How to tame your outbreak: 2, the fight against Malaria

In part 1 of How to tame your outbreak I have shared with you the three necessary steps to control an outbreak. These were: gather information, contain the spread and keep it safe. In theory it is as simple as opening a bag of crisps on a lonely and rainy Tuesday evening whilst sitting on the couch ready to watch Legally Blonde for the tenth time. Controlling an outbreak in practice is a whole different ballgame.

Now , I could share with you all the Outbreak control plans and actions about every Virus, Bacteria and what, but since I work closely with a Malaria Elimination Task Force (METF) at the Myanmar-Thailand border, let’s use Malaria as example.

So here we go: how to tame your Malaria Outbreak?

Step 1: gather information

Malaria is caused by a parasite and is transmitted via mosquito’s. They suck blood from a Malaria patient and inject that blood into a new patient, thus infecting them. We know what it is and also how it spreads. That was the easy part.

Step 2: contain the spread

To contain Malaria there are really three options we could take:

Option 1: eliminate the mosquito. In real life, super difficult, it is easier to erase the West African Black rhinoceros than these little biters.

Option 2: prevent it from biting you. DEET or bednets are helpful, but it’s not realistic for people living in remote areas to use DEET all the time.

Option 3: make sure everybody that gets infected is treated before a mosquito can bite them and spread it further. This means early detection and treatment with the anti malaria drugs that kill the parasite. With the upcoming resistance (here we go again) this option can also become very challenging.

So which option to choose? You could start with option 3: early treatment. Now this can be a tricky part. Especially in a rural area like right here on the border, there are many villages and people tend not to stay in just one place. They work in one place, live in a next and their family is somewhere else again. This means that in order to successfully contain the outbreak, you will have to map out all the villages that you need to target. In the case of METF this is over 1500 villages. Then you need:

  • Healthposts where people can go to get tested and treated.
  • Healthworkers, educated people to diagnose and treat patients
  • Medication, power supply, charts, needles, tests, alcohol (not to party into the night but to disinfect), etc.
  • Education of all people, including villagers. People need to understand what you’re doing and why they need to come as soon as they have fever.
  • A way of communication between the health posts and the hospitals in order to be able to send the severe patients in time for care

METF currently has over 1200 health posts with more than 1600 health workers. Can you imagine the work goes in to an operation like that?! And how much money, perseverance, guts (especially in the remote and unsafe areas) and love for the people? In the meantime, you can try option 1 and 2 (kill the mosquito and prevent the bites).

Step 3: keep it safe

The WHO grants a certificate that a country is “Malaria Free” (like Paraguay recently) when:

“a country has proven, beyond reasonable doubt, that the chain of local transmission of all human malaria parasites has been interrupted nationwide for at least the past 3 consecutive years; and that a fully functional surveillance and response system that can prevent re-establishment of indigenous transmission is in place.”

This means that, although my wonderful colleagues at METF have done a tremendous job already, saving thousands of lives in at least two countries, we’re not getting the certificate yet.

Containing an Outbreak is newsworthy and is a certain money collector. Keeping it safe is the part of the “outbreak” that funders are least interested in. It’s not news anymore. No extra figures to show. It’s just being there and staying there and not going anywhere until you’re sure. And that could take years and years. However, don’t get your guard down. Venezuela was declared malaria free in 1960 but had a big outbreak in 2016 with 240,613 patients and 280 deaths. As soon as you stop being prepared, it will come back.

So thank you METF and keep fighting the good fight.

 

Picture: Suphak Nosten: In the middle of the border, the one crossing for care, the one to provide care, across the border

 

How to tame your outbreak

After all the previous blogs we can honestly say that outbreaks occur. Already many times in history and definitely many times more in the future. These outbreaks range from being relatively mild (the seasonal flu) to very deadly (Ebola), from being brand new and scary (Nipah virus in India) to being as old as the Pyramids and almost extinct (Polio).

With every outbreak Super Avenging Guardians of the Corporis fighters – normally called Epidemiologists – ask themselves the same questions: how do we manage and contain the outbreak? How can we improve the public health in order to eliminate the pathogen (Viruses, Bacteria and all other stuff that makes people sick)?

