Forgotten killer disease: Farmers' bare feet and mud in the field

Melioidosis is also a neglected disease in Vietnam.

Prasart Songsorn is a 56-year-old farmer who lives in Northeast Thailand. Every day, he had to wake up before dawn to go to work. In this tropical country, if you do not wake up early, the scorching heat from the sun plus the rising steam will make people unable to work.

Prasart took his bare feet into the field. The mud is still warm. He does not wear boots, because his boots are warm and hot. In fact, Prasart did not want to buy anything, it only made him more anxious between the difficult and poor families.

Having diabetes since the age of 40, Prasart is almost still healthy and does not take a day off. Therefore, when he began to feel short of breath and high fever on the first day of June last year, he still tried to come to the field.

Only until it was impossible to hold back, Prasart went to a local hospital. In fact, it's just a community health facility a few kilometers away. And Prasart walking.

Here, doctors said he had kidney disease due to neglect of diabetes without treatment. They transferred him to a higher level hospital in Ubon Ratchathani city, nearly 2 hours away. And when he got here, Prasart's condition was very heavy.

Melioidosis is a mysterious disease for most people.

Aroon, Prasart's younger sister, did not believe that he had diabetic kidney disease as the local doctors said. ' He found it difficult to breathe, how could it be a kidney problem? 'she thought. Aroon expects good doctors in the city to find out what is really happening to his brother. But then, they didn't have the answer either.

For more than a week, Prasart suffered from a mysterious disease that no one knew what it was. Only when he died, Aroon's brother knew his brother had been infected with melioidosis . Although melioidosis is one of the leading causes of pneumonia in Thailand, especially in the rainy season, it is still a mysterious disease for most people.

' We have never heard of melioidosis, ' said Sompurn, Prasart's younger brother. ' After the loss, we were given a small leaflet, talking about how infected melioidosis from the soil and how to protect ourselves .'

Since beginning the study of the disease in 2002, Direk Limmathurotsakul at the Oxford Mahidol Tropical Medicine Research Unit (MORU) has found melioidosis to be forgotten. ' Melioidosis is being forgotten, so much so that the World Health Organization does not list it as a forgotten tropical disease', Limmathurotsakul said at the 2017 Biological Threat Conference. Washington, DC.

Melioidosis is a bacterial infection. It can cause a variety of common symptoms, including fever, muscle aches, abscesses and coughs, making researchers call it " a great refuge ". Diagnosis of melioidosis is difficult. It requires skillful testing of patient samples, which can take up to more than a week. But that's often the time when patients like Prasart can't hold it.

Melioidosis is a bacterial infection.

These have contributed to a lack of general assessment of the situation, meaning that no one knows how many cases of melioidosis in Thailand - or anywhere else in the world. And Limmathurotsakul is here to carry out his life mission: Light the light on melioidosis and unearth it as one of the most important tropical diseases ever forgotten in the world.

His greatest battle was not to resist the pathology of melioidosis, but it was a more formidable enemy: the stagnation and indifference of government officials. Limmathurotsakul knows melioidosis is a big problem; The question is whether he can make people pay attention to him as well?

Melioidosis is being forgotten.

'Melioidosis is being forgotten, so much so that the World Health Organization does not list it as a forgotten tropical disease ' - Limmathurotsakul

Back in the 1910s, British doctor Alfred Whitmore and his assistant surgeon CS Krishnaswami were horrified at the situation at Rangoon General Hospital, Burma (now Yangon City, Myanmar). Often, there are male patients hospitalized, dead or in critical condition with fever, malnutrition and signs of opium addiction.

At first, Dr. Whitmore suspected these people were using real opium. But the severe speed of the disease along with abscesses, away from the addict's injection site, made him think again.

When two doctors isolated bacteria from the abscesses of patients, they realized they were also found in their lungs and spleen. The disease is actually a serious infection. They named the bacterium Bacillus pseudomallei . But that is the time when antibiotics have not yet been born, finding the cause does not help patients who are exhausted by infection.

