Ebola Outbreak Spreads to a Nearby City

Health officials at the World Health Organization (WHO) reported this week that the most recent Ebola outbreak, which began in a remote village of the Democratic Republic of the Congo (see this blog, May 12, 2018), has spread to a nearby city of over a million people. Only one case of Ebola has been reported in the city so far, but the fear is that the outbreak could spread more quickly now, making containment more difficult. In a city, tracking down and potentially vaccinating every individual who has been exposed to a patient becomes much more difficult.

Keep your fingers crossed. We'll be watching this outbreak closely.

Another Outbreak of Ebola

The Ebola virus that killed more than 11,000 people in four African countries in 2014-2015 has broken out again - this time in a remote village in the Democratic Republic of Congo. So far, 17 people have died from the newest outbreak, including one nurse who was caring for victims.

The 2014-2015 outbreak was so deadly because the countries involved and various medical aid agencies were slow to respond. This time around, health officials are taking no chances. The World Health Organization is mobilizing a rapid response force that includes medical experts, equipment, and medical supplies, including a new Ebola vaccine. The affected area is just three hours away by road from a city of over a million people. If the virus reaches the city, containment of the outbreak could become much more difficult.

From past experience, health officials believe that by attacking viral disease outbreaks early and hitting them hard, outbreaks can be stopped in their tracks before they can spread very far. It worked (minus the new vaccine) in stopping a previous Ebola outbreak in the Democratic Republic of Congo in 2017. Let's hope it works again.

Testing Zika Vaccines

Here's a question for you. Suppose that you had been working on a vaccine for the Zika virus, and now you have what you think might be a good one. How are you going to prove its safety and effectiveness?

Testing your vaccine for safety would be relatively easy; you'd give it to just a few people at first, and then to dozens, then hundreds of volunteers until you could prove that it was free of dangerous side-effects. But the real difficulty would be to prove that it is effective; that is, that it actually would prevent a Zika virus infection. Zika infections are relatively rare, even in Zika-infections regions. And you can't just test the vaccine on the persons who do become infected; vaccines have to be given before an infection occurs, not after.

So here are your options: 1) Administer the vaccine (or a placebo) to tens or even hundreds of thousands of healthy people in a Zika-infected region, so that just by chance you will have vaccinated a few people who will contact Zika at some time in the future, and then wait, or 2) administer the vaccine (or a placebo) to perhaps a few hundred volunteers and then deliberately infect them with the Zika virus.

Because Zika infections are relatively rare, the first approach is likely to be prohibitively expensive, time-consuming, and might never achieve the desired result. That's why researchers are proposing the second approach; deliberately infecting vaccinated and unvaccinated volunteers with Zika. The researchers argue that a Zika infection, like the flu or a cold, is a relatively minor illness for an adult. The real danger is to a woman who is pregnant, because a Zika infection during pregnancy can lead to serious birth defects in an infant. For that reason, the researchers say that any women in the proposed study would have to agree to avoid pregnancy for the duration of the study.

Still, some ethicists are queasy about the proposed study. Accidents (including unplanned pregnancies) happen. And this study would be of no benefit whatsoever to the persons who would choose to volunteer; they'd have to be doing it solely out of altruism.

What do YOU think?

Australia May Become the First Country to Eradicate Cervical Cancer

If the current trend continues, Australia may become the first country to virtually eradicate the HPV virus that causes cervical cancer. How did they do it? Health officials credit an aggressive government-financed vaccination campaign begun in 2007 that targeted 12-13 yr.-old girls, combined with a catch-up program to vaccinate older girls and women up to the age of 26 that was completed in 2009.  By 2015, 53% of women in the now 18-35-yr.-old age group had been vaccinated. More importantly, rates of HPV infection have dropped from 22.7% to less than 1.5%. That's a 93% decline in HPV infection rates!

Why did HPV infection rates drop so dramatically when only 53% of the women have been vaccinated so far? It's the well-known "herd effect" - when enough people in a population are immune to a transmissible disease organism, it's much harder for the organism to be transmitted from person to person, even though some people are not yet immunized.

Although health officials have not yet seen a dramatic decrease in the number of cases of cervical cancer, that's because it can take years for cervical cancer to develop after HPV infection. At the moment, the number of cases of cervical cancer is just beginning to decline. Nevertheless, officials are confident that with continued aggressive vaccination against HPV, within 30-40 years cervical cancer will be a thing of the past in Australia.

