Guatemalan Migrant Child Flu Death Illustrates Larger Deficiency in How Influenza is Managed

The tragic and likely avoidable death of a recent death of a Guatemalan child migrant in US Custody from influenza (type B) illustrates many deficiencies of how physicians and other providers mismanage influenza. In addition to the unique circumstances of the child’s detention that are being reviewed, there are important aspects of this case that merit scrutiny from a medical perspective.

1. The common cold does not ordinarily cause 103 degree fevers. The boy was reportedly diagnosed with the common cold after his medical visit yet exhibited fevers of 103F. While it is true that some benign viral infections in children can cause high fevers, I don’t think it is the usual course for a common cold caused by rhinovirus. In most circumstances a search for another etiology (including pneumonia with a simple chest x-ray), especially in someone who is a traveler and is being housed with many other travelers would be pursued. Additionally, there are ways to confirm the common cold through respiratory viral panels that are widely available, use sensitive molecular technology, and are rapid. It appears the patient was tested for Group A Streptococcal infection (“strep throat”) alone.

2. Antibiotics are not needed for the common cold. If one diagnoses the common cold, antibiotics are not warranted and are wrong to prescribe. The common cold is caused by a host of viruses and no antibiotic is indicated for their treatment. In fact, prescribing an antibiotic is incorrect and exposes the patient to unnecessary side effects and fosters the development of antibiotic resistance in the patient. Additionally, an antibiotic prescription may give one the false idea that they should wait out the illness waiting for the antibiotic to “kick in” when, for a viral illness, it never will. If the provider believed the patient to have the common cold — which was not confirmed — what justified the use of an antibiotic?

3. Flu (and other viral) testing and antiviral prescribing are underutilized. While it is true that clinicians are good at spotting influenza clinically in many cases and treated appropriately, it clearly wasn’t the case here. There are myriad flu tests available however it appears none were used in this case (not even the poorly sensitive rapid tests which are not recommended for use in the latest Infectious Diseases Society of America guidelines). Testing for flu helps establish the diagnosis and is often a prompt to prescribe antiviral medications as well as to refrain from prescribing antibiotics.

It is clear that this child’s experience was not usual — he may have been dehydrated, malnourished, not vaccinated against influenza, and suffering from other conditions — but his death really should prompt scrutiny of how the medical community interfaces with influenza in all settings. We will face future severe flu seasons and future pandemics. It is only by becoming adept at dealing with seasonal influenza that any resiliency to influenza pandemics will develop. As this case and others in migrant and non-migrant populations will illustrate in the upcoming season which has already accumulated 11 pediatric deaths, clinical management of influenza needs to be optimized.

Flu Vaccine: Boldly Going Where No Vaccine Has Gone Before

I just read about a fascinating infectious disease experiment that is ongoing on the International Space Station. The experiment is focused on determining what effect being in space for a prolonged period will have on influenza vaccine response.

In this study, astronaut Scott Kelly and his Earth-bound twin Mark Kelly both will receive influenza vaccines at regular intervals and have the resulting immune response measured. As all immune systems in every species that possesses one on Earth involved in a gravity-laden setting, it is not surprising  that the absence of gravity can alter function. For example, space is known to be a T-cell suppressing activity. Also, the environmental microbiological environment on the space station is one very different than that on Earth and that difference likely impacts immune function as well. 

The nuanced changes in immune response to the flu vaccine will be fascinating to see unraveled. Such experiments will play a role in understanding T-cell function more fully, a crucial need in the quest to improve vaccines and understand the intricacies of the immune system.

Faith Healers & Infectious Diseases: Never Should the Twain Meet

I think that more than any other category of illness (with the possible exception of cancer) infectious diseases, because of their penchant to be explosive, mysterious, and sometimes deadly, attract faith healers to the scene. It's not surprising since the germ theory of disease has really been an accepted part of medical practice for only about 150 years. 

The germ theory supplanted fallacious ideas about the four humors, miasmas, and even the evil eye as well as evil spirits. So it is not surprising that faith healers and mystics had roles in prior plagues, epidemics, and pandemics. Even in the modern era, witch doctors were prominent in the West Africa Ebola outbreak.

The movie 6 Souls, which I recently watched, addresses this topic with respect to the 1918 influenza pandemic. 

