Healthy Précis Quarterly - adarash.net
Transcript of Healthy Précis Quarterly - adarash.net
Healthy Précis Quarterly | Issue 30 | March 2020 | adarash.net | [email protected] Page 1
-—-——-—--—————-———————-————----------------------------Panel Adarash, |March 2020 -———--——-——-——-——--———————-—————-—----- Healthy Précis Quarterly
Primer Simply put, “life” is nothing but conscious existence, in which health and disease are its two critical elements. Of
diseases known to humankind, infectious diseases are the worst. Causation is being connected to omen, miasma,
germs, the epidemiologic triad, and to multi-factorial causation – in that chronological order. Life is also a marvelous
and taxing journey, in which a protracted war and endless battles, against infectious diseases, are horrific realities
ever told inside “travelers” stories – devastations of biblical proportions, transforming the social fabric, in their own
eccentric ways. Environmental sanitation and personal hygiene; developing antimicrobials, antitoxins, and vaccines
are being instrumental in the obvious decline of the burden of infectious diseases. Advances in guidelines and
technology help identify, track, and control infectious agents, safeguarding the complex journey. So far,
accomplishments are extraordinary, particularly in nations with high-income economies. While semi-similar patterns
are being seen, nations with low-income economies remain improving, but at slower than snail pace. Worldwide,
despite successes on record – resistant strains, emerging and re-emerging infectious agents, coupled with
population increase, social-economic-political instability, massive and frequent travel, and climate change – the war
continues protracted; the battles, potentially devastating, but winnable; and life goes on, nonetheless. As most
critical issues in life, infectious diseases are not only health issues, but human rights issues, as well – a question of
morality. Indifference is inexcusable! With that overture, we cordially invite all adarashians for a conversation on
“life,” as you see it, in the context of infectious diseases.
As always – a coffee table conversation starter, with family and friends
Note: This flyer is not a prescription or a medical advice to anyone. Please call your doctor or your local health
department for any information, including on COVID-19.
Introduction
Trying to define the word/term “life,” may be a
mistake, rather a challenge, if you will. Anyways,
here in the galaxy of Healthy Précis Quarterly
(HPQ,) we consider life as a conscious existence
— living and non-living, the surrounding
universe, the known and unknown, the
objectives and subjective, actions, reactions,
interactions, communications, and the resultant
realities of presence.
Obviously, the state of a conscious existence
dictates, health and disease, as everybody’s
concerns. Living level of knowledge on health
and diseases is a survival tool, indispensable. To
that effect, conversation on the subject, with
colleagues, family and friends, will serve as
enabler. Based on textbooks and articles, in the
public domain — HPQ, our informal, ultra-
synoptic flyer, is here to further that intent.
Prior to the twentieth century, diseases like
cholera, diphtheria, poliomyelitis, tuberculosis,
plague, malaria and smallpox, among others;
were dominant causes of the burden of disease.
The burden of infectious diseases has been on a
decline since the dawn of the twentieth century.
By mid-twentieth century, major causes of the
disease burden in nations with high-income
economies, shifted from infectious to non-
infectious diseases. While similar patterns are
being noted, progress continues at a slower than
snail pace, and as such, infectious diseases remain
as major causes of the diseases burden, in
nations with low-income economies.
Healthy Précis Quarterly | Issue 30 | March 2020 | adarash.net | [email protected] Page 2
[“…It is time to close the books on infectious diseases,
declare the war against pestilence won, and shift national
resources to such chronic problems as cancer and heart
disease”: William H. Stewart, US Surgeon General, 1967]
Yet, infectious agents are still everywhere [in the
environment and in/on our bodies;] may evolve,
become resistant to treatment, and are easily
transmissible. That profile enables infectious
diseases to emerge [SARS, HIV/AIDS, MERS,
Ebola, Zika, and now COVID-19], and re-emerge
[malaria, tuberculosis, influenza, and measles,
etc] on a continual basis.
Moreover, population increase, massive and
frequent travel, deforestation, growing contact
between humankind and other animals, climate
change; social-economic-political instabilities;
poverty, and the lack of withstanding healthcare
systems – intensify the continual threat, on a
global scale.