Well, in short, it is like the ‘Program for a Treatment of Alcohol Addicts’ by HouseofRecovery.org …  it takes three steps.

Step 1: Gather information

In order to control an Epidemic, we have to find out “what” before we can proceed with “how” and “when”. It is essential to gain more information about the pathogen and the way it infects people. An outbreak of flu requires a different approach than a diarrhea illness.

And should it be an unknown pathogen, you start with searching for the first infected patient. Then try to figure out how the other patients got infected, write a book about it, become the world leading expert and get a Nobel Prize at the age of 79. Oh, and during all this don’t forget to go to step 2.

Step 2: Contain the spread

If you know how it spreads, you have to try to contain it. Step 2 is actually two different routes:

Route 66: You take care of the current patients

Road to perdition: You try to not let any more people get infected

Sometimes driving these roads can be fairly easy. For the biggest outbreak of Cholera in London back in the mid-19th century (killed hundred thousand people), all they needed to do to stop it was shutting down the main water pump. But to be fair it took them years to figure out the answer to step 1: what it was and how it spread. We’ll come back to that in a different blog.

But most of the time, driving these roads are very challenging. Especially because you have to drive them at the same time.

Step 3: keep it safe

At this point you have successfully stopped the big outbreak, very well done. But the challenge that you’re facing now is to keep it that way. Because if one patient gets infected from a different part where there are no health posts, this one patient can be the patient zero for the next outbreak and you’ll have to start all over again.

This means that you can never let your guard down. Not until a long time.

There you have it. Now we can tackle any outbreak!

Next time I’ll give you a nice example of outbreak control…

 

 

picture: Louise Annaud/Medecins Sans Frontieres via AP

HIV: PrEPare for the future

One day I read the magazine “Hello Gorgeous”, a glossy magazine about living with HIV. And I got a lot of looks, you know what I mean, not the ones you hope to get. Will this ever change? How I sometimes wish that I could just to take a quick glimpse into the future and know how everything will turn out. Just like I have this urge to skip to the part in the book where the killer reveals itself. But I never do. What fun is reading when you know the ending, what fun would living be when you know it all? So, I speculate and think about now and the future. And today, I think about the future of HIV.

The Future is now

What kind of world would it be if we would use pills to prevent ourselves from getting HIV?

Well, it is the world we live in now. As we speak healthy men who have sex with men (thus have the greatest risk), are given anti-HIV medication before they have unprotected intercourse in order to prevent them from getting the virus. The name: Pre Exposure Prophylaxis or in short; PrEP. And yes people, it’s a great success in the Netherlands. Instead of swallowing MDMA before going to a Dancefestival, men are PrEP-ing up before going to “party”. And it’s expanding to other countries as well (the usage of PrEP I mean, not parties, well, maybe those too, but…, never mind).

Now I know the most common response: we’re enabling people to have sex without a condom, it only protects against one STD, can’t they just wear condoms instead of taking medications that can have side effects? Oh wait, those were the responses to the contraceptive pill. They only protect against a child and certainly are invented to give us the freedom to protect ourselves to that one particular “STD”. However strange this “new” intervention might seem, maybe in the future we will look back and conclude it’s actually not so different than what we were already doing.

And whilst we’re there, in that future I mean, let’s check if my following HIV predictions came true.

I predict a second spike in HIV infections

With the lack of fear for HIV, I really think we will get a second peak in infections.

But why is this really a problem, I hear you say. Isn’t HIV a chronic disease nowadays that takes just one tablet once a day, so why bother, you add. Well, maybe you’re right (thanks for reading my previous post), … but maybe this will convince you:

There is not just one type of HIV, there are more with different resistance patterns.

If you go through life thinking “I already have HIV so let’s lose the condoms and have some fun”, I would say DON’T. You might attract a new different type of HIV, giving you a high viral load again. This type might be resistant to the drugs you were taking for your own type. Yes, HIV can become resistant to medications just like bacteria. And if that happens and we don’t find a way to cure the virus, we end up with a virus we’re not able to control any longer. And we’re Back to the Eighties, where the first HIV infected people suffered and died.

