Reason Prevails in Maine

Reason Prevails in Maine

A district court judge in Maine has lifted the state-imposed quarantine order on the clinically normal, uninfected, Kaci Hickox.  Justice LaVerdiere indicated that the court was aware the the actions and cult of fear were based on "bad science and bad information", and ruled in favor of Hickox, provided that she continue self-monitoring practices as recommended by MSF and the CDC.  Governor LePage responded with displeasure, indicating that his responsibility was to keep the public safe in the State of Maine.  I, for one, am grateful that at least one public servant recognized that my safety as a Maine resident has precious little to do with Kaci Hickox.

Finally, I am grateful for the well-deserved commendation Justice LaVerdiere gave to Nurse Hickox:
"We would not be here today unless Respondent generously, kindly and with compassion lent her skills to aid, comfort and care for individuals stricken with a terrible disease. We need to remember as we go through this matter that we owe her and all professionals who give of themselves in this way a debt of gratitude.”

Let's not forget how and why we the public came to know her name.  

Bonus Dose of Ebolology: The Perception of Controversy

The Perception of Controversy

If I hear one continuous theme throughout this outbreak from non-colleague friends, it is that they do not know what to believe.  Ebola is terrifying.  The CDC says not to worry.  The news talks about it constantly.  The President reminds us that only 2 people have contracted this disease on US soil...ever.  There are forced quarantines implemented by state governors.  Anthony Fauci says they're ridiculous.  When presented with conflicting information, it is human nature to play things safe.  Why risk the disease with the 90% mortality rate that kills you after your bleed from your eyeballs?  

The trouble is that there is virtually no scientific controversy here.  Those of us who underwent nearly a decade of training on the topic are feeling quite reasonably confident about directions, control measures, and risk assessment.  The volume of news coverage is not proportional to the risk posed.  Let me say that again for the folks in the cheap seats: constant discussion on CNN does not necessarily equate to constant and unrelenting risk of your own death by Ebola.  It just doesn't.

With regard to the actions of Chris Christie and Andrew Cuomo (and coming soon to the debate from Maine, our own Paul LePage)...they are not scientists.  They are pandering to the masses.  This does not mean that they have some special insight or knowledge.  It means that they are playing on public fears.  A frightened public rallies around its leader.  That is their expertise, and they utilize it very well.  Sidebar: do note that I am equally chiding a D and an R, here.  They are doing what they know how to do: rally the public and play on mood.  They are not scientists, and their actions should in no way be interpreted as evidence of anything other than their career choices.

This issue could not have been encapsulated better than in this interview with the Dr. Robert Dixon, UMaine-Fort Kent VP for Academic Affairs, who was answering why UMFK student Ted Wilbur, Kaci Hickox's boyfriend, would not be allowed on campus until November.  Pay close attention to what he says at 0:42.  "Even though the science is one aspect of this, we have to pay attention to the way people feel."  No, sir, you don't.  You have an opportunity to stand up and say, "I trust the experts, and am encouraging us as a community to calm down."  You blew it, Dr. Dixon.  You, of all people in all professions, chose to disregard academics and evidence, and bow to hysteria.  Well done.

No wonder everyone is confused.

Trust the people who do this for a profession.  Remember the motives of those in other professions.  There is no controversy here.  There is a mixed message, but not mixed evidence.  The evidence overwhelmingly indicates that we are all going to be okay.

 

5:00 Dose of Ebolology: Closing the Borders is not the Answer

Closing the Borders is not the Answer

This is a question that will not go away.  It seems like such a simple solution, doesn't it?  Don't let anyone in, and we'll be safe.  This is not so simple, as it were.  

1.) If someone passes through enough countries, it will be very difficult to track their origins.  Stoppage of fever monitoring and contact tracing because "our borders are closed" would be irresponsible and ineffective.

2.) Mali reported its first case this week, and it is not clear if Cote d'Ivorie has active cases or not.  There would constantly be countries added and taken off the "block" list.

3.) What does one do with a U.S. citizen who wishes to come home?  There are major civil liberty issues at play here.

4.) MSF, USAID, and related aid groups desperately need help.  We should not make it harder for volunteers to come and go.

The key to preventing more cases in the US and Europe is stopping this epidemic in West Africa.  Let our workers come and go as they need.

Bonus post coming tonight, post Trick or Treating!

4:00 Dose of Ebolology: Ny, NJ, and Kaci Hickox

New York, New Jersey, and Kaci Hickox

Imagine you have just spent a month away from home.  You've been in 100+ degree temperatures, in cumbersome gear, doing work that can only be described as truly emotionally draining.  I'd imagine looking forward to seeing my loved ones, breathing fresh air, and sleeping in my own bed.  After hours of transit, you're finally back in the US!


...and you're immediately taken into custody.  You do not know why.  You are forced to miss you connecting flight, because you've been detained by authorities.  You have not broken any laws, and do not have a lawyer.  You were on your way home, and did not imagine you'd need one.  You did not imagine that the states of NY and NJ had gone insane during your flight.

You are taken to a tent.  It is not heated.  No one is allowed to come in and see you without being "cleared" by the authorities detaining you.  You are not sick, but they are telling you that you are a threat to the public.  You've seen sick people, ironically, and know exactly who poses a threat to public health.  You are being held, and no one is telling you when you can leave.  No one is telling you who has the authority to hold you.  You have, effectively, lost your right to Habeas Corpus when you have done nothing wrong.

