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Interviewer: Ever since the first case of monkeypox was first identified in the U.S. in May of 2022, there's been concern about the virus and its potential to spread. With newsfeeds featuring images of patients with rashes and lesions, as well as the news that by August, monkeypox has been seen in nearly every U.S. state, it leaves some to wonder if this could be another pandemic.

We spoke with two virologists from University of Utah Health to get their professional opinion to better understand the virus, how it spreads, and perhaps most importantly, how to protect yourself.

Dr. Sankar Swaminathan is a professor and the chief of the Division of Infectious Diseases at University of Utah Health. Dr. Adam Spivak is a researcher and physician with the Infectious Disease Clinic.

Dr. Swaminathan, let's start with the basics. What is monkeypox, and how does it impact the body?

Dr. Swaminathan: It's a viral infection caused by a virus that is related to smallpox and causes lesions or sores on the body, and really can be any part of the skin or mucus membranes. That's the inside of the mouth and the genitals. So that's the primary symptom that people have. It can also cause fever and swollen lymph nodes.

The type of lesion can be quite variable, but generally speaking, they start out as bumps, papules, and they can have a little indentation or dimple in the center of that papule. They can become pus-filled, and eventually, they scab over and they fall off, and they can leave a scar. They're fairly deep-seated, so they can be quite painful. And especially if they're in the mouth or genitals or the rectum, these places obviously can cause a lot of pain.

Interviewer: Now, where exactly did the disease come from? I've never heard of monkeypox before until just a month or two ago.

Dr. Swaminathan: It's been recognized in Africa, in various parts of Africa for quite a while, for decades in fact, and there's been very little spread outside of local populations.

Interviewer: And why are we seeing it now?

Dr. Swaminathan: That's a very good question, and I think a lot of people are trying to answer that. Like I said, we haven't seen this sort of person-to-person transmission, particularly in Western Europe, and in the U.S., and other parts of the world, and now it's become essentially a worldwide problem. The WHO has declared it to be such.

And I primarily think it's just found a niche in people who have close contact, particularly sexual contact, and it's spreading in a way that it might not have been spreading before. It doesn't necessarily mean that the virus has changed, although I think that remains to be determined, whether there've been any changes in the virus that's making it behave in a new way.

Interviewer: And speaking of that, when the World Health Organization declared it an emergency, what are these different groups so concerned about with this particular disease, with its spread, etc.?

Dr. Swaminathan: We realized that there's potential for widespread transmission. And how widespread it's going to be or can be, I think, still remains to be determined, but there's enough of a risk that the WHO has alerted everybody to this.

I think it's compounded by several factors. One is I think our capabilities in terms of testing, vaccination, and treatment have all been somewhat limited, which has allowed the disease to spread pretty rapidly in some areas like New York, and I think the concern is that this could happen elsewhere.

Interviewer: So why don't we move on a little bit to talking about how to identify this disease? So we've talked a little bit about that it looks like a lesion, but some of the things I've been seeing online is it looks like an ingrown hair, or it can be really hard to spot. For someone who is concerned or wants to know whether or not they might have monkeypox, what exactly are they going to be looking for before they go and get help?

Dr. Swaminathan: First I think is how likely it is that they've been exposed. It's people who have been in situations, parties, or group encounters, or raves, or whatever, where they are in contact with a lot of different people, so that's the risk factor.

And if you have had recent intimate contact with somebody, and you don't know exactly what their recent contacts have been as well, it's possible that they may have transmitted it to you without your realizing it.

And like you said, some of the especially initial manifestations may not be particularly alarming or severe, so that transmission could occur even though people aren't aware that they are infected.

Interviewer: Do the lesions change over time, how it expresses itself on the skin?

Dr. Swaminathan: Yeah, they usually progress or evolve. Like I said, they'll start out as a bump and then can become more liquid-filled, pus-filled, can become more painful, and they can break down so that they form an open sore. But eventually, they will scab and fall over. And this can take a couple of weeks or more for it to be fully cleared, and for the person then to not be infectious.

Interviewer: So these particular lesions are . . . like you were saying, they're full of the virus. That's a major infection vector, is the lesions themselves?

Dr. Swaminathan: Correct.

Interviewer: Okay. Are there any other vectors for this particular disease?

Dr. Swaminathan: Certainly other intimate contact like kissing and so on could spread it, but mostly it's skin-to-skin close contact. It can be spread by infected or contaminated clothing, bed sheets, towels, things like that. So any time people are living together in the same household, there's a possibility for transmission even if they're not having intimate contact with each other.

And also, we think that droplets . . . This doesn't seem to be a primary means of spread, but droplets from person-to-person who are sitting in close enough proximity that coughing, sneezing, even a lot of talking could potentially have airborne spread in that manner through respiratory droplets.

Interviewer: Now, does the disease impact anything other than the skin, or is it just a lesion-based kind of virus?

Dr. Swaminathan: Like I said, the other systemic manifestations as we call them are that you can have fever, and swollen lymph nodes, and fatigue. There haven't been any deaths in the U.S. that we know of from this, but it can be quite a severe illness in terms of . . . Usually, there's actually spontaneous recovery, but can lead to fairly severe symptoms that would make somebody not want to get up and leave their bedroom.

Interviewer: Would it require people to get hospitalized for any reason?

Dr. Swaminathan: It could, but generally speaking, we haven't seen that. Hospitalization might be required for severe intractable pain, or inability to swallow, eat, getting dehydrated, or secondary infection, an infection on top of the lesions with a regular bacterial infection, for example. Those would be unusual, but possible reasons why people would have complications and require hospitalization.

Interviewer: So how does someone keep themselves safe from monkeypox?

Dr. Swaminathan: So I think avoiding those types of encounters as much as possible is really almost the only way to protect oneself. Having multiple sexual partners and not knowing very much about what their risk has been, what are their habits, and so on.

Interviewer: In my research, I have been finding some really strange ways to protect oneself. We've had people being like, "I know it's hot in the summer, but just wear a long sleeve t-shirt, and you'll be just fine." I've seen, "Put Carmex on your lesions, and you'll be able to prevent the virus from passing to another person." Are there any known ways to prevent the spread of this disease? And is there any merit to any of these?

Dr. Swaminathan: So I think that you can take precautions if somebody in the household is known to be infected. And I think it would be straightforward, even if it wasn't easy, to make sure that there are no shared utensils, and no shared bedclothes, towels, and all that kind of thing, and that those were properly sterilized in the wash and dryer.

However, as we said, because it's not just from the act of having sex, that intimate contact would be hard to prevent with barrier methods. You'd essentially have to encase yourself from head to foot to prevent skin-to-skin transmission. And once you have lesions, there's no question that you should seek medical attention, and you should isolate. Because until those scabs are all gone, you're going to be potentially infectious, and you should really not have any type of skin-to-skin contact with other people.

Interviewer: So if someone does contract monkeypox, if they see those lesions, what is the first thing that they should do?

Dr. Swaminathan: I think if there's a concern that there's monkeypox, they can get tested. And we have started testing here at ARUP. We can generally get tests back in two to three days, and maybe sooner. And hopefully, we can keep up with the demand because I have a feeling that demand is going to continue to increase. But it's very good that ARUP . . . There are many labs that have now been approved to do this kind of testing, and we're not just depending on one or two centralized state or CDC labs.

Interviewer: So Step 1, if you think you've got something, go get tested. If that test comes back positive, what's the next step?

Dr. Swaminathan: Like we said, prevent yourself from giving it to other people. So you would need to isolate and take the precautions, which you can get detailed instructions from a healthcare provider.

And there is an oral treatment, which is approved for smallpox but is not officially approved for monkeypox because it really hasn't been tested in clinical trials against monkeypox, but we think it would work. It works in animals against monkeypox, and it certainly works in the laboratory, and it's a similar virus. So this drug called Tecovirimat, or TPOXX, should work, but it's only approved and can only be given under strict regulations.

So we're restricted in who we can give it to, and it's basically for people who have severe disease. There are various definitions for that, but it has to be severe disease, not just mild, a few skin lesions. And also for people who are at high risk, so people who are immunocompromised, whose immune system is weak, whether it's from cancer, or an organ transplant, or advanced HIV infection, or other immune deficiencies. So those people would be eligible for being treated, and we can treat them if we think that they have monkeypox, or we know that they have monkeypox.

Interviewer: But for most people, the treatment is not necessarily approved for everybody that gets monkeypox?

Dr. Swaminathan: Correct.

Interviewer: So quarantine, what does that look like in a household? Are you closing yourself off in a single bedroom?

