Burkholderia pseudomallei is an endemic soil-dwelling bacterium in southeast Asia, where it causes melioidosis. Direk Limmathurotsakul discusses his work to improve the official reporting numbers and how.
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Melioidosis can present in a number of ways, such as sepsis, pneumonia, or abscesses. Because the symptoms are not specific, diagnosis requires isolation of the Burkholderia pseudomallei bacterium. Risk factors for disease include diabetes and exposure to the soil and water in which the bacterium lives.
In 2012, only 4 people were officially reported to have died of melioidosis in Thailand, but microbiological records suggest the real number was closer to 696. Scientists like Direk worked with the government to improve reporting requirements and the numbers now reflect a more accurate assessment of the disease burden. More accurate official reporting can lead to more public health campaigns, resources, and support for both scientists and patients.
Social media campaigns and a YouTube competition help to raise local awareness of melioidosis. The YouTube competition engages the community by allowing them to enter videos in their own dialect, which then inform others about how to minimize risk factors for melioidosis.
The AMR Dictionary gives simple definitions to jargon surrounding the problem of antimicrobial resistance. The definitions are translated into multiple languages in ways that make sense with colloquialisms. For example, in Thai, many people refer to antibiotics as antiseptics or anti-inflammatory drugs, and the dictionary takes local use into consideration in its definitions.
“[B. pseudomallei] is not difficult to grow; it grows on any standard medium. The difficulty for the bacterial culture is that without proper training, you may read it as contaminants and throw it away. Even if you start the identification, if you are not careful, you may stop as Pseudomonas species and you won’t determine if it is Burkholderia pseudomallei or not.”
“I started to realize that no matter how many papers I publish, I will have less impact if I don’t talk with the Ministry of Public Health.”
“If you want to make a change, you need not only scientific support, you need political support, you need lay people support, you need general public support. When the voices align, change will occur faster and easier.”
“Before 2015, the total number of cases reported to the Ministry of Public Health was about 10 per year...in 2015, the data from our hospital was entered in the Ministry of Public Health and the number of deaths in our hospital jumped from 15 to 120 immediately. Just one hospital.”
“I love to find a solution to questions and mechanisms for those questions.”
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History of Micobiology Tidbit
Direk’s story really emphasizes not only the importance of scientific observations, but the importance of communicating those observations. In this case, it wasn’t enough to publish in a scientific journal that might win him accolades from his peers, but he needed to communicate the numbers of melioidosis deaths to the politicians who could allocate additional resources. Reporting for a number of diseases is required by governments, as Direk noted, and a number of international bodies, such as the world health organization, collect data about certain diseases as well. Obviously this hasn’t always been the case. How did these reporting systems come into play? That’s the topic of today’s History of Microbiology Tidbit.
As you might expect, the impetus for tracking diseases came from outbreaks of a major disease. In 1851, cholera had affected 12 countries to such a degree that they organized the first International Sanitary Conference in Paris, France. Each country had two representatives: one, a diplomat, and one, a physician, and this first conference was held with the goal of standardizing quarantine across international borders, to prevent importation of cholera, plague, and yellow fever.
Cholera had been affecting many European countries throughout the early 1800s. Remember, this was before the germ theory of disease was popularized by Louis Pasteur and Robert Koch, and before John Snow tied the source of cholera to contaminated water - the prevailing idea of disease transmission at the time was the miasma theory, that bad air spread illness and disease. Low spirits were also thought to predispose one to epidemic diseases, and doctors would drink a few glasses of wine when treating infected patients, not to the point of becoming drunk, but to become ‘merry.’ Can you imagine your doctor being tipsy? In fact, John Snow had postulated 2 years prior to the first conference that cholera was transmitted by fecally contaminated water but the British medical delegate, J. Sutherland, did not believe this and argued against any efficacy of quarantine measures for cholera patients.
Sutherland actually argued that cholera and similar outbreaks were “purely epidemic,” but that meant something different in the 1850s - here, Sutherland means that a large number of people experienced the same conditions, eg atmospheric, climate-related, or soil conditions, and thus quarantining wouldn’t stop the spread of disease from these miasmic conditions to the patients.
So what came of the first International Sanitary Conference? Nothing. There was such disagreement among the delegates that they all basically went home and kept quarantining, or not quarantining, as they had been doing in their home countries anyway. That obviously didn’t stop the cholera outbreaks, and the second conference convened in 1859, with Snow’s epidemiological examination of the Broad street water pump completed and even the presentation of vibrio-shaped cells associated with cholera by Italian microscopist Filippo Pacini. This conference lasted for FIVE MONTHS - can you imagine a conference lasting this long? - and was as fruitless as the first.
Conferences were convened again in 1866, 1874, 1881, and in all there were 14 conferences held among a growing number of countries hoping to address the international issues surrounding disease. The last of these was held in Paris in 1938. Gradually, progress was made toward international regulation and reporting standards. At the fourth conference, the first proposal for a permanent international health bureau was made to centralize epidemiological reporting across all countries. The proposal was shot down at this conference, but eventually these conferences were the spiritual predecessor of the World Health Organization, formed as the World Health Assembly in 1946.
In 1969, over a century after the first International Sanitary Conference, the International Health Regulations or IHR were formed with the intention of monitoring and controlling 6 serious infectious diseases: cholera, plague, yellow fever, smallpox, relapsing fever, and typhus. The IHR have been revised several time since, most recently in 2005, to address modern disease threats including influenza and SARS. These disease reporting agencies are vital for identifying and combating disease outbreaks. As Direk explained to us today, you can only fight diseases you are aware of, and updating the notifiable diseases is important at both global and national levels.
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