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Infected

Colorado is no stranger to deadly infectious diseases—in fact, our medical community is among the most experienced in the nation. We break down the lethal germs already present within our borders and explore how experts would battle new infiltrators.

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Here in Colorado, safely nestled in the middle of the United States, it was easy to feel insulated from far-flung infectious diseases like Ebola, which began its tear through West Africa last summer. Until, of course, the disease flew into Dallas/Fort Worth International Airport, just 770 miles from the Mile High City. It was at that moment we all began to hope the Centennial State’s long history of expertise with deadly germs—from the first tuberculosis sanatoriums in the early 1900s to the cutting-edge research currently coming out of the CDC’s Division of Vector-Borne Diseases in Fort Collins—would keep us safe. “When it comes to infectious diseases, especially the ones that are of major concern to humans,” says Dr. William J. Burman, director of the Denver Public Health department, “Colorado has always been very active
in research and very focused on effective public health strategy.”

Well equipped with world-class hospitals and highly trained specialists, Denver may be in a better position to manage deadly contagions than other places on the planet—like, say, Liberia (and maybe Dallas?). But with the gates of Denver International Airport—the fifth busiest airport in the world in terms of planes arriving and departing—just 25 miles from downtown Denver, places with underprepared health-care systems aren’t so far away anymore. Which begs a question: How exactly would we deal with an Ebola virus infection in Denver? And perhaps even more important, how do our local medical experts respond to outbreaks from the dangerous germs (plague! hantavirus! tularemia!) already living here?


Germ Factory

Flu is Colorado’s most deadly infectious disease, but these six infections are nothing to sneeze at.

Viruses and bacteria are everywhere—on shopping-cart handles, computer keyboards, even in the air—making infectious disease the greatest threat to humans worldwide. In Colorado, the Department of Public Health and Environment monitors 57 potentially lethal infectious diseases. By law, local hospitals and laboratories must report the most serious bugs, like tuberculosis, within 24 hours. The rest, such as hantavirus and tularemia, must be relayed to the proper authorities within seven days.

The department’s Disease Control and Environmental Epidemiology Division analyzes these numbers regularly. “This is the process that identified the listeria outbreak in 2011,” says Dr. Tista Ghosh, the division’s director and the deputy chief medical officer. “We got reports of several cases in one week—normally we see only a few of them a year—and launched an investigation.” Listeria, a rare foodborne bacterial infection, caused the deaths of 33 people nationwide, including 12 in Colorado, before epidemiologists linked it to contaminated cantaloupe from, yes, Colorado. While Ebola may make you feel a little squeamish, it’s more often infections like the ones caused by listeria—and the six others detailed below—that should give you the heebie-jeebies.


Overlooked

Colorado’s most deadly infectious disease isn’t getting its due.

During the 2009-10 season, influenza put 2,041 Coloradans in the hospital, killing 82 of them. The responsible strain—H1N1, aka the swine flu—was one of the more lethal in recent history; however, influenza takes thousands of American lives every year. Strangely, no one seems all that worried about it. In fact, hospitals aren’t even required to report outpatient cases. “If a new infectious disease came along and did what the flu does every season, we would declare it an emergency,” says Dr. William J. Burman, director of the Denver Public Health department. “It would be on the front page of the paper all the time, and yet it passes by with hardly even
a comment.”

As a point of comparison, the 2014 Ebola outbreak didn’t kill anyone in Colorado (two Ebola patients did die in other states). Nor is the Africa-born virus as easy to catch. Unlike the highly contagious flu, which is transmitted through the air, Ebola requires contact with the blood (or other bodily fluid) of an infected individual. Yet most of us fear
the Ebola virus much more than a bout with the common flu. “Ebola is dramatic; it’s terrible,” Burman says. “And so it gets a lot of attention. What we’re not so good at, as a community, is talking about those unsplashy, unsexy infections.”

The good news about influenza is, of course, that it’s somewhat preventable. Colorado doctors recommend getting the flu vaccine (for everyone six months and older) as soon as it’s available, which is typically in September. “You can get the vaccine from your doctor, or even at the grocery store,” says Dr. Lisa Miller, an epidemiologist at the Colorado Department of Public Health and Environment. The key is to get it—even if “Deadly Flu Pandemic Paralyzes Front Range” isn’t splashed above the fold of the Denver Post.


