Rocky Mountain High: Could it be the result of a Fever?

One of my friends alerted me to the fact that Phoenix Coyote Shane Doan is recovering from Rocky Mountain Spotted Fever (RMSF), a dangerous tick-borne infection that often requires a competent clinician to diagnose and preemptively treat.

RMSF is caused by Rickettsia rickettsii and is spread to humans through the bite of one of three ticks: the American Dog Tick, the Rocky Mountain wood tick, or the brown dog tick. These ticks have a wide geographic spread. 

Despite its name, however, 4 states account for the majority of RMSF cases: North Carolina, Oklahoma, Arkansas, Tennessee, and Missouri. Interestingly, in Arizona--which may be relevant to Doan's case--there is a newly established foci of infection in the eastern part of the state which is tied to transmission via the brown dog tick and large populations of roaming dogs. 

The initial presentation of RMSF is what makes it so challenging as it can appear to be just an ordinary viral illness. If overlooked, individuals may develop more serious infections that can be debilitating or even fatal. The characteristic rash may not be present until later in the course of illness. In areas where RMSF is known to circulate, doxycycline is prescribed routinely for illnesses that fit wide criteria for possible RMSF in order to avoid any delays in treatment. 

So long as RMSF remains a clinical diagnosis, as the result of serological tests may take days to obtain, it serves as another example of the value of the astute clinician who is able to discriminate the hoofbeats of a zebra from a horse.

Chickenpox Party Pooper

Yet another reason to avail yourself of the shingles and chickenpox vaccines: shingles increases the risk of stroke and heart attack, especially in those under the age of 40.

This finding, published in Neurology, was a retrospective study that included over 100,000 individuals with shingles and found that those under 40 who experiencing shingles had a 50% increased risk for heart attacks as well as increased risk for mini-strokes (TIAs) and full strokes.

These findings reinforce the fact that this virus is not benign and should not have the privilege of having parties in its honor to help foster its spread. 

Can The Bunny stop Botulism?

Today during  a lecture I delivered on botulism, the topic of ultra high temperature (UHT) pasteurization of milk came up. 

Specifically, I was discussing the vulnerability--at multiple points--of the US milk supply to intentional botulism contamination, the subject of a famous paper.

While milk pasteurization is an OK (~70% effective) preventative, UHT pasteurization is much better and essentially reduces the vulnerability to zero. However, as audience members attested, the taste of UHT pasteurized milk is a big drawback. Additionally, certain groups oppose UHT pasteurization for various reasons (nutritional concerns, etc).

I wonder if NesQuik (strawberry or chocolate) makes it taste better? If so, it could be touted as a resiliency-enhanced measure!

2013 Eradication Final Score: Polio 8 countries, Guinea Worm 4

Since I work on a daily basis with DA Henderson, the man who led the only successful effort to eradicate smallpox from the planet (see his excellent book), the eradication of other infectious diseases are always something I track. 

Since smallpox, only the cattle disease rinderpest has been eradicated. 

Two major eradication efforts are currently underway with varying degrees of success. One is focused on polio, the other on guinea worm disease. Polio remains in 8 countries; guinea worm disease (dracunculiasis) in 4.

To eradicate polio is actually a tripartite task,  as the disease is caused by three types of poliovirus. Poliovirus type 2 was eliminated in 1999 and type 3 is likely on the verge of eradication. Type I is a different story, however, and has proven difficult to extinguish and has been abetted by social and political developments conducive to its spread. 

In 2013, polio cases increased by approximately 62% (from 2012) largely as a result of importation of cases to countries from which it had been previously driven out (Cameroon, Kenya, Somalia, Ethiopia, and Syria).

Polio remains endemic in 3 countries: Afghanistan, Pakistan, and Nigeria. In Afghanistan and Pakistan there have been several reports of violence directed against vaccinators by the Taliban. There is also an excellent book on the topic of polio in Pakistan detailing the structural problems involved there.

Guinea worm disease, on the other hand, experienced a 73% decline in cases from 2012 and remains in South Sudan, Ethiopia, Mali, and Chad.

As the new year unfolds, it will be fascinating to track the progress--and setbacks--of these two programs. For a good overview of eradication in general, see this book. 

Mom, Apple Pie, Handwashing, and Influenza Vaccination

The recent news story regarding a pregnant healthcare worker refusing a flu vaccination has generated much controversy prompting her firing by the hospital, I  decision which I fully support.

A few points, most of which I have made in response to the HHS plan for influenza vaccination of health care workers and some other places (Today's Hospitalist, ACEP News): 

• Employers have the right to set the conditions of employment, including what vaccines they require be received by employees
• Employees are free to refuse such vaccinations and face the consequences which could include being asked to wear a mask, refrain from patient contact, or termination
• Influenza vaccine, thought not a panacea with its ~60% effectiveness, is the only preventative countermeasure we have against this virus
• The influenza vaccine is unequivocally safe, as it is in all demographic subgroups, for pregnant women and, in fact, pregnant women are at elevated risk for severe influenza which can lead to miscarriage, among other things

As a physician, I view the influenza vaccine as part of my professionalism as well as a patient safety issue. While I respect the right of individuals to abstain from the vaccine--at their own peril--employers should not countenance such behavior, especially healthcare facilities.