Game Over!

Hey everyone! Tomorrow I’ll be shutting this baby down and the Body Horrors blog will solely be accessible at the Discover Magazine website. When you access any of my articles, you’ll be redirected to that article’s home on Discover.

Sadly, this means that you will no longer be updated by email whenever I publish a new article. I hope you’ll take a moment to bookmark  Body Horrors at Discover or try using Feed My Inbox or Blog Alert to receive emails whenever I get around to writing my latest article. Both Feed My Inbox and Blog Alert allow you to receive free emails notifications of blog posts and, while it’s not the most convenient system, I’ll hope you give it a shot and see if it works for you. All you need is your email address (you have one of those, right?) and this link: http://feeds.feedburner.com/BodyHorrors.

You can do it, I believe in you!

Body Horrors: Big Things Have Small Beginnings

Hello everyone! I’m stepping out from behind the curtain to share some very big news: Body Horrors has a brand new home at Discover Magazine!

I know. I know! It’s terribly exciting! I’m elated and nervous and so very humbled to have my blog hosted by this fine institution, not to mention having this incredible opportunity to continue developing as a science writer and infectious disease scholar. Today in my “hello world!” post at the blog’s new home I wrote,

I began Body Horrors as an experiment in writing about the public health of infectious diseases and parasites – an experiment that is still running today, a carefully cultured organism that’s constantly evolving and growing.

Without the curiosity and interest of my readers, yes you!, this blog wouldn’t be the vibrant, thriving organism (or is it a parasite?) that it is and so I want to thank you for visiting, reading and commenting on my articles. Thank you thank you thank you! I know the reaction of some people to the content (viruses! microbes! parasites! oh my!) of this blog is this so I appreciate you hanging in there. Your visits and comments are greatly appreciated, truly. I put a tremendous amount of research into my articles as well as a fair amount of pre-publishing agony and anxiety over tone and sentences and images – you wouldn’t believe how much time I spend coming up with pun-riddled titles – and it’s gratifying to know that not only do people enjoy my work but that they’re learning from it. I am continually in awe that people get a kick out of the things I write. So thank you.

I’ll be doing very much of the same sort of gig at Discover that I’ve always done: writing about the history, sociology and anthropology of infectious diseases and parasites to ultimately figure out just how are we humans managing and molding the presence of infectious diseases in society and vice versa, which is otherwise known as the practice of “public health”:

This is the most complex and fascinating component of our relationship with the bacteria, viruses and parasites that we coexist with – how do we as a society educate ourselves on preventing and controlling disease and can we change our own behaviors so as to do so more effectively? Not only do these public heath needs serve as some of the most difficult challenges we face today (see: polio eradication) but they also have the potential to be the most enlightening and innovative achievements that humans can accomplish, ever since Antonie van Leeuwenhoek found squirming animalcules under a microscope and since John Snow controlled the 1854 cholera outbreak in London. It’s not rocket science but it is human science and that is also what this blog about – a celebration of the intersection between humans and microbiology.

I’ll also be starting up a recurring series of articles over there called “Microbial Misadventures,” detailing unfortunate mishaps where human meets microbe in novel and unusual circumstances that challenge our assumptions about how diseases are spread. Here’s just a hint of an upcoming  article: anthrax, hippies and drum circles. See? I told ya it’s gonna be good.

Remember: both microorganisms and humans need nutrients, love and a petri dish to grow so I do hope you’ll join me in my blogging (mis)adventure and venture over to Body Horrors at Discover! Sadly, in a week or two I’ll be shutting this ol’ girl down and making the final, permanent move to Discover. So go! Go to Discover! Godspeed!

Thoughts on the New Bird Flu H7N9 & It’s Animal Connection

Much of the United States is mesmerized by the belligerent squawks from North Korea’s Kim Jong-un and the volatile tension straddling the Korean peninsula, but I’m more concerned about what is happening in China right now and the troubling trickle of news on a new bird flu strain H7N9.

At least 16 people have been infected, patients who were widely distributed through the geographic enormity that is China, and already six have died. But what makes this small cluster of flu cases unusual is its timing – we usually see flu outbreaks emerging in the fall and winter months and we are just now breaking into the month of April – and that this type of flu strain is not known to infect humans.

H7N9 seems to be following a well established pattern of other emerging viruses: originating in east Asia, the infection appears to have a tentative association with wet markets and butchering, and is of zoonotic or animal origin. We’ve seen this situation previously with Nipah virus in Malaysia infected pigs and slaughterhouse employees and with SARS and its birth in the wet markets of Guangdong Province in China.

Laurie Garret masterfully crafts an unnerving story, of unknown unknowns regarding these human flu cases and the potential linkage between the thousands of pigs and fowl carcasses that clogged Chinese waterways in March.

Here’s how it would happen. Children playing along an urban river bank would spot hundreds of grotesque, bloated pig carcasses bobbing downstream. Hundreds of miles away, angry citizens would protest the rising stench from piles of dead ducks and swans, their rotting bodies collecting by the thousands along river banks. And three unrelated individuals would stagger into three different hospitals, gasping for air. Two would quickly die of severe pneumonia and the third would lay in critical condition in an intensive care unit for many days. Government officials would announce that a previously unknown virus had sickened three people, at least, and killed two of them. And while the world was left to wonder how the pigs, ducks, swans, and people might be connected, the World Health Organization would release deliberately terse statements, offering little insight.