It Could Happen To Us

Our city is not immune to scary infectious diseases. Here, how Denver would respond if—or when—one arrives.

It’s already happened in Atlanta, Omaha, and Dallas: An infected person boards a plane in West Africa and brings Ebola home with them. Fortunately, no one with the virus has landed at DIA. At least, not yet.

“We had to evaluate a passenger [in late September] flying in from West Africa with an illness,” says Dr. William Burman, director of Denver Public Health, the arm of Denver Health devoted to keeping the public safe by tracking communicable diseases and promoting healthy behaviors. The passenger—we’ll call him John Smith—left Africa, connected through Europe, and became sick on the final leg to Denver. Smith told a flight attendant he was sick (and concerned, considering his country of origin), prompting the attendant to make a call to DIA, which sent an ambulance to meet the flight and notified Denver Public Health and the Centers for Disease Control.

At the scene, paramedics called Denver Public Health’s 24-hour monitoring system, and an infectious disease public health specialist evaluated Smith over the phone. “Based on his symptoms and where he’d traveled in West Africa,” Burman says, “they were able to rule out Ebola, and the passenger was sent home.”

Had Smith displayed symptoms of Ebola, such as red eyes, rash, or flulike discomfort after exposure to an infected person, he would’ve been admitted to the hospital for testing. Technically, any of Denver’s major medical centers can handle infectious diseases, but since Denver Health Medical Center had been designated as a treatment center for Ebola, Smith would’ve been taken there.

At Denver Health, Dr. Connie Price, the chief of infectious diseases, would take over. Price would place the patient in a sealed-off section of the ward in a single, negative-pressure room. The doc would require her staff to use gowns, gloves, eye protection, respirator masks, hair covers, and disposable shoe covers to prevent contact with the patient’s blood and bodily fluids. “There are a lot of similarities between our facility and the one in Atlanta [where three American doctors who returned from Liberia with Ebola were cared for],” Price says.

Since there is no cure for Ebola, Price and her staff would administer the best ICU care available, including giving fluids and meds to maintain blood pressure. Says Price: “Our job is to keep the patient alive to allow his immune system to fight the infection.”

Beyond the patient, Denver Health’s other, just as critical job is ensuring no one else on the premises contracts Ebola. It’s a task easier said than done. In Dallas, two nurses working with Thomas Eric Duncan, the first patient diagnosed with Ebola in North America, contracted the disease in what the CDC called a breach of protocols. This doesn’t surprise Price, but she says it is avoidable. “Putting on and taking off protective garb is complex,” she says. “It requires lots of equipment, a certain sequence, and hand hygiene between steps. We use a checklist and a buddy system to make sure we get it right.”

Denver Public Health also initiates contact-tracing to track down people the patient may have interacted with and get them evaluated. Depending on the situation, the state health department and the feds could get involved. “This is not just for Ebola,” Price says. “We use these protocols for a variety of threats.” Although she’s aware of the pitfalls of being overconfident, Price is certain Ebola and similar diseases would not get far here: “We have practice with infectious disease every day in Denver.”


This Is Not A Test

Three promising infectious disease research studies happening right here in Colorado.

Dengue Hemorrhagic Fever
Dr. Edwin J. Asturias, a doctor at Children’s Hospital Colorado and the associate director at the Center for Global Health at CU, is helping developing countries learn how many of their citizens are infected with dengue—a mosquito-borne virus that’s the leading cause of death in the tropics and subtropics. “We’re using mobile technology—like texting—in Guatemala to identify individuals with symptoms, and then we go out to test their blood,” Asturias says. “The goal is to help governments know where their hot spots are so they can employ control measures—like bed nets and spraying for mosquitoes—that we’ve used with success in other areas.”

Middle East Respiratory Syndrome (MERS)
An expert in emerging pathogens, Dr. Samuel Dominguez—a pediatric infectious disease doc at Children’s Hospital Colorado and an associate professor at the University of Colorado School of Medicine—wanted to better understand MERS, a viral respiratory illness first reported in 2012 that’s killed 30 percent of those infected. In a pilot study, Dominguez studied the virus in bats. “We wanted to find out if they could be persistently infected with these viruses,” he says. “Also: Does it make them sick, stay in their systems, leave their systems? We also had uninfected bats living alongside infected ones to see if they contracted it.” He expects his analysis—which should help scientists better understand the host range and duration of the infection—to be completed by mid-2015.

