Latest Zika News

Zika continues to be in the news. 

The country of Columbia has widespread Zika virus. But Columbia is claiming that they are not seeing the increase in microcephaly that is being found in Brazil. There is no known explanation for this discrepancy. The scientists in Columbia that are not absolutely convinced that Zika causes microcephaly. Columbian scientists think that this connection between Zika and microcephaly might be scientific misdirection based on bad statistics. What amounts to a correlation/causation fallacy. This kind of scientific fallacy has happened plenty of times in the past. As of yet I think that most people believe there is a link between Zika and microcephaly. 

Correlation/Causation fallacies are very easy to fall into. I remember when hairy ears were thought to be connected to heart disease. So people would trim their ears, as if that would help their heart. It was ridiculous. And in my field, it was thought that estrogen treatment for older women prevented heart disease. It required many years to correct this wrong idea. We now know that estrogen treatment is preferentially taken by fit women. This explained the fact that women on estrogen hormones had less heart disease. In a randomized trial, there was no protection from heart disease. This false conclusion took many years to correct. 

The estrogen link to breast cancer is still not understood at all. Even by very smart people. Estrogen is about as carcinogenic as a nose. It is a normal part of a woman's body. (Please note that noses do form cancer.) In the Woman's Health Initiative it was found that estrogen increased the breast cancer risk in women about 7 in 10,000 cases. But it similarly lowered the risk of colon cancer. So in the worst case scenario the cancer risk is a wash. Also note that changing 7 cases from colon cancer to breast cancer should save lives. In the WHI, after two years, the increased breast cancer risk was just about gone. The risk line was just about to cross over to lowered risk (consistent with many older studies) when the WHI was cancelled prematurely. I would invite anyone to go and read the WHI report and see that the risk for breast cancer was just about to cross over into protection. There is one graph that shows this. Cancelling the study early was a violation of the study protocol and wiser calmer heads should have kept the study going. 

The Aedes mosquito continues to spread. It is an invasive species anywhere in the Americas, so eliminating it should not damage the ecosystem in any way. Right now there are plenty of videos of insecticide trucks fogging entire cities, and workers with leaf blower sized backpack devices fogging inside homes. There appear to be an army of them working in South America. 

Even though removing Aedes mosquitoes will not hurt the environment, widespread insect fogging may have a detrimental effect on the environment or on human fetuses. It will certainly create resistant forms of other insects. 

There is no chance that insecticide is going to remove Aedes. There are just too many of these mosquitoes in too many places. Insecticide will reduce them, but it will not eliminate them. So humans are now seemingly committed to large scale long term continuous insecticide exposure everywhere there are Aedes mosquitoes. 

There is a much better strategy that has worked in the past. It is mosquito birth control. There is a British biotech firm, a small firm, that can create sterile Aedes male mosquitoes. These mosquitoes then go and mate with wild female Aedes. The offspring will not grow to adulthood. This British firm has also tagged their Aedes mosquitoes with a color that glows red in the presence of some kind of special light. Maybe a black light. This is a great way to follow the progress of their birth control measures. As a Gyne, I am familiar with birth control. Birth Control sometimes works. 

Here is a news story that is right now 3 hours old, at the Independent News in the UK: 

http://www.independent.co.uk/news/uk/home-news/zika-british-team-say-they-have-a-remedy-for-the-virus-a6859046.html

So if the sterile males go out into the wild and shoulder aside their more fertile cousins, then the Aedes mosquitoes will not successfully reproduce. 

So birth control can work. There are several theoretical problems here. According to the principle of natural selection, the more fertile members of a species should survive. So if there are some female Aedes out there that can smell out their nonfertile mates, and not mate with them, then this won't work for them. Also, fogging of insecticide will kill the Sterile males too, so those two methods will work against each other, not support each other. This exact birth control technique has been used in the past to remove pests from agriculture. It sounds a lot safer than insecticide to me. 

I tell my pregnant patients to avoid insecticide while pregnant. There are not enough studies to prove that these chemicals are safe for fetuses. It may be that fogging reduces Aedes, but that pregnant women exposed to insecticide have some other birth defects from the insecticides. Hopefully someone has figured out that risk. Eventually, the scientists will get to the bottom of this. 

Thanks for reading. 

Dr John Marcus 

blog at doctorjohnmarcus.blogspot.com 

89 North Maple Ave 

Ridgewood NJ 07450 

Comments are welcome. 

