Eat Shit and...Ride

I can't count how many times I have said that understanding the mysteries of the microbiome will unlock the secrets to many physiological and pathophysiological process. The latest example of the microbiome's explanatory power regards the athletic prowess of elite cyclists. In a new unpublished study, that is getting a crapload of press, the microbiomes of elite and amateur cyclists were compared and, not surprisingly, differences were found. Particularly intriguing was the presence of the anaerobic bacteria Prevotella in half of the elite cyclists and none of the amateurs. An archae (Methanobrevibacter archaea) -- a disparate branch of life from eukaryotes (us) and prokayrotes (bacteria) was also more likely to be present.

This study is thought provoking and has many implications and it will be important for this to be thoroughly vetted through the peer-review process -- as studies on rugby players have. It will also be essential to untangle this correlation to try and determine causation -- is the microbiome difference related to the enhanced performance of athlete or the result of their diet, their exercise regimen, their genetics, or some other factor. If the microbiome is causative, poop doping could become a real phenomenon for enhancing athletic prowess (it already has promise in weight management and treatment of Clostridium difficile infection).

Though it's not quite time to follow athletes into the port-a-John, the promise of microbiome research is definitely making poop exponentially more appetizing each day.

The Ebola Inferno: A Review of Dr. Hatch's Memoir

I just finished another Ebola memoir by an American doctor who battled the virus during the West African outbreak. Inferno: A Doctor's Ebola Story by UMass's Dr. Steven Hatch is much more than patient vignettes and is really an intimate window into how an academic infectious disease physician fared against a deadly virus. 

Dr. Hatch's book moves from his first pre-Ebola visit to Liberia in which he was tasked with building medical capacity in a country ravaged by a recent civil war to his return to the country in the midst of the Ebola outbreak.

It is now almost cliche to say that the usual measures didn't work in Liberia because of the populace's distrust of the government and that one-size-fits-all solutions don't exist. Dr. Hatch unpacks that statement by weaving into this narrative an important discussion of the origins of Liberia and the civil war. As Dr. Hatch demonstrates, both of these factors distinctly shaped the response to the virus as did the Christianity and animistic beliefs of the population. 

Another aspect of the book that bears highlighting is Dr. Hatch's unfortunate navigation of the myriad details regarding his return to the panic-stricken US and the inanity of bureaucracies that were responsive less to science than to pandering politicians. 

I highly recommend the book.

Face to Face with Ebola: A Review of Dr. Kent Brantly's Memoir

Remembering the height of the worldwide Ebola pandemonium in 2014 is instructive 3 year later. All the names, dates, controversies and places from that era have long faded from headlines and the memories of the general public. Even I, who was keeping up with Ebola on an almost minute-by-minute basis, sometimes forget the intensity of the outbreak and continual media coverage. 

One of the first explosions of worldwide media occurred, of course, with the infection of American family medicine physician and medical missionary Dr. Brantly in Liberia. His infection, his transport back to the US, and his receipt of experimental therapeutics were unprecedented in the history of Ebola. The opposition to his transport to Atlanta was also unprecedented, disturbing, and shocking. 

I was one of those who vociferously argued for Dr. Brantly's evacuation to the US where he received state-of-the art treatment and recovered. Because of those efforts I made in the media at the time I was honored to be in the same room with him during a White House event. But I had no real familiarity with his personal experiences in Liberia and with Ebola.

I recently read Dr. Brantly and his wife's memoir of the experience Called for Life: How Loving Our Neighbor Led us into the Heart of the Ebola Epidemic. This book, written in 2015, is not only a gripping and poignant account of the Brantlys experiences with the outbreak but also how they coped with Dr. Brantly's infection.

The book weaves together the Brantly's decisions to enter the medical field and the career choices they made with the narrative of the Ebola outbreak. Many of the observations included are, by now, familiar (e.g. the unique challenges of containing Ebola in an urban populated area that emerged from civil war, the angry mobs, and the overall logistical challenges. However, to me, the value of the book is chiefly Dr. Brantly's recounted of his own personal experience with Ebola.

A few important points he makes merit emphasis:

• The initial negative Ebola test which required repeating given lack of sensitivity at early infection
• The necessity of ruling out malaria and initially treating for malaria empirically
• The voluminous diarrhea and ensuing electrolyte abnormalities of Ebola and the absoulte need to correct them
• The role of experimental agents and the challenges with administering them in a resource-challenged environment 

My favorite part of the book is Dr. Brantly's recounting of the  appearance of a top Ebola virologist outside his window in Liberia to discuss experimental treatments with him. 

Reading this family physician's account of his successful battle with the deadly Ebola virus is well worth it.

Confronting Our Deadliest Enemy

The world of infectious disease changes almost daily and with the well-overdue newstream-like enhanced focus on emerging infectious diseases the field has basically transformed. Emerging infectious diseases did not, however, supplant other concerns such as bioterrorism, dual use research, endemic infections, and antimicrobial resistance. All of these topics are now the bread-and-butter of infectious disease. A new book by Professor Michael Osterholm, a renowned leader in the field, is a must read for those with an interest (advanced or novice) in the field.

Deadliest Enemy: Our War Against Killer Germs is a comprehensive expertly-guided tour that spans all the major issues, outbreaks, and controversies in the field that have occurred over the past several decades. While many of these incidents are familiar, the value of the book is getting Professor Osterholm's analysis and opinion which provide deep insights and platforms for further thinking on the issues

Chapters topics span toxic shock syndrome to gain-of-function research and everything in between. Some particular standouts, to me, where Professor Osterholm's very personal battle with Lacrosse encephalitis, his discussion of MERS, his treatment of the economics of vaccine, his four-tiered threat matrix analysis (pathogens of pandemic potential, pathogens of critical regional importance, bioterrorism, and endemic infections), his "Crisis Agenda", and his unrivalled analysis and solution to influenza vaccine shortcomings.

In his decades long career, Professor Osterholm has been at the forefront of the field and led myriad investigations and influenced policy at the highest level and his book is an important distillation that I highly recommend.

Ebola Back in the DRC: An Opportunity for New Tools to be Tried

The latest appearance of the Ebola virus, which has caused approximately 30 identified outbreaks in humans since it was first recognized in 1976, will provide an opportunity to gauge how outbreak response has improved over the past 3 years. That this outbreak is occurring in the DRC, a nation relatively adept at managing the virus, will likely lead to its rapid extinguishment. Thus far, there are 11 suspected cases and 3 deaths in the remote area of the DRC where the disease has reappeared. The index case has secondarily (and fatally) infected one of his caregivers and his taxi driver. Contacts are under surveillance and thus far one has tested positive (and there is some concern that all suspect cases are not truly Ebola).

In recent years, in the wake of the horrific 2014 West African Ebola outbreak, new tools and strategies have been formulated and refined including a vaccine, a concept-of-operations for vaccination, and enhanced supportive care (not to mention the rapid involvement of WHO for technical assistance). 

In the coming days, as the outbreak unfolds and case numbers change it will be important to see if, in addition to the tried-and-true measures of case finding, isolation, and body fluid protection, the Merck vaccine (or others) is used to accelerate the control of this outbreak. Currently, a GAVI stockpile of 300,000 doses of the Merck vaccine stands at the ready.

Emerging infectious diseases, exemplified by Ebola, will continue to plague the human race and it is only by continually improving our response efforts through science and preparedness that they can be beaten back.