Maryn McKenna

Journalist and Author

Q&A With Contagion's Science Advisor (Plus Spoilers!)

By Leave a Comment

If you are a disease geek, then yes, you will love Contagion, the all-star Oh God Oh God We’re All Going To Die movie that opened last night. Paramyxovirus! R-nought! BSL-4! And, bonus, so many insider references to the CDC that the script could double as an epidemiology drinking game. (Go to the end of this post for my fact-check of CDC references. They’re spoilery and thus hidden on the next page.)

To me, the fascinating thing about Contagion is how seriously it takes its epidemiology, its virology and even its sober sense of how unprepared most Americans are for a mass-casualty disaster (as captured in this April report from the National Biosurveillance Advisory Committee).

To find out where those came from, I asked its chief science adviser: Dr. W. Ian Lipkin, who is the John Snow Professor of Epidemiology, and Director of the Center for Infection and Immunity, at Columbia University’s Mailman School of Public Health, dubbed a “master virus-hunter” by master science-writer Carl Zimmer in the New York Times. Here’s our email Q & A.

Maryn: Given past “science” movies — Outbreak, for instance — I was surprised that the science in this movie is so solid. Was this your doing, and how did you manage it?

[Read more…]

The Wakefield fraud and the return of whooping cough

By Leave a Comment

By, now, 24 hours later, I imagine that everyone who cares about the subject has read or heard about the BMJ’s masterful assessment and rejection of the original paper that linked childhood vaccines and autism, calling it an “elaborate fraud” perpetrated by a researcher who had entered into a relationship with class-action attorneys. (Here are the BMJ’s editorial, the first part of the investigation, and the concurrent blog by the journalist who pursued the story for almost a decade.) That original paper, by a British physician named Andrew Wakefield whose license to practice has since been revoked by the UK’s General Medical Council, did untold damage to public health: It sparked a distrust of vaccines that has led to the return of almost-beaten diseases around the world.

The BMJ’s pronouncement and its larger significance for distrust of vaccines have been thoroughly covered by major media (CNN, Associated Press) and by a number of good bloggers, including Orac,  PZ Myers and Seth Mnookin (author of a forthcoming book on vaccine refusal). I’ve been wondering what I could add to the discussion. In the end, I thought I’d re-run this, a post from last summer when Superbug was still at Blogger. It’s a look at the return of those potentially deadly diseases from the perspective of a patient, who happened to be me.

A few years ago, I went to India on a reporting trip. When I came back, I had a troublesome cough. I figured I’d picked up a bronchitis aggravated by New Delhi’s smog-laden air, or by the dung smoke from the fires in the villages where I’d spent most of my time. The cough got worse instead of better. It was especially bad at night: I’d lie down to sleep and that would trigger a paroxysm. Sometimes I’d cough until I couldn’t breathe. A few times, I vomited. Eventually my side began to hurt. (Months later, I discovered I’d cracked a rib.)

As a medical reporter, I spent most of my time around doctors and nurses, but I had a rule about never bothering them — first because I was pretty healthy, and second because no one wants to be the guy at the cocktail party who finds out someone’s a doc and backs them into the corner of the buffet table. But one day, worn out by the spasms, I mentioned my symptoms to a friend. His eyes got big. He went and got a textbook.

I didn’t have bronchitis. I had pertussis — whooping cough.

This made no sense, of course. Between a day job as Scary Disease Girl and a childhood spent moving between continents, I am pretty much the most vaccinated person on the planet.  I’d had my full series of pertussis vaccinations as a child. Surely I was protected?

Actually, no — and unless you’ve had a booster, neither are you. The immunity created by the 5-dose childhood series wanes over time; by the age of 12, even fully vaccinated people are vulnerable to pertussis again. Since 2006, the Advisory Committee on Immunization Practices has been recommending a single additional pertussis (Tdap) booster for anyone between the ages of 11 and 64. That may seem like overkill — adult cases of pertussis in previously vaccinated people are often milder than the child version; after all, I survived my bout. But as with so many vaccines, the beneficiary here isn’t just the adult taking the booster. Even more, it’s the more vulnerable person to whom that adult might pass the disease: an elderly person with age-related immune decay; someone with a chronic disease; an infant too young to be vaccinated. In those people, the disease can and does kill — as it did an 18-day-old infant, Nelyn Baker, whom I wrote about in 2004.

