{"id":6085,"date":"2015-05-21T23:11:48","date_gmt":"2015-05-22T03:11:48","guid":{"rendered":"http:\/\/blogstemp.wpengine.com\/?p=6085"},"modified":"2015-06-04T15:36:46","modified_gmt":"2015-06-04T19:36:46","slug":"which-infectious-diseases-do-we-fear-too-much-which-not-enough","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/which-infectious-diseases-do-we-fear-too-much-which-not-enough\/2015\/05\/21\/","title":{"rendered":"Which Infectious Diseases Do We Fear Too Much? Which Not Enough?"},"content":{"rendered":"<p><a href=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2015\/05\/the-house-of-fear.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignright size-medium wp-image-6095\" src=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2015\/05\/the-house-of-fear-199x3001.jpg\" alt=\"the-house-of-fear\" width=\"198\" height=\"300\" \/><\/a>My friend (and HIV\/ID colleague) Mauro Schechter sent me a\u00a0funny email the other day &#8212; from Brazil, where he lives and works:<\/p>\n<p style=\"padding-left: 30px\">I just read your<a href=\"http:\/\/blogstemp.wpengine.com\/index.php\/who-guidelines-on-naming-diseases-are-well-meaning-sensible-but-kind-of-boring\/2015\/05\/13\/\" target=\"_blank\"> post<\/a>\u00a0and watched the news clip about Powassan. And you still wonder why we think you Americans are paranoid disease freaks? 65 cases in 12 years in a population of 350 million, and you&#8217;re worried??? [The three question marks are his.]\u00a0<em>Definitely<\/em> something to get worried about.<br \/>\nMauro<\/p>\n<p>His last sentence registered 10 out of 10 on the sarcasm meter, and of course Mauro has a point &#8212; the risk of getting a severe case of Powassan encephalitis is tiny, even in tick-filled New England. Can\u2019t we Americans find something more appropriate to be afraid of?<\/p>\n<p>On the other side, we&#8217;ve had a couple of cases in our\u00a0hospital, and\u00a0it really can be quite serious. More importantly, we USAers have a deep-rooted fear of not having enough to fear, and a new tick-related illness fits that void\u00a0quite nicely &#8212; especially on a slow news day.<\/p>\n<p>Which made me wonder &#8212; which Infectious Diseases do we fear too much? Which not enough? Here&#8217;s a list, compiled with extensive scientific rigor and years (ok, minutes) of painstaking research:<\/p>\n<p><strong>FEAR TOO MUCH:<\/strong><\/p>\n<ul>\n<li><strong>Rabies.<\/strong> It&#8217;s hard to say that a disease that is nearly 100% fatal and causes thousands of deaths a year can be feared too much, but that&#8217;s the bizarre\u00a0situation with rabies in the United States. The reality is that we have typically <strong><a href=\"http:\/\/www.cdc.gov\/rabies\/location\/usa\/index.html\" target=\"_blank\">1-2 cases of rabies here each year<\/a><\/strong>, and there is no evidence that this is likely to increase anytime soon. Yet think about all those urgent calls, late night trips to the emergency room, and series of rabies vaccine given for possible &#8220;occult&#8221; exposure to bats. Remember <strong><a href=\"http:\/\/cid.oxfordjournals.org\/content\/48\/11\/1493.full\" target=\"_blank\">this Canadian study?<\/a><\/strong>\u00a0They estimated that the number of people needed to treat to prevent one case of\u00a0rabies after bat-in-bedroom-but-no-bat-bite (longest compound phrase I&#8217;ve ever written) could be as high as 2.7 million!\u00a0Not surprisingly, the Canadians no longer recommend rabies vaccine after bats are found in the bedroom. <strong><a href=\"http:\/\/www.cdc.gov\/mmwr\/preview\/mmwrhtml\/rr5703a1.htm\" target=\"_blank\">We still do.<\/a><\/strong><\/li>\n<li><strong>Pharyngitis, possible strep throat in adults.<\/strong> The most feared\u00a0complication of strep throat is arguably acute rheumatic fever, but:\u00a01) \u00a0Strep throat is mostly a disease of children and young adolescents, most adults have some viral thing (see below for an important exception);\u00a02) Most acute rheumatic fever occurs in kids\u00a0as well &#8212; even many ID doctors of a certain age (that means <em>older than I<\/em>) have never seen acute rheumatic fever in an adult; \u00a03) The incidence of acute rheumatic fever has been incredibly low for years in our country, for reasons independent of antibiotic use.<\/li>\n<li><strong>Conjunctivitis.<\/strong> This ugly, uncomfortable malady\u00a0makes people really, really scared, and brings out horrible fears of contagion in the school and workplace. You&#8217;d think it was a serious, and highly contagious ID emergency. It isn&#8217;t.<\/li>\n<li><strong>Mosquito-related\u00a0Encephalitis.<\/strong> 2005 was a relatively bad\u00a0year for Eastern Equine Encephalitis &#8212;\u00a0and there were 21 cases in the whole country. But most years there are only a few, yet this doesn&#8217;t stop the near annual news media terror when some mosquitoes test positive. <strong><a href=\"http:\/\/jacksonville.com\/news\/health-and-fitness\/2015-05-07\/story\/warnings-issued-first-case-eastern-equine-encephalitis\" target=\"_blank\">Or a horse dies!<\/a><\/strong>\u00a0Or the <a href=\"http:\/\/www.bostonglobe.com\/metro\/regionals\/north\/2014\/09\/20\/spraying-limited-peabody-for-west-nile-virus-amesbury-for-eee\/fCgmkaRhRpyZPML73MIumI\/story.html\"><strong>mosquito spraying starts!<\/strong><\/a>\u00a0Fear of West Nile Virus means a\u00a0dead bird\u00a0can\u00a0lead to panic, triggering <strong><a href=\"http:\/\/www.mass.gov\/eohhs\/docs\/dph\/cdc\/arbovirus\/faq-dead-birds.pdf\" target=\"_blank\">unnecessary calls to the Department of Public Health.