Chikungunya is coming...

The waves of infectious diseases are lapping against America’s shores. Always have, always will. Most of these diseases are not emerging at all, but have been around for quite some time, or are just slight variations and combinations of humanity’s old foes. Although America certainly has her lymph nodes full with Hepatitis, Herpes, Gonorrhea, Influenza, HIV, MRSA, VRE, E. Coli, you name it. The public health infrastructure and medical professionals of America should not let their guard down against the next encapsulated stranger to knock at our immunological door. Not a new strain of flu: that we can wrap our heads around. Panic stricken, and haphazardly, but we can deal with a new strain of flu. Definitely a virus. For my money, I would keep a look out for Chikungunya. Think West Nile, only with more dead people. (No picture of Chikungunya exists, however, it's purported to look exactly like Sindbis virus, below.)



In addition to having a sweet name, Chikungunya is an Alphavirus in the Togavirus family. Serologic evidence shows that it spread from central Africa to other parts of the world. The virus is mostly localized around the Indian Ocean. The signs of illness closely resemble that of Dengue fever, which is widespread in South America. Symptoms is a terrible sickness including headache, nausea, vomiting, joint pain, and muscle pain. The disease is spread by mosquitoes (surprise, surprise). The African and Asian strains of Chikungnya are associated with the Aedes aegypti mosquito: the same mosquito that transmits Dengue Fever and Yellow Fever.



On the Continental United States, we are relatively free of the A. aegypti mosquito, due in large part to the introduction of the Asian Tiger Mosquito (Aedes albopictus), which out competed A. aegypti. The few cases of Chikungunya seen in the US are returning travelers. The fact that America has not seen an outbreak is remarkable. The Asian tiger mosquito widely populates the Eastern United States. If infected, the US could experience the same patterns of disease that we saw from West Nile.



West Nile Virus (WNV) first showed up in New York, wreaking havoc with old people’s immune systems. It took a while to figure out that it was its own virus, as it shares so much in common (as far as lab tests were concerned) with known encephalitic viruses. There are four main geographical regions the mosquitoes live: up to the Mississippi, to the Rocky Mountains; Sonora Desert; and the West Coast.
Are we looking for it? The CDC is aware of it, and academic microbiologists see it on the horizons. But are primary care physicians or state/county health departments? Perhaps. There have been outbreaks on the Reunion Islands, and the French health Ministry is diligent is developing a vaccine. However, the only known vaccine was developed at USAMRIID, as Chikungunya is a potential threat to US troops. It’s nice to see tax dollars hard at work.
Whatever we decided to do, or however the disease presents itself, keep an open mind to strange infections. Always remember, to the virus, we are the invaders.

WHO information
CDC information

Enserink, M. (2007). INFECTIOUS DISEASES: Chikungunya: No Longer a Third World Disease Science, 318 (5858), 1860-1861 DOI: 10.1126/science.318.5858.1860

Vazeille, M., Moutailler, S., Coudrier, D., Rousseaux, C., Khun, H., Huerre, M., Thiria, J., Dehecq, J., Fontenille, D., Schuffenecker, I., Despres, P., & Failloux, A. (2007). Two Chikungunya Isolates from the Outbreak of La Reunion (Indian Ocean) Exhibit Different Patterns of Infection in the Mosquito, Aedes albopictus PLoS ONE, 2 (11) DOI: 10.1371/journal.pone.0001168

Tsetsarkin, K., Vanlandingham, D., McGee, C., & Higgs, S. (2007). A Single Mutation in Chikungunya Virus Affects Vector Specificity and Epidemic Potential PLoS Pathogens, 3 (12) DOI: 10.1371/journal.ppat.0030201

Tropical Flu?

I would estimate that most blogs by people who think they have something to say begin with "sorry I haven't written in a while." I'm not sorry.

I work in infectious diseases. The word tropical comes up frequently. It refers to areas around the equator. It also used in phrases like "tropical disease" or "tropical medicine." Tulane has a department called tropical medicine. Of course, there is the London School of Hygiene and Tropical Medicine.

