An ongoing dialogue on HIV/AIDS, infectious diseases,
May 21st, 2015
Which Infectious Diseases Do We Fear Too Much? Which Not Enough?
My friend (and HIV/ID colleague) Mauro Schechter sent me a funny email the other day — from Brazil, where he lives and works:
I just read your post and 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’re worried??? [The three question marks are his.] Definitely something to get worried about.
Mauro
His last sentence registered 10 out of 10 on the sarcasm meter, and of course Mauro has a point — the risk of getting a severe case of Powassan encephalitis is tiny, even in tick-filled New England. Can’t we Americans find something more appropriate to be afraid of?
On the other side, we’ve had a couple of cases in our hospital, and it 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 quite nicely — especially on a slow news day.
Which made me wonder — which Infectious Diseases do we fear too much? Which not enough? Here’s a list, compiled with extensive scientific rigor and years (ok, minutes) of painstaking research:
FEAR TOO MUCH:
- Rabies. It’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’s the bizarre situation with rabies in the United States. The reality is that we have typically 1-2 cases of rabies here each year, 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 “occult” exposure to bats. Remember this Canadian study? They estimated that the number of people needed to treat to prevent one case of rabies after bat-in-bedroom-but-no-bat-bite (longest compound phrase I’ve ever written) could be as high as 2.7 million! Not surprisingly, the Canadians no longer recommend rabies vaccine after bats are found in the bedroom. We still do.
- Pharyngitis, possible strep throat in adults. The most feared complication of strep throat is arguably acute rheumatic fever, but: 1) Strep throat is mostly a disease of children and young adolescents, most adults have some viral thing (see below for an important exception); 2) Most acute rheumatic fever occurs in kids as well — even many ID doctors of a certain age (that means older than I) have never seen acute rheumatic fever in an adult; 3) The incidence of acute rheumatic fever has been incredibly low for years in our country, for reasons independent of antibiotic use.
- Conjunctivitis. This ugly, uncomfortable malady makes people really, really scared, and brings out horrible fears of contagion in the school and workplace. You’d think it was a serious, and highly contagious ID emergency. It isn’t.
- Mosquito-related Encephalitis. 2005 was a relatively bad year for Eastern Equine Encephalitis — and there were 21 cases in the whole country. But most years there are only a few, yet this doesn’t stop the near annual news media terror when some mosquitoes test positive. Or a horse dies! Or the mosquito spraying starts! Fear of West Nile Virus means a dead bird can lead to panic, triggering unnecessary calls to the Department of Public Health. Plus there was this bit about canceling high school football. As with rabies, it’s important to acknowledge that these conditions can be incredibly serious, and life threatening — but should they occupy such a big space in our collective fear center?
- Bronchitis. First a little cold, which lingered, but now it’s become bronchitis. Terror, and cue up the Z-Pak!
FEAR TOO LITTLE:
- Influenza. “It’s just the flu”, people say. But people are wrong, pretty much every year. Let’s hope our vaccine gets better — how about one that you only need every five years, not one that needs to be repeated more often than renewing your car’s registration? Progress in the flu vaccine — whenever that happens — will have a transformative effect on community health.
- Clostridium difficile. The emergence of the hypervirulent strain of C. diff 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 “routine” post-operative course caused severe C diff, leading to a colectomy in a previously healthy patient. But how about before the prescription?
- Infectious endocarditis and other bacterial complications of injection drug use. The outbreak of IDU-related HIV in Indiana is appropriately getting plenty of press — HIV is still an incurable disease, much-feared among everyone, including those who inject drugs. But all ID doctors know that the rise in use of heroin has led to a much more pervasive epidemic of endocarditis and other serious invasive bacterial infections. And these are emphatically much harder to treat than HIV, and so much more immediately life threatening. Do people with addiction fear these as well?
- Atypical mycobacteria. There should be a support group for patients with non-tuberculous mycobacterial infections. Pulmonary and non-pulmonary infections from these diverse bugs can be incredibly tricky to diagnose and treat, yet hardly anyone in the non-medical public knows about them. Why is that?