Dr. Swaminathan: That would be the easiest way to do it, but that doesn't mean you can't come out of your bedroom. You should probably not share the same furniture as other people until you are over your period of isolation.

Interviewer: And how long is that period?

Dr. Swaminathan: Three weeks or so. All the lesions have to have been essentially healed over.

Interviewer: And how long after they've all been healed over are you good to go?

Dr. Swaminathan: Once all the lesions are healed, you shouldn't be infectious any further.

Interviewer: Is there any potential long-term consequences for a monkeypox infection?

Dr. Swaminathan: Not that I know of, but again, we're somewhat in uncharted territory. But generally speaking, recovery is thought to be complete.

Interviewer: So not super life-threatening, but you might be left with some scars?

Dr. Swaminathan: Yes.

Interviewer: Severe scars? Mild scars?

Dr. Swaminathan: Again, it depends on the number and location of the lesions.

Interviewer: So let's talk a little bit about vaccination. Is there a vaccine available for monkeypox?

Dr. Swaminathan: Yes. So the one that's currently being given is a vaccine that is based on the same virus that's used to vaccinate against smallpox. We don't routinely use that live form of vaccinia of smallpox vaccine because we've stopped vaccinating people against smallpox since the '70s. That vaccine is available and is thought to protect against monkeypox as well, but the incidence of complications with that vaccine is high enough that that older smallpox vaccine is not being used for monkeypox.

What we have is a newer vaccine that's made with a weakened or attenuated form of vaccinia that can't replicate, but it can stimulate the body to make an immune response against smallpox, and monkeypox, and so on. And that is effective both in animals that are challenged with monkeypox as well as in the laboratory. So that's the vaccine that we can give, but it is in somewhat limited supply currently. And like I said, we prioritize people who are at highest risk for it.

Interviewer: Now, speaking to you, Dr. Spivak, one of the first questions I'd like to ask you just to get it out of the way, with your experience researching viruses and treating HIV, is monkeypox a gay disease?

Dr. Spivak: Nope. It's a human disease. I don't know that there is such a thing, certainly not in virology, not in medicine, and not in existence in the world that I'm aware of such a thing as a gay disease.

And by way of background, I'm a physician caring for people living with HIV, very interested in preventing HIV, and I study HIV in the laboratory. Certainly, there's some background to my answer there, as, of course, HIV as a predecessor to this one, this latest outbreak of monkeypox, was often labeled a gay disease.

And just to elaborate a little bit because that, of course, sounds purely like opinion, the number one risk factor for acquisition of human immunodeficiency virus worldwide is heterosexual sex.

Interviewer: Heterosexual sex, really?

Dr. Spivak: Yep. So there are about 75 million people worldwide that have ever acquired HIV infection. Approximately half of them have died of the disease in the last 40 years since we first discovered it. So there's somewhere around 35 million people living today on Earth with HIV. And again, the majority of those folks acquired this disease sexually through heterosexual sex between men and women.

There's a fairly complex and really fascinating story about why HIV is prevalent among gay men, among men who have sex with men, and transgender women in Europe and in the United States. And that has to do with the transmission of the virus as it evolved, as the epidemic spread, where it first originated in West Africa, out to Haiti, and out to the Western world through sex, but also through blood products.

It's a complex story, but in any case, there are some pretty well delineated and well-understood reasons why HIV is more prevalent among men who have sex with men, again, in the United States and Europe. And that, of course, did give rise to this false notion that this was a gay disease, that heterosexual individuals were not susceptible, that this was somehow something that could be attributed to a man having sex with a man, which is entirely untrue.

And I think that the way I try to summarize that for medical students is to say that the disease actually . . . In the case of HIV, of course, it can also be transmitted through injection drug use, but by and large, we consider it a sexually transmitted disease, and that means humans having sex. The disease does not tend to discriminate, but people do.

Interviewer: And so while we are seeing more cases currently in the U.S. among men who have sex with men, that does not mean that this disease is any . . . there's not anything about the disease that specifically impacts one orientation over the other.

Dr. Spivak: No. There is zero evidence of that being the case. It does appear to be disproportionately affecting gay men at present, but the best we understand . . . And again, I think it's worth pointing out that there are a lot of unknowns here, and I certainly would not ever claim to sit here and have all the answers. In any case, the best science now seems to indicate that this virus spreads through skin-to-skin contact. And that is to say contact with your skin against the lesion on someone else's skin. Sex is a fantastic opportunity for skin to meet skin.

I don't think we really have a good answer as to why it is occurring predominantly among men who have sex with men, but as far as we know right now, there is absolutely no reason to think that this could not be spread from any type of skin contact, again, healthy skin touching against skin where there is a lesion. And we all have skin.

Interviewer: So, with that in mind, is this technically a sexually transmitted disease, or sex just happens to be a place where skin-to-skin happens?

Dr. Spivak: Yeah, I think it's a really terrific question because certainly, the biological mechanisms are exactly as you said, that sex is a great opportunity for skin to be vigorously rubbing against skin, and so a great opportunity for the disease to spread. But that's not the only way that we come into contact skin against skin.

When we call something an STD or sexually transmitted disease, that obviously implies a specific route of transmission. I think this could be categorized as an STD. There are also implications for that, around calling something an STD, because of our morals and our discomfort, I think, in our society about talking frankly about sex. That, I think, has given a lot of people in medicine pause about calling this an STD.

And I think we're trying to be sensitive to the fact that there were lessons to be learned, and there are lessons to be learned about HIV. And as I shared with you, sort of a common misconception 40 years into an epidemic that frankly should be controlled, but isn't . . . and I'm talking about HIV . . . there's still this perception that this is a gay disease. As I shared with you, that's just not born out by facts. There's nothing about this virus that indicates that it has any predilection for gay men at all.

Interviewer: So circling back to the state that we're in right now with monkeypox, we see the news every day, it's on the rise, it's scary, it leaves scars, we've done pieces about how it's transmitted, etc., but are there any steps that someone can take to make sure to protect themselves from potentially getting infected?

Dr. Spivak: Yeah, that's a great question. And the answer in some respects is similar to what we've learned, unfortunately, the hard way with COVID, though you could argue the glass is half full there, and I'm getting at vaccines. We have a vaccine against monkeypox, which is pretty remarkable that we actually had the vaccine present before the outbreak. And again, that's the glass half full.

The glass half empty is there's not a lot, not enough to go around. We don't have it here yet. That's largely because the supply is limited, but the Department of Health to their credit acquired vaccine from the federal government and tried to disperse it quickly. The Utah AIDS Foundation led by Ahmer Afroz has done a phenomenal job at getting information out and actually getting vaccine and distributing it.

I think we have a long way to go there, meaning that a lot more folks probably should be vaccinated. And frankly, anyone who wants to be, thinks they may be at risk, should be vaccinated. I don't think at this point, and we're in mid-August of 2022, that we have enough vaccine to go around. And so there have been decisions made about who gets priority, which is unfortunate from a public health standpoint because this is going to allow the disease to spread.

It is a disease that's spread skin-to-skin and spread by touching or coming in contact with these lesions, and so what that means is beyond vaccines, which are preventive, if you think you may have this, you should come and get checked out. We have a great diagnostic test.

And ARUP has been at the forefront. They're a phenomenal lab. They're an international leader, and they came out in end of July with their own monkeypox PCR test. Our clinic managers, and the urgent care staff, and people in the ERs, and people in our primary care clinics have rapidly become aware that this is out there. We're seeing more cases because people are coming in, and then physicians, and physician associates, and APCs are recognizing it. And clinic managers, and nurses, and clinic staff are taking the right maneuvers to sample the virus, meaning there are collection procedures that have to be put in place.

All this happened very quickly, and I think COVID did teach our health system how to be a little more quick to respond. And so that's been really encouraging. Working together, we can recognize this. Led by Jeannie Mayer, a hospital epidemiologist here, we can really as a system start to adapt to a new disease. So that's all encouraging.

I would say that people need to be aware that it's out there. They need to come in and get checked. We have a great test, and we actually have a great treatment. I could keep going on and on, but I'll stop there.

Interviewer: There seems to be a lot of fear out there right now, especially with limited supplies of vaccines, etc. Do you think that fear is founded?

Dr. Spivak: I do. Yeah, I do. It's scary. I've cared for a few individuals with monkeypox, and I'd say one thing. Again, I tend to be a glass-half-full, optimist-type person. It's not COVID. And what I mean by that is people are recovering. We have, to my knowledge, yet to have a monkeypox fatality, and yet it is symptomatic. People experience a lot of pain with it.