The Journey Life, as a conscious existence, takes a marvelous and
taxing journey. Health and disease are part of the
inherent itinerary – in which countless infectious
agents, by default, come bundled in the natural
contract. It remains mystery, for how long the
journey continues, but we are here, overlapping
in time and space. Therefore, to add structure to
the rather intricate subject matter, and for
nothing much but convenience, we put forward
four segments of concept transitions, around
the dynamics of infectious diseases – time zero
to the present.
[1) Superstition to miasma, 2) miasma to germs, 3) germs
to the theory of epidemiologic triad, and 4) the theory of
epidemiologic triad to the theory of multi-factorial
causation]
1. Superstition to the theory of miasma:
Superstition, that attaches omen [good and evil]
to every surprise of the time – in its essence and
of its nature, was never much of a help in the
war and battles against diseases in general and
infectious diseases in particular. [It] nonetheless,
out of necessity, might have helped triggering
the inherent human potential, igniting the prime
“tinkering out of the box” phenomena – the first
fundamental jump onto the theory of miasma.
Short of prophesying on infectious agents and
contagiousity, miasmatic theory serendipitously
connects, of course firstly infectious diseases to
the surrounding environment – aka, “bad air.”
The theory of miasma provides the basis for
actions by sanitary reforms that result in initial
declines of the burden of infectious diseases.
2. The theory of miasma to germ theory: History
has it, a connection between germ and disease
was proposed far earlier during the sixteenth
century. However, it was during the nineteenth
century when Pasteur, Koch, and Snow are
regarded pioneers of germ theory, in their own
ways. Ever since, germ theory remains rooted in
science, playing transformational role in finding
disease causing microorganisms, life cycles, and
mode of transmissions; the bases for developing
antimicrobials, antitoxins, and vaccines – plus
prevention, control, and eradication strategies.
As result, most of the known infectious diseases
controlled, and the burden noticeably declined.
However, germ theory, possesses soft spot, in
fully explaining models of causation, and
criticized for simplifying [agent – disease,] the
more complex dynamics of occurrences of
infectious diseases.
3. Germ theory to the theory of epidemiologic
triad [agent, host, and the environment]:
Beginning in early twentieth century, the theory
of the epidemiologic triad came to rescue germ
theory, unfolding the complex dynamics of
infectious disease causation.
[Stallybrass: Principles of Epidemiology and the Process of
Infection, 1931: Three factors are coined as key in the
Healthy Précis Quarterly | Issue 30 | March 2020 | adarash.net | [email protected] Page 3
spread of disease – the host, the environment and the
reservoir. Am J Epidemiol, 2003; 157:856-857]
The theory of epidemiologic triad states, for a
disease to occur, the involvement of [agent,
host, and environment] is necessary. Meaning,
the mere presence of the “agent” is not always
sufficient for a disease to occur. In doing so, it
speeded up the efforts and successes in many of
the infectious diseases.
The theory of the epidemiologic triad however
falls short of presenting its applications in
complex scenarios, especially in the spectacles
of non-infectious diseases.
4. The theory of epidemiologic triad to the
theory of multi-factorial causation: The theory of
multi-factorial (web of) causation refers to a
chain of causation, in which each link is a result
of complex actions and interactions of preceding
events – (individual factors (component causes),
one or more causal pathway (sufficient cause),
and a component that appears in every pathway
(necessary cause)).
The theory of multi-factorial causation serves
well the fields of infectious and non-infectious
diseases that are likely to have complex diseases
processes – but still, the way the theory lends
itself to prevention and control measures is not
straightforward, to put it lightly.
On a related note, contributions of the four
consecutive industrial revolutions and precise
translations in the fields of health and disease
are astounding. From direct cell culture and
gram stain, to genomics and proteomics and all
the rest in between – from hardcopy registries
and hand calculations to big data and quantum
computing – advances in technology remain
pivotal in many aspects of transformations,
including in the prevention, treatment, control,
and eradication of infectious diseases. The ever-
evolving Koch’s postulates are still important.
[Genomics and proteomics have the potential to ((provide
accurate and rapid identification of infectious agents),
(determine specificity, sensitivity, resistance and
mutations), and (guide effective, specific, and direct
treatment options)) – vital in the fields of public health!]
