Measles & Making a Quick $100,000+

When someone offers to pay over $100,000 to someone for proving something that is already incontrovertible, it makes me wonder. 

In this case, a "biologist" in Germany  offered a cash prize, not for proving a fancy mathematical conjecture, but for proving that measles is an infectious disease versus a disease of social separation (!). This scenario is odd for numerous reasons that include:

• Rhazes, before the year 1000, counseled people to avoid the disease lest it become an epidemic.
• The virus that causes the disease was isolated in the 1950s.
• Instead of social separation being a cause, as conjectured by this biologist, it is social interaction that abets the virus as a susceptible population of a certain size is required for the virus to sustain transmission.

That, in the 21st century, we are faced with a debate over a fact of reality long established is more than just a curious novelty--it is evidence of an erosion of the intellect and a true return to the primitive in which nebulous causes for diseases held sway and humans lived in a demon-haunted world.

Adding Layers to my Understanding of Tuberculosis

When I teach medical students a concept my technique often involves reducing the concept down to the level of simple observation or unsophisticated laboratory or radiographic tests. This approach allows the medical student to not get lost in complexity and lose track of what's actually going on, namely a patient with certain signs or symptoms. 

As an avid attender of myriad infectious disease lectures I, myself, also tend to prefer this type of teaching approach. At a recent meeting of the Baltimore Tropical Medicine Dinner Club, on whose board I serve, I was treated to an exceptional employment of this very technique by an icon in the field of tuberculosis pathology: Johns Hopkins University's Dr. Arthur Dannenberg. 

What Dr. Dannenberg did in this lecture is reduce all the esoteric jargon of tuberculous pathology to literally entities visible to the naked eye (i.e. lesions on rabbit lungs). This lecture deepened my understanding of tuberculosis immensely because it provided me with a new framework to think about tuberculosis, namely as balancing act between two types of T-cell response. One type of response kills infected macrophages, the other activates macrophages to kill the bacteria. 

Using this paradigm it becomes much easier to understand why 90% of people are resistant to tuberculosis and never develop the disease after exposure. The infecting bacilli that survive the initial onslaught by alveolar macrophages are kept in check by a response which kills the cells that harbor them, creating a solid foci of necrosis surrounded by macrophage sentries poised to act. Most human's immune systems are able to keep this foci which, as it liquefies may leech out bacilli, in check (latent TB) but in those whose are unable, macrophages must release firepower on the area, causing the classic destructive lesions of tuberculosis. Aging and immunosuppression are two factor that can lead to loss of control and symptomatology. Similarly the poor population results of the BCG vaccine might be related to the fact that only a small proportion of the population actually needs it.

Such an understanding of tuberculosis provides a green light to think of therapy and vaccines differently. Primarily, tuberculosis therapy involves the prolonged use of antimicrobial therapy to kill bacilli in both the active and the latent stages. Therapies to keep the initial foci of necrosis from liquifying could modify therapy for latent TB. Additionally, immune modulation to dampen inflammation could also play a role (steroids are currently a part of the regimen used in tuberculous meningitis).

A proper conceptualization of a disease is really the only true means to understanding and conquering it.

Preparing Minds for Bioterrorism

I often give interviews to the press on various infectious disease topics and a few months ago I was talking to a journalist and referenced the anthrax attacks of 2001. The journalist replied, “Oh yeah, the anthrax 'scare' back then.” I replied, “it wasn’t a ‘scare’ it was an attack in which 22 people were infected and 5 murdered via spores being sent through the US Postal System.”

That 14 years have now passed since the Amerithrax attacks means that those horrific times have faded from people’s memory and that’s not a good thing because the threat remains.

With that context in mind, my colleagues and I wrote a clinical review paper with the aim of refreshing clinician’s minds with new information on these important infectious diseases (anthrax, plague, botulism, tularemia, and smallpox). We were ecstatic when the most prestigious medical journal in the world, The New England Journal of Medicine, accepted it for publication.

The subtext of the entire update is that it is vitally important for clinicians—the front-line defense against these pathogens—is armed with the knowledge necessary to recognize and treat these diseases as well as know when to sound the alarm.

