Episode 8: Malaria cheats, Ebola stacked the deck and Influenza counts cards

Today, we're going to look at what happens when pathogens help each other terrorize us dainty meat bags. Today's round up is the terrifying trio of Malaria, Ebola and Influenza. Let's look at what they have in common...

1. Early disease symptoms: 

Fever, malaise, headache and muscle pain - otherwise known as, "waking up one morning with a headache and not wanting to get out of bed." Messrs Malaria, Ebola and Influenza all cause you to feel this way in the early stages of disease while the pathogens (two viral, one parasitic) are still replicating like crazy getting ready to make you infectious.

 

2. Geographical location: 

Mr. Ebola, when he isn't taking plane rides, lives in Western and Central Africa. As far as we know, he doesn't call anywhere else home. Mr. Malaria is a bit more wide spread. You'll run into mosquitoes carrying his progeny all throughout Africa, Asia and Latin America. He's an equatorial monster who needs nice warm climates. Then there's Mr. Influenza, he lives just about anywhere and he's not picky about hosts either- pigs, birds, humans, it's all the same to Influenza.

 

3. Disease incubation time: 

This is where they start to distinguish themselves. Mr. Influenza doesn't really screw around at the casino. He goes right to the poker tables and starts making his money. The incubation time for this little fellow is only 24 to 48 hours. But he'll make you feel crappy for weeks afterwards as he's ravaged your body and stolen away with a whole lot of your savings accounts- at least the currency that cells deal in: protein.

Then next up is Mr. Ebola, whose incubation period is anywhere from 2 days to 21 days depending on your current state of health. He's an insidious little thing, going around your body, slipping his RNA into cells in preparation for the master heist with the same skill any old brigand in a Western movie would slip some aces in the deck.

Mr. Malaria takes his time,using 8-25 days before you show signs of having this little freeloader in your body. He not only replaced all the decks, he corrupted the Blackjack dispensing machines as well. It's like an episode straight out of CSI Las Vegas. 

You don't want to play poker with these boys.

4. Advanced symptoms: 

Ok this is when most sane people would go to the hospital, because with all three of these gnarly little criminals, you're vomiting, you're feverish, your muscles and joints are killing you and your head feels like it's about to split like a rotten melon. However, when you're this sick we can start to tell the wee bastards apart. Mr. Malaria and Mr. Influenza both like to cause problems with your lungs: pneumonia in Influenza's case, pulmonary edema and acute respiratory distress in Malaria's case.

Mr. Ebola doesn't really bother with your lungs, although you may be coughing up bloody phlegm as you start to bleed internally. He's more focused on trashing your intestines and such so you'll vomit out his progeny or plant them all over the bed in your diarrhea. And while Mr. Influenza will make your stomach unhappy, he's not making you bleed into your internal cavities. Mr. Malaria is too busy trashing your brain and making you seizure and fall into a coma to worry about infecting poop. However, as Mr. Ebola causes your fever to go over 103F, he's going to cook your brain from the inside out and you still might win a one way ticket to seizure-ville.
 

 
With all these similarities, it's easy to see how the outbreak got out of control in an area of the globe where doctors are scarce, health care is poor and people are destitute.

It's also clear to see how important it is that we quarantine sick people for a reasonable period of time, AND test them using sensitive measures like our bench top PCR Ebola RNA test, our Influenza RapidKits and our Malaria Rapid test which tests for pieces of the parasite. That way, we know who just walked into the casino and what table they're going to.

-Dr. M

Episode 7: Dress for Success

AKA "All About Personal Protective Equipment" or PPE

See Dallas hospitals...this is how the US Military keeps Medical Personnel safe from Ebola:

NMRC Ebola Testing Lab: Photo credit of US AFRICOM Chief Petty Officer Jerrold Diederich
http://www.africom.mil/newsroom/photo/23721/naval-medical-center-labs-support-operation-united-assistance

Let's go over what this fine young Navy Medical Corps officer is wearing. PPE- the only line of defense between our health care workers and a nasty end.

Talking points:

1.       Why is PPE important for Healthcare workers but not the rest of us?

a.       Well, here’s the deal guys. Mr. Ebola is not very infectious early on in the disease; there are not enough viral particles in the blood to cause high levels of sustained spillage into a bodily fluid (spit, sweat, urine, vomit, poop). It takes a few days for Mr. Ebola to really get ramped up. Once he’s had the time to get going, then your fluids are way more infectious. But by then, most people are pretty sick and getting medical care. So while it is possible to still spread Mr. Ebola while you’re in the “I have a fever, ugh” stage, it would require a lot of exposure to the infected person. 

             i. For example, a spouse would be what we Epidemiologists call a “high risk contact”, because chances are you have been exposed to their kisses and other stuff, which unfortunately for said spouse, are potentially virus-ridden. If you, random stranger sitting next to them on a plane, happened to bump into their leg or share air space, you’re not going to get the virus. I mean, unless they sneezed in your face or something gross like that. But once the infected go to a hospital in the “I can’t stop puking” phase…they’re shedding virus all over the place. And the nurses cleaning up after them and taking their blood and getting up close and personal are the ones in danger. There is way more virus hanging around in that hospital waiting for someone to get sloppy or for an accident to happen.

