Pathogens are notorious for not respecting national borders, or species borders, or personal borders. Vigilance, vaccines, and Purell can do a lot to protect you, at home and when traveling.
Elizabeth Talbot, M.D., Associate Professor of Medicine, Dartmouth Geisel School of Medicine, Division of Infectious Disease, Attending Physician Dartmouth Hitchcock Medical Center. Consultant to the CDC, New Hampshire Department of Public Health.
During This Episode We Discuss:
- Recorded a year prior to Covid: the risk of global pandemic potential such as Ebola, Zika were discussed.
- Globalization’s effect on the transmission of disease.
- Our risk for viral disease transmission from exotic pets.
- Travel Medicine.
- Colds, Flu, and flying.
- Vaccine Safety.
- Inappropriate use of antibiotics with a viral illness.
“Some of those inconveniences that we roll our eyes about are there for a purpose, for the most part. With Ebola, everyone understood that ports of entry from the areas that were impacted had extensive screening. long lines. Yes, it’s inconvenient, and it’s annoying especially under a jet lag condition, but that part of our contract in society is that we comply in ways that are going to keep our population safe”
Elizabeth Talbot, M.D.
- The Plague Year by Lawrence Wright, New Yorker Magazine January 4, 2021
- The End Of October by Lawrence Wright 2020
Speaker 1 (00:06):
A baseball game, a day in a park with friends and family, fishing and a remote stream, work, travels, providing for loved ones, or heading out for adventures. Whatever you do, whatever you enjoy, you need your health. The Original Guide to Men’s Health is presented by the Washington State Urology Society to help take you through the steps necessary to get the most out of life. If you have invested in a retirement plan for your future, why not invest in your body. After all, it makes better sense to retire healthy and enjoy your future. These podcasts are a guide for how to take care of yourself. If you take care of your car and maintain it, why not do the same for your personal machine, your body. If you know you should, but haven’t yet, the information in these podcasts contains some easy recommendations for where, when, and how to get started. Follow the podcast. As we explore men’s health with renowned experts, and embark on a journey towards better health. What is one of the major annoyances of life? The common cold, the flu. When we look at trying to stay healthy, we tend to think of just general health, and colds are one of the major nuisances of life. But let’s go beyond the common cold and flu. Let’s talk about the potential for epidemics, global pandemics, and concerns regarding the globalization of disease. What do we know? What do we have to be concerned about? We’ll explore all of that on today’s episode of the Original Guide to Men’s Health.
Speaker 2 (02:07):
Today on our segment of the Original Guide to Men’s Health, I’m fortunate to be with Dr. Elizabeth Talbot. Dr. Talbot is a professor of medicine at the Geisel school of medicine here at Dartmouth. We’re sitting in her office at Dartmouth Hitchcock Medical Center. Dr. Talbot had extensive training in medicine, first in internal medicine doing an internship at the University of Iowa, and then residency at Duke University, and then fellowships in infectious disease in international health at Duke. She has been here at Dartmouth since 2003 and is an expert in infectious diseases. So Dr. Talbert, welcome. Thank you very much. I think we have a choice here of starting with the individual and working to the global health, or starting global health and working back to the individual, and maybe we’ll start with global health and some concerns regarding pan-epidemics and what you can tell us about the encroachment of society and its effect on infectious diseases. And then we’ll work down to keeping people healthy and talk about vaccinations, and then how to avoid the flu. Okay.
Speaker 3 (03:18):
All right. We’ll run the gamut of it. But I think it’s an interesting challenge that you set up to us because, what has been thought of as out there, is no longer really not impactful to us no matter where we are. Right? So globalization has impacts at so many different levels. And my particular interest is how the climate change and the intricacies of how we encroach on our environment are impacting those microbes and their reservoirs, the animals they live in; how they’re impacting us on a daily basis, and whether we travel out of our nooks and crannies or not.
Speaker 2 (03:58):
So for listeners, we wonder about what that actually translates to as far as our risk. We’re all familiar with seeing Ebola where we have a leap from animals to man. Fortunately, it was contained. SARS, a more impactful, bigger population. But these things are representative of what you’re talking about and the potential of animal diseases leaping to humans.
