Measles: Still "A Thing" (in the US in 2016)

Buried amongst the myriad Zika virus headlines, so hard to find it took some looking, is news of measles cases in the US...again. While not as explosive as the recent Disneyland-linked outbreak the 2 cases that have occurred this year are instructive as they are cases that should not be occurring in the US.

The cases occurred in the states of California and Texas. In Texas, an unvaccinated child who traveled internationally -- where measles is rampant -- was infected and later exposed classmates at an elementary school early in January. That this happened in Texas is not surprising as it is the 2nd least vaccinated state and this low rate of vaccination is reflected in the fact that some of the students exposed were not vaccinated. It appears, however, that herd immunity as well as luck delimited the impact of this case as no secondary cases occurred and the incubation period has since passed.

California, where the other 2016 case occurred, is the state in which a new law was enacted to increase the rates of vaccination in schools by eliminating religious and "philosophical" exemptions. California, being the epicenter of the 2014-2015 outbreak, also had a major reminder of the danger of measles that had ripple effects that led to increased vaccine confidence among the vaccine-hesitant. The details of the California case haven't been released and it will be important to determine the circumstances surrounding this case.

More measles cases will occur in the US this year and many children will remain unvaccinated kindling for this virus.

Walking Like a Darwinian in the Galapagos

I recently returned from a 10 day trip to the Galapagos Islands and, for those who know me, it may be unheard of for me to take an actual vacation. However, this was no ordinary "vacation" but an intellectual experience (via Linblad Tours and National Geographic). The Galapagos Islands were the site in which a young twenty-something kid named Charles Darwin got the germ of the idea of evolution by natural selection. Just to be able to go to a place in which idea that changed the world like Darwin's took root is inspiring in its own right. 

Imagine being in a place in which Darwin is appropriately lionized with statues of him in skateparks (another one of my loves)! 

The expedition I was on was led by naturalists all of whom were experts on the myriad geographic, oceanographic, and biologic facts concerning the Galapagos. They are a class of their own and I imagine myself being an "infectious disease naturalist" -- if such a thing existed. While sea lions, iguanas, lizards, and exotic birds were constant visual presences, science, inquisitiveness, and rationality were the constant intellectual presences. 

Darwin's pathbreaking insights into life -- the mystery of mysteries -- are the bedrock of infectious disease and explain so much so elegantly. Walking in a place in which such profound thought took place is an exhilarating experience.

The 4th PHEIC of the Apocalypse: Zika?

Today, the World Health Organization convened and determined that cases of microcephaly and Guillain-Barre Syndrome potentially linked to the spread of the Zika virus in South America represents a public health emergency of international concern (PHEIC). This is a designation only H1N1 influenza, polio, and Ebola have been granted. Before the past few weeks Zika virus was not something on the radar of most Americans but is now the subject of headlines warning of devastating complications in the fetuses of pregnant women. Post-Ebola, many infectious diseases prompt doom-and-gloom headlines that do not provide full context and threat analysis—an essential process to help the general public determine the level of concern they should have.

A declaration of this sort deserves some discussion because it is not obviously clear to many, including me, what criteria are used in the deliberation. Ideally, the criteria for a PHEIC should be transparent, objective, and entirely derived from the medical and scientific facts that are known. The chain of reasoning employed should be reproducible by anyone with the same facts. While formal objective criteria might be deviated from in what often is a highly politicized process, at least it will be better known when it does. 

However, after polio -- a disease that has been largely eliminated from the globe via vaccination --- was declared a PHEIC, it became clear that other extraneous considerations might be at play. Similarly, when Middle East Respiratory Syndrome (MERS), a zoonotic disease without treatment or vaccine transmissible from person to person and similar to SARS (from which the whole apparatus of PHEIC derives from), did not meet the criteria, it was puzzling. Chikungunya is another case in point.

While the Zika PHEIC is, contrary to the way it is being reported upon, narrowly focused on microcephaly and other neurologic complications (and not Zika as such) it seems that in a post-Ebola world public health authorities are seizing the opportunity to capitalize on the importance infectious disease is now given. This is a two-edged sword as many diseases like MERS are given short-shrift but others given the spotlight.

What is needed is clear objective criteria bereft of any consideration but the science, something that is difficult to ascertain in the current context.