Infectious Diseases: How They Spread, How To Stop Them
CELESTE HEADLEE, HOST:
This is TALK OF THE NATION. I'm Celeste Headlee in Washington; Neal Conan is away. The flu season hit this year early and hard in many areas of the country. CBS News reports that in Wisconsin, flu hospitalizations have reached 1,300, that's up from only 389 last season. They also reported that in Ohio, there have been 2,000 hospitalizations compared to only 86 during the last flu season.
On Saturday, New York Governor Andrew Cuomo declared a public health emergency for the state of New York, and last Wednesday, Boston Mayor Thomas Menino declared a similar emergency within the city of Boston. So what's going on now? Actually, give us a glimpse into how the United States handles all communicable disease outbreaks? What are still susceptible to, and what tools do we have to present, prevent their spread?
So public health officials, workers, volunteers, we want to hear from you. What decisions have you had to make about domestic disease outbreaks? Give us a call, the number is 800-989-8255. Our email address is email@example.com. And you can also join the conversation at our website. Go to npr.org; click on TALK OF THE NATION.
Later on in the program, we'll be talking about snakes, but first Dr. Anita Barry is the director of the Infectious Disease Bureau at the Boston Public Health Commission. She joins us from member station WBUR in Boston. Dr. Barry, thanks so much for joining us.
ANITA BARRY: You're welcome.
HEADLEE: So first of all, I wanted to kind of get the update. We've gotten a lot of news from many other places in the country. What's happening in Boston?
BARRY: Well, it's been a tough flu season for us this year, and unfortunately the information coming in suggests that it's not slowing down yet.
HEADLEE: Well, you are a member of the Boston Public Health Commission, and I imagine there's commissions like this in every major city. What exactly does somebody on that commission do?
BARRY: Well, we do what's called surveillance and control of contagious diseases. That means we track disease like influenza, influenza that are cases that are confirmed by lab testing have to be reported to us, and then we do follow-up on those cases.
So for example if we get a flu case in someone, and the follow-up indicates they're a resident of a nursing home, one of our public health nurses reaches out to that nursing home and says: Is your staff vaccinated? Are the residents vaccinated? Anybody else sick?
We also put together data for others, so that they'll know what's going on, what the trend looks like.
HEADLEE: But that requires that the case of whatever it is to be reported, I mean, that person has to go to a hospital or be seen by a doctor in order for that report to happen.
BARRY: That's correct, but we have very good working relationships with health care providers and institutions in Boston, and our reporting is actually quite good.
HEADLEE: What I mean is - sorry to interrupt you, but what I mean is if somebody's just sitting at home suffering with the flu, you won't hear about it.
BARRY: Oh that's absolutely correct. So we know that even though we've had over 900 cases reported now, we could multiply that by a factor several times, and that would likely be the true number of people who have had influenza.
HEADLEE: So where's the drawing line? And who decides to issue a public health emergency? And how many cases do you have to have, or how severe does it have to be?
BARRY: I think what contributed to Boston's declaring a public health emergency was first of all the number of cases, the trajectory of the cases, we were hearing about more and more cases every week. What we were seeing in emergency departments, we track influenza-like illness seven days a week from every emergency department in the city.
And we were hearing from our health care partners, the hospitals, the community health centers, that their staff was really, really stressed, and they were having trouble keeping up with the number of people coming in with influenza.
You know, there's very little give in the health care system, and it's not just a question of fewer beds, but it's also the staff, who live in the community, also can get influenza. So we were hearing that the health care partners were very stressed and decided that it was really time to try to get the most effective preventive measure that we know, vaccination, really done widely throughout the city.
HEADLEE: We're speaking with Dr. Anita Barry, who is a director of the Infectious Disease Bureau at the Boston Public Health Commission. And obviously they just declared a public health emergency in Boston specifically. Do you know how many cases of flu you have right now in Boston?