Nothing changed much after 80 years, between the time Whitmore and Krishnaswami discovered the strange disease and when Limmathurotsakul graduated from medical school. The disease was officially known as the disease in 1932, scientists discovered the bacteria that caused Burkholderia pseudomallei (the name was changed in 1992) throughout Southeast Asian countries, although the disease focused primarily in Thailand, Myanmar, Cambodia and Laos.

Learning how to treat melioidosis is a fire test process. Limmathurotsakul read a lot about the disease in the curriculum, but he never tried to treat a patient until he came to Sunpasitthiprasong Hospital in Ubon Ratchathani.

Although antibiotics are available to fight infection, there are very few antibiotics that can treat melioidosis. Moreover, once the patient has been to the hospital, their condition is too heavy to be treated with antibiotics.

' About half of my patients have died. It's like a coin toss , 'Limmathurotsakul said.

During the rainy season, from July to October, the weather stirred up the bacteria hiding in the soil and water. Scientists still do not know how human melioidosis is infected. One theory is that rain evaporates bacteria, then, we breathe.

The rainy season is also the time when rice farmers like Songsorns have to work many days in the field. Walking barefoot in the mud and working with bare hands can make them infected with melioidosis. The result is an overloaded hospital.

During Limmathurotsakul's first rainy season at the hospital, he faced terrible repetitive days.

' You go around and you see patients with melioidosis, a patient with melioidosis, melioidosis, melioidosis. Every two or three days, one of them died , 'Limmathurotsakul recalls. New patients with melioidosis are put into the correct bed of a new person.

That year, more than 100 fatal melioidosis patients, calculated separately in Sunpasitthiprasong. Though tired and embarrassed, Limmathurotsakul knew that people under his care were luckier than most other melioidosis patients. At the very least, they were treated at a hospital capable of diagnosing and treating melioidosis.

The rainy season is the time when melioidosis outbreaks are strong.

Symptoms that are easy to confuse make it difficult to diagnose melioidosis. Same strain of bacteria, but it can cause pneumonia in one patient, but it is a blood infection in another patient, another patient has an abscess in the elbow.

In a small study on hospital size, more than half of children infected with melioidosis had a local infection, most of which occurred in the salivary glands. Meanwhile in Australia, where melioidosis often breaks out in remote northern regions, infected elderly men often suffer from abscesses in the prostate.

Still the same as Dr. Whitmore's age, melioidosis is diagnosed by cultivating bacteria from abscesses, urine, sputum, blood or anywhere else that the doctor thinks can find the disease. This, Vanaporn Wuthiekanun, a microbiologist at MORU gently explained. She has worked with melioidosis in Sunpasitthiprasong for more than 30 years.

" It will be easy if you have experience, but it is a challenge for those who haven't , " she said. The test is also time-consuming, and like the family of Prasart Songsorn, many people do not know what happened to their loved ones until they died, at which point the bacteria were discovered.

Even when melioidosis is diagnosed when the patient is alive, treatment of melioidosis is not easy. This bacterium has a waxy outer membrane that can resist most antibiotics. Medicines such as gentamicin, used to treat pneumonia and septicemia, are not effective against melioidosis.

Therefore, the treatment of melioidosis must take ceftazydim , intravenously two to four weeks in the hospital, followed by three to five months of antibiotics when the patient has been discharged from the hospital.

The sooner Melioidosis is detected and treated, the better. But according to Wuthiekanun, even emergency treatment does not guarantee that patients will survive. The rate of melioidosis death in Thailand fluctuates at 50% when Limmathurotsakul starts its work and has not changed much since then. In Northern Australia, at least 10-20% of melioidosis patients will die.

Those numbers are huge, comparable in standards of infectious diseases, explained Patrick Harris, a doctor in Australia. Other neglected tropical diseases have mortality rates: malaria (0.2%), dengue fever (1%, higher in severe cases), Chagas disease (less than 5%) and disease leptospirosis (5-15%).

