded) was in Kikwit (DRC) in 1995.  This--once considered large--300+ person 1995 Ebola outbreak has many lessons for today, as presented in a book published in late 2014 by Laurie Garrett. Ebola: Story of an Outbreak, extracted from Garrett's Betrayal of Trust: The Collapse of Global Public Health (with a new introduction focused on the West African outbreak), provides an in depth view of the Kikwit outbreak highlighting the struggles that physicians, many of whom are now everyday names in infectious diseases now (e.g. Ali Khan, Pierre Rollin, David Heymann), encountered in trying to extinguish this outbreak.

Many of the incidents described presage what occurred in West Africa: distrust of government authorities, belief in a mystical origin (which includes a special hippopotamus), graft, corruption, and intense press coverage. The lesson I found most instructive is that after the outbreak abated, within a couple of years, public health infrastructure and public health behaviors had again eroded to dangerously low levels. Such a devolution illustrates that resources infused from outside are effective in the short term, but are not sustainable without actual acceptance from the local population as a rapid regression to the mean takes place. For example, safe burial practices ceased, the etiology of Ebola was placed back in the supernatural realm, and an ambulance became a limo for a local government thug. This regression to the mean is occurring even more rapidly in West Africa where, while the disease still rages, lax public health practices by local populations have given rise to a shadow--and open--epidemic that continues to burn.

 As someone who was captivated by Garrett's The Coming Plague and who also enjoyed I Heard The Sirens Scream, I highly recommend this book as an important guidepost to understanding the challenges faced in West Africa.

How GMOs Could Have Prevented Nigerian Mystery Illness Cluster

Each time a cluster of illness occurs there is a process to determine its cause. One of the first thing that comes to mind with clusters, broadly speaking, is determining whether an infectious disease is present or something else. "Something else" will include a list of things, chief of which is a common exposure to some toxin. 

The recent cluster of illness (blurry vision, headache, alterations of conciousness) in Nigeria--which recently experienced several imported cases of Ebola--sparked concerns of Ebola, for obvious reasons. However, it appears that no infectious cause of illness is responsible for this event which has claimed the lives of 18.   

Currently there are two competing explanations: methanol contaminated gin and the WHO's preliminary hypothesis: pesticides. Both are good explanations because they fit the symptomatology of the cases and are biologically plausible. Final diagnosis should be able to confirmed with laboratory testing. 

The investigation of this event illustrates several aspects of public health investigations, the most important of which is the importance of surveillance. Without knowing what illnesses are occurring in an illness, it is impossible to detect unusual occurrences and place them in the context of what is the usual baseline mix of disease in an area. 

Another aspect of this case is the possible link with pesticides (which may not turn out be the case). Though I am a big fan of pesticides as I value human life and the conditions required for our flourishing--such as an abundant supply of food--pesticides can be dangerous if the quantity ingested exceeds a threshold. Because of these limitations, alternatives to pesticides are actively sought. One such alternative are GMO crops that are resistant to plant pathogens. One would think that such a pathbreaking advance in genetics and agriculture would be embraced, yet it is not.

Why are GMOs feared? It is not because of any evidence of their danger for there really isn't any as no one has died or been harmed from GMO-poisoning (an oxymoron). Yet for those who seek an alternative to pesticides, which cause up to 20,000 illnesses yearly in the US, GMOs are often considered off-limits because of the vocal anti-science, anti-reason, anti-GMO movement which often resorts to threats, violence, and property destruction in their nihilistic quest. 

Remember the corn we eat and the dogs we walk are all GMOs as artificial selection and breeding for specific traits are exactly the principles behind all genetic engineering. 

You would think that people that scream "safety" would actually care about safety and embrace GMOs, but it isn't safety that motivates them, it is hatred of the human minds that made GMOs possible.

Listeria: Another Reason Why You Should Not Drink Hot Dog Juice

The bacteria Listeria has a special place in my heart--not to imply that I don't love all bacteria in their own special way. Listeria is in the headlines again with the national recall of Blue Bell products being announced after 10 cases of listeriosis were reported in 4 states, 3 of which were fatal.

Though listeria has only a small slice (~1%) of the total food-borne illness burden, it does claim a substantial proportion (~20%) of food borne deaths granting it a special status. This is really a ubiquitous bacteria that is present in herd animals and the soil. It can contaminate soft cheeses, hot dogs, deli meats, cantaloupes and other products. The immunocompromised, pregnant, and newly born are at particular risk for severe infection.

What makes it so deadly is its ability to move from the GI tract to the blood and then to other organs. One place where it is particularly damaging is in the central nervous system. Listeria meningitis and encephalitis have particularly high mortality rates.

The best means to prevent listeria are safe food handling procedures (i.e. avoid hot dog "juice" exposure) and for those at particularly high risk to avoid eating foods that may be contaminated with listeria. There is also an innovative product (ListShield) containing viruses that attack listeria (bacteriophages) that can be sprayed directly onto food to kill the bacteria.

So why does listeria have a special place in my heart? It's not its actin "jets" (so cool) or tumbling motility (really endearing to watch). It is because as a operating room volunteer in the mid-1990s applying to medical school, I knew I wanted to be an infectious disease physician. When I was done volunteering, I would roam over to the infectious disease division and poke around looking for real life infectious disease physicians and researchers. One day, I stumbled upon a researcher (who has long since left my institution) who worked on listeria and he explained its microbiology and disease-causing attributes to me with such passion, I'll never forget the incident and the time he took to indulge my interest in infectious disease.