Plague
Dr. Marty Schriefer, the chief of reference and diagnostic activity in the Bacterial Diseases Branch at the CDC’s Division of Vector-Borne Diseases in Fort Collins, has spent the past five years developing a dipstick-style test to identify plague. “Plague is a treatable disease, but it has to be treated quickly,” says Dr. Lyle R. Petersen, director of the Division of Vector-Borne Diseases. “That’s not often how it works in places like Uganda. But with this test, we can diagnose plague in clinics without any lab equipment in just minutes. And we can produce the kits [which were awaiting FDA approval at press time] for less than $1 each.”


The Satellite Office

When it comes to the national public health institute of the United States, otherwise known as the Centers for Disease Control and Prevention (CDC), most people think of the city of Atlanta. The federal agency has been located there since its inception in 1946. But here’s a little-known fact: One—and only one—division of the CDC focusing on infectious diseases exists outside Georgia. We sat down with Dr. Lyle R. Petersen, the director of the CDC’s Division of Vector-Borne Diseases, located in Fort Collins, to learn more about the work happening an hour north of us.

5280: Are you guys the black sheep of the CDC? Is that why they stuck you in Colorado?
Petersen: It’s kind of a historical accident. Back in the 1930s, ’40s, and ’50s, there was a mosquito-borne virus called Western Equine Encephalitis, which was very common and killed thousands of horses, and even people. A lab was put in Greeley to get a handle on the issue. In 1967, it was decided to move the laboratory to Fort Collins because of the unique collaborative work that was being done with CSU. We’re actually located on the CSU campus and have a very symbiotic relationship.

Vector-borne disease sounds like it has something to do with geometry.
Vector-borne diseases are those that are largely spread by mosquitoes, fleas, and ticks. Almost all of these diseases are dramatically increasing in frequency and distribution all around the world. West Nile is a good example. This was an African virus that was imported into the New York City area in 1999 and then spread across the country. What’s fairly unique is that northern Colorado has one of the highest incidences of West Nile in the entire country. For some reason, it’s a real hot spot. So it turned out to be a good thing that we have the foremost research institute in the world in a hot spot for West Nile.

Has your division had any contact with Ebola?
It’s not our focus, but our epidemiologists are capable of working on any emergency response. We have folks working in Atlanta, Africa, and even in Dallas. At any given time, our people are investigating outbreaks or doing specialized studies all over the world.

It’s hard not to envision your office like the labs in The Hot Zone.
We have about 250 people who work here in Fort Collins, in a four-story building encompassing laboratories and office space. We grow mosquitoes and fleas and ticks. It’s a very interesting place. Some of these diseases we study are bioterrorism agents—diseases like tularemia and the plague have been weaponized by other countries. Needless to say, the security here is pretty high.

Bioterrorism? Sounds scary.
It can be. Remember when plague turned up in New York City in 2002? Plague shouldn’t be in the eastern United States, so we were alerted. We’re able to identify where these strains come from and determine if there is or is not a bioterrorism incident. In that case, it turned out the couple who got sick in New York had actually been infected in New Mexico. Because of the kind of work we do, we could look at the bacterium itself and match it back to New Mexico and not, say, Afghanistan.

Factoids
– The most common vector-borne diseases in the United States are West Nile virus, Lyme disease, and Rocky Mountain spotted fever.
– West Nile virus was unknown in the United States before 1999. In 2012, it infected 5,674 Americans.
– Almost all vector-borne pathogens are zoonoses (meaning they can live in animals as well as in humans), making them even more difficult to control.


Chronic Adversary

With fewer people dying of AIDS here in Colorado and across America, there’s an unexpected roadblock to eradicating the disease: apathy.

Take a few seconds to try to remember. Send your mind back to the late ’80s and early ’90s, and conjure the emotions you felt when you heard about Rock Hudson or when you watched Magic Johnson’s emotional press conference. Remember the fear in your stomach? The panic, the stigma, the ghastly photos of the afflicted? So how, less than 35 years after HIV was first recognized in the United States, has this infectious virus evaporated from our collective consciousness?

The answer is quite simple: HIV/AIDS is no longer a death sentence in America.