BARRY: We have about 935. We're still counting. And we know that the percentage of visits to emergency departments related to influenza-like illness is over five percent at this point. If you compare that with other times, when we're not seeing influenza, that would be more like 1.2 percent of visits. So we're seeing a huge influx of cases.
HEADLEE: Which is bigger than normal.
BARRY: Yes, it's bigger than normal, and it's earlier than normal. And part of that is probably related to the particular strain of influenza that's predominating in this city, and that's a type A, H3N2 strain. I would also add we've had six deaths in the last month or so, including one in a child.
HEADLEE: Well, you know, I think you're far out of my network for health insurance, but let me consult you as a doctor here real quickly. What is my first symptoms of - that I have the flu and not a cold?
BARRY: You feel like you've been hit by a truck. You get a fever, often with a sudden onset. You have a severe headache. Your muscle aches all over. You may have a dry cough. Your throat may be sore. You're extraordinarily fatigued. In fact in one study, the best predictor of someone having influenza, as opposed to something else, was if a person could not get out of bed.
Unlike colds, where people tend to have a scratchy throat, not such a high fever, maybe a runny nose, but they don't have that debilitating feeling of fatigue.
HEADLEE: And does everyone who has flu, if they're experiencing those symptoms, do they have to go to their doctor or the hospital? Is that required to get better?
BARRY: No absolutely not, and we don't encourage everyone to go to their health care provider because frankly that would really overrun the system. We encourage people instead to try supportive measures. Take medication to control your fever. Drink lots of fluids. Rest. But some people, we know, will have a more difficult time if they get influenza.
Children under five, seniors over 65, people who have other health problems, diabetes, asthma, heart problems, pregnant women, we know that if these people in these groups get influenza, they're more likely to have severe illness and to end up in the hospital. So if you're in one of those high-risk groups, we certainly would encourage you to call your doctor. Don't just go in, call your doctor first.
HEADLEE: And stay home, I assume, or keep your kids home from school. But I wonder if you could tell us, Dr. Anita Barry, the difference between a quarantine and an isolation.
BARRY: Sure. Isolation means you're restricting the movement of someone who is ill and contagious with a particular disease. On the other hand, quarantine is restricting the movement of someone who has been exposed to a contagious person. So the person you quarantine isn't sick, and they're not contagious yet, but you're asking them to stay put because they may be becoming ill and contagious very soon.
HEADLEE: All right, that's Dr. Anita Barry. Thanks so much for joining us. She's a director of the Infectious Disease Bureau at the Boston Public Health Commission. She joined us from member station WBUR in Boston, Massachusetts. Thank you and good luck, Doctor.
BARRY: You're welcome, and stay healthy.
HEADLEE: Thank you, I hope so. Also with us right now, Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention, administrator of the Agency for Toxic Substances and Disease Registry, and he joins us from a studio at the Centers for Disease Control and Prevention in Atlanta. Thanks so much for joining us, Dr. Fieden.
THOMAS FRIEDEN: Great to be here, good afternoon.
HEADLEE: So, I mean, we've heard about how severe this flu season is. What exactly does the CDC do to fight that?
FRIEDEN: CDC works 24/7 to protect America and Americans from threats to health and safety, whether they're from this country or abroad, whether they're infectious or environmental or non-communicable. We basically are here as the prevention agency and health protection agency.
HEADLEE: All right, so we have to contain airborne communicable diseases - flu, TB, whopping cough. The CDC keeps track of instances of that. How exactly do you go about doing that? I mean, if you somebody that walks in with TB to a hospital, what does the CDC - specifically, what do they do?
FRIEDEN: We work with a broad range of partners, state and local health departments, professional societies that work with doctors, nurses, pharmacists and others, and we track information from many different sources, whether that's emergency department visits or reported cases of disease or claims data, information that allows us to track trends both on an ongoing basis through things like phone surveys or interview surveys or even examination surveys, and through the health care system.
But we're able to work closely with health care providers in large part because of state and local health departments. One of our closest partners are the state and local health departments that are the first line of defense to find and stop an outbreak.
