Infectious Diseases Blog – ‘The Pathogenda’ Part 3

Spring continues to bring its oft’ mixed blessings of sunshine and showers, as expressed over four hundred years ago in this short poem by Thomas Tusser in ‘A Hundred Good Points of Husbandry’, 1557. It goes like this: "Sweet April showers, Do spring May flowers." This sentiment seemingly finds resonance with current world problems where we are seeing a resurgence in ancient diseases even as more modern plagues retreat and retrench.

A polio outbreak centred in Jerusalem has prompted Israel’s return to the WHO’s list of polio “outbreak countries.” Israel now appears along with 28 other countries on the WHO’s Global Polio Eradication Initiative’s list of countries with polio outbreaks, after being declared polio-free in 1988. Nations including Egypt, Iran, Ethiopia and Ukraine are also on the list of outbreak countries — places where the virus was halted but has resurfaced — while Afghanistan and Pakistan are considered endemic countries. As of Monday 7 March 2022, a case of circulating vaccine-derived poliovirus type 3 (cVDPV3) was confirmed in Jerusalem, the first case of polio in more than 30 years, spurring deep concerns and a renewed vaccination drive. According to the latest Health Ministry figures, released last week, there have been 6 confirmed polio cases, all among unvaccinated patients. In addition, there is a high likelihood of another case in an unvaccinated child, and an eighth potential case that is being investigated. Traces of the disease have also been found in the sewage system in Jerusalem, Beit Shemesh, Tiberias and Modiin Illit. Over the past month, more than 18,000 children in the Jerusalem area have received a polio vaccine dose as part of the ministry’s push to reach those who were unvaccinated or partially vaccinated. Like much of the world, Israel administers polio vaccines, spread out in multiple doses, to children as part of its standard vaccine regimen. Polio spreads mostly from person to person or through contaminated water. It attacks the nervous system and can sometimes paralyse people within hours. The disease mostly affects children under 5 and has been largely wiped out in wealthy countries.

Dr Sharon Alroy-Preis, the Health Ministry’s public health director, explained last week that during the years 2005-2013, polio vaccinations were scaled back as the disease was vanquished in the country and many babies did not get all the necessary doses. One Jerusalem child who was recently diagnosed with polio has weakness and paralysis on one side, she reported. “That is just the tip of the iceberg, under which there are many other infected children,” she assessed. Disease experts have warned of the real prospect of a resurgence of polio cases — in manageable numbers but enough to leave some children with long-term damage. Traces of the virus have occasionally been found in sewage samples in Israel, but have not resulted in any clinical cases for several decades:

It doesn’t necessarily get any better once a pandemic has been stamped out, as seen with Long COVID, Zika-associated birth defects and severe dengue in secondary infections. Recuperating and valetudinarian invalids beware: Ebola Virus Can 'Hide Out' in the Brain After Treatment and Cause Recurrent Infections. This coming after one individual was diagnosed 5 years after an outbreak in Guinea. Now, one year on some new data is shedding light on how this could have happened; some viruses just keep giving:

But we are not alone as a species in suffering the slings, arrows and viruses of outrageous fortune. Wildfowl-mediated bird-flu has been ravaging hen houses across Europe and North America playing havoc with egg and meat producers and triggering a rise in food prices that are further fuelling inflation and the cost of living. In the US alone, a growing epidemic of bird flu across the East Coast and Midwest has led to more than 23 million birds dying or being destroyed since February. According to the US Department of Agriculture, after circulating for months in Asia and Europe, a newly emergent and highly pathogenic avian influenza (HPAI) has been detected in commercial and backyard farms in more than 20 states. Individual farmers have been forced to cull hundreds of thousands, sometimes millions, of birds to check the spread of the disease.  Shell egg prices have jumped to $2.88 a dozen (up more than 50%) since Feb. 8, when the first case was identified in a commercial turkey flock in Indiana. No humans have tested positive in the US yet, but the economic toll could be major. The first US epidemic in 2015 cost the poultry industry more than $1.5 billion and caused egg prices to nearly double. To be clear, some birds have died from the disease itself, but the vast majority are being culled to try to stop the deadly and highly infectious virus from spreading. That includes millions of chickens and turkeys in barns and backyards that had been raised to provide eggs or meat. So, what is bird flu? Bird flu is caused by avian influenza Type A viruses, which spread naturally among waterfowl and can infect wild birds, domestic poultry and other animals, though rarely humans. There are more than a dozen strains of bird flu, which are classified as either "low pathogenic" or "highly pathogenic," depending on their ability to spread disease and kill poultry. It’s rare in humans, but possible

The strain dominating the US right now, Eurasian H5N1, is however considered highly pathogenic and one of the known pandemic threats to humanity. So far it has failed to transmit effectively or sustainably into human populations but has had a few failed attempts in the past with a worryingly high case fatality ratio (CFR = 50%). The main source of infection is migratory waterfowl, such as ducks and geese. "They get infected but don't get sick," Denise Derrer, public information director for the Indiana State Board of Animal Health, said. "Then they shed the virus in their droppings or wherever the land."  That means the spread could peak in a few weeks, when spring migration reaches its high point, and not abate until June, when the birds settle into their summer breeding grounds. How the virus gets from barn to barn is still not entirely clear, which makes it hard to get a grip on the situation. So far, the current strain of H5N1 has been reported in Asia and Europe. In the UK, eggs can no longer be labelled free-range because hens have been cooped up for months to avoid infection – we now have the designation: ‘barn eggs’, which doesn’t have the same hippy-vibe as free range but is still a large step up from battery eggs – as a student I worked on farms that had all three and barn ‘aint so bad. The trouble right now is that H5N1 is getting entrenched – the ever capable and Ab Osterhaus trained Marion Koopmans, an Erasmus MC virologist and adviser to the World Health Organization (WHO), has said the situation was “horrible” for the free-range poultry industry and has also called for “vigilance” in her Twitter feed. “The ecology has changed drastically in just a few years. We now have local circulation all year round in Europe, it’s not just a seasonal threat. It has a permanent presence in the wild bird population.” Among the worst outbreaks: a single occurrence at a poultry farm in Wisconsin will now result in 2.7 million egg-laying chickens being killed.  In Iowa, the US' top poultry state, HPAI detected in a commercial flock in Buena Vista County resulted in the destruction of 5.3 million egg-laying chickens. An outbreak in Osceola County on March 31 resulted in 5 million birds being killed. Big numbers.