Speaker 3 (04:32):
Yes, that’s right. Animal diseases, or zoonotic, in my language, and my mother tongue, where we pay attention to the diseases that primarily affect animals but have the capacity to infect us humans as well. So these are called zoonotics and most of our emerging infectious diseases are zoonotic. That is, if a disease is going to jump species to humans, it’s very much likely to be in an animal in some forest in some ecosystem. Now, whether it requires an insect to help it jump or not, we saw this with Ebola and a very dramatic, I thought memorable way, in 2014, where a two-year old child was playing with a bat in his father’s compound and succumbed to Ebola. And, as part of the cultural practice of that region in west Africa, he underwent a traditional burial where his body was washed and the effluent was drunk ceremonially by many people who came to pay their respects to this village chief’s son’s death.
Speaker 3 (05:42):
And this disseminated disease and, you know, one of the most dramatic events we have in our own memory, and yet, Ebola has not passed, has it? So, those of us who pay attention to what’s going on in the global arena know several things. One, that there continues to be a reservoir of Ebola. We now recognize that this virus can remain dormant in humans and then rear its ugly head through sexual contact. We recognize that the people who are impacted by the Ebola virus in that terrible epidemic are still suffering ill effects. They’ve not been able to return to the function that they want to in their societies. So, it’s been a huge setback in so many ways for those countries that were impacted: Sierra Leone, Guinea, and Liberia. But it’s also active in the Democratic Republic of Congo right now.
Speaker 3 (06:45):
I don’t see it very commonly in our lay press. I think it’s just something we fatigue about, you know, what terrible thing is going on and where. Yet, this is an epidemic that is wildly out of control because of new reasons. Now, the human impact there is open conflict. So there are many armed groups. This is the first time that we’ve not only had to don the personal protective equipment, those crazy, you know, space suits that we needed to safely take care of patients. We also need helmets and flak jackets because healthcare workers are coming under open aggression in the area where this epidemic is spreading pretty uncontained right now, in the Eastern part of the DRC.
Speaker 2 (07:30):
Two things. One, it sounds like a recipe for expansion of the disease, where you want to have containment and you speak with experience having been on the front lines of Ebola.
Speaker 3 (07:43):
That’s right. I did certainly work in my public health capacity here in the United States to try to help healthcare facilities be prepared in case there was an imported case, but I also went to West Africa myself twice to serve in our role of educating healthcare workers who are coming from all over the world with little or no experience in caring for such patients. So, it reminds me too how often we have to strike the right balance with regards to education and empowerment so that people understand true risk, but also keeping the global attention on what’s an absolute catastrophe in that region of the world and what is promising to become endemic. That is, you used the word pandemic earlier. So just to be very intentional about the use of those words, we have our outbreaks or epidemics, which are very regionally contained to a jurisdiction. Then, these can become broader and wider pandemics such as what happened with SARS where an ill person boarded a plane from Asia in the way that we were most regionally impacted, went to Toronto, and essentially immobilized that city and created true morbidity and mortality, people getting sick and people dying, but also, an economic cost that is almost incalculable. That city was essentially closed to traditional business and tourism.
Speaker 2 (09:10):
So we, as a population across the globe, encroach on previously unpopulated areas, our encounter, our risk increases somewhat for these diseases.
Speaker 3 (09:25):
I guess that’s right. So I am very concerned about what we know of climate change and how that influences our environment, not only with increased temperature, but with also increased humidity in many settings. So for example, what we’ve seen in the emerging infectious disease of Zika, this disease exploded in the Americas in the recent years in part because the climatic conditions in the Americas were ideal for the Aedes Aegypts mosquito, which transmits that disease as a vector. So because of humidity, because of temperature, because of some of the nasty tricks that mosquitos have in terms of being able to reproduce in water the size of a bottle cap that’s strewn about in impoverished neighborhoods, for example, this was a perfect storm allowing for the introduction of that disease into the Americas in a very dramatic fashion.
