Medical Care

Medical Education

Some Topics

  • Infection Surveillance

    Public agencies take credit for the control of infectious diseases achieved by reducing the microbial contamination of food, air, and drinking water. Improved sanitation and personal hygiene improved infection control. Infections such as typhoid and cholera transmitted by contaminated water were major causes death prior to the 20th century and were reduced dramatically by improved sanitation. Smallpox was eliminated by vaccination and some the most common endemic diseases continue to be controlled by vaccination. Sad to say, the successes of the 20th century are not secure. Old infections reappear in more virulent forms and new infections emerge to challenge systems of control. Sustained attempts to develop vaccines against major threats such as influenza, AIDS dengue and malaria have limited or no success.

    Biologists in the 21st century witness the processes of evolution which are most rapid in bacteria and yeast cells. These single-celled organisms are favored by geneticists since they replicate in a matter of hours and evolving genetic changes occur quickly. Bacteria acquire antibiotic resistance after repeated exposure to antibiotics that kill susceptible bacteria, leaving the resistant ones who eventually dominate the gene pool. Viruses evolve most rapidly. New and more virulent mutations continue to be a threat to human survival. Influenza viruses evolve so rapidly that new vaccines have to be developed every year to immunize human populations against infection with new variants of the virus.

    Hein summarized current trends: "As the world becomes smaller through global travel, we have learned that there are no limits to how far, or how fast, infectious diseases can travel. We have seen Legionnaires' disease spread through ventilation systems, HIV through transfusion of unscreened blood, and numerous animal-to-human and air travel-related infections. We are also seeing the evolution of microbes, and some novel genetic mixes. Many new pathogens are actually genetic mutations of older ones. Infectious diseases clearly represent the Mendelian laws of survival, showing us that this field offers a continuum of diverse challenges that have been difficult to predict and sometimes difficult to control; this is unlikely to change. " (Ingrid G. Hein . A 20-Year Look-Back: Two Steps Forward, One Step Back. Landmark Developments in Infectious Diseases. October 20, 2015)

    Bartlett wrote: "Predictions in this field are particularly dangerous, on the basis of a history that is dense with surprises in nearly all facets of the discipline. For example, Ebola was most everyone's choice for medical story of the year for 2014, but this infection was barely on the radar screen 1 year ago. The influenza vaccine recommended for the current epidemic was created for the anticipated H1N1 strain, but the influenza now causing widespread disease is largely the H3N2 strain. Chikungunya is hard to pronounce and was rarely seen until the enormous epidemic in the Caribbean that spilled over to the United States in returning travelers—and, more worrisome, it achieved endemic transmission by mosquitoes in Florida. Antibiotic resistance has been a notorious concern for more than a decade, but 2014 brought federal legislation to address the problem, with a $1.1 billion price tag that came to most as a surprise.." (John G. Bartlett. Predictions for the Field of Infectious Diseases for 2015. Medscape. Jan 29, 2015.)

    My interest in infection surveillance and the lack thereof peaked after I developed an airborne fungal infection. I used simple microscopic techniques to diagnose my infection and invented a low tech culture method that allowed me to monitor the infection. Most of the physicians I encountered when I sought help to identify and treat the fungal infection were not helpful. Indeed some were remarkably stubborn in their ignorance and denial. I encountered, for example, the spurious argument that the infection has not been reported in BC before, therefore you can't have it.

    There are several facts to acknowledge.

    1. Infectious agents constantly evolve.

    2 The distribution of infectious agents is always changing. Planet wide events such as global warming, travel and the shipment of goods and foods long distances connect all regions of the planet. The idea of localized disease is obsolete. Increasing populations and increasing urban density are ideal for infection transmission. Transportation of people and goods all over the world means that infections become worldwide in a matter of days, not localized. I continue to meet physicians who think they are living in the nineteenth century and refer to localized, "endemic" infection.

    Climate changes allow the migration and proliferation of vectors such as mosquitoes that carry dengue, west nile virus, malaria, and yellow fever. Other major diseases likely to spread with global warming are cholera, filariasis and sleeping sickness. Fungi and bacteria are transported by wind, water, animal vectors and by every mode of human transportation.

    3. In Canada, medical awareness of diseases caused by fungi is limited and prompt, accurate diagnosis is unlikely. Diseases that are little known and are hard to diagnose become diseases that "never occur around here."

    4. Infection Surveillance systems are inadequate everywhere on the planet. In Canada surveillance systems either don't exist or if they do exist they are passive and disease-specific. Communications among local physicians and public health services are poor to non-existent. Canada lacks information-sharing. "New" diseases will not be recognized quickly or treated effectively.

    5. There are many different infections at work in every community on any given day. The difficult task of identifying even common infections is seldom undertaken by community physicians. Local information about infections currently afflicting a community is often not available.

    Morse reported that concerns about the spread of infectious diseases such as influenza or severe acute respiratory syndrome (SARS), revealed the need for global early warnings and rapid responses that did not exist. He stated: ”Although progress has been made, many gaps remain. A number of the gaps can be addressed through increased political will, improved resources for reporting, improved coordination and sharing of information, raising local doctors awareness, and more efficient triggers for action. The increasing availability of communications and information technologies worldwide offers new opportunities for reporting. “ [Health Affairs 26, no. 4 (2007): 1069–1077]


    Influenza surveillance has improved in recent years. In Canada, FluWatch, a national influenza surveillance system, is coordinated through the Centre for Infectious Disease Prevention and Control at the Public Health Agency of Canada. Sentinel physicians collect blood samples for influenza detection; participating labs can accurately identify serotypes of the viruses which change within months. The limitation has been that physicians and patients remain ignorant of the infections prevalent in their own communities.

    In 2009 The emergence of a new H1N1 influenza virus created a frenzy of misinformation and panic. TV news showed people wearing paper face masks, the latest signal that the world is a dangerous place. While I have broadcast my concern for many years that infection surveillance is inadequate and promoted a new ethic of social responsibility, I found the frantic media reports about the swine flu to be offensive if not absurd. Social responsibility means -- don't spread infections you have acquired; if you are sick, stay at home.

    Suddenly, quick tests for influenza were deployed worldwide and every news organization broadcast daily influenza reports in a chaotic, confusing manner. Individual examples of deaths from influenza were reported creating the false impression that the swine flu was a new and deadly menace. Every year, for many decades at least, thousands of people died from influenza infection but no-one reported their fate. In previous years you had to be a dedicated researcher to find morbidity and mortality reports to understand the severity of influenza infection. Every year new variations of influenza virus spread thought the world, but the modes of transmission, the rate and extend of spread were scarcely known. Every year other viruses would spread widely with scarcely any mention in the media and little international cooperation in the identification of animal reservoirs and tracking of human to human transmission. In my medical news blog I wrote "a brief review of the Swine Flu Scare of 2009 - a great pile of nonsense that seem to have overwhelmed even the most cautious of scientists. This is not to argue that H1A1 viruses are innocuous, but to develop a perspective on the relative threats of viruses in general and to reveal that the evidence for swine flu as a special threat was lacking."

    In the Northern hemisphere, viral epidemics cause up to 80% of all respiratory illnesses. The most common infections are caused by six viral groups: rhinovirus (RVs), respiratory syncytial virus, influenza virus, parainfluenza virus, corona virus, and adenovirus. In one study of 285 children admitted to hospital with lung infection, viruses were identified in 125 - respiratory syncytial virus (107), influenza (9) and parainfluenza type 3 (9). Clinical and radiologic diagnoses included bronchiolitis (127), interstitial pneumonia (47) and lobar pneumonia (91).

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