Yet another plague panic

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Thirty plus years in medicine has given me some perspective as has infectious diseases (ID). One of the almost TNTC cool things about ID is that infections, unlike the diseases of modernity, have been plaguing humans since before we were humans.

There is a sense, a usually unvoiced assumption, on the part of many people that we are supposed to be healthy, that our default mode is good health and that with the proper diet and attitude we could obtain the health that was ours before the fall.

I think not. I see no perfection in any human, except maybe my wife who would achieve perfection if only she liked beer and steak.

We are a hodgepodge of anatomic and physiologic compromises that allowed us to spread across the world. But if you like to read history, you realize that most of the time we died like flies from infections, trauma and other medical problems. The variations that allowed us to survive malaria or tuberculosis led to sickle crises and the metabolic syndrome. Even with evolution no good mutation ever goes unpunished.

And, immunologically, we are perhaps as individual as snowflakes. We currently lack the cost-effective technology to check for the many polymorphisms that increase or decrease our odds for infection. Just have the wrong form of snot and it increases your risk for meningitis. Who knows what genetic variations are lurking to increase (or decrease) the risk of disease?

So I do not see the baseline for animals as healthy, just healthy enough to survive and reproduce and there is not a lot that can be done to be healthy beyond the simple basics: don’t be fat, eat a reasonable diet, exercise, avoid too much alcohol and any tobacco. No matter what you do you will get old and sick and die, but if you were lucky enough to get the right genes (please, let me have my mother’s not my father’s) you may get a reasonably healthy life.

Men at some time are masters of their fates:
The fault, dear Brutus, is not in our stars,
But in ourselves

I also expect infections, new and old, to sweep across the world. It happens all the time. There was no AIDS when I started medical school. West Nile Virus was not in the US until about 1999. Since then West Nile has spread across the US to all lower 48 except Oregon. We still have had very little local transmission of West Nile in Oregon. I credit the hops. H1N1 influenza had not been seen for 50 years but it came back like gangbusters in 2009.

Infections spread across the world all the time. It may be birds (West Nile) or planes (SARS) or boats. Bubonic plague was unknown in the West until steam ships brought to San Francisco in 1900, and then plague spread across the west.

There are many factors that can contribute to outbreaks and the spread of infectious diseases. You need susceptible hosts, you need an infectious organism, and you need an efficient mode of transmission.

The best ways for infections to spread are coughing and sex. Avoid sex with someone who is coughing I always say. The nice thing about sex as method of spread is that the organism does not have to be present in high amounts or be very infectious since sex appears to be a past time that people enjoy repeating. Most people with herpes, as an example, are never symptomatic and secrete small amounts of virus all the time.

HIV has been interesting. In the old days, before we knew about HTLV-3, we only knew the risks for HIV, one of which was having many sexual partners. It was not uncommon for patients to report Wilt Chamberlin numbers for their sexual contacts. That has changed and there is some suggestion that as the number of partners has declined along with an increase safer sex, HIV may have become more virulent. With less opportunity to be passed on, only the more infectious/virulent strains survive, although HIV maintains the same mode of transmission.

Every couple of years there is a new infection that gets everyone worried. HIV, SARS, West Nile, Legionella, MERS –CoV have been the worries in my time.

Now Ebola is the current infection most in the news with 1,700 cases and 930 deaths as of today. It took six months to cause that many cases in an area with a population of around 20,000,000. And this in an area with a horrible infrastructure for both health care and infection control. While a ghastly outbreak, Ebola does not appear to be particularly infectious or pose much of a pandemic risk.

Compare that with H1N1:

From 12 April 2009 to 10 April 2010, we estimate that approximately 60.8 million cases (range: 43.3-89.3 million), 274,304 hospitalizations (195,086-402,719), and 12,469 deaths (8868-18,306) occurred in the United States due to pH1N1.

and perhaps 250,000 deaths worldwide. Ebola, from an epidemic potential viewpoint, appears to be trivial. It looks to be one of many localized outbreaks of awful diseases in the world that are common and may be increasing in the future.

Ebola is spread by direct contact with blood or secretions from the infected person and as such should, in areas with resources, be controlled with aggressive infection control procedures. Based on what is known to date, I do not worry overmuch about the spread of Ebola in the US. Direct contact is not a very efficient way to transmit infections, especially infections that are rapidly fatal. Most infections routinely spread by direct contact are relatively indolent. Maybe I am overly sanguine, but I do not see much to worry about with Ebola from either an epidemic potential or having patients brought to the US.

Thirty year of following infection control procedures and I have yet to catch an infection from a patient. I remember at the start of the AIDS epidemic there were those who refused to care for AIDS patients due to worries of catching the disease. It never worried me since I knew the modes of transmission and I did not partake of those behaviors. That said, I still remember the first AIDS patient I took care of, before we knew about HTLV-3, offering me a chocolate from the box at his bedside while declaring he would have to “spit in my mouth” to pass on AIDS. While I had no problem touching the patient, shaking hands and doing an exam, I politely declined the chocolate. I would eat one today however, as long as it didn’t have walnuts.