Speaker 3 (10:26):
So yes, climate change, yes also encroachment on environments where people had not normally had contact to some of the animals that traditionally are reservoirs for these diseases. An example that comes to mind for that is the MERS-CoV. So this is an abbreviation that is the Middle Eastern Respiratory Syndrome Coronavirus. So when clinicians recognized in the Middle East that they were seeing a very dramatic and severe respiratory disease in otherwise healthy persons, a very classic epidemic investigation was undertaken, and they identified that there was a new virus recognized in these humans who are sick. And this was essentially a bat cold virus. So a Coronavirus that was classically known to infect bats with a mild illness. And yet these people had no contact with bats. What was the bridge reservoir animal for this zoonotic disease? Investigation showed it was the camel. So, humans have a great deal of contact to camels in the Middle East and it turns out that some of the animal husbandry puts those camels in closer contact to the bats who are the primary reservoir, the place where that virus usually lurks in our environment. So not only are we encroaching on environments and ourselves becoming exposed to, think of the Ebola example, but we have contact to animals that are also being exposed to new kinds of reservoir animals and therefore, in their own viruses.
Speaker 2 (12:07):
So without being overly dramatic, a lot of us would hear that and say, well, we’re not really concerned about that here in the United States, and yet given the globalization of travel, and the fact that an airplane can transport an infected person within hours to a potential sterile area that hadn’t been exposed, again, without being too dramatic, how concerned should we be, and are we prepared?
Speaker 3 (12:37):
We should be appropriately concerned, that is we should be aware that it happens and be compliant with some of the efforts that public health is making to prevent that. So for example, not bringing in fruits and vegetables across borders that aren’t meant to be crossed without scrutiny. Some of those inconveniences, right, that we roll our eyes about, are there for a purpose for the most part. So with Ebola, I think everyone understood that ports of entry from areas that were impacted had extensive screening. Well, yeah, they’re long lines and it’s inconvenient, and it’s annoying, especially, you know, under a jet lag condition, but part of our contract in society is that we comply in ways that are going to keep our population safe. It’s not just about travel though I would say. There are risks in the United States for some of these diseases that feel out there to become, using a big epidemiologic word, autochthonous. That is, that we can introduce pathogens, viruses, bacteria, whatever, to our local population of insects and allow spread here in our own country.
Speaker 3 (13:46):
So this became very relevant during Zika because an ill person can travel (yes, that’s the point of introduction), and then that ill person with virus in their blood can be bitten by an American mosquito that then goes on to bite another American who has not traveled. And that’s the dangers of autochthonous transmission and establishing new infections in places that never been before. Another thing, another aspect, another way, that globalization can potentially impact us with some of these infectious diseases is our propensity to, for example, want exotic pets. You know, when goldfish, cats, and dogs are not enough, sometimes people want to import animals that really had no right being here. So the example that has been dramatic in the recent past is that of Monkey Pox. So this virus, which is a very serious virus now entrenched in the Prairie dogs of the Midwest, was introduced by the exotic pet trade. So somebody thought it would be really cool to have a Gambian Giant Pouched Rat as a pet and that animal imported this disease to spread now and become endemic, part of life, in the United States. So I think we are prone to do things that are not always wise, and that’s one of my pet peeves, if you will, to import exotic pets, especially breaching rules that are in place to keep us safe.
Speaker 2 (15:18):
Let’s move a little bit towards travel medicine and someone who wants to move beyond the standard vacations and move to more exotic areas. We now have a specialty of travel medicine in most medical centers and more cities. So give everybody a little background about what they should do if they’re thinking of doing some travel.
Speaker 3 (15:38):
Absolutely. I am very passionate about this as well, that is, when you go to places and encounter new dangerous pathogens, especially the viruses, bacteria, parasites, etc., that you do well to visit an expert in that field who can tell you what’s there in your place of destination and how you can protect yourself. So I do a lot of travel medicine and I enjoy it very much because it allows me to credibly keep up to date with outbreaks and disease movements in human populations. It’s not just about the shots, which is something I often hear, but it’s more comprehensive with regards to what’s the latest crime scam, what’s your risk of terrorism, what is your greatest risk of death or coming back urgently and emergently. And it is also about staying safe with regards to the food that you eat and the fluids that you consume.
