I'm putting this post together on Father's Day, and tomorrow is Juneteenth, a holiday increasingly recognized in the US. Today two of my 3 sons are farther away than usual, one in Berlin, Germany, at the Special Olympics World Games and another working in healthcare in Mekele, Ethiopia. The third member of the triumvirate remains in the eastern US time zone.
Can anyone guess which state was the first to make Juneteenth a permanent state holiday?
Influenza Rising in Southern Hemisphere
The most recent World Health Organization update on influenza, published on June 12 with data current as of May 14, not surprisingly shows an uptick in flu activity in sections of the southern hemisphere. The influenza AH1N1 2009 pandemic strain and B Victoria lineages predominate, meaning we are likely in good shape from a vaccine standpoint for next winter in the US.
RSV and covid haven't increased to the same extent as flu in the south, for the most part.
Polio Vaccine for Travelers
'Tis the season for world travel, but I'm thinking many folks aren't aware of newer polio risks around the world. Spurred by the pandemic and various war zones, polio vaccination has waned. Also, as I've noted in the past we're seeing vaccine-derived polio disease via transmission from recipients of the oral live polio vaccine. The CDC continues to update polio vaccine recommendations for travelers. Twenty-nine countries around the world have circulating poliovirus, but in addition to the "usual suspects" the list now includes both Canada and the United Kingdom.
Certainly the risk can vary in settings within these countries, but primary care providers should remember to discuss vacation plans with families, not just out of interest but to make sure they are informed of any risks and where to find resources. Make sure all children are up to date on immunizations, including polio, and some adults may wish to receive a one-time killed polio vaccine booster if traveling to a high risk country.
'Demic Doldrums
Here in the US we continue with our low levels of SARS-CoV-2 circulation in most jurisdictions; now we rely primarily on ED visits and hospitalization rates for any early warning given our lack of other good community monitoring tools. The FDA VRBPAC group met on June 15 to advise on composition of the next covid vaccine, and I was able to attend most of the meeting including the important parts of the discussion sessions. All 3 US vaccine manufacturers (Moderna, Pfizer, and Novavax) presented data.
As most providers know, the XBB sublineages (XBB represents a recombination of omicron strains) now predominate; the ancestral strain has virtually disappeared from circulation in humans, as have all subsequent strains except for the omicron lineage. Without going into perhaps agonizing detail, most authorities agree that covid vaccines for the near future should focus on the XