What do Legionnaire's, Parrots, and Sharks Have in Common: A Review of The Pandemic Century

The latest book on pandemics and infectious disease that I’ve made my way through is Mark Honigsbaum’s The Pandemic Century: 100 Years of Panic, Hysteria, and Hubris, “a book about these events and processes, and the reasons why, despite our best efforts to predict and prepare for them, they continue to take us by surprise.” That theme is an important one that deserves attention as time and again, a new infectious disease threat appears and calamity ensues. This cycle repeats over and over.

True to the panic and calamity aspect, Honigsbaum begins his book discussing shark attacks occurring in the North Atlantic, a supposed venue in which such attacks were not known to occur. Sound familiar? We’ve heard that a lot: Ebola doesn’t occur in West Africa, Zika doesn’t occur in the Western Hemisphere, Chikungunya is restricted in its geographic spread, etc etc

Infectious diseases — though we try to find strict laws of nature to confine them — are fluid physical phenomena whose dynamics are influenced by countless factors that are very hard to account for in models and cannot be dogmatized. It is not a foregone conclusion that each pandemic threat can be easily beaten back as we have seen with malaria, tuberculosis, influenza, and HIV (to name a few prominent ones). As New York Times science journalist Carl Zimmer notes in his review of the book: “What made this past century unusual was not pandemics per se, but our expectations about beating them. The germ theory of disease and other scientific advances in the 19th century fostered a sense of mastery over the microbial world.”

Honigsbaum’s book is divided into several chapters recounting various outbreaks and pandemics. Some of these are familiar such as the 1918 influenza pandemic, the 1976 Legionnaire’s Disease outbreak, SARS, and HIV. However, some are less familiar such as the parrot fever (psittacosis) outbreak that occurred in 1930s America. Of this outbreak, Honigsbaum colorfully writes:

Perhaps the most important factor of all, however, had been the popularity of lovebirds with American consumers and the lucrative interstate trade that saw itinerant peddlers going door-to-door offering parakeets to widows and housewives. In 1930, the idea that these cute American-bred birds might be the avian equivalent of Trojan horses was too disturbing to contemplate.

I recommend this book to those who want an easily digestible account of pandemics and outbreaks that are not only headline-grabbing but reveal holes in our preparedness and knowledge regarding infectious disease and microbiology. When each outbreak occurs, it is invariably followed by conspiracy theories, fake news, panic, sometimes disregard, and a whole host of other human responses that are driven by the uncertainty that characterizes the early days of a response. This is nothing new and is something that will continue but will hamper response and containment activities. The value of learning the history contained in this book is as Carl Zimmer notes in his review, “Surely the value of understanding history is that it gives us a chance to stop repeating our mistakes.”

5 Feet Apart: A Movie About Social Distancing, Cystic Fibrosis, Burkholderia

Cystic fibrosis (CF) is a genetic disease that every medical student becomes familiar with because it is common, causing by a single amino acid substitution, and has a clear link with severe lung (and other organ system) disease that can result in the need for transplantation,. LIfespan of patients with CF is severely curtailed and CF patients are plagued with infection after infection as their lungs are clogged with thickened secretions. It is the third leading cause of lung transplantation. Often, these infections involved highly drug resistant — as an ID fellow I vividly recall a twentysomething female die of a totally drug resistant Pseudomonas fluorescens infection — and ominous bacteria.

Infection with the Burkholderia cepacia complex, however, is the most significant of these infections. This gram negative bacteria targets those with cystic fibrosis and immunosuppressive conditions. When a cystic fibrosis patient is colonized with this complex, their chances of survival diminish. This fact leads some transplant centers to refuse to transplant patients with this recalcitrant infection.

The complex consists of a group of bacteria (one is even called B.metallica), with varying degrees of importance. Genoserovar III — B.cenocepacia — is the most dangerous and only two institutions in North America including one in the US (not surprisingly UPMC) will offer transplants to these individuals because the mortality post-transplant can be exceedingly high.

With these facts as context, I wanted to draw attention to a movie that, surprisingly to me, focused on this bacterial complex. Five Feet Apart is a 2019 movie that tells the story of young cystic fibrosis patients struggling with their disease, holding out for new treatments, and hoping for transplants. As part of their regimen they are forbidden to be close to other CF patients to avoid transmission of infections, which is difficult when there are romantic connections developing. One character suffers from B.cepacia and the movie details the efforts of medical professionals to try new treatments on him while also preventing it from spreading to other patients, particularly the protagonist. Not surprisingly, this story was inspired by a real life couple who were transplanted at — again no surprise — UPMC.

While the movie is not a medical documentary, the fact that it highlights the social aspect of infectious disease — the social (and emotional) distancing that can occur with an transmissible infection and how hard that can be to cope with for patients makes it particularly compelling to medical professionals. I think it is a film well worth watching for this aspect.

Hopefully, better CT treatments — drugs that modulate the function of the abnormal gene such as lumacaftor and ivacaftor — will diminish the need for transplantations and increase lifespans.