That is what happened to Kaci Hickox.  She is not sick, and poses no risk as of now.    

That is why she is so angry.  You know what?  She has every right to be.  We should be angry on her behalf.

(NOTE: I am currently writing this in the great state of Maine, where Kaci is out and about on her bike right now.  Ride on, Friend~)

3:00 Dose of Ebolology: Why is there no Vaccine for this??

Why is there no Vaccine for this??

There will be.  Treatment with antibodies (via ZMapp or blood trunsfusion) works very, very well.  That is a promising sign that vaccination will be successful.  Human trials begin in West Africa in January, as led by Institute for Human Virology and others.

Stay tuned: this is a major tool to be added to the toolbox imminently.

2:00 Dose of Ebolology: The Drame Brothers

The Drame Brothers 
Amadou and Pape Drame are 11- and 13-year-old brothers who live in New York City.  They recently moved to the US from Senegal.  Notably, Senegal is a West African nation, and it did have a very small number of (properly contained) Ebola cases.  None have been reported since August.  Needless to say, there is no reason to expect a Senagalese individual would be an Ebola carrier.  A few weeks back, the Drame brothers started to be teased at school, and other kids wouldn't pass them the ball during gym or let them play on common equipment.  Last week, Amadou sneezed while at school.  Some kid shouted "he has Ebola!!"  He was then punched in the face.  Pape came to help his brother.  Both were beaten up.  A month ago, both boys loved their school, and were happy to be in America.  These kids did nothing wrong.  Similar stories of persecution and bullying of West Africans are started to creep out, and I am beyond disappointed by it.  We are all responsible for perpetuating this climate if we are not working to change it.  Listen to experts.  Do not listen to newscasters.  Do not listen to politicians.  Listen to experts.  When we don't, we create and enable a climate where these boys are targeted and beaten.  They deserve better.  

1:00 Dose of Ebolology: Ebola's Mortality Rate in Context

Ebola's Mortality Rate in Context

Further Update: Dr. Craig Spencer has fully recovered, is from of Ebola, and has been released from the hospital.  This officially brings the case:fatality ratio in the US to 1:9

UPDATE: Dr. Craig's Spencer's condition has been upgraded to "stable" from "serious but stable".  Hopefully he continues to recover, and will become person #8 to walk out of the hospital.

EBOLA KILLS UP TO 90% OF THOSE INFECTED!!!!!!!!!!!!  

So scream the headlines.  For a long time, this was absolutely true.  Depending on the strain and healthcare options available at the site of an outbreak, it is often still true.  The official mortality rate of the current epidemic in West Africa is wavering between 50% and 55%.  In other words, this outbreak is a little less "fatal" than others, but still-living or dying has the same odds as a coin flip.  The mortality rate in West Africa is disturbingly high, and we as a society can and should do better.  Why am I and my colleagues NOT PANICKING ABOUT AN OUTBREAK IN THE US????

Clinical outcomes from Ebola cases are very context dependent.  Effective treatments such as fever control, fluid replacement, dialysis if need be, and passive transfer of antibodies do exist, and Western countries have the infrastructure to administer these interventions quite effectively.  9 people have been diagnosed/treated in the United States.  1 (Thomas Eric Duncan) has died, and it is important to note that Duncan did not receive treatment until he was already critically ill.  1 (Craig Spencer) is hospitalized and his condition is serious but stable.  The other 7 have walked out of the hospital completely recovered.  

In other words, in a Western healthcare setting, the mortality rate is more or less inverted.  This is still quite serious-I do not mean to minimize it-but let's keep it in perspective and context.

12:00 Dose of Ebolology: How dangerous are Dr. Spencer and Nurse Hickox's Actions?

12:00 Dose of Ebolology: How dangerous are Dr. Spencer and Nurse Hickox's Actions?

Drumroll for an anticlimax......

They are not dangerous.  Neither of these extensively trained professionals have done anything wrong that will endanger the public.  Please think it through for a minute: both of these individuals gave large blocks of their time to put themselves at risk (actual risk) in order to curb the spread of disease.  Why in the world would either one then turn around and callously enable the spread of disease?  That narrative does not make sense.

Craig Spencer was monitoring himself.  When he developed a low-grade fever (and was not likely to be shedding virus), he immediately and properly sought treatment under strict isolation.

Kaci Hickox is not sick.  As of this point, there is no evidence that she is infected.  If she is, and later develops clinical signs, she will be isolated.

These people are servants of humanity, and deserve our respect.  They do not deserve to be demonized.  Finally, and more practically, they are not dangerous.

   

11:00 Dose of Ebolology: Africa is a Very Big Place

11:00 Dose of Ebolology: Africa is a Very Big Place

Reports abound this week of children, teachers, principals, and office workers being sent home (notably without sickness) because they had recently visited an African country.  The epidemic is centered in Africa-this is true-  but it is a very, very, very big place.  The principal banned from school in Louisiana because he had visited Zambia?  That would be roughly equivalent to quarantining people in Seattle because we have a case in New York.  That is ridiculous.

