Kaci Hickox: From Ebola Nurse to Liberty Defender

A very significant development in the world of infectious disease policy occurred earlier this week. Nurse Kaci Hickox settled her lawsuit against the state of New Jersey which irrationally detained her for an erroneous forehead temperature reading as she returned home after battling Ebola in West Africa. The detention she suffered was a prominent part of the news cycle and her struggle to have her individual rights respected was something I intransigently defended in the press. Ms. Hickox never had Ebola and never posed a risk to any individual. 

The most significant aspect of Ms. Hickox's lawsuit settlement is that she got the state to establish a sort of bill of rights for those detained under New Jersey's quarantine power including the right to counsel, the right to contest the detention, the right to be notified of hearings, and to send/receive correspondence. The terms of the settlement will form the basis to hopefully change other states quarantine policies.

The government, as the protector of individual rights with a legal monopoly on the use of force, should and does have the power of quarantine. This power is exercised to protect individuals from infection from others in the context of a contagious infectious disease that poses a demonstrably serious threat to health. In this context, infectious agents must be viewed as projectiles emanating from the body and, as such, when they impact others, are violation of their rights compelling government to act.

However, the government cannot arbitrarily wield this power and it must be based exclusively on the actual threat posed. To quarantine someone is to delimit their liberty and must absolutely be justified and exercised in a stepwise fashion based on risk and compliance for the absolute minimal time possible. What cannot enter into this decision -- and unfortunately it does and will -- is political expediency, pandering to public fear, or an "abundance of caution" overreaction.

Ms. Hickox's work moves us closer to this ideal and she deserves praise for her heroic struggle to reform quarantine laws that were used capriciously, irrationally, and unjustly against her.

Don't Finish Your Antibiotics -- They Probably Weren't Necessary

It's a tale as old as time: when you're prescribed a course of antibiotics, finish it no matter if you feel better after a few doses. The implicit rationale behind that maxim was that if one is being prescribed antibiotics, it is because they have been accurately diagnosed with a bacterial infection in which antibiotic treatment will be helpful. 

Every antibiotic one takes has two aspects to its nature. Antibiotics, even narrow spectrum ones, impact not only the offending bacteria but also others who are bystanders. Those bystanders are reduced in population opening up space for more dangerous bacteria as well as putting pressure on bacterial populations to select for and evolve resistance (collateral selection). Broad spectrum antibiotics do this on a larger scale and that's why they should be used only when the clinical situation warrants it (i.e. wide uncertainty about the cause of a patient's symptoms). 

There is a risk benefit calculus that must occur with each dose of an antibiotic. Does the risk of antibiotic resistant bacteria developing and antibiotic side effects occurring outweigh the benefit of the antibiotic. Obviously, in a viral infection the risk strongly outweighs the benefit.

The other aspect of this issue is that often antibiotic courses, even when they are needed, are prescribed for arbitrary amounts of time. Courses of 7 days, 10 days, 14 days may have little to no rationale behind them. More and more studies are showing shorter course therapies are optimally effective and there has been a movement to shorten courses of antibiotics as much as possible. A new piece in the British Medical Journal is a tour de force  as is this excellent piece by Brad Spellberg. 

The point is that if an antibiotic is prescribed injudiciously -- as most are -- each unnecessary dose one takes is harmful. Also, each prolonged course of antibiotics that exceeds what is necessary confers unneeded risk. Of course, when a course is appropriately and rationally constructed to ameliorate the infection one should take the prescribed dose so as not to foster recrudescence of the infection with possibly resistant organisms (targeted selection).

Antibiotics are a precious resource that changed the face of medicine and improved human life immeasurably. The threat of antibiotic resistance is one of the most pressing problems medicine faces. Exploding arbitrary dogma to optimize antibiotic use will be essential.

The Battle of Fresno: Mosquitoes vs. The Human Mind

An important turning point in the war against mosquito-borne illness may have just occurred with the release of Wolbachia-infected Aedes mosquitoes in Fresno, California. Aedes mosquitoes have been a major scourge of humankind for centuries and are responsible for the spread of such major infectious diseases as yellow fever, dengue, chikungunya, and Zika. 