Given the prevalence of H5N1, does it pose a threat to humans? Human infection is still rare, with fewer than 900 cases reported since 2003, according to the WHO. Most have been among people working directly with infected birds. Even if an infected chicken wound up at your local supermarket, avian influenza is not a foodborne disease, so you couldn't contract it from eating contaminated poultry. You’d have to, from investigations into human outbreaks, have wildfowl in your home or swim in wildfowl(ed) rich waters. So far in this epidemic, only one case has been reported in the UK – the house-sharer.

As H5N1 has a very high mortality rate, and the longer and larger the wave of outbreaks, the higher the chances it could mutate into a strain that is more infectious to humans, US health officials are closely monitoring the situation. The CDC has also produced a candidate vaccine virus as a precaution. During the last major bird flu epidemic (December 2014 to June 2015), more than 50 million chickens and turkeys were destroyed in what the USDA called "the largest poultry health disaster in US history." Some 39 million birds were euthanized between mid-April and mid-May 2015 alone. One in eight egg-laying hens either died or was destroyed during the 2015 epidemic. It lasted 6 months.

Prices quickly soared, on top of the energy/inflation crisis: In the first five weeks of the epidemic, wholesale poultry prices increased 17% domestically and remained inflated for years. The current bird flu outbreaks are adding a premium on poultry and eggs right now: Between Feb. 18 and March 18, the wholesale price of broiler chickens shot up nearly 20%, while the price of pork only rose about 4% but, conversely, beef actually became 3% cheaper. They clearly don’t raise beef cattle on grain exported from the Ukraine – grass is free.

I’ll leave the last word to the experts: "I think the number of the birds [killed] could be in the same ballpark" as the 2015 epidemic, biochemist Henry Niman, who has been mapping the locations of Eurasian H5N1 cases said. "And I think price increases will be comparable, too." More spring rain, May flowers may be on hold.

COVID news now: Recent concerns that recombinants may arise amongst SARS-CoV-2 viruses are now a reality. Recombinants have been identified between Delta and Omicron and now between variants of Omicron itself, namely BA.1 and BA.3:

Around 30-40% of all coronavirus deaths in the United States have occurred among people with diabetes, according to recent studies, and public health experts hope that the sobering statistic will force policymakers to finally take on the diabetes crisis. Diabetes impairs the immune system but it can also be accompanied by high blood pressure, obesity, and other medical conditions known to worsen a coronavirus infection.  Diabetes patients who were hospitalised with COVID-19 spent more time in the ICU, were more likely to be ventilated and less likely to survive the infection, according to several studies done so far. One study found that 20% of hospitalised COVID-19 patients with diabetes died within one month of admission. In the U.S., diabetes affects 34 million Americans–13% of all adults. Diabetes also disproportionately affects Latino and Black Americans, much like the pandemic has, highlighting systemic failures in public health. It’s not that diabetes itself makes COVID inherently worse but rather uncontrolled diabetes, which is really a proxy for other markers of disadvantage. Also did you know (I admit, I didn’t) that both blood vessels and adipose cells produce pro-inflammatory IL6, in comparison to myocyte-derived IL6 (a myosine) which conversely decreases the expansion and layering of new adipose tissue – is there a link here to obesity and COVID-related cytokine storms? I don’t know that either, yet:

And a final thought for the week: It’s not widely discussed on TV chat shows or the Today Programme but tuberculosis (TB) heavily influenced fashion and beauty standards in the Victorian era. Leaving knock-on effects to last into the modern era, shaping our perceptions of beauty for a century. As TB symptoms include fevers (causing dilated eyes, red lips, and flushed cheeks) and weight loss – the ‘heroin chic’ appearance but also promoted by the widespread consumption (no pun) of opium in the form of laudanum and the pale and lissom, gentile society pervaded and poisoned by the liberal use of arsenic in everything from arsenical dyes to asthma drugs – this look became a symbol of aesthetic suffering, goodness of heart and poetic nobility – as expressed in paintings from the Pre-Raphaelite period onwards. Before antibiotics, TB victims slowly wasted away until their eventual death from consumptive disease – but pale skin and thinness were seen as markers of feminine beauty, so when the disease spread among upper-class women, society romanticised people’s symptoms and their inevitable decline and fall. Fashion transformed itself to suit this ideal, with women adopting tight corsets and long, flowing skirts to accentuate their thin waists. Some even used makeup to lighten their skin, redden their lips, and add a blush to their cheeks. It wasn’t until the late 19th century, when Robert Koch discovered Mycobacterium tuberculosis and germ theory emerged, that doctors realized TB was contagious. Flowing skirts soon came under fire for sweeping up and bringing germs into the home, whereas “health corsets” were introduced as an alternative to their tight predecessors, which limited lung movement and blood circulation, worsening TB symptoms. I’ll not go into high heels or wigs this time around – decorum est and all that…Happy Easter to all and may your gardens bloom. June latest.