Fever, Fluids, Food in acute infections

well um dr stephen option can is has uh kindly agreed to talk to us there was a clinical professor school of population and public health is that right stephen yes faculty of medicine university of british columbia right so basically i i know you've been working on a paper which is sort of challenging some of the almost almost sort of not quite axioms but things are such that are so frequently done in modern clinical practice that when someone has a fever you reduce the fever when someone's ill we try and give them lots of drinks and when someone's ill um we try and feed them but but you're sort of rethinking this aren't you i mean how would you sort of summarize the the the argument we're going to be looking at today stephen please so my paper focuses on uh three aspects of fever basically the fever itself food and fluids and a lot of advice that we give to patients because sometimes when a patient's sick you want to give them advice that they can do something to help themselves but a lot of the advice we give is not evidence-based and is sometimes not useful or even harmful and you know with a severe infection like covet going around we're seeing a lot of this i think potentially harmful advice being given to people so the first aspect is fever this is a part of your immune response and it's the way the body fights off infections that you know a single bacteria virus can't rapidly change its temperature but human can and so we can rapidly increase our temperature viruses are only effective over a certain temperature range so it makes it harder to survive in the body and the higher the fever is generally a sign of a more serious infection so if you have a very high fever why turn that off if it's trying to fight the infection so that's another important point the second aspect is fluid you know people often say you know every public health website will tell you drink plenty of fluids uh when you have a fever and that's exactly the opposite thing you should do because when your body is a fever it actually releases a hormone that retains water because normally when an animal becomes sick you know it's going to hide in its burrow try and keep warm it's not going to be eating or drinking so if you're not eating or drinking you want to conserve that water you have and that's what the body does whatever water you have when you get sick it's trying to hold that in so if you're holding water and then you're drinking plenty of fluids on top of that that fluid has to go somewhere and so if you're drinking say water or something like that generally that fluid goes into the cells so it can go into the lungs you know if you have a cold you really want your lungs to fill up with fluid that's not going to help you breathe stores and cells in the brain so people often get headaches you know when they get a high fever a lot of that is due to just doing the wrong thing and the same with fluid if an animal is sick you know it's hiding in the spuro it's not going to be eating and so generally what the body does is it consumes itself you know there's stored fats and sugars that it breaks down to fight that infection because if you ever had a a large christmas dinner you know that you know afterwards you feel quite tired because it consumes a lot of energy energy to digest and so when you have a serious infection um you know that time that you're spending uh digesting food is taking away from energy you could spend against the infection which is the more important thing uh at that time wow so basically what we're saying is for for the vast majority of people with acute infections whether that's caused by bacterial or viral illness it's usually best not to artificially lower the temperature with with medicine such as paracetamol or acetaminophen it's best not to give them too much in the way of fluids and and it doesn't matter if someone doesn't eat for 24 48 hours for the vast majority of people does that that's right and and and your contention is that this will have an improved clinical outcome that they will be sick for a shorter period of time they're less likely to die what's the practical outflow of following these three pieces of advice yeah i think i think your survival from you know a serious illness is going to be much higher and also you know i mean that's that's an important part of the immune response is the fever and when i was first writing this paper you know a year ago there was no such thing as long cove but in people getting staying ill long after the illness had gone away and you know i i'm thinking now that you know maybe some of that is because we're turning off the immune system right when we're starting to fight that infection and then that's causing negative effects on you know various organs and and some long-term effects you know that people might be suffering from because they shut the immune system off right at the very beginning wow i mean this is of course the reason we're doing this interview is this is what i believe for a long time myself but it's it's pretty radical most people associate a fever with abnormality therefore they need to get rid of it so i i think if we start off by looking at fever in a little more a little more detail stephen if that's okay i mean how how is the fever generated when someone has say a viral or a bacterial infection what's happening physiologically in the body to raise the body temperature so it's controlled by the hypothalamus which controls your regular body temperature so during the winter time you'll feel cold you're going to put on