A different argument not “to shop” for HIV, is that having HIV makes you more susceptible for other diseases, especially other STD’s. Nowadays gonorrhea is becoming more and more difficult to treat and when (not if) the second HIV peak comes, there will definitely also be a gonorrhea outbreak that is not easily cured.

I’m confident that HIV has still unknown tricks to show us. It’s waiting, lurking in the dark…

I predict there will never be a HIV vaccine

Making vaccines is extremely difficult. In general researchers need three things from a disease in order to make a good vaccine.

  1. You can get a natural immunity for it. This means that some people recover from the disease by themselves or there are people known who just don’t get infected.
    HIV: Nobody has developed natural immunity against HIV.
  2. You have to be able to manipulate the pathogen in order to make sure it doesn’t really infect you. You want a vaccine to be safe, not to give you a deadly infection.
    HIV: No manipulation has fully succeeded to make it safe.
  3. You have to get sick from it.
    HIV: Nobody is sick because of HIV. Weird, but true. HIV doesn’t make you sick. It affects your immune system making it inoperable but the virus itself doesn’t cause a disease.

These things in combination with the fact that HIV mutates faster than the X men, outsmarting our immune system and all the different known subtypes, you can imagine the challenge. The attempts to make a vaccine have not been successful and unfortunately, I predict they never will be.

Let’s find a vaccine against stigma

One day I read the magazine “Hello Gorgeous”, a glossy magazine about living with HIV. And I got a lot of looks, you know what I mean, not the ones you hope to get. And that is unfair and unnecessary. If my predictions come true, which I don’t hope of course, HIV is here to stay. It’s a part of our past, present and yes, also our future. Let’s deal with it, accept and not be judgmental about it. My idealistic self would like to urge you to go to a public place and read something that clearly has HIV stated on it to get people used to it. But maybe the best vaccine against it, is just not to give in to stigma.
If you see me or anyone else read the magazine, don’t give that look. Just smile or give a friendly nod. Or, why not, let me be the idealistic hippy my husband always I am for once, let’s hug.

 

HIV, the power of fear

What are the chances of getting HIV? Take a guess. What if you use a needle of an HIV patient? What is the risk when having unprotected sex with an HIV infected person? The answer will follow, but I am 99,7% to 99,9% certain your percentages were too high.

What people used to fear

In the 80’s and 90’s people feared HIV. You get a megaload of viruses in your blood at once and your immune system gets severely beaten up. In the next 5-7 years of your life one by one your immune cells get killed by the virus, making it impossible to fight any infections. You get a pneumonia from a fungus that you normally don’t even notice. You die from the “simple” infections that seize any opportunity to make you sick (opportunistic infections). And you would die, weaker than an Autumn tree leaf.

Rules in how to get infected 

There are some “easy” ways to make sure you get HIV is you really want to (why would somebody try to get infected you ask now, just keep reading).
HIV is transmitted by blood and sex. The hospitals and blood transfusion banks test any donated blood for HIV (amongst other infections) so a blood transfusion won’t get you infected. When you are a big fan of injecting drugs don’t use clean sterile needles, same for tattoos. If you have sex with somebody you don’t know the HIV status of, never use a condom. If you do all this, you have a certain risk. Yay! Just kissing somebody won’t get you HIV and neither will hugging, touching or sitting on their toilet seat.

You might think I am crazy. Please understand, some people are really not afraid anymore. They no longer fear it. In some scenes it’s even a matter of “waiting until I get the infection” and they go have sex with HIV positive people to “just get it over with”.

Why people still get infected

Don’t they have self-control? Why is it so difficult to follow the “easy rules” not to get it? (read the previous part and add “not” in every sentence)
There are multiple possible answers to that.

First of all, people are not saints. Even the girls of All Saints asked for Booty Calls, and we all know what that stands for. You didn’t follow the rules all the time. For not following some easy rules, let’s call them mistakes, in life, well, be grateful you didn’t end up getting a horrible disease.

