Dean Ford’s Blog

When we hear that someone has been diagnosed with meningitis, we pray that it’s viral. The bacterium Neisseria meningitides is one of the cruelest of our bacterial pathogens – and there are many. Although quite a few of us have the bacterium as part of our natural bacterial community, it may be deadly to those you are close to, even fatal in a very short time. The thought that a kiss can be deadly is not one we want to dwell on, but our time in college is also a time when we explore relationships and may even meet the person we spend the rest of our lives with! To me, it should not be an option. If there’s a vaccine out there that can prevent our young people from transmitting this pathogen through a simple kiss, then vaccinate!

I remember being diagnosed with “suspected meningitis” on a family holiday in Western Ireland. I was probably about 11 at the time. I vaguely remember a splitting headache and nausea, a hospital bed, grim faces, even grimmer talk of a flight to London, and a lumbar puncture – which turned out to be negative. I don’t remember being scared, I didn’t know anything about the disease at the time, but I suspect my parents were terrified. It’s not just the human toll in illness, disabilities and lives lost; the emotional toll – the fear – amongst students, faculty, staff and health workers at an educational institution cannot be easily quantified. The economic toll however is vast – of a real or perceived outbreak – canceled events, students withdrawing from school, declining recruitment, etc.

It’s not always an easy decision, given the mixed messages we are given from the media. We’ve had approved vaccines for meningitis for a number of years, but the recent outbreaks that have tragically shaken US campuses in recent months have been caused by a strain that we call Serogroup B – not one that the older vaccines, sensibly required by a limited number of States for almost all incoming students to dormitories on their campuses, are effective against.  Fortunately, approval of a Serogroup B vaccine has been expedited and the first one was approved in October 2014, the second this January. So, we don’t have several years of widespread use to confirm the safety of the product, but at the same time, the process of approval is fairly rigorous with several thousand people tested, with a few reporting the usual side effects of a sore arm, headache, diarrhea, and other minor and temporary complaints.

It’s beginning to look a little like the measles debate, if you opt out, you put public health at risk. These may not be fully tried and tested vaccines, with multiple years of data to support their safety, but everything science knows about them is that they will save lives. My public health background tells me this is absolutely the right thing to do – and our scientific colleagues are working tirelessly to improve the efficacy and safety of our vaccines every day. This isn’t a religious or political choice – if you decide not to vaccinate you reduce our herd immunity – our ability to withstand the onslaught of disease. You are responsible for other people’s morbidity and mortality, make your choice.

You’re in the restroom at one of your favorite restaurants, and you can’t help but read the extensive instructions to employees about hand-washing: wash hands for at least 20 seconds, clean between fingers and under fingernails, turn off taps with paper towels, etc. Have you ever seen anyone actually wash their hands for 20 seconds outside of a healthcare setting? Don’t overlook this habit, because washing your hands could just save your or someone else’s life. I recently heard that the requirement for posting hand washing instructions represents too much regulation. But I beg to differ. When it comes to public health, I am convinced we need more regulation, and not less.

It may shock you to know that studies suggest that ~80% of people fail to wash their hands after using the toilet, changing diapers, or other potential contact with fecal material. Admittedly, that number drops to 50% or even less in the more developed countries. Why should this be of concern? Because one of the more frequent outcomes of consumption of fecally-contaminated food or water is the norovirus, which has the delightful symptoms of projectile vomiting and explosive diarrhea. Another is a toxigenic form of a natural inhabitant of the human gut called Escherichia coli O157:H7, which can be fatal. Regulations that enforce good hygiene are one of the most important ways of reducing risks of exposure to these pathogens.

When the pandemic flu returns, SARS or other easily transmissible diseases such as measles, these will be caught from the simple act of touching door handles, taps, levers that work the bathroom paper rolls, pressing buttons that work the air-dryers, chairs we pull back at the tables, buttons we push on the escalator, anything we touch at the gas station, vendor machines, cash dispensers, computer keyboards, and of course, from the filthiest of all, our cell phones…. I could go on.