a sweater or turn up the heat in your your room or you know wear a thicker coat um but when you get a fever the body decides okay 37 degrees celsius is not good enough we need to raise it to say 40 degrees celsius so now when your uh body's 37 degrees all of a sudden you feel cold you get the chills you might get shakes or riggers and so what your body is actually trying to tell you is warm up go live under some warm covers dress more warmly so it's trying to give people that information you know to change their behavior so that because you can imagine you know raising your body temperature from 37 to 40 uses up a lot of energy and it's just a waste to use your body's own energy to generate that fever when you can just lie under some warm covers or get a hot water bottle or something like that so it's trying to give you that information to save your energy and stay warm but people often want to take you know medication because they think i don't feel well let's take some medication but you know what's the point of taking anti-fever drugs if it's going to prolong your illness or worsen your illness maybe you temporarily feel a little bit better but over the long term it's it's not going to help so acetaminophen which is paracetamol it's exactly the same drug or tylenol it's the same thing and i ibuprofen are common medicines that people take to reduce fever will will those drugs actually have any antiviral or antibacterial effect no those drugs themselves don't have any therapeutic effect against the virus or bacteria or anything like that and there are some animal studies to suggest in fact the animals survive less well develop more serious infections when you use those drugs so so these medicines are treating the symptoms to make someone feel better in the short term and they do make someone feel better in the short term but but they are actually working against the body's own deliberate attempt to rate to raise the temperature right each medication has different mechanisms of action and with paracetamol what it does is it causes your peripheral veins to dilate so you know you're losing heat um but also you know if you're giving that higher doses irregularly to a patient uh it often causes a drop in blood pressure and so to counter that they will often give the patient more drugs to bolster the blood pressure more fluids to fill up the veins to try and increase the blood pressure but all this is working against what the body's trying to do and actually can make uh the situation a lot worse for the patient [Music] i've heard of i've heard of pyrogens stephen what are they pyrogens are molecules in bacteria and viruses that stimulate a fever so the there are certain conserved molecules in in these infectious agents that the body can recognize oh this is a gram negative bacteria or this is gram-positive bacteria and then that shapes the type of immune spawn response that a person will develop afterwards so important uh ways to recognize something that doesn't belong in your body and then the pyrogens will be recognized in the hypothalamus which will just turn the temperature up is that the way it works right so if it if the body gauges that it's not a serious infection you might not get a fever or maybe only a mild fever if the body gauges it's a more serious infection you know you get much higher fevers uh depending on on what it uh how serious it seems to the to the immune system it's quite incredible isn't it and um and as as the temperature goes up uh as someone develops a fever you've already said that the uh the viruses if there's viral infections the virus the viral particles won't replicate as effectively is that true yeah it does um because a virus or bacteria you know these are like single cells that you know they they don't operate over wide temperature ranges like humans can live in the arctic they can live in the tropics you know we can live over wide temperature ranges but a virus or a bacteria has certain optimal ranges that they live in so like cold virus usually gets into your nose because you're breathing it out your nose is actually a little bit colder your nasal patches passages are colder than the body so they like to live in those colder temperatures so when you get this fever uh it makes it much more inhibitable to the virus and is it the same for same for bacterial infections same for bacterial infections there's a certain range that um you know is optimal for them and then when you get these higher temperatures it's a little bit harder for them to survive and replicate depending on what temperature you can produce so this will probably be related to the enzymatic systems within the organism isn't it that the enzymes are very specific to a particular temperature range right there's a lot of aspects of their replication and enzyme production and things like that that operate in certain temperatures the body releases certain molecules to protect its own cells and its own immune system so that they can operate more optimally at higher temperatures so the higher temperatures are uncomfortable for the for the organism but what do the higher temperatures do to bolster the immune system of of the of the individual well um also it does seem that some immune cells function more optimally at higher temperatures you know enzymes can work much more rapidly so there's a little bit of efficiency that goes along with these higher temperatures that seem to be uh working hand in hand with the fever itself and is this the cells in the innate in the innate uh immune system or is this these the cells in the the adaptive