The full HPV vaccination regimen costs about $400 per person in the U.S.; probably less in a country like Australia with a government-sponsored program. Sounds like a pretty good deal to me.

Development of Antibiotic Resistance in the Natural Environment

A report from the United Nations Environmental Program offers a useful summary of how the presence of low concentrations of antibiotics in the environment can lead to bacterial antibiotic resistance.

According to the report, antibiotics make it into the natural ecosystem in three ways; 1) via improper disposal of unused prescriptions of antibiotics, 2) through the inadequate treatment of wastewater, and 3) in agricultural waste as a result of the heavy use of antibiotics in farm animals. The report suggests that these low concentrations of antibiotics contribute to antibiotic resistance. In other words, it's not just the over-prescribing of antibiotics for humans that leads to antibiotic resistance; it's also a slow, ongoing process as a result of current environmental contamination. In addition, we know very little about how certain other substances in the environment, such as heavy metals, further contribute to antibiotic resistance.

If the report is correct, we may need to pay more attention to sewage and wastewater treatment, as well as working toward curbing the over-prescribing of antibiotics for farm animals, as well as for humans.

The report contains a handy visual flow chart (p. 15) that teachers might use to explain this subject to students.

A More Effective Shingles Vaccine

Shingles is a condition characterized by an itchy, painful rash that can last for weeks. It's caused by the same virus that causes chickenpox in children. In adults who had chickenpox as children, the virus can re-emerge later in life, causing shingles. Nearly a third of all untreated adults over 50 are likely to develop shingles at some time in their life.

There has been a vaccine against shingles, called Zostavax, since 2006. However, Zostavax has proven to be only 51% effective in preventing shingles. Consequently, many people who were vaccinated with Zostavax still came down with shingles.

Now there's a new, improved vaccine against shingles, according to a press release from GlaxoSmithKline. Last month the Advisory Committee on Immunization Practices recommended the new vaccine, called Shingrix, even for adults who have already been vaccinated with Zostavax.

Shingrix is reported to be 97% effective; nearly twice as effective as Zostavax.  Shingrix may be better in another way, too. Whereas the older vaccine consisted of live but attenuated (weakened) viruses, Shingrix consists of just a subunit of the virus, making it much less likely that the body will have a negative reaction to it.

Ebola Infection May Lead to Cataracts in Children

The Ebola virus epidemic that swept through several West African nations from 2013 to 2016 killed more than 11,000 people. An additional 17,000 people were infected but survived. But now a new problem has surfaced, according to an article in The Seattle Times; in some patients, the Ebola virus remained in the fluid inside the eyes, leading eventually to severe inflammation of the eyes (uveitis), a thickening and scarring of the lens (cataracts), and a potential loss of vision. Cataracts are generally a condition found in the elderly. But they've been found in Ebola survivors as young as five, even if the child had seemingly recovered from the Ebola infection and the virus was no longer detectable in his/her blood.

The findings are disturbing, because they show that patients who were thought to have "recovered" from their Ebola infection can still harbor the virus in bodily fluids not normally tested by health officials. How and when those hidden reservoirs of infection might re-emerge is anybody's guess. You can be sure that health officials will be asking questions and following up.

H7N9 Bird Flu is Still Around

Have you forgotten about bird flu? Well, don't, because it's still around. In fact the 2017 flu season was the worst ever, according to the CDC. From Oct. 2016 to the summer of 2017, the H7N9 strain of bird flu infected 759 people. About a third of them - 281 people - died. That's nearly as many as the total number of deaths in the four previous years combined.

CDC officials consider H7N9 to "the influenza virus with the highest potential pandemic risk", according to a weekly report from the agency. Fortunately, the virus has not yet evolved to be easily transmitted between humans; nearly all cases to date have been the result of contact with infected birds. But if the virus ever does mutate to become more easily transmissible between humans, watch out!

Health officials continue to monitor the virus closely for any signs that it is changing in ways that would make it a worldwide threat. But so far, all cases have been in China, Hong Kong, and Macao.

A New Antibiotic to Combat Antibiotic-Resistant Gonorrhea

Scientists have discovered an entirely new antibiotic that may be useful against strains of gonorrhea bacteria that are resistant to most current antibiotics. It's called closthioamide. It was discovered in 2010, but it has taken until now to learn how to produce it in large enough quantities to be useful.