- Fusobacterium necrophorum. The adolescent or young adult with severe exudative pharyngitis, systemic toxicity, and a negative strep test could easily be dismissed as having “only” viral pharyngitis. Yet we now know that a subset will be PCR positive for fusobacterium, the primary cause of septic jugular vein thrombophlebitis (Lemierre’s syndrome), a potentially devastating complication.
- MRSA. New drugs notwithstanding, and even with a decline in incidence (what’s causing that?), MRSA remains the most difficult to treat commonly encountered infection out there. Just ask any ID fellow — what other common infection persists so stubbornly, or recurs so frequently, despite “appropriate” antibiotic treatment?
- Vaccine-preventable diseases of childhood. Self-explanatory.
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 should go, and concluded it could be on both lists — feared too much by some, too little by others.
See if you can guess why.
33 Responses to “Which Infectious Diseases Do We Fear Too Much? Which Not Enough?”
Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
Biography | Disclosures | Summaries
Learn more about HIV and ID Observations.
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I have taken to calling bronchitis “post-infectious cough”. This seems to do the trick of conveying to my patients that it results from airway inflammation after some other previous infection, including your typical URI. Most patients “get it” that bronchitis’s lingering cough doesn’t require an antibiotic, but some people still insist they need a Z-pak. Sigh.
I certainly do have a fear of multi-drug resistant TB becoming a pandemic. Does that put me on your Brazilian friend’s list of “paranoid disease freaks”? 🙂
Your timing was impeccable. Deet packed for long weekend on the Cape. Thanks!
Hi Paul. I wonder if we should add herpes to your list of diseases that we are too worried about. Although there are rare, life-threatening complications of HSV, in most cases it is nothing more than a cold sore in a private part of the body, with outbreaks diminishing in intensity and frequency over time. I think because of our cultural attitudes towards sex, our dare-I-say prudishness about it, we have turned herpes into a plague and those who have it into degenerates. I can’t tell you how many times patients have come to me after their first outbreak sobbing, demoralized, racked with guilt and convinced that they are now unlovable. I have had patients say the words “I will never ever be able to be in a relationship again now.” That’s devastating and, I think, grossly out of proportion to the actual virus.
I’m quite surprised that an HIV/ID blog doesn’t include tuberculosis on this list.
Globally, it kills AS MANY as HIV/AIDS – 1.5 million every year. There are ~9500 cases in the US alone. Drug-resistant strains are on the rise around the world. And on top of that – there’s no effective vaccine for adult TB.
In terms of funding & media, TB doesn’t get enough attention; but NEJM? That’s disappointing.
Gazi,
I’m in agreement that TB is a huge global problem (as is rabies). In the USA, however, incidence has been declining for years, and case numbers are at record lows. Maybe someone should do a similar post about global threats!
http://blogstemp.wpengine.com/index.php/now-for-some-good-news-tb-cases-continue-to-decline/2010/03/24/
Paul
I read this article and thought it was a good example of fear-mongering: Fluffy and you might co-create a nasty flu virus that will kill millions! http://www.nj.com/healthfit/index.ssf/2015/05/dog_flu_appears_in_nj.html Well, they don’t say it will kill millions, but you get the point, I hope.
These articles are always filled with such good humor, especially the bronchitis >> terror >> zpak.
In regards to Lyme Disease, here in Iowa I diagnosis several cases every year. However, it has become the new “Fibromyalgia” in our clinic: patients coming in with vague symptoms, have looked up their symptoms on the Internet and have self-diagnosed themselves.
Explaining testing isn’t really indicating in the absence of tick bite (which is either always missing from the history, or they bring in a wood tick, a random bug, an acorn, etc) goes in one ear and out the other. When they’ve finally worn you down and you test and it comes back negative, they retort (…drumroll…) “seronegative Lyme disease”.
They eventually find their way to a “Lyme specialist” who puts them on IV rocephin, oral doxy, anti-malarials, etc.