A good example of that was the fungal meningitis outbreak. It was the Tennessee Health Department that sounded the alarm based on an alert doctor, an alert clinician saying this seems abnormal to me, I'm going to call the local health department, I'm going to - the health department said yes, we're going to investigate that. The health department person in charge of that had been trained at CDC. Her staff is funded by CDC to track, find and stop outbreaks of disease, and that's what we do 24/7.
HEADLEE: All right, and I want to again call out to our listeners. We want to hear from you. If you're a teacher, a parent, a public health employee maybe, tell us a story about when you've had to make a decision to contain a communicable disease. What did you do? You can give us a call here at 800-989-8255. Or email us, it's firstname.lastname@example.org. And Thomas Frieden, at what point would we have to quarantine people who had been exposed to the flu, how many cases?
FRIEDEN: Quarantine is not something we use in influenza. Flu spreads pretty readily. It's flu season. It's not too late to get vaccinated. If you're sick, and you're very sick, you're having trouble breathing, or you have an underlying condition, you should see your doctor. If you're sick with cough and fever, you should stay home so you don't infect others and so you can feel better quickly.
But quarantine isn't something we do in influenza. For a variety of the infectious diseases, the best thing that we can do is to help other countries control them.
HEADLEE: Oh, that's a good question. We're going to go more into that after a break. Dr. Frieden stay with us. And again give us a call if you've ever had to make a decision, as a parent, as a volunteer, to contain a communicable disease. The number is 800-989-8255. Or send us an email, email@example.com. Stay with us. We'll talk more in a moment. I'm Celeste Headlee. This is TALK OF THE NATION from NPR News.
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HEADLEE: This is TALK OF THE NATION from NPR News. I'm Celeste Headlee. As flu infections tick up across the country, every cough in the checkout line or sniffle on the bus raises hackles about spreading disease. But flu is far from the only communicable disease outbreak that the U.S. is prepared to contain. There's actually a national quarantine system that's set up to handle outbreaks including tuberculosis, plague, smallpox, cholera.
According to the CDC, there are 20 quarantine stations at ports of entry and borders around the U.S. Fortunately, officials don't often need to enforce large-scale quarantines. The most recent was the Spanish flu pandemic of 1918.
But we want to get your stories. If you're a public health official, a worker, a volunteer, parent, we want to hear from you. What decision have you had to make about containing a communicable disease? Right now we have on the line Julie(ph) from Athens, Ohio, if I can figure out how to pick up. There we go. Julie in Athens, Ohio, you have had to make a decision related to your child's communicable disease, right?
JULIE: Yes, he was diagnosed - my son was diagnosed with measles at just 13 months old. It was three days before he was expected to get (unintelligible)...
HEADLEE: He had measles, but you had to make the decision to isolate him?
JULIE: Well, he didn't get the measles diagnosis until day three. So we noticed the outbreak, and we didn't recognize it because most people don't get the measles anymore. And so when we realized he was sick, the first ER visit resulted in a diagnosis of a virus, but he was still cleared for daycare. And so we didn't - I just had that mother's intuition. I didn't feel comfortable sending him to daycare.
And when he met with his pediatrician, she said absolutely keep him home. So we kept him in isolation.
HEADLEE: Wow, I bet the other parents are thanking Julie in Athens, Ohio. Thanks so much for that call. And here's another phone call, this is Jennifer(ph) in San Antonio, Texas. The question is: When have you had to make a decision to contain a communicable disease in your own family or your own life? Jennifer, when has that happened to you?
JENNIFER: We were part of the initial swine flu epidemic.
HEADLEE: Oh wow.
JENNIFER: And the small town where I live decided to close the whole school district, decided to shut down the schools for two weeks. And the churches participated, as well.
HEADLEE: In closing everything down, nobody go in to church, everyone staying home?
