It is the thick of cold and flu season and most of you probably know we’re in the midst of a pandemic of a novel swine flu virus, H1N1. This will be the first winter since the virus emerged last spring, and epidemiologists are waiting on tenterhooks to see what will happen. Swine flu has been grabbing a lot of attention in the press, but several other pathogens have also either arisen recently or become notably stronger. This has happened enough that alarming headlines are now commonplace.
Up to the early part of the 20th century, the leading cause of death in this country and around the world was infectious disease. Our grandparents and great-grandparents grew up with the constant threat of typhoid, diphtheria, scarlet fever, cholera, polio, and tuberculosis. Between the mid-1940s and the late 1970s, our health-care culture developed a conqueror’s attitude toward these and other pathogens. With advanced water treatment facilities, the development of antibiotics, and the availability of vaccines for several of the most threatening childhood diseases, the menace of death by infection seemed a thing of the past.
Then, in the late 1970s, we got schooled: the worldwide appearance of human immunodeficiency virus (HIV) quickly humbled any assumptions about the human triumph over infectious diseases. AIDS was quickly followed by hepatitis B and C, and the consequences of bacteria with the power to become antibiotic-resistant began to make themselves known. Today, we don’t exactly tremble in the face of microbial invasion, but we certainly have begun to treat this possible threat with more respect.
This edition of Pathology Perspectives is dedicated to the discussion of a select group of pathogens that have some specific characteristics: they cause infections that are increasingly common, they’re difficult to treat, they pose public health threats, or they have aspects of all three. I will provide a brief overview of some of today’s headline grabbers, the “superbugs,” with suggestions for finding more information in the selected sources section that follows. The purpose here is not to alarm or cause nightmares; it is to inform and educate so that readers may be better equipped to protect themselves and their clients, and to share accurate information with others. This gives us tools to avoid infection and cross-contamination—either by knowing when to cancel appointments, or by taking appropriate hygiene precautions in our work settings.
MRSA
The superbug most often referred to in today’s headlines is MRSA: methicillin-resistant Staphylococcus aureus. This pathogen has been widely discussed, even in these pages (see “Mercy, Mercy MRSA!” Massage & Bodywork, July/August 2008, page 112). MRSA was first observed in hospital settings in the early 1950s—less than 10 years after the widespread implementation of the penicillin family of antibiotics. It occurs in several subtypes that can cause infections of the lungs, urinary system, skin, and bloodstream. When MRSA broke out of the hospital settings in the 1980s, it became associated with boil-like skin infections that run a significant risk of turning septic—that is, of leading to life-threatening blood poisoning. MRSA is, of course, of special interest to massage therapists, because it can be spread through indirect and nonsexual contact; and, because it is resistant to most first-line antibiotics, it can be difficult to fully eradicate an infection.
VRSA
MRSA is usually sensitive to an antibiotic called vancomysin, but concern has been growing about the evolution of vancomysin-resistant bacteria. This pathogen has arrived. Called VRSA (vancomysin-resistant Staphylococcus aureus), it is still mostly found within hospitals, where it is responsible for endocarditis, blood poisoning, wound infections, peritonitis, and catheter contamination. VRSA is usually responsive to other antibiotics, but it can be a long and dangerous process to figure out which ones to try.
Flu
Seasonal Flu
Of the three flu types that regularly make the headlines, the one that probably poses the greatest threat to the public health is the one that gets the least press: regular, garden-variety, type A seasonal flu. This group of viruses infects up to 15–20 percent of the general population (up to 60 million people) each year, and is responsible for the deaths of some 36,000 in the United States annually. Groups most at risk are the elderly, very young, and those with other complications including: immune suppression, asthma, cardiovascular disease, and diabetes.
Avian Flu
Regular seasonal flu has relatively high communicability and relatively low mortality—that is, it’s easy to catch, but it isn’t usually deadly. By contrast, the most virulent form of H5N1 avian flu (“bird flu”) has a high mortality rate (in some settings 30–60 percent of the people who get sick die from this infection), but a very low communicability rate. It is a virus carried by wild water fowl (ducks, swans, geese) and spread to domestic poultry. People who handle dead birds may catch the virus, but so far it doesn’t spread easily from one human to another: this has only been recorded in a couple of instances, and it hasn’t yet broken out of immediate family groups. The epidemiologists who track avian flu are concerned that the virus may eventually go through an antigenic shift, in which genetic material from this virus combines with material from seasonal flu to carry the high communicability of one and the high mortality rate of the other. Interestingly, pigs are a reservoir where both human flu and bird flu can coexist, so this is being watched closely.
Swine Flu
Until May 2009, swine flu (or H1N1 flu) was rarely seen in the United States. H1N1 flu is actually difficult to catch from animals, but it is highly communicable from human to human. This is seen in the fact that after one case was identified in Mexico in March 2009, within six months it had been labeled a pandemic. It also has a high morbidity rate—that is, people feel sicker for longer with H1N1 flu than with seasonal flu. Early evidence suggested that the H1N1 flu might be extremely dangerous, but its mortality rate is actually as low or lower than that of regular seasonal flu. There are some important differences though, most notably that H1N1 flu tends to affect children and young adults more severely than seasonal flu, and the communicable period can last 7–10 days after symptoms develop. Pregnant women appear to be at highest risk for hospitalization and death with the H1N1 virus.
