Personal Reflections on a Pandemic by Thomas AE Platts-Mills, MD

Thomas AE Platts-Mills, MD

By Thomas AE Platts-Mills, MD

While starting to think about an annual report on the division, I realized that it was irrational not to think about the context. For the first time in 50 years as a doctor and 38 years as a division head, I have been holding clinics by telephone, avoiding going into town and certainly not going into the hospital. The arrival of a novel virus that is both highly contagious and carries the risk of major pulmonary morbidity eclipses almost all other aspects of medicine.

The ‘context’ for me inevitably includes history both personal and earlier. Infectious disease has had very little impact on my own life. Our family vacation in the summer of 1948 was disrupted by a move away from the sea-side on the Isle of Wight to a farm close to London. This occurred because there was a polio epidemic and many people thought polio was spread through the water. Death was not unfamiliar to my parents as there had been a truly terrible loss of life in the 2nd war. Pearl Harbor occurred when I was two weeks old and the battle of Moscow was going on that winter during which a million Russians and 600,000 German soldiers died. Before I was two, Nimetz had won the Battle of Midway and the Russians had won both Stalingrad and the second battle of Kursk. Once I was conscious, we moved to London and in 1950, I met my 90-year-old great uncle Donald Cree. He had gone to sea at the age of fifteen after watching two older brothers die of pulmonary TB, a fate that he successfully avoided. In 1951 my father and I flew to New Zealand to visit his family and there I met the original… Dr. Daisy Elizabeth Platts-Mills. In 1918 she played a significant role in the management of the Spanish Flu in a hospital in Wellington. That influenza was an incredible killer. Outbreaks of the disease among soldiers in the Great War had a mortality rate as high as 20%. This occurred in the U.S. among troops in boot camp and in the UK among troops held in a camp in Eastbourne for several months after they returned from the trenches. Equally some ships loaded with NZ soldiers who had survived the 4th battle of Ypres at Passchendale, had lost as many as 20% of their passengers to influenza before they reached Auckland. My mother’s father did not die of influenza, because he was hit by a random piece of shrapnel just before the 2nd battle of Ypres and he died on the 12th of May 1915.

After 1918, there was a progressive and ultimately dramatic decline in the mortality rate of infectious diseases, including an almost 90% decrease in TB mortality before the introduction of Streptomycin. Since the development of an effective polio vaccine and broad-spectrum antibiotics, there has been remarkably little public panic about infectious disease in the USA or the UK. Two episodes of flu that I can remember making an impact. One in 1957 (Asian Flu) which put my older brother in bed for a week and the other in January-February 1969 when I was already a third-year medical resident. In that year, despite having several previously healthy middle-aged men extremely sick in the hospital, I don’t remember much in the way of public concern or protective clothing. The contrast between COVID and HIV is astonishing. Attending in general medicine at UVA between 1984-1990, we regularly looked after AIDS patients who were dying. The contrast was that it had become clear that it required a real effort for doctors to get infected from a patient with AIDS, i.e. sharing needles which were not recommended.

There are important lessons to be learned from the great epidemics of the past and the Great Flu was certainly not “the deadliest” (see” The Great Influenza” by John Barry page 87). Black Death was the most dramatic. It hit Europe in the 1340s and killed at least one-quarter of the population. Yersinia pestis had probably been around for a thousand years, but the plague of the Black Death was the worst recorded episode. Equally important it reoccurred in the UK and other parts of Europe (including London) at varying intervals up to 1665, which was documented by Daniel Defoe in “A Journal of the Plague Year”. The outbreaks of plague stopped after the Great Fire of London in 1666. Primarily because the town was rebuilt after the fire, under the influence of Christopher Wren, which resulted in a dramatic improvement in public hygiene. In the mid-17th century, the population of England had not yet fully recovered from the original pandemic of plague, and it only recovered slowly over the hundred years after the plague was no longer a problem. The population was still controlled by several other killers including pertussis and smallpox.