JENNIFER: Right, but I was a teacher at a private school when the private school kept teaching, we still had classes. And so everybody in the school got the swine flu, including me and my two children.
HEADLEE: Oh I bet that did not make you happy. That's Jennifer calling from Texas, thanks so much. The question for you is: When have you had to make a decision like this to contain a communicable disease in your own life? You can call us at 800-989-8255. Our email address is firstname.lastname@example.org. Or just join the conversation at the website, it's npr.org, and then click on TALK OF THE NATION.
We're talking with Thomas Frieden, Dr. Thomas Frieden, he's director of the Centers for Disease Control and Prevention. And I wanted to also bring in Lawrence Gostin. He's a professor of global health law at Georgetown University Law School, joins us right here in Studio 3A. Thank you so much for being with us.
LAWRENCE GOSTIN: My pleasure.
HEADLEE: So I wondered if you could react to that story that Jennifer told because one of the things you are expert on is the - where quarantine meets civil liberties, right?
HEADLEE: So in her private school, she got exposed, and her whole family, to the swine flu because the private school had the option not to close down.
GOSTIN: Yeah, I mean school closures is certainly one of the things that are discussed in terms - when you have major outbreaks. The state is entitled to require the closure of schools, and I'm not sure whether they did that at that time. But it's really interesting that, you know, there was a little tick-down in flu over the Christmas holidays because everybody...
HEADLEE: Was out of school.
GOSTIN: Was out of school. So schools are, as Tom Frieden knows a lot better than me, schools are a place where kids mingle, and a rapidly communicable disease like influenza can spread around quite quickly.
HEADLEE: Well, that's Lawrence Gostin. Let me bring it back to you, then, Dr. Thomas Frieden with the CDC. When does it become bad enough that you close down public schools? Is that something that you do in conjunction with the state?
FRIEDEN: We've looked at this quite closely, and initially with the H1N1 pandemic, we saw explosive outbreaks of flu in schools. In fact I was still New York City health commissioner at that time, and we had one non-public school that had over 1,000 cases of the flu.
And what - as we learned more, we learned that school for flu should close in one of two circumstances: either so many staff are sick that they can't safely continue to run; or it's a school that includes many kids with special needs, who may be more susceptible to severe illness from the flu. But in general, closing schools hasn't been as necessary as we initially thought in the H1N1 pandemic.
And we also found that shorter closures seemed to be somewhat as effective as longer closures. And furthermore, if you surveyed kids and asked what they did when they weren't in school, they weren't home. They were out in malls, they were at movie theaters, and so closing schools may not always be the right answer.
But I'd love to spend a minute on the measles, the situation that was mentioned earlier, because it's such an important lesson. We've actually eliminated measles from this country. Every case of measles we get now is a measles case that ultimately has come from another country: a traveler, a student who went overseas to study and came back with it.
Measles is just about the single most infectious disease that we have, and when there's a single case, it can spread quite rapidly in hospital emergency departments, schools, daycare and other places. So it's one of those things that really emphasizes that we're all connected by the air we breathe, and controlling measles around the world is going to protect us here at home.
And that's why at CDC we have this dual approach of fighting global disease threats abroad and protecting us at home, and measles is a great example of that. We've seen a big reduction in measles cases around the world over the past decade. That reduction has resulted in more than four million children not dying from measles because it's still often a deadly disease.
But it remains all too common around the world, and had last year over 200 cases imported to this country from other parts of the world, and I'm glad things went well in Athens, Ohio, but it is a challenge, and it's one of the things that reminds us that we are all protected by the air we breathe.
HEADLEE: Right, and yet, Lawrence Gostin, this brings up kind of the issue with public health, right, because there are privacy concerns here. I mean, to a certain extent there's the public good, there's that - and then there's your right to privacy, there's your right for self-determination. At what point do you think we become in danger of crossing those lines?