Without getting to uppity, I think it's relatively clear that this is a vestigial expression reflecting our colonial past. (Well, not America's colonial past, as we have only ever had one major colony.) The first class I took, that actually switched me from chemical engineering to public health was entitled "Invention of Tropical Disease." So, those of you who know me, yes, this is not my idea. The course discussed after the Scientific Revolution with the invention of modern science, and more importantly, new instruments. Those "haves" went around to the relative "have nots" and set about to describe them in terms of latitudes and "constitution." The British discussed the tempers and humors, while taking temperatures and being humorous. They brought disease, and brought back disease. (Look up Colombian Exchange.)

Indeed, when we think of maladies like Malaria or Yellow Fever, the idea near automatically shoots in our head of "the tropics." I don't know what it is to discriminate based on biome, but is that the case? We had malaria up through the Mississippi Valley, and Yellow Fever destroyed much of New York and Philadelphia in the 1700s. But our friends DDT and air conditioning came along. With those developments, the mosquitoes no longer bothered us, and transmission was gone.

Now these are tropical diseases...

But are we seeing the reversion back to the idea of tropical disease when describing those diseases that are most decidedly not tropical: INFLUENZA.

Lot's o talk about flu these days, as there should be. We have H5N1, H1N1, and our punctual friend, the seasonal flu. It's fairly commonly understood that flus originate in Southeast Asia, as a result of farming practices, or what have you. Travel then begins to spread it around the world, and around and around and around we go.

But there is a new theory that suggests something slightly different. Think about this: Maryland has the flu when? Like the rest of the US, in the winterish months. Why? Because we are in the northern latitudes. When does Argentina get the flu? In Maryland's relative summer. Why? Because it's in the southern latitude. What about the middle latitude by the equator? Yes. THE. TROPICS. Although they have relative peaks, they have flu near year round.

A theory from a guy named Colin Russell at Oxford came up with the Source Sink theory, which implicates the equator latitudes with their background flu as the source of our flu. Fascinating as a viroloimmunomicrobiologist. But Are the tropics getting a bad rep? Perhaps I'm overstepping the implications of calling flu a tropical disease.

Just my thought for the day.

Less than noble Nobels.

In 1927 the Nobel prize was given to Austian physician, Julius von Wagner-Jauregg. He observed that many people suffering from syphilis ended up in mental institutions with the conditions of 'general paralysis of the insane,' GPI.

Well, he also observed that those who came down with malaria were less susceptible to GPI. He also knew that syphilis died in heat (in a test tube), and was curious if the fever brought about by malaria would stave off the neurodegenerative effects of syphilis. You can always cure malaria by quinine.

He invented Malariatherapry. Obviously, this is 1927, and all of this is a moot point with the development of anti-biotics.

I wonder...

(NOTE: I understand the huge ethicial problems dealing with the next statement.)

Can malariatherapy halt the progression, if not cure, leprosy?

This would have to be a retrospective cohort study, as it might be easier to give anti-biotics than malaria to someone with leprosy, and therefor an observational study would be Tuskegeesque.

The leprosy bacteria can't thrive when it gets too warm, that's why sufferers lose fingers, ears and eyebrows first, where it's cooler. So would inducing a high fever, like the one brought about from Malariatherapy cure or ameliorate the symptoms/disease at all?

Just throwing that one out there...

The Land of the Menstrating Males

Schistosomiasis.



A buddy of mine is studying this Neglected Tropical Disease in China as part of a Fulbright Scholarship. I thought I would give him a shoutout.

bigbigbelly.blogspot.com

From his blog:

"Schistosomiasis, also called snail fever, is known in China as the “blood-sucking disease” (血吸虫病). It is also commonly referred to as bilharzia, or in scientific circles, as Schistosoma japonicum. No matter the name, it has plagued the people of China for at least over a hundred years.

*NOTE: Schistosomiasis, as it is understood in modern terms, was only identified in the mid-19th century. However, symptoms of the disease have apparently been recognized in China for quite some time. Writings that date back well over a thousand years describe a water-borne disease that attacks people in much the same manner that we today understand schistosomiasis to do.

