Malaria Vaccine

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Science, Aug 8, 2013, DOI: 10.1126/science.124800, reports a new highly successful Malaria vaccine. Stephen Hoffman's intravenous (IV) vaccine consists of live attenuated plasmodium falciparum sporozoites -- labeled pfspz.

In a group of volunteers given four or five intravenous injections of the vaccine: 0/6 of the volunteers receiving five injections contracted malaria when later inoculated (p=0.018); 3/9 of the volunteers given only four injections (p=0.028); and 5/6 of the untreated volunteers contracted malaria. Despite the small population, the results were significant.

Prior experiments had shown that multiple mosquito bites by infected but radiated Mosquitos induced immunity. Hoffman took the process forward in employing numbers of radiated sporozoites. Sub-cutaneous injections did not work well, but the intravenous injections did.

Logistics in Africa may pose a problem in that the vaccine requires delivery in liquid Nitrogen containers. The IV dosing may not be so difficult because the volume is quite small, but getting patients back for four more injections likely will be. The authors suggest including the malaria vaccine along with other routinely delivered frozen veterinary products as a feasible avenue. Go.nature/mae5tu has a helpful summary on the background development of the vaccine.

Prior malaria vaccination attempts proved only slightly effective. Malaria remains, despite slow improvement, the number one killer worldwide with deaths estimated by WHO to be between 490,000 and 836,000 in 2010 and cases worldwide between 154 million and 289 million.

Global warming may once again result in Malaria's spread to northern regions, as p. vivax did in the first half of the twentieth century as far north as Archangel, Russia. (Lat: 64.5333)

The emergence of an effective vaccine comes at a good time. It remains to be seen if the vaccine works on other than the p. falciparum variety and on young children.

Under Diagnosis

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Even when we have the right diagnosis, the underlying cause is often ignored. This is a trend in part driven by economic expediency and the over simplification of practice guidelines. Better to just call it congestive heart failure, CHF, and forget the meriode of complex causes. The same can be said of valvular disease, arrhythmias, chronic kidney failure etc. How many times do we change the acronyms and theories of pathophysiology?  As we discredit each theory, we replace it with another one on equally shaky ground. Does obesity cause diabetes or does diabetes cause obesity? Does sleep apnea cause cardiovascular disease or does cardiovascular disease cause sleep apnea? When you cannot find anything wrong with the complaining patient, is it in her head, or is she suffering from environmental and genetic factors that are pulling her apart? Who is to say that the controlled study today is any better than the one done in the fifties?

Medicine is on the cusp of a breakthrough in knowledge. Genomics and proteinomics offer new understanding of etiology that will change much of what we think we know.  Even then, the theories will be a moving target. No wonder, faced with these vagaries, those who would presume to write standards of best evidence look for the four-digit diagnosis.

Disease is a mal adaptation to the environment. If you look at it that way you open a Pandora’s Box of considerations, but that is the art of medicine. If we continue to promote simplified guidelines for diagnosis and treatment, we reduce the physician to a technician. There are those who consider such standardization a good thing from the viewpoint of highly efficient industrial practices. One has to ask one’s self, can medicine be privatized and run like IBM with industrial standards of efficiency and performance, or does the patient suffer from an over simplification?

I want my doctor to open Pandora’s box looking for all the underlying causes.

Adult Onset Diabetes and Obesity

Share |Until legislators put the common good ahead of their fast food lobbyests and get sugars out of the packaged food supply, our only defence against the out of control epidemic of diabetes and obesity stems from early detection and agressive treatment. 

Unfortunately the current standard limits detection of diabetes to fasting blood sugar tests, and initial treatment to oral hypoglycemics. Juvenile diabetes is another matter, but protocals call for adult diabetes that does not respond to first line hypoglycemics to be treated by adding more powerful oral hypoglycemics. This polocy based on so called best evidence codifies the too little too late axium of treatment.

Early detection and early treatment will greatly reduce the mortality and morbidity of adult diabetes, but fasting blood sugars detect the disease long after the disease has damaged other organ systems. The damage results from the high osmotic pressure acompaning higher glusecose levels, like a storm front moving throughout the vascular system and extracellular fluid compartment damaging basement membranes and connective tissue.

In order to get a handle on the control of adult diabetes and obesity too, one needs the concept of pre-diabetes to catch the disease before it mets the current criteria for diagnosis. A hemaglobin A1c will help with an earlier detection. HbA1c measures the glucose on red blood cells. Red blood cells have an average life of 120 days in circulation; therefore, testing today measures the average high points of circulating glucose over that time span. The follow up diagnosis of pre diabetes might beter be with a 5 hour glucose tolerence test.

Interestingly, the first signs of diabetes seen in the clinic often include arcus senilis, A-V nicking, obesity or polyuria. Such is a testimony to our lack of rational preventive medicine guidelines.

The patient can often reverse pre-diabetes with diet and exercise. Failing that one might better turn to small doses of regular insulin before meals rather than oral hypoglycemics. Patients want a pill in order to perpetuate a denial of the disease or a denial of their obesity. The only way to overcome that resistance is by education. Here again the advertising by the drug companies for mor powerful and more toxic oral hyperglycemic medications works against us. If the physician believes in tight control and is passionent about it, that entheusiasm and passion can be transmited to the patient. 

Most endocrinologists and many internists urge treatment of adult onset diabetes with regular insulin or equivalent. Not the long acting kind but fast acting physiological insulin before meals.

I learned this technique and philosophy over fifty years ago in medical school. Why is knowledge forgotten? That may be another question. To the point, my clinic diagnosed pre diabetes and treated it aggressively with diet and exercise. HbA1c at frequent intervals identified early advances in the disease. We were very successful with the pediatric subcutaneous fine needle attached to thin tubing and a push button fountain pen like measured delivery device.

Patient compliance depends on patient education and an agreed upon strategy to protect vital organs and extend life expectancy. Life style changes come  easy when you have a needle in place as a reminder. It works.

With regard to the oral hypoglycemics, some have a use, but most are the promotion and advertising product of drug companies valorized by lobbying and tainted publications -- and yes the protocols of best evidence as well. Again early diagnosis is the key. Modern medicine lacks sufficient emphasis on diagnosis.