GOSTIN: Well, I mean, the whole area of public health and infectious diseases in particular always has a tension between individual liberties and the common good. It's privacy, it's liberty, it's autonomy. Do you require somebody to have a vaccination? Do you not? Do you disclose the fact that they've got a disease? Do you not?
I mean, there's no hard and fast rule, but generally speaking if the individual's behavior or just condition, infectious condition, poses a threat to the public's health, the very first thing you want to do is cooperate, educate, counsel. But at the end of the day, if they're going to harm others, then I think the public good outweighs the individual...
HEADLEE: If I have whooping cough, for example, and I want to stay in my house, and they want to isolate me, they can?
GOSTIN: Well, I mean, if the public - if the state...
HEADLEE: If they feel it's a danger...
GOSTIN: If the state feels that it's a danger, the same would be true of tuberculosis. As Tom said, we try very hard not to use coercive measures. We don't want to send any epidemics underground. But I think it's long been true in public health and public health law that in those cases where you need it, you must use it.
HEADLEE: We have an email here from Diane(ph), and it sounds like this is a question for you, Dr. Thomas Frieden. Diane says: I've written airlines and federal agencies to suggest that masks be available to people who feel they might be contagious while they're traveling. Airplane flights are a real vector. We could at least have some prevention measures available to those people who are aware enough to use them.
What's your answer? What do airlines do?
FRIEDEN: Well, what - we have seen some spread of disease on very long flights, for example flights longer than eight or nine hours have been associated with spread of tuberculosis from patients who are not on treatment. Really it gets back to what Larry was saying: Your right to swing your fist ends at my nose, and your right to have a disease and not take treatment for it ends when you may infect others.
At the same time, we have to provide At the same time, we have to provide services to people who are ill, so that they can get cured or effectively treated. And we, as a community need, to work together so that we reduce disease because we can do that better together than any of us individually, for example, by getting immunization rates up. We protect not only our own family, but families around us, and they protect us. So we are all connected, and that's an important thing to consider.
Wearing a mask on an airplane is something that can be potentially helpful. It's pretty hard, though, because you take it off for a while or you put your hands to your mouth or your nose and you can continue to spread disease. So if you're really sick, the better thing is not to travel. That may be difficult sometimes, but it's not so clear that masks are that effective. Interestingly, in some other parts of the world, people commonly wear masks when they're not feeling well, but that's not part of our culture here.
HEADLEE: And we're looking for your response out there. If you had to make a decision as a public health worker, an official, a parent, a volunteer, call us on 800-989-8255, or email us at email@example.com, just as R. Frasier(ph) did. R. Fraser writes this: In our library, where I'm the director, we are disinfecting all materials that are returned thought the winter. #fluseason. That's probably a good idea. And also on the line with us right now is Zack in Houston, Texas. Zack, an instance in which you had to make a decision about containing a communicable disease?
ZACK: Yeah. Last year, during the holiday season - I run a restaurant - and one of my workers got sick and went home. You know, I'm definitely happy for that. I don't want to get people sick. But unfortunately, it got a number of my staff members sick. I get vaccinated every year, but I actually had to shut down for a whole month, lost a lot of money. And the employees that weren't sick were rather frustrated with it. And so this year, starting on the 1st of November, I offered to pay for the vaccining(ph) of my employees. And at the end of November, if you aren't vaccinated, you won't working the season.
HEADLEE: Huh. Interesting.
ZACK: So, yeah.
HEADLEE: That's Zack in Houston, Texas. And, Larry, you are making motions like you have a response to that.
GOSTIN: Well, I mean, I was - one of the things I was thinking about, I mean, Tom mentioned, I think really importantly, that population-based vaccination for common diseases, childhood diseases like measles or influenza, are really important. But there are also pockets of groups that really need to get vaccinated. I mean, one of them would be health care workers. And the questioner's view about food workers trigger that idea because lots of health workers are exposed to disease. They can expose patients to disease. And if they're not immunized - and sometimes, they're not, even with influenza - then the question is what to do. And some places require it, some really strongly encourage it, and it's certainly highly recommended.