I think, obviously, it's to be avoided, but it's not quite in the same ballpark, I think, when we talk about in the intensive care units across the country where there was no vaccine, no treatment, and it was spreading like wildfire. We're really not in that situation.

But on the other hand, as I shared earlier, there are a lot of unknowns here. Maybe this is a mild strain, and we're going to see it get worse, or who knows what. But I don't think so. I think this is going to be a little bit milder.

I think the fear is justified because our public health measures aren't enough. We don't have enough vaccine, and we should be vaccinating everybody that wants a vaccine. We don't have quite enough of this therapeutic medicine to go around. It's a bit of a headache bureaucratically to get it, though I'll say that is part of my job, and we'll do it, jump through the paperwork hoops. That's fine.

The first patient I've treated with this drug called Tecovirimat, which is specifically . . . It's not FDA approved, but they have what's called an investigational new drug application, and that allows us to give it for this indication. The very first patient I've used the drug for had a really exciting turnaround in his symptoms, severe pain, and rash, and within about 48 hours, he got better. Now, that is what we call in science an N-of-1, but no side effects and a great recovery. Obviously, we have a lot more to learn, but that's encouraging.

Interviewer: Lyme disease. What is it, what are the symptoms, and what you can do about it? That's next on The Scope.

Announcer: Health tips, medical news, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: Dr. John Kriesel is a physician and researcher in the Division of Infectious Diseases at University of Utah Health. And today, we hope to learn more about Lyme disease. Let's just start with the beginning, what is Lyme disease?

Dr. Kriesel: Lyme disease refers to Lyme, Connecticut, which is a region in the country that had a long-standing mysterious disease. It was later found to be due to a bacterium called Borrelia burgdorferi. So Lyme disease refers to infection with Borrelia burgdorferi.

Interviewer: All right. So how do you get this infection?

Dr. Kriesel: Well, Lyme disease is generally tick-borne infection and it's found commonly in the northeastern part of the United States. Also in the Midwest and the southeast part of the U.S., occasionally in the western U.S. You get it from ticks, generally, that harbor the Borrelia organism and then transmit it to people.

Interviewer: All right. So at some point, if you have Lyme disease, a tick got on your skin and did what ticks do, put their head in and gave you the bacteria?

Dr. Kriesel: That's right.

Interviewer: Okay. And there are some places in the United States that have it. There are some places that don't. Not all ticks carry it, it's just certain varieties. Is that correct?

Dr. Kriesel: Right. It's these Ixodes ticks. They're small ticks. There aren't many of them in Utah and we don't have any endemic cases in Utah that we know of. We've looked, believe me.

Interviewer: Yeah.

Dr. Kriesel: But we do have Ixodes ticks. We just don't have any Ixodes ticks that carry the Borrelia organism as far as we know.

Interviewer: Yeah, as far as we found. Okay. Who's at risk for Lyme disease?

Dr. Kriesel: Well, I think people that live in endemic areas are relatively high risk. And of course, I think men are at higher risk than women possibly because they get more outdoor exposure, typically. People who work outside in their yards or in their occupations often become infected.

Interviewer: What are the symptoms of Lyme disease?

Dr. Kriesel: Well, people get an initial febrile illness and then they get a rash. I call it erythema migrans rash. You can certainly look up pictures of that, but that's considered to be . . . tick exposures, usually people don't find a tick because they're too small. But tick exposure in areas working outside or being outdoors and then getting an erythema migrans rash with a febrile illness.

Now, the illness often includes fatigue, lethargy, headache, sometimes neck stiffness, muscle aches, joint aches. And when patients travel in and they have a compatible illness, to Utah, we certainly ask them about possible tick exposure and then any rash that might develop.

Interviewer: And how do you diagnose that?

Dr. Kriesel: The acute disease is a clinical diagnosis, so you have to have exposure to an endemic area and then you have to have a compatible illness. Usually I think 80% are followed by the rash. So if you have those things, then you don't need to do a test. You just need to treat the patient.

Interviewer: Okay.

Dr. Kriesel: But chronic disease is harder. So somebody who has, say, a facial palsy, or heart rhythm abnormalities, carditis, or arthritis in one or more joints, or some sort of a neuralgia pain syndrome, this is a much more difficult thing to diagnose. And that requires antibody tests called serologic tests that we do in the blood.

Interviewer: So it really comes down to if you catch it early enough, if somebody sees a tick on them and then starts having these symptoms and gets the rash, pretty much case closed. You've got it figured out.

Dr. Kriesel: Right. Well, again . . .

Interviewer: As much as one could have a case closed in medicine.

Dr. Kriesel: Again, most people can't see the ticks because they're so small. But if they have a compatible exposure and a compatible illness, yes, that's a diagnosis of the acute illness.

Interviewer: But the trick is, somebody had an exposure, they didn't realize it. A few months later, they start experiencing some symptoms that they try to track down, then that's when you have to do the antibody test.

Dr. Kriesel: Exactly.

Interviewer: And it can be confused for a lot of other diseases, I've understood.

Dr. Kriesel: Well, it's a serologic test, so you're looking at antibodies that people make against Borrelia burgdorferi, right? Either by ELISA test or another test called the C6 Test or Western Blot Confirmatory Testing. So these are all special antibody tests, but there are other spirochetes in the world. So Borrelia are not the only spirochetes. Syphilis is a spirochete, Leptospirosis is a spirochete, so there could be cross-reactivity between diseases. So the first stage in serologic testing for Lyme disease involves an ELISA or an EIA, enzyme immunoassay test. And that's the screening test. It's like the HIV screening test, right, only it's for Borrelias.

And then if that's positive, then it goes on to a confirmatory test. The confirmatory test is called the Western Blot Test that involves specific bacterial antigens on a paper and then you see if there's antibodies that react to those antigens. So that's how that works and there are very specific criteria set forth by the CDC in these accredited laboratories to make that diagnosis.

Interviewer: And it could be a tricky diagnosis to make.

Dr. Kriesel: It could be tricky. It is tricky and frequently misinterpreted.

Interviewer: Lyme disease, probably prevented by keeping the ticks off you. Is that about the best way to prevent it?

Dr. Kriesel: Right. You can refer to the CDC. They have some specific recommendations. Actually, there's nice little brochures and I think the Utah Department of Health may have something similar.

Interviewer: All right. And then, if it's been determined that I have Lyme disease, what are the treatment options at that point?

Dr. Kriesel: That's a good question. I think we treat patients with doxycycline initially. There's also been some interest in treating possible exposures, post-exposure prophylaxis, but we don't really have occasion to do that very much here because the prevalence is so low.

Interviewer: So is this a shot? Is this some oral pills?

Dr. Kriesel: No, no, no, it's a pill. It's antibiotic pills.

Interviewer: An antibiotic pill.

Dr. Kriesel: And there are a number of different pills that could be used.

Interviewer: Okay. And then, is it ever completely treated or will you kind of have the symptoms or have the disease? It can only be controlled?

Dr. Kriesel: My understanding is the disease typically is cured, that the antibiotic treatment is curative. But there are always concerns about so-called post-Lyme syndrome. What are the diagnostic criteria for that? How do you make that diagnosis in patients? And that's kind of a more of a gray area. But can there be persistent infection? Well, not as far as I know.

Interviewer: Okay.

Dr. Kriesel: Right. But people can be re-infected and people can have difficult, prolonged infections and people may have symptoms that go on even after the spirochetes are eradicated.

Interviewer: That would be related to the fact that they did have Lyme disease?

Dr. Kriesel: Potentially.

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Interviewer: The University of Utah is home to the only Ryan White-sponsored HIV clinic in Utah, treating up to 90% of Utahan HIV patients. We're joined today by two doctors from the clinic to speak on what that clinic offers.

Announcer: Health tips, medical news, research, and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: We're sitting down with Dr. Claudia Goulston. She is an Associate Professor in Infectious Diseases, and Dr. Rosado, who is the Medical Program Director for the Ryan White Program. When it comes to HIV and AIDS treatment and diagnosis, and things like that, where does the Ryan White Program fit within the Salt Lake community?

Dr. Rosado: So the Ryan White Program, basically, the purpose of this program is to treat people who are HIV infected and are unable to pay for HIV therapy, because the HIV therapy is very expensive even in this country. We also have funding to do HIV testing mainly for partners of our patient, spouses, and anybody who wants to have an HIV test, we can do that using Ryan White funding.

Interviewer: So, Dr. Rosado, how many people do you see here in Salt Lake?

Dr. Rosado: In the clinic, we had about 1,600, 1,700. It depends. Patients that come to our clinic, not all of them are Ryan White patients because we see people who are Medicare, Medicaid, or they have primary insurance. That's the total of the 1,600 patients. But people who quality for Ryan White is about 500 patients that receive Ryan White funding.