Sending home school children because they have recently been in countries with NO active cases?  Also ridiculous...and potentially very damaging.  These children are missing schoolwork and lessons.  They are missing playing with their friends.  They are potentially being stigmatized (more on this potential danger-literally- at 2:00).  Their parents are forced to secure childcare...and pay for it...or miss work themselves.  All this because not enough of us can effectively read a map?  This is not okay.  This is hysteria, and we as a society are simply enabling bad behavior.

Ebolology Part 2: More Calming Balm

...because Part 1 was not enough to create a counter-epidemic of rationality!

For our 10:00 dose of Ebolology, I think I'll simply hit you with another dose of calming balm.  Reread and refresh, and then we'll discuss new aspects of this growing mess at 11:00.  

Please share; spread reason, not fear!!!

 Original Text (as linked above):

10:00 Dose of Ebolology: Dr. May's Calming Balm.

We've all heard it: "stay calm", said by dudes in suits who may appear not to have a handle on things. Meanwhile, the internets rage with panic. If you know and trust me, please hear this one: do stay calm, and keep things in perspective. With respective to the infirm and the deceased, we are not talking about a large number of people here in the US and in Europe. Said people are truly not particularly contagious, unless you are sprayed by their innards (hence secondary infections from index cases tending to be nurses and physicians). Said people are also usually not up walking around once symptomatic, which is when they are contagious, because, you see, they are quite sick. If you've had contact with a patient, please be vigilant. If you have not, please be calm. I promise these will get more interesting and practical, but I figured this one needed to come first.

A Letter from MSF Regarding Dr. Spencer and Nurse Hickox

Like many MSF supporters, I received a letter this evening addressing the action taken by Dr. Craig Spencer prior to his clinical illness becoming apparent.  If you are concerned about Dr. Spencer, or are interested in Nurse Hickox's situation, please click here to view the letter.

There is no need for concern.  Please pay these professionals the respect they deserve~

Happy Birthday, Jonas Salk

Today Dr. Jonas Salk, inventor of the world's first polio vaccine, would have been 100.  His vaccine (the "IPV") is still in use.

Today, millions of children are alive and well because of this man (and/or his rival and colleague, Dr. Albert Sabin).

I am grateful for today's Google Doodle, which honors Dr. Salk.  It serves as a reminder that there was a time when scientists and physicians that broke new ground and did risky work for the good of humanity were heroes.  I think it's time we brought that back~

5:00 Dose of Vaccinology: The Herd Immunity Argument

5:00 Dose of Vaccinology: The Herd Immunity Argument

Often, people justify not vaccinating their children because of "herd immunity".  The reasoning goes that this notion should keep their child safe without being vaccinated, so why risk ("risk", really) it?  Before my verdict on this is given, allow me to quickly define herd immunity.  This is the concept that disease transmission requires a certain level of susceptible population density, and if the susceptible population is tiny because most people are immune, that disease transmission will not occur.  In other words, if 198 adults and 2 children are standing in a crowd and 1 of the children has the chicken pox, very little will probably happen because the majority of the adults are immune.  Make sense?  Okay, moving on.

Point 1: Not everyone in a given population can be vaccinated for various completely valid reasons (congenital immune deficiency, cancer treatments, ingredient allergy, whatever).  Similarly, not everyone who is vaccinated responds equally well and achieves protective immunity.  These individuals are protected by herd immunity.

Point 2: So the argument goes, vaccines are "potentially dangerous" so you will allow your child to benefit form herd immunity.

Point 3: this not only reduces the robustness of herd immunity for those who must rely on it (see point 1), but implicitly implies that you will gladly reap the benefit of someone else's risk (again, "risk") without a valid need to do so, which...

Point 4: Makes you kind of an ass.

Unprofessional?  Yes.  So very true, however.

  

4:00 Dose of Vaccinology: What are These Toxins I hear About?

4:00 Dose of Vaccinology: What are These Toxins I hear About?

Like all good urban legends, this one has a grain of truth in it.  There are "toxins" in some vaccines, and they are exactly what you want immunity against.  First, a disclaimer.  I am not talking about mercury.  The words "vaccine" "toxin" and "mercury" have all mated into some kind of amorphous blob of scary with two pecks of unrelated truthiness in it.  A small number of vaccines (NOT ALL) contain a small amount of mercury as a preservative.  On a parts-per-million basis, getting one of these shots roughly approximates eating a tuna sandwich.  Another point to consider is that there is a preservative in them for a very good reason.  If you're wondering what it is, ask one of those poor folks who had fungal spores jacked into their spine a couple of years ago.  Moving on...

The actual "toxins" in some vaccines were alluded to in the 11:00 dose that referenced diphtheria.  Some bacterial species actually cause their disease symptoms by producing toxins.  I also mentioned this when discussing cholera in Haiti a few days back.  Since the toxin generates the disease, the toxin is the most important thing to raise protective immunity against.  Purified bacterial toxins that lead to tetanus, pertussis, diphtheria (and, now in clinical trials, C. diff!!) are deactivated enough to not cause their associated diseases while still generating protective immunity.  Voila!

So, the toxins aren't toxic in this case.  The sicknesses are avoided.  All is just fine.      