A few facts about the 1918 Spanish Flu:

• Caused by an H1N1 virus
• Spread was likely fostered by WWI
• Killed at least 50 million people worldwide

In 6 Souls, a faith healer offers his "skills" to those who fear the pandemic while having his own children inoculated (an anachronism since the influenza vaccine was not available at that time). The townspeople figure out this hypocrisy and punish the faith healer accordingly.

It's important to remember that during the time of the 1918 pandemic the cause of influenza--so named because it was originally thought to be due to the influence of the stars--had not been established. There was no vaccine, no antivirals, and no antibiotics to treat the secondary bacterial infections that were the chief cause of death. I am sure that desperate individuals, like those in the film, unfortunately turned to faith healers who preyed upon the relative ignorance and desperation of the world at that time. 

To me the pathbreaking nature of the germ theory stems from its ability to provide a rational, natural, and causal explanation for illness, sweeping away any appeal to the mystical and cutting off faith healers at the root. Even today, let alone in 1918, there are pockets of the population where the germ theory has not penetrated fully into the populace as evidenced by those who forego vaccination and the practitioners of Christian Science who eschew antibiotics. 

Why Did 5000 Chickens Almost Cross the Road?

Remember avian influenza? The deadly version of flu that passes from poultry to humans and has caused outbreaks in many nations, most notably China. While we were dealing with Ebola panic and now a severe seasonal influenza outbreak, these viruses continued to spread (despite the lack of headlines).

The latest version of avian influenza to generate concern is H7N9 which has infected about 500 people since March of 2013, killing one-third. Taiwan has had 4 imported cases. The virus is spread to humans through direct and indirect contact with poultry. Limited human-to-human spread may also occur.

Because of the connection with poultry, control measures are centered around delimiting exposure to potentially infected birds. This often involves closing markets, culling, and inspections. 

An ongoing dilemma in Hong Kong involved a plan to inspect all local chickens at a small checkpoint while the market is disinfected after a culling of close to 20000 birds because of the potential for H7N9's presence given imports from a mainland farm tested positive for the virus. This arrangement was not found to the liking of the farmers who believe it will prove too onerous for them to conduct business.

Their response was to threaten to release 5000 live chickens into the busiest streets of Hong Kong. Not only would that action cause a major calamity but if any of the birds are harboring H7N9 (or other avian influenza viruses that can infect humans) could potentially widen exposure which is traditionally restricted to market-goers. They have since rescinded the threat. 

This incident illustrates why infectious diseases are so important. In just this one snapshot, you see economics, commerce, trade, government, and healthcare all intermingled. The ripple effect of certain infectious disease can be far-reaching and touch on virtually all aspects of modern civilization. 

Sir William Osler once remarked that to know syphilis--which has the ability to cause disease in every organ system--is to know medicine; similarly, to know infectious disease is to know the world.

Hoping CBS's Scorpion Will Tackle Infectious Diseases

A rag-tag yet elite group of disillusioned geniuses saving the world (in cooperation with the Department of Homeland Security) is just my kind of story and is the subject of the new CBS drama Scorpion. While I would prefer that they were battling infectious diseases (an idea for a future show?), the first episode focused on cybersecurity issues. However there was one mention of an infectious disease--a tenuous connection, I know.

In one scene, a human calculator character wipes down a diner countertop and states that over 20 diseases can be contracted from chicken. While I never counted the number of chicken-borne diseases, there definitely are a lot of them.

Poultry are naturally carriers of many bacterial pathogens, notably Campylobacter and Salmonella which can cause gastrointestinal illnesses. Cooking chicken thoroughly is enough to kill the bacteria (cook pot pies thoroughly) but cutting boards and counters can become contaminated and cross-contaminate other foods prepared on the same surface.

In my view the most ominous poultry-based infection is, hands-down, avian influenza. This disease, with fatality rates that rival Ebola's, is a clear existential threat that poses a perpetual threat to humanity. Influenza viruses, when adapted to humans, are adept at spreading between humans. Fortunately we have not seen sustained human-to-human transmission of an avian influenza virus, but as many flu viruses have acquired this capacity it is essential to prepare for this eventuality. Currently, infections are centered around individuals who have exposed themselves to the virus in poultry markets and similar settings.

I would love to watch Scorpion's group of geniuses tackle this problem because it is one of the most vexing ones in infectious disease (I know one of its stars, Katharine McPhee, has taken an active interest in another vexing infectious disease: malaria)