In China, during the 1950s, 10 million people were discovered to be infected with the disease, and the areas affected, or at risk, covered a population numbering near 100 million. However, beginning in the 1950s, in line with Mao’s new ideology (the power of mass movement and cooperative effort), entire populations in schistosomiasis-endemic areas were mobilized against Oncomelania (the vector) snails and recruited to drain rivers and ditches. The number of people infected with schistosomiasis was reduced from 10 million in 1955 to 1.52 million in 1989. Moreover, the area of snail-ridden regions in China was reduced by 76.6% (originally 148 billion m2). Schistosomiasis, which was once an endemic disease in 699 communes in 347 counties, was basically eradicated in more than 200 counties and cities by the end of 1979. Oncomelania snails were eliminated in two-thirds of infested areas and two-thirds of schistosomiasis patients were cured. For more on Mao-era initiatives and achievements, check here. However, several sources document a re-emergence, or rise in schistosomiasis with the beginning of the post-Mao era, particularly in rural areas. And in major schistosomiasis-endemic zones (marsh and lake regions of southern China and the Yangtze River Basin), estimates have been made that 60 to 100 million people are still at risk of schistosomiasis infection/re-infection. For more, check here.

Schistosomiasis is an intestinal parasitic infection caused by Schistosoma japonicum, which involves humans, intermediate snail hosts, and the environment to complete its complicated life cycle. As eggs are discharged into the water via the urine or feces of infected humans or animals, they hatch into larva called miracidia, which must infect the Oncomelania snail in order to continue their life cycle. These adult snails are 6-8 millimeters in length and have a preferred habitat on the surface of the water’s edge, or buried in the mud up to depths of 30 centimeters. Once inside the snail body, the miracidia reproduce and transform into free-swimming larva called cercariae. It is the cercariae that, once fully developed, are distributed into the environment and eventually enter the body of a human or animal target. People may be infected by simple contact with the water (for example, when bathing, farming, fishing or swimming) where infected snails live. Once within the human body, adult female schistosomes release eggs, some of which are passed out in the urine or feces (starting the cycle anew), while others are trapped inside body tissue. The immune reactions to the tissue-imbedded eggs are the cause of disease. In one specific manifestation of schistosomiasis, there is progressive enlargement of the liver and spleen, among other damage. Although treatment is effective and relatively uncomplicated, it does not confer immunity to the disease, meaning that individuals living in endemic areas run a high risk of re-infection. Without treatment, schistosomiasis may lead to chronic urinary tract infection, cirrhosis of the liver, or even death. For more information on morphology, life cycle, or human epidemiology, check here and here and here.

Schistosomiasis is a disease that is transmitted via one of the most common and familiar vectors, especially among Chinese farmers and rural residents; water. The disease can be prevented by interrupting the life cycle of S. japonicum at one of several points – each point posing distinctive problems and requiring a unique approach: While anti-schistosome drugs prove great efficacy, they are expensive and do not prevent re-infection. Eliminating the vector snails is highly time- and labor-intensive and often damaging to the environment through interference with streams, rivers, and lakes, which may harm marine ecosystems and produce other unknown consequences. Lastly, water sanitation/human-waste education is both time- and money-intensive, but could help prevent urine and feces containing live eggs from contaminating the water."

Lesson learned: stay away from snails.

Human Health Terrain Teams

Public health is the bastard of academia. It's ability to find models and ideas from a wide range of disciplines makes it such a great field to work in. Often, the military can shed some light on how to provided better care to those already sick, or to keep others from getting sick.

Napoleon's chief surgeon, Dominique Larrey pioneered the ambulance to more effectively clear the battlefield of wounded.

The transmission of Yellow Fever was confirmed by an Army Physician, Walter Reed. (Cuban physician Carlos Finlay theorized that the mosquito was the vector twenty years earlier.)

The importance of citrus was discovered by Dr. James Lind, who was in the employ of the British Navy.

Today, public health professionals who are working overseas who are finding difficulty facilitating their programs (and there are plenty of you out there), take note from the Military once more.

"In accurately defining the contextual and cultural population of the task force battlespace, it became rapidly apparent that we needed to develop a keen understanding of demographics as well as the cultural intricacies that drive the Iraqi population."
—Major General Peter W. Chiarelli, Commander, 1st Cavalry Division, Baghdad, 2004-2005

The US is fighting a bunch of someone's somewhere, and not seeing the sort of success that was expected of them. I do not intend to talk at all about American military excursions in Iraq and Afghanistan, other than their creation of Human Terrain Teams. (We will talk about Provincial Reconstruction Teams later.)