immune system or is it affecting both types of immune cells it's affecting both and what's interesting is um they did a randomized study in children uh getting their routine vaccinations so it was a vaccination with multiple against multiple pathogens and they randomized them to acetaminophen or placebo and they found that the patients that took the acetaminophen had a much less immune response so less antibodies and things like that they measured uh engaging immune response and many subsequent studies have been done in adults and children and they'll show the same thing if you suppress the fever with acetaminophen or ibuprofen when you're getting a vaccination you get a very much inferior immune response to that so we know that the fever is going hand in hand with the immune response guiding that action against the um against these pathogens which is important when we think about the covet vaccination um you know do you really want to take acetaminophen um you know beforehand or afterwards if you're getting that vaccination are you going to get a good immune response probably not so this febrile response is enhancing the immune response for natural infection and enhancing the immune response that we get to our artificial immunity which is basically i guess what is vaccine vaccination is and yet routine advice even from doctors all around the world seems to be to reduce fevers if you're ill or to take uh ibuprofen paracetamol acetaminophen after a vaccination if you have a febrile response so so the this is basically contradicting a lot of official advice around the world at the moment isn't it yeah i mean we've traditionally said that you know fever is not that important you know it doesn't make a difference but actually there is a wealth of studies um some studies in humans but mostly in animals uh that show that it is quite important and if you look across the animal kingdom all mammals produce fevers all birds produce fevers and then you've got some animals that can't alter their temperature like reptiles and amphibians they can't alter their temperature but they can move to a warmer environment and what we see is those animals as well have a febrile response if they be become infected they'll move to a warmer environment a snake will go somewhere in this burrow or somewhere in the sun to heat its body up much higher than it would normally when it's healthy and we also see this in fish and even insects so you know you look across the animal kingdom and all these animals are trying to generate a febrile response when they have an infection uh but humans are the only exception they're trying yeah ones that bring it down absolutely so this is quite incredible all mammals generate a febrile response when they have infections or all birds do yeah and quite a few fish and insects and uh as we've said reptiles lizard snakes seek to increase their body temperature by some mechanism so what what that's saying to me stephen is this is a massively highly conserved characteristic does that does that relate to what you're saying right it's you know it wouldn't spread this because if you look at it it's a as a huge metabolic cost for a bird yes a mammal to generate that energy to increase its body temperatures so you know why would it have that huge metabolic cost during an infection unless there were some significant benefits of that response now if i have a metabolic deficit i'll go to the kitchen and make myself a sandwich it's not too difficult but in the survival situation spending that amount of energy to increase the temperature could be the difference between dying of starvation or or surviving it's it's a massive thing in in a natural environment isn't it so so for an organism to use such a lot of energy to generate a febrile response says to me that this febrile response must have a really significant uh purpose and adaptive advantage yeah for sure and um you know there's a concept they call it sickness behavior and a lot of uh behaviors that an animal has when it's sick you know they used to think well it's debilitated from its disease but what they've come to understand is this sickness behavior is actually behavior that helps them overcome the infection so you know maybe they're not grooming themselves like they normally would so they look pretty scruffy during an infection but you know it's not so important to groom yourself if you're an animal if you're wanting to spend that energy to fight the infection instead abso absolutely so if this had been a deleterious feature in animals it would have been selected out by natural darwinian processes millions and millions of years ago because it's conserved in every branch of the evolutionary tree right it means it's had an advantage in every single branch of that tree and it's a survival advantage so an animal that develops a fever will be more likely to survive therefore more likely to reproduce therefore more likely to pass its genes on i mean that is uh that is pretty convincing argument to me but um what what people always say to me is uh but fever's dangerous what happens if my fever goes too high um so what do i say to those people so i mean you have to differentiate between something like fever or heat stroke like if you're out in the hot sun during the day and you just become fainter or something like that because of the high temperature you know that's the environment that's controlling your temperature not your body but in the fever the body is controlling the temperature and they've done studies and they've shown that if you don't do anything with the fever