3:00 Dose of Vaccinology: A Great Success Story

3:00 Dose of Vaccinology: A Great Success Story

Today is World Polio Day.  Only 3 countries remain polio-endemic, meaning there are only 3 places in the world-Pakistan, Afghanistan, and Nigeria- where this virus is still routinely circulating and entrenched.  They have been satellite outbreaks in other countries, but all link back to one of these places.  This is a major achievement!  Polio left children temporarily and in many cases permanently paralyzed.  If the virus struck neuron that coordinator muscles related to breathing, breathing would stop (as would life, at that point!).  Polio was targeted early in the development of vaccines, driven in part by American mothers who were terrified for their children's safety, and in part by initiatives begun by Roosevelt, who himself was left paralyzed by polio.

I would like to share some images of the news that a polio vaccine had been generated and was now available.  They are very impactful.  As I discussed with a colleague last summer, when both of our sons had a virus that presented as an annoying, naggy fever, we were lucky to be conversing as annoyed mothers rather than terrified ones.  Summertime fevers 60 years ago meant something very different.

Jonas Salk becomes a national hero

Enormous lines formed to receive a dose of the polio vaccine

Because people didn't want their children's lungs paralyzed, causing them to require "iron lungs" 

2:00 Dose of Vaccinology: Misinformation Kills People

2:00 Dose of Vaccinology: Misinformation Kills People

The reason I wanted to start today by setting parameters around what vaccines are vs. what they are not is that I knew I wanted to write this post.  This one is the important one.  The reason is that if parents choose do their own reading in order to make decisions for their children, they are frequently coming at it from a caring place.  They don't want bad things to happen to their children.  I have children, and I completely and utterly get that.  Here's the rub: not everyone cares about you children the way you do.  Some people care about their own agenda.  Some people care about being famous.  Some people care about selling you things.  Of course, some people genuinely believe they're disseminating helpful information, but do not necessarily have the expertise to parse all of the nonsense that the above three are hawking.  

I don't imagine I need to link all kinds of anti-vaccine sites spouting nonsense, or factually validated but snarky sites debunking said nonsense (though I can if anyone would like).  There are two overarching phenomena at play that I think would be far more helpful to bring up:

1.) When it comes to scary stuff that affects our kids, blind trust in people who may or may not patronize you while using terms you don't understand (and why should you?) is not always easy when there is a more relatable voice shouting very loudly.  The thing to consider is that factuality is not dependent on the messenger.  The risks of vaccines are what they are (and 'what they are' is trivial), even if the person saying them can't be bothered to explain how or why.  The risks of infectious diseases are what they are (and 'what they are' is substantial), even if the person telling you they are not is lovely and patient and kind.  I promise, Hib will give your child meningitis whether or not you believe it is a problem.  It is totally unprejudiced like that.

2.) The way search engines work highlights how evil (I do not use that word lightly) some of these groups are.  Their sites are filled with words that are likely to garner more hits from people they are likely to persuade, whereas "fact sheet" type sites are filled with different terms.  Think "shot" versus "immunization".  "Germ" vs. "bacteria".  Then there is the care that goes into naming the organization.  There is no more egregious example of the than the change of the group "Concerned PArents Against Vaccines" to "The National Vaccine Information Center".  Which sounds like experts work there?  Same group of (expletive) people.  Numerous peer-reviewed bioethics journal articles have broken down the digital data on this.  It is sickening (no pun intended).  Those who design their sites this way are some truly terrible people.   

Handing your baby over to be shot full of things that you've read may be dangerous and then watching them cry hysterically is gut-wrenching.  I get it.  There needs to be extreme trust there.  What is not immediately seen by parents is the far more insidious danger that unvaccinated children are in, because the extreme trust was given to the University of Google.  

Put your trust in the right place.

  

1:00 Dose of Vaccinology: Why Your Daughter Needs Gardisil Even Though it's for an STI and she's 11


Ah, this question.  It's a close relative of "Why does my baby need a hepatitis B shot?".  It turns out that one had quite a valid answer that made us all less uncomfortable (namely, Hep B is frequently transmitted by infected mothers to their babies prenatally or perinatally, and God knows how toddlers are with body fluids).  But Gardisil...that one makes us think about the inevitable reality that someday our children will have sex.  Finish shuddering so we can move one.  Good?  Okay.  Here are the things about Gardisil:

1.) IT.IS.A.CANCER.VACCINE.  Yes, it prevents infection by certain strains of Human Papilloma Virus, but somehow it has been lost in translation that we care about these strains because they cause cervical cancer.  Fun fact: they also cause penile cancers and head/neck cancers, so this isn't just a "people with daughters" problem or a "heterosexuals only" problem.  Girls in this age group were the populations the clinical trials were done on and cervical cancer is the most prominent complication, that's all.  But I digress from my point: this is a cancer vaccine.  As a scientist, do you know how many time I've been asked at parties, "hey, when are you guys going to cure cancer?"  Well, folks, here you go.  You're welcome.

2.) Your children will one day have sex.  Get over it.  Have the guts to keep them from getting infected, no matter how uncomfortable it is for you to think about.

3.) Michele Bachmann recited an anecdote from a random lady, and to many people this now this means Gardisil causes mental deficiencies and it's best not to risk their children's health.  More on (mis)information and parental decision making at 2:00, but here's the thing: It is best not to risk you children's health.  You know what is a health threat?  Cancer.  Eye on the ball, guys.

4.) I am a mom of sons.  If my opinions and actions are meaningful to anyone on the topic of infectious disease, I plan to have them vaccinated against HPV with Gardisil as soon as they are of age.

12:00 Dose of Vaccinology: The Privilege to Make Stupid Decisions

A few weeks ago, articles like this one were circulating.  Sadly (on two fronts), it is absolutely true.  Some very affluent school districts in Southern CAlifornia have immunization rate comparable to, or lower than, South Sudan (depends on the vaccine in question).  There is sadness in here for the South Sudanese, who for numerous economic, infrastructural, accessibility-related, displacement-related, war-related reasons have lower-than-we-would-like immunization rates.  There is also sadness of the deep-sighing, head-desking, face-palming variety for those Californian parents and their nationally distributed counterparts.  What is privilege it is to be so blissfully unaware of deadly diseases because you've never had to see them.  What a privilege it is to be allowed to make such an asinine decision.  The 2:00 does will focus on some of the factors that go into the making of that decision (I'm toying with calling it "The People I Would Like to Shank for What They do to Well-Meaning Parents")

2013-2014 was a *great* year for this nonsense here in the U.S.  We currently have an ongoing pertussis ("whooping cough") epidemic in California, and had a national measles outbreak (in addition to some unrelated regional outbreaks).  Both of these statements are absurd.  This is needless suffering.  

The measles outbreak got rather close to personal for me, because there were cases in Boston. My spouse rode the commuter rail every day, and then came home to snuggle and kiss our 3-month-old son.  Our son who was too young to be vaccinated was put in secondary contact with potential measles infection.  This is related to why I love that our pediatrician will not allow unvaccinated children in his practice.  No measle-sneezes on newborns ever need to occur in Western countries.  Ever.  That is not only grossly stupid; it's grossly unfair.  

11:00 Dose of Vaccinology: Why Does my Kid Need a Diphtheria Shot When No One Gets That Anymore?

The answer to this question is elegantly simple: "no one gets diphtheria anymore" because most of the people in the general public are vaccinated.  The organism that causes this disease, Corynebacterium diphtheriae, is alive and well on Planet Earth.  The protein it makes that causes the disease diphtheria ("diphtheria toxin") is kicking around, ready and waiting.  The reason you do not see this disease is because most of the people you encounter have antibodies, generated during vaccination, that soak up diphtheria toxin before it can cause illness.

There is excellent real-word evidence for this in two forms:

1.) The bacteria and the toxin are readily detectable in animals and even in healthy (vaccinated) humans (if this seems counterintuitive, tune in at 4:00 for an explanation).

2.) Destabilization of governments often leads to declines in vaccination rates, usually due to the closures of clinics and hospitals, shortages of vaccine doses, or the loss of programs that paid for them.  There are numerous examples of this (the polio outbreak in Syria last summer, for one, and the TWO within the US this past year-more at 12:00), but an extremely well-characterized example with diphtheria came after the fall of the Soviet Union in the early 1990s.  Again, this is certainly not unique to diphtheria.

The things about microbes is that they're invisible.  Just because you don't see them doesn't mean they're not there.

10:00 Dose of Vaccinology: What a Vaccine is, and is Not

What Vaccines Are:
Back to basics, for a start!  Vaccines are, in brief, preventative measures.  They expose your immune system to levels of certain disease-causing agents (pathogens) that will create "protective immunity"; in other words, a response that will be able to prevent an immunocompetent (ie, "healthy") individual from becoming infected.  These can be made of dead pathogens, purified (and inactivated) parts of pathogens, or live but very, very weak pathogens.  They are one of, if not THE, most successful health interventions in human history.  They are still necessary (more on this later today).  They are effective at preventing disease.  They are critical to world health.

What Vaccines are Not:
(detailed posts on some of these later today)
Vaccines are not treatments.  They are preventions.  They must be administered prior to disease threats to be effective (with a single quasi-exception).  Vaccines are not poisonous.  Vaccines are not dangerous.  Vaccines are not "overwhelming to the immune system" (honestly...has you kid ever stuck their hand on a sticky railing at Disney World and then eaten with it?  FAR more immunostimulatory, I promise).  

Let's start today with these basics in mind.  See you at 11! 

Vaccinology Day!

Beginning at 10 AM EST, hourly posts on this topic 10/24/2014.

Sewage and Cholera, Voices from the Front Lines

I am sharing two comments left in response to the post about cholera in Haiti.  These were made by friends who spent two years in Guyana, serving in the Peace Corps.  Their insight is invaluable, so I thought I'd share!  Thanks again, Ilana and Nate!

-MM

In the Words of Ilana Echevarria-Stewart:

Meghan thanks for sharing this. Really great insight on a continuing problem that doesn´t seem to get much attention since the earthquake. 

Like Nate mentioned, living in the 2nd poorest country in the Western Hemisphere, I am not surprised that the lack of sanitary infrastructure is what perpetuates this epidemic. Many rural communities in Guyana didn´t have latrines or had very few ones causing them to defecate into rivers (their primary source of drinking water) or anywhere with some bush cover. In fact, we worked in a small community of only 100 people and Red Cross installed 5 latrines for the community. However, because they wanted these latrines to be (more?) sanitary they built them pretty far away from the houses. Unfortunately, this had the opposite effect as hoped. Since they were so far away, community members continued to defecate outside their doors and not use the latrines. So they just sat there and were used more like trash cans or bat houses!