These special male (non-biting) mosquitoes are infected with a bacterium that renders them sterile such that eggs produced after mating with a female are non-viable. Over time, as more sterile males are released it becomes difficult for females to couple with uninfected males and populations fall. Lower mosquito populations will translate into lower rates of human disease. 

Wolbachia are an endlessly fascinating genus of bacteria that have the capacity to influence their hosts in interesting ways. Rendering male mosquitoes sterile is just the tip of the iceberg. In fact, Wolbachia infected worms responsible for filariasis may be responsible for the damage these parasites cause in humans and are a potential target for treatment. The implications Wolbachia have in biological systems and evolution are too numerous to list.

My hope is that these altered mosquitoes are tremendously successful and help construct a new a paradigm in the control of mosquito-borne diseases. Thankfully, these mosquitoes have managed to avoid the misplaced stigma placed on the related GMO mosquitoes -- which I also unequivocally support.

When it comes to eradicating Aedes mosquito species from the planet, it is important to realize that the standard of value that should be operative here is human life -- not mosquito life and not "pristine" nature.

As each species struggles to survive, all of the tools available are employed. For humans, our greatest tool and means of survival is our mind. These altered mosquitoes, the result of a chain of scientific discovery and achievement are stellar products of the human mind coping with the problem of improving human life and their release is a cause of celebration.

The Tracking Zebra Bulletin Newsletter

After a little bit of prodding, I've decided to add a newsletter to my blog's features. This newsletter -- I think I'll call it The Tracking Zebra Bulletin, will feature some highlights from the blog, some news stories I might have commented on, and other little features like speaking engagements, media appearances, and papers I publish. I anticipate this will be, on average, a weekly newsletter.

For those of you subscribe to the blog by email, that will still continue but you may want to subscribe to the email newsletter separately because it will have some content in addition to my blog posts. 

Here's the link.

Thanks for reading.

Gardasil: The iPhone of Vaccines

Today while scrolling through my Facebook feed a post caught my eye because it was about Gardasil, the revolutionary vaccine that has changed the face of myriad HPV-induced cancers. The post, which I would not click on, purported to detail a case of someone receiving the vaccine and developing leukemia. Looking through the comments, one stuck out. It explicitly called into question ever trusting pharmaceutical companies. It struck me as conspiratorial, arbitrary, and so misplaced. 

I, for the life of me, do not understand why there is any animus towards Gardasil -- it really is on the level of the polio vaccine in its importance to me (I also highly regard Cervarix, the other HPV vaccine). This vaccine, constructed through really cool processes involving viral like particles (VLP), has the capacity -- if adopted at high enough levels to eradicate HPV-caused cervical, vaginal, vulvar, penile, anal, and head/neck cancers. Not many other vaccines can do that. The evidence is already beginning to amount as the vaccine, first protective against 4 chief strains of HPV and now 9, has had the time to begin to impact rates of precancerous lesions as those who received the vaccine are now entering eras in their life (post sexual debut) when these changes first appear and are diagnosed. In New Mexico, for example, this is evident even with poor uptake.

There is very close to zero safety concern with this vaccine (see here and here) which should be as routine for boys and girls as all childhood immunizations are. However, I think the strong connection with HPV acquisition and sexual activity has caused some parents to balk for whatever reason (even physicians sometimes demur when including the HPV vaccine in the list of schedule vaccines at a given visit). It's odd to me that this objection comes up when hepatitis B vaccine is targeted against another a virus that can also be sexually transmitted and it is given soon after birth.

When you ask someone to articulate their opposition to Gardasil it is often something they are unable to give logical arguments and instead, at most, rattle off a litany of anecdotes they've heard or come across on the internet that are almost always wrong. The same type of people who claim the government has a "cure for cancer" locked up somewhere are the same type who shun an actual preventive cure for HPV-induced cancers. Consistency is not something that is the strong suit of the conspiracy-haunted mind.

Worse than anecdotal evidence, to me, is when they just arbitrarily assert that pharmaceutical companies are out to poison and kill everyone -- as if that would increase their profit or shareholder value. Such insults and attack on integrity not only insult the pharmaceutical company personnel who brought this product to market but also the scientists who meticulously devoted their lives to solving this problem (one of whom received a Nobel Prize).

In my estimation, Gardasil is technologically as important as the iPhone and it, and the individual minds that made it possible, should be lauded.