Well, life goes on – and in a global aggregate,
every resultant moment of the future is a little
better than the previous. Else, we would not be
where we are today. In such a complex journey,
social order and responsible governance are
critical. When it comes to health and disease,
infectious diseases in particular – nations that
succeeded building a solid social order and
responsible governance are light-years ahead of
nations that are still engulfed in social,
economic, and political instabilities.
The War and the Battles
As a conscious existence and complicated
journey, life, comes with a state of “war and
battles,” between humankind [leaving aside
other animals and plants for now,] on one hand
and risk factors in general and infectious agents
in particular, on the other – the war protracted,
and the battles endless and devastating but
winnable. While, the involvement of infectious
agents in the war and the battles is obviously
passive, the mission, for both parties essentially
is preserving their presence – survival!
[There is a long list of known infectious agents, including
((bacteriophages, plasmids, transposons), (Chlamydia,
mycoplasmas,) ricketsias, virus, bacteria, fungus, protozoa,
helminthes, ectoparasites, and Prions.)]
Infectious agents play a beneficial role in the
natural ecosystem, but some can be pathogenic
and cause disease. Generally, infectious agents
take comfort in a milieu that provides [sugar,
vitamins, minerals, and other chemicals,] invade
and multiply. Infectious agents evolve, including
through antigenic drift and shift; and may
develop resistance to treatment.
Healthy Précis Quarterly | Issue 30 | March 2020 | adarash.net | [email protected] Page 4
Inherently, the human body possess cascade of
immune mechanisms against invasions and
infections. Antimicrobials, antitoxins, and
vaccines are effective armaments. Individual and
herd immunity fortify the power necessary in
surviving the protracted war and the inevitable
and endless, battles.
Characteristically infectious agents are resolute,
and transmissible – directly or indirectly. While it
is possible to have more than one – say, a
couple of viral infections concurrently, it is
unlikely that an individual would have symptoms
from more than one viral agent at the same
time; for a simple reason of dissimilar incubation
periods. Once invasion or infection ensues and
body’s immune response triggered, signs and
symptoms may follow. Certain invasions and
infections however, may occur without
producing any signs or symptoms.
Some infections may resolve by themselves, for
others chronic inflammatory process may ensue
– immunization, prophylaxis, and treatments are
able to divert the dynamics. Generally, infectious
agents do not discriminate by age, gender, and
race, country of origin, religion, or political
affiliations. Seriously!
Up until the end of the nineteenth century,
plague, cholera, typhoid, tuberculosis, influenza,
and malaria among others, resulted in repeated
outbreaks with devastating loss of lives and
disruption of the social fabric. Transitions from
hunting to agricultural society, first industrial
revolution, the creation of towns, poor housing,
unsafe water supply, and unsanitary waste
disposals are factors critical fueling the
protracted war and endless battles, against
infectious agents.
Fast forward to the beginning of the twentieth
century, the burden of infectious diseases
started to show a significant decline, initially due
to actions taken through sanitary reforms, and
subsequently as result of the development and
use of antimicrobials, antitoxins, and vaccines.
The success was extra-ordinary in nations with
high-income economies, while nations with low-
income economies persistently lag behind.
Earlier in the twentieth century, in nations with
high-income economies, crossover of the major
causes of the burden of diseases happened from
infectious to non-infectious conditions.
Throughout the latter decades of the twentieth
and early twenty-first centuries, drug resistant
strains (malaria, tuberculosis) and cancer-
causing microorganisms (helicobacter pylori,
HBV, HPV) explained. Chronic diseases, including
various forms of cancer, increase vulnerability to
infections.
Overtime, prevention, treatment, and control
measures intensified and many of the dominant
infectious diseases drastically declined, and the
idea of eradication became within reach;
smallpox (1980), case in point – poliomyelitis
next in line, on a global scale.
During the early 1980s, the burden of infectious
diseases surges, in all nations, but even more in
nations with low-income economies, as result of
the emergence of HIV/AIDS. In nations with
high-income economies, infection-diseases-
death, from HIV/AIDS meaningfully declined at
the end of 1990s. Nations with low-income
economies are still struggling against a dual
challenge – the already established [endemic
and epidemic] levels of infectious diseases, and
the unabated emergence of HIV/AIDS.