While reading the NPR article what really stood out to me is that over $9 million of aid has been given to this country, yet no long-term solution has been implemented. So many of these problems have easy solutions but require long-term program and infrastructure implementation. However, it just seems easier to put a cheap band-aid on it and then act surprised when it doesn’t work. Why only build 5 latrines, why not build compost latrines that don’t require someone to empty it out and doubles as a fertilizer? There are solutions out there, they just aren’t being implemented. 

I could keep going on about this and the second issue of proper rehydration, but I´ll save you from it. These health issues are near and dear to my heart and being on the ground really helped me understand the many pros and cons of aid organizations and how they don’t always efficiently help these underdeveloped countries. 

Thanks for including me in this Dr. May

In the Words of Nate Stewart:

Wow. Thank you for reaching out with this information. I had no idea that cholera had affected/killed so many, or that it's a toxin from the bacteria that causes the diarrhea, or that the treatment is simply to properly hydrate! 

As someone who lived in the second poorest country in the Western Hemisphere (Guyana), I'm still awestruck when I learn about how exponentially worse things are for Haitians. As detailed in the NPR article you linked to, there are no sewers. None. Latrines are a luxury and have to be emptied by hand. Many people just go to the bathroom in a plastic bag and throw it. Until they get sewers, the Cholera problem seems intractable. 

Thanks for raising my awareness Meghan!

Fun Facts About Flu Vaccines

Flu Vaccines, A Prelude to this Week's Vaccinology Day (10/23) and Next Week's Fluology Day

Some fun facts!

1.) Flu shots take approximately 2 weeks to fully protect you from influenza infection.  Get one ASAP, not after flu season starts

2.) Traditional flu vaccines do not, cannot, give you the flu.  They are composed of killed viral particles.  FluMist is live, but severely attenuated.  If this still worries you, go with the classic needle variety and you'll be fine.

3.) Respiratory tract infections (often secondary pneumonia following influenza) are annually in the top 10 leading causes of adult deaths in the US.  True story.

4.) Influenza leads to lots of lost productivity at work, and has an actual, quantifiable economic impact.  Get a flu shot so your co-workers won't hate you for passing along work (or worse yet, huddling and sniveling at your desk).

5.) Seriously, why risk it?  Flu clinics are often offered by employers and by elementary schools (ours is soon!), but there is always the CVS, Rite Aid, Target, Wal-Mart, Walgreens, Whatever-your-grocer-of-choice-with-a-pharmacy option is!  No excuses for lack of access.  Make time and stay healthy! 

Bonus: If you do not get a flu shot and go to the ER with a fever because you think you have Ebola, you're a serious jackwagon.  That's all that can be said.

A Lasting and Unwelcome Souvenir for Haiti: Cholera O1 El Tor 

The world watched in horror in December 2010 as Haiti, the poorest country in the Western Hemisphere, was rocked by a 7.0 earthquake.  International aid groups and the United Nations jumped into action to help in search, rescue, recovery, and rebuilding efforts.  Unfortunately, one group of UN workers from Nepal inadvertently brought an unwelcome gift: Vibrio cholerae [serogroup O1, strain Ogawa, biotype El Tor, to be precise].  Haiti had been free of cholera for decades, but the run came to an end in Febrauary of 2011.  It is now Fall of 2014, and the Haitian cholera epidemic continues on having sickened over 100,000 and killed over 8,300.  Why?  Infrastructure is a big reason.  Cholera is a waterborne illness spread by the fecal-oral route (sidebar: yes, that means exactly what it sounds like it might mean, skeevy as it is to think about!).  Improper water treatment, both on the ingestion end and waste end, perpetuates these types of diseases.  NPR's health blog gives an interesting description here.  In any event, cholera has once again gotten a foothold in Haiti, and it isn't likely to be eradicated from the country (or the island of Hispaniola, for that matter) for the foreseeable future.

There are many reasons I like to discuss cholera (there will certainly be a Cholerology Day upcoming!), but a big one has to do with its transmission, pathogenesis, and tendency to disproportionately kill the impoverished.  One reason relates back to water infrastructure.  Another major one other relates back to medical infrastructure.  Believe it or not, cholera is an incredibly treatable illness.  The symptoms of voluminous (seriously-we're talking gallons per day) diarrhea are caused by a toxin made by the bacterial agent V. cholerae.  Importantly, the symptoms are NOT from V. cholerae in and of itself.  The bacteria bug out of there when the symptoms start!  Nope, it's all about the toxin.  Since cholera patients typically die of dehydration, the treatment is simple: REhydration!  If patients are rehydrated until they clear the toxin, they recover nicely.  If, however, you haven't any clean water to drink, a hospital nearby with sterile saline/ringers to give you an IV, or the money to afford either if they were available, you're a bit stuck.  So, in short, those with access to a very simple treatment live, and those who don't are more likely to die.

We can do better than that.

All of That Anxiety was for What, Now?

The incubation period has ended for Dallas Ebola patient Thomas Eric Duncan's household contacts, and will shortly end for hospital staff.  It would appear that we're not all going to die after all.  Who knew?!?!?!?

Oh wait...

Properly trained experts knew.  Right.  Seriously, CNN should talk to one every so often.

5:00, Your Final Dose of Ebolology: How Does This End?