most fevers won't go beyond 40 or 41 degrees celsius above 42 is extremely rare so it's not like if you don't treat it it's just going to keep going up and up and up and there's going to be this huge danger of brain damage or something like that in fact the body is is quite in control of the fever but also means that you support that fever appropriately so keeping warm uh is is a good thing but you don't want to keep too warm like you you don't want to be putting so many blankets on that you're sweating um you know and drenching in sweat because now you're you're not you're again you're not following the clues the body's giving you you just want to keep your skin warm and dry and during a normal febrile infection the fever goes up and down and up and down it's kind of like um you know an army fighting you know it thrusts and it attacks and then it might pull back a bit and then it attacks again and so the fever has this complex pattern where it's going up and down and so you just have to support that if you're feeling cold put on more blankets if you start to feel hot take those blankets off because that's that's the normal pattern is as this up and down a fever so the way i feel when i'm sick is very much a product of my physiology and neuronal circuitry that's actually hardwired into my brain with synapses that use specific chemicals that are actually in the very structure of my brain that are controlling this very thing right yeah it's it's not an accident i mean it's we don't second-guess you know how many immune cells the body produces or the type of immune cells but we we try and second-guess the fever it doesn't know what's doing with in terms of fever but in fact you know this is quite highly regulated um a spot response as it's going along against the infection and is promoting the function of the immune system and making life very uncomfortable for the for the pathogenic microorganisms or viruses that are causing the infection now um i'm very happy with that in in adults um you know i've looked after many adults with fevers of 40 degrees centigrade and that they don't seem to come to any harm even 41 degrees centigrade so um if if me as an adult if my fever was 41 42 degrees centigrade for a period of time i'd feel pretty awful but it's not actually damaging my body tissues is that what you're saying that's right yeah yeah now what about children how does how are children different well you know for a small child under five they're a little bit different from adults because they have a very large brain size relative to their skull their skulls still kind of small relative to their brain and so there is on the rare occasion uh the development of febrile seizures during fevers and so people become concerned and and they've studied this and they've shown like the seizures that occur during fevers are are largely harmless but they have done a lot of studies looking at randomized trials where they they treat patients with anti-fever drugs or placebo and they found that in these studies doesn't help prevent seizures doesn't help treat seizures so that's that's something to consider but the other consideration is um you know how much fluids you give that child because the more fluid you give that again is is stored in the body and it has to be put in somewhere and so that can go into the brain cells so actually if you give a child like a lot of water to drink and they're having a fever the brains the brain will swell and actually you you increase the chance of that child developing a seizure this is what we call this is what we call cytotoxic cerebral edema isn't it right where the individual cells swell up before we go into that though i was taught in fact it was drummed into me when i was a student that children under the age of two can't efficiently control their body temperature they can't efficiently thermoregulate therefore for example a one-year-old child with a fever the fever could keep going up and up and up until it would potentially damage the uh the the the proteins in the brain what's the what's the current thinking on that well again you know it's the body that's controlling that fever obviously if a child is um you know when the fever is going up you don't want to you know have them overheat by giving them too many blankets but you know you just want to work with that um that change in temperature so that they're comfortable but generally it's again just like adults it doesn't keep rising and rising right so and that's that's true even under the age of two um right so so actually babies are actually able to control the body temperature whereas for generations people have been taught that babies can't control their body temperatures effectively um not to the same degree as as an adult can um but you know sort of a developing immune system there but in general a fever if appropriately managed is not dangerous to that child certainly not as dangerous as the infection it's fighting i think this is one thing we tend to forget because we've been brought up in an era of antibiotics we forget that the most common cause of death throughout human history has been infectious disease this is what people die of and that they are dangerous conditions so that that's i'm pretty convinced by you by your fever argument there stephen that's lots of good evidence for that um what about the fluids let's go into thinking about fluids if someone has an acute infection um what what's your thinking about fluid uh giving fluids fluid resuscitation drinking large amounts of water maybe first of all if we talk about how the body