2      So why are all these doctors and nurses getting infected?

A.       So this plague bomb patient is sitting in a hospital bed, most likely the ER or urgent care. They’re puking into bags and having diarrhea all over the toilet. Mr. Ebola is starting to hang out. Hopefully, we sweep them away into an isolation room and then decontaminate the heck out of whatever space the infected were in. The nurses and doctors taking care of the patient are going to have to deal with getting all that biohazardous waste away from the patient and away from anyone else. Without getting exposed themselves!! So there are a lot of pieces of clothing these health care folks need to use. Like the following:

                   i.      The base layer: Clean scrubs, latex non sterile surgical gloves.

                   ii.      The main layer: moisture proof surgical gown or preferably Tychem coveralls, Nitrile examination gloves snugly fit over the cuffs of the gown/coverall, surgical cap, FFP or N95 respirator at minimum, knee high PVC boots

                  iii.      The top layer: Waterproof apron long enough to cover top of boots, Face protection: Either a Wrap-around Face Shield OR Tyvek hood and wrap-around Goggles/Face Shield.

                               *****       Order of removal: 1. Apron, 2. Gown/coveralls and outer gloves as one unit, 3. Boots, 4. Hood/Goggles or Face shield, 5. Inner gloves-- Respirator (There is a nifty way to remove these concurrently depending on what kind of respirator you have). Health care people have to pay attention as they remove layers that they A. Do NOT Contaminate the inner layer and B. watch for ANY suspicious signs of rips, tears or penetration into inner layers. And if you screw up at any step in the sequence, you’ll be wanting a shower with quaternary ammonium compounds depending on what got contaminated during what part of the sequence.

**     That sounds difficult to manage getting on and off in the right order every single time.

                     B. It is. The folks at USAMRIID, Emory and Nebraska and NIH have trained for YEARS to get it right. Clearly the rest of the nation’s healthcare workers have not. Otherwise, the Nursing Unions would not be gearing up to throw their employers under a very large bus. Also, even if you train perfectly and reduce your risk of a slip up to like 1-2% per time, that gets cumulative when you estimate one nurse might put on and take off PPE a good 250 times in the case of one patient. So that’s now a ~15% chance, give or take, to get Ebola over the course of ONE patient.  
                     C.  Now imagine you have 50 patients, like the Ebola Treatment Units in Africa. This is why so many doctors and nurses in Africa are getting sick and dying. And why Doctors without Borders trains the heck out of the people they send into those countries to work their hospital/treatment centers. 

The CDC has finally updated their PPE guidelines to come more in line with what I'd consider gold standard, probably in response to having their assess chewed on live television. Funny how that works.... Check out their website. Otherwise remember, love the Tyvek.

I also want to share a cool website with you guys, it's called Eboladeeply.org. There are some seriously awesome interactive bits that are of a level most lay people can grasp.

-Dr. M

Episode 6: The Return of the Virus

Or why we just can’t kill these buggers off. 

Treating Ebola

There are no good options for “curing” viruses. In order to explain why, we have to address a primary difference between bacteria and parasites VS the virus. Bacteria and parasites are living things. They have their own little microbe way of eating and “breathing” depending on how they live. You can target their little microbe energy factories, or their walls/membrane/skin. You can poke holes in them and let the harsh environment butcher them. You can starve them out. But not the Virus. The virus uses your own body as a host. Your cells are the ones doing its dirty work and then exploding with newly made virus after its gutted your cells like a used up neutronium rod. Nothing left but waste. 

What’s a doctor to do? Don’t dismay, we have options. We created or discovered compounds that stick to a virus and block its ability to invade a cell. That’s what Zmapp is, the Ebola drug that was used up this week on the patient in Norway. The company is scrambling to make more, but the process is slow and lengthy. It’s actually three antibodies stuck together in a way to paralyze Ebola and keep him from wriggling his way into your white blood cells.  

 

Poor Mr. Ebola is getting eaten by the Police.

We also have drugs that inhibit special types of viral synthesis, but that only works on certain “strandedness” of RNA viruses. See you can have RNA viruses- positive or negative strand versions, DNA viruses, and you can have single or double strand versions of both. Occasionally we’ll find proteins to target that inhibit some of these replication types without killing the human holding the virus inside. For example, a lot of HIV drugs do this, anything that ends in -cyclovir. But these drugs tend to be very specific. They only work for the one subtype of viral replication.

