Friday, June 5, 2015

There is an Urgent Need For an Epidemiologist on 'Game of Thrones'

Courtesy: NBC News
"Game of Thrones" has seen its fill of death and destruction and it comes in many forms. A psychotic king, snow zombies, a crazy bastard who enjoys flaying, oh and weird diseases that a mere touch can trigger. A press release just sent out by Indiana University-Purdue University Indianapolis, discusses the importance of Westeros desperately needing an epidemiologist. A what? Basically a disease detective and they need one quickly to help with the numerous, yet fictional, diseases that seem to plague Westeros. Namely, greyscale.

Check out the complete release below for a little education on diseases in general and a break down of what's infecting Westeros. Be sure to tune in this Sunday at 9 p.m. on HBO for the next episode, "The Dance of Dragons."

Fans of the HBO TV series "Game of Thrones" (and the books on which the series is based) know you can’t take a stroll through Westeros without tripping over a knight, a sellsword or a black-cloaked Ranger of the Night’s Watch. But when it comes to protection from harm, what many citizens of the fictional Seven Kingdoms really need these days is an epidemiologist.

It seems the mysterious and deadly greyscale, an infectious disease that leaves its victims’ flesh stiff and dead, has returned. The skin of those afflicted becomes cracked and turns an ominous mottled black and grey color before becoming stone-like to the touch. And that means that White Walkers, dragons and would-be kings with itchy sword fingers aren’t the only things citizens need to fear.

What is greyscale? How is it spread? What are the control measures? And most importantly -- especially for a certain disgraced former advisor to the Mother of Dragons -- is there a cure? These are all questions that have taken on new urgency in the current season.

Whether in Westeros or places a bit closer to home, two questions are always asked with the emergence of any “new” disease: “What is this?” and “Am I at risk?” From the Black Death that killed as much as half the population of Europe during the 14th century to last year’s Ebola outbreak, our history is full of “plagues and poxes” that emerge, wreak havoc and cause panic.

When it comes to managing outbreaks of greyscale in Westeros, the response has been a bit, shall we say, unrefined. The most common way to prevent greyscale from spreading is to cut off any body part showing signs of the disease, but this treatment is not always effective. Here in the real world, we have a secret weapon that the characters in "Game of Thrones" don’t have: epidemiologists.

Epidemiologists are disease detectives who use their knowledge of science and their training in public health principles to answer the “who, what, where, when, how and why” of any disease.

If a modern-day epidemiologist were to appear in Westeros, what might they do to combat greyscale? Tom Duszynski, a faculty member in the Department of Epidemiology at the IU Richard M. Fairbanks School of Public Health at Indiana University-Purdue University Indianapolis, has a few ideas.

“With an infectious disease, time is of the essence,” Duszynski said. “One of the most important first steps an epidemiologist takes is to accurately and quickly define the specific characteristics of any newly discovered disease. Many diseases have similar symptoms, so it is critical that those responding to an outbreak have criteria by which to determine what is really a case of the disease and what isn’t.

"One of the challenges with last year’s Ebola outbreak was that it occurred at the height of flu season. Both illnesses are marked by high fevers and lethargy in their early stages. It was important for caregivers and first responders to know the difference between the two so they could take appropriate steps.

"With greyscale, I’d want to know what marks a true case of the disease so nobody is dragging out an ax if they get a bit of psoriasis on their leg.”

Duszynski notes that casting a wide net helps to identify as many cases of the disease as possible.

“My case definition may be something like, ‘any previously healthy individual who developed greying and flaking skin that has hardened over the past six months,’" he said. “Discoloration of the skin can be caused by a lot things, including poor blood flow. Flaky, scaly skin can be symptoms of a bad sunburn or eczema. So I’m going to catch all these in my case definition net. I can throw out those that aren’t truly greyscale later. As I catch more and more cases in my net -- and exclude those that aren’t true cases -- I can refine my definition to capture only true cases.”

According to Duszynski, the next steps are to determine how a disease is transmitted and what its reservoir is. The reservoir -- where the disease lurks before being transmitted -- could be a person, animal, plant, body of water or particular environment, such as a cave.

“Each disease has a portal of entry, which is how it gets into the human body, as well as portals of exit," he said. "The portals of exit are important to know, because if the disease is transmitted person-to-person, you would want to know how it leaves the body. Maybe there is an intermediate host, such as a mosquito, that can pick up the infectious agent from the reservoir and transfer it to a susceptible person. If I know these things, I can begin to prevent infection, which is the ultimate goal.”

If greyscale is spread from person to person, Duszynski says he would want to implement isolation and quarantine.

“These are two very distinct terms used in public health," he said. "They are often confused, but they have different meanings. Isolation is what people are placed in when they have the disease -- they are acutely ill and they are infectious, meaning they are able to transmit the infection to another person. We would isolate those people to prevent them from spreading the disease and keep them in isolation until they are no longer infectious.

"I would put people in quarantine if they have been exposed to the disease but haven’t yet developed signs or symptoms; and they would remain in quarantine for the maximum incubation period, which is the maximum amount of time that has occurred between when someone was exposed to the disease and when they developed the disease. So if an infectious person were in a room with 10 other people, I would put the one person with the disease in isolation and the other 10 in quarantine.”

Armed with the knowledge of what a case of greyscale is, how it is spread and what its incubation period is, an epidemiologist could achieve the ultimate goal of prevention.

“This is exactly what public health does with any disease,” Duszynski said. “Disease prevention requires the implementation of control measures to prevent the spread of disease. The control measure could be as simple as hand washing, or something as complex as developing a vaccine. The biggest challenge is getting people to implement the control measure.”

When asked if he would be eager to address the greyscale outbreak himself, Duszynski chuckles. “I suspect it would be quite a challenge to eradicate or contain greyscale. Effective public health practice depends on modern science to help identify infectious agents, and Westeros doesn’t appear to have laboratories that are up to the task.

"An epidemiologist in Westeros would also have to contend with the local population’s belief in mystical forces. That was a challenge for early public health practitioners in the real world, as well. It wasn’t until the early 1900s that the germ theory started to combat the belief that disease was spread by supernatural forces or ‘bad air.’ Finally, I think I would need a better communication system than sending a raven to get the word out about prevention and containment protocols.”

Looks like fans will have to wait and see whether greyscale will add to the legendary body count of "Game of Thrones," or whether some of Duszynski’s ideas find their way into an upcoming episode and save the day.

-Larissa Mrykalo