About that Medieval MRSA Remedy...

Over the past 24 hours, I have seen approximately five million references to the following news story: 

Anglo-Saxon Cow Bile and Garlic Potion Kills MRSA

Ancient medicine cures all!!  We're saved from MRSA!  This seems very exciting!  Something that kills the indestructible 'superbug' MRSA, or methicillin-resistant Staphylococcus aureus, is desperately needed from setting medicine back 100 years.  Now we have the answer!  Er...maybe not.

Here's the thing - this finding does not surprise me in the least.  Garlic, onions, and most certainly bile have all been shown to inhibit bacterial growth in a laboratory.  I do not find this report particularly astounding at all.  For topical use on wound infections, it could be a helpful solution.  However, topical infections do not usually kill people.  Septic, visceral, lung, and central nervous system infections do.  In those cases those pesky factors like toxicity (is it poisonous?) and pharmacology (is it digested?  Is it absorbed into the bloodstream?  Can it cross the blood-brain barrier?) become important.  In deference to those obnoxious and weedy details, I present the following (non-exhaustive) list of things that will kill MRSA:

1. Hydrochloric Acid
2. Arsenic
3. Ionizing Radiation
4. Bleach
5. Fire
6. 200 proof (100%) ethanol, isopropanol, or methanol
7. Cyanide
8. Volcanoes
9. Chlorhexidine
10. Iodine
11. Sulfuric Acid
12. Glass beads
13. Honey
14. Sodium hydroxide
15. Formaldehyde
16. Neosporin (really!)
17. Autoclaving
18. French press
19. Freezing it at -80 celsius and then rapidly thawing it at 60 celsius a few consecutive times
20. Nail polish remover

My point here is to take this very cool and fun story with a grain (boulder, whatever) of salt.  Something that kills bacteria does not necessarily make a great clinical antibiotic.  In any event, prescribing "fire" for patients seems like there would be a lot of forms involved.

Foreshadows from the Science Fair

Two important things will happen this April (though I concede only one of them is important outside of our household): my eldest son will participate in his first science fair, and the anniversary of the Reagan Administration's first public acknowledgement of HIV and AIDS will occur.  Those two things seem completely unrelated, but in my world they are very tightly linked.  My elementary school science fair project was originally titled "Germs", until my mother corrected me on the term and had me title it "Disease-Causing Microbes" (thanks, Mom).  I had always found disease interesting, and the science fair seemed like the place to act on it.  My mother, a nurse practitioner with an MPH, was a willing resource and shared many of her books.  I began making a poster with lists of the different types of "germs" (er, disease-causing microbes).  While I was working on a column about viruses, she told me that I had to put "AIDS".  I replied that it wasn't in the books and she, her voice strained, agreed.  "But it will be someday, and it's important that you add it."  

In hindsight, I get it.  I get the strain in her voice, and her insistence that this newfangled AIDS thing was a big deal.  I was a little girl, and I didn't know that people were dying of a disease that the US government was stubbornly refusing to acknowledge largely because of whom it tended to affect.  If I had known, I wouldn't have understood why.  In the years since, the US government and US-based foundations have poured billions of dollars into the science, diagnosis, treatment, and prevention of this disease.  Not bad for 31 years of work.  Not bad at all.  

As for science fairs?  Sometimes they foreshadow things.  If history repeats itself, my son will be a professor writing a paleontology blog (or whatever the modern equivalent is) at 11:30 PM someday.  Sometimes science fairs give the intellectual kid a chance to be rewarded as such.  Or at the very least, they create yet another reason for my boy to talk about dinosaurs.  

Talking About Vaccines: Maybe We've Been Doing it Wrong

(Image: Coursera, "Epidemics- the Dynamics of Infectious Disease")

Recently I have been working on a piece for the Bangor Daily News about pending legislation in Maine that would make vaccine opt-outs and exemptions more difficult to acquire.  This is an important topic up here, since our immunization rates fall below herd immunity threshold.  Translation: unvaccinated persons are officially at elevated risk for contracting vaccine-preventable diseases.  This not only means the medically exempt; it means kids who had been exempted voluntarily, and most tragically of all, all infants up to one year of age.  As such, members of the state legislature have introduced a bill to address this problem and restore the state of Maine to herd immunity levels in defense of all infants and the medically fragile.  Makes sense to me.

I have been having trouble writing this piece, because every time I finish it, I hate it.  It sounds like every clinical or scientific defense of vaccinations I've ever read (those snarky ones on BuzzFeed and HuffPo, or this wonderful piece in Grounded Parents notwithstanding).  Why should this piece be any different from the others, where we try and repeatedly fail to sway hearts and minds into protecting children?  How the heck do we lose this argument so frequently?  It's baffling!  This seemed well outside my expertise, so I started talking to some colleagues who are experts in neurosciences.  Paydirt.

Of the phenomena discussed, one has given me something reasonable to try with this article.  Apparently somewhere deep in the limbic system, our brains are conditioned to believe things as true based not on how much sense it makes, but on how many times we've heard it.  Reading up on this a bit more, I found a paper that discussed this idea with regard to vaccine policy.  The upshot of my exercise is this: by systematically debunking vaccine myths, we keep repeating them.  The context is irrelevant to that very primal part of our brains.  We keep repeating them.  A great example I can think of here would be the "birther" nonsense about Barack Obama.  No matter how many ways his birth in the state of Hawaii has been documented, verified, and everything else, a disturbingly high number of people still believe he was born outside the United States.  Instead of saying "in response to suspicions he was born in Kenya, blah blah blah", a more effective presentation would have been "President Obama was born in Honolulu, as documented here."  The second statement does not repeat the myth, and the first does.

I am going to start my BDN piece from scratch.  I am further going to reconstruct my course materials for the med students on how to talk with patients about vaccines.  "In the state of Maine, a 6-week-old infant is at risk for contracting whooping cough due to low immunizations rates.  This has a high rate of death, and an almost universal chance of leaving surviving infants with permanent damage to their respiratory tract.  A critical way to address this is to ensure that everyone in the household has received a safe and effective TDaP vaccine" would hopefully be a good place to start!

What Doesn't Kill You...

...may leave you permanently disfigured, disabled, and shunned, if we're speaking about infections.  In particular this is true of a group of ailments known as "neglected tropical diseases", or NTDs.  These are infections that disproportionately (and in most cases exclusively!) affect those in developing countries across the tropics.  We may be tempted to think that because they do not leave millions of deaths in their wake, they are not an important health topic.  This could not be further from the truth.  Take infection with the parasite Onchocerca volvulus, for example.  This worm infects the eye, and causes terrible scarring of the cornea as the immune system tries desperately to kill off the parasite.  Never mind the maddening feeling of a worm twitching and rolling in one's eye; the most impactful outcome of this disease is the corneal scarring.  Patients are left blind, hence the common name for the infection of "river blindness".  Those affected are often left unable to work, hunt, farm, and otherwise maintain their economic security.  

A young South Sudanese woman with river blindness due to Onchocerca volvulus (Photo from http://therefugeeroad.blogspot.com/ )

Perhaps more infamous among these diseases is elephantiasis (or lymphatic filariasis, clinically speaking).  This is caused by a few different species of parasitic worms including Wuchereria bancrofti and Brugia malayi, and is characterized by intense swelling of individual limbs, causing them to resemble the limbs of elephants.  The limbs are swollen with lymph fluid and adult worms.  If a patient is able to access anti-parasitic medications such as ivermectin or albendazole, this will only keep them from transmitting the disease to others.  It will not cure them.  If every living worm was killed, the disfigured limb would remain.  Similarly, the stigma would remain.  Though elephantiasis is transmitted by a bite from an infected mosquito, the perception of patients as unclean is widespread.  Affected persons are often unable to find a willing employer even if they are physically able to work.  Some are shunned by their families.  This disease may not kill, but to pretend it is therefore unimportant is a fallacy.

An elephantiasis patient in Bhutan (Photo: Mark Brazinski) 

How can one help solve this problem?  Prevention of infection is key.  This means widespread access to medication or more ideally the development of preventative vaccines.  Since these will by definition be unprofitable endeavors, research studies to discover and develop them are often funded by Federal governments, international agencies, or charitable foundations such as those run by Jimmy Carter and Bill and Melinda Gates.  In addition to politically or financially supporting research, there are other ways to address those already infected.  A growing number of companies seek out NTD patients as employees as part of their business models.  One of my favorites is Global Girlfriend, which employs women as artisans to hand-make clothes, jewelery, and accessories and sell them worldwide via the internet.  Most touching, every order includes the story of the woman who made the product.  My particular favorite is my Congo Solidarity Skirt ("river"): it was made by a woman who lost the use of her leg due to polio, and was abandoned by her husband.  She now has an income and a home.  There are many ways to have an impact on these non-killing, life-shattering diseases.  Please remember them.

TB is Trending on Facebook!!

And Let's not Forget What we Just Learned

Several weeks ago a high school student in Kansas was diagnosed with active tuberculosis, a disease characterized by cough, fever, night sweats, and wasting.  Active TB patients are capable of transmitting the infection to others, but those others typically do not become sick right away.  The TB bacteria infect their lungs in a dormant state, termed latent infection.  These individuals are not contagious; the bacteria are sequestered in their lungs, and they are not coughing to facilitate its transmission.  

