Author’s Note, 2014

Disease detectives learn something new from nearly every investigation of an infectious disease outbreak. In writing this introduction to the paperback edition of Deadly Outbreaks, I thought it might be useful to review investigations conducted since the book was published—and to consider what these experiences have taught us. Here are my lessons learned:

One: Prepare for the Unexpected. The diversity of infectious disease outbreaks in the U.S. between September 2013 and December 2014 confirms that—when it comes to infectious microbes—we must always be ready for the unexpected. This fall, for example, a strain of enterovirus—a common type of virus that typically causes mild cold-like symptoms—unexpectedly caused severe respiratory disease in children (especially children with asthma) that required hospitalization and intensive care.1 Several unusual foodborne outbreaks occurred as well. Last winter, more than 630 people in twenty-nine states fell ill with salmonellosis after eating meals prepared from a contaminated frozen chicken product purchased at supermarkets across the country. The causative strains of bacteria were resistant to several common antibiotics. Another multi-state outbreak of gastrointestinal illness, which affected more than three hundred people, was traced to imported batches of fresh cilantro contaminated with Cyclospora, an intestinal parasite endemic to the tropical and sub-tropical regions of the world.

Something else unexpected: The New York Times recently reported on the surprising legal aftermath of a nationwide investigation of fungal meningitis that was winding down when Deadly Outbreaks was published.2 More than a year earlier, medical detectives had determined that a medical steroid product used to treat lower back pain and sciatica had been contaminated with a common mold called Exerholium rostratum. Injected into patients’ spines and joints, the mold caused spinal infections, meningitis, and strokes, leading to sixty-four deaths. On December 17, 2014, The New York Times stated that two executives of the Massachusetts compounding pharmacy that prepared the contaminated product have been charged with twenty-five acts of second-degree murder in seven states.

Two: We Are All in It Together. Over the past year, the United States was directly affected by two epidemics that are causing devastation in other parts of the world. Last spring, two Saudi healthcare workers on vacation in the U.S.—one in Indiana and one in Florida—fell ill with a dangerous, SARS-like disease caused by the Middle East Respiratory Syndrome coronavirus (MERS-CoV). Both were hospitalized, and both survived. In October, a traveler from Liberia visiting friends and family in Texas was hospitalized with Ebola hemorrhagic fever, three days after being sent home from the emergency room because of an initial misdiagnosis. The traveler, Thomas Eric Duncan, died a little over a week later. Two nurses who cared for him contracted Ebola fever; fortunately, both survived. Since then, one other person in the U.S. has been diagnosed with Ebola (an American doctor returning from Guinea), and five Americans who contracted Ebola while working on medical response teams in Liberia and Sierra Leone have been evacuated to the U.S. for treatment.

The outbreaks of MERS and Ebola fever illustrate that—especially when it comes to infectious diseases—we live in a global village where everyone is potentially exposed to everyone else. Helping other nations control outbreaks at their source is therefore a matter of self-interest as well as a humanitarian imperative. Infectious microbes, which have always traveled between countries and continents—in people, animals, insects, and objects—can spread faster than ever before in today’s world of air travel and global trade. Therefore all of us are at risk, no matter where we live.

Three: We Are Fortunate to Live in a Country with a Strong Public Health System. My final observation is that each outbreak that occurred over the past year, whether at home or abroad, confirms the major take-home lesson of Deadly Outbreaks—that we are fortunate to live in a country with a public health system that we can take for granted as being there when we need it. The Ebola outbreak in West Africa, in particular, demonstrates in stark and painful terms what can happen when a society lacks a routine way to detect unusual diseases, isolate and treat infectious patients, and prevent disease from spreading in homes, hospitals, and the community.

With these ideas in mind, I dedicate the paperback edition of Deadly Outbreaks to the brave and resourceful medical detectives and laboratory scientists who work behind the scenes to keep us safe.

Alexandra M. Levitt, PhD

December 30, 2014

1 Over the course of the fall and winter, physicians reported an unusual number of cases of children hospitalized with muscle weakness or paralysis. As I write, an investigation of these cases—which do not appear to be associated with enterovirus infection—is underway.

2 Jess Bidgood and Sabrina Tavernise. Pharmacy Executives Face Murder Charges in Meningitis Deaths. New York Times, December 17, 2014.