Human Terrain Teams are part of the larger Human Terrain System, which is charged with creating Human Terrain Maps. Basically, instead of looking for the enemy, a counter-insurgency war is often fought by winning hearts and minds, rather than military battles. In the US war on terrorism, destroying the enemy is relatively easy to finding them. (I say this with no military experience, but I don't think I'm inaccurate.)

There is controversy as to the role an academic anthropologist can play in a theater of war. The Vietnam War did something similar and created projects like the Phoenix Program, which one might not want to repeat again. I am reasonably certain that these points of contention do not apply to groups conducting medical or health related work, but I could be wrong, and would welcome comments of discussion on that topic.



By understanding more about the populations your fighting around, by interpreting their disputes, language, etc, your can more effectively employ their help to accomplish your goal. So, if your goal is to kill your Tali-buddies, or to convince people to wash their hands, you should familiarize with your surroundings as much as possible. Fortunately already their is a field of medical anthropology that does exactly this. I am curious how systematic or obligatory their efforts are in an applied setting, not just academic.

We see this in marketing: Sierra Mist wanted to distribute their product in Germany. Well, Mist is the German word for Shit. And this is just a simple translation...

From my limited experience, I see examples that land on both sides. On the one hand, academics who go out into the field are typically pseudo-aware that there are cultural forces at work that they need to harness. Perfect example is Paul Farmer and Partners in Health.

There are also many more examples of groups who go to a foreign country armed with their own set of goodwill and ideals (more than likely paternalistic, in the author's opinion) who might be able to accomplish their shot-term goal, but their contribution is more for their own reasons than the people.

-There are NGOs in Southern Africa who provide baby formula for HIV postitive mothers, so as to lower the chances of passing the virus to their infant. However, there are reports that down the road from the clinics are piles of unused baby formula because it is a sign and a stigma of being HIV positive. [Citation]

-The government of Burkina Faso wanted to implement a national health insurance the people could buy into. The program was an utter failure as no one bought into the prgram and it lost several thousand dollars, just in start up costs: the government would have been better off just giving everyone a few thousand dollars. Why did it fail? Because the marketing was geared toward the women in the household, who are not the primary purchasers. A look at a Guinness poster that displays "Black Power" in East Africa is an interesting comparison on why you might be better off hiring a marketing agent rather than an anthropologist! [Citation]

Of course the successes are plentiful as well, however, I believe that many projects might be aided with the employ of converted HTTs.

I am an expert in nothing but making snide remarks, however, I do believe that persons carrying out public health projects in other countries can learn a few things from the military's Human Terrain System. I would be curious if we have something similar in public health, and perhaps maybe we should make one.

Human Health Terrain Teams. You heard it here first.


FURTHER READING-

US Army HTS- http://leav-www.army.mil/fmso/documents/human-terrain-system.pdf

New Yorker Article- http://www.newyorker.com/archive/2006/12/18/061218fa_fact2

New York Times Article- "Army Enlists Anthropologists in War Zones."

Wired Magazine Article- http://blog.wired.com/defense/2007/07/when-anthropolo.html

A Blog from a former member of a HTT- http://iraqht.blogspot.com/2007/07/iraqs-human-terrain.html

The Cataphract's Cataracts

Ophthalmology is global health's low hanging fruit. The treatments for the most common diseases are effective and low cost. With the WHO/IAPB goal of eliminating preventable blindness by 2020 (clever), I think starting with cataracts, this is one goal we can hit as a civilization.

Humans depend on vision more than any one of their other senses. A loss or compromise in vision can have large detrimental effects on quality of life for an individual and economic loss for a society.

There is perhaps no better example in ophthalmology, or medicine for that matter, than treatment of cataracts.


(Courtesy of the WHO)

Cataracts are an clouding of the lens of the eye. The leading cause of cataracts, as most eye disease, is birthday candles (senile cataracts). However, several other genetic conditions and infectious diseases can exacerbate their manifestation. Radiation can also play a large part: airline pilots are three times more likely to develop cataracts than their non-airborne counterparts. So wear sunglasses.