Speaker 3 (16:32):
Is it okay to brush your teeth with tap water? Probably not. Is it okay to use ice cubes? Probably not. What vaccinations are appropriate for you to keep safe here in the US and if you travel? So we’re experts in travel medicine. And I think that most people would reflect that they are happy with their travel medicine appointment because they feel empowered in ways to stay safe. They’ve done everything they can with regards to antibiotics and antimalarial drugs and getting their vaccinations. So absolutely, if you’re going to the tropics, it’s very much worthwhile seeking out a specialized travel clinic.
Speaker 2 (17:12):
You would advise actually seeing the practitioner rather than just going online and looking up the latest details.
Speaker 3 (17:20):
I would. I of course love the Centers for Disease Control and Prevention’s website, which is informally referred to as the “yellow book.” It’s now an online book that used to be physically on shelves, but it tries to keep up-to-date. It’s published annually and often and makes an assumption that these pathogens respect national borders, which they don’t. So we can really nuance protecting you in travel clinics. And I think that’s the intention of the CDC, is that this gives some groundwork and some background information to you, but that really it’s in your best interest to attend a specialized travel clinic before any travel to the tropics. I sometimes have a hard time getting folks in my travel clinics to receive the flu vaccination, if I might make that transition for a moment?
Speaker 3 (18:11):
And just with regards to travel, I marvel that people are ready to put their arm out for all kinds of exotic vaccinations, but then when it comes time to talk about flu, they say, “oh, I don’t get the flu shot.” Well, in fact, the most common vaccine-preventable disease in international travel is influenza, the flu. And so, that’s one that I think that people should think twice and three times about when they’re going on any trip, because acquisition is really common in the airports and planes and then in sights of destination. And flu is a misery, whether you’re home in your own bed or you’re in a tent on the Savannah, you really want to not have flu.
Speaker 2 (18:51):
So yeah, it can be deadly for segments of the population.
Speaker 3 (18:55):
Up to 50,000 people a year die of flu every year in the United States. It is not a trivial disease.
Speaker 2 (19:00):
No, not at all. And we have available resources. We’re lucky in this country that you can be anywhere in this country and get a flu shot.
Speaker 3 (19:11):
Speaker 2 (19:12):
And many communities, even if you don’t have health insurance, will allow you to get a flu shot through public health. Speaking of flu and illness, how would an individual, besides getting a flu shot, help themselves out during flu season?
Speaker 3 (19:29):
Well, this is where the recommendations are not very sexy, if you will. But they work. So, Purell or alcohol based hand rubs are remarkably effective in reducing the risk of auto-inoculation, that is, shaking somebody’s hand, opening a doorknob that somebody who is ill just had opened, and then inoculating yourself by touching your eye, touching your nose, or ingesting. So, copious use of that, especially in public places like airports or hospitals or your clinic locally. So, befriend Purell or whatever your local alcohol-based hand rub. Just plain hand-washing is good. I often hear in our own cold area here up at Dartmouth that people don’t like washing their hands too often in a day because you get dried out and cracked and whatnot. But, the alcohol-based hand rubs now come with moisturizers and really there’s very little excuse not to do that. I always tell my patients and people who are interested in their best health to avoid ill people. That can be socially awkward. You know, you’ve been seeing Aunt Betty at Thanksgiving dinner and she’s coughing and sneezing. How do you get away from that, or not shaking hands at church, if you’re of a Catholic persuasion, that kind of thing? You need to make decisions in your best informed risk-benefit. if you’re going to shake hands during the flu season, make sure you have Purell in your pocket.
Speaker 2 (20:55):
Would wearing a high filtration surgical mask, if you’re in an environment that would lend itself towards getting infected, be useful?