It is curious that people worry about Ebola, yet little is said about Dengue, another very common hemorrhagic fever that is at our doorstep.

The World Health Organization (WHO) estimates that 50 to 100 million infections occur yearly including 500,000 DHF cases and 22,000 deaths.

Dengue has the most efficient mechanism for infection spread known: mosquitos. I have seen it estimated that half of all human deaths are due to infections spread by mosquitos. Dengue is present throughout Central and South America and the mosquitos that spread the infection, Aedes aegypti and Aedes albopictus are ubiquitous in the Southern half of the US (and, sadly, Oregon). 40% of people who have never left Brownsville Texas (and who would not want to leave Brownsville Texas?), have serologic evidence of Dengue. There has been an outbreak in the Florida Keys and where there is Dengue, there follows Yellow fever.

Both diseases have the potential to spread (or re-occur as in the case of Yellow fever, which caused considerable morbidity and mortality in the 17th and 18th century US) with global warming and the potential northern spread of the mosquito vector. No one seems worried about these two infections, but instead fret about Ebola, some of it totally wackaloon.

There are many infections to worry about, with potential for local outbreaks, epidemics and pandemics. But that has always has been the case. The best we can do for most infections is a holding action, keeping them at bay with public health measures such as vaccines and potable water. Unfortunately, I doubt we will ever repeat the successes such as the eradication of smallpox and rinderpest and many of the predicted short term changes (the next 1,000 years or so) would likely increase the spread of many infections.

These infections do offer opportunities for those in the world of pseudo-medicine. For some, like the Natural News, perhaps alternative medicine is preferred term, because it suggests the alternate universe, the one where Spock has a goatee, and not the real world in which I live.

Although homeopaths have weighed in on the appropriate magic water to be used to treat Ebola, evidently homeopaths are not heading for Africa to prove the efficacy of their therapy and there will be scant opportunity for them to use their magic in the US or Europe to treat Ebola.

Homeopaths love to credit the proof their superior therapeutics to the cholera outbreaks in London in the 19th Century. Given the purging and bleeding that were the standard medical therapy at the time, the nothing of homeopathy was likely better than the dangerous interventions of the time.

There have not been many epidemics this century for which homeopathy could test their mettle. H1N1 hit hard and fast and to judge from the few papers on homeopathic treatment, it can be judged as hit or miss. Or perhaps miss and miss, give the quality of homeopathic research that resulted from the H1N1 epidemic.

We may be primed for a new epidemic in the US: chikungunya. It is in the Caribbean where it is going gangbusters: in 8 months over 500,000 cases.

Six out of 10 cases have been reported from the Dominican Republic, which tallied 307,933 cases in Epidemiological Week 31, up 26,000 cases from last week. In addition to the DR, Guadaloupe reported 71,000 cases, Haiti reported nearly 65,000 and Martinique recorded 54,000. The French side of St. Martin, where the epidemic began has reported 4,500 cases.

Now that is an epidemic. Spread by mosquitos, almost everyone who gets the virus has symptoms: fevers, muscle and joint pain, rash and headache, often quite severe. Death is rare.

There are now a few cases of chikungunya transmitted in the US, and once it gains a toehold it should spread fast. It took West Nile less than a decade to cross the US, although it had help from birds. Perhaps it will hit the poor disproportionately since they do not have air conditioning to keep themselves cool and away from mosquitos.

Homeopaths have treatments for chikungunya, although they retain their usual inability to understand the difficulties in assigning causality to events when treating a process that by its nature is self-limited.

We are probably on the cusp of millions of cases of chikungunya in the US. Given that there is no specific treatment or prevention (besides avoiding mosquito bites) for chikungunya and 70-90% of those infected will become ill, it is perfect opportunity for homeopathy, and the other pseudo-medicines, to put up or shut up. An epidemic is probably coming for which medicine only has supportive care, the perfect opportunity for pseudo-medicines to demonstrate their superior effectiveness with modern methods.

Somehow I suspect it will not happen.

P.S.
Idle thoughts. I have asked psychiatrists why practicing homeopathy does not meet the criteria for delusional disorder. I always get a blank look. I am not a fan of the DSM, mostly as one past girlfriend or another has used it in attempt to classify me and I am well aware of the sordid history of using psychiatry as a means to suppress those whose opinions are unpopular. The latter is certainly not appropriate.

It seems to fit and homeopaths are a danger to others, since they act on their delusions. Probably a weakness in the DSM rather than homeopaths.

It remains one of the curiosities of human culture and medicine. People can believe in and practice medical systems that are totally divorced from reality with an acceptance found in no other profession. Weird.