By the end of March, at least 20,000 pig carcasses and tens of thousands of ducks and swans had washed upon riverbanks that stretch from the Lake Qinghai area all the way to the East China Sea — a distance roughly equivalent to the span between Miami and Boston. Nobody knows how many more thousands of birds and pigs have died, but gone uncounted as farmers buried or burned the carcasses to avoid reprimands from authorities.

We are very early into this developing scenario and this spate of cases could fizzle into just a blip in the news cycle and on the infectious disease radar. You should read Maryn McKenna’s reasoned and calm analysis here and to devour a slew of delicious infectious disease geek resources at the tail end of her article.

The point I want to make here is a reminder of how closely intertwined the lives of humans are with the lives of the animals we breed and eat. Not many of us raise pigs in the backyard or hear the cock’s crow in the morning and it’s easy to forget that for thousands of years we have lived in close proximity to our poultry and livestock.

But this is still the case in developing nations and particularly those with industries reliant on raising and butchering animals for the global market as well as people supporting a family with their hens and chicks. It is these people and places that are at most risk of emerging zoonotic infections like H7N9 and they require careful surveillance and monitoring of the health and well-being of both people and animals. Remember: catching a novel disease from an animal is the rule not the exception.

Resources

The most important link I can give you: “The New Bird Flu, And How To Read The News About It” from Maryn McKenna.

A timeline of events from Laurie Garret’s article “Is This a Pandemic?” in the short news cycle of H7N9. Her article can be accessed here.

Shanghai will be temporarily closing its live poultry markets on Saturday due to fears of a spreading H7N9 .

Suck It: The Ins and Outs of Mouth Pipetting

If you ever find yourself working in an infectious disease laboratory, whether it’s of the diagnostic or research variety, the overarching goal is not to put any microbes in your eye, an open wound or your mouth. Easy enough, right? Wear gloves, maybe goggles, work in fume hoods and don’t mouth pipette. When working with pathogenic bacteria and viruses, priority number one is Do Not Self-Inoculate.

This is obvious for anyone who has worked in a shiny biology or chemistry lab or seen an episode of CSI: Crime Scene Investigation (we’re all friends here, just admit it), but one of the most commonly used pieces of equipment in labs prior to the 1970s was the leading cause of laboratory-derived infections: the honorable pipette. How could that be possible, you ask? By using one’s oral cavity with the pipette to measure and transfer liquids.

Today our manual pipettes are rather sophisticated, plastic-y devices perfectly calibrated for moving precisely exact milliliters, microliters and picoliters of valuable solution from one vessel to another, whether it’s of a urine sample, some spare radioactive material you have lying about or toxic solvents. But before the development of cheap mechanical pipettes in the ’70s, using your mouth to pipette solutions was more than a common sight, it was a way of the lab.

Former Centers for Disease Control (CDC) parasitologist, Dr. Mae Melvin (Lt), examines a collection of test tubes while her laboratory assistant mouth pipettes a culture to be added to these test tubes. Source: David Senser/CDC.

Don’t worry, reader, I heard you tentatively whisper, “just what exactly is mouth pipetting, dare I ask?”

Like so: insert an open-ended glass capillary tube into your mouth. Place the opposite, tapered end of the tube into a solution of your choice. Microbial stews, blood, cell culture, it is totally your call. With a method that carefully mimics the sucking of a straw, draw a solution upwards through your man-made pipette to your desired volume using the tension created by the reduced air pressure – yes, suction! Maintain the tension with your mouth. Do not suck too hard and inadvertently slurp the solution into your mouth. Careful now. Gently move the pipette end from one vessel and release your precious cargo into yet another vessel.

That is mouth pipetting.

A wonderful demonstration of mouth pipetting by Dr. Armand Frappier, a microbiologist and expert on tuberculosis. Look closely: you can see him draw a dark liquid slowly towards his mouth. What could it be? Soda, a culture of TB, serum for cell cultures? You can watch the entire video clip that this GIF is based upon here. Source: Musée Armand Frapper.

The sparsity of history on pipetting techniques (itself a shocking shortcoming, I’m sure you’ll agree), forbids us from generalizing the prevalence of this phenomena. But we do know that it was the source of a ridiculous number of accidents, whether swallowing a corrosive or toxic substance or an infection with one’s research material  (1). A survey of 57 labs in 1915 found that 47 infections  were associated with workplace practices and more than 40% of those were attributed to the practice of mouth pipetting. A longitudinal study of 921 workplace laboratory infections from 1893 and 1950 found that 17% were due to “oral aspiration through pipettes or to splashes of culture fluids into the mouth (2).”

Infection through the use of one’s oral cavity was such an occupational hazard that it warranted an article, “The Hazards of Mouth Pipetting,” from two gentleman working for the U.S. Army Biological Laboratories. In 1966 they wrote,

although the use of pipettes in the early chemistry laboratories undoubtedly led to accidental aspiration of undesirable toxic and poisonous substances, the first recorded laboratory infection due to mouth pipetting occurred in 1893 … [with] the case of a physician who accidentally sucked a culture of typhoid bacilli into his mouth …

compared with the equipment and procedures required to avoid other types of microbiological laboratory hazards, the method of avoiding pipetting hazards is so elementary, so simple, and so well-recognized that it seems redundant to mention it [emphasis added by author]. However, continued accidents and infections in laboratories illustrate, even today, that there is a lack of acceptance of the simple precautionary measured needed (2).