Interviewer: And Dr. Goulston, why is a program like this important for a population like this?

Dr. Goulston: Well, many people are uninsured or underinsured, as the case may be, and so it kind of dovetails with that. And we have all sorts of providers within the clinic that work as a medical home to help get patients care. So we have case managers that can help treat patients and get them into care. We have counselors, psychiatrists, OB-GYN, neurology in our clinic as well and we work with all these different subspecialties to try and give them the best care possible.

Interviewer: So that sounds like a pretty comprehensive care. So that's at Clinic 1A? Is that important for the treatment? It's not just medication, it's everything else?

Dr. Rosado: Well, again, we offer a comprehensive HIV care to our patients and we try, as Dr. Goulston mentioned, to have a medical home model so the patient can come to that clinic and they can see the HIV provider. If they need to see psychiatric care, mental health, neurology, or OB-GYN, we have all those services in the clinic.

Interviewer: I mean, programs like Ryan White where you can get these new treatments and things, it . . . I mean, treatment is not like it was 20, 30 years ago, right?

Dr. Goulston: Not at all.

Interviewer: How has it changed?

Dr. Goulston: Well, now, we have many regimens that are single-drug or single-tablet regimens once a day. We have much lower side effects and very effective, and it is much more tolerable for patients to take and to remember. We used to have treatments that could be up to five times a day with miserable side effects, and those days are gone.

Interviewer: So it's not a death sentence anymore either, right?

Dr. Goulston: If you take your meds and can afford them and can carry through, then people can live.

Interviewer: So Clinic 1A . . . So it's treatment. Do they offer services for prevention?

Dr. Rosado: We do. In Clinic 1A, we do offer clinic services for prevention. But we need to emphasize here that the Ryan White Program doesn't pay for TRUVADA for prevention or HIV PrEP, because the funding for Ryan White is for people who are HIV infected. But we do see patients that are taking PrEP, TRUVADA, to prevent HIV. Usually, these people have their own insurance. And the company that makes TRUVADA, Gilead, they do have a patient assistant program. If a patient is unable to pay for the medication, they can offer the medication for free as long as the patient qualifies.

Interviewer: So say a listener who might be HIV-positive, underinsured, or not even have insurance, where they can go get more information for the Ryan White Program?

Dr. Rosado: Now, these people can go online and Google "Ryan White" and they will get all the information they need. In Utah, they can call the University Hospital Clinic 1A and we can offer them more information about Ryan White. We see anybody who wants to come to the clinic, and I need to mention, including people who are undocumented. As long as they are a Utah resident, they qualify for the Ryan White. And the reason I say this is Ryan White is present in every single state. The only qualification will be that you have HIV and you reside in that specific state, and you are unable to pay for your medication. The Ryan White, definitely, will cover your HIV therapy.

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Interviewer: New FDA approved oral medication that has been shown to prevent transmission of HIV, we're talking about PrEP today on The Scope.

Announcer: Health tips, medical news, research, and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: We're here with Dr. Claudia Goulston. She is the associate professor in infectious diseases, and she is a HIV specialist. When it comes to HIV, prevention is huge, right?

Dr. Goulston: Correct.

Interviewer: Because I've been hearing that it's what, 40,000 new cases in America each year?

Dr. Goulston: That's the ones that are known.

Interviewer: Why did you specify that? Are there tons that aren't known?

Dr. Goulston: Potentially, there's a lot more than that. They actually estimate around 50,000 at least.

Interviewer: And that number doesn't seem to be changing. Why is that?

Dr. Goulston: No. Because even though we prevent cases, some people are not on medications and some people also don't know that they're HIV positive, and so their risk is high and spreading it to other people.

Interviewer: When it comes to prevention, what is the tried and true best way to prevent infection?

Dr. Goulston: Condoms, first.

Interviewer: Is it that simple?

Dr. Goulston: It's that simple. But there's also PrEP, which is pre-exposure prophylaxis, which is with a medication that they can take called TRUVADA, and that helps prevent cases in people who engage in higher risk behaviors.

Interviewer: I've seen down at the Pride Center and stuff, there's posters and stuff about PrEP. What is PrEP exactly? How does it prevent? It sounds like it's a full blown vaccine, but . . .

Dr. Goulston: No. It's a medication that you have to take every day and it prevents you from getting HIV if you engage in sex or exchange blood with someone who has HIV.

Interviewer: Now, is it expensive?

Dr. Goulston: It's extremely expensive. It's about $1,700 a month.

Interviewer: Wow, and is that just because it's new? Is that because . . .

Dr. Goulston: No. That's the cost. It's not new.

Interviewer: So it might be a little easier to just . . .

Dr. Goulston: It's part of the cocktail that we give patients when they have HIV.

Interviewer: It's the same cocktail that you give after the infection, but it helps prevent it?

Dr. Goulston: Correct.

Interviewer: What are some of the side effects of PrEP?

Dr. Goulston: First, you have to have to not be HIV positive to begin with. We screen patients for that. It can also treat hepatitis B, which is one of the good things about it. But as far as side effects, it can cause renal toxicity which is kidneys, and it can also cause osteoporosis or thinning of the bones.

Interviewer: Are those side effects pretty common? Are those . . .

Dr. Goulston: The thinning of the bones takes a while and the kidney dysfunction can occur in not the majority, but in some patients it can occur.

Interviewer: This isn't necessarily . . . It's not 100% prevention?

Dr. Goulston: No.

Interviewer: What are the rates of prevention?

Dr. Goulston: It's supposed to be helpful in up to 90% if you take it. But if you don't take it, it doesn't work, number one. Then if you have someone who has a more resistant virus and they are the person who's infecting you, there has been one case of transmission in someone who is taking PrEP and was documented to actually be taking it at the time that they were infected, but they got it from someone who had a resistant virus.

Interviewer: What kind of patient is PrEP good for?

Dr. Goulston: Anyone who has multiple partners. It would be a good person or someone who is monogamous with a partner who is HIV infected, that would be a good one, or someone who is in a partnership and they want to get pregnant, and one of the couple is positive and the other one is negative.

Interviewer: After talking about prevention and PrEP, if there is someone who is wondering about it or might be engaging in some of these behaviors that might expose them to HIV, what is the one take-away message you would have for them?

Dr. Goulston: That PrEP is effective and it can reduce the risk for HIV by at least 90%, and that they should come in if they're so interested, and we can help them.

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Interviewer: It wasn't too long ago that HIV treatments were a nightmare and the diagnosis was a death sentence. What's treatment like today for HIV positive patients?

We're here with Dr. Adam Spivak. He's an assistant professor in the School of Medicine and he specializes in HIV. And today we're talking about some of the HIV treatments available these days. How is the treatment today different than say what we did 10 years ago, 20 years ago? How has treatment changed?

HIV Treatment and Care Has Changed in Recent Years

Dr. Spivak: I think one of the things we've come to recognize is that the real revolution in HIV care began roughly in the mid '90s, by 1995, '96, with the introduction of combination antiretroviral therapy and you go back to the medical journals and recognize from the scientific studies how miraculous that was. Taking a disease that for the previous 15 years, from its first descriptions of AIDS in 1981 through, again, the mid '90s, this was a death sentence for patients. This was a disease that we really could slow down but not stop and that was killing more and more people every year. And we got these amazing combinations of drugs and people started to do fabulously well.

However, that didn't seem to apply to everybody and even though the drugs were so great, it was really under the rubric of a controlled medical study that we were seeing the benefits. And so, when you bring those into the real world and you're asking people to take at least in those days, difficult combinations of medicines that had lots of side effects, had to be taken every day, some with food, some without, some refrigerated, some not, it was extremely difficult to do. Even the most compliant patients, any of us trying to take medicine three times a day, it's difficult. And to ask people to do that up to 20 pills, it was really, really hard.

So I think what happened in the late '90s, early 2000s, was the recognition that we needed to do more than just sort of have the medicines available. And a physician just writing a prescription is not enough, which is perhaps an obvious thing in retrospect. But a clinic like ours is trying to really maximize the benefits of these medicines by providing enough of the resources to actually make it happen.

Interviewer: So specifically with medicines, what has changed? Are we still dealing with those 20 pills a day, 3, 4 times a day or what are they dealing with now?

Dr. Spivak: Yeah, luckily that has also changed and so that's really perhaps what we would call version 1.0 and that's way actually, luckily in our distant past. What has happened in the last certainly 10 years or so, is that we've gotten some new medicines and what the drug companies have also provided, are combination pills. So we have some new classes but also a recognition that those early days, medicines are only good if you can take them, you can tolerate them. And we are now to the point where we have four or five first-line regimens that are one pill, once a day.