Secondly, using a condom is a bit of a nuisance. You’re in the middle of “something” and then you have to stop, find the condom, free the condom, lock the condom and then probably start the “something” all over again and finish the messing around until there is some unloading in the condom. Not really romantic, so yes, I understand that people in the heat of the moment skip that step.

But the actual answer why people still get infected is not about having self-control or if it is too difficult. It is about having a lack of fear. If smoking one cigarette today would lead to certain death tomorrow, people wouldn’t smoke. If having unprotected sex today would kill you within a week, well, I tink you’d do your utmost to find those condoms.

Low risk, not lethal

What are the chances of getting HIV? The actual risk to infection, and mind you these are rough numbers and very much influenced by the amount of virus in the blood, is actually not so high. If you use the needle from an HIV positive person (not on medication), your risk is approximately 0.3%. I know, you thought it was higher. If you have sex with an HIV positive person (with no medication), that chance is even lower. Depending if the woman or the man is infected it’s around 0.1%. Yes, it’s possible to get infected if you just have sex one time, but you are a very unlucky person. And of course the risks increase if you have sex with more people and especially with anal sex or other ways that give minor (or even major, still not judging) tears in anus or anywhere else getting blood involved.

What is really happening: unprotected sex, low chance of getting HIV, and if getting HIV, you don’t die tomorrow, you probably won’t even die within seven years, in fact: you might just die of old age. Almost overnight, HIV went from this terrible lethal disease to a chronic disease that’s easier treated than some types of diabetes. Some diabetes patients need three tablets three times a day. HIV patients take one tablet, once a day for the rest of their lives, with hardly any side effects.

Why use a condom? There is nothing to Fear.

Second wave of HIV infections?

This change in prognosis for the HIV infected patients was, and still is, great news. The number of newly infected patients with HIV is still declining. Also, great news. However, I predict a downfall, or upfall.

In the beginning of HIV, people were scared. They knew that they would die a horrible disease if they didn’t take care of themselves. They started to use more condoms. The rate of HIV infections went down, as well as for the other STD’s.

These days people are not fearing HIV. They’re less likely to use condoms, increasing their risk to all STD’s. We are already witnessing increases in STD’s like Chlamydia and Gonorrhea. These STD’s are easier to transmit then HIV. That might explain why we don’t see an increase in HIV infections, … yet.
I’m afraid we will be seeing a second spike in HIV infections in the near future. And then we’ll be living in a world with more complicated infections and an ongoing war against bacterial resistance.

It’s ok to be a little bit afraid sometimes. It might save your life.

Next time: the near future of HIV…

 

 

Image: http://www.dailytrust.com

Ground Sero: when the world saw AIDS for the first time

Did I ever tell you that I like infectious diseases? No matter how horrible they are sometimes. The beauty of an infection is that one day it’s the deadliest in the world, like a bacterial pneumonia, the next moment you have penicillin, and everything is different again. Horrible diseases get chronic almost overnight.
The scary thing is: you don’t know from the start what the disease is and if it will ever be treatable. The most notorious diseases in this case is the ultimate queen of infections: HIV, AIDS, SIDA, Kimi. The story is like a movie. Better said: the story is used in many movies. And there’s a reason. It has a spectacular start, a thriller like chase and a (sort of) happy ending. Let’s look at the start and how the world seroconverted.

1981
Reagan has just started his powerplay with the cold Russians, in Tanzania president Nyerere is working his fourth term and the Netherlands are recovering from the inauguration of Queen Beatrix. Three places in the world, miles apart that don’t have anything in common. Or so it seems. This year, all three of them and many more, will be confronted with a disease that nobody knows. Oh, and 13 year old Lisa Lopez has no idea yet that she will be conquering the world a couple of years later with TLC and their hit song “Waterfalls”. Why is that related? Just continue reading.