5:00, Your Final Dose of Ebolology: How Does This End?

I’ll give my infamous answer…it depends.  It depends on our response, on how much we are willing to support stopping the outbreak (socially, financially, politically, philanthropically, et cetera), on how much we are willing to trust experts over charlatans looking for their 15 minutes, and how much we are willing to let people do their jobs.  The suggested interventions of airport screening on entrance is certainly not a failsafe; after all, Duncan and Vinton flew and both would have legitimately passed by the screeners.  Closing the borders would largely be a bad move because 1.) it does nothing to solve the problem; and 2.) undocumented entrance would be completely unmonitored.  It is also, frankly, un-American.  “Give us your tired, your weak, your huddled masses yearning to breathe free, the wretched refuse of your teeming shore”…I love this line from the poem on the base of the Statue of Liberty.  It’s something to be proud of, and it’s something to live up to.  Another thought that bears repeating: we know how to solve this problem.  We just need the will and the labor to do it.  I’d also argue we know how to prevent it in the future.  Passive transfer of antibody (ie, treating people with blood transfusion from recovered patients, or ZMapp) being associated with recovery strongly indicated that a simple killed vaccine would be successful.  I’ll leave you all with a quote from the great Will Eisner: “We have this history of impossible solutions to insoluble problems”.  This problem has a solution. Support it! 

4:00 Dose of Ebolology: Can I do Anything About This?

YES, plenty.  Practically, literally, and thematically, you can do something about this and about whatever the next thing we all freak out about is.  Here are some thoughts:

Demand rational discussions, and don’t buy into the hype.  This outbreak has occurred irrespective of immigration laws.  It is not Barack Obama’s fault.  We are not all going to die.  Sending troops to build hospitals will ultimately help Americans in addition to Africans (see 11:00 dose).  If a headline ends with a question mark, it is not news because it hasn’t actually happened.  Be calm.  Demand a higher level of discussion.  If it doesn’t interest you, please talk about something else.

Be generous.  Government responses are notoriously slow; however, NGO responses are swift and immediate.  Support them.  Doctors Without Borders has been operating clinics since last March.  They have been trying to treat, educate, and contain, all by donor support.  If you are worried about Ebola in America, give them money.  Stemming this crisis in West Africa is THE ONLY way to finish this epidemic.  Also, it’s, you know, humane.

Demand better of your public servants.  Though it may seem otherwise, we did not elect our members of Congress for entertainment (though they are often hilarious on the Daily Show).  We elected them to listen to our concerns.  All members of Congress have web-based inquiry submission where you can submit and voice concerns.  Use that service…you’re paying for it, after all.  Here is a link to help anyone find their Senators and Representatives:
http://www.usa.gov/Contact/US-Congress.shtml

Support public funding for Science and Research.  Why is there no cure for Ebola?  Because there’s no market for it.  The private sector has its place, and it is very important, but basic research generates drug targets.  It generates basal understanding of disease transmission dynamics and control.  Also, little known fun fact: drug companies can (AND DO) apply for Federal grant funds as often as universities.  These are not wasted dollars.  Invest in science, and we’ll solve problems!!    

3:00 Dose of Ebolology: Expect the Insanity to Grow (but not necessarily the Ebola)

Apparently people have been starting to present with fevers that they would ordinarily shrug off, terrified that they have Ebola even though there is virtually no index of suspicion (in other words, no way they could have contracted it).  It’s mid-October, which is relevant here because it’s almost flu season and norovirus season.  If everyone who vomits and/or has a fever rushes to the ER under the assumption they have Ebola during flu and noro season…hold on to your freaking hats, folks.  If you remember nothing else from today, remember this point: There will be more fevers…but not necessarily more Ebola.  Also, get a flu shot.  

2:00 Dose of Ebolology: Emory, Omaha, and the Dallas Clustermess

No transmission has occurred from infected patients at the high-containment hospitals at Emory University in Atlanta or the University of Nebraska hospital in Omaha.  However, the index case (and subsequent satellite infections) of the US outbreak did not involve those hospitals until today (10/16/2014).  They all involved Texas Presbyterian Hospital in Dallas, Texas.  The infection of two nurses has been touted as evidence of the coming apocalypse.  Here’s what went down in Texas:

1.) The index patient, Thomas Eric Duncan, presented with a fever of approximately 103 (absurdly high for an adult), and a recent travel history including Monrovia, Liberia.  He had also had extensive contact with a sick woman there, but it is not clear if this was disclosed to hospital staff at this time.  He was inexplicably sent home.  Giant alarm bells should have gone off, yet did not.  Blame is to be shared all around (triage nurses, treating nurses, and attending ER physician), since all had access to the information, and none put it together.

2.) Two days later, Duncan returned to the same hospital critically ill and he was isolated and tested for Ebola.  He was not isolated in high containment, and initial “isolation” was via curtain and not with dedicated nursing staff.

3.) Nurses and physicians wore protective gear after isolation, but were not trained in its operation and use.  Blood samples were not indicated as coming from an isolated, containment-requiring patient, and so laboratory staff were not using protective gear.

4.) Medical staff who treated Duncan were placed on fever watch and voluntary quarantine.