" Globally, the burden of melioidosis is still quite large, probably because infected people do not report it in time. They cannot go to the hospital quickly. Melioidosis is common in communities. Poor people, rural farmers, who may have to go a long way to reach a big city or hospital. There are many other social factors involved in this issue, "said Dr. Harris. to speak.

Areas of circulating melioidosis.

Limmathurotsakul said his laboratory actually received only a small number of patients, out of total cases of melioidosis across Thailand. Many patients died before they could go to the hospital. Some others seek help outside the hospital, from people without expertise, ready to prescribe them all kinds of medicines, from penicillin to massage cigarettes.

Limmathurotsakul recognizes that Thailand is facing a serious situation of melioidosis. If only he had to witness 100 deaths from melioidosis in just one hospital and in just one rainy season, it was estimated that tens of thousands of Thai people were dying from it each year.

However, since Thailand reported the first case of melioidosis in 1947, the official annual death toll is very small - even in the mid-2000s, statistics show that the incidence of melioidosis is only about 1 / 100,000.

Laos did not record any cases of melioidosis until 1999. In Myanmar cases occurred in 1945, but were only recorded on tourists. Poor statistical data creates a spiral: donor agencies will not grant money to do research on a seemingly bogus disease, but without money, scientists like Limmathurotsakul cannot work. In order to statistics data proving melioidosis is a disease exists.

" The main problem people try to ask is how many people are dying from the disease, if we can't answer, policy makers won't act at all ," he said.

Melioidosis - a forgotten disease in the tropics

Melioidosis (also known as Whitmore disease) is an acute infectious disease caused by Burkholderia pseudomallei .

B. pseudomallei is a bacterium that lives in soil and water, so the main route of infection is through contact with skin scratches with soil or water containing bacteria. Infection through the respiratory route by inhaling bacteria particles, usually from the wind before the rain is also suspected by some scientists. Some studies also show evidence that patients may be infected with melioidosis through contaminated food.

However, there is no convincing scientific evidence of human-to-human transmission or from animals to humans through the air. Therefore, cases of melioidosis infection are often sporadic rather than outbreaks of epidemics or pandemics.

The first case of melioidosis was discovered in Burma, Myanmar in 1911 by the English scientist named Alfred Whitmore (his name was given to the disease).

The first case discovered in Vietnam was recorded at the Pasteur Institute, Ho Chi Minh in 1925.

According to the research of Dr. Trinh Trach Trung - Head of Scientific Research Department, Institute of Microbiology and Biotechnology, Hanoi National University:

Data show that, from 1948 to 1954, about 100 French soldiers were infected on the Vietnam battlefield. During the Vietnam War, about 350 American soldiers were infected.

In the 70s and 80s of the last century, Whitmore was also called with a "Vietnamese - time bomb" to refer to an infectious disease in Vietnam, then incubated for a long time before getting sick when Retired US veterans.

After the liberation of the country, only a few major hospitals in Hanoi and Ho Chi Minh City announced cases of infection.

One of the reasons for this lack of information in lower level hospitals is that clinicians do not know much about the disease and are not vigilant for diagnostic tests, clinical laboratory testers do not have a review process. disease testing and also have not paid attention to disease testing.

Therefore, Whitmore is a neglected infectious disease in Vietnam.

A fever began in February. Pailat Ganjanarak realized that he could hardly bear the additional fatigue, chills and vomiting. Because of that, he went to squeeze the medicine, a popular cure in this part of Thailand. It can cure all mild illnesses. But in the case of Ganjanarak, squeezing the medicine doesn't help.

Then, the 55-year-old man, who owned a small grocery store, went south from Ubon Ratchathani, to meet a local doctor who diagnosed inflamed Ganjanarak and prescribed him various types of steroids. . After a week, Ganjanarak's disease became worse than ever. Twelve days of antibiotics do not help. His illness kept getting worse and worse.

" I was very sick, could not even walk ," he recounted.