Within that pill are three different medicines. They're co-formulated, minimal side effects. Again, very easy to take. Take on an empty stomach, take them with food, really not a huge deal. And this has really freed people to live their lives and take these medicines on a regular basis, without missing them, and basically live long healthy lives.

What to Expect at an HIV/AIDS Clinic

Interviewer: Besides the medications, just the straight up treatment. Take me through. An individual has tested positive for HIV and they come into your clinic. What do they expect when they come to the clinic there?

Dr. Spivak: HIV, even though the picture I was just painting, had been a life-threatening, devastating illness, and is now essentially a chronic medical condition that can be well controlled with medications, it's a disease with a lot of stigma. And so it's a devastating diagnosis to have, it is an extremely difficult thing for patients who are newly diagnosed.

So my first visits, and I know this is the same with my colleagues in the clinic, when I sit down with a patient who is new to the clinic and new to the diagnosis of HIV, we essentially spend the first visit or sometimes first several visits, just talking it through. Just talking about what it means. A lot of reassurance. A lot of education trying to get the patient up to speed with modern treatments, with life expectancy, with how they acquired HIV.

There's often a lot of discussion, a lot of reflection about what happened, what risks were taken, what can be changed going forward. I think I'm an optimistic person at baseline, but there's a lot to be optimistic about in this illness. And I think one of the messages I try to get across is that, "You're going to be okay. You're going to be fine. This is a partnership. We have phenomenal treatment. You're going to live a long healthy life."

And again, perhaps on the on the bright side or the silver lining, any number of patients that will come back after six, nine months, a year, obviously we have been seeing each other in clinic in the interim but they'll come back and reflect upon those first visits and they'll tell me how much they've changed.

A lot of the changes that they identify in their life after a diagnosis of HIV are positive changes. Some of the behaviors that may have put them at risk in the first place leading to their diagnosis have changed. Their lifestyles have changed and so I think certainly if people could go back and reduce those risks and minimize their chances of HIV diagnosis, they would.

But I see this a lot where people come in and realize that this in some ways was a wake-up call and they're leading a healthier, happier life than they were, believe it or not. So it's not necessarily something we tried out right away, but there can be some positive benefits. So it's a lot of talking. We take it slow at first.

Interviewer: So if there was one thing with the new treatments, with the clinic care and everything, that you would tell to someone who had just found out that they were HIV positive, what would it be?

Dr. Spivak: I would say what I tell my new patients, which is, "You're going to be okay. We're going to take care of you. You're going to live a long, healthy, productive life and you're entering a new phase of that life with a new set of partners who's going to help you through."

updated: December 1, 2022
originally published: February 22, 2017

Interviewer: Misconceptions and misunderstandings about HIV AIDS up next on The Scope.

Announcer: Health tips, medical news, research and more for a happier healthier life, from University of Utah Health Sciences, this is The Scope.

Interviewer: So we're here with Dr. Adam Spivak. He is an assistant professor in the School of Medicine and a specialist in HIV. What we're talking about today is some of the misconceptions. Even in 2016 we've learned so much about the virus and what it means, but some of these misconceptions still are out there. So, let's go ahead and cover some of these. What about transmission? Like, can you get HIV from kissing another person or touching them or sitting on a toilet seat or some of those old kind of . . .

Dr. Spivak: HIV is transmitted primarily sexually, and it can also be transmitted through blood. It cannot be transmitted through saliva, through casual contact, sharing a toilet seat in a public bathroom, sharing food with someone who is HIV infected. None of these are at all put anybody at risk.

Interviewer: But those stigmas did exist once, right? Because they must've come from somewhere.

Dr. Spivak: Oh absolutely, absolutely, and of course in the early days when AIDS was first described in the early 1980s we didn't actually even know what caused it. It took two years. It was not until 1983 that a novel retrovirus, HIV, was discovered as the cause of AIDS. So you can imagine a disease that was causing such severe illness and deaths and you don't know what causes it. We didn't even know entirely that it was an infection for those first few years that a lot of stigma, a lot of stories circulate, and certainly those are powerful and have a way to persist.

Interviewer: One of the other misconceptions at least historically that might still kind of linger on today is you just see some of these old news clippings or these old photographs and things like that where people are referring to HIV and AIDS as a gay disease, as a gay cancer or something like that. We're starting to find out that that's not true.

Dr. Spivak: Yeah, no, no, no. Worldwide HIV is transmitted sexually actually through heterosexual sex as the predominant form of HIV transmission. In the early days again populations that seemed to be hardest hit were gay men, men who have sex with men, injection drug users, sex workers, and interestingly enough people of Haitian descent. But again, that has persisted along with the recognition of the early spread of AIDS among gay men as this population to be shunned. Of course when we're talking about the 1980s we're talking about a group that was very much discriminated against that felt very marginalized. Unfortunately a new disease, a lethal disease, a disease of unknown origin that seemed to be spreading like wildfire had the effect of amplifying a lot of those frankly prejudices that were already present in society.

Interviewer: What about HIV positive women who might be worried about whether or not they can ever have kids or be pregnant? What are some of the misconceptions about that?

Dr. Spivak: One of the real highlights, one of the bright spots with regard to prevention of HIV transmission is mother to child transmission. What we have learned through a number of really well done studies and now many years of clinical practice is that pregnant women with HIV who are started on anti-retroviral therapy on the treatment for HIV really do not pass on HIV to their infants. We know that even a single dose of the medicines given at the time of delivery can reduce transmission from mother to child. It appears as best we understand it that HIV transmits at the time of delivery. Even just a dose or two doses of the medicine at that time is a very powerful preventative. We go a few steps further than that and get mom fully treated, and in those circumstances transmission from mother to child is almost unheard of in the United States and Europe where we do this on a regular basis today, so a real bright spot in terms of HIV prevention.

Interviewer: What about some of the ideas and maybe stigmas that the disease is a death sentence, that if you catch it your life's over?

Dr. Spivak: When AIDS was first described in the 1980s up until the mid-1990s, we did not have reliable treatment and this often was a cause of death in folks that were otherwise young and healthy and in the prime of their lives. The stigma, the stereotype, the concept that HIV AIDS is a death sentence certainly has its roots in truth. However, it's 2016. Starting in the mid-1990s as we've discussed, 1995, '96, the introduction of what we call combination anti-retroviral therapy, new drugs hit the market. It's still what we use today. These are fabulous treatments for HIV. Our patients are living long healthy lives. They have to take the medicines every day.

Untreated absolutely it is devastating to the immune system. It leads to what we call opportunistic infections and ultimately to death. We saw that very graphically in the first decade and a half of this illness. However, what we see today with patients that are able to come in to our clinic, get access to care, take their medicines on a regular basis is that they are leading long, healthy, productive lives and are doing fabulously well.

Interviewer: What's one of the top things that you would suggest for people to have done on this World AIDS Day?

Dr. Spivak: Oh absolutely I think the most important thing that people can do is get tested. I say that because the vast majority of the United States population has never had an HIV test. Now most people may not be actively at risk for HIV which is to say they're not practicing unsafe sex, they may not be injecting drugs, but we do know and there've been a number of studies that have shown that there are quite a number of people living today who have HIV who are not diagnosed. That's a tragedy on a number of fronts. We've talked about the ability to get these folks treated. It ultimately will affect their health. They're also at great risk of spreading the disease.

So, I think the test we have for HIV is one of the best diagnostic tests in modern medicine. It's incredibly accurate. A negative test in the setting of someone who's not at risk for HIV is very reassuring. It sits on their medical chart and they never need to get tested again. We're trying to get most people from zero to one to get tested. Of course the few folks who may have been at risk in the past or still practicing high risk behaviors with regard to HIV, and we're able to identify them and diagnose them with HIV, we're really going to be able to not only help them but help potentially partners help them from spreading the disease.

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Interviewer: Killing malaria with light? We'll talk about that next on The Scope.

Announcer: Examining the latest research, and telling you about the latest breakthroughs. The science and research show is on The Scope.

Interviewer: I'm talking with Dr. Paul Sigala, Assistant Professor of biochemistry and the University of Utah. So Dr. Sagala, malaria isn't something that we think of a lot in the U.S. but it's actually quite a problem in other parts of the world. Can you talk about that a little?

Dr. Sigala: Malaria is really one of the most urgent health problems facing the world. It has been for many decades. Even now with all of our great public health advances, hundreds of millions of people every year around the globe get infected by the malaria parasite, leading to nearly a million deaths. Tragically, most of those deaths are among children under the age of five in Africa.