responds physiologically when there is a when there is an infection and when there is a febrile response um what physiological or pathophysiological changes occur in the fluid management systems of the body as a result of that infection so when you have an infection and fever the higher the fever the higher your fever goes the more the body releases a hormone it's called antidiuretic hormone and that hormone has the job of keeping water in your body and so the higher the fever the more water it's going to keep in the body the less you're going to urinate so the whole goal of the body is to conserve water during a fever because you know if you're debilitated uh normally you wouldn't be eating or drinking uh if people weren't otherwise giving you advice people often you know when you're sick you often don't have the same food doesn't taste as good no you're not as thirsty but that can vary depending on the type of infection uh if you have cholera where there's a serious amount of diarrhea and you're losing a lot of fluids you can't just keep not drinking but you have to drink the appropriate type of fluid because if you just if you're a cholera patient you have diarrhea and you're drinking water that will kill you because when you're losing those fluids you're also losing electrolytes and so it's important if you're going to replace fluid um you have to replace those electrolytes as well yeah this is what we call oval rehydration salts isn't it right so you know if you have covid you're probably not losing a lot of fluid but some diarrheal illness uh you might be losing a lot of fluid or if you're vomiting or something like that um so we're differentiating here so respiratory infections we probably don't need to take extra fluid gastrointestinal infections where there's a fluid loss we do need the fluid but it's it's better to take it with associated salts and electrolytes as well as just pure water right if you're taking the wrong type of fluid uh you're gonna be a lot worse off because if you drank pure water presumably that would affect the osmotic potentials in the blood wouldn't it right so i mean your your blood is actually fairly salty and uh if you just fill your body up with water um you know and you're losing electrolytes uh eventually your body just can't function properly uh the cells swell and um yeah you can you can die from that yeah so for acute respiratory infections if you gave someone large amounts of fluid for example intravenous fluids you would have more fluid in the body could that potentially increase the amount of fluids collecting in the alveoli for example as occurs with acute respiratory distress syndrome in covered severe copper disease well it depends on the type of fluid so when you give patient iv fluids you're generally giving fluid with electrolytes but it depends on the sodium concentration of that fluid is it isotonic fluid the same concentration as the blood or is it hypotonic which is a lower concentration so if it's a lower concentration of the blood what happens is that excess fluid goes into the cells if it's the same or higher the fluid gets drawn back into the bloodstream so basically when you're when you're shifting fluid into the cells that's when you get a lot of side effects people get more difficulty breathing they get headaches they get nausea vomiting um so that can get a lot worse if you're not using the right type of fluid right so in a respiratory tract infection for example it would be acceptable to give say 0.9 normal saline which is isotonic right i mean but these are hospitalized patients you know a person at home is not going to be worrying about that but you know at the start of an infection you don't want to over hydrate because what we see with serious lung infections we saw it with sars we see it with covid often patients come to the hospital with a condition called hyponatremia which is a low blood sodium and that low blood sodium doesn't just happen because the person's losing a lot of sodium it's usually because they're taking in a lot of fluids which dilute the blood and um you know when you when you come in with hyponatremia your risk of a poor outcome is much higher so you know you want to avoid that certainly from the beginning of the infection so high po neutrino low salt in the blood more fluid will go into the alveoli more fluid will go into the cells and as you said more fluid will go into the brain cells potentially causing it yeah fascinating now i have always been taught in chest infections and um i'm very happy to reverse all of this but i've always been taught that you give plenty of fluid in chest infections because if you restrict the fluid in chest infections this is going to increase the viscosity of the the mucus in the mucociliary clearance system does that i mean that's one of those things that kind of makes sense but is there any sort of scientific evidence for that any scientific rationale for that um no there isn't any scientific evidence for that and traditionally patients with these infections would get more generous fluid intake but they found over time that the patients that were getting the generous fluid intake were doing a lot worse than the patients that were getting the more conservative fluid intake but it's taken a long time for that those changes to happen so now when the patient's ill they're a little more cautious with how much fluid is taken in but you know it depends on what you do beforehand before you get to the hospital sure and that this of course is the ultimate proof i i can make up any imaginative very neat