As my hero Louis Pasteur famously said, “chance favors the prepared mind” and our hope is that our paper will prepared the minds of those crucial to protecting this nation from another bioattack.

Dr. Sheri Fink Brought the Lessons of Katrina to Pittsburgh

On the night of March 2, 2015, I had the opportunity to hear Dr. Sheri Fink lecture in Pittsburgh, my hometown. To all in the field of catastrophic health event preparedness, hers is a household name as her unmatched effort to understand the crisis in the healthcare facilities of New Orleans after Hurricane Katrina can be thought of as no less than foundational for the entire field—quiet an achievement.

What Dr. Fink’s work does is concretize what the term “crisis standards of care” is all about. Indeed, the events depicted in her book Five Days at Memorial (which I discussed in a prior post) illustrate exactly what happens when these standards are not in place and ad hoc decision-making becomes the norm and a DNR order is translated to mean “do not rescue”.

That we have now developed these standards and that these discussions are not taboo are thanks to Dr. Fink’s diligent work.

What I loved most about her lecture and found quite inspiring, apart from the content, is the fact that this was a physician-turned-journalist exemplifying all the best aspects of medicine. Her inquisitiveness, her passion for her work, and her ability to translate abstract concepts into concretes (to wit, she wrote a piece for inclusion on Chipotle bags about these topics) are all attributes of the best physicians and something to emulate. Her lecture had the all to infrequent attribute of being able to equally appeal to both the physicians in the audience and to the general public alike.

To hear such a renowned voice, who often references Aristotle, discuss topics such as hospital preparedness, crisis standards of care, Ebola, and a battle field hospital anywhere—let alone in the comfort of my hometown—was a rare treat. 

Rational Use of Antibiotics: Nearly A Hundred Years War

When I discuss antibiotic resistance, a point I am sure to make is that these compounds are to be treated like precious commodities. In the modern era, that strikes many people as odd because they have taken countless courses of different antibiotics and have always recovered. There always seems to be a new antibiotic released that their PCP may try them on if their symptoms are particularly recalcitrant to the first course. Medicine will always develop new antibiotics, they assume. 

Last week, I had the pleasure of listening to Harvard University's Dr. Scott Podolsky discuss the topic of antibiotics, not from the usual perspective that is focused on a prophecy of a post-antibiotic era (a valid concern), but from a historical perspective. Such a perspective allows one to place antibiotics and their overuse into a much larger context that is informed by an understanding of how antibiotics rose to such prominence that today prescriptions for them are literally demanded of physicians.

In his talk, part of C.F. Reynolds Medical History Society's annual lecture series at the University of Pittsburgh, Dr. Podolsky highlighted an important of the pre-antibiotic era that is often overlooked--and may hold the key to combating infectious diseases more rationally in the future: serum therapy. Serum therapy was a means of using products manufactured by the immune system against specific microbes in another individual.  It was the opposite of broad-spectrum and was largely supplanted by the much simpler use of broad-spectrum antibiotics. Today, we have anti-serum therapies for diseases like botulism and tetanus. But, there is a lot of effort to develop modernized serums, aka monoclonal antibodies, which we saw used experimentally against Ebola in the form of ZMapp and which already exist for anthrax and RSV. Moving back to specific therapies is a sure means to not only delimit antibiotic resistance but to avoid the collateral damage to the microbiome that is probably just as important.

Another aspect of Dr. Podolsky's talk I found fascinating was the prescience of those at the dawn of the antibiotic age, such as the first president of the Infectious Diseases Society of America (IDSA) Dr. Maxwell Finland, who realized the dangers of injudicious use of antibiotics and established early principles for antibiotic stewardship.

One of the themes from Dr. Podolsky's lecture that resonated with me was that the current debates on rational use of antibiotics we are in reaches back several decades and understanding the terms of the debate, at its inception, is an important and over-looked task. Thanks to Dr. Podolsky for doing the intellectual work needed to make these facts easily accessible and able to be integrated into the modern context.