INFECTIOUS DISEASE
Outbreak: No longer the stuff of Hollywood movies
Contagion. 12 Monkeys. The Andromeda Strain. Even Rise of the Planet of the Apes and World War Z. Since the last half of the 20th century, there’s been no shortage of films and TV series about infectious diseases and their sequelae. Audiences seem to have a fascination for anything that threatens humanity, and pandemics are no exception – especially when they’re getting the full Hollywood treatment.
The reality in 2015 is very far removed from a movie soundstage. A report released on December 18, 2014 by the Trust for America’s Health and the Robert Wood Johnson Foundation found that the recent Ebola outbreak “exposes serious underlying gaps in the nation’s ability to manage severe infectious disease threats.” The report, entitled Outbreaks: Protecting Americans from Infectious Diseases, concluded that the entrance of Ebola into the United States – along with Angelina Jolie’s chicken pox and the National Hockey League’s mumps outbreak – “highlighted cracks in America’s public health defense against infectious disease.”
The Trust for America’s Health report cited the nation’s half-hearted defense against Ebola and other infectious diseases on complacency. Dr. Kent Brantly, an American doctor who contracted Ebola while treating patients in Africa, and others are working to correct that. In a December 15, 2014 interview with NPR, Dr. Brantly said this: “It’s a good thing that this is still a conversation in our government and in our public. People are still dying every day in West Africa from Ebola, and that sense of urgency I expressed back in September is still very much there.” And on December 30th, actor Jeffrey Wright and his Hunger Games cast mates, along with anthropologist and physician Dr. Paul Farmer, teamed up with the Ebola Survival Fund to produce an online video about the virus’s devastating effects. Their goal was to use social media to raise awareness about the worldwide crisis, and also to temper fears on the home front by underlining that available resources differ vastly in both quality and quantity.
Ebola is actually just one of a large group of viruses, says Dr. Nancy M. Khardori, Professor of Medicine and Chief of Infectious Disease at EVMS. It’s dreaded because it’s fatal so much more often than others, and because it’s so transmissible. “The world has become a global village,” she explains, “and it doesn’t take long for a disease that appears in one country to spring up in another country. That’s why it’s so important for everyone – medical and lay people alike – to remember that we can no longer think that we’re safe if Ebola appears in a far off country. It can get to places very quickly, as it got to America.”
Dr. Khardori believes there may be a vaccine for Ebola within the next five years. For now, the best results appear to come from taking the blood of an Ebola survivor and using it to help fight the disease. As he was returning home from Africa, Dr. Brantly received a blood transfusion from a 14-year Ebola survivor. He survived, and has now donated his own blood for other patients. Dr. Khardori explains: “When a patient survives, it means his body was able to produce an antidote that fights the infection. His blood can be duplicated in the laboratory to produce monoclonal antibodies. These antibodies bind to the virus and prevent it from spreading.”
It’s not just the recent, high-profile Ebola cases that are giving infectious diseases specialists in Hampton Roads cause for concern. “Complacency is definitely a problem in the area of HIV,” says Dr. Daniel Kluger of Riverside Infectious Disease Specialists. “The message that HIV is still out there, and potentially devastating, is not as wide spread. The number of new cases hasn’t changed in decades – as many as 50,000 new cases each year nationally,” he says. And unfortunately, there’s a significant population that’s HIV positive, but undiagnosed. “The fact that there’s such a large burden of people who haven’t been tested or who deny the results helps perpetuate the ongoing epidemic,” he says. “And left untreated, the natural history of HIV without intervention is that that patient will go on to develop AIDS in 10 or 12 years, and ultimately die from it.”
Yet there is no need to die from HIV, confirms Dr. Khardori. “AIDS at this point has become a chronic disease, very easily treatable in most cases. Very seldom do we find a situation where we cannot control the disease.”
That is, of course, if the patient is compliant. “You can look at HIV as a success story in terms of the highly effective antivirals we have today,” says Dr. Conrad Schwab, an infectious disease specialist with Bayview Physicians. “New treatments continue to come out that are much less toxic and more potent, better tolerated and easier to comply with.” In August of 2014, Dr. Schwab says, the FDA approved a once-daily fixed-dose combination of drugs called Triumeq. Like other HIV therapies, Triumeq is expensive, Dr. Schwab says, but adds, “We are fortunate that there is state assistance for people who need medications, and drug companies do try to provide copay assistance for those who qualify. These drugs are covered by standard insurance to a lesser degree. Cost shouldn’t be a barrier to getting treatment.”