California, US of A
Out of the blue, hundreds of young men start dying. Young, gay men. It’s a disease nobody had seen before and gets referred to as Gay cancer. The first reports suggest that the disease is spread through inhalation of a substance (like the inhalation of poppers), and really, definitely not an infectious disease. It leads to an immunodeficiency in men with a “particular lifestyle”. Vegans have a particular lifestyle, as do priests and the Eskimo, but in this case they were referring to male patients that, in the year prior to the symptoms, had sex with many different men. Beware, this was before Grindr and the Gay pride. A new term is made to describe the illness: GRID – Gay Related Immuno Deficiency.

Moshi, Tanzania
On a completely different continent, Dr William Howlett also gets introduced to this new disease. However, the case definition is definitely different than the USA one. Here, they look out for flying testosterony hunks, the primary affected group seems to be travelling men and stewards, who can easily transfer the disease from one country to the next. And whatever you may think about business men and stewards, in the definition of Tanzania’s dictionary the word “gay” is absent.

Haarlem, the Netherlands
Closer to my home, my currently retired supervisor (then a flaming thirty-year old) Reinier ten Kate saw a great denial. Most specialists that get in contact with the disease, don’t recognize the disease and can’t evaluate the risks properly. They see regular infections, but then all at the same time. So, they are categorized as many diseases, instead of being this special one. Specialists that never had to deal with acute situations all of a sudden found themselves in the Emergency Room and doctors whose medical fields seemed miles apart suddenly had to sit together and discuss. Could it be? The Gay thingy from the USA? In the small country of the Netherlands, surely we wouldn’t get this disease, right?! But unfortunately, denial is not always the answer.

Moshi, Tanzania
In the meantime, Dr Howlett identified 200 female prostitutes as potentially infected. The idea that a disease could have preference for a sexual orientation is classified as ridiculous. Still today the biggest infected group in this country is women.

California, United States of America
Back to our American friends. It appears to be difficult to get political attention and money to conduct decent research. Since the disease is primarily seen in Homosexuals in this country, the Christians call it the Wrath of the Jedi Khan, wait, no sorry, a wrath of God (I always confuse the two).
However, other patient groups start to get infected. Hemophilia patients, that receive blood transfusions very often, get infected. This proves that the disease is blood transmittable and is not per se related to having sex with men. Regardless, the rule is started that gay men are excluded from being a blood donor. A personal frustration of mine seeing that I have female friends that are at more risk of becoming HIV infected than my best friend that spend years spooning his long-term partner.

1983, World
Apparent is that the term GRID didn’t quite cover the problem and a new abbreviation is introduced to the world: CD (Compact Disc). Oh, and; AIDS: Acquired Immuno Deficiency Syndrome, caused by the Human Immunodeficiency Virus (HIV).

1994, TLC
The newly formed girl group TLC try to help the world with their “Waterfalls” by singing about dangerous lives and the consequences of this, including HIV. In an attempt to cast of the stigma around the disease, they sing about a girl infecting a boy.

Read for yourself:
Little precious has a natural obsession for temptation
But he just can’t see
She give him loving that his body can’t handle
But all he can say is, “Baby, it’s good to me”
One day he goes and takes a glimpse in the mirror
But he doesn’t recognize his own face
His health is fading and he doesn’t know why
Three letters took him to his final resting place 

Other songs about HIV/AIDS:
Madonna – In this life
Elton John – The last song
Bruce Springsteen – Streets of Philidelphia
U2 – One
Acda en de Munnink – Niemand sterft aan liefde
Janet Jackson – Together again
And many more.

That’s the history, this is how we as a species got in contact with this new virus that changed many lives forever. But stay tuned, the story continues next blog!

IMAGE: APAP PHOTO/RICK MAIMAN

 

A trip down the Vagina

Something interesting happened last week. I wrote this blog about the vagina and send it to my husband/editor. He said it made him nauseous and decided to edit the Ebola story instead. What happened to our world that we prefer to read about the agonizing deaths of thousands of people instead of reading about a little vaginal discharge?
This week there wasn’t a second option though. Let’s hear what you think!

