By Robyn Alie, Manager, MMS Health Policy and Public Health
“There are a lot of bad bugs in the world. And there are different bad bugs in different parts of world. And all the bad bugs are bad.”
— Alfred DeMaria, MD, state epidemiologist (shown delivering the 2016 Annual Oration on Zika)
How is global disease tracked in the Commonwealth, and how does that influence patient care? Vital Signs asked Alfred DeMaria, MD, medical director of the Bureau of Infectious Disease and Laboratory Sciences in the Massachusetts Department of Public Health (MDPH) and the state epidemiologist, how outbreaks abroad become local.
How and why do emerging infections and outbreaks in other parts of the world affect Massachusetts?
The most important factor is that more people are traveling. People from Massachusetts go to the developing world — as tourists, to work, to learn — and then they come back after being exposed to conditions that we need to pay attention to. People from all over the world come to Massachusetts as well.
For example, all the cases of measles we have dealt with have originated in people who’ve traveled from other parts of the world. There’s very little transmission of tuberculosis (TB) in Massachusetts. Close to 90 percent of cases of TB we diagnose in Massachusetts are in people who went elsewhere in the past — five to 50 years ago — who are now, for a variety of reasons, developing active disease. If we don’t do something about TB in the rest of the world we will never eliminate TB in Massachusetts.
What other diseases are you monitoring?
Last year, there was an outbreak of yellow fever in Angola, and it spread to the Democratic Republic of the Congo. Fifty years ago, nobody from Massachusetts was likely to go there. Now we have to be aware of outbreaks that occur in the developing world as well as in the developed world.
It’s very important that we keep an eye on what’s going on not only with transmission but also with control efforts. Another good example is avian influenza in China. We’re monitoring the surveillance that the Chinese CDC is doing on human cases and bird cases, because they’ve been observing an increase. Now, is the level of concern such that we would warn every clinician in Massachusetts to be on the lookout? No. But it could conceivably get to that.
How does your surveillance affect clinical practices here?
The MDPH gets a lot of calls from physicians in Massachusetts who are concerned about certain cases that have implications because someone has traveled. They say, ‘I have this patient with pneumonia who is not responding to therapy. They were traveling two weeks ago; should I be concerned?’ And the answer is yes.
A special concern, though not big in volume, is people who seek health care elsewhere and could be exposed to organisms in health care facilities. In other parts of the world, people can just buy antibiotics over the counter, so the opportunity for organisms to become resistant is higher. The first cases we’ve seen in Massachusetts of the New Delhi strain of gram-negative organisms — which are resistant to multiple drugs, including the carbapenems — were in people coming from different parts of the world. They can be Massachusetts residents who went to India, for example, for surgery.
If you’re not aware of it, if you don’t recognize it, then there’s potential for spread within a facility. We work closely with our hospitals on infection control. If somebody goes from the hospital to a nursing home carrying one of these bugs, we have to make sure that the nursing home does what’s necessary.
Another example is Candida auris. This is a yeast that was not really identified in human infection until fairly recently, but has the potential for being resistant to the drugs that are used to treat yeast infections. It also has the potential to contaminate the environment, so somebody using the same room after a patient is discharged could conceivably be exposed. There have been outbreaks related to different strains of Candida auris that were first seen in South Asia, East Asia, South Africa, and Venezuela. We had a webinar recently on Candida auris.
How can physicians stay informed about these threats?
We try to keep people aware. But if they want to be aware of more, and be aware of it earlier, they should subscribe to the CDC’s clinical alerts.
ProMED-mail is an international system of communication about emerging and potentially emerging infectious diseases. Physicians can always call us if they have a concern.
Report Infectious Diseases
Call the Division of Epidemiology and Immunization at the Massachusetts Department of Public Health at (617) 983-6800 or (888) 658-2850 (days, nights, or weekends).
