Enterovirus D68. The new polio?

News from CDC is that there have been more cases of a strange paralytic syndrome in children in which limbs go limp following what appears to be an upper respiratory illness (http://emergency.cdc.gov/han/han00370.asp). Some, but not all, of these children have tested positive for Enterovirus D68 (EV-D68). The cluster announced yesterday is in Colorado and involves 9 children. Earlier this year California reported twenty cases of the same illness that had occurred over a 2-year period (http://www.nytimes.com/2014/02/26/health/unknown-form-of-paralysis-strikes-california-children.html?_r=0).

So, has polio returned in a new guise?

I am not old enough to remember polio. I remember receiving the oral vaccine and seeing old black and white newsreels of children in iron lungs, but no one I knew had contracted the disease. Even during my training I didn’t see a case. Although the disease is believed to have been around since Greco-Roman times, it wasn’t until the late 19^th and early 20^th centuries that humanity was plagued by epidemics.  Like EV-D68, polio belongs to the enterovirus family and is transmitted person to person via the fecal-oral route.  Believe it or not the epidemics of last century are attributed to improved hygiene. With less exposure to the virus during infancy there was a decline in immunity that resulted in a more severe illness later in life when exposed. Most polio infections (95%) are inapparent, meaning they don’t result in any symptoms or paralysis, yet the person is capable of transmitting the virus. Among those with symptoms only about 1% get paralysis. To any individual the risk was low, however, on a population scale this was disastrous. During the peak years there were about 20,000 cases of paralytic polio per year in the US. After vaccine was introduced in the 1950s there was a dramatic decline and polio in the United States was all but forgotten.

I was speaking to a public health historian the other day. She told me that when she was in graduate school she was told that infectious diseases had been conquered and that it was pointless to study them. Chronic disease was the new frontier.  Short sighted to say the least. Ebola, Legionnaire’s disease, HIV, Hantavirus, SARS, Nipah and MERS have all emerged since this professor was told to forget about the field. West Nile virus moved into a new hemisphere, we’ve had an influenza pandemic and Chikungunya exploded in the Caribbean. Forget what you were told, infectious diseases will be with us as long as there still is a planet earth.

Consider this. Your 4-digit PIN number has 10,000 possibilities. There are ten options for the first digit, i.e., zero through nine. Since one can repeat numbers there are also ten options for the next three digits. That’s 10x10x10x10, or 10,000.  A computer program can run through every possible PIN number very quickly. Supposing a thief had a program that could submit the guessed PINs to your account. It wouldn’t take long before he or she was staring at your account balance.

Now consider the ever-changing world of nature. Instead of PIN numbers we are talking about the genetic code, large sequences of DNA or RNA. Each location is like the digit of a PIN number. Nature is like a huge supercomputer, changing the genetic code constantly. The change here is a mutation and instead of allowing access to your bank account the mutation of concern is one that improves the organism’s chance of survival or increases virulence. Millions and millions of mutations don’t, but by chance alone, sooner or later, a mutation is going to result in is a more virulent organism or one that can cross species. This is why there will always be new infectious diseases on the horizon. EV-D68 is a RNA virus. RNA viruses are more prone to mutation (influenza for example). But has EV-D68 somehow mutated to become a paralytic virus like its cousin polio? We don’t know yet. Right now the occurrence of paralysis is quite rare.

Meningococcal disease in young men of color, Brooklyn, New York

Meningococcal disease is a severe bacterial infection often called “spinal meningitis” or just “meningitis” by the media. Although it can spread from one person to another it is not as contagious as the popular press makes it out to be. Household members, sexual contacts and persons who share cigarettes or drugs are at the highest risk for catching the disease which is potentially deadly, claiming as much as 20% of victims. There is good news though, there are vaccines for meningococcal disease.

Meningococcal disease can be insidious. Often it looks like the flu at first, with fever, sore throat, chills, muscle pain and just feeling punky. A rash might develop which looks like small red dots that don’t go away when pressed with a finger (known as blanching). If meningitis develops these signs are much easier to recognize: headache, stiff neck, eye sensitivity to light, vomiting and a fogginess of mind. If you have any of these symptoms don’t delay. Especially if you have HIV. Contact your physician. This disease is readily treatable with simple antibiotics.

NYC has had two large outbreaks of meningococcal disease in the last decade. One in 2006 and another in 2011-2013. Both outbreaks were centered in Brooklyn, specifically the neighborhoods of Bedford-Stuyvesant, Crown Heights and Brownsville. The most recent outbreak affected men who have sex with men (MSM), many of whom were HIV-infected. The outbreak was thought to have been conquered in February 2013 but there have been 4 recent cases in HIV-infected MSM prompting new concerns and efforts to quell the disease. It is not yet known exactly how the disease is moving through the community but there is some evidence to suggest that multiple anonymous sex partners and sharing of drugs is involved.

The response to these outbreaks has been vaccine campaigns. One issue is that the vaccine’s effectiveness in HIV-infected is unknown and two of the recent 4 cases had been vaccinated with the recommended two doses. Still it is better to be vaccinated, as there may be some level of protection and prevention of the most serious outcome. Death.

Another issue is that there is a population of young men who are bisexual or not openly gay who have not gotten the message about vaccine. Many of the recent cases fall into this group. This is where the greater community can help. If you know someone who is at risk for meningococcal disease tell him or her about the vaccine. Urge them to protect themselves. Friends and family want them to stick around, so perhaps they’ll do it for you. One needn’t announce their sexual preferences to receive vaccine. Walgreens/Duane Reade and CVS pharmacies will give the vaccine no questions asked. Check to see that your local pharmacy has it in stock or where the nearest store with the vaccine is located. For those without insurance, you can visit one of the City’s free clinics. The Fort Greene location has Saturday hours. There will be a free vaccine event Sunday (September 7, 2014) at the 3^rd annual Bushwig event. Look for the van near the venue at 389 Melrose Street, Brooklyn.

Lastly, don’t allow fear to paralyze you into inaction.

Ebola won't be a pandemic

Between 2,000 and 5,000 travelers arrive monthly in the New York City metropolitan area from the West African Countries currently struggling to contain the Ebola Virus outbreak. It is highly unlikely though that an individual infected with the virus will arrive here without the medical community knowing about him or her.  Any passenger found to be sick on the flight would be reported to the CDC Quarantine Station by the flight crew and whisked into isolation with full infection control precautions in place. If the illness starts after arrival all emergency departments are prepared to isolate the sick traveler and determine the etiology of the febrile illness. Typhoid fever, cholera and malaria are infinitely more likely than Ebola.

Of the fifty or so people who have arrived in NYC from West Africa sick none have even had an illness worrisome for Ebola let alone the disease. This includes the well-known patient at Mt. Sinai. Should a patient with Ebola arrive in NYC there would still be little reason for the general public to be concerned. The primary transmission risk for Ebola is to health care workers who do not have adequate personal protective equipment and persons handling infected bodies during burial rites. The health care systems in the affected countries are both understaffed and under resourced, a problem not present in NYC (or anywhere in the US for that matter).  NYC has the ability to rapidly test suspect patients, something that isn’t easily done in West Africa. Additionally, Ebola, unlike say measles, isn’t contagious until after symptoms begin, so there is time to implement control measures. Ebola isn’t airborne so to be infected one needs to come in contact with body fluids. The risk of Ebola transmission is low during the beginning of the illness, therefore hospital infection control precautions can be put in place in time and reduce the risk to health care workers. Ebola just isn’t the type of disease to pose a risk to the general US population. It’s not the Andromeda strain.