physiological rationale in my head which may or may not relate to reality but if the empirical data from actually looking at groups of patients that are given small amounts of fluid and large amounts of fluid if the difference between those groups that is the evidence isn't it this has to be based on on empiricism right yeah the the lungs fill up with water and it's not really helping helping the patient yeah wow so so in increased respiratory infections uh best to let the fever do its own thing the body knows best what it's doing uh best not to over hydrate the patient because we don't want the blood to be diluted we don't want water going into the alveoli or into the cells where it's doing no good so and presumably uh eventually though the patient will start feeling thirsty then it would be appropriate for the patient to drink when they feel thirsty right so um you know the body's giving you those clues so yeah if you're thirsty it depends on how much you know usually if you're lying in bed you're not losing much fluid there um so you don't have to be worried like oh i need to keep this patient hydrated um but if they are thirsty um you know make sure it's ideally to use uh fluid with electrolytes in it is better yes yeah in hospital we have this quaint old expression push fluids and sometimes we push fluids plus sometimes we push forwards plus plus plus it is supposed to reflect the amount of fluid pushing that we do but what we should be doing is listening to our patient and just letting them drink if they're thirsty and asking for fluids if not not sort of foisting fluids on them as a pseudo-therapeutic right because the fever goes up and down and sometimes the fever will drop rapidly and the patient will be sweating profusely losing a lot of fluid there so sometimes that fluid loss is excess if they've been taking a lot beforehand and sometimes they're losing some essential fluid just to try and cool themselves down um you look at a lot of older movies about you know how the person had a fever and then the fever broke and the patient now is okay because the fever broke so you know back then they let them have the fever and once it broke you know they were fine and they recovered um but you know if they've lost a lot of fluid you want it you know salt from or sweat is yeah salty so you want to replace that with relaxer lights if they're going to drink if they're thirsty so what's called the crisis point isn't it the point at which the fever right first starts to go down good so um basically i've been teaching student nurses the wrong thing for the past 30 years i'm going to have to amend my my notes on that and that that's that's quite serious that's quite a serious point because you know most people are still teaching that you should encourage fluids in any form of respiratory infection whereas what what you are now saying from the data you've looked at is that just going to give you soggy lungs right now i wrote another paper on that previously specifically looking at fluid during febrile infections and of course we'll certainly post all these links that would be excellent uh what about food if someone's acutely ill regardless of the cause of the infection um what's the current thinking on feeding them not feeding them types of food to feed them so there's this old expression feed a cold starved fever and if you search the internet for the interpretation of this uh expression um sorry i just got an interruption here um yeah yeah okay so if you're um the interpretation is that you should feed a cold like if you have a cold just eat as much as chocolate yeah yeah and if you have a fever maybe you have to starve um but if you look at the older interpretation of this expression you know from the 1800s and earlier there's a lot of talk about how people have been misinterpreting this expression to do exactly the opposite and the older interpretation is basically if you feed a cold you're gonna have to starve a fever later because feeding a cold makes it worse it's kind of like an expression like spare the rod spoil a child they're not saying don't discipline your child but you should actually spoil them it's basically if you don't discipline them then you're gonna end up spoiled or lie down with dogs wake up with fleas they're not encouraging you to lie down with dogs to get fleas they're saying if you lie down with dogs you're going to get these fleas so people have misinterpreted this expression and you know there's some ancient writings on here by ancient medical story and celsius which i talk about who talks about you know people eating heavily during infection feveral infections and people waiting till after the fever is gone and they seem to do better if they're not eating and so what we've seen physiologically is that um when the fever's higher and higher uh what happens is the your your gastrointestinal tract starts to shut down so you're not producing the acid you're not moving the food along so it doesn't want to take food anymore and often when people are ill they don't have that appetite that they would when they're healthy so does if i eat a large meal now in a healthy condition does that use a lot of energy to digest that meal and to metabolize the products of that meal yeah it uses a huge amount of energy to digest in the end you'll get more energy than what you're using but uh it does use a huge amount of energy and a lot of people feel tired after a heavy meal um you know and that's just because you're using a lot of energy to digest that but that if someone is using a lot of metabolic demand to generate fever