By the 1970s, mouth pipetting had fallen out of favor as swanky, mechanically adjustable and cheap pipettes flooded the market (3). They were not only infinitely safer but also far more accurate. Instead of drawing a semi-approximate volume of solution with the imperfect measuring device that is your mouth, standardized and calibrated pipettes were available that could zip up a solution to one’s desired volume. More precision. Better experimental results. Less contamination. More ergonomic. Fewer infections. Nowadays, mouth pipetting is explicitly banned from laboratories.

A woman mouth pipetting to select specimens of ectoparasites. Source: National Library of Medicine

And, indeed, you might think that this old school technique is thankfully old news and good for a giggle but mouth pipetting is still practiced in some countries. A study looking at the lab practices and biosafety measures of Pakistani lab technicians found that mouth pipetting was reported by 28.3% technicians (4). This paper was published just last year, in August of 2012. Another study in 2008 found that Nigerian technicians working in clinical laboratories were not only improperly vaccinated against many of the preventable diseases that they were testing for (!) as well as eating and drinking in the lab but 1 in 10 also reported mouth pipetting (5).

Lest you think this is just happening in developing countries, be rest assured that American teenagers and young adults will always find a creative way to  jeopardize their health. In 1998, a 19-year-old nursing student in Pennsylvania was  hospitalized for several days following infection with a unique strain of Salmonella paratyphi she was working with in a lab; the case report strongly suggests that mouth pipetting was the culprit behind this particular microbial misadventure (6).

Another article from 1995 assessing lab accidents found that 13% of laboratory-acquired infections were a result of mouth pipetting. That’s 92 accidents attributed to someone in a lab deliberately putting a pipette or capillary tube into their mouth and sucking up some solution laden with microbes (7). Clearly, we still have a way to go in dissuading people to stop using pipettes as straws.

A technician mouth pipetting environmental water samples in Malta. Image: E Mandelmann. Source: History of Medicine

Mechanical manual pipettes have been a godsend to technology and the sciences, saving researchers time and resources in measuring and transferring liquids. Pipettes now serve as an icon of the scientific pursuit of knowledge – we’re all familiar with the close up of the gloved hand and pipette tip hovering over some glowing liquid. It’s banal, efficient and ubiquitous. It’s the dogged, unsung hero of the lab but there were several decades when our method of pipetting was also a microbial misadventure in the waiting.

Resources

“There are reports of laboratory infections by means of the pipette with quite a variety of microorganisms. In the intestinal group: typhoid, Shigella, salmonella, cholera; among others, anthrax, brucella, diphtheria, hemophilus iniluenzae, leptothrix, meningococcus, Streptococcus, syphilis, tularemia; among viruses, mumps, Coxsackie virus, viral hepatitis, Venezuelan equine encephalitis, chikungunya, and scrub typhus.” Download this neat article on the history and epidemiology of lab-acquired infections here.

Want to see more pictures of mouth pipetting? Of course you do! I’ve been collecting them on the Body Horrors tumblr here, here, here, here and here. Here’s a sign. And here’s a riff on a meme.

References

1) AG Wedum. (1997) History and epidemiology of laboratory-acquired infections. J Am Bio Safety Assc. 2(1): 12-29

2) Phillips GB &Bailey SP (1966) Hazards of mouth pipetting. Am J Med Technol. 32(2): 127-9

3) JA Martin (April 13, 2001) The Art of the Pipette BiomedNet Magazine. 100

4) S Nasim et al (2012) Biosafety perspective of clinical laboratory workers: a profile of Pakistan. J Infect Dev Ctries. 6(8): 611-9

5) FO Omokhodion (1998) Health and safety in clinical laboratory practice in Ibadan, Nigeria. Afr J Med Med Sci. 27(3-4): 201-4

6)B Boyer et al (1998) The microbiology “unknown” misadventure. Am J Infect Control. 26(3):355-8

7) DL Sewel (1995) Laboratory-Associated Infections and Biosafety. Clin Micro Rev. 8(3): 389-405

HILL, N. (1999). Laboratory-acquired Infections: History, Incidence, Causes and Preventions, 4th edition. Eds. C. H. Collins and D. A. Kennedy. Butterworth Heinemann, Oxford 1999. Pp. 324. ISBN 0 7506 4023 5. Epidemiology and Infection, 123 (1), 181-181 DOI: 10.1017/S0950268899002514

Meet Your Mites

Just two months ago, I had the distinct pleasure of acting not as a science scholar but as a research participant. Instead of having my face in a book, I willingly offered it to a woman who diligently scraped my forehead in search of Demodex mites. I know that it’s everyone’s humble dream to contribute their own exquisite arachnological flora to Science with an S and so, yes Reader, I can feel your oozing envy.

I spent the last weekend of January in Raleigh, North Carolina attending the incredible Science Online 2013 conference and one of the events at the opening reception included an opportunity to “Meet Your Mites” from the Your Wild Life team. As you can imagine, I quite literally squealed for joy. Demodex is one of my favorite parasites and I was eager to contribute my own special brand of commensal to a subject that is little studied. While waiting impatiently in line, my fellow participants and I gazed at a video of a squirming captive mite recently scraped with spatula from a very lucky individual and excitedly wondered if we too would see our own Demodex under the microscope.

