Important message from Ebola and Enterovirus– The “Bugs” are Still Winning ! But this won’t be the “Big One”
The Ebola virus has dominated the news these past few months, especially with several patients now being treated in US hospitals. There is a valid concern that this virus could spread out of control and become a major worldwide epidemic. It is spreading rapidly in Africa. In some ways we are fortunate with this organism. Ebola is not as virulent as many. Basic infection control principles, if applied appropriately, will go a long way to minimize the ultimate spread of the Ebola virus. The CDC has issued guidelines for hospitals and health care workers on identifying and treating Ebola patients, which (for the most part) are implementing standard infection control procedures that are already in place. While there is no known cure, we hear fleeting news of an experimental drug and even a possible vaccine that could be effective. We currently celebrate the physician who contacted Ebola and now appears free of the disease. So we wait and keep our fingers crossed. So far, our medical infrastructure can manage this organism in this country. We are reasonably prepared.
In the last couple weeks, we have been hearing more about the recent outbreak of a subtype of enterovirus which is rapidly spreading amongst young adults. Health care systems are scrambling to control this present situation.
When I was in residency my program director was an infectious disease specialist. He reminded us back in the early 80’s that despite the latest generation penicillins, their derivatives, and other super antibiotics of the time, the bugs were still winning. I believed him, but I was firmly convinced that in my lifetime, we would eliminate the dangerous pathogens with the advent of even more broad spectrum super antibiotics and improved aseptic technique . I joked that the field of infectious disease could be eliminated in my generation. He just grinned.
Well guess what? In 2014, some thirty years later, despite our advanced technologies and powerful medications, we are no closer to beating the bugs. In fact, there are numerous signs indicating we are actually losing the fight, bad. Super-resistance is rapidly developing as antibiotics are indiscriminately overused. Organisms such as MRSA (that were not even known 30 years ago) are increasingly prevalent. On top of that, there are few, if any, major antibiotic breakthroughs down the pipe. We are unlikely to see any pharmacological “game changers” in the next few years. Antibiotics randomly kill the “good” bugs as well as the bad. To this day, we do not know how the elimination of normal good flora by current antibiotic regimens may adversely effect us. The field of probiotics is in its infancy.
From a procedural perspective, our hospitals and health care facilities are better prepared than ever for a potential outbreak. Specific infection control and management protocols are now in place in all facilities and there are regular disaster drills with the health care community at large to keep the delivery system on its toes. The CDC and other organizations have amassed tremendous information on how to be proactive and minimize the effects of potential epidemics. Practically speaking, we are better prepared than ever.
But are we just kidding ourselves? Ebola, as serious as it is, will doubtfully be the “Big One”, but how close are we to a more serious epidemic?
Historical epidemics– small pox, plague, severe influenza, and others– have all had similar outcomes. They had a community prevalence in the 30% range and an overall mortality of 70-80% of those infected. They rapidly ravaged the population. The outbreaks eventually became self-limited, but not until a substantial amount of the population was lost. Think of those numbers now in modern perspectives.
Imagine a typical city of one million people with 10-15 hospitals and perhaps 7,500 total beds. Thirty percent prevalence translates to 300,000 patients sick within a short period of time. The delivery system would be quickly overwhelmed and all potential treatment modalities would be rapidly consumed. Health care workers, in the middle of the disaster, would be disproportionally effected and among the first to contract the disease. Even if beds and antibiotics were available, there would be few around who would be experienced to administer any treatment.
So within a couple weeks, even with our protocols, infrastructure, medications and preparations, our health care system would be completely wiped out– all effective care in the community will come to a standstill. Patients will die at home and in the streets without any type of medical treatment, even if a treatment were available.
What has curbed epidemics in the past? Enough casualties occurred in the population so that the massive spread would slow down and ultimately either reach an equilibrium steady state, or die out completely. Those lucky few who either avoided the disease or had some intrinsic natural immunity would survive and the population would gradually re-establish itself, but at a cost of huge loss of life and resources.
A very bleak scenario indeed.
I do not wish to diminish the importance of the Ebola outbreak, as it has already caused a great deal of pain and suffering, with over a thousand deaths in Africa alone, but I very much doubt that Ebola will become the “Big One”.
A much more likely scenario, mundane as it might sound would go as follows:
A sudden mutation of a common and otherwise manageable pathogen, such as a staph, strep, influenza virus, or even enterovirus would occur in the community. These organisms are intrinsically much more virulent than Ebola. The spread of the organism would be not only direct contact, such as Ebola, but also through vaporized droplets. The disease would quickly rip through the community. With modern globalization, migration through the population at large would be equally rapid and know no national bounds. Anywhere on earth that man could potentially travel would be at risk of exposure within weeks. Despite the many guidelines and practices now in place for the management of an acute infectious outbreak, it will not be enough to overcome the huge patient demand. The health care system worldwide would shut down and nature will ultimately take its course.
So let’s not deceive ourselves; the “Bugs” still rule. We should pride ourselves in our advanced technology and scientific protocols. They will serve us well with the smaller, less virulent outbreaks… but we have far to go…. they will fail when we get the “Big One”.
What can we do as a society to better prepare ourselves? First of all, we need to acknowledge that the “Bugs” are still ahead. As part of a comprehensive international initiative we need to:
1. Continue our efforts to promote public programs on a world wide basis for improved individual and community hygiene. Education of the population is critical. The best way to minimize the spread of an epidemic is to stop it COLD as soon as possible before the spread truly gets out of control. Basic sanitation and initial infection control is our first line of defense. This continues to be a huge challenge in underdeveloped and poverty-stricken countries.
2. Avoid using antibiotics unnecessarily. Patients expect antibiotics for their colds and flu even though the great majority of them are viral…. the antibiotic doesn’t do a thing. All this process does is produce super-resistant organisms.
3. Aggressively pursue newer and better pharmaceutical alternatives, and as these are developed, use them thoughtfully and cautiously to minimize the development of resistance.
4. Healthcare infection control protocols need to be continually updated and better implemented. Simple techniques such as hand washing are still not universally implemented.
The question is not IF there will be a new epidemic, but WHEN.
Let’s hope the “Big One” is not soon.