There is always the counter-argument that we must, in fact need, to continuously challenge our immune systems, unless our system has been compromised. Don’t worry, we have plenty of opportunities to do this – through our drinking water, through the air we breathe, home cooking techniques, pets, travel and all of those everyday habits that expose us to a fascinating array of microbes. But our best defense against illness – and this is true worldwide – is basic hygiene and sanitation, for which hand-washing is the cornerstone.   So, let’s continue to encourage each other, and especially those preparing and serving our food, to wash their hands thoroughly. Scanners now exist to assess effective hand washing – I’ll patronize the restaurant that implements this technology.

I know it shouldn’t, but it still amazes me when I hear people say they had measles when they were young and it didn’t do them any harm – so why bother to vaccinate? I had measles too, and I was one of the lucky ones.

Measles continues to be a significant killer globally, with mortality risks greatest amongst those malnourished or without access to healthcare. In the US, before vaccination programs started in the early 60s, several hundred people died each year, many of them young children. Earlier in the century, mortality in the US was much higher, reflecting the poorer health conditions and nutritional status of the population.

Measles remains a leading cause of death among children in many less developed countries. But it’s not just mortality that we have to worry about. Other health complications can arise from measles infections that may result in hospitalizations and significant healthcare costs. Vaccination programs have changed that picture in the developed world, and they are beginning to raise our hopes for successful eradication worldwide, just as we’ve achieved for smallpox, and may be close to achieving for polio.

The people who I have deep sympathy for are those who say they vaccinated their child, and he/she subsequently developed autism. Thank you for vaccinating your child, you may well have saved another child from dying from the disease. It is natural to need something/someone to blame when your child is diagnosed with a debilitating disease, but science has found no credible links between vaccination and autism. Yes, there can be a very limited number of injuries and even deaths associated with any vaccination program, but the numbers are minuscule compared to the lives and injuries saved. This is why scientists are constantly working to improve the safety and efficacy of vaccines (a plug for continued and increasing funding for biomedical research).

An individual’s decision not to vaccinate their child, whatever their reasoning, is a decision that puts family members, their neighbor’s children, their children’s school fellows, their community and the broader population at risk from a potentially debilitating disease, with a risk of death, particularly amongst young children in the socio-economically challenged parts of our country.

Ill-informed politicians, celebrities and “internet quacks” will, I’m afraid, continue to stir our fears – they put the very fabric of our public health system at risk – not only in this country – but globally, to their and our shame.

Check out Orenstein, Papania and Wharton (2004), in the Journal of Infectious Diseases, for the story of measles elimination in the United State. http://jid.oxfordjournals.org/content/189/Supplement_1/S1.long

On September 30, 2014, the CDC announced the first Ebola case diagnosed in the United States. CDC’s director has no doubt that the case will be contained. We hope he is right, but either way this is a pivotal moment for the CDC, the US and the healthcare community.

In the early 90’s I was privileged to be part of the Harvard School of Public Health’s New and Resurgent Disease working group. This group was the first of its kind to begin to explore why we were seeing what seemed to be both new, and resurgent disease outbreaks, epidemics and pandemics, both in the US and globally. I was there as the water guy – interested in new strains of waterborne diseases and the surge in toxic algal blooms along our coasts. The tragic HIV/AIDS pandemic was in full swing, with no effective treatment at the time (there is still no cure, and control through antiretroviral therapy did not begin until the late 1990s) – a disease that continues today as one of our top five infectious disease killers in the developing world, together with lower respiratory tract infections, TB, Malaria and diarrheal diseases.

At the time of our working group, HIV/AIDS had killed millions of people worldwide and hundreds of thousands in the US, but there seemed to be a plethora of others emerging/resurging – the massive outbreak of cryptosporidiosis in Milwaukee in 1993, caused by an organism that was barely recognized as a human pathogen before the emergence of HIV/AIDs. Epidemic cholera returned to South America after more than a hundred year absence and a new strain of epidemic cholera had emerged in India.

From the mid 70s through the 80s we had seen Lyme disease, Legionellosis, hantavirus pulmonary syndrome, Ebola, Marburg and Ehrlichiosis emerge as newly recognized diseases, and a resurgence of dengue, plague, yellow fever, diphtheria – and perhaps most worrying of all, rapidly increasing numbers of drug resistant cases of TB, malaria and others – the direct consequence of our treatment and animal husbandry practices (a subject for another blog) – practices that together with hygiene and immunization programs had led many to feel that death from infectious disease would soon be a “thing of the past.” We wrote in the “Ecologist,” “Suddenly, the euphoric proclamations of freedom from infection seem, at best, premature; at worst, dangerously hubristic.” (Levins R, et al. The Emergence and spread of new diseases. The Ecologist 1995; 25:21-26.)