You can see a Youtube video below of a mite that yielded to the executioner’s spatula from the Science Online event below!

Your Wild Life is a “team of scientists, science communicators, students, and citizens who are passionate about exploring the ecological frontiers that exist right under our noses.” Thus far they’ve ventured into some amazing, uncharted territory – looking at the bacterial biodiversity of belly buttons and armpits, the spectrum of arthropod species in human households, among other fact-finding missions that seek to illuminate the underlying richness that lives within and around us.

Meet Your Mites is their very latest biological mission on this little known buggie. In fact, the most that we know of Demodex mites is that … well, that they can be found on people’s faces. We don’t know much of anything about their evolutionary history, their geographical distribution and prevalence, or their preference for cosmetics. Just what are these little guys (and girls) up to? Why are they nesting in our eyebrows, crawling over our eyelids and eating our sebaceous goo? What kind of awful cosmological practical joke is this?

Megan Thoemmes is a research assistant affiliated with the this endeavour and she kindly enlightened me on this very fun project.

What is the goal of the Meet Your Mites project? 

The purpose of this study is to map the evolutionary history of Demodex mites with the expansion of human populations through time and space. Despite their intimate, parasitic relationship with human hosts, Demodex mites have not been extensively studied. We will trace the evolutionary history and  diversification of Demodex mites, and in doing so, gain new insights about the radiation of human populations.

Why now? 

This is the age of personal science, where we are learning about the similarities and differences between people and their own individual biomes. Understanding our association with these organisms is an important piece of the picture when figuring out the relationships we have with the species that live on, in and around our bodies. This project also serves as an opportunity to reach out and engage the public in both interesting and significant research. What have you guys found so far?

The project is still in its infancy, so we don’t have a large sample size or any solid results yet. We have just had our first round of sampling events, and we are trying to figure out our methods for getting the best possible DNA sequences from the mites, but we do seem to have a good method for sample collection. We’re also working out a new way of getting mite DNA from an individual’s face that would allow the participant to easily sample themselves, while allowing us to get a large number of samples from around the world.

Even though we are still in the early stages of the project, I suppose that one of the most interesting observations we have had is that there is a lot of morphological variation across the individual mites, and we think it is possible we could be seeing more than the two previously described species of human specific mites. 

Under the microcope, a captured Demodex brevis, one of two species of Demodex mites found on humans. Image: Your Wild Life.

The Meet Your Mites project hopes to shed light on the ancient history of one of our most ancient and overlooked commensals. I’m eager to hear what they discover and to see if one of my own little mite sidekicks has yielded any of my precious bodily secrets. And if you’re in the Raleigh-Durham area, you can contribute to this form of citizen-science too, as the project is hosting various “face sampling events” over the year. You can sign up here to be notified of upcoming events and check out their website on the project here. Face sampling, ya’ll, face sampling! How can you resist?

Resources

Visit the Your Wild Life website to learn more about their fun projects, the resarch team and read their blog.

Dr. Rob Dunn heads the Your Wild Life project with Dr. Holly Menninger and has written a book on the subject of our commensal comrades. You can purchase his book here and visit his website here.

On Equilibrium & Balance in Your Microbial Universe

Two recent studies that shed light on the inner workings of our bacterial ecosystems, otherwise known as our microbiome, have me musing on the nature of disease and pathology, of harmony and balance.

The first study caused a stir in the media with its admittedly unorthodox solution to a brutal bacterial infection; I’m speaking of the infamous “fecal transplant” study conducted in the Netherlands that was used to treat chronic, untreatable C. difficile infections. Commonly referred to as “C. diff,” this infection is notoriously difficult to cure, not to mention a dreadful and painful nuisance in those afflicted. Many researchers know that the infection can be attributed to a bacterial imbalance in the gut, a “persistent disturbance with a reduced diversity of intestinal microbiota (1).” When a population of C. diff bacteria edge out existing gut flora beneficial to your intestinal ssytem, they establish a dominant presence that’s marked by severe abdominal pain, appetite loss and watery diarrhea that can lead an unfortunate individual to use the restroom up to 15 times each day. The ominously named fecal transplant in question is a radical method of restoring balance to the gut, infusing processed feces laden with good bacteria from a donor into the gut of a person afflicted with C. diff. The goal, and a successful one at that, is to replace C. diff with a more amenable population of fecal bacteria.

The second study that’s been on my mind concerns those wicked bacteria on your face that cause the dreaded “z word” – zits! Though you may not know it, your face is host to several strains of the skin-dwelling bacteria Propionibacterium acnes. Researchers at the University of California, Los Angeles and Washington University have found that people who suffer from acne have a greater preponderance of two particular strains of P. acnes, R4 and R5, than clear-skinned folk, who have a greater proportion of strain R6. Their study suggests that blemishes and pimples may be a result of an asymmetry or population imbalance between the good and malevolent strains of P. acnes. The force is within us and it is a battle for clear smooth skin.

A few of the microorganisms that comprise the body’s system of microbiomes. There is an interactive version at Scientific American that you can play with here. Image: Bryan Christie for Scientific American. Click for source.

Yes, I know the subject is gross – poop and pimples, great! – but these recent studies reinforce a compelling idea about our microbiomes that has been brewing for a few years: that some infectious diseases may be due in part to a disharmonious balance between pathogenic bad-guy bacteria and our resident commensal good-guy bacteria. The day-to-day working of our bodies – our gurgling gut, the relentless give-and-take of our lungs and even the zinging neurotransmitters in our brains – relies on equilibrium and balance in our ecosystems.