Triumeq doesn’t involve boosted protease inhibitors, and the less frequent dosing makes it more effective. “We used to have to tell patients to set their clocks every four hours, to take their dose,” Dr. Schwab says. “Today, we can give them one pill, and if they take it regularly, they can have a lifespan that comes close to matching that of someone who isn’t infected.”
The flip side, unfortunately, is that infectious disease specialists are seeing resistance to many of their treatments emerge as well. “Antibiotic agents became available in the early 1940s,” Dr. Khardori explains, “and they have been quite effective at saving lives. But they’ve been used so widely that the organisms they’re designed to kill have adapted and have become resistant.” For years, she says, patients adamantly demanded antibiotics for themselves and their children, although the trend has lately reversed. But more public education is still needed to help patients understand the doctor’s reluctance to prescribe them.
“We can’t always identify the exact bacteria that’s causing the infection,” Dr. Khardori says, “and while antibiotics aren’t toxic, if we give an antibiotic that won’t cure the infection, the patient has been exposed to antibiotics for no reason.”
Help from the microbiology lab may solve the challenges of diagnosis. “I attended a conference last year where we were told that the person in the microbiology lab would become our best friend,” Dr. Schwab says, “because there are polymerase chain reaction tests they have now for influenza, which can keep us from giving medication to someone it cannot help. I dream of the time when a patient might present with pneumonia, and we can do a test for viral and bacterial organisms right then and there. I think in the future, there will be multiple tests we can run on the same specimen to get a more complete picture.”
In fact, Dr. Schwab says labs are coming out now with a blood test that will allow doctors to tell if a patient has staph aureus, and if it’s resistant – the MRSA type of staph aureus – physicians will know immediately what kind of antibiotic to prescribe. As a member of the infection control committee at Chesapeake Regional, he is excited about the new medications that are available to treat these conditions – and for the advancements in diagnosing them.
One diagnosis that can – and should – be made is Hepatitis C. It’s a viral infection, and the leading cause of cirrhosis of the liver, as well as in transplant failure. There are about 3.2 million Americans infected with HepC, and 17,000 new cases every year. “We haven’t had a good treatment for it,” Dr. Schwab notes, “but now new combination treatments, while costly, are better tolerated and have dramatically improved the sustained virologic response rates from 50 percent or lower of older combination therapies to well over 90 percent, while shortening the treatment duration from one to two years to a few weeks or months. That is revolutionizing Hepatitis C treatment, much as happened with HIV treatment in the late 1990s.”
A further word about vaccinations. A January 8, 2015 article in The Los Angeles Times reported that as many as 12 measles cases had been connected to visits to Disneyland and Disney’s California Adventure Park. At least six of these cases occurred in people who were unvaccinated for the disease, two of whom were infants. It’s not the first such report of measles in the United States. “There are outbreaks nationwide, and this is something that just should not be happening,” Dr. Kluger says. “It’s really disappointing, in the year 2015, to still be arguing about this.”
Dr. Kluger is referring to a 1998 paper published in The Lancet, written by Dr. Andrew Wakefield, which linked various childhood behavioral and intestinal problems to the MMR vaccine. The paper was retracted and labeled ‘fatally flawed’ by The Lancet in 2010 when it was revealed that Dr. Wakefield had fabricated his research. He was later cited for ethical misconduct, but unfortunately, people still point to his research to rationalize withholding vaccines from their children. “The American Academy of Pediatrics weighs the evidence before they make any recommendations,” Dr. Kluger says. “I agree 100 percent with its recommended vaccination schedule.”
Finally, a look at the 2015 flu. The season is earlier this year than usual, and strain that is circulating for the most part isn’t included in the vaccine released in the Fall. “The choice of strains is usually made the Spring before, based on the predictions, last season’s information,” Dr. Kluger says, “but they’re just predictions. But while the vaccine isn’t as active as we would have hoped, I still believe everyone should get it.”
That, and constant vigilance about hygiene, especially hand-washing, Dr. Schwab says, “We preach prevention.” Dr. Khadori agrees: “Microbes are microscopic. What you don’t see can hurt you.”
