Allergic to Taking a Travel History

Of all the ongoing revelations regarding the first domestically diagnosed case of Ebola in the US, the one that I find most problematic is the fact that the patient initially presented to the hospital, made his travel history known, and was discharged.

It has been reported that the nursing records indicated the travel history but this information was not communicated to others on the care team.

This is a real error.

As an infectious disease physician, travel history is something I always emphasize and not just for Ebola. MERS, chikungunya, dengue, and malaria are all other diseases in which the travel history can be key to the diagnosis. Even for those within the US, travel history is crucial. Diseases like hantavirus, plague, Rocky Mountain Spotted Fever, histoplasmosis, and coccioidiomycosis (and now dengue) have a geographic element to their domestic epidemiology.

No doubt this patient's drug allergies (or their absence) were plastered all over his chart and tethered to his wrist. Travel history is the lynchpin of our defense against emerging infectious diseases and it merits the same level of importance.

The Ebola Gazette

A quick run down of some important developments with the Dallas Ebola case:

• Apparently, the patient's travel history was known at his first presentation but not communicated to the rest of his care team--a major flaw. I am sure the patient's allergies were easily communicated so why not his travel history?
• EMS workers are part of the circle of contacts and their ambulance will be cleaned appropriately
• There is some concern over one particular contact of the source patient

In other news, enterovirus patient deaths have been reported in Rhode Island. 

Ebola Does Dallas

So it looks like the inevitable--based on the sheer size of the outbreak and travel patterns-- happened, an infected non-healthcare worker from Liberia was diagnosed with Ebola in Dallas. While the details are sketchy at this point this case illustrates the extreme importance of asking a travel history in patients who may have been in Ebola-stricken areas. This patient departed Liberia on September 19 arrived in the US on September 20 and was not experiencing symptoms--and thus not contagious--until a few days later, on September 24. Interestingly, the patient first presented for care on September 26 but was not admitted to the hospital on September 28. 

This case, like any Ebola case, can be treated in an ordinary hospital and need not require a containment facility (as the four evacuated patients have been placed in). I, for one, hope that this case is taken care of in the "ordinary" setting of Texas Presbyterian Hospital to illustrate how non-contagious Ebola patients are when cared for using appropriate personal protective equipment.

Another thing to remember is that the US has adeptly handled imported cases of Lassa Fever and, Ebola family member, Marburg multiple times in the past. To quote CDC Director, Dr. Tom Frieden: "There is no doubt in my mind that we'll stop it here."

Ebola will not find the US as hospitable a place as Debbie did Dallas.

Scorpion Grants My Wish: An Infectious Disease Episode

Last week I hoped Scorpion, the new CBS show about a team of geniuses that assists the Department of Homeland Security, would focus on an infectious diseases as well as other problems. Well, this week they granted my wish and they were immersed in responding to a pathogen, related to the common cold virus, synthesized specifically to infect the California governor's daughter and a few others.

What the Scorpion team was facing was a biohacker who employed synthetic biology for a sinister purpose. Synthetic biology, the realm of biology that deals with the creation of novel genetic sequences, holds tremendous promise for curing disease, specifically targeting therapy as part of personalized medicine, and revolutionizing biotechnology. 

However, just like almost every trade, there are dual-use concerns with the rise of synthetic biology, the biohacker movement, and DIY biology. I share some of these concerns but have an overriding fundamental belief that all these developments are essentially good and representative a major advice for mankind. 

While the show requiring some suspension of disbelief--an antidote was made in two hours--it is good to see these issues penetrating into popular culture.

What do Tippecannoe, Typhoid, and the Dallas Cowboy Cheerleaders Have in Common?

In several media interviews I've done on Ebola, I've been asked about historical examples of infectious diseases contributing to the demise of nations--a real fear in Liberia. Some of the examples I've given include: the Aztec Empire & smallpox; Napolean's army and typhus; Justinian's Plague & the Roman Empire; and the Plague of Athens & the Athenian Empire. 

In the US, infectious diseases have made their mark on history too. Think of the Panama Canal and Yellow Fever or the Yellow Fever epidemic in Philadelphia. A recent paper, published in the journal Clinical Infectious Diseases, adds another to the list: the death of President William Henry Harrison.

Renowned medical historian and infectious disease physician Dr. Phillip Mackowiak, whom I've had the pleasure of hearing dissect the death of Alexander the Great, challenges the long-held notion that President Harrison died from community acquired pneumonia--a leading killer even today. 

In its place, Dr. Mackowiak suggests typhoid fever and based on the notes of President Harrison's personal physician it seems to be a convincing argument. One clue is the President's lack of an accelerate pulse, a hallmark of infection with Salmonella typhi.

In fact the single case of typhoid fever I've diagnosed had me anchoring my conclusion to just that. Staring at a college student with a fever of 104F and a pulse rate of 80 after recent travel to India, I was certain of my diagnosis.

It's interesting to speculate on the historical ramifications of President Harrison's death which included, among other things, the annexation of Texas and Mexican-American War. 

So, when asked about the impact of infectious diseases, one can connect a microbe to the Dallas Cowboy Cheerleaders by way of the 1 month presidency of William Henry Harrison. 

Tippecanoe and Tyler Too--that almost sounds like a cheer.