To date, closthioamide has only been tested in the laboratory on samples of gonorrhea bacteria known to be resistant to most antibiotics. It worked on nearly all of the samples. The next steps will be to try it on animals (to demonstrate its safety) and eventually on humans (to reaffirm its safety and prove that it can cure gonorrhea infections in patients). If all goes well, some day closthioamide may be a new weapon in the arsenal against gonorrhea and other bacterial infections - at least until the bacteria develop resistance to it!

A Skin Patch to Deliver the Flu Vaccine - An Update

Remember the skin patch (this blog, Mar 13, 2014) that was being developed to deliver vaccines without an injection? Back then, the patch had only been tested to see how well the dissolvable microneedles of the patch would be tolerated by patients. Last week the same researchers reported that it has now been tested with the flu vaccine.

In the latest study, healthy volunteers received the flu vaccine either by skin patch or by the usual syringe and needle, both administered by a health care worker. An additional group of volunteers were instructed to administer the skin patches themselves, to determine if self-administration was as effective as administration by a health care worker. The results were encouraging. Increases in antibody titers (a sign of immune system activation) were the same in both of the groups that used skin patches and the group that received an injection. Furthermore, the number of adverse reactions was similar in all groups. In other words, the skin patches seemed to deliver the vaccine safely and effectively, even when the patches were self-administered.

So are we done? Not quite. This was a Phase 1 study; a small number of volunteers was recruited to test the method's safety and potential effectiveness (in this case, potential effectiveness was assessed as an increase in antibody titer). A much larger study will be needed to see if the skin patch vaccine delivery method actually reduces the incidence of the flu. A much larger group of patients will be needed, since not everyone in a population gets the flu. This part of the study will probably take at least several more years.

Perhaps some day you'll be able to order a flu vaccine skin patch on the internet, have it delivered through the mail (or by a drone!), and administer it yourself. Today we're one step closer to that goal.

Compounding Pharmacy Executive Goes to Prison

The co-founder and head pharmacist of a now-bankrupt New England compounding pharmacy has finally been sentenced to prison. Under his direction the pharmacy failed to ensure the sterility and safety of its products, which ultimately killed 76 people (see this blog, Jan 2, 2015).

Although the executive's conviction and sentencing finally closes this unfortunate case, not everyone is satisfied with the verdict. The executive was cleared of charges of second-degree murder that might have resulted in a 35-year sentence. Instead, he was convicted of racketeering and fraud, for which he will spend only 9 years in prison.

A New Outbreak of the Ebola Virus in 2017

On April 22 a 45-year-old man in a remote area of the Democratic Republic of the Congo (DRC) was diagnosed with the Ebola virus; call him the new "patient zero". In less than a month there were 20 more suspected cases and three deaths. Is this the start of a new outbreak? And if so, what is being done to prevent another outbreak like the 2014-2016 outbreak that killed over 11,000 people in Guinea, Sierra Leone, and Liberia?

It would be encouraging to think that "it'll be different this time", and maybe it will. For one thing, Merck has developed a vaccine that appears to be effective against the 2014-2016 strain of Ebola. There are already stockpiles of the vaccine on ice. But the vaccine is still considered "experimental". It has not yet been approved by the FDA, and so it can only be used in carefully monitored clinical study protocols designed to document the vaccine's safety and effectiveness. The DRC does not yet have an approved clinical study protocol on file, according to an article in Science. The government will need to decide whether standard containment strategies are likely to suffice, or whether it can establish an approved study protocol quickly enough to be able to vaccinate people at risk before the outbreak gets much worse.

You might think it would be a no-brainer to establish a clinical study protocol. It is not. Requirements would include the ability to keep the vaccine refrigerated the vaccine at all times - no small task in remote region of the country. Furthermore, an approved clinical study protocol would require extensive record-keeping, including follow-up of all vaccine recipients for an extended period of time. There's even a requirement for ethical oversight and for obtaining informed consent from all vaccine recipients.

And so we wait. We wait to see what the DRC does about this latest outbreak, and whether the outbreak spreads.

Lyme Disease is On the Rise

People who live in the Northeast are aware of Lyme disease; a baffling, debilitating, bacterial infection spread by bites from certain types of ticks.  Lyme disease is difficult to treat if not detected and treated early.  The forecast is for an increase in the number of cases of Lyme disease this summer. The reason is an increase in the population of field mice last year; mice, it turns out, are a preferred host of the ticks that spread the disease.