5.) As of now, two nurses who treated Duncan are now infected.  Nina Pham sought treatment under isolation immediately upon presenting with a low-grade fever.  As of now, her prognosis is favorable.  She is currently being treated at NIH in Bethesda, MD

6.) Amber Vinson violated quarantine measures and traveled via aircraft (healthy during outbound travel, febrile during return trip to Dallas).  The passengers on that flight are now being monitored.  Vinson has been transported to Emory for treatment.  The increased number of persons being monitored has accelerated fears.

Can anyone highlight the institutional failures here?  There were several.  This does not mean the CDC is lying and that doomsday is imminent.  This means that a hospital in Texas did an especially crappy job with a patient’s initial assessment, and a nurse did an especially crappy thing by traveling despite quarantine.  The CDC has responded by recommending any positive cases be transferred immediately to Emory, Omaha, NIH in Bethesda, MD, or St. Patrick’s in Missoula, MT.

1:00 Dose of Ebolology: If we should be calm, why is the news hysterical? Where Can I find information for myself?

Say it with me: Cable news networks are for entertainment. Their objective is not necessarily to inform you; it is to keep you watching. In other words, the news has a vested interest in your freaking out, and therefore staying tuned. Some of us have strong opinions of this being akin to yelling fire in a crowded theater, but I digress. I want to share some good links that rather than providing narratives and stories, provide data (and often blogs from the field, for interest). They provide things like numbers of cases, geography and distribution of cases, numbers of available (or needed!) hospital beds, and efficacy of experimental treatments. If you want to be informed, these are the places to go. Here are some links and descriptions:

The home page for the World Health Organization. See the entire Ebola section on the right hand menu.
http://www.who.int/en/

The Disease Outbreak News for the WHO. This includes all reportable diseases, not just Ebola.
http://www.who.int/csr/don/en/

The Ebola page for Doctors Without Borders (MSF).
http://www.doctorswithoutborders.org/.../medical.../ebola...

The home page for the International Society for Infectious Diseases
http://www.isid.org/index.shtml

PROmed is a reporting service, where disease outbreak news items are posted. This is hosted by the ISID.
http://www.isid.org/promedmail/promedmail.shtml

12:00 Dose of Ebolology: "Those People"

I was disturbed greatly by two things more than any other in the recent days. These things held up a cultural mirror, and I didn't like what we saw. 1.) "Why are we bringing THOSE PEOPLE" here? Why are we risking our safety for "THOSE PEOPLE"?; and 2.) The within-24 hour response of 400,000+ petitioners to save Excalibur the dog, who was euthanized for his contact with an infected nurse in Spain. Now, I love dogs. Really, I do. I think Excalibur should have been quarantined rather than euthanized. This isn't about Excalibur, though. This is about months and months of silence as human beings were dying, and 400,000 people mobilized by a Western woman's dog. Just let that one sink in for a moment.

(Photo by Sergio Perez/Reuters)

THOSE PEOPLE are now "we people" (ie, Americans). Think that one through. I know the tendency is to blame "those people" for the fact that we are now "those people", but in reality...there are just sick people. Sick people whose only offense was having the bad coin flip to be born where there would one day be a terrible disease outbreak, or whose crime was TRYING TO HELP those who were already sick.  This is not about race. This is about affluence and poverty. 

11:00 Dose of Ebolology: How Can We Make This Problem Go Away?

Put simply, we send our expertise, money, and labor to West Africa and we help stop the outbreak at its source. Though many of us would love to see this done altruistically, the reality is that altruism and self-serving have the exact same mechanism here. I'll share a link to a very interesting paper (hat tip to Karla Feeser) that gives mathematical parameters to the continued spread and reintroduction of cases all over the world IF the situations in Liberia, Sierra LEone, and Ghana are not contained. This is very simple: if you do not want to see more Ebola cases in the West, throw you voice, money, and support behind stemming it in Africa. Look at the (lack of) spread in the US and Europe, despite airlifted patients. We know how to solve this problem. Let's go do it.

http://www.mobs-lab.org/ebola.html

http://www.who.int/csr/resources/publications/ebola/response-roadmap/en/

10:00 Dose of Ebolology: Dr. May's Calming Balm.

We've all heard it: "stay calm", said by dudes in suits who may appear not to have a handle on things. Meanwhile, the internets rage with panic. If you know and trust me, please hear this one: do stay calm, and keep things in perspective. With respective to the infirm and the deceased, we are not talking about a large number of people here in the US and in Europe. Said people are truly not particularly contagious, unless you are sprayed by their innards (hence secondary infections from index cases tending to be nurses and physicians). Said people are also usually not up walking around once symptomatic, which is when they are contagious, because, you see, they are quite sick. If you've had contact with a patient, please be vigilant. If you have not, please be calm. I promise these will get more interesting and practical, but I figured this one needed to come first.

Ebola Day!(NOTE: Ebola Day was actually 10/16/2014.  This blog was started as a forum to share the exercise, and create others, at the urging of several interested persons)

Today is going to be Ebola Day for me. Starting at 10 AM EST every hour I will post an Ebola-related status and a challenge. Feel free to share amongst your friends if you like or feel free to ignore the endeavor completely. Given how alarmed many people are I figured I could share a bit of expertise on the matter. I'll start with this thought: the History Channel's tagline is "what happens over there matters over here". Think about how this applies not only to the outbreak but to future actions and policies.