Then I see them back when they get C. Diff.
Chagas disease, maybe?
http://cid.oxfordjournals.org/content/49/5/e52.full
Great blog as always Paul!
Fear too much: Post-Splenectomy overwhelming sepsis.
I feel for asplenic people and for the very rare person who develops Streptococcal or Meningococcal sepsis or Capnocytophagia infections in this situation, but it seems to be incredibly rare now in our highly vaccinated population and may not justify the enormous effort put into spleen registries etc. We have not had a case of post-splenectomy sepsis at my very large, haematology/oncology heavy hospital in over five years.
The other one is Ebola – it is clearly a terrible disease and in West Africa it has caused havoc, but we haven’t had a single case in my country – it would make a neat study to analyse the opportunity cost of the Ebola response in the West and work out how many smoking cessation courses (cost per QALY about $400) could be funded and the increased mortality in hospitals where about a third of all senior staff were tied up for more than two months in meetings about Ebola, not doing our regular jobs properly.
Foot infections in persons with diabetes. These affect up to 25% of all those with diabetes during their lifetime and are the major diabetes-related cause for hospitalization. A substantial percentage lead to lower extremity amputation, which is associated with a 5-year mortality of over 50%. Fortunately, if properly treated, most can be cured.
Lyme, for three reasons. (1) The cardiac conduction system disease and cardiomyopathy can leave a devastating anecdotal clinical impression; this is a diagnosis worth not missing. (2) What to do about all the people who have been treated for lyme but have persistent symptoms? (3) What to do about all the people who are being treated for chonic lyme disease despite unclear clinical-pathological correlation and evidence of treatment benefit?
I live in an area with endemic rheumatic fever. It is interesting to see the resurgence of an old disease which I hadn’t seen acutely in 30 years.
I like the idea of a third category, too much & too little, like Lyme. HCV would easily fit that bill. Feared too much by insurance companies yet too little by susceptible individuals.
Useful and fun reading with my morning coffee – I enjoy your writing.
In 1948 it poliomylitis. Today’s seem like nothing in comparision.
I completely concur about conjunctivitis. Right along with that would be head lice. Although that may be more disgust than fear…
Feared not enough, worldwide: TB, malaria, and sexually transmitted diseases. Even more so, multiresistant bugs.
Then, those contagious diseases not involving microbes [as far as we currently know – remember, stomach ulcers were once a non-infectious disease too]: anorexia, self-harm, copy-cat suicide, religious and political extremism, terrorism, obesity, sedentary lifestyles. Not necessarily in that order.
How about head lice on the feared too much category? The AAP has new guidelines on not keeping children out of school, but parents (& some schools) still throw up their hands in horror when they hear a student has head lice!
My wife voted to include it — it was a runner up!
Paul
Remember Hanta virus? Bubonic plague? These diseases can start a public frenzy when mentioned here in California. But Cocci? Not a second thought.
Thanks for your blog, Paul! It’s very nice learn with humor.
My greatest (but in fact small) fear are the diseases we still don’t know. Is possible to travel to Africa, Southeast Asia or even some places here in South America, without think about that?
Outside of pulmonary and infectious disease journals this is the first time I’ve seen nontuberculous mycobacterial (NTM) pulmonary infections, such as MAC/MAI, and M. abscessus, mentioned as infectious diseases to be concerned about. I have NTM and bronchiectasis, and am retired clinical research RN.
Good References:
http://www.jthoracdis.com/article/view/2023/html
http://downloads.hindawi.com/journals/bmri/2014/919474.pdf
Thank you for bringing this forward.
NTM great support and information:
http://www.inspire.com/groups/lung-infections-and-diseases/topics/lung-infections/
http://www.ntminfo.org/patients/physician-referral-list
Enjoy your blog! Possible disagreement about the flu. Everything you read cites the same number–36,000 deaths per year but this is a number that is made up, based on modeling. Does anyone know the true mortality rate or incidence? Some studies have that number very low. Is it possible that we really could be overly concerned about it? Appreciate your thoughts.
