Dr. Kevin Most: Measles & Infectious Diseases
This past week we heard about measles spreading across the US, Bacteria that are resistant to many antibiotics and a fungus that is spreading across the country that is concerning. We thought we would take a few minutes to discuss these, not to scare you but to make sure you are informed.
Measles- This word for most of us is just a word in a vaccine, MMR or Measles , Mumps, Rubella. If you were born after 1960 chances are that you received the vaccine MMR as a present for your first birthday, however we now know that 2 doses of the vaccine are needed to give the best chance for coverage. In 1989 the CDC changed the dose recommendation to 2 from 1, so there is concern for individuals born after 1957 and before 1989, that they may have only received one dose of the vaccine as that was the recommendation at that time. Now many in that group have gone on to have a second dose, often required by schools, however we know there are many out there that may think they are protected as they did get the one dose of the vaccine. This historically has not been an issue as we have high vaccination rates and thus we are protecting each other by minimizing the chance for spread, a concept termed herd immunity. If you fall into that age group of 30-60 and are concerned you can talk to your doctor and they can do a blood test to see if you have antibodies or they may consider giving you a booster dose. The current recommendations for Measles immunity requires 2 doses of the vaccine for the best coverage, the first dose at 12 months and the booster at age 5-6. That vaccine gives us each around 97 % coverage against each of the 3 viruses.
We have not eradicated these viruses from the US and in fact outbreaks are still very common around the world. The US has kept these pretty much under control with the exception of 2014 when we noted over 600 cases of measles in the US. However, 400 of those cases came from a single Amish community in Ohio. 2017 we had 116 cases, 2018- 372 cases and it appears to be on a big increase as we have seen 465 cases in 11 states as of mid-April. In Illinois we have had 5 cases, which is close to our norm for the entire year.
Recently in New York there was another large outbreak in an Orthodox Jewish community in New York. This reached a large enough concern that that NY has declared a Health Emergency and is requiring vaccinations in portions of Brooklyn where the recent outbreak occurred. New York as a state has been a hot center for Measles, since last fall they have had close to 300 cases with many more expected now, as 78 new cases were reported this week alone.
The concern is that we have had a bunch of recent cases and couple that with a lot of anti-vaccination pockets in the country.
Measles is highly contagious, it is caused by a virus that is shared by being exposed to coughing and sneezing. The virus can live in air and on surfaces for up to 2 hours. As we discussed last year the world is getting smaller and we have many countries where measles is common and rampant, so the spread is much easier as travel has allowed this. One can be contagious with the virus prior to having the rash, they may have cough, sneezing and fever often followed by the rash 10-14 days later. They are spreading live virus before they even know they are infected.
Measles symptoms include runny nose, conjunctivitis, cough, sneezing, fever and a body rash. The individuals feel miserable and can for a week or 2, the bad thing is the rash does not start until 3-5 days after the symptoms start. This is bad as the individual is spreading the illness before they know they have it. Only a small number of individuals will go on to have the more serious complications like a brain infection or pneumonia.
Although many may feel, “so what, it is a little rash and cough?’ before this vaccine it had a huge impact on the health of our children. A measles ear infection are very common and cause permanent hearing loss, the child can get pneumonia, or a brain infection called encephalitis. Women who are pregnant and exposed to measles may give birth prematurely. This is not a benign disease in 1980 we had 2.6 million deaths due to measles, now vaccination rates around the world have helped but we still have close to 100,000 deaths due to measles most in children under the age of 5.
Think about a classroom of non-vaccinated kids, when one child comes in with a highly contagious illness and spreads it to the entire class in one day, and then to the entire school. The impact it had on schools, parents, families and the local economies was major.
Many may question the value of vaccines, what they have to realize is, all we are doing is teaching the immune system how it should work in a more controlled environment while eliminating the bad outcomes a virus may cause if left alone. Remember before vaccines, patients would have an illness and then be protected from future exposure as their immune system would now block any future chance of illness. Unfortunately going thru that natural process was painful, disruptive and in some cases deadly.
It is unfortunate that we had a fake study that was published by Dr Andrew Wakefield in 1998 that falsely touted a link between autism and vaccines. What is worse is we have some celebrities that continue to tout this, it is sad that we will listen to Jenny McCarthy or Jake Cutlers wife instead of the 100’s of true studies that show no link between autism and vaccines. I feel sorry for the parent who does not vaccinate their child thinking they are protecting them from autism yet end up with a life-threatening illness that exposes many others.
Candida Auris- This is the name of a fungus that causes serious infections. I am not sure if we have ever discussed a fungus, so let’s take a minute and discuss some basics. A fungus is not a bacteria and it is not a virus. It is a living organism that has a wide spectrum of its family, yeasts, molds and even mushrooms are considered fungi. Most fungus thrive in warm moist areas, the most common fungal infection in humans is athletes foot. It is caused by a specific fungus and is a nuisance but is not overly concerning in most people as some simple hygiene changes and an antifungal cream will clear it up. There are many more fungus that can cause mainly skin infections.
In 2009 a new fungus was identified, Candida Auris, this has been noted in 12 countries including the US. Now this is not thought to actually be “new”, it is thought that this strain has been around for thousands of years, it was just not identified. To put things in perspective there are over 5 million different species of fungus, yet only a few hundred of them will cause human disease.