Speaker 3 (21:06):
Well, that’s an interesting question. So for the personal protective equipment, certainly during SARS and some of the more dramatic events we’ve had of global attention, people stocked up and thought that it might be part of their best armamentarium to have a box of masks in case they were out in public where people are sneezing and coughing. And I think especially if you’re a vulnerable person, such as by a compromised immune system, you know, if your doctor’s giving you a TNF-alpha inhibitor for a rheumatologic disease like rheumatoid arthritis, or if you’re approaching a bone marrow transplant, heaven forbid that kind of thing, then yes, forego the fashion and don the mask. And those come in two flavors, or two main types of masks. One is the surgical mask as mentioned. And the other is the high particulate filtration mask, the so-called N95. So I’d let you know that the N95 is really effective to prevent airborne diseases like Tuberculosis, but probably is not very practical in a daily way, like in a grocery store or a church or wherever, because it is such a good filtrator that it can make it hard to breathe and you sweat underneath and etc. So most folks who are looking to us to avoid some of the circulating respiratory viruses, especially if they’re compromised in some way, immunologically speaking, do well with the surgical masks.
Speaker 2 (22:28):
And then everybody’s favorite concern is flying.
Speaker 3 (22:33):
Yeah, I have heard this so often that people have the belief that the air in an airplane is somehow dirtier than their air at home in terms of pathogens. It’s an interesting misconception and I like to dispel it because I think people feel very helpless when they’re in a long haul flight and with the belief that they’re inhaling pathogens. I think I can release you from that fear because actually there’s far more air exchanges in an airplane than there is in this office we’re sitting in, for example. You know, so, the air itself is remarkably clean within an airplane. The challenge we have and getting ill on a plane is who sat in your seat before you, or, what’s going on with your arm rests and the tray that you’re about to touch all over and then potentially inoculate yourself from.
Speaker 3 (23:28):
So I like to bring Wet Ones or wipes to clean my environment when I’m going to be on a long haul flight and I won’t have many options to escape the pathogens that are entrenched in my environment there. The other risk in airplanes is sitting next to that person who’s oozing and leaking and snoozing and snuffling. And I don’t think many people get very much satisfaction when they ask if they can be reseated. But you might make that case, especially if you have a compromised immune system, if the plane isn’t completely full, and asked to be reseated if the person next to you is suffering with something. That’s one strategy.
Speaker 2 (24:05):
And it’s, you know, difficult for people, but if you’re sick and you don’t have to go out, don’t do it if you can stay home from work.
Speaker 3 (24:17):
Yes, I absolutely see that as a contract we make to one another, that if you know you have an infectious, contagious disease, you owe it to your neighbors, maybe who are sick in ways you don’t know, or to the other kids at the daycare where your kid goes, I think we need to build in some safety net that people can stay home from work when they need to. And I think that we’re seeing that, especially in the healthcare environment, that if you’re a doctor or a nurse and you’re sick, you got to mask up or more likely you should probably stay home during your infectious period. So, I think we need a significant culture shift that we should not tolerate sick people in our environment, especially in an era where people are compromised by the medicines that they take for underlying disease.
Speaker 2 (25:01):
And, something like the flu, you’re most likely to inoculate somebody during what part, when you have a fever?
Speaker 3 (25:12):
Yes, that’s right. The initial stages of a flu, the true influenza, are the most infectious. But there are even diseases that transmit before you even have a symptom. So that’s pretty hard, right? So for example, measles. If you have been exposed to somebody with a rash illness, that’s something that probably should be investigated because you can spread that pretty much like wildfire. It’s one of the most contagious diseases that we know about in our society and you can spread it before you’re with any symptoms at all.
Speaker 2 (25:48):
And since we’ve made that leap to measles, let’s talk about vaccinations and this concern that people have that they shouldn’t vaccinate their children.
Speaker 3 (25:59):
Deep sigh. As you might expect, I see the vaccinations that we have available to us as vaccinations are the great success story of public health. In the last hundred years, we have seen a remarkable decline in morbidity and mortality from some of these diseases that now our doctors have never seen. Measles, in some cases, mumps, and certainly smallpox and other diseases that were absolute plagues now are almost historic. And yet, as you’re alluding, we have a tragic upswing in concerns around the safety vaccinations. So, the great setback we’ve suffered as a society globally has been the false report put out by Dr. Wakefield regarding the association of the measles, mumps, rubella, the MMR, with autism. This is a fabricated report that has been subject to criminal investigation because of the falseness of it. And yet, the notion persists that there may be an association that is a causation. People are sometimes concerned or have heard this story from Dr. Wakefield, the fabrication that MMR may cause autism. In fact, it happens that most autism declares itself at about the same age as the MMR vaccine is given, and therefore, it is temporarily coincident, but not causing disease. And any credible doctor has seen this data and believes wholeheartedly, I certainly do, that this has been a great setback to us and a tragic blip in the history of the success of vaccines.