<\/a><\/strong>\u00a0Plus there was\u00a0<strong><a href=\"http:\/\/blogstemp.wpengine.com\/index.php\/west-nile-virus-and-friday-night-lights\/2008\/09\/05\/\" target=\"_blank\">this bit about canceling high school football<\/a><\/strong>. As with rabies, it&#8217;s important to acknowledge that these conditions can be incredibly serious, and life threatening &#8212; but should they occupy such a big space in our collective fear center?<\/li>\n<li><strong>Bronchitis.<\/strong>\u00a0First\u00a0a little cold, which lingered, but now it&#8217;s become\u00a0<em>bronchitis. <\/em>Terror, and cue up the <strong><a href=\"http:\/\/blogstemp.wpengine.com\/index.php\/azithromycin-linked-to-cardiovascular-death-not-a-placebo-after-all\/2012\/05\/16\/\" target=\"_blank\">Z-Pak!<\/a><\/strong><\/li>\n<\/ul>\n<p><strong>FEAR TOO LITTLE:<\/strong><\/p>\n<ul>\n<li><strong>Influenza.<\/strong> &#8220;It&#8217;s just the flu&#8221;, people say. But people are wrong, pretty much every year. Let&#8217;s hope our vaccine gets better \u00a0&#8212; how about one that you only need every five years, not one that needs to be repeated\u00a0more often than renewing your car&#8217;s registration? Progress in the flu vaccine &#8212; whenever that happens &#8212; will have a transformative effect on community health.<\/li>\n<li><strong><em>Clostridium difficile. <\/em><\/strong>The emergence of the\u00a0<strong><a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC2600085\/?report=reader\" target=\"_blank\">hypervirulent strain of C. diff<\/a>\u00a0<\/strong>should profoundly change the risk vs benefit calculation with any antibiotic prescription. Has it? I know one oral surgeon who will never use clindamycin again, after a &#8220;routine&#8221; post-operative course\u00a0caused severe C diff, leading to a colectomy in a previously healthy patient. But how about <em>before<\/em> the prescription?<\/li>\n<li><strong>Infectious endocarditis and other bacterial complications of injection drug use. <\/strong>The outbreak of IDU-related HIV in Indiana is appropriately getting plenty of press &#8212; HIV is still an incurable disease, much-feared among everyone, including those who inject drugs. But all ID doctors know that the rise <a href=\"http:\/\/www.bostonglobe.com\/metro\/2015\/03\/11\/opioid-crisis-really-about-heroin\/bPkbdkNpxPQDF7htWSxhqN\/story.html\" target=\"_blank\">in use of heroin<\/a> has led to a much more pervasive\u00a0epidemic of endocarditis and other\u00a0serious invasive bacterial infections. And these are emphatically\u00a0<em>much<\/em> harder to treat than HIV, and so much more immediately life threatening. Do people with addiction fear these as well?<\/li>\n<li><strong>Atypical mycobacteria.\u00a0<\/strong>There should be a support group for patients with non-tuberculous mycobacterial infections.\u00a0Pulmonary and non-pulmonary infections from these diverse bugs\u00a0can be\u00a0incredibly tricky to diagnose and treat, yet hardly anyone in the non-medical public knows about them. Why is that?<\/li>\n<li><a href=\"http:\/\/blogstemp.wpengine.com\/index.php\/fusobacterium-pharyngitis-and-the-limits-of-limiting-antibiotics\/2015\/02\/21\/\" target=\"_blank\"><em><strong>Fusobacterium necrophorum.<\/strong> <\/em><\/a>The adolescent or young adult with severe exudative pharyngitis, systemic toxicity, and a negative strep test could easily be dismissed as having &#8220;only&#8221; viral pharyngitis. Yet we now know that a <a href=\"http:\/\/annals.org\/article.aspx?articleid=2118593\" target=\"_blank\"><strong>subset will be PCR positive for fusobacterium<\/strong>,<\/a>\u00a0the primary cause of\u00a0septic jugular vein thrombophlebitis (Lemierre\u2019s syndrome), a potentially devastating complication.<\/li>\n<li><strong>MRSA<\/strong>. New drugs\u00a0notwithstanding, and even with a decline in incidence (what&#8217;s causing that?), MRSA remains the most difficult to treat commonly encountered infection out there.\u00a0Just ask any ID fellow &#8212; what other common infection persists so stubbornly, or recurs so frequently, despite &#8220;appropriate&#8221; antibiotic treatment?<\/li>\n<li><strong>Vaccine-preventable diseases of childhood.<\/strong> Self-explanatory.<\/li>\n<\/ul>\n<p>Would be interested to hear what conditions you think should be on these lists. And as the days grow longer, and we get closer to peak Lyme season, I thought long and hard about where Lyme\u00a0should go, and concluded it could be on both lists &#8212; feared too much by some, too little by others.<\/p>\n<p>See if you can guess why.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>My friend (and HIV\/ID colleague) Mauro Schechter sent me a\u00a0funny email the other day &#8212; from Brazil, where he lives and works: I just read your post\u00a0and watched the news clip about Powassan. And you still wonder why we think you Americans are paranoid disease freaks? 65 cases in 12 years in a population of [&hellip;]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3,5,8],"tags":[],"class_list":["post-6085","post","type-post","status-publish","format-standard","hentry","category-health-care","category-infectious-diseases","category-patient-care"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/6085","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/comments?post=6085"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/6085\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=6085"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=6085"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=6085"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}