Interviewer: There are treatments for malaria. How effective are those?

Dr. Sigala: We currently have good treatments. So artemisinin in combination therapy is the frontline therapy and has really been an amazing drug that's saved millions of lives so the importance of was recognized. The discoverer in China was awarded, or shared the Nobel Prize last year. But like most of the drugs that have come before it, eventually parasites come up with ways to develop resistance. And so much attention right now is trying to devise either new drugs that can be combined with artemisinin to overcome that resistance or other ways to combat or reverse multi-drug resistant.

Interviewer: Part of what you're trying to do is understand how malaria works so that you can come up with ways to block it. One of the ways you're doing that is looking at how it interacts with heme, which is part of our red blood cells.

Dr. Sigala: Right, so parasites infect red blood cells, which are the most heme rich cell in the human body. And parasites also utilize heme as a cofactor in its own heme proteins. So it needs a way of getting heme and so we've been looking at how the parasite is able to either make its own heme or scavenge our heme within the red blood cell.

Our red blood cells, during their early development stages, had their own heme biosynthesis enzymes that were massively productive in generating lots and lots of heme. And those stick around in the mature red blood cell. They're not ordinarily active. But what we found with the parasites living inside, that we came up with a way to hyperstimulate the activities these enzymes in a way that allows us to kill the parasite.

Interviewer: Help me understand this. So you can take advantage of some of the heme synthesis tools that happen to be floating around in our blood that we make.

Dr. Sigala: That's right. So these are enzymes that are inside the red blood cell but are no longer active because our red cell heme synthesis petered out at the end of development of those cells. But the enzymes are still there, so when the parasite is inside it now has the enhanced ability to take up nutrients and other compounds from the serum. And so one of the compounds that we found that we could put in actually stimulates the activity of these remnant human enzymes that are there. And some of the intermediates that accumulate as a consequence of that activity actually sensitize the parasite such that when we hit the parasite with light it kills it.

Interviewer: What is the light doing?

Dr. Sigala: So there are classes of compounds that are phototoxic. Meaning that when they absorb light they lead to generation of what are called reactive oxygen species, or really reactive molecules that kind of rapidly react with all sorts of biomolecules and just kill the cell in which they're generated. This is utilized for a form of cancer therapy, which is called photodynamic therapy and we think there are possibilities for adapting this approach for potentially treating malaria.

Interviewer: So how can you do that? I mean, first of all, how are you even getting light in there? This is inside your body.

Dr. Sigala: That's right. So that was part of the creative challenge here. It's not very practical to imagine inserting a fiber optic cable in someone's blood stream and trying to illuminate every infected cell. It's additionally challenging because falciparum malaria sticks to the walls of our blood vessels, so called sequesters, which means a lot of the really mature forms are not in active circulation which makes it difficult to target them.

So we wanted to devise a strategy that overcame the reliance on an external light source and what we figured out is that we could use a compound called luminal, that's a very well characterized chemi-luminescent compound. Meaning it's a small molecule that gives off light. And when we combined luminal with other compounds to simulate heme biosynthesis that those would converge within the parasite infected red blood cell and would generate light within that cell and selectively kill the parasite.

Interviewer: I think you had told me once before that the luminal is actually what's in glow sticks. Right?

Dr. Sigala: That's right. So it's commonly used in glow sticks and also in police departments for forensic reasons for trying to identify blood at blood scenes because one of the curiosities of luminal is that it needs to be activated. And it gets activated by interactions with iron so heme has iron in it. So blood that's a blood spot at a crime scene is exposed to the air and so when you spray luminal in it, it activates it.

But chemistry is also what contributes to the specificity of luminal targeting the malaria parasite. Because it requires this iron activation mechanism, most human cells tightly sequester iron and it's not readily available. But the parasite during its normal 48-hour cycle degrades up to 80% of all hemoglobin within a human red blood cell, breaks the protein part up into amino acids. The heme though, it basically sequesters into a vacuole so all of the iron within that heme is now much more exposed than it would be in a healthy red blood cell. Which then provides ready access to then activate luminal when it is delivered.

Interviewer: That's very convenient.

Dr. Sigala: It is.

Interviewer: So how are you investigating this in the lab? Kind of what stages are you at?

Dr. Sigala: Right, so what we have so far have done is explored in principle whether in an x-vivo culture system can actually potently kill the parasite with this type of combinatorial treatment. And the answer is yes, we certainly can. What we discovered along the way is that not only is the ALA, amino linoleic acid, plus luminal effective, but it synergizes very well with the current antimalarial compound, artemisinin in what is really a new twist. And so the combination of all three of those compounds is extremely potent in vitro at killing the malaria parasite.

So the next challenge is really to ask whether this will be effective in vivo. That's challenging to do directly in humans but one can turn to studies with plasmodium species that infect rodents. There are mouse malaria and those provide a ready means to ask, can we cure a mouse from malaria using a combinatorial treatment with these compounds?

Interviewer: Something else I wanted to bring up is that the parasite that produces malaria is actually somewhat mysterious. There's actually a lot we don't know about it.

Dr. Sigala: That's right. For a bug that we've been battling for thousands of years and especially in the current age of understanding so much about genes and genomes, it's unusual. It's an opportunity to deepen our understanding about how a highly effective parasite carries out its mission and devises clever new strategies to survive within our cells. So it teaches us something about general mechanisms in biology, but more importantly it means there are opportunities because those genes and potentially the proteins themselves are so different from our own proteins that we can selectively target them if we're able to understand their functions in a way that really avoids toxicity to our bodies.

Announcer: Interesting, informative, and all in the name of better health. This is The Scope Health Sciences Radio.

Interviewer: What is the thing you should be worried about if you end up with a dog bite? We're going to talk about dog bites next on The Scope.

Dr. Troy Madsen's an emergency room physician at University of Utah health care. And if you get bitten by a dog, what do you need to know? Dr. Madsen, go.

Dr. Madsen: So the biggest thing we think about with dog bites are infection. That's probably the first thing that comes to mind for me in any kind of bite dog, cat, whatever, but in particular with dog bites. So when I see someone with a dog bite, first of all, I'm looking at the wound itself. Are they moving their hand okay? Let's say they got bitten on their hand or on their forearm. Do all the tendons seem like they're intact? Can they feel? Are the nerves working okay? Is the blood flowing okay, making sure there's no damage to any of the vessels there? So anything I would do it any sort of laceration, that's what I'm doing with the dog bite.

But the big thing, I think, about say someone falls and cuts their arm or cuts their arm with a knife or something like that versus a dog bite would be the infection risk because dogs, like any other animal including humans, have lots of germs in their mouth. So typically what I'm thinking about there is getting the wound cleaned out really well, making sure it's washed out really well. And then often with these bites I'll put people on antibiotics. So I think if you're bitten by a dog that's the big thing you're thinking about is, number, one getting this cleaned out really well. Number two, was it a fairly deep wound or something where maybe you should be on antibiotics for a few days to prevent an infection there.

Interviewer: All right, so if you take a look at it and it's a deep wound then it's a no brainer, you probably should go to the ER?

Dr. Madsen: You really should.

Interviewer: The instant care would they be able to handle something like?

Dr. Madsen: Instant care would be fine.

Interviewer: They'll be able handle that as well and get that stitched up. But if it's just kind of a minor bite, they kind of broke the skin a little bit, then you need to watch out for infection.

Dr. Madsen: You do. And I think if it's a minor bite in those situations, if it were me, I would just wash it out really well.

Interviewer: Soap and water?

Dr. Madsen: Sure. You can use some soap and so might kind of might hurt. Quite honestly, if you just run the tap, just get a lukewarm water going, put your arm or whatever affected body part of was put it under there, let it just run for five or ten minutes, just wash that out really well, that's really going to do the job. And you can avoid putting a lot of soap on there, causing a lot of pain. I think just getting lots of water running through it, just flushing it out is going to be effective, and you know you can try some antibiotic ointment on there as well. But I think the big thing to watch for there is any signs of infection where it starts to get red, swollen, getting drainage from the wound, then absolutely in that situation, you need to get to an urgent care or an ER, get in and get on some antibiotics.

Interviewer: Some redness is normal though right after a bite like that?

Dr. Madsen: Some redness, yes, but I expect usually the redness is going to go down within 24 hours. If it's getting bigger after 24 hours, that's a sign of infection.

Interviewer: And get that taken care of immediately.

Dr. Madsen: Exactly.

Interviewer: All right. So if it's a dog that's known to you then I think we've covered it. But if it's a dog that's not known to you, then you've got people worried about rabies.