Speaker 2 (28:03):
And I think it’s that temporal relationship that we certainly empathize with people who have children with autism and feel that there was a cause-effect relationship. But they don’t realize that it just is the onset and happens to be about the same time that most kids get vaccinated.
Speaker 3 (28:21):
Yeah. And then, the epidemic of autism is an independent tragedy that is not to be understated. That indeed, people, families, and society suffer with this disease that we need to know a lot more about. But what we do know, is that they are not associated, that autism is not associated with vaccines. This has been studied many different ways by many credible groups, and I believe it wholeheartedly.
Speaker 2 (28:45):
Yeah. And the harm that can come from not vaccinating.
Speaker 3 (28:49):
Is far greater. So the resurgence of some diseases that we thought we had put behind us, like mumps, which can cause deafness, which can cause sterility; and measles, which causes death and encephalitis and certainly a great loss of productivity, during any epidemic, these are very costly and very terrible when they happen and they are happening increasingly in societies that are avoiding the vaccination.
Speaker 2 (29:17):
I’m going to ask you one more topic because I know you have to go, about superbugs and antibiotic resistance. I think antibiotics have been overused. We’re trying to be more cautious about how we use antibiotics and when.
Speaker 3 (29:32):
That is a great topic. I am very passionate about that one too. So, just as vaccines have been a great success to us, of course, antibiotics have saved so many lives and reduced so much suffering. And yet, there is a pendulum swinging toward overuse and inappropriate use. How often when we feel sick do we expect that an antibiotic might turn it around? And that’s rarely the case during the flu season. That is, with influenza, adenovirus, rhinovirus, on-and-on, these are not affected at all by antibiotics and you have a far greater chance of suffering an ill effect of the antibiotic than you do from the virus itself. So, this is a very complicated issue in terms of resetting appropriate use of antibiotics. It’s at the patient level, the patients and their expectations. It’s at the doctor level. You know, I have a seven-minute appointment with a patient with a cold and it might be just easier to write a prescription.
Speaker 3 (30:35):
That’s the wrong way to go. It’s at the advertising level. We see on television, we hear on the radio, we read in magazines, you know, how great these antibiotics are. And then we even have a very sinister space where antibiotics are used, and that is in agriculture. So antibiotics are used by the tons to promote food and animal growth and to keep them healthy, but mostly the former. And there’s a great effort afoot to curtail that because we know we’re engendering drug resistance that is making these antibiotics ineffective by these overuse scenarios I’ve painted. So we have a long way to go on that front and it’s a great topic. So don’t push your doctor for antibiotics if you have a cold. It’s the wrong way to go.
Speaker 2 (31:25):
Well, I would sit here all day and ask questions, but I know you have a patient and I don’t want to be the one to make you late. So I truly appreciate your time and your expertise. Thank you.
Speaker 3 (31:37):
Thank you. Great topics. Thank you very much. And maybe you’ll invite me back someday.
Speaker 2 (31:42):
Absolutely. It’s a pleasure. Thank you.
Speaker 1 (31:42):
This completes another podcast chapter of the Washington State Urology Society’s Original Guide to Men’s Health. This is Dr. Richard Pelman reminding you to take care of yourself. Washington State Urology Society wishes to thank all contributors who volunteered their time and knowledge. The information presented is the opinion of the speakers. The society also wishes to thank Sean Fox for his invaluable technical assistance. The music theme, San Juan Bells, was written and performed by Dr. Dave Whiting. The podcasts are the property of the Washington State Urology Society. Reproduction and use without the express consent of the society is strictly prohibited. For more information about men’s health, visit wsus.org or visit your physician or care provider.