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Oh, the vagina. What a wonderful thing to have. But sometimes it’s not. Half of the population has one but somehow, we are afraid to discuss this very common organ. Better to ask someone how they are recovering from a brain seizure, to explain the pain of kidney stones or to share that you have fungal infection of the foot, then to ask about any kind of infection concerning the vagina. 49,6% of the world population knows about, but rarely talks about. Many of the other 50,4% in the world think they know about and only talk about it platitudes. Let’s share some truths about the vagina: sometimes things get smelly, itchy, red, hairy, floppy, tight, wider, wet or dry. You never know what will happen tomorrow.

There, I’ve said it. Now continue and break some taboo’s!

Act of Pheromones

All grown up women have pubic hair. All of them. Yes, some are enrolled in the tiring fight against hair, shaving, waxing or whatever. But it always comes back. Why do we have it? Pubic hair is said to have two functions. The first is to cause less friction during the “physical act of love” (Friends quote, sorry), the second assumption is that the hair makes sure all the lovely smelling pheromones are nicely distributed to the environment, especially future sexual partners.
A recent study by the way revealed that women who shave all their pubic hair have more risk of STD’s than with pubic hair, implying a protective function. I think this has more to do with the idea that a bald vagina is more likely to be found in single woman with multiple sexual partners. But this could be pure speculation.

Floppy awareness

All women have two sets of labia. From the day they were born. Two outer labia, and two, more floppy, inner ones. This labia issue is a big thing nowadays. The outer labia, everyone is cool with, but those inner ones… Some cultures encourage girls to pull these labia frequently to increase the floppiness as it is considered beautiful.
In Western countries we have a different labia fashion sense. Influenced by the porn movies we think that any asymmetry or floppiness down there is strange and should be resolved by surgically “correcting” this mistake. That is so stupid. As a famous philosopher once said: “different people, different pussies, especially the men”. Can we please agree that every woman looks different down there and also that there are NO mistakes. Stop cutting up healthy women please!

In the gland scheme of things

Located just in the top of the vagina where the two inner labia meet is a little – for some women bigger, but that’s ok, remember the famous philosopher –  nob. That nob is what is left of a possible penis when we were just a fetus and randomness determined whether we would become a boy or a girl, and it turned out to be the latter. That is also why men have nipples.
A woman’s clitoris is just as sensitive as the tip of the penis. But wait, there’s more, at least in most of the penises… A penis consists of two swelling glands. That fill up when aroused and cause the erection. Same for the vagina. Attached to the clitoris are two of these glands that go to either side. When properly aroused – whatever makes you tick ladies,  probably not by a man saying ‘doing you wanna?’ – these glands swell and so will the clitoris. Making it easier to find… hint, hint…

Opening up and let go

Further down we first encounter the urethra opening, that is where the pee comes out, and then the actual vagina. It’s the small hole where the penis goes in and a baby head (!) can come out. Amazing right?

In order to keep this opening open and smooth, your vagina makes a discharge. Every woman has vaginal discharge. It’s usually white/transparent, not a strong smell and not buckets full. This discharge is made by the lactobacilli, which is also found in yoghurt and yakult, enjoy your breakfast. The lactobacilli keep the pH of your vagina nice and sour and bacteria unfriendly. Without the discharge you would get bacterial and fungal infections every day. Washing this part with anything other than water will mess up your normal system and increase your risk of infection. Even those “special” soaps are a bad idea. Not needed! You’re not supposed to smell like box full flowers and strawberries down there!
If the discharge gets a color, has a foul smell or different consistency, go see a doctor or a pharmacist. Chances are you have an infection. No worries, it is easily treated. If not treated you get pain, itching, pain during sex, fishy smells and you are more susceptible to STD’s.

Don’t feel ashamed about this. Every doctor has seen young girls and grown up women, itching, nervous and embarrassed, that washed themselves with stuff like lactacid every day and used a vaginal shower after sex. Every doctor heard many of these complaints and are happy to talk about yours and help you.

So there you have it. What have we learned? All women are similar yet somewhat different. Looking like a Pornstar shouldn’t be a goal in life. Water is the best cleaning method for your most precious organ. Oh, and don’t be afraid to discuss these things with your doctor.