Influenzaphobia & More?
Like your lists, but …
The problem with ineffective and need for effective influenza vaccine is clear. Why are we pushing ineffective influenza vaccine on healthy low risk patients? The push for universal use of the available (ineffective) vaccines by governments and some employers seems irrational and that’s a bad idea. Why? 1. What’s the point of fear mongering if there is nothing to do about it? 2. Gives effective vaccines a bad rap and makes it more difficult for those of us on the front lines to sell the value of effective vaccines. 3. Looks as if the benefit of current influenza vaccines = financial gain for the manufacturers with little gain for the people.
And … for those infectious diseases in the Top Ten that should be feared, give us a prevention, early diagnosis and definitive treatment hints, eh?
Dr. Mike
Agree we worry too much about group A Strep, and not enough about Fusobacterium and “other” causes of pharyngitis, both known and unknown. When a severe sore throat promptly responds to an antibiotic, SOMETHING was growing where it wasn’t supposed to be whether we identified it or not.
Unless you have some kind of underlying condition, you worry too much about influenza.
And “bronchitis”, PLEASE get back to me ASAP with how you are able to rule out all atypical pulmonary infections in the 5 minutes you have in the clinic to make the decision to treat or not!! Recall that in hospitalized children with pneumonia, 20% were atypical. Is one in five enough to worry or not?
Hi Dr Sax. I have an off topic question. I’m a surgeon and deal with a lot of wounds. I follow you on Journal Watch; you seem like a smart guy and I appreciate your sense of humour. So I thought I’d ask you about something that bugs me and that I can’t find anything about in the literature. Why are ID specialists not concerned about the topical antibiotics that are sold in stores everywhere without prescriptions (and used willy nilly by many doctors for that matter) and of course advertised and promoted as being useful? As far as I can tell there is limited evidence of effectiveness of any of the topicals in any but a few limited situations. And wouldn’t their widespread and indiscriminate use be contributing to the overall genetic pool of bacterial resistance?
I’ll have to agree with you on this. Many patents feel that they are combating their infection with OTC topicals only to wait to come in for treatment rendering them with with a mess of E. coli, MRSA and the like. The media and other propaganda have used fear of bacterial infections for the use of their increased sales and now instead of just cleaning and covering we are using OTCs for paper cuts and increasing the overall genetic pool of bacterial resistance. Remember how MRSA came about –
Fear too much: anaerobic pulmonary infections in any patient that vomits.
Great blog. Totally agree that people should be fearful of NTM and Mac Lung Disease especially if they have COPD, Bronchiectasis or other chronic lung disease. I have Bronchiectasis I had Nocardia Nova back in 2008 and I had Mac Lung Disease in 2012 as of right now am Mac free. The treatment is grueling to say the least and has a very high reocurrance rate. I wish more Dr.s would educate themselves on both Bronchiectasis and Mac lung disease. It can be very hard to find competent Dr.s that really know what they are talking about pertaining to these diseases. I have been fortunate to have some of the best Dr.s, but having said that I talk to people in different support groups daily that are having a very hard time finding Dr.s to deal with these diseases in a knowledgable and caring way. Thanks for listing NTM as it is growing by leaps and bounds which is not a good thing.
You know what else is terrible? Chikungunya.
Paul,
I understand the reasoning in your reply & I apologize that I came off insulting in the first. I just want to point out that the CDC reports that last year, the US’s decline of TB slowed down (http://www.nlm.nih.gov/medlineplus/news/fullstory_151561.html).
Thank you for your work.
We, as a population, have been propagandized into believing that all bacteria etc are poisonous and therefore, instead of simply employing good hand washing techniques, believe that everything must be as sterile as the operating room. Creating a sterile environment for living is not good for our immune system. Remember when you would play in the dirt??? Those who did have great immune systems and have shown, in my history, to be able to overcome much more than others! Also, why / since when did every mother bring her child in for a stuffy nose and we prescribe for them? We have become our own worse enemy in the fight against germs. Is it too late to correct this???