Polio Wars: Dying for Vaccination in Pakistan

I discussed, in a prior post, the progress of the global polio eradication effort. Last year marked a major setback in the eradication effort as 9 countries reported 389 cases. Though not even a month old, 2014 has already seen 4 cases occur--all of which are located in the North Waziristan region of Pakistan. 

It is no accident that Pakistan remains the biggest obstacle to polio eradication given the continued murderous violence Taliban Islamists direct at polio vaccinators. Since July of 2012, 33 individuals associated with the vaccination effort have been killed. 

The contrast between those who are working to improve human life by working to eradicate one of mankind's scourges from the planet and those who seek to relegate mankind to a state in which polio is allowed to spread with abandon couldn't be starker. 

Treating Anthrax in 2014

It's been almost 13 years since the anthrax attacks of 2001 and, not suprisingly, medical care has advanced during that time. Accordingly, the CDC has released new guidelines for the treatment of anthrax. 

Several important highlights include:

• Attention to the coagulation defects that occur with anthrax with the goal of keeping fibrinogen levels above 100 and avoiding pharmacological thromboprophylaxis
• Emphasis on the drainage of pleural effusions--a procedure linked to improved outcome
• Carryover of the recommendation for 60 days of post-exposure prophylaxis
• Delineation of anthrax with possible meningitis from anthrax without possible meningitis
  • In cases where meningitis is a possibility the recommendation to use 3 drugs with high CNS penetration, 1 of which should be a protein synthesis inhibitor (ciprofloxacin, meropenem, and linezolid)
  • In cases where meningitis has been ruled out the recommendation to use 2 drugs, 1 of which should be a protein synthesis inhibitor (ciprofloxacin + linezolid)
• Use of an anti-toxin therapy such as raxibacumab (or anthrax immune globulin--not FDA approved)

Overall, the guidelines are highly evidence-based and consistent with standard infectious disease and critical care practice. Hopefully, when followed the 45% mortality rate experienced in 2001 would be significantly diminished (in the cases that have occurred in the US since 2001, no patient has died).

HIV & Church Attendance: Mortification of the Flesh, Not Just for Saints

An interesting study appeared in a recent issue of Clinical Infectious Diseases focused on HIV and church attendance. The variable of interest was the presenting CD4+ cell count, a major predictor of morbidity and mortality, and its relationship to church attendance. The study was conducted at UAB in Birmingham, a major HIV/AIDS research center.

The striking finding is that HIV+ men who have sex with men (MSM) and were regular attendees at church were more likely to present for care with CD4+ cell counts less than 200 cells when compared to those who did not attend church. This finding did not apply to men who have sex with women or to women who have sex with men.

One of the implications of this study is that religious proscriptions against homosexual activity (see Leviticus 20:13) may prevent individuals who engage in such activity from partaking in HIV screening activities and subsequently cause them to present for HIV care late, potentially jeopardizing their own health and posing a heightened transmission risk to others.

This finding is not surprising to me and I believe it is the direct result of dogmatic religious ideas that unequivocally confer a negative moral evaluation in a realm in which morality is wholly inapplicable--an individual's unchosen and irreversible sexual orientation.

Would that MSM who attend church cease to sanction their own moral condemnation which, based on the results of this study, has the potential to incite self-immolation.

"Is that Mange or Bubonic Plague You're Sporting?"

In the animated feature film, The Nut Job, one of the squirrel characters asks a disheveled appearing rat with  if its appearance is the result of mange or bubonic plague. Being always attuned to the mention of infectious diseases in popular culture I notice that rats are often viewed as harbingers of infectious disease, even by animated squirrels. 

Rats can be vectors of many infections, most notably plague and murine typhus, in which their fleas can spread plague bacteria to humans. But other less renowned infections can be spread as well.

Interesting pathogens that can be spread via the bite of rat are Streptobacilus monilloformis and Spirillum minus. These bacteria cause "rat bite fever", which has been known to occur for over 2000 years. This disease causes rash and arthritis in the most cases. A select group of cases, however, experience relapsing infection that can lead to endocarditis (infection of the heart valves), meningitis, and sepsis. Untreated, the mortality rate can reach 13%. 

Mange, the disease mentioned in the movie, is caused by parasitic mites. Sarcoptic mange is basically the canine version of scabies. Rarely, humans can contract sarcoptic mange, but the affliction is usually self-limited in humans as the mite is unable to complete its lifecycle in humans. Rats have their own specific mites, but can also contract sarcoptic mange. 

Overall, though, rats are not in any way special as sources of zoonotic diseases. However, rats will likely continue to be the subject of heightened scrutiny of health inspectors and the public--as the residents of Hamelin can attest.

Strep and Mono: Bonnie & Clyde or Crips & Bloods?

A recent study published in the Journal of Infectious Diseases provides a great illustration of the intricate interplay between humans and 2 microbes, highlighting how pathogens interact with each other in order to facilitate their spread. 

The study is focused on the interaction between Group A streptococcus (GAS)--the cause of "strep throat"--and Epstein-Barr Virus (EBV), the cause of infectious mononucleosis.

As 20% of children are colonized with Group A streptococcus and EBV persistently infects 90% of the population, the two pathogens may have important influences on each other given that both of their habitats are the oropharynx.

EBV infects cells in two manners, lytically and latentenly. The lytic type of infection results in active viral replication, viral shedding and cell death facilitating spread. The latent type of infection, on the other hand, is relatively quiescent. Understanding what causes the switch from latency to a lytic infection is of great interest.

In this study, it was determined that GAS colonization can prompt EBV to emerge from latency and become lytic and enhance its presence in saliva thereby increasing the likelihood that it will spread to other humans. 

I think that this paper is fascinating because it highlights the fact that pathogens interact, not only with the host, but, with each other in an elaborate manner that impacts transmission. 

EBV's exploitation of GAS colonization is akin to one criminal exploiting the distraction that the presence of a rival criminal creates to go on a crime spree of contagion. Or maybe they're more like Bonnie and Clyde?