When Sally Hemmings arrived in Paris in 1787, Jefferson was concerned for her health because contrary to his recommendation, she had not had smallpox or been variolated. Because of this she was initially confined to the house, and in November 1787 she was sent to another house outside Paris to be variolated and subsequently “quarantined” for forty days, incidentally the true origin of that word (see chapter RE: Dr. Sutton in “The Hemmingses of Monticello” by Annette Gordon-Reed). At that time smallpox was very dangerous in Paris, and this was still ten years before the introduction of vaccination by Jenner in 1798. It is important to recognize that he used the same procedure on the skin that had been used for many years, he simply established that using pus from a dairymaid with cowpox, instead of using pus from a case of smallpox, was equally effective and much safer. This vaccine was so effective that it was still the primary therapeutic or preventative strategy when smallpox was eradicated nearly 200 years later. In the 19th century, Pasteur established a vaccine for rabies that was still in use 100 Years later. By contrast, Koch, who had identified the tuberculosis bacillus, failed to produce an effective vaccine. Indeed, the early failures with the TB vaccine cast a shadow over his reputation. It is important to remember, that there have been many failures in the history of vaccination. Malaria and HIV are obvious examples, but equally, attempts to produce a “universal” vaccine for influenza have failed which is why we still attempt to produce a new vaccine each year. Interestingly last year the CDC reported that the influenza vaccine was only 12% effective among subjects over 70 years old, i.e. exactly those individuals who have a maximum risk from SARS COVID 2 virus. By contrast, a previous member of the faculty of the Allergy Division, Dr. John Guerrant, had the Spanish flu in 1918 and maintained that he didn’t have any symptoms related to influenza in the following 80 years! For further insight into the problems with the influenza vaccine see the RFA issued by Dr. Fauci and his colleagues at NIAID in March 2020.

Arguably the most striking feature of COVID-19 is the speed with which it can spread through a community. This characteristic, if unchecked, allows severe cases to suddenly appear in large numbers even if they are only a small proportion of the infected cases. There is an interesting question about how many of the victims in 1918, who died about 2 weeks after the onset of symptoms, could have been saved with intense care and broad-spectrum antibiotics. The other striking feature of COVID-19 is that infected individuals can infect other individuals for several or even many days before or after they are symptomatic. Dealing with these problems is impossible without an effective method of testing for the virus. This was particularly true in the United States because the public health service including the CDC “chose” in Jan and Feb not to solicit help from the established laboratory testing companies with developing mass production of tests for this virus. The contrast with the experience in South Korea and Germany is particularly disturbing. As a result, for several weeks we were in a similar situation to that which my grandmother faced in 1918, because we did not have an available test to identify the virus, and we didn’t have a specific treatment for the disease. This situation may not last long because the virus appears to be more genetically stable than influenza. This means that the potential for a long term vaccine is much better than for HIV, TB, malaria, or influenza. In addition, despite several early failures, it looks increasingly likely that one or more of the vaccines for COVID and/or the monoclonal antibodies that “cured” our President, will prove to be effective.

Early this summer it seemed wise for the mature members of our community to self-isolate and attempt to work from home. However, it soon became clear that all the members of my group had chosen to continue working. In addition, they had fully adopted both masks and social distancing. In addition, they had identified a major gap in the COVID-19 testing which was the need for an assay for serum antibodies in units that can be compared with other labs i.e. µg/ml. Our lab has remained busy. The main disease we study is the alpha-gal syndrome which also has ramifications into CAD and IBS. ….. The alpha-gal syndrome occurs because we don’t carry the oligosaccharide galactose-alpha-1, 3 galactose and have natural antibodies against it. It. When I say “we” I don’t mean most humans, I mean all (i.e.100.00%) cannot create the galactose-alpha-1, 3-galactose linkage. Recently a radical evolutionary explanation for the consistency of this difference between primates and other mammals has been published by Uri Galili. He proposes that at some time about 10 million years ago, an enveloped virus or another pathogen, appeared which carried alpha-gal and which was 100% lethal to those of our ancestors who also carried this oligosaccharide. By contrast, although only a minor proportion of the population of primate ancestors had pre-existing antibodies against alpha-gal, they were the only survivors. He has proposed the term “catastrophic evolution” for this event. I would suggest that this is a rather sobering thought in view of the current COVID-19 epidemic. However, the real lesson may be that the present population of the world, and the fantastic levels of overseas travel, guarantee disasters such as the Great Flu or COVID. Is the occurrence of two severe pandemics in a mere 100 years a warning to the human race?

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