Because vaccine immunity fades, pertussis is always with us: in good years, about 1,000 cases across the United States. Lately, though, we’re in bad years. Pertussis cases are rising dramatically, in Alabama, Georgia, Arkansas, Texas, South Carolina, Michigan, Oregon and Ohio. The worst by far is California, where so far this year almost 1,500 cases of pertussis have been reported and another 700 are suspected — compared to 258 for the same time period in 2009. (Jan. 2011 update: The California count is now 7,800 cases, and 10 children have died.)

“We are facing what could be the worst year for pertussis that this state has seen in more than 50 years,” Dr. Gilberto Chávez of the California Department of Public Health said last week in a statement put out by the agency’s Center for Infectious Disease.

The worst news in this upsetting trend is this: We’re doing it to ourselves. As far as anyone can tell, the rise in pertussis is not due to any change in the organism, or to any mysterious error among the manufacturers who make pertussis vaccines. It’s due to vaccine refusal, to parents turning away from vaccines because they think the vaccines are more harmful than the diseases they prevent — or, more selfishly, because they think the wall of immunity created by other vaccinated children will protect their unimmunized ones.

That’s an incorrect assumption, by the way. Work published last year by several scientists at Kaiser Permanente of Colorado found that unvaccinated children were 23 times more likely to contract pertussis than vaccinated ones. And yet, as numerous stories (LA Times, MedPage Today) have pointed out, California’s epidemic has blossomed in a state that gives some of the most generous “personal belief exemptions” from vaccination — and the epidemic’s worst hot spots neatly correlate with the most concentrated areas of vaccine refusal.

Pertussis is an awful disease. A child in the throes of a paroxysm sounds like nothing else on earth. Children turn blue, give themselves black eyes, die. We kept it down to manageable levels with the help of a vaccine. That we would willingly bring it back it is beyond belief.

(For a physician’s take on pertussis, see this post by my fellow former Scibling Pal MD. The CDC’s information page on pertussis is here and the National Network on Immunization Information explains the vaccination schedule here.)

Flickr/NizNoz/CC

CDC warns of deaths from H1N1 flu + bacterial infections

By Leave a Comment

Over at CIDRAP, my colleague Lisa Schnirring writes tonight about the CDC’s concern over increasing numbers of deaths from bacterial pneumonia in people who have come down with H1N1 flu.

We’ve talked about this before here. Our concern of course has been MRSA, and there is good evidence that there have been fatal MRSA infections in flu victims. But the primary culprit now is not MRSA but pneumococcus (S. pneumoniae):

Anne Schuchat, MD, director of the CDC’s National Center for Immunization and Respiratory Diseases, told reporters at a press briefing that the CDC is seeing an increasing number of invasive pneumococcal disease cases around the country, but the numbers were particularly high in Denver at a time when pandemic H1N1 activity was peaking in the area.
Over the past 5 years the Denver area averaged 20 pneumococcal disease cases in October, but this year the area recorded 58, and most were in adults between the ages of 20 and 59, many of whom had underlying medical conditions.
Health officials expect to see more pneumococcal disease when seasonal flu circulates, but the infections typically strike people who are older than 65. In past pandemics secondary bacterial pneumonia infections, particularly those involving Streptococcus pneumoniae, frequently contributed to illnesses and deaths.

This is particularly troubling and sad because we have good vaccines for pneumococcus, one for adults and a different one for children. Only, people are not taking them: Uptake is only about 25% in high-risk groups and much lower in the general population, despite urgings from CDC and other health advisory boards.

Perhaps it’s not surprising that people have not heeded advice to get the pneumococcus vaccine as a protection against flu’s worst effects, given that uptake of the flu vaccine itself has been so low. But if you or someone you love is in a high-risk group, it would be a really good idea to rethink that.

It's World Pneumonia Day

By Leave a Comment

Readers, we talk all the time here about the unexpected and deadly attack of MRSA pneumonia, both on its own and as a sequela of influenza infection. But we should acknowledge that MRSA pneumonia is part of an epidemic of pneumonia, an under-appreciated disease of severe lung inflammation that takes the lives of 2 million children each year around the world.