then that is basically an energy reserve that the body doesn't have spare at that particular period of time it can just use its reserves for that period of time right because you're not just generating fever you're producing immune cells and a lot of other proteins that are signaling the molecules are signaling your cells to fight this infection so there's a lot going on and normally what the body does is shuts down the the gastrointestinal tract and it uses its stores of fat and sugars to break down to power that response a lot of times the patient you know if they're really ill they'll they'll try and eat anyhow and then they'll throw it up because this the stomach is not working anymore so the body will just spew it back um it's trying to tell you look this is not the time to eat wait till your fever is down maybe your appetites come back you can have a little food so to put that more technically what we're saying is it is quite normal to become catabolic during acute infections that's right yeah and people with acute infections also have a lot of muscle loss don't they um they break down a lot of protein to produce antibodies in the immune response but as you say if the gastrointestinal tract is not in in a position to uh accept food then [Music] there's not much really you can do about that i think we just have to realize that this catabolic state of breaking things down is normal that there will be a period of weakness after that that's why we have this old-fashioned concept of convalescence that you could be weak for a while after after an acute infection and that is basically part of the body's normal response right they've done some animal studies showing that um you know they did a study in mice with malaria and they showed like what happens if it loses say one or two percent of its body weight or two to three percent and no body weight loss and so they had these different levels and they looked at survival from this uh from this infection and they showed that yeah you need to these animals that lost a certain percentage had the highest survival but if they lost too much weight then they had a lower survival so there's kind of a ideal spot in which you're going to be losing a little bit of weight to overcome that infection but not too much so it's as if you are supposed to lose a certain amount of weight there's an optimism right your body's using its own reserves to fight that infection because um you know you're digesting food uh in the time that you've digested your meal um you know you're being overcome by uh that infection yeah yeah yes yes absolutely if you use the energy to digest the meal you'd have no energy to generate the fever therefore death becomes a possibility you know it's kind of like um if you're in a fortress in a castle and you have this enemy force coming towards your castle and you think okay we gotta defend our castle but then you look at your watch it's six o'clock and you think well that's usually when i eat why don't we just go to the dining hall and eat our meal and we'll have that energy to fight when the meal is over and so they go to the dining hall and then the castle is you know the ladders come up and the castle's overtaken and they had their meal but they they lost the battle there i haven't heard that analogy before it's a really good one nice that is an excellent analogy now the thing i like about this this idea is what we're saying is any infection um the the febrile response the body naturally retaining fluid and does not giving too many excess fluids and does not giving people food when they're in this catabolic state this is going to help the body survive the entire spectrum of infectious illness um yeah this is yeah yeah i think it's very important that this is done sort of from the beginning because as i mentioned those vaccine studies show that's that's when your body is shaping that immune response against the virus it's producing the antibodies it's producing you know various t cells and other other immune cells that will fight that uh infection later on but you know it's that initial point where it's really shaping the immune response to this totally new pathogen it hasn't encountered before so it would have been that very interesting wouldn't it for phase three studies on vaccines to take into account whether someone had artificially reduced their fever or their or taken antibiotics after their vaccine as opposed to people that hadn't because what we would find or the the very strong hypothesis of what we would find here is that people who have not artificially reduced their fever got a stronger immune response right yeah that would be a very interesting uh study to do and even with the covet vaccines that are going on now you know that's something they can look at is you know are the patients that take these anti-fever drugs getting a lesser response or more likely to not gain a protective response at all so this thinking would say well hey would you like to increase the the effectiveness effectiveness of your covered vaccine if you'd like to increase the effectiveness don't treat the symptoms while you're generating the immune response let the body do what bodies have been doing on this planet for half a billion years now and and get it right it's fascinating just just one final question stephen there's so so much interesting stuff there but you mentioned uh historical characters a few times do you think do you think as a modern researcher you've got things to learn from um medical thinkers in the past scientific thinkers in the past well if you look through