So, what is so special about this fungus? There are a few things, one is it is difficult to identify. You need specific technology called Maldi Tof, to identify this fungus. The second is that this fungus unlike others can survive on cool dry surfaces. The third is it is one that can cause infection in humans. The fourth and possibly the most important is that is resistant to the medications that we used to treat fungal infections. Put all of these together and you have a bug that can live in any environment, is difficult to identify, can cause infection and is difficult to treat. This is why we have the concern.
Although first identified in Tokyo in 2009, the fungus has spread across the world. In the US, we have had nearly 600 cases identified as of the end of February. The concern is that Illinois has had almost 150 cases and is second to only New York who has identified over 300 cases. It has been identified in 12 states. We know there are more cases out there but many sites do not have the technology to identify the bug.
Should we be concerned? Our concern is not for the general public, this is not a fungus that is going to cause a major infection if a healthy individual comes in contact with it. The concern for those individuals is spreading it to areas where we are concerned. Spreading this to hospitals and nursing homes is the concern as they care for immunocompromised patients and do invasive procedures.
The CDC is still learning about this bug. The goal is to identify early and stop or minimize the spread. Hospitals are taking it very seriously and looking for it actively in patients they are concerned about and the hospitals are also very diligent in the cleaning of all areas of the hospital.
This bug can cause infections in bloodstream and may be severe enough to cause death. The patients who have these infections are often sick or being treated for other illnesses in hospitals and nursing homes. It is important to identify these patients as the bug is very resistant to the common medications we use to treat fungal blood infections. Doctors are finding that using one medication in these patients will not be enough, in many cases they will need to use three or more to control or treat this bug.
There will be a lot more of this in the upcoming months and years as we identify more and struggle with controlling the spread.
Probably the biggest concern is the thought that this is the tip of the iceberg and that we need to be ready for more superbugs to start showing up. The overuse of antibiotics has certainly led to many bacteria that are now resistant to many common antibiotics. We know that viruses can mutate as we see each year with influenza, that will possibly eliminate the few drugs we have to treat them and now the fungus is starting show that it too may play a large role in the world of “Superbugs”
In the New York times last week there was a front page article on “miracle drugs doing harm in Kenya”. The article shares exactly what we are concerned about with superbugs and how it occurs. In many areas near Nairobi they have highly populated areas with minimal sanitation. This leads to many infections, some of which can be deadly. One of the reasons the infections are deadly is because of the misuse of antibiotics in that country. A small example, a bacteria called salmonella can cause an intestinal infection that if not treated or treated incorrectly can lead to dehydration and in severe cases death. In the United States the number of cases of Salmonella is close to 1.5 million and unfortunately these result in around 450 deaths a year. Often the deaths are noted in young children or the elderly. Now let’s compare that to Kenya where they see 45,000 children die from Salmonella every year. How can that be? The same bacteria here in the United States can be easily treated with antibiotics, yet in Kenya that same bacteria is resistant to antibiotics in 70% of the cases.
Why does that occur in Africa and not here? In Africa you can buy antibiotics over the counter in any pharmacy without any input from the physician. The poor African people are looking for anything to help and pharmacists are more than willing to see them a few pills. The patients in Africa are getting the wrong medication at the wrong dose for the wrong length of time. What happens in these cases is we see resistance form and the bacteria that survive are no longer killed or even slowed by the current antibiotics.
We all think that antibiotics are expensive in the United States, and in many cases they are. In many countries across the world they are not only cheap they are not regulated and can be purchased in any pharmacy. This allows for bacteria to multiply and survive as superbugs. The world is very small and a bacteria halfway around the world could be seen here within a matter of days. This should concern us all.
So what can we do in the general public? We can use great hand hygiene, especially when around those who are ill. We can listen to our doctors when they tell us that the infection that we have is probably a virus and that an antibiotic is not only not needed but may lead to problems in the future. This is probably the toughest one as people feel miserable for weeks at times and just want to get better quickly. They often think an antibiotic is what they need when in fact they need time, rest and fluids. We live in a society of “Now”. We do not have time for illness and we want a cure now.
So why are antibiotics bad for viral illnesses? First and most important is that antibiotics do not kill or fight viruses. If they don’t do anything for these common cold, viral bronchitis, or sore throats not caused by strep, why do we take them? Some doctors are pressured to give an antibiotic, some individuals have “old” antibiotics hanging around their home from previous infections where they stopped the course, and others borrow from friends and family members. Each of these cases ends up with the same scenario. We are exposing some bacteria to lower than effective doses or timing and by dong this we are selecting out the strongest bacteria and allowing them to multiply.
The easiest way to think of this is you have 100 bacteria, 95 of them would be killed with an antibiotic, even though they are not causing an infection. The 5 that are resistant survive and start to multiply, so now we have just selected out the strongest bacteria but not taking the right medication at the right dose for the right time. These bacteria can then multiply and cause infection but they are resistant to antibiotics and are on the way to be a super bug. MRSA is the one that has gotten the most attention in the past few years. This is a bacteria that we could treat with penicillin or a cousin of penicillin but now that strain of bacteria is not bothered by penicillin and it has no effect on them, they multiply and caused expanding infections.