Because of his anxiety, his wife Ganjanarak drove him to Sunpasitthiprasong Hospital, hoping the doctors there could identify his husband's mysterious disease. Right until mid-March, more than a month after Ganjanarak became ill, new blood tests gave answers.

Although he has lived almost his entire life in Thailand, where melioidosis is the most common, Ganjanarak has never heard of it. Most of his friends too. " Most people don't believe me because they have never heard of it ," he said.

According to Pornpan Suntornsut, from the MORU-Sunpasitthiprasong unit of melioidosis, Thai people all know about leptospirosis - a bacterial infection that can cause kidney disease - meningitis and pneumonia. But rarely does anyone know about melioidosis. She said only about 2% of people in Ubon Ratchathani know what melioidosis is. Even doctors don't know much about it.

For Suntornsut, this reflects the official attitude towards milioidosis. The patient had no questions about melioidosis, while doctors could not make a quick diagnosis and the government did not have enough data - or enough political will - to take any action.

An increase in the number of diabetic patients may also increase the number of melioidosis cases.

Another problem is the reporting system of illness in Thailand. Limmathurotsakul said after the Second World War, the government wanted a method to detect and prevent cholera outbreaks. At that initial time, all the patients needed to do was call a phone to the Ministry of Health and a person would be sent to care and investigate them.

However, in the past 60 years, more and more diseases have been added to the list of reports - the current total is 78 infectious diseases. Yet in almost all Thai hospitals, including hospitals with 1,000 beds, the capacity to treat 200,000 patients per year, there is still only one full-time officer reporting all of these cases, according to Limmathurotsakul. share.

He said this made it possible for the system to change priority subjects: " This year, we have outbreaks of dengue fever, so the Ministry of Health requires reporting dengue. We will report. We need data to inform people across the country, whenever there is an outbreak of influenza, avian flu, Ebola, cholera . anything scary in the year, they will say, OK, this year is a priority . "

Melioidosis is not a disease that causes major outbreaks or pandemics, and it is not the media that can jerk the title or get the attention of the government - it only causes silently infected infections to be fine. determined.

Melioidosis usually does not spread from person to person, reducing its priority even further. The disease also tends to affect poor farmers in rural Thailand, another factor that makes it less of a concern.

Scientists sampled water to test bacteria that cause melioidosis.

On the other side of the western Thai border is Laos and Cambodia, similar challenges appear. At Angkor Hospital for Children in Siem Reap, Paul Turner recorded about 40 to 50 cases of diagnosis of hospitalized melioidosis infection each year. He estimates that throughout Cambodia the number must be in the thousands, but because of the local nature of the disease, the government does not require reporting on it.

The final consequence is that reports of melioidosis, both in Southeast Asia and elsewhere in the world, are incomplete. There have been cases of melioidosis in Brazil and throughout Africa - patients who do not travel, which means they are infected with bacteria right in their place of residence.

Limmathurotsakul and David Dance, a British doctor who are studying melioidosis in Laos, believe that this situation is still only part of the burden of disease, because melioidosis seems to resemble many other tropical diseases and It is very difficult to diagnose.

And this burden will increase due to two factors: climate change and diabetes.

Across the Indian Ocean in Sri Lanka, infectious disease doctor Enoka Corea called on his colleagues to monitor cases of melioidosis 10 years ago. In the first few years, they only found one or two cases. Now, the cases have frequently appeared with stable frequency.

" We suddenly found that before, we had only recorded about 10 cases of melioidosis each year. But then, the number increased to 23, to 65, then to 100 ," Corea said. She also said that the annual number of melioidosis patients will continue to increase, because climate change is causing more severe weather events, eroding bacteria from the soil, as well as increasing the area that bacteria B. pseudomallei can grow in the world.

The effects of climate change have begun to feel in Australia. Climate models predict that many parts of the country will become epidemic risk areas for melioidosis. An increase in the number of diabetic patients may also increase the number of melioidosis cases.

Although no one knows exactly why, diabetes increases the risk of melioidosis. And when a diabetic patient has melioidosis, their condition often worsens, such as a blood infection or pneumonia, which increases the risk of death.