Dr. Madsen: So the big thing to know is if you know the dog, if it's your dog, if their shots are up to date, you can observe the dog after the bite, you don't need to rush in and get rabies shots. If it's a dog where this is some random dog, and you don't know whose dog it is and you don't know where the dog went, you need to think about rabies, and that's something to go to the ER for or an urgent care could handle this as well to look at getting the rabies vaccine to prevent rabies.

Interviewer: When a dog that's not known to you attacks you, would they be showing symptoms and signs of rabies? Or could they be asymptomatic, not showing those symptoms and signs and still have rabies?

Dr. Madsen: They could. It's hard to say and it may not be florid rabies where it's classically you know you hear foaming at the mouth as rabid dog. But just any time you're bitten by a dog and you just cannot track that dog afterwards or you just don't know if they've had their shots, you need really need to get the rabies vaccine in that situation.

Interviewer: And don't wait for, "I'll just see how I feel."

Dr. Madsen: Yes, don't wait to see if you get rabies and wait for that because there's not much you can do once you have rabies.

Interviewer: Is there anything else to keep in mind when it comes to a dog bite?

Dr. Madsen: I think the big things again are watch for infection, and use your judgment in terms of getting to the ER to get on antibiotics depending if this is a larger wound versus something you could just wash out treat at home. Again, always think about rabies if you don't know the dog, you don't know whose dog it is, get in, get the rabies vaccine.

updated: August 19, 2020
originally published: August 19, 2016

Interviewer: You just had a surgical procedure and a few days later an infection develops. Would you know what that even looks like? We'll talk about that next on The Scope.

Announcer: This is From the Front Lines with emergency room physician Dr. Troy Madsen on The Scope.

Interviewer: Dr. Troy Madsen is an emergency room physician at University of Utah Health Care, and one point we were talking about some of the things that you see and one of the things that you see fairly commonly are surgical site infection. So if somebody has had a procedure done and it's gotten infected, which can happen, and then they come into the ER to get treatment. Tell me a little bit about that.

Dr. Madsen: You're right. It is something that happens. Surgeons do everything they possibly can do to limit the infection rates with sterile procedure and all the steps that are taken during and after an operation, but infections still are not uncommon. We do see those cases in the ER of people who have had operations and have infections, and I think the biggest thing that's challenging with this is sometimes we see cases where people have really severe infections.

Interviewer: Like they waited too long?

Dr. Madsen: Exactly. And you think to yourself, "Man, if they had just come in two days ago, they could have just gotten on an antibiotic and gone home." But at this point it's become so severe that they have to be admitted to the hospital on IV antibiotics, sometimes have to go back to the operating room to open that up and try and get that infection out. So it's certainly worth knowing what to watch for.

The number one thing is fever. If you've had an infection, if you're having fevers, that's a reason to absolutely call your surgeon. They will likely tell you either see me in clinic tonight or today or tomorrow or go to the ER to get blood work done and take a look at the wound.

The other thing we'll see is drainage from the wound. It's natural to have some kind of drainage, maybe a little bleeding from the wound after an operation, but if you start to see this yellowish colored or darker colored pus coming out of there, or you're seeing this on the dressing that goes on the wound, that's a reason to again call your surgeon and/or get to the ER.

The other big thing is redness around the wound. You figure you had part of your body cut open, it's going to be kind of irritated, kind of inflamed, but when you start to see this bright red color around a wound, you touch it, it feels warm, that's another pretty serious sign that you've got an infection in your wound.

So these are probably the three biggest things that I see; drainage from the wound, redness around the wound, fever, all reasons to get in touch with your surgeon, get someone to take a look at this, and then possibly get on an antibiotic to catch this early enough so it's not something that requires hospitalization or another surgery.

Interviewer: So it sounds like time is crucially important, and it's not one of those things that you might want to go, "Well, I'm just going to wait another half day and see if it starts looking any worse."

Dr. Madsen: Exactly, and there's no harm in just having someone take a look at it. It's a time where you really do have to be careful. No harm in having someone take a look and say, "Actually, that's normal, that's what's expected after surgery," and then giving it another day or two, but you want to catch these things early.

Interviewer: Yeah. So call your surgeon. If you're not able to get a hold of them, an urgent care if they're open, would that be okay?

Dr. Madsen: Yeah, as long as you've got someone who can look at it, an urgent care or . . . they may prefer you to come to the ER, just because if it's the ER, preferably the one affiliated with the hospital where you had the surgery, because then the ER knows exactly what the procedure was. The surgeon can then access all the records from the ER. It just makes it a little easier that way to get a sense of what's going on.

Interviewer: Gotcha. So have somebody take a look at it. Take it seriously.

Dr. Madsen: Yes.

Interviewer: Especially if you just had a surgery.

Dr. Madsen: Absolutely.

Announcer: TheScopeRadio.com is University of Utah Health Sciences Radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at TheScopeRadio.com.

Interviewer: What is pertussis, what can you do about and can adults get it? That's next on The Scope.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Interviewer: If you get a nasty cough that will not just go away it might be pertussis. The odds are slim but it could be. To find out more about pertussis in adults we're with Doctor Tom Miller here at University of Utah Health Care.

Pertussis; tell me a little bit about it and then tell me how an adult can get it.

Dr. Miller: Pertussis was commonly known as whooping cough and occurred most commonly in children prior to the development of an effective vaccine, and it was deadly. A lot of kids died of whooping cough in the old days.

Interviewer: Another one of these things that the vaccines have made a huge difference, and we forget about it, right?

Dr. Miller: We forget about it and actually what's happened is that kids all in the United States generally get this vaccination for pertussis and it effectively prevents it, but as we get older our immune system forgets about exposure to the vaccine and immunity wanes. And you know what? People coming into the country who are not vaccinated can bring pertussis in.

It's a very highly infective bacteria so you don't need much in the way of bacteria to become infected. And when you are infected, if you are older you could end up with not whooping cough but something called the 100 Day Cough.

For a few days you just feel real crappy. You feel very poorly, you have a sore throat and you develop a cough. It's awful. It's what we call paroxysmal cough. It's deep, it's rapid, it's unending and it's so bad sometimes that it will make you vomit, throw up. It's terrible.

So that's why the recommendation now is that as an adult you should receive a pertussis vaccine with your tetanus and diphtheria vaccine. You only need that once in adulthood but if you don't have that you then are at risk to pick up pertussis should you run into a child or even an adult who might be carrying pertussis. And again, it doesn't take much in the way of contact to develop pertussis.

Interviewer: So how is it transmitted?

Dr. Miller: It's transmitted through vapor droplets. Somebody coughing, they can pick up the bacteria in that way. And again, it's highly infective. Many times patients don't know they have pertussis when they are adults because they don't have this barking whooping cough that the kids used to get. They just start with a cold, but the severity of the cough is the thing that makes physicians think about it.

Now, you can treat the patient once they develop the cough and it can get rid of the pertussis bacteria but it doesn't get rid of the cough, and that cough goes on and on and on, and it's a devil to treat if you can even treat it.

Interviewer: So I guess the message here is if you haven't had that pertussis booster, you should get that.

Dr. Miller: Get the booster. Absolutely.

Interviewer: It is something you see on occasion.

Dr. Miller: I do see it on occasion. In Utah, we have an increase in the rate of pertussis in adults because of our immigrant population. They're not always vaccinated when they come into the country.

Interviewer: International Airport.

Dr. Miller: The simple way to protect yourself is to make sure you get that booster.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there's a pretty good chance you'll find what you want to know. Check it out at the scoperadio.com.

updated: January 2, 2019
originally published: June 28, 2016

Interviewer: A new tool that could completely change how we diagnose infectious diseases, up next on The Scope.

Announcer: Examining the latest research and telling you about the latest breakthroughs, the Science and Research Show is on The Scope.

Interviewer: I'm talking with Gabor Marth, professor of human genetics at the University of Utah and co-director of the USTAR Center for Genetic Discovery.

Diagnosing infectious diseases is still a significant problem in medicine. Right now in the clinic, you either do a culture or maybe a PCR test to see what's infecting a person. You have co-developed a tool called Taxonomer that's taking a completely different approach.

Gabor: Taxonomer is a software tool that is able to look at DNA fragments, which is what current technologies are able to produce from blood from an infectious disease patient, and identify the organisms that are present in that sample.

These types of tools, in my opinion, are very likely to replace the tests that you mentioned, that are based on specific hypotheses. We have to know what the strains that we are looking for in these patients, whereas tools like Taxonomer will be able to look at the DNA sequences and tell you upfront what pathogenic organisms are causing the patients disease.

