Vaccination is the Real Baptism: From the Mouth of SMILF

What is the difference between baptism and vaccination? That's a question that is raised in the latest episode of Showtime's SMILF. SMILF is a clever new comedy based upon the life of Frankie Shaw, who has multiple roles (star, writer, etc.) in the show. 

On first glance, readers might say that baptism is a mystical religious ritual and vaccination is a science-based medical practice that are completely different and they would be right. But Shaw, ingeniously, sets up a great juxtaposition. A couple of episodes back her character Bridgette, confronted with the threat of chickenpox in her unvaccinated child and realizing the child's biological father's opposition to vaccination (because he believes they are poison and government mind control), has the child surreptitiously -- and laudably -- vaccinated.

End of story...except for the baptism issue.

Bridgette, again very admiringly, is not religious and has not permitted her son to be baptized despite her mother's fervent Catholicism. When the child's father finds out about the vaccination and simultaneously is offered an opportunity to have the child baptized, he falsely creates an equivalency between the two actions and has the child baptized.

It's this false equivalency -- in the face of a gulf wider than the Red Sea--that is worth thinking about. Vaccination, in 2017, is performed because of the clear benefit it offers the individual being vaccinated against specific infections for which the risk is not neglibile. This benefit is evidenced by falling childhood mortality rates, rising lifespans, and the recession (and even the eradication) of vaccine-preventable diseases. Vaccination is performed because it is evidence-based, biologically-plausible, and has proved tremendously successful. 

Baptism, on the other hand, is none of this. It is performed to supposedly nullify the sin that every human is allegedly born with through no fault of their own. These "sinful" babies, if they fail to be baptized, are prohibited entry into a paradisiacal afterworld. To me, nothing can really be more cruel or calculatingly devious than to morally damn all humans by virtue of their being born and offer as the only solution a primitive ritualistic practice. Far from being a protective like vaccination, baptism is the opposite for it exposes one to the true poison of religious dogma that one is immersed in along with the "holy" water. 

The true baptism is one that is the culmination of the painstaking scientific inquiry and research that has allowed our species to tame some of the more dangerous members of microbial world.

Thanks to the talented Frankie Shaw for making this point so clearly, dramatically, and entertainingly. 

Pursuing Diagnoses to the End of the Earth

One of my general principles when treating and diagnosing infectious diseases is to try and pursue a cause as far as I can. With a specific cause, one can discontinue treatments that were being used to cover all possibilities and provide as specific targeted therapy as is available. In addition to immediate treatment related implications there are others that, while not changing treatment (a mantra I hear all too often), are vitally important: infection control and epidemiologic intelligence. 

When a hospitalized person with pneumonia is diagnosed with a specific virus such as, for example, parainfluenza virus for which there is not a specific antiviral treatment several things happen which include discontinuation of antibiotics (hopefully) and placement of the patient in droplet isolation to prevent contagion. However, if the specific diagnosis is not made the patient will languish on the floor marinating in antibiotics while coughing the virus onto his roommate and others. 

A recent news story from a suburban Pittsburgh newspaper highlights the other important aspect of specific diagnoses: epidemiologic intelligence. The piece details a 74% uptick in the number of pneumonia cases in young adults diagnosed in a chain of urgent care centers in the area. This cluster of illnesses is important and interesting as influenza season really hasn't fully commenced in the region. However, what strikes me about this episode is that there seems to be no effort to understand which microbe is behind the cases: is it parainfluenza, an adenovirus, mycoplasma, RSV, a rhinovirus, a coronaviruses, legionella, pneumococci or some combination of different viruses and bacteria? Unfortunately, that is something that urgent care centers not associated with hospitals tend never to pursue because "it doesn't change patient care" despite the fact that it could have crucial epidemiologic importance. In many ways urgent care centers are places where symptomatic treatment without regard to causation is the norm and expected treatment paradigm.

What if these undiagnosed cases contain new microbes making their first forays into humans? What if there are important changes in viral prevalence occurring? We probably won't know because no diagnostic tests were likely done. Also, a good proportion of those cases are likely viral in nature but invariably were given a "Z-pack" nonetheless or potentially harmful steroids.

To me exploring these syndromes to identify the cause is what the specialty of infectious diseases is about. To me, in 2017, when there are multiple diagnostic tools in relatively easy reach in the US ranging from point-of-care influenza molecular diagnostic tests to multiple pathogen assays (also point of care) that there really should be no barrier to ordering these tests, especially at urgent care centers where patients are insured. 

The diagnostic black hole in infectious disease in developed countries really baffling to me and makes no sense given that microbes have no borders. Recall that the 2009 H1N1 influenza virus emerged in Mexico and was first recognized in San Diego in a patient with mild symptoms who happened to have a diagnostic test that "doesn't change treatment" ordered. 