A Seminal Event: A Review of Recounting the Anthrax Attacks

It has been almost 18 years since the anthrax attacks in which 22 people were deliberately infected with the deadly bacteria to which 5 people succumbed. To many of those who do not work in the field, this event has likely faded from memory. In lectures to medical students a few years ago, anthrax was described as some sort of “panic” that occured post-9/11 with little appreciation that it was an actual attack. Given this context, a new book by an FBI agent (and PhD scientist) who worked the case is a welcome retelling of the events from a law enforcement and forensic vantage point. R. Scott Decker’s Recounting the Anthrax Attacks: Terror, the Amerithrax Task Force, and the Evolution of Forensics in the FBI is an easily accessible book that recaptures the environment of 2001 and details the birth of microbial forensics.

Decker does an excellent job recounting the ups and downs of the investigation . However, for someone familiar with the investigation I was disappointed to see several key elements not discussed. For example, Decker describes in detail the wrongful pursuit of Steven Hatfill and mentions a civil lawsuit regardings leaks but does not mention the fact that the https://www.theatlantic.com/magazine/archive/2010/05/the-wrong-man/308019/ on television and that taxpayers had to oay him millions of dollars for their (literal) dogged pursuit of him. Decker also gives just brief mention to the National Academies report on the forensic scientific approach used to reach their conclusion regarding the ultimate identity of the anthrax mailer, which I believe strongly delimits what the microbial forensics was able to conclude. No where does Decker mention the baffling approach the government took to defending itself in the lawsuit filed by the widow of the first victim in which they stated, in a court filing, that the identified anthrax mailer “did not have the specialized equipment” needed to commit the attack. (For more on the merits of the case I refer you to this PBS Frontline piece).

Despite what I think are serious omissions, I do think that the book is compelling reading as it underscores the threat of biological weapons, provides a great deal of information on how the investigation progressed, discusses how the government had to develop the wherewithal for such an unprecedented attack, and shows the birth of microbial forensics. The book also revisits tantalizing coincidences such as 9/11 hijackers renting an apartment from the first victim’s colleague’s wife as well as the activities, the tracing of the repositories that held the Ames attack strain, the legal travails of an anthrax vaccine manufacturer, and numerous other incidents that are important to understanding the complexity of a bio-attack. For these I think it is recommended reading for those in the field and who have an interest in this topic.

Learning about Tuberculosis at the Opera (Again)

I had one more tuberculosis-related opera on my list and just had the opportunity to experience it. Again, the disclaimer — I am not a regular opera consumer but am someone who has an interest in consumption. Verdi’s La Traviata which predates La Boheme, is based on a novel and play that recounts the life and demise of a famous courtesan from tuberculosis. Since it was written several decades before La Boheme it is not surprising that tuberculosis is a fatal disease.

One of the elements of this tuberculosis portrayal is that the main character, VIoletta, is a well-accepted, highly sought-after person of interest despite her sickness. Today, tuberculosis is known as a contagious infectious disease and those with pulmonary tuberculosis (who are smear positive and not on therapy) are not the people who should be interacting all that much with the general public until their disease is under control.

Robert Koch discovered Mycobacterium tuberculosis as the cause of tuberculosis in 1882 — decades after La Traviata — dispelling mistaken notions regarding the cause of tuberculosis, including heredity or a disposition/temperament. In La Traviata, there is a line about how a person lives confers susceptibility (which is not entirely untrue) but in the opera it appears to matter-of-factly be more about continual parties and being a courtesan than any moral judgment.

Perhaps the lack of fear of contagion explains why tuberculosis wasn’t stigmatized at that time and it was only with Koch’s discoveries and the acceptance of the germ theory of disease, that tuberculosis exposure was re-conceptualized as something to be avoided. When tuberculosis modern descendant (in terms of widespread infection, targeted demographic, etc) appeared that type of view of disease

The Perfect Predator is the Perfect Lesson in Persistence

I have been a proponent of the concept of using bacteriophages as medical treatment for some time. They have always seemed, to me, to be an elegant precise solution to bacterial infection. Phages, viruses that infect bacteria, avoid the issue of antibiotic resistance and antibiotic side effects. They are safe — every mouthful of water is chock full of them— and ubiquitous and have a fascinating history. I have written about their use and advocated policy changes in order to facilitate their adoption but often this was not compelling. A new book by infectious disease epidemiologist, Steffanie Strathdee and her husband psychologist Thomas Patterson, does, however, provide a compelling case that will not be ignored.

The events detailed in The Perfect Predator: A Scientist’s Race to Save Her Husband From a Deadly Superbug center on Patterson’s acquisition of a life-threatening multi-drug resistant Acinetobacter infection overseas and the Herculean efforts Strathdee expends in order to save his life. The book exquisitely details the daily ups and down of Patterson’s critical illness as he is continually swallowed in the throws of septic shock. Had this happened to anyone other than Patterson and Strathdee, that would be the end of the story but Strathdee excelled at finding a non-traditional cure for what would in 99 out of 100 instances a terminal infection.

Strathdee turned to the forgotten technique of using bacteriophages and, by now, this part of the story has been well publicized. What I particularly gained from reading this book was the diligent efforts of teams to match phages to the exact strain of Acinetobacter, construct cocktails, and work out the logistics of intravenous administration all the while successfully navigating the bureaucratic hurdles needed to use such a product.

Strathdee’s impassioned fight for her values, using cutting edge science and first-rate minds (including her own) to find an elegant solution is a lesson for how the battle against antimicrobial resistance can be won. Pushing through barriers, removing obstacles, following the science, and relentlessly persevering are important emulatable attributes that should be brought to bear on what is arguably the greatest health crisis humans currently face.

By paving this road, Strathdee has become a great benefactor of humankind.