XDR-Tuberculosis
First, there was tuberculosis: a slow-growing, spore-bearing bacillus that is spread through airborne mucus droplets. A deep breath pulls it into the lungs where as few as 10 microoganisms are sufficient to set up an infection site. About 90 percent of the world’s 2 billion people with tuberculosis exposure stop here: the infection is isolated inside a small cyst in the lungs and it never reactivates. But about 10 percent of those exposed will develop primary tuberculosis disease and be able to spread the infection to others. A six-month course of antibiotics clears the infection (this has made TB much less of a threat for us than for our grandparents), but misuse or incomplete use of the drugs leads to drug-resistant forms of TB. Multidrug-resistant TB (MDR-TB) requires much more hazardous and expensive drugs, for 18–24 months. When this regimen fails, another pathogen can develop: XDR-TB, or extremely drug resistant tuberculosis. This infection resists almost all antibiotics, and it has a survival rate of only 30 percent. And the kicker: a person with active MDR or XDR tuberculosis can share their more dangerous infection type with others when they sneeze, cough, or even just speak. Statistics on MDR and XDR tuberculosis are difficult to gather, but MDR-TB has been diagnosed in almost every state, and XDR has been identified all over the globe.
Others to watch
Other pathogens that should probably be on our watch list include the following:
Cryptosporidium
This is a paramecium similar to giardia that has become resistant to chlorine. It is common in recreational water (public pools and fountains), as well as streams, lakes, and rivers. “Crypto” can cause abdominal pain, watery diarrhea, and dangerous dehydration. It is spread easily through indirect oral-fecal contamination.
Clostridium difficile
This anaerobic spore-bearing bacterium is common in the gastrointestinal tract, where it is often found in peaceful balance with other intestinal flora and fauna. But when that environment is disrupted by antibiotic use, this particular group of bacteria appears to flourish, leading to painful diarrhea and dehydration. In the worst cases, the toxins excreted by the bacteria can cause acute inflammation and patches in the colon (pseudomembranous colitis) and even cause the colon to become dangerously enlarged (toxic megacolon), which puts the patient at risk for perforation or rupture and subsequent peritonitis. “C-diff” sometimes clears if the triggering antibiotic use is stopped, but sometimes it must be treated with its own antibiotics. It is a stubborn, long-lasting, hospital-based infection that can be spread through indirect oral-fecal contamination.
necrotizing fasciitis
This infection (usually with group A hemolytic Streptococcus aureus, but occasionally with other bacteria) causes the death of subcutaneous soft tissue. Also called “flesh-eating bacteria,” it is an aggressive, rapidly spreading pathogen that moves along deep fascial planes, destroying soft tissue as it goes. These infections can start with tiny nicks or cuts to the skin: needle pricks, paper cuts, and torn hangnails are all possible portals of entry. The best outcome for necrotizing fasciitis is early diagnosis, intravenous broad-spectrum antibiotics, and aggressive removal of damaged tissue (which can mean amputation).
Strategies for the Future
As we scan our environment for new and old pathogenic threats, we are having to reevaluate our arsenal a bit. Many of our old standbys, especially in the realm of antibiotics, have lost their potency. Even some of the brand-new antiviral medications aren’t standing up to the newer varieties of flu. The future of infection control may look significantly different from the past. Some of the innovations we are considering include the production of synthetic bacteria-killing viruses (bacteriophages) that target specific infections. If phage therapy fulfills its promise, viruses will be adapted and manufactured to keep up with bacterial resistance. Phages are already in use for humans in other countries, and applications for infection control in farm animals are under investigation here. Because phages are different from standard drug therapies, however, it will be a long road to figure out a way to get FDA approval for use in the United States.
Other out-of-the-box thinking for tough bacteria includes the use of “blue lights” to kill MRSA bacteria. Several minutes of exposure to non-dangerous levels of targeted blue light (without ultraviolet radiation) appears to kill up to 80 percent of these extremely tough pathogens. The exact mechanism isn’t yet understood, so whether MRSA can develop blue light resistance is still an open question.
Ultimately, for massage therapists and everyone else, infection control comes down to the most basic common sense applications. Washing hands frequently, covering any possible portals of entry for infection, turning our heads away to cough or sneeze, using disposable tissues, practicing good hygiene at home and in the office, and—perhaps above all—staying away from others when we’re sick, will provide the best possible protection for ourselves and our clients that we can offer.
A legitimate argument could be made that the constant, unceasing, sleep-ruining stress of worrying about a potential infectious threat may be more dangerous than the infection itself. Because the best defense in this situation is information, I urge all massage therapists to gather the clearest, most accurate information they can find on the pathogens that they encounter the most. Then, use it to stay healthy, make careful choices, and move joyfully forward with the knowledge that you have controlled the things you can control, and you can let go of the rest.
Ruth Werner is a writer and NCBTMB-approved provider of continuing education. She wrote A Massage Therapist’s Guide to Pathology (Lippincott Williams & Wilkins, 2009), now in its fourth edition, which is used in massage schools worldwide. Her new book, Disease Handbook for Massage Therapists, is now available from Lippincott Williams & Wilkins. Werner can be reached at www.ruthwerner.com or wernerworkshops @ruthwerner.com.