Cataracts have afflicted humans for centuries. Galen a Greek physician for the Romans developed "couching," which is quite literally sticking a sharp point into the lens to move it to one side or the other, sans anesthesia.

The treatment is the removal of the lens through surgery, and replacing the lens with an artificial "intra-ocular lens" or IOL. With modern technology, the lens can be broken up using "phacoemulsification," or using ultrasound to break up the lens and suck it out of the eye with an incision no more than millimeters across. In countries that do not have "phaco" machines, the cataract needs to be removed manually with a larger incision.

More information on the manifestations and treatment of cataracts is below.

What is stupendous about cataracts is they account for 48% of the worlds preventable blindness. That itself might not sound like cause for celebration, but for twenty dollars, and twenty minutes, a trained ophthalmologist can take someone who couldn't even detect light, and restore their vision to 20/20, barring any other vision disease. In India, within the next year, a surgery can more than 1,500 times pay for itself for some patients. With the pie chart below from the WHO, we can see cataract's role in global blindness compared to other eye conditions.



There are many groups whose mission statement is to eliminate blindness in their populations. Some groups do it better than others, and some have a unique model for "cost recovery" that allows them to continue operations without an over-reliance on donations. In short, you have about 40% of your patients pay for surgery, and about 60% of your patients don't. The most well known groups work in West and South Asia for the same reason Willy Sutton robbed banks: that's where the blindness is.



One of the more studied models for eye care delivery to patients around the world at low to no cost is the Aravind Eye Hospital in India. The founder, the late Dr. Venkataswamy describes Aravind.'Our effort is to make Aravind an instrument of the Divine Will. We strive to forget our limitations and work with the direction of the Divine Will, not in a vain superficial way but with a deep commitment and faith that guidance comes from a higher level of consciousness. Then one is able to work with the great confidence that comes only with that faith and realization that we are all part of a spiritual capacity or spiritual power. It is then that all of nature works with you. You don't feel that you are a superior being but you are an instrument in the hands of a higher force and it is in that spirit that we meet our day to day struggles and successes.'

What is also unique about Aravind is their creation of Aurolab, which makes their own IOLs and suture at cost. The sutures and IOLs are then available around the world for other groups to use at cost. Aravind is studied all over the world for their cost-recovery model and commitment to the treatment of blindness.

A unique method of eye care delivery is the ORBIS Flying Eye Hospital. They took a huge plane and fitted it with teaching classrooms, treatment rooms, an operating room, and a recovery room. The plane flies all around the world. You can check out the itinerary here.



With all these different groups giving different models of care delivery, which one is the "best?" How can we define "best?" Cost-effective might be a good place to start. Equity of patient care might be another. The year is 2009, and the WHO with the International Agency for Preventable Blindness set the Vision 2020 goal: to eliminate avoidable blindness by the year 2020. "International Organizations" love to set arbitrary years for some percentage of an arbitrary goal to be reached. But with eleven years to go, and a near majority of preventable blindness treatable with effective and cost-effective therapeutics, I think this is a goal we can actually meet as a civilization.

I like cost-recovery models that after a clinic/hospital is built, it can pay for itself within three years and be generating money after that. Those dollars can then go into expanding services, or to pay investors who now have a vested interest in expanding the reach of the hospital. Another venue of social entrepreneurship, like everything else, with it's drawbacks.

Cataract Fun Fact- Although I do not have a copy of his slit lamp microscope exam, many scholars believe that Monet had cataracts. I mean, who comes up with this?



Further Reading-

WHO Cataracts- http://www.who.int/topics/cataract/en/
NEI Cataracts- http://www.nei.nih.gov/health/cataract/cataract_facts.asp

Economic Impact of Blindness- http://www.who.int/ncd/vision2020_actionplan/documents/frickfosterAJO1354712003.pdf

International Agency for the Prevention of Blindness- http://www.iapb.org/

Vision 2020 Campaign- http://www.v2020.org/

Aravind Eye Hospital- http://www.aravind.org/

Combat Blindness Foundation- http://www.combatblindness.org/cms/

Himalayan Cataract Project- http://www.cureblindness.org/

ORBIS- http://orbis.org/blindness.aspx?lang=1