You might be asking, what about Tekmira, the other anti Ebola drug? Well that’s a unique baby all in its own class. Tekmira is a micro RNA or small interfering RNA (siRNA for short). What it does is 1. get inside the host cell, 2. find the viral RNA and 3. insert itself to disrupt the viral code. Stops replication in its tracks, IF you can get the code sequence just right. Which is why Tekmira hasn’t been used on a patient yet, other than some lab research monkeys who all managed to survive Ebola with the drug on board. Promising stuff!

Hospital Care:

So with all these Ebola patients, why are we keeping them in hospitals with no drugs available? Part of keeping these people alive is supporting their failing bodies. They are dehydrated, we’re trying to give them IVs and oral electrolyte solutions. AKA mega-gatorade. If they get bacterial infections secondary to the Ebola trashing their digestive tract, we’ll treat those with antibiotics to kill the bacterial freeloaders. 

And in Africa, we’re trying to give them proper nutrition, to correct long standing mineral and vitamin deficiencies that are impairing their immune systems’ abilities to fight back. We need to support the person and then let them do the dirty work of surviving Ebola, if they can, while we wait for the pharmaceutical industry to push out brand new technology as fast as they can make it.

Vaccines:

Vaccines are great, if you have one! We had Polio eradicated for a long time, or so everyone thought, by widespread global vaccination strategies. The influenza vaccine helps billions reduce the severity of their infections so they can stay out of the hospital and not get secondary pneumonias when the flu visits their office building. Things like measles and mumps were a glimmer of the past for a long time because children were routinely vaccinated.

 No thanks to the anti-vaccine movement, we now see measles trashing up the skin of young children again in America. Maybe those parents will learn their lesson when their teenager comes to give them grief in 10 years about the scars maiming their bodies just because they didn’t “believe” in vaccination for common childhood diseases. Regrettably, vaccines for Ebola are still in the works. Although believe me, the research industry is powering through a lot of sleepless nights to get a product out there and start protecting the healthcare workers and healthy family members of the sick.

-Dr. M

Episode 5: The Fruit Bat Strikes Back

AKA “Where does Ebola come from?”

Mr. Ebola is here to explain his circuitous route to infecting humans. Take it away little buddy!

Mr. Ebola: Well you see my friends Marburg et al and I have been hiding in the depths of Africa for easily hundreds of years. You meat bags would never know. I first showed up on your radar in ’76. We like bats. Three species to be specific, the hammer-headed bat, Franquet's epauletted fruit bat, and the little collared fruit bat. But Marburg has his own preferences, and my fellow Ebola strains have theirs too. 

Dr. M- So you’re enzootic (cause no disease to little disease and infect small to medium amounts of population) in fruit bats?

Mr. Ebola: Well, not exactly. We mix it up. There are a few strains of me and we’re not all the same. Ebola-Zaire likes to make his bats pretty sick. Ebola-Sudan is also pretty wicked to his bats. I’m actually a new strain, they’re probably going to name me Ebola-Guinea or something stupid and lame like that. 

Dr. M- What would you like to be called?

Mr. Ebola: He who covers the Earth.

Dr. M- Hey now Mr. E, isn’t that getting a little ahead of yourself? There is a very small amount of evidence that filoviridae like yourself and Marburg infect bats as far reaching as the Philippines and Southeast Asia, but we’re not sure if you are one of those strains. It could just be your buddy Marburg.

Mr. Ebola: Wouldn’t you like to know meat bag? Bwhahahahaha

Dr. M- You do know that world health organizations and governmental entities are out there sampling everything from wild primates to dogs to pigs to bats trying to pin down where you hide right?

Mr. Ebola: Knowledge can’t help you meat bag. Sure we kill the gorillas and the chimps for fun.

Dr. M- Well actually, yeah it can. I mean if we prove that you are actually an epidemic or outbreak in bats caused by transmission via some kind of parasite like a strebelid fly, then all we have to do is kill off the flies. Save the humans and the monkeys and the bats a whole lot of trouble.

Mr. Ebola: Go die in a fever meat bag. 

Dr. M- *Sighs* It’s “Go die in a fire” Mr Ebola.

Mr. Ebola: Same difference…to your precious brain. *cackles* 

Dr. M- Well in the meantime, most West African countries have prohibited the butchering and sale of any kind of raw bushmeat- primate or bat – in an effort to cut down on possible transmission lines from the wild Ebola reservoir to the human populace. Regrettably, as food becomes scarce due to lack of workers for the harvests, people are more likely to encroach on the forest and wild animals in search of something to eat. Just another reason to try to support the flow of trade and international aid to the region with the basic necessities as well as medical supplies.