Today, Nov. 2, has been declared World Pneumonia Day by an enormous coalition of global health organizations that includes UNICEF and Save the Children. (Mis amigos Latinos sabrán que está hoy también Dia de los Muertos. Fitting, no?) From their press release: “Pneumonia takes the lives of more children under 5 than measles, malaria and AIDS combined. The disease takes the life of one child every 15 seconds, and accounts for 20% of all deaths of children under 5 worldwide.”

World Pneumonia Day is being marked by events around the globe (here’s a clickable map) and by the release of a World Health Organization report, the Global Action Plan for Prevention and Control of Pneumonia. The plan has three main goals, aimed at the recourse-poor countries where most pneumonia deaths occur:

  • promote breastfeeding to ensure children’s nutrition and good immune status
  • protect immunity by guaranteeing the distribution in the developing world of the pneumonia vaccines we take for granted in the industrialized world, against Haemophilus influenzae and Strep pneumoniae (pneumococcus)
  • treat children when they need it by making sure that there is adequate, local primary care and — important for our purposes especially — also making sure that antibiotics are used appropriately, but not overused.

The international organization GAVI (formerly known as the Global Alliance for Vaccines and Immunization, now going just by its acronym) has announced plans to immunize 130 million children worldwide against pneumonia and other diseases by 2015.

I want to underline that pneumonia is of interest to us for several reasons: not just because we are concerned for MRSA pneumonia, but also because we are in the midst of the H1N1 pandemic, and as we have talked about before, bacterial infections appear to be playing a role in a significant percentage of the deaths. There is no MRSA vaccine, but there are Hib and pneumo vaccines, which might have prevented some of those deaths. So increasing the administration of pneumonia vaccines could affect the course of this pandemic right now, as well as the fates of children all over the world who have not contracted this flu but will be in danger of bacterial pneumonia in the future.

More evidence of MRSA involvement in H1N1 flu

By Leave a Comment

When the H1N1 pandemic started at the end of last April, few of the case-patients seemed to have any secondary bacterial infections. This was unusual: In the 3 20th-c pandemics, the only ones for which there are good records, bacterial pneumonias seem to have accounted for a high percentage of illness and death. But H1N1 was unusual in a number of ways, and so health authorities wrote down the lack of bacterial infections as one more quirk of this novel strain.

Comes now the CDC to say that while that may have been the case in the spring, it is not now. In a conference call conducted Monday for doctors, which I covered for CIDRAP, the agency said that out of 77 deaths for which it had excellent autopsy data (a small subset of the deaths so far), 22, or 29%, had some bacterial co-involvement. Among the 22, the leading bacterium was S. pneumoniae (or Pneumococcus), but S. aureus was the second leading cause, with 7 cases, and 5 of those cases were MRSA.

(There is not yet anything online from that call to link to. A transcript is promised, and the CDC reps conducting the call said the data will be out soon in the MMWR. I’ll update when possible.)

In fact, there is an emerging literature on the role of bacterial infections in illness and deaths in this flu, and an emerging consensus that bacterial infections are playing a bigger and more serious role than was thought at first. At the ICAAC meeting two weeks ago (more on that soon), KK Johnson et al of the Women’s and Children’s Hospital of Buffalo, N.Y., along with researchers from two other institutions, described two severe and ultimately fatal infections with H1N1 complicated by community-strain MRSA. The victims were children, a 9-year-old girl and a 15-year-old boy, who arrived at the emergency room several days after being seen for mild flu symptoms. Both children died of necrotizing pneumonia, one 11 days after being hospitalized and one 3 days. Cite (no link available): K.K. Johnson, H. Faden, P. Joshi, J. F. Fasanello, L. J. Hernan, B.P.Fuhrman, R.C.Welliver, J.K. Sharp and J. J. Schentag, “Two Fatal Pediatric Cases of Pandemic H1N1/09 Influenza Complicated by Community-Acquired Methicillin-Resistant Staphylococcus aureus (CA-MRSA),” poster G1-1558a.