TB bacteria sequestration in lungs during latent infection
L. Ramakrishnan, Nature Reviews Immunology 12: 352-366, 2012

As it turns out, the first student has infected 27 others, who are now in the latent stage of the disease.  Those students are not contagious.  All 28 persons are currently undergoing antibiotic treatment, and are expected to recover fully without infecting anyone else.  How frightening is it that there are 28 tuberculosis patients in Kansas?  It is actually quite a normal level.  We do not tend to hear about it, but TB is not spectacularly unusual in the least.  

As we just learned with Ebola, assessment of risk to others is well understood.  Nothing to worry about here.

A New Ebola Case in the US Illustrates Our Collective Learning

A clinician working with Partners in Health was evacuated to the US from Sierra Leone after developing Ebola virus disease.  The patient is currently being treated at the National Institutes of Health, and is at present in critical condition.  Early in infection this clinician was treated/attended by twelve of his or her colleagues resulting in their exposure to Ebola, and they were similarly evacuated to the US and remain in quarantine (note, not isolation) in Nebraska, Maryland, and Atlanta.  One contact in Omaha showed clinical signs Monday and was promptly isolated; however, that patient has since recovered and has thus far tested negative for Ebola.

A PIH Clinician treats an Ebola patient (photo courtesy of Partners in Health)

There is a subtle, unspoken victory here that warrants a celebration of sorts.  I looked this morning on CNN for an update on this patient's condition, and could not find one.  Similarly, ABC News had not written about this case for 3 days.  In October, this would not have been the case.  In October, there were loud cries for the blocking of Ebola treatment of American citizens in the US.  Among my least favorite descriptors - "those people" - was frequently shouted.  No one is shouting now.  No one is being vilified.  No one doubts that this patient, who can only be described as selfless and heroic for how s/he became infected, deserves to come home and receive medical care.  I take this to mean that we as a society have learned.  We have come to realize that no one was being lied to; no one was promising safety where there was imminent danger.  I take it also to me that we as a profession are a small step closer to regaining some trust.  

May you be well soon, NIH Patient.  Thank you for your service.

One is too Many

Though it has faded from the headlines to some extent, new measles cases continue to be diagnosed in the US following a large, multi-state outbreak of the vaccine-preventable disease.  Patients were initially exposed following visits to Disneyland, and satellite cases appeared across the country.  What has not been discussed much is that satellite cases have also appeared in other countries that were exposed in California.  The World Health Organization report "Measles-The Americas 2014-2015" also describes a fatal case in Brasil.

Courtesy of the Centers for Disease Control and Prevention

Pushback against criticism of parents who choose not to vaccinate their children for nonmedical reasons has included arguments that "measles is not that bad a disease", and "only 1 or 2 in 1000 patients die" (called out in this excellent piece in Science Based Medicine).  Excuse me, can you repeat that?  "Only 1 or 2 in 1000 die"?  One in 10, 1 in 1000, 1 in 1000000...if the "one" is someone you love, it doesn't matter one damn bit how many other people were left alive.  This has to particularly sting if you chose not to vaccinate your child.  This is an exceptionally cruel reality when your child is unable to be vaccinated (often due to age in the case of measles).  In a circumstance such as measles where there is a safe, cheap, and easy way to prevent it?  One is way, way too many.      

Victory in Liberia

Late last week the last known Ebola patient in the country of Liberia was discharged from the hospital.  This represents a number of victories, both large and small.  Beginning with first principles, Beatrice Yardolo left the hospital alive and well.  Things will never be the same -three of her children lost their fight with Ebola- but she recovered.  Last year at this time, when workers for MSF were sounding an alarm that went unnoticed for several more months, a patient leaving the hospital in anything other than a body bag was something to celebrate.  

 Beatrice Yardolo begins the rest of her life (Photo Abbas Dulleh, AP)

This epidemic was so different from previous outbreaks in many ways.  The sheer size and scale of it was unprecedented.  The circulation in major cities was a new and terrifying feature.  The departure of Ebola from the African continent resulting in spread between humans had never happened before.  The epidemic has sustained for over a year.  Many, myself included, suspected that Ebola would become endemic in West Africa.  In other words, it would become entrenched enough that transmission would just go on continuously between humans, and the epidemic would never officially end.  The discharge of Ms. Yardolo signals that we were most likely wrong, and the epidemic will end someday.  That is outstanding news.  

'Someday' is not in sight, however.  While Nigeria, Mali, Senegal, Spain, and the United States are now considered free of Ebola and there are no known active cases in Liberia at the moment, there is still a lot of work left to do in Sierra Leone and Guinea.  Both have see cases begin to resurge a bit after a lengthy decline.  But we as scientists have learned a lot in a very short time about Ebola, and I am cautiously optimistic.

For Liberia, the work of fighting the epidemic is taking a backseat to the next challenge.  For Liberia, it is time to rebuild.