Mr. Ebola in the hepatic artery with a candlestick, uh I mean viral replication

The media today is all up in arms since Mr. Duncan died of Ebola in Texas. I, for one, do not understand why anyone is shocked. He had a disease with an average 70% fatality rate. There was a pretty good chance that he was going to wind up dead. Let’s stop traumatizing the poor man’s friends and family by airing his death on every bloody news channel, ya?

-------------------------------

Let’s talk about why this thing is killing so many people, despite excellent levels of health care here in America and Europe. Mr. Ebola is going to walk us through how he makes you sick.

Symptoms you might have Mr. Ebola:

1.      FEVER: Fever goes along with a lot of viruses. Here’s why- Mr. Ebola hangs out in your blood stream infecting and killing cells of the vessel walls AND white blood cells inside the vessels. Your white blood cell warriors aren’t taking this sitting down though. They are kicking and screaming and putting up a fight. Their little screams and battle cries come in the form of Cytokines. Little molecules that are cells’ way of talking to each other. White blood cells love to scream in the tune of “Tumor Necrosis Factor” when viruses are invading. There are many types of TNF, but TNF Alpha gets right to your brainstem. And your brainstem, upon hearing the little molecular screams for help, decides it’s going to try to burn the virus out by cranking up the heat. See most viruses can only reproduce at certain body temperatures. Outside their happy range, they slow down and the white blood cells have a chance to kill them and gain the upper hand. But Mr. Ebola doesn’t give a shit if you crank the heat up a few degrees; he’s just going to happily continue his murderous rampage through your body. Meanwhile, your brainstem doesn’t know what it is doing isn’t working, so it just keeps on with the program.

It's like American Psycho with less Christian Bale...

2.      Vomiting and Diarrhea: Mr. Ebola can infect your liver cells along with the blood vessels that feed and nourish all of your gastrointestinal organs. These liver cells start dying left and right releasing all sorts of nasty chemicals they should be detoxing for you. Dead cells+ nasty toxic soup+ bleeding into your gut from leaky blood vessels = really pissed off nerves in your gut. These pissed off nerves are going to feed back into the automatic part of your brain to tell you that you feel like crap, you’re really nauseous and putting food in your impaired stomach might not be a good idea. Because Mr. Ebola is going around slaughtering cells and destroying vascular pathways. All that blood and stuff leaking in your gut is nasty and your body tries to flush it out with diarrhea, much to Ebola’s joy as it slides right out of you into the next host. Losing all that fluid is going to make you quite dehydrated, and if you get too dehydrated you’ll go into hypotensive shock, because your body can’t afford to lose any more fluid and is running on empty. And if you are really  unlucky, all those dead liver cells will lead to the next thing...

3.      Disseminated Intravascular Coagulation aka 'DIC': So your liver produces clotting factors to help keep your blood not too thick and not too thin. The nice medium porridge viscosity.  When Mr. Ebola slaughters the liver, you start running low on clotting factors and the chemicals that turn clotting off. And now your blood proceeds into an impaired ability to clot on both ends of the spectrum. A tip, your blood vessels routinely sustain small injuries that your body patches up on its own. Start running low on clotting factors, and you can’t keep up with the daily damage. Start running low on Anti-Clotting factors and you'll be throwing clots where there should be none. The next thing you know, you’re bleeding out of your eyeballs. And losing even more blood is going to drop your blood pressure so low you’re dead before you know it…

4.      Severe headache/confusion: So the rest of your brain doesn’t like being dehydrated/low on blood, cooked alive by fever and roasted in angry white blood cell Cytokines. Its response is to try to tell you to slow the heck down and go rest so you can spend your energy fighting off infection instead of working. That’s pretty much what a headache is, unhappy over-taxed brain cells. The more unhappy, hot and worn out they get, the crummier your ability to think becomes. Eventually you’re delusional, staggering about and falling out of your bed. This makes Mr. Ebola happy because you are too disoriented to try to warn others you’re a plague bomb who has diarrhea running down its leg.

5.      Muscle pain/weakness: Your muscles can’t really do their best if you are feverish, dehydrated and drowning in a sea of dead white blood cells. They are a helpless bystander watching all of the carnage wash up on their shores.

6.      Organ Failure: Eventually the rest of your organs just can’t take it anymore. Imagine living in a toxic waste dump. That is what Mr. Ebola has turned your body into. The sea of inflammatory Cytokines, the waves of dead cell debris and the complete lack of a decent blood pressure has starved the rest of your body into giving up the ghost. The nastiest image of the Gulf of Mexico after an oil spill is nothing compared to your body. And Mr. Ebola still wins, because he can hang out in your dead meat sack and infect someone who gets exposed to your rotting dead tissues and fluids. What an A-Hole.

-Dr. M