Mom, Apple Pie, Handwashing, and Influenza Vaccination

The recent news story regarding a pregnant healthcare worker refusing a flu vaccination has generated much controversy prompting her firing by the hospital, I  decision which I fully support.

A few points, most of which I have made in response to the HHS plan for influenza vaccination of health care workers and some other places (Today's Hospitalist, ACEP News): 

• Employers have the right to set the conditions of employment, including what vaccines they require be received by employees
• Employees are free to refuse such vaccinations and face the consequences which could include being asked to wear a mask, refrain from patient contact, or termination
• Influenza vaccine, thought not a panacea with its ~60% effectiveness, is the only preventative countermeasure we have against this virus
• The influenza vaccine is unequivocally safe, as it is in all demographic subgroups, for pregnant women and, in fact, pregnant women are at elevated risk for severe influenza which can lead to miscarriage, among other things

As a physician, I view the influenza vaccine as part of my professionalism as well as a patient safety issue. While I respect the right of individuals to abstain from the vaccine--at their own peril--employers should not countenance such behavior, especially healthcare facilities.

Jane Eyre, Louse Dodger

I recently watched the 2011 movie version of Jane Eyre. Since it has been about 20 years since I read the novel in high school some of the plot details had become somewhat hazy (pun intended for the really nerdy), including the multiple instances in which the infectious disease typhus is mentioned.

In the novel, typhus runs rampant at Lowood, the boarding school to which Jane is sent, and Jane's wicked aunt falsely reports Jane's death from typhus to another relative. Jane herself never contracts the disease.

Typhus, not to be confused with typhoid, is caused by Rickettsia prowazekii and carried by the human body louse.  The word is derived from the Greek work typhos, which means hazy or smokey, a reference to the dazed mental state characteristic of the disease. Because of the relationship between cleanliness, the body louse, and the typhus microbe, this disease has a special place in history--one of my favorite aspects of infectious disease.

Epidemic typhus was considered a major health threat for most of history and remains so for certain parts of the world today. The use of epidemic typhus as a bioweapon is also a concern.

Probably the greatest role typhus has taken on is in thwarting Napolean's invasion of Russia, the subject of The Illustrious Dead. Typhus was also responsible for the death of President Franklin Pierce's son. Today, the disease occurs in situations enticing to lice such as in refugee camps. 

One of the other reasons I like typhus is because one of its foremost researchers was Hans Zinsser, who delivered my favorite quote regarding infectious disease, capturing the entire allure of the discipline:

Infectious disease is one of the few genuine adventures left in the world. The dragons are all dead and the lance grows rusty in the chimney corner. ... About the only sporting proposition that remains unimpaired by the relentless domestication of a once free-living human species is the war against those ferocious little fellow creatures, which lurk in dark corners and stalk us in the bodies of rats, mice and all kinds of domestic animals; which fly and crawl with the insects, and waylay us in our food and drink and even in our love.

The Amalgamation of Critical Care & Infectious Disease

When I decided, upon the completion of my infectious disease fellowship in 2009, to pursue another year of training in critical care medicine, I was perceived crazy given the rigor of such a fellowship and the fact that I was (and still am) an ID addict. (Plus, I had also completed a combined residency in Internal and Emergency Medicine).

My answer to those who questioned my motives was that I didn't want to be an ID physician who steps back once the patient becomes critically ill and requires ICU care. Critical care physicians are trained to be adept at almost everything and often need little to no consultative help from other sub-specialists, leaving the ID physician with little to add. The ICU is also the place where infectious disease often reach their culmination--particularly infections I am very interested in such as emerging infectious diseases and influenza--and I like the unique challenges of managing all aspects of the patient's care, which is the role of a critical care physician. I have a similar sentiment regarding Emergency Medicine, where all these diseases initially present. 

Last night in the ICU served to reinforce my sentiment.

Overnight I admitted two patients with severe infectious diseases, one of which required extraordinary interventions to keep alive. That patient, transferred from a rural hospital with likely influenza pneumonia, progressed throughout the night from requiring moderate amounts of ventilator support to ultimately, after a series of rescue interventions, being placed on ECMO. Trying to halt the onslaught of the infection and the resultant failure of multiple organ systems was extremely challenging.

It is these challenges, inherent in working in an ICU, where the melding of infectious disease and critical care medicine reaches its apotheosis and its what I like to do.

Vitamins: Should They Go The Way of The Flintstones?

I am often asked about what individuals can do to protect themselves from infections, particularly the common cold. 

If one goes to any convenience store it's easy to find several "immunity boosting" concoctions consisting of several vitamins (B-complex, C, etc) which are non-trivial in cost.

Does vitamin supplementation have any effect on the rate of respiratory infections or the like? (One major caveat, I am assuming the consumption of a regular diet in the developed world by an immune competent individual.)

The answer is no.

Studies have repeatedly shown that vitamins, especially D and C, have no effect on the rate of upper respiratory infections. Of course, these facts don't stop the hordes of people that swear by them from spending money on what could be duplicated for about $1--with better taste, in my opinion--by consuming a can of V8.

Moreover, vitamin supplementation--as such--has not proven to be efficacious for any reason (mortality, etc) prompting a great editorial in Annals of Internal Medicine entitled "Enough is Enough: Stop Wasting Money on Vitamin and Mineral Supplements" with which I totally agree. 

The Flush Heard, but not Smelled, Around the World

This Christmas I learned about a seemingly popular gift, at least in my network: Poo-pourri. Poo-pourri is sort of the equivalent of pre-exposure prophylaxis against...the stench of feces. 

One sprays the liquid into the toilet bowl prior to use and the oils contained in the substance neutralize/mask the odor. 

Since my writing is ostensibly educational, a few facts:

• The sulfur-containing products of intestinal bacterial are what produce the characteristic odor
• The repertoire of different bacteria present in one's stool is severely altered, for the long term, by antibiotic use for -- a phenomenon that explains how C.diff infection occurs and the rationale for fecal transplantation for severe or recurrent cases
• A toilet can serve as a rocket launcher for fecal bacteria creating a toilet plume, though this is not thought to be an infection risk (with one caveat below)
• The Flush Heard Round the World: during the SARS pandemic in 2003, a SARS-infected visitor to a large residential housing complex in Hong Kong experienced diarrhea and his flush created an aerosal the sparked hundreds of cases (see my take on a recent paper on this topic)

Proctologists have nothing on infectious diseases physicians.