Interviewer: So if you have a patient that's sick, you take a little blood, you have to get the DNA from that blood sequence for all the genetic material, I guess. And then that sequence information goes in the Taxonomer, and Taxonomer catalogues everything that's in there.

Gabor: Yes, as you mentioned, in traditional clinical tests you would have to ask "Does this patient have this particular strain of, which specific pneumonia strain this particular patient has." Sometimes these experiments fail. Some of the strains go better in the media that are used in laboratory tests than others. When the same data goes to a Taxonomer you just get an unbiased view of which strains and what proportions are present in the patient. That will help the physician diagnose the patient much faster, and in a much more objective manner.

Interviewer: So there are some really stand-out characteristics of Taxonomer. These are based on the software called Iobio, which is what you developed, correct?

Gabor: Taxonomer itself is the engine, it is the software that is able to take a DNA fragment and tell you which organism that DNA fragment presents. And it's married to Iobio, which is a web-based analysis platform that my laboratory is developing, that allows interactive, real-time and high visual representation of the data.

Interviewer: So yes, one way I've heard it described is that it's like putting a super computer in the hands of your average user, it has that much power behind it. But it's accessible on the internet.

Gabor: This is actually an accurate description because the computational power that allows Taxonomer to run is enormous but all that is hidden from the user. It's what's called the backhand of the architecture, there is a powerful computer sitting in the background that performs the computation in very, very intensive classification job. But what the users see is almost immediate response and almost immediate results.

Interviewer: And so before, this type of analysis took a lot longer and probably had to be done by a specialist, right? A bio-informatic specialist. But now anybody could do it. Is that the idea?

Gabor: Many, many things that the average user will be able to do. Of course, this is not to say that there is no longer need to for a . . .

Interviewer: We don't need you anymore.

Gabor: More involved analysis and expert analysis, but what Taxonomer will be able to do, it will be able to give a scientist, or even a lay-person, an immediate view of what is the overwhelming characteristics of the data. For example, we have examples of an Ebola patient. And when you look at the viral composition of the blood taken from this Ebola patient, you will see that pretty much 100% of the viral load in this individual is Ebola. So that's a very, very obvious and easily interpretable answer to the question of what's making this person sick.

Interviewer: Well like you said, a lot of the strength of this tool is that it's very visual, and that helps people take in information in a different way. Can you talk about that a little bit? Why you think that's an important component.

Gabor: That's how the human mind works. Experts can be trained to look at large data files and textual outputs coming from software and interpret that data in a scientifically meaningful fashion. But our human brain doesn't quite work that way. We like to see things, we like to use the brains innate analytical abilities to start from an image to develop an understanding. And that is the underlying philosophy behind the Iobio project.

Interviewer: In a few years how do you envision Taxonomer, in particular, being used?

Gabor: I view this that its applicability is going to be very wide. This is going to be a very wide and generally applicable tool. Some of the applications that we can foresee today will be infectious disease identification in the clinic that will require expert review of the data. Moving forward, the obvious application will be pathogen identification in the field, under field conditions.

Once the technologies are developed for portable and faster DNA sequence can be used under field conditions. This is only scratching the surface, checking sanitary conditions in restaurants and many applications that we can think of now and many even more applications that will become clear in the future.

Announcer: Interesting, informative, and all in the name of better health. This is The Scope Health Sciences Radio.

Interviewer: Tapeworms. How do you know if you have one and where did it come from, anyway? We'll examine that next on The Scope.

Announcer: Health tips, medical news, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: Kristen Case is from ARUP Laboratories, which is one of the country's top labs that specializes in identifying parasites so doctors know how to treat them. My first question for you, Kristen, is - and I'm sure it's the same thing that's on everybody's mind when they hear the word "tapeworm" - how much weight can I lose if I have one, and will it be in time for swimsuit season?

Kristen: Yes.

Interviewer: I mean, I joke, but look. I did an internet search. Look at this.

Kristen: Yes, you can lose weight if you have a tapeworm. That's one of the symptoms of having a tapeworm.

Interviewer: Yeah. This ad I found on the internet is an actual ad, "Sanitized tapeworms, jar-packed to lose fat."

Kristen: Yes.

Interviewer: That was a weight loss method at one point.

Kristen: Yes, it is, and it actually still is, but not in the United States. In other countries you still can infect yourself with a tapeworm to lose weight.

Interviewer: Ugh. So, okay, I'm imagining that's probably not a good idea, and let's get to that in a second. But first of all, if you get a tapeworm that you didn't want, how do you even get that? I don't even know how that happens. Is it from the ground?

Kristen: You get tapeworms from undercooked meat.

Interviewer: Okay.

Kristen: Undercooked beef, pork, and even fish.

Interviewer: That's where they live.

Kristen: Yes.

Interviewer: All right. So you consume that, then it ends up in your intestines or your stomach? Where does it live?

Kristen: It does. Yes, the end of the life cycle for that parasite is in the human intestine, and from there it just grows and grows. For example, the fish tapeworm, it can grow up to 30 feet.

Interviewer: Oh!

Kristen: It can live in you for up to a decade undetected.

Interviewer: And then if it does that for a decade undetected, then it just finally goes through its life cycle?

Kristen: Yeah.

Interviewer: Then do you pass it?

Kristen: Yes, you would pass it.

Interviewer: So that's when you go . . .

Kristen: That's when you would know.

Interviewer: "Oh, man."

Kristen: When you start passing segments of the tapeworm, that's when you know that you have a parasite, typically.

Interviewer: Oh, okay. Got you.

Kristen: There are some other symptoms like abdominal pain, weight loss. You can get anemic because that parasite is taking the nutrients from your intestines, so you can become anemic and have some vitamin deficiencies. But what that really presents like is you're tired, you're lethargic. That can mean a lot of different things to a doctor and so as they're trying to figure out maybe what you have, the parasite continues to grow undetected.

Interviewer: So then what do doctors start doing, because what you described as symptoms, you described tired. Who isn't? Who doesn't feel tired or run down? How do they even start to unravel that that's what it is?

Kristen: Usually, it's when the human passes a segment of that parasite or of that tapeworm. That's when they have the "ah-ha" moment, or if you're a really big sushi enthusiast, and you're eating a ton of raw fish and you tell your doctor that, he might start doing some testing for a tapeworm.

Interviewer: Okay. So then the doctor would take some sort of a stool sample, send it to you at ARUP Laboratories, and then how do you determine if somebody has a tapeworm? Is there some sort of a test or do you just put it under a microscope and start looking for them?

Kristen: Yes. We do some processing to that stool specimen, concentrate it so we can see as many parasites as possible if they're there, and then we look at it under a microscope. A very highly-trained person sits at a microscope and looks for what we call "eggs" or "ova" that are passed by these tapeworms in the stool.

Interviewer: So if I have a tapeworm, those will be there?

Kristen: Yes.

Interviewer: You might not see evidence of the tapeworm other than that, though?

Kristen: Yes.

Interviewer: Okay. So then you see that and you let the doctor know, "Well, your patient has a tapeworm." What does the doctor do at that point? Is there a treatment?

Kristen: Yes. Depending on which parasite you have, or which tapeworm you have, the doctor will prescribe some medication that kills that parasite and then the tapeworm passes.

Interviewer: All right. So other than the symptoms you kind of described, maybe some anemia, are they really dangerous?

Kristen: They can be and again it depends on which tapeworm. There's a tapeworm called "Taenia solium". You get it from eating undercooked pork, and it actually can go to your intestines or it can travel to other parts of your body and even end up in your brain. If it does end up in your brain that could have devastating results.

Interviewer: Sure, that would make sense. Here in the United States, how much of a danger is it that you're really going to get one, though? Are we pretty good here?

Kristen: Yes. Our food is really safe in the United States. We have food inspectors and things like that. But it is possible. We do receive tapeworms at ARUP that the person has no travel history outside of the United States, so that means that they would've contracted it somehow in the United States.

Interviewer: So it can happen, but it's not something to be super-freaked about?

Kristen: No. It can happen, but it's not very common in the United States.

Interviewer: A lot of times you see the eggs, and that's how you know that somebody . . . Have you actually been sent a tapeworm?

Kristen: Yes. We get a couple tapeworms that you can see with the naked eye. We get at least a couple a month. To the naked eye, the different tapeworms have some different characteristics, and so we can identify which type of tapeworm they have from that segment. Again, tapeworms are not super-common in the United States, so don't be scared. If you like your beef rare, I say eat it.

Interviewer: Okay.

Kristen: If you do travel to other countries where the food isn't inspected as well as it is here in the United States, be careful.

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