One member of our working group, the acclaimed author Laurie Garrett, then a writer for Newsday, spent a year’s fellowship with us researching her new book, “The Coming Plague: newly emerging diseases in a world out of balance.” Published in 1994 by Farrar, Straus and Giroux, her book presents one of the most compelling and readable accounts of the phenomena of new and resurgent diseases, including a chapter dedicated to the first outbreak of Ebola. This should be required reading for all!

Not long after Laurie’s book was published, Ebola inspired the film industry to produce the film “Outbreak” (1995), about an Ebola like virus that emerges in Zaire and then spreads to a small town in the US. Of course, the CDC and military are able to eventually control the outbreak, a message that I fear creates complacency amongst those of us in this country who are currently untouched by Ebola in Africa today.

Speaking about Ebola, and in response to the undeniable fact that we are only a plane ride away from Africa, Anthony Fauci, the director of the US National Institute of Allergy and Infectious Diseases, considers it extremely unlikely that an outbreak could occur because of our healthcare system and isolation procedures. He is probably right, but his logic only applies if we can recognize an infected individual, and that individual seeks care. Many viruses are transmitted by the aerosol route, e.g., pandemic flu – placing passengers in a confined environment such as an airplane at risk of infection through proximity to an infected individual. Current thinking is that the known strains of the Ebola virus are primarily transmitted through direct contact with bodily fluids.

In fact, the CDC’s Quarantine and Isolation website provides Ebola Guidance for Airlines which state: “The risk of spreading Ebola to passengers or crew on an aircraft is low because Ebola spreads by direct contact with infected body fluids. Ebola does NOT spread through the air like flu.” Sound science behind this statement is hard to find. In fact you can find some information on the web that seems to contradict this assumption.

Am I trying to be an alarmist? Actually, I’m trying to make the argument that we in the US do not have all the answers, and that there is no guarantee that our healthcare and isolation systems will effectively deal with the next potential pandemic. We have to fight these diseases where they originate, and do everything we can to prevent an outbreak becoming an epidemic and then a pandemic. It is also ethically indefensible to allow a killer-disease to decimate rural villages when we have convinced ourselves that we have both the technical expertise, and the resources to mitigate these threats in our own country. Ebola is now global – yes, it is still in Africa but it has now emerged in the Democratic Republic of the Congo, Guinea, Liberia, Nigeria, Senegal and Sierra Leone – previous countries included Zaire, Sudan, Gabon and Uganda. In Liberia, clinics in its capital city, Monrovia – with a population of over 1,000,000 – are currently overwhelmed. Sierra Leone’s capital, Freetown, may soon face the same challenges.

With more then 3000 killed in this current outbreak to date (and this number may be considerably higher), we can no longer think of Ebola as causing sporadic outbreaks in geographically isolated areas. This is no longer a “cry for help” from a poor African country. We needed to act internationally on a major scale at the beginning of the outbreak – now we have to throw all our resources at mitigating the African epidemic – because it will continue to spread. Instead we have governments blaming the world health organization (WHO) for a slow response, and the WHO blaming governments.

How many reports have you seen that end their title with “a call for action”? I’ve written them myself in relation to waterborne disease – but does action ever happen? The last decade has seen significant threats from the specter of infectious disease pandemics – SARS, H5N1 and others – and arguably we should now be capable of an effective global response. But it didn’t happen, there is no excuse, but I’m afraid we’ll hear many from all quarters, continued finger-pointing and limited action. This is happening in Africa and it’s complicated by war, poverty, corruption, issues of sovereignty, malnutrition and a plethora of different disease states.

Yes, that’s exactly why diseases like Ebola often emerge in African countries, or in countries that lack the resources to provide the necessary response. We in the health professions need to keep these global crises at the forefront of debate – the public and our politicians cannot be allowed to lose interest, the stakes are too high. The current Ebola outbreak clearly demonstrates that we lack the commitment to human society to prevent this kind of catastrophe until its almost too late – or perhaps it already is. If this turns into a pandemic, all of us are responsible for our complacency, the least we can do is hold our politicians accountable for a strong US response.