" Both (diabetes and climate change) will almost certainly increase the incidence of melioidosis in the future , " Dance said.

Even when colleagues predict the number of cases of melioidosis will increase in the future, Limmathurotsakul still struggles to persuade the Thai government to recognize and evaluate current melioidosis as a burden.

At all levels of the industry, he found problems. For health care facilities at the highest level, their problem is the lack of time and resources, or fear of being granted reprimand when not reporting cases of melioidosis earlier. However, for the management, they do not want to cause panic among the people and do not believe the current data is important enough.

Limmathurotsakul is one of the pioneering scientists studying melioidosis

"I had to change the perception of all levels of industry ," Limmathurotsakul said. This process involved years of meetings with government officials, from small hospital staff to the Minister of Health.

At the same time, Limmathurotsakul and his team began collecting data and developing computer models to estimate the burden of melioidosis. In 2016, they published the first global estimate of the incidence of melioidosis, and this figure was much higher than anyone could predict.

Their research shows that there are about 165,000 people suffering from melioidosis each year and 89,000 of them die. More importantly, their work shows that melioidosis hotspots are beyond Southeast Asia, including India and Sri Lanka.

" Actually, that article is just the beginning ," Dance said. " It was the beginning of the effort to raise awareness about melioidosis to help people understand if predictions from the main research model. corpse, melioidosis is actually a much more terrible killer than other familiar diseases. "

Along with Limmathurotsakul's years of persuading government officials to improve statistics on melioidosis, this high-profile report led to changes in official attitudes towards the disease.

In Ubon Ratchathani, Thailand alone, the rate of melioidosis infection increased from 4.4 cases / 100,000 people in the early 1990s to 21.0 cases / 100,000 people in 2016, thanks to the improvement of the system. listed. The more hospitals report more and more cases of melioidosis, Limmathurotsakul hopes this will encourage other hospitals to join. He also hopes statistical data will boost new research.

However, stopping melioidosis will require more than just statistics. Therefore, some other scientists began to be interested in developing vaccines or building new medical facilities.

Wearing boots is a simple way to prevent melioidosis when working in agriculture.

Across the green rice fields in Thailand, farmers are still hunching over their fields, wading mud up to the calf. Most farmers go barefoot. And you will understand why they did it when it returned to noon, even when standing on the shore.

Sweat will spill out from all your pores. In less than five minutes, you will be wet, your hair is sweaty. Even wearing sandals, your feet will be extremely burning. Right now, wearing boots is a funny idea.

But that's exactly what the MORU group wants to recommend to farmers.

Bumping mud is a way to spread melioidosis. In the past, weather was what prevented boots sold to farmers. Suntornsut nói rằng với một vài trường hợp chính thức của bệnh melioidosis được báo cáo, hầu hết mọi người sẽ không chịu đi ủng.

Nhưng bây giờ, khi căn bệnh này đang được công nhận, các nhà nghiên cứu sẽ dễ dàng nói với những người nông dân về tầm quan trọng của việc đi ủng và uống nước đun sôi để diệt vi khuẩn. Mặc dù vẫn còn quá sớm để có thể đánh giá kết quả, Suntornsut cảm thấy những nỗ lực của nhóm mình đã được đền đáp xứng đáng.

Limmathurotsakul thì đã có thể thay đổi thái độ của chính phủ về việc phải thống kê bệnh melioidosis, nhưng cuộc chiến của anh còn lâu mới kết thúc. Ngồi đằng sau bàn làm việc của mình ở Ubon Ratchathani, anh ngả người và dừng lại sau gần hai tiếng đồng hồ nói không ngừng nghỉ về melioidosis.

"Bạn cần tiếp tục công việc ", anh nói. "Bởi vì nếu bạn không tiếp tục, không có bạn ở đây, chẳng ai khác sẽ làm công việc này. Bạn không thể hy vọng rằng ai đó sẽ làm điều đó cho bạn".