Cases of Lyme disease in the U.S. have tripled in the past 20 years, according to the Centers for Disease Control and Prevention (CDC).  For more on why that is, see the recent article in The New York Times.

How can you prevent becoming infected? Your best defense is to avoid being bitten by ticks.  If you are outside in a tick-infested area, be sure to check yourself carefully for ticks after coming back inside.  Most ticks won't actually bite you in the first 12-24 hours or so, so it pays to get them off of you as soon as possible.

A New Vaccine Against a Diarrhea-Causing Virus

A new vaccine may represent an improvement over older vaccines against a deadly virus that causes severe diarrhea in children. The virus, called rotavirus, kills over 200,000 children under the age of five each year, mostly in Pakistan, India, and the African continent.

Current rotavirus vaccines have two drawbacks; they are only partially effective, and they require refrigeration. The need for refrigerated transport and storage of a vaccine or medicine is a real problem in very poor and very rural environments, where infrastructure is inadequate and even the availability of electricity may be sporadic. The new vaccine, called Rotasiil, is manufactured by an Indian company and was tested in Niger, where it proved to be 67% effective; as good or better other vaccines currently available. It does not need to be refrigerated, it can be delivered orally, and as an added bonus it's expected to be inexpensive, or at least cheaper than other available vaccines.

Over 200,000 childhood deaths a year, and you've probably never even heard of rotavirus! In the U.S., rotavirus infection is rare because vaccination against rotavirus is just part of the normal childhood vaccination schedule; its given as either one or two doses before the age of six months. Just goes to show that there are a lot of pretty nasty bugs out there, and not everyone in the world is equally protected against them.

Bird Flu is On the Rise Again

A deadly type of bird flu known to be transmissible to humans, called H7N9, seems to be breaking out again this flu season in China. H7N9 has caused only modest outbreaks since 2013, the year it was first identified (see this blog, Apr. 17, 2013). The intensity of yearly H7N9 outbreaks peaked in 2014 and then seemed to decline in 2015 and 2016, leading some health officials to think that the worst was over. Not so, it seems. The current 2017 outbreak of H7N9 (which began in October, the typical start of the winter flu season) is the worst outbreak yet. According to the World Health Association (WHO), more than a third of all cases of H7N9 flu ever recorded have occurred during this year's outbreak, and flu season isn't over.

H7N9 bird flu is not easily transmitted from birds to humans, but it is quite virulent. The death rate from confirmed H7N9 infections in humans is nearly 40%. So far, there are no confirmed cases of human-to-human transmission. Health officials worry that if/when the virus mutates in a way that makes it easily transmissible between humans, we could face a worldwide pandemic.

For now, H7N9 outbreaks have been confined to China, where close contact with poultry is much more common than it is in this country. Are we prepared for a H7N9 bird flu pandemic? The short answer is "no". At the moment there is no vaccine against it. Let's hope that a change to human-to-human transmission of H7N9 doesn't develop anytime soon.

Gaining Ground on Clostridium difficile Infections

One of the most dangerous of all gut bacteria is a bacterium called Clostridium difficile.  C. difficile can cause diarrhea so severe that it can lead to death, especially in older patients in hospitals and nursing homes, in whom it is most common.  To make matters worse, it is difficult to treat because it is resistant to most antibiotics.  Although it is present in most people, its population is normally kept in check by the presence of other "good" bacteria, which tend to out-compete it.  But when nearly all of a person's gut bacteria are wiped out, for example when the person is given antibiotics, C. difficile can reproduce explosively, overwhelming the body's defenses.

Although C. difficile was first identified over 80 years ago, it wasn't until this century, when a strain of C. difficile developed resistance to most antibiotics, that the bacterium became a serious clinical problem.  In a 2015 study published in the New England Journal of Medicine, the Centers for Disease Control and Prevention (CDC) reported that in 2011, C. difficile infections caused about 15,000 deaths directly and contributed indirectly to another 14,000 deaths.

But now health officials are seeing signs that C. difficile infections may be on the decline.  One of the key factors may be our more enlightened use of antibiotics; i.e., only when truly needed.  By reducing the indiscriminate use of antibiotics, especially in hospitals and nursing homes, there have been fewer opportunities for C. difficile to gain a foothold.  But there are other signs of hope, too.  Several vaccines are in the works, and Merck has a new (and expensive) drug called Zinplava that is at partially effective at reducing recurrent infections.  Even fecal transplants (to reintroduce competing bacteria; see this blog, Feb. 23, 2014) seem to help, though these are still just in the experimental stage.