This may sound a little wishy-washy, maybe even a little New Age-y, but we’ve seen this phenomenon before on a macro-scale. We’ve seen it with the invasion of cane toads and rabbits in Australia and the ensuing devastation of the country’s ecology. Most of us see it everyday around 7 am and 5 pm on our highways. Heart attacks and arterial congestion, runaway climate change, and the United States subprime mortgage crisis and housing bubble.

At a time when we are plowing through our available stockpile of antibiotics to treat bacterial infections, giving some consideration to the exciting ideas unearthed by these studies might change the very way that we treat and think of microbial diseases. What other human diseases could be attributed to asymmetrical microbial warfare, to a disruption in the harmony of our microbial communities? What ailments could we treat by adding healthy bacteria to a bad situation? Wounds seething away with MRSA? Urinary tract infections in women? What of obesity and anxiety? The possibilities may not endless, but they may very well be within us.

Resources

“The infusion of donor feces is a potential therapeutic strategy against recurrent C. difficile infection (01).” Find out more about the “fecal transplant” procedure used to treat recurrent C. diff infections here.

For more on the battle between good and bad P. acnes strains, check out this write-up of the acne study here at Wired.

“Microbes defy a simple notion of individuality. They are essential to our biology, and they travel with us from birth to death. Yet they also flow between us, and can be found in water, food and soil.” A lovely article by Carl Zimmer, “Our Microbiomes, Ourselves” at the NYT.

Discover the organisms that comprise the body’s microbiome in this neat interaction here.

References

(1) E van Nood et al. (2013 ) Duodenal Infusion of Donor Feces for Recurrent Clostridium difficile. N Engl J Med 2013. 368: 407-415

(2) S Fitz-Gibbon et al. (2013) Propionibacterium acnes Strain Populations in the Human Skin Microbiome Associated with Acne. J Invest Dermatol. Epub ahead of print.

van Nood, E., Vrieze, A., Nieuwdorp, M., Fuentes, S., Zoetendal, E., de Vos, W., Visser, C., Kuijper, E., Bartelsman, J., Tijssen, J., Speelman, P., Dijkgraaf, M., & Keller, J. (2013). Duodenal Infusion of Donor Feces for Recurrent Clostridium difficile. New England Journal of Medicine, 368 (5), 407-415 DOI: 10.1056/NEJMoa1205037

A Nepalese Odysseus: XDR-TB is in South Texas

The Wall Street Journal has a superb write-up of a Nepalese man infected with extremely drug resistant tuberculosis (XDR-TB) who is currently detained at the US border in South Texas. XDR-TB is resistant to four of the major types of antibiotics that are used to treat and control TB infections and this man is the first person with this particularly dangerous strain of TB  to cross the border and be quarantined in this country (1).

Traveling in all of the modern ways known to man – by foot, car, boat and plane – the man ventured from his home in Nepal, traipsing through South Asia, flying to Brazil and hoofing it through Central America until reaching the southernmost tip of Texas.

From the WSJ,

His three-month odyssey through 13 countries – from his homeland of Nepal through South Asia, Brazil, Mexico, and finally into Texas – shows the way in which dangerous new strains of the disease can migrate across the world unchecked.

The Nepalese patient was taken into custody by the U.S. Border Patrol in late November as he tried to cross the border illegally near McAllen, Texas, according to Department of Homeland Security officials. The government declined to name him. He was transferred five days later to an Immigration and Customs Enforcement detention facility in Los Fresnos, Texas, and put into “medical isolation” with suspected tuberculosis.

 His XDR strain has been seen only once before in the U.S., in another patient of Nepalese origin, according to the government description.

A map of the U.S. Quarantine Stations. Staffed with quarantine medical and public health officers from CDC, they’re located at 20 ports of entry and land-border crossings where international travelers arrive. Image: CDC. Click for source.

Our Nepalese man has innocently launched a global public health dilemma: of the potentially thousands of people that this man came across in his odyssey, who else has he infected? It will be a herculean and futile task for public health officers as many of the people that he may have passed on this pathogen are in a similar socioeconomic, nomadic situation – fellow tenacious migrants that quickly move from one place to another in their journey for economic sanctuary and personal salvation.

This case is a powerful reminder that globalization and innovations in travel have radically changed the rules of the game for dangerous and communicable infectious diseases. Of the 950,000 international travelers that arrive in the United States every single day, good public health institutions like the US quarantine stations scattered throughout the country are vital to monitoring hitch-hiking drug-resistant pathogens (2).

Please click here to read the WSJ’s article “Dangerous TB Patient Detained on U.S. Border.”

Note: To be specific, XDR-TB is resistant to the two first-line drugs, isoniazid and rifampin, used to treat TB initially, plus any fluoroquinolone and at least one of three injectable second-line drugs (i.e., amikacin, kanamycin, or capreomycin).

Resources

A fact sheet from the CDC on XDR-TB.

Reference

(1) B McKay (March 1, 2013) Dangerous TB Patient Detained on U.S. Border. Wall Street Journal. Accessed on March 7, 2013 here.

(2) CDC (August 3, 2012) Public Health Interventions Involving Travelers with Tuberculosis — U.S. Ports of Entry, 2007–2012. MMWR. 61(30); 570-573.