The diagnostic test you order or fail to order may be more consequential than you think. 

A Humorous (and informative) Look at Plagues: A Review of Get Well Soon

It's hard to write a humorous but yet historically and scientifically sound account of plagues that have thrown our species into calamity time and time again. Yet, Jennifer Wright does just that in Get Well Soon: History's Worst Plagues and the Heroes that Fought Them. 

In this easily digestible book, Wright covers topics very familiar to connoisseurs of death and destruction due to infectious diseases such as syphilis, typhoid, plague, cholera, smallpox, and tuberculosis but also ones that received comparatively less attention but are nevertheless endlessly fascinating such as Von Economo's encephalitis, the dancing plague, and a human-induced plague of lobotomies for psychiatric illness. 

Some of the most humorous aspects of the book include discussion of the exploding frog cure for plague, the pigeon cure for plague, and her unrepentant challenge of the anti-vaccine movement. One of my favorite lines, explaining herd immunity, is:

“So if enough people decide that their yoga teacher is really onto something and they are not going to immunize their kids, because they are going to feed them a whole bunch of grapes instead, then the number of immunized people drops beneath the percentage necessary for herd immunity to be effective.”

Integrated into the narratives of these episodes is not just humor but many important recommendations for how to deal with infectious disease emergencies. For example, in her account of the 1918 influenza pandemic Wright highlights the constraining effects of WWI laws in the US  prohibiting journalists from writing about anything that could diminish morale. Wright explodes the sheer insanity and backwardness of such an approach, in what I believe to be the most valuable chapter of her book. These lessons need learning as evidenced by the 2003 experience of SARS in China and the ongoing campaign to call cholera just "acute watery diarrhea" in parts of Africa.

For a great overview and uncanny insights into history's plague's I highly recommend Get Well Soon and hope that Ms. Wright continues to apply her considerable talent to these topics in the future.

Giving the Plague no Quarter in Madagascar

Plague, for very good reasons, is something that will always capture headlines and panic individuals. It is an infectious disease that entirely disrupted civilization on multiple occasions and has become the stuff of legends involving everyone from Roman emperors to Nostradamus. Indeed for most of human history plague, caused by a bacteria that spreads from rodents via the bite of flea, was an existential threat, until it was tamed by scientific discoveries that discovered its origin and its susceptibility to antibiotic therapy. In many parts of the world, this taming of plague has made it a non-issue but a new outbreak on the African island nation of Madagascar has some worrying characteristics that merit swift action to extinguish what could become a larger problem. 

In Madagascar, close to 700 individuals have been infected with 57 succumbing to the infection. What makes this outbreak particularly notable, despite occurring in a country that has hundreds of annual plague cases, is that many of the cases are of the pneumonic form. This form of plague, which involves infection of the lungs, is the form that can be transmitted between humans through coughs and sneezes in little droplets that travel about 3 feet. Also, cases are occurring in urban areas giving the bacteria more opportunity to find new hosts. 

These factors have prompted public health agencies to take prompt actions including the creation of a treatment center and the delivery of antibiotics. So far, the risk of international spread is low -- despite an importation to the Seychelles. However, in the wake of Ebola it is crucial, even in low international risk situations and with effective antibiotic therapies, to not allow infectious diseases to any breathing room 

The Mystery of Malaria in Italy

It's said that half of all humans have died from one infection -- malaria. But today in many parts of the developed world malaria is just a travel or global health concern. However, it must be remembered that relegating malaria to such a status was a great human achievement as malaria had a much bigger planetary profile in the past -- indeed Washington DC was literally, at one time, a malarious swamp. 

A new case of fatal cerebral malaria in northern Italy is a stark reminder that this disease can have a much bigger impact if it is allowed to. Italy was freed of malaria in only 1970 the result of strong eradication campaigns that beat the mosquito back. However, there have been reports of recent possible local transmission in the southcentral part of the country. It is unclear, at this time, how the disease was contracted as the patient had not traveled abroad. An unknown pool of possibly Italian Anopheles mosquitoes is infected with the parasite and just found the right opportunity to transmit to the now deceased four year old child. There is some question whether a contaminated needle may have played a role as well as travel related malaria cases were treated around the same time at the same hospital.

Malaria is a complex infectious disease that has marked the human race and provided a tremendous evolutionary pressure on our species. Alarming rates of drug resistance to artemesinin, if they spread to Africa, could be catastrophic.

The disease, however, can be defeated --but only if humans put all the resources of their mind into the fight. Bed nets, insecticides, vaccines, antimalarials, and genetically modified mosquitoes should all have major roles in this fight for the best chance at success.