history fever's gone up and down where people said it's a good thing people said it's a bad thing and it's changed throughout history and actually there's an old english expression a spring fever is a physic worthy of a king which basically says if you get a fever in springtime it's just as good as getting the king's own medicine um because a lot of times there'll be reports of cases where a patient had this infection and um they had a high fever and whatever and it also eliminated some other illness they happened to have that they had had chronically um you know so people don't realize you know how good an infection like this or a fever like this can be just to um you know not just to that immediate infection but other health problems as well yes that happened to be that absolutely so so basically the body knows what it's doing so so if you take malaria for example when someone develops a very high fever the sort of pyrogens that are being produced by the immune system in response to the to the malaria parasite it recognizes that a particularly high fever is needed and then the appropriate febrile response is generated is that is that kind of what the thinking here is that's right and actually you've done a few randomized trials in in malaria and shown that if you take the anti-fever drugs actually the course of infection is much longer than if you didn't take any anti-fever drugs so uh just shows that you know the you're really hampering your immune response if you're taking these drugs it just takes longer for the immune system to figure out how to fight the infection you know i've just thought a fascinating study here would be to review people with covid19 infection from the current pandemic note which ones give these symptomatic fever reducing treatments and see how that relates to the uh prevalence of long covered in those in those people in the future and uh from what you're saying we would hypothesize that people who um treat their symptoms to lower the fever who don't let the body have its own physiological immune response they will potentially get more long-covered cause it causing a greater long-term burden of morbidity into the future potentially potentially even organ damage right and the problem is trying to find people that didn't treat the fever because you know the public health advice is just treat the fever and and you'll feel better and it's not going to make a difference so you know it's hard to find the people that had the higher fevers but then didn't treat them because the public health advice is just not there and i i've um i was going to read this paper in great detail to prepare for this again but i've read parts of it it's very well written it is absolutely packed with evidence um the the evidence base for this to me is is now conclusive the evidence what more the evidence is if for all of these things you mentioned very very high evidence base why do you think it is that a lot of public health bodies are not moving with the evidence based on this why are they stuck in the past i think a lot of it is due to the fact that um a lot of this research was done in the past so there were a lot of studies done in the 30s the 40s the 50s looking at the effects of anti-fever drugs and survival in animals with infections or the effect of temperature you know putting it animal at a higher temperature versus a room temperature and showing that the animals at the higher temperature survive longer from a variety of infections and a lot of the modern studies they sort of morphed into looking at reptiles and fish and insects and things like that which don't seem so relevant to humans and that information just hasn't been pieced together to show you know what what benefit could be achieved in humans but i think that argument about the highly conserved nature of the febrile response is a really convincing really convincing argument actually it's part of it stephen that that is fascinating but we're going to uh put links to all of your papers of course um that would encourage people to to look at i think i think there's messages here for the uh the lay person at home uh i think what we can certainly say is think twice about reducing your fever don't voice huge amounts of fluid on people that might not want them uh don't force food on people that want them these things are perfectly normal during a fever but i also think there's so much for public bodies to take on board here and individual clinicians because uh you know even just in my recent clinical practice you come across so many people that just don't seem to understand this basic difference between the symptomatic treatment and and the the causative treatment so um i mean i i think that that's that's that's definitely what you're saying is it so if someone had a bacterial infection you'd want to carry on treating the cause of that by giving the antibiotics right we're talking about treating the the the symptoms here and uh it's that quick fix isn't it you know if i've got a patient who comes in with a fever and they feel awful and i give them a gram of paracetamol or acetaminophen they'll feel better straight away and they'll think i'm clever because i made them feel better straight away yeah we have so many drugs that we use to treat symptoms i mean if a person is sick and they're not coughing we can take a drug

Channel: Dr. John Campbell

Views: 1,613,137

Keywords: health, disease, medicine, medical education, pathophysiology, campbell, human biology, fever, covid, infection

Id: sP65st24crc

Length: 49min 41sec (2981 seconds)

Published: Sun Jan 24 2021