Surgical Skin Closure, Staples vs Sub-cu

Yesterday I posted about Zika virus and how it is dangerous to neural tissue, especially for a fetus. This Zika problem will be with us for a couple of years until we can get a handle on it. I've seen pictures of the "war room" at the CDC where the epidemiologists have their daily meetings. I think the CDC is in Atlanta but it might be located at least partially near Washington DC.

Today a patient came in for her PP visit and we discussed her surgical closing technique. I had a doctor covering my practice who is a very skillful and caring physician. The patient needed a C-Section and I wasn't on.

My covering doc closed her skin incision with cosmetic subcuticular dis-solvable stitches.  So my patient has had the skin closed both ways now. First with staples, second with sub-cu.  And she now has a strong preference.

I know that the staples are a bit more work, and patients are worried about the removal. The removal is usually almost painless as the staples slide ride out once they are unbent.

Why are the staples beneficial?

-They are completely removable.
-They are very smooth and shiny, so no germs can get a hold of them.
-They never break down and fail their job of holding the skin
-When they are gone, they are utterly gone, leaving nothing behind to dissolve.
-When they are gone there is skin touching skin and nothing else in between. This is far more comfortable, softer, and smoother.

Why don't people like staples?

They feel and look unsightly while they are in. And they have to be removed.

In my opinion staples just do a better job and are worth the extra work.

The science does not show a preference between between staples and subcu dissolvable sutures. There have been a number of randomized trials. Obviously the trial cannot be blinded because the doc doing the stitching can see what they are doing. I suppose the incision can be evaluated later by someone who is blinded as to the closing technique.

In any case the studies showed no difference in the quality of the skin incision outcome. Of note, though, the studies that I read were done in academic medical centers where the infection and complication rates were far higher than a private community hospital. The academic centers infection rates were about 8 times higher than my hospitals. This surgical complication rate is a reflection of the socio-economic stress of poverty, the higher workload of the staff, and the riskier patient mix. I doubt if the less experienced staff has anything to do with it, but it remains possible. It is possible that the older facilities have less modern infection control technologies, such us laminar flow air handling in the operating room.

I think that if that same study were done in a place like my hospital, there is possibly a different outcome.

In my experience the staples provide a better outcome. Once they are removed they provide a far more comfortable and smoother incision.

Every once in awhile a patient will pick a doctor based on their known closure technique. I would like everyone to know that I will do whatever technique they want. I will give them my advice and then honor their wishes. Hopefully that will satisfy the needs of those who don't like the idea of staples. I am perfectly qualified to do cosmetic sub cu. I studied 6 weeks of cosmetic surgery at the Cook County Hospital in Chicago Illinois. That was a great time for me. I learned a lot. And I have been doing surgery every since.

So if you don't want staples, then I will do the sub cu. But if you want the best, then ask your surgeon if they can do metal removable staples. (The dissolvable staples are more like the sub cu).

Zika Virus in Pregnancy. 

Zika Virus has been in the news quite a bit. It seems very bad. How bad is it? 

7 days ago there were very few cases known and published in the US. 

3 days ago there were 33 cases. All were cases caught outside the US, and brought here. 

Yesterday was the first case caught in the US, given from one person to another by sexual exposure. Sexual transmission seems to be a previously unknown method of transmission of Zika Virus. 

As of yet, there are no known mosquito transmissions in the mainland US. Although Puerto Rico, Guam, etc may be at higher risk, because of their tropical climates. 

It seems inevitable that there will be mosquito borne cases in the US. 

In Brazil, there are 4000 cases of microcephaly in newborns. This is a huge increase, and is thought to be possibly from Zika infections. Zika seems to have an outsize affect on neural tissue. Zika gives adults a case of Guillen Barre Syndrome: 

https://en.wikipedia.org/wiki/Guillain%E2%80%93Barr%C3%A9_syndrome 

Guillen Barre is a disorder of neural tissue. 

And in fetuses, it somehow affects the neural tissue of unborn children. Somehow the neural tissue is destroyed. I have seen the CT scan pictures, and the brains are seemly destroyed, at least partially. It is a real disaster for these children, families, and societies. I don't think anyone knows for sure how the neural tissue is destroyed but it is certainly possible that the virus gets into the cells, grows there, and kills the cells. Once the brains are destroyed, the head stops growing, and the child has a small head. This is called microcephaly.