Obviously, the twenty-first century inherited
increased risk of resistant strains, emergent, and
re-emergent infectious agents. What will come
anew is everyone’s guess. Massive and frequent
travel, population increase; social-economic-
political flux; the increasing contact between
Healthy Précis Quarterly | Issue 30 | March 2020 | adarash.net | [email protected] Page 5
humans and other animals, climate change, and
fragile healthcare systems make the war
protracted, and the battles still devastating,
nevertheless, winnable. Remember Ebola!
We are witnessing in real-time, the spread of the
new virus SARS-CoV-2 infection, which is
responsible for [COVID-19] that originated from
China and continued around the world. The
World Health Organization declares the COVID-
19 a pandemic on March 11, 2020.
The coronaviruses are common in people and
many different species of animals. Earlier
reports indicated an unconfirmed animal-to-
person spread of SARS-CoV-2, as many patients
had some link to a large seafood and live animal
market, suggesting a likely single, recent
emergence of this virus from an animal
reservoir. Later on, reports indicate that a
growing number of patients reportedly did not
have exposure to animal markets, indicating a
person-to-person spread: a) airborne (may be
not to the extent of the traditional sense)
transmission through coughs or sneezes
droplets, b) spread from contaminated subjects
or fomites that are contaminated objects, and c)
possibly a fecal transmission. Person-to-person
spread was subsequently reported outside
China, and many counties around the world.
The estimated incubation period for SARS-CoV-2
is 14 days. Meaning, someone who is infected
with the virus that causes COVID-19 is likely to
develop symptoms during those 14 days. While
spread might be possible before people show
symptoms, the dominant period of
communicability is when they are most
symptomatic.
SARS-CoV-2 is a newly identified pathogen, and
no known immunity in humans. At this point in
time, everyone exposed is assumed susceptible,
but there may be risk factors increasing
susceptibility to infection. Transmission in health
care settings and transmissions in closed
settings are the two dominant transmission
dynamics, so far. With viruses that are spreading
easily, and a higher level of susceptibility in the
community — the risk of a [community spread]
should be a great concern.
The attack rate among those aged 18 years old
and under, appears relatively low. JAMA
reported the case fatality rate 2.3 percent on
average, 80 percent among patients aged
between 70-79 years old, and 14.8 percent
among patients aged 80 and above.
As always, public health is in the forefront in the
war against the COVID-19 pandemic. Prevention
is the essence, when we think of measures of
control. There is no vaccine against the SARS-
CoV-2 infection — not yet, just to keep you
hopeful. There is no treatment available.
The CDC advises to take steps to protect
yourself and others.
To protect yourself:
a) Clean your hands often — Wash your hands
often with soap and water for at least 20
seconds especially after you have been in a
public place or after blowing your nose,
coughing, or sneezing. If soap and water are
not readily available, use a hand sanitizer
that contains at least 60% alcohol. Cover all
surfaces of your hands and rub them
together until they feel dry. Avoid touching
your eyes, nose, and mouth with unwashed
hands.
b) Avoid close contact — Avoid close contact
with people who are sick. Put distance
between yourself and other people if
COVID-19 is spreading in your community.
This is especially important for people who
are at higher risk of getting very sick.
Healthy Précis Quarterly | Issue 30 | March 2020 | adarash.net | [email protected] Page 6
To protect others:
a) Stay home if you are sick — Stay home if you
are sick, except to get medical care. Learn
what to do if you are sick.
b) Cover coughs and sneezes — Cover your
mouth and nose with a tissue when you
cough or sneeze or use the inside of your
elbow. Throw used tissues in the trash.
Immediately wash your hands with soap and
water for at least 20 seconds. If soap and
water are not readily available, clean your
hands with a hand sanitizer that contains at
least 60% alcohol.
c) Wear a facemask if you are sick — if you are
sick: You should wear a facemask when you
are around other people (e.g., sharing a
room or vehicle) and before you enter a
healthcare provider’s office. If you are not
able to wear a facemask (for example,
because it causes trouble breathing), then
you should do your best to cover your
coughs and sneezes, and people who are
caring for you should wear a facemask if
they enter your room. Learn what to do if
you are sick. If you are NOT sick: You do not
need to wear a facemask unless you are
caring for someone who is sick (and they are
not able to wear a facemask). Facemasks
may be in short supply and they should be
saved for caregivers.
d) Clean and disinfect — Clean AND disinfect
frequently touched surfaces daily. This
includes tables, doorknobs, light switches,
countertops, handles, desks, phones,
keyboards, toilets, faucets, and sinks. If
surfaces are dirty, clean them: Use
detergent or soap and water prior to
disinfection.