At the end of 2013, an estimated 12,623 Coloradans were living with HIV or AIDS. The key word there is “living.” Since the mid-’90s, doctors have been perfecting the use of antiretroviral therapy (ART) to control HIV. While there’s still no cure, these drugs reduce the impact of HIV on the body, keep the immune system functioning, and even prevent the opportunistic infections that used to kill tens of thousands of HIV/AIDS patients each year. In fact, antiretroviral therapy is so effective today that it is uncommon for HIV to progress to AIDS. The illness is now considered a chronic condition.

But here’s the issue: HIV/AIDS is still here. In fact, in 2013 alone, Colorado physicians diagnosed 302 new cases of HIV. That’s 302 people—friends, relatives, neighbors, and co-workers—who contracted what is, if left untreated, a fatal disease with no cure. The majority were men who have sex with men, but 41 of them were women. A handful were intravenous drug users; 11 were over the age of 60; and four were under the age of 13.

Although we have treatments that allow people with HIV to live long, healthy lives (albeit with a certain amount of stigma, frequent medical visits, and the requirement of taking daily medication forever), apathy is allowing HIV/AIDS to persist. Our success in handling the bug has come at a price: The general public isn’t afraid of it anymore. And without that fear, there’s little motivation to act. “People aren’t dying from HIV like they used to,” says Dr. Mark Thrun, director of HIV/STD prevention and control at Denver Public Health. “The problem is there’s still more work to be done.”

In addition to universal screening (which was recommended by the CDC in 2006 but is still not occurring on a large scale across the country), Thrun and his colleagues are spreading the word about two medications everyone should be aware of. The first, Pre-Exposure Prophylaxis (PrEP), which was approved by the FDA in 2012, prevents HIV. PrEP is a pill taken once a day—similar to birth control pills—that thwarts HIV, even in those who are having sex with an infected partner. Post-Exposure Prophylaxis (PEP) is more comparable to the morning-after pill; since 2005, people who believe they may have been exposed to HIV can get a prescription that will prevent them from contracting the virus (so long as it’s started within 72 hours of exposure). “We have the tools to eliminate HIV right now,” Thrun says. “Even one HIV infection in Colorado is unacceptable.”


Woman On A Mission

A Denver doc helps women with HIV have healthy babies.

As part of the United States Refugee Admissions Program, 26-year-old Jessica* relocated to Denver from Ethiopia. It was in that east African country where she contracted HIV as a younger woman. It wasn’t until two years after integrating into her new mile-high community—where, for the first time, she began receiving antiretroviral drugs—that she and her husband started thinking about having a family. Unlike many women in her native country, Jessica had a doctor to help her deliver a healthy child safely.

For more than 14 years, Dr. Judith Shlay, a family medicine physician and associate director of Denver Public Health, has been helping women bring HIV-negative babies into the world. Just 20 years ago, that was a dicey proposition. In fact, as recently as the late ’90s, the ability for an HIV-positive woman to give birth to a baby free of the virus was a one-in-four crapshoot. Today, Shlay’s work has reduced that risk to almost zero for her patients.
Although Shlay recommends every woman see her doctor if she’s considering getting pregnant, Shlay’s approach begins when a pregnant woman first steps through the clinic’s door: At Denver Health Medical Center, HIV screening is now a standard part of the tests administered at the start of pregnancy. “Universal testing is powerful,” Shlay says. “A groundbreaking study in 1994 showed as a result of testing, the subsequent proper treatment dropped the chance of a woman passing HIV on to her baby from 22.6 percent to 7.6 percent.”

The reason is straightforward: If a woman sticks to her antiretroviral drugs, the HIV is regulated to the point at which it’s no longer present in her blood and vaginal fluids and therefore cannot be easily passed on to her baby. But first, a woman has to know she has HIV. And second, her medical team needs to know so it can ensure she has the necessary drugs.

Getting the remaining 7.6 percent down to zero is trickier. Transmission doesn’t usually occur in utero; instead it can (rarely) happen during delivery or through breastfeeding (this is often the case in countries where women are uneducated on the subject). Ensuring the baby doesn’t get HIV and the mom stays healthy means training a large group of people to be vigilant. From the counselors who explain to mothers the risks of breast milk to coaching nurses working in the delivery room, handing an HIV-free baby to an HIV-positive mother takes an army.

The system Shlay has orchestrated took 10 years to perfect and is still evolving. But it’s working: Jessica welcomed her first child, a healthy baby boy, into the world in January 2013.  “As long as the woman stays engaged and takes her medications,” Shlay says, “I can be 99 percent sure her baby will not get HIV.”

*Not her real name.

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