HEADLEE: You're listening to TALK OF THE NATION from NPR News. Let's go now...
HEADLEE: Hang on just a second, Dr. Frieden, if you would. I wanted to take this call from Judith in Chico, California. And, Judith, you have an interesting story about a time when your family was involved in containing a communicable disease.
JUDITH: Yes. In the '40s, my oldest sister had scarlet fever, and I don't remember if it was the city or the county public health legally quarantined the whole family in my house. No one could leave.
HEADLEE: And how long?
JUDITH: I don't remember how long it was.
HEADLEE: But it probably seemed like ages.
HEADLEE: Judith, thank you so much for your call from Chico, California. And let me maybe bring that back to you, Dr. Thomas Frieden. That's probably pretty rare, right?
FRIEDEN: It's quite rare. Right now, we have treatment with antibiotics for the bacteria that causes scarlet fever, so that's not something that we need to isolate people for. I was saying earlier that it's interesting that Zack has done this. It's a very successful thing to offer flu vaccine in workplaces. And we're finding that about a third of adults who got vaccinated this year got vaccinated either in a workplace or in a pharmacy. And as you make things easier for people, they more likely to do them.
There are incidents where we do have to isolate people, for example, people with tuberculosis, that's infectious to others. But in those cases, what we're really doing is protecting the public and making sure that they're offered the best possible treatment. And Larry, of course, has done very important work n this area, seeing how we can do that with full respect for both ethics and autonomy as well as the law.
HEADLEE: Well, let me bring this back to you, Lawrence Gostin because I wanted to remind listeners, especially of the incident during World War I, American authorities incarcerated more than 30,000 prostitutes. They are trying to curb the spread of venereal disease. And - that's obviously is a case of the overreach of this power. But how far have we come from that? Have we guaranteed against that kind of overreach?
GOSTIN: Well, one of the things to always remember is that infectious diseases are very scary and they bring out lots of cultural biases. And sometimes, those cultural biases are directed to particularly vulnerable, marginalized communities. And there have been instances in the past where we have clearly overreached and really targeted people based upon a subtle animus or prejudice against their race, their religion, whatever it might be.
HEADLEE: Their job in this case?
GOSTIN: Yeah, or their job, and that, you know, that can be a - that is wrong. Now, can it happen again? One of the thing - I hope it wouldn't. But during the SARS outbreaks a number of years ago, it reminded me of two things: one was - your last caller talked about quarantine at home, and home quarantine was used quite a lot particularly in Canada and other countries. I think it was here - used here a little bit as well but mostly Canada. So quarantine doesn't mean that you're necessarily going to be put away somewhere. You could just be...
GOSTIN: ...as CDC has often said, a better term might be shelter in place. It's a very good...
HEADLEE: And certainly sounds nicer.
GOSTIN: It's a good - or it's a snow day. But also, during SARS and even during H1N1, she went to Asia and other parts of the world, you'd often see this kind of big overreaching in mass quarantines. And so it's something we shouldn't just feel too comfortable with.
HEADLEE: All right. You just heard Lawrence Gostin. He's a professor of global health law at Georgetown University Law School. He joined us here in the studio. Thanks so much for being with us. We also spoke with Dr. Thomas Frieden, the director of the Centers for Disease Control and Prevention. He joined us from a studio at the CDC in Atlanta. Dr. Frieden, thank you so much.
FRIEDEN: Thank you.
HEADLEE: I wanted to read this email here from Meg who says: As a child, my parents had to decide whether to fly with me on a plane or wait out a hurricane on the Gulf Coast, they ended up choosing to fly mainly because I had several other health concerns at the time, and I was on day five of the chicken pox. So they decided to fly. When we come back, the Python Challenge. Burmese pythons are wreaking havoc in the Everglades. So from now till mid-February, the public can hunt them and win prizes. More on that after a short break. I'm Celeste Headlee. It's TALK OF THE NATION from NPR News.