Finally, there is one recent paper that is online, and it describes MRSA necrotizing pneumonia plus flu in an adult, not a child. It comes from Hong Kong, from a group that were the first to describe SARS pneumonia and thus have a lot of experience in surfing the early wave sof a pandemic. In this new paper in the Journal of Infection, they describe the death from necrotizing pneumonia of a healthy 42-year-old man who was in the hospital only 48 hours. They believe this is the first H1N1+MRSA death to be recorded in the medical literature, and so they use the opportunity to issue a warning to doctors: If a flu patient arrives with what appears to be secondary pneumonia, drugs that can treat MRSA must be prescribed, or the infection will flourish unchecked and death will result. The cite is: Cheng VCC, et al., Fatal co-infection with swine origin influenza virus A/H1N1 and community-acquired methicillin-resistant Staphylococcus aureus, J Infect (2009), doi:10.1016/j.jinf.2009.08.021.

We’ve been talking since the beginning of this pandemic, and before that, about the unique hazards of MRSA + flu coinfection. (Archive of posts here.) It’s important ot understand that the bacterial pneumonias now being recorded are not only due to MRSA; Pneumococcus is playing a role as well. That is important because, unlike MRSA, we have vaccines against Pneumococcus; in the United States, one vaccine is approved for children and a second related one for adults. With no MRSA vaccine anywhere, and no H1N1 vaccine yet, it is worth considering whether to take a pneumococcal vaccine for additional protection as this pandemic unfolds.

Catching up on some reading: health care reform, food bugs, vaccine, MRSA+flu

By Leave a Comment

Folks, while I was caught in travel hell, some excellent stories and blogposts were released. Here’s a quick round-up of recommendations for a rainy weekend:

  • At Roll Call (covers Congress like a blanket), Ramanan Laxminarayan, PhD MPH, of the rational-use-of-antibiotics project Extending the Cure and infection-control physician Ed Septimus, MD make a strong argument for including control of hospital infections in health care reform. Hard to argue against when you realize that HAIs cost the United States more than $33 billion each year.
  • At Meat Wagon, a blog of the online magazine Grist, the always-excellent Tom Philpott digs into the ongoing outbreak of antibiotic-resistant Salmonella in hamburger meat. Key quote: “Outbreaks of [antibiotic-resistant foodborne illnesses] are really ecological markers — feedback that our way of producing meat is deeply unsustainable and really quite dangerous.”
  • The Associated Press reports that the long-in-development staph vaccine made by Nabi Pharmaceuticals may have received a second life: It’s been purchased by international pharma giant GlaxoSmithKline in a $46-million deal.
  • And finally and sadly, the Sacramento Bee reports that a California nurse who died of H1N1/swine flu also had MRSA pneumonia. Karen Ann Hays, 51, died despite being extremely healthy: she was a triathlete, skydiver and marathon runner. No one yet has been able to say whether she caught the flu — or MRSA — at work (though her partner believes that to be true), but her death has fueled disquiet among members of the California Nurses Association, who are protesting a lack of protective equipment for nurses.

For those of us concerned about MRSA pneumonia — and we have been talking here since the start of the H1N1 pandemic about the danger of MRSA co-infection — that last item about Hays’ very sad death should underline a vital point. Public health authorities have been stressing that H1N1 is most deadly when the infected person has a pre-existing condition: pregnancy, heart disease, obesity, diabetes, cystic fibrosis. It is possible that MRSA infection is also a pre-existing condition that will put anyone infected with flu at risk of deadly complications.

If you have had MRSA, even a minor skin infection — and especially if you have experienced recurrent infections — you should probably discuss with your personal physician whether you should take the H1N1 vaccine when or if it becomes available. It could be the step that prevents a minor case of flu from tipping over into something much more serious.

MRSA in space

By Leave a Comment

No, really — but not quite the way you think. The weekly geekfest that is Aviation Week and Space Technology reports that the payload of the space shuttle Atlantis includes a MRSA experiment. The goal is to investigate whether bacteria held in the microgravity of space become more virulent — this was done earlier with salmonella — and then to determine whether any new virulence markers suggest targets for a potential staph vaccine.

A vaccine of course, is the Holy Grail of MRSA research — and it has remained frustratingly out of reach. For a great review of past research and future challenges, see this review article from March.