Progress is being made, though sometimes it seems slow.  All we can do is keep trying.

AIDS "Patient Zero" Was Wrongly Accused

For many years, it was believed that the first outbreak of AIDS in the U.S. was triggered by just one person, dubbed "patient zero". That belief was popularized by Randy Shilts's best-selling book And The Band Played On, published in 1987. Patient zero was allegedly Gaetan Dugas, a French-Canadian flight attendant who was thought to have picked up H.I.V. in Haiti sometime in the late 1970s. Mr. Dugas died of AIDS in 1984. After his death Mr. Dugas was vilified by the media; a 1987 New York Post headline called him "The Man Who Gave Us AIDS".

The myth of "patient zero" persisted for almost 20 years. It wasn't until 2014 that careful detective work provided convincing evidence that HIV actually arrived in New York City around 1971 and was well established in the U.S. before Mr. Dugas became infected. And just recently, DNA analysis of a sample of Mr. Dugas's stored blood confirmed that he was not the infamous "patient zero", if indeed there ever was one.

Mr. Dugas was not the villain he was made out to be, despite the fact that he continued to be sexually active after he became infected. He deserves our belated apology.

Did They Think the State was Kidding?

In July of 2015 the California legislature passed a law that requires all children to be vaccinated before they can attend school (see this blog, July 8, 2015). Unlike the previous law, the new law does not permit exceptions for either personal or religious beliefs. The new law will be phased in over seven years; this year and each subsequent year, all students entering kindergarten and the seventh grade will have to be vaccinated. (Current tenth- through twelfth-graders are exempt from the new law, as they'll all be out of school in three years anyway.)

The Sacramento Bee reports that in the Fulsom Unified School District, 145 kindergartners and seventh-graders were sent home on Tuesday last week (the first day of school) for failure to have the required vaccination documentation. By Friday, 98 of those students still had not returned to school. Do parents who oppose childhood vaccinations think the state is kidding? If they stick to their convictions they'll have to home-school their children.

I'm with the state and the school district on this one. It's time to hold the line against the anti-vaccine movement.

We're Just One Step Away From a Superbug

The possibility that a strain of bacteria might develop total resistance to all known antibiotics (i.e., a superbug) continues to haunt us. Slowly but surely, more and more bacteria are increasing their resistance to antibiotics faster than we can create new antibiotics. No bacterium is completely resistant to all antibiotics yet, but a recent discovery suggests that we are just one step away from that point.

Right now, one of the most antibiotic-resistant of all bacteria is carbapenum-resistant Enterobacteriaceae (CRE for short). CRE has developed resistance to all antibiotics except an old antibiotic developed 50 years ago, called colistin. But now researchers have discovered a strain of E. coli bacteria that is resistant to colistin. If this strain of E. coli ever transfers its genetic material to CRE (the equivalent of bacterial mating), then we are in for real trouble.

Will it ever happen? No one knows. But bacteria have proven themselves to be highly adaptable. The era when antibiotics were the answer to bacterial infections may be coming to an end. We may have to find new ways to combat the bacteria of the future.

Sexual Transmission of the Zika Virus

In healthy adults, the Zika virus causes only mild flu-like symptoms.  80% of infected adults never even know they are infected. However it's a dangerous virus nonetheless, because women who are infected during their pregnancies can give birth to infants with a birth defect called microcephaly.

When Zika first appeared in South America, it was believed that the virus was transmitted exclusively by mosquitoes that thrive in South American countries with warm, humid climates. However we now know that the Zika virus can be sexually transmitted. Until yesterday, all 14 documented cases of sexually transmitted infections in the U.S. had been caused by Zika-infected men (who infected their partners, either male or female). But now the CDC has reported the first documented case of transmission from an infected woman to her male partner in the U.S. The significance of sexual transmission is that it raises the possibility of an outbreak of Zika virtually anywhere in the world, not just in areas in which the Zika-transmitting mosquito is found.

Scientists are working feverishly on a vaccine to prevent Zika infections. It will take some time before one is available. In the meantime, pregnant women (and their male partners) should be aware of the dangers of traveling to countries where the Zika-transmitting mosquito is common.