Centers for Disease Control and Prevention (CDC) (2012). Public health interventions involving travelers with tuberculosis–U.S. ports of entry, 2007-2012. MMWR. Morbidity and mortality weekly report, 61 (30), 570-3 PMID: 22854625

Adventures in Dentures: The Street Dentists, Barbers & Tattoo Artists of India

My father-in-law David is a dentist and he recently emailed me an astonishing, must-watch video, “The Dentist of Jaipur.” A short documentary by Falk Peplinski that made the rounds of film festivals in 2006 and 2007, the four-minute film shows two men in this famed city in Rajasthan, India practicing dentistry on the streets.

The short, jaunty film begins with the opening of a rusty toolbox containing a stained and well-used toothbrush, tweezers and assorted metal implements. Ungloved hands unload and carefully lay out tools trade on a red blanket – medicinal bottles, dentures, mouth mirrors, pliers, a spoon. One man deftly pulls the cap off of a syringe, and rubs his fingers down the needle. Those cursed, fat flies that are omnipresent in India flit through the video resting on dentures and dental molds.

A street dentist in Bangalore with sets of individual teeth and dentures in 2006. Image: Matthew Logelin, Creative Commons. You can see more of Mr. Logelin’s work at his Flickr account here.

Pushkar and Pyara Singh, otherwise known as Doc-Junior and Doc-Senior, practice their trade on a sidewalk near a pretty fuchsia bougainvillea bush outside an unidentified train station, close to a stash of rickshaws awaiting customers disgorged from the busy station. Pyara Singh earnestly tells the camera, “The only difference between the rich doctors and us is that they have fancy chairs, fan, servants, x-ray and other gadgets. They take a lot of money. Normal people can’t afford that.” 

In the film, the duo mix methyl methcrylate paste, repair and install dentures, file teeth, inject who-knows-what substances and “practice dentistry” to their best ability without gloves, face masks, autoclaves to sterilize equipment and tools, or any proper sterile technique or infection control practices out on the open street. In one viscerally tough scene, the men inject a watery rose-colored liquid into a middle-aged woman’s mouth then use pliers to wrench a tooth that’s promptly discarded for the flies on the sidewalk. The scene made me squeal in terror so, for the faint of heart, know that the scene starts at 2:52 and lasts until 3:12.

For those that aren’t familiar with the kaleidoscopic charms of India, one of the most fascinating aspects of the country is its massive street economy. You can find anything you want on the sidewalks of this country, whether it’s fried delicacies, tattoos, freshly pressed fruit juices, sex or bus tickets, you just need to know where to look. I lived in India for nine sublime months in 2007 and 2008, mainly in Mumbai and Kolkata with extensive traveling in between. I saw an enormous amount of this massive country – Rajasthan, Maharashtra, Goa, Karnataka, Kerala, Tamil Nadu, West Bengal, Uttar Pradesh – traveling alone on trains and buses and rickshaws and I fell deeply in love. I definitely partook in the street economy – fried food, hot chai, juice. If you can name it, I probably ate it on a street in India. Though I never saw any instances of street dentistry, barbers shaving patient men on sidewalks were a commonplace sight throughout the many cities and towns I traveled through. And many of the friends I made on my travels received haircuts and shaves from these street barbers.

In one of my more vivid memories, I saw a young man in Kolkata that was setting up a blanket and carefully laying out tools in preparation for tattooing any willing pedestrians. I remember being absolutely gobsmacked as this man noticed me stalling pedestrian traffic on the sidewalk, my jaw gaping and eyes wonderstruck, and he eagerly beckoned me to get a quick tattoo under the underpass of a bustling intersection where many buses dropped off passengers. For months I had seen hundreds of Indians sporting black and fuzzy tattoos on their inner forearms and hands, typically of the om or aum symbol that is ubiquitous in the country. This sacred syllable was spray-painted on walls, incorporated into restaurant names, depicted as glittery stickers sported on buses and trucks and sported proudly on many Hindus as a poorly drawn tattoo. You may have noticed in the “Dentist of Jaipur” that the Singh duo both sported fuzzy tattoos on their hands.

A roadside barber shaving a customer in Varanasi. Image: R Barraez D´Lucca, Creative Commons. Click to see more of D’Lucca’s work.

These types of intimate professions – dentists, barbers and tattoo artists – that practice on the streets and sidewalks of India can play a vital role in the transmission of infections in their clientele. Unsafe, communal practices with razor blades, syringes and any tools that break the skin barrier are tailor-made for the spread of bloodborne infections. These are high-risk procedures conducted in a country with staggeringly high rates of hepatitis B and C, the two most serious bloodborne infections in the hepatitis family (1). Though the Singh dentist duo are obviously fulfilling a need in the community, they’re doing it with quack science and medicine. These guys can’t possibly deliver good healthcare beyond performing primitive mechanical work. What they’re really doing is jeopardizing their clients’ health by performing medical procedures with no regard to the spread of possible infections from the environment, themselves and from their own customer’s bodies.

A few public health studies conducted in India have found that street barbers in particular are quite adept at spreading bloodborne infections. A 2010 study found that patronage of local barbers in Bangalore was a major risk factor for hepatitis B virus among blood donors; a customer that frequents barbers in this fast-moving technology hub is more than four-times more likely to carry the hepatitis B virus (2). Another study found that visits to roadside barbers was a major risk factor for hepatitis C (3). Getting tattooed in the country is also another predisposing and risky behavior (4).