Visit https://www.cdc.gov/coronavirus/2019-
ncov/prepare/prevention.html for more
information.
Interim Guidance from the CDC on “Preventing
the Spread of Coronavirus Disease 2019 in
Homes and Residential Communities” is also
available at: https://www.cdc.gov/coronavirus
/2019-ncov/hcp/guidance-prevent-spread.html.
Bottom-line
Grouping 193 individual nations into four broad
categories – (high-income, upper-middle-
income, lower-middle-income, and low-income)
economies; to present aggregated social,
economic, and political profiles; like measures of
health and diseases, will likely fall short of
reflecting realities, since individual nations
(within and without,) for all intensive purposes,
are heterogeneous.
Anyways, beginning in the twentieth century,
major causes of the disease burden in nations
with high-income economies have significantly
declined. Furthermore, a crossover between
infectious and non-infectious diseases was
observed as the major causes of the disease
burden, resulting in a distinct transformation in
disease prevention and control strategies.
[“The top-ten causes of death in nations with high- Income
economies: ischemic heart disease, stroke, Alzheimer’s
disease; trachea-bronchus- lung cancers, COPD, lower
respiratory infections; colon and rectal cancer; diabetes,
kidney diseases, and breast cancer.” The WHO (2016)]
On the contrary, even today, endemic and
epidemic levels of infectious diseases, that are
already established, plus any emergent, and re-
emergent diseases, weigh more, as major causes
of the burden of diseases in nations with low-
income economies.
Healthy Précis Quarterly | Issue 30 | March 2020 | adarash.net | [email protected] Page 7
[“The top-ten causes of death in nations with low-income
economies: lower respiratory infections, diarrheal diseases,
ischemic heart disease, HIV/AIDS, stroke, malaria,
tuberculosis, preterm birth complications, birth asphyxia
and birth trauma, and road injury.” The WHO (2016)]
The profiles for the top-ten causes of death in
nations with upper-middle-income and lower-
middle-income economies appear to approach
that of nations with high-income economies.
Worth a repeat: Resistant strains, emerging, and
re-emerging infectious agents remain real
threats. Population increase and travel; social,
economic, and political flux; increasing contact
between humans and other animals, and climate
change make the threats, even worse. The risk
of epidemic and pandemic level of infectious
diseases remains high. COVID-19, case in epic
point!
Furthermore, the burden of infectious diseases
(all diseases for that matter) is not only a health
issue – it is also a human rights issue. Failed
governance, prejudice, discrimination, and
stigma, intensify the already overwhelming
barriers that vulnerable segments of populations
shoulder. Protecting citizens from diseases,
infectious diseases included, is a prime purpose
of the existence of any governments.
[“(1) Everyone has the right to a standard of living adequate
for the health and well-being of himself and of his family,
including food, clothing, housing and medical care and
necessary social services, and the right to security in the
event of unemployment, sickness, disability, widowhood,
old age or other lack of livelihood in circumstances beyond
his control. (2) Motherhood and childhood are entitled to
special care and assistance. All children, whether born in or
out of wedlock, shall enjoy the same social protection.”
Article 25: The Universal Declaration of Human Rights,
1948]
All things that matter considered, and cognizant
of the astounding success in the fight against
infectious diseases; the journey remains
turbulent, the war frustratingly protracted, the
battles brutally devastating and endless, but
potentially, winnable – a dire picture that
persists hanging over the landscapes of all
nations, through the twenty-first century.
Yard of the Future
Eliminating social-economic-political instabilities; providing safe water and food
supply, sanitary waste disposal system, increasing availability of antimicrobials,
vaccines and other disease prevention and control programs are imperative — not
only against infectious diseases, but also against all rounded problems in society.
Most importantly, the burden of infectious diseases (all diseases for that matter) is
not only a health issue, but also a human rights issue. Failed governance, prejudice,
discrimination, and stigma intensify the already overwhelming barriers that
vulnerable segments of populations shoulder. For a healthier and safer future and
the elimination of immoral health disparities – processes of civil society, specifically
those focused on human rights, ought to be exercised, explicitly and proactively, on
a global scale. It is a small world, after all!