There are no antizika antiviral medicines.

There is no Zika vaccine. 

The official position of the Brazilian Government is that women should put off being pregnant until something more is known about Zika Virus.   This will take some time. Delaying an entire countries childbearing has not been done in recent memory. Again, this is something new. 

As of this moment, there are far more questions than answers about Zika. 

Here are a few helpful links: 

http://www.cdc.gov/zika/pregnancy/question-answers.html

http://wwwnc.cdc.gov/travel/page/zika-information

http://www.cdc.gov/ncbddd/birthdefects/microcephaly.html

http://www.cdc.gov/zika/pregnancy/index.html

http://mothertobaby.org/fact-sheets/deet-nn-ethyl-m-toluamide-pregnancy/pdf/

There are a few facts:

Eliminating mosquito bites will likely eliminate risk. How can we eliminate mosquito bites?
-Keep doors, windows, and screens closed.
-Don't travel to tropical climates right now, without precautions.
-Don't have unsafe sex with anyone who has been to a Zika prevalent area.
-When summer comes use air conditioning. Mosquites prefer the warmth. Cold keeps the mosquitoes out or inactive.
-If outside, use long tight pants, sleeves, socks, etc.
-Use special clothes that are permeated with permethrin. Personally, I have never seen such clothes for sale, but this is what the CDC says to do. I suppose if you can get Permethrin, you can spray your own clothes with it.
-Use highly effective insect repellent. DEET seems to be the best, in my opinion. Use it on all exposed skin, and even on your clothes. And use it even if pregnant. Use it copiously.
-Don't go outside when mosquitoes are active and present.
-Remove all standing water from the land. This is where mosquitoes breed.
-Treat standing water with insecticide or some other effective treatment.
-Use insect foggers outside, on a personal or municipal basis.

And finally, as a society, we need to control the Aedes Aegypti  mosquitoes.
https://en.wikipedia.org/wiki/Aedes_aegypti.
This is not the only nasty virus or disease transmitted by this mosquito.

There are some biological control mechanisms to control this mosquito. But we will have to get over our natural inclination to protect species. It is rare for humans to conduct deliberate annihilation of a species, but it has been done before. Smallpox has been destroyed. Some agricultural pests have been destroyed. Other infectious diseases are on their way out. If we can vaccinate everybody we can stop more infectious diseases. But vaccinating everyone requires some force, as there will always be selfish individuals who wish to take advantage of the herd immunity we provide them, while not simultaneously helping to provide that immunity. These individuals will need to be either convinced or coerced. Somehow. My personal politics preclude the use of force on people, but I would support some kind of strong coercion for this. Like keeping unvaccinated kids out of schools.

Worldwide, 140,000 people die of measles every year:
http://www.usatoday.com/story/news/2015/07/02/measles-death-washington-state/29624385/
These deaths are preventable with the vaccine. Everyone who declines the vaccine is part of the problem, not the solution. We all must accept the risk of the vaccine in order to benefit from the vaccine. And the risk of the vaccine is very very low. My children have been vaccinated as per the normal schedule. There was no doubt in my mind that it was a good idea. And now my kids cannot kill anyone by transmitting measles to someone. This, to me, is profoundly beneficial. And sensible.

So this Zika virus is going to infect a lot more people.

We can control it in the USA because we have measures to control mosquitoes that other nations don't have. Of note, living in a cold climate is not a protection. As anyone who has fished in Canada or Alaska knows, in the summer, there are tons of mosquitoes. And the mosquitoes come back every year. They survive the winter.

We have been down this road before. West Nile Virus was a similar kind of event. Ebola had a very high mortality, but was controlled with really heroic efforts by some people who deserve a Nobel Prize, like Doctors Without Borders. There are significant new epidemics every year or two.

And in fiction, I have read several doomsday novels about killer viruses. Mostly man made viruses.

Steven King wrote "The Stand". There is a very good movie as well.
More recently, Russel Blake wrote "Upon a Pale Horse".
Both are good books.

Here is a list of books about epidemics:

http://www.goodreads.com/list/show/19535.Best_Fiction_Books_About_Diseases_or_Viruses

Please use the links above. I hope to be able to give better answers in the future.

Thanks
Dr Marcus
Blog is at doctorjohnmarcus.blogspot.com

89 North Maple Ave
Ridgewood NJ USA 07450