“Dentist of Jaipur” points out that the dental work by the Singh duo can cost as little as  80 rupees, about $1.50 today. For most people in India that live on less than $2 a day, this is already an expensive transaction so imagine the costs of receiving care from trained professionals with, as the elder Singh puts it, “fancy chairs, fan, servants, x-ray and other gadgets (5).” Though Doc Junior compares the work they do to fixing a bike, these guys aren’t replacing a bike’s inner tube or aligning its wheels – they’re tampering with a temperamental ecosystem of bone and tooth and blood and bacteria. Whatever analogy you try to extend this to, our mouths are not anything like bikes.

The street dentists are clearly fulfilling a much-needed service but that cheap and fast procedure, whether it’s a new tooth, tattoo or clean-shaven face, comes a much greater price – gambling with one’s long-term health. So, please, reconsider that appointment you made with your local street dentist.

Resources

Infections such as hepatitis B and C may be spread at the Hajj, the annual Muslim pilgrimage to Mecca, due to the unygenic practices of street barbers that shave the faithful following the end of their pilgrimage. You can read my article about the phenomenon at Buzz Kill: Blood-Borne Disease Transmission at the Hajj.

There are SO MANY photos of street dentists on Flickr. Go here to take an Internet nosedive into this niche of street culture.

Wikipedia has a nice little article on the phenomenon of street dentists here.

References

(1) Abraham P (2012) Viral hepatitis in India. Clin Lab Med. 32(2): 159-74
(2) Jagannathan L et al (2010) Risk factors for chronic hepatitis B virus infection among blood donors in Bangalore, India. Transfus Med. 20(6): 414-20
(3) Thakral B et al. (2006) Prevalence & significance of hepatitis C virus (HCV) seropositivity in blood donors. Indian J Med Res. 124(4): 431-8
(4) Kumar A et al. (2007) Prevalence & risk factors for hepatitis C virus among pregnant women. Indian J Med Res. 126: 211-215
(5) “India – New Global Poverty Estimates“. World Bank. Accessed on February 19, 2013.

Abraham, P. (2012). Viral Hepatitis in India Clinics in Laboratory Medicine, 32 (2), 159-174 DOI: 10.1016/j.cll.2012.03.003

Mardi Gras at the Leprosarium

Fat Tuesday is only a few days away and the residents of New Orleans are convulsing with anticipatory excitement and glee at the weekend parades, balls and crawfish boils leading to the grand finale. Mardi Gras is one of the finest celebrations in the world and what makes it particularly unique is the egalitarian nature that lies at its very heart – everyone is welcome to come witness and participate in Carnival. And for those very few who are not, Mardi Gras comes to them.

Mardi Gras celebrated at the Louisiana Leper Home in Carville, Louisiana in 1957. There is little information about this image though it appears to be a procession of drumming jesters through the facility – the recreation center, most likely – during their carnival ball. Residents and staff in formalwear can be seen in the background. Click for source.

In 1894, on an abandoned sugar plantation located just outside of Baton Rouge in the small community of Carville, Louisiana, the doors to a new facility dedicated to the quarantine of leprosy were opened. Ostracized by their family and communities, men and women were shipped in barges from New Orleans along the Mississippi River to the Louisiana Leper Home where they were housed in former slave quarters (1). Some were handcuffed on the barges, forcibly exiled from their homes and families and their very lives to be imprisoned and shunned by society (2). The leprosarium would operate for over a century and serve as the last hospital in the industrialized world completely dedicated to the “treatment” of leprosy. Catholic nuns associated with the Daughters of Charity of St. Vincent de Paul would serve as their caretakers.

Just as residents of Louisiana don masks and costumes to watch and revel in the sights of the parades, so too would the quarantined residents of the leprosarium. Concealing their identity and disfigurements, the leprosarium’s residents could have their own day to celebrate Mardi Gras, liberated socially and psychologically from their  disfiguring disease.

Miniature floats rode in their Krewe of Carville parade, constructed from bicycles, wheelchairs and carts scavenged throughout the facility. The King and Queen of Mardi Gras were elected yearly and announced at the carnival ball. In 1995, an observer of the Carville festivities wrote that the doubloons – collectible aluminium coins specific to each Krewe –  were imprinted with the outline of an armadillo, the animal now known as the natural reservoir of Mycobacterium leprae, the bacteria that causes leprosy (1).

The Queen and King of Mardi Gras in 1998 at the Louisiana Leper Home. At that time, the facility had been renamed the Gillis W. Long Hansen’s Disease Center. Photo: Jeffrey Braverman. Source: M. Gaudet. (2004) Carville: Remembering Leprosy In America. University Press of Mississippi.

In her wonderful essay on Mardi Gras at the leprosarium, Marcia Gaudet writes,

Mardi Gras for the Krewe of Carville follows the general structure of urban Mardi Gras celebration in Louisiana, with costumes and masks, a parade with music, food and drink, favors or tokens being thrown or begged for, general revelry, role reversal, and symbolic inversion. It is unique, however, in that the participants are residents or staff members of the Gillis W. Long Hansen’s Disease Center.

To act carnivalesque is to be allowed to be ‘abnormal’ for a while. paradoxically, to celebrate Mardi Gras, like any other masquerade holidays, is normative – it is not only allowable but even expected that one will participate in the seasonal customs. Thus, for people who are already stigmatized as ‘abnormal’ in society, the masks and the occasion allow an opportunity to engage in normative behavior, to act “‘normal.’ (1)

In 1999, the facility closed its doors to receiving resident patients, though a few long-term patients remain on the site out of comfort and security after the many decades of quarantine on the site. The facility now serves as a museum and a research center for leprosy, its masques, balls and floats no more than echoes in the past.

Resources

A heartbreaking article from the New York Times, “Both Home and Prison, Leprosy Site May Shut” on the closure of the facility.

The website for the National Hnsen’s Disease Museum currently operated by the US Department of Health and Human Services. I went to the museum a few years ago and loved it!

Note: A big thank you to Rosemarie Robertson at the Louisiana Office of Public Health for the Mardi Gras picture of parading drummers!

References

Louisiana Office of Public Health (July-August 2003) Carville: The Gillis W. Long Hansen’s Disease Center. Louisiana Morbidity Report. 14(4): 3

(1) M Gaudet. (1998) The world downside up: Mardi Gras at Carville. J American Folklore. 111(439): 23-38

(2) S Jauhar (June 23, 1998) Both Home and Prison, Leprosy Site May Shut. The New York Times [Online]. Accessed on February 8, 2013 here.

Gaudet, M. (1998). The World Downside Up: Mardi Gras at Carville The Journal of American Folklore, 111 (439) DOI: 10.2307/541318

Super Bowl XLVII: Full Contact Infectious Disease

This year, Super Bowl XLVII is held in my hometown of New Orleans sandwiched between two Mardi Gras weekends! Residents of my darling city are calling the resulting three-week party extravaganza “Super Gras” which will certainly have public health implications in the many weeks to come. The city’s residents tend to collectively fall ill with respiratory bugs and sinus infections – otherwise known as the “Mardi Gras bug” – following a traditional two-week celebration so it will be interesting to see how Super Gras will treat us this year. Let’s hope that the “chunder from Down Under” norovirus will not join us in our festivities!

Last year, I published an article looking at contact sports and skin infections, in particular herpes gladiatorum and MRSA infections among wrestlers, football and rugby players:

Skin infections are the most common injury associated with all sports. All that body bashing and face-to-face smearing in contact sports does wonders for spreading skin or cutaneous infections. A number of these ailments are common to us non-athletic mortals – athlete’s foot, jock rash and ringworm (or tinea corporis). 

Most people rightfully assume that HSV-1 infection is a rather personal, intimate matter: we hear about transmission between a mother and her child, between romancing couples and so on. This makes sense considering that it’s spread by respiratory droplets or direct contact with infected lesions; you’ve really got to get up close and personal in someone’s face if you want to get a sense of what HSV-1 infection feels like. But given social situations with a generous amount of skin-to-skin contact with many individuals – sports, for instance – the virus will happily engage in a bit of unplanned host-hopping. As such, it has a frustrating tendency to erupt into outbreaks in sports team and during competitions.

In the spirit of vainglorious sports rituals, go on and check out Herpes Gladiatorum: Full Contact Infectious Diseases to know just what exactly is going on in the New Orleans’ Superdome this year. Play on!

May the Vaccines Be With You!

The poster for the clever Star Wars Public Service Announcement featuring C-3PO and R2-D2 from the CDC and the Department of Health, Education, and Welfare encouraging parents to vaccinate their children against preventable infections. Click for source.

What is the best way to persuade parents to get their kids vaccinated against preventable diseases? Tug sentimentally at the heartstrings? Appeal to common sense and logic? Shame and blame?

Or how about going the pop culture route and using characters from one of the most popular movies in history as the CDC and the Department of Health, Education, & Welfare did in April 1978?

The poster on the right and the short commercial below feature the characters C-3PO and R2-D2 speaking directly to the “parents of Earth” on the necessity of vaccinating their children fully against polio, measles and whooping cough and the dangers of not doing so. As C-3PO admonishes a coughing R2-DC, “Droids don’t get diseases like whooping cough, or measles, or polio. But children do. All you need is a little rewiring but children need to be fully immunized but, alas, so many are not.”

I think it’s a particularly inspired moment in public health propaganda. If you’re going to convince wary parents to get their children vaccinated, why not use the Force?

– Rebecca Kreston

Resources

See more public health posters from the National Library of Medicine’s exhibition, “To Your Health: An Exhibition of Posters for Contemporary Public Health Issues.”

Washington state is the midst of a whooping cough epidemic – there were 4,815 cases of the disease last year – and certain types of vaccines may be to blame for a drop in efficiency and protection over time. Maryn McKenna goes into greater detail here.

The White House just quashed a petition for the country to “secure resources and funding, and begin construction of a Death Star by 2016.” Paul Shawcross, the Chief of the Science and Space Branch at the White House Office of Management and Budget, has a very inspiring and feel-good letter about why the Death Star will not be built but that the USA is on the right track for space exploration irregardless.

References

Wookieepdia: The Star Wars Wiki. (Unknown date of publishing) “Star Wars Immunization PSA.” Accessed January 15, 2013 here.

Boyle, Eric (September 23, 2003) “Infectious Disease: Immunization.” From the  Visual Culture & Public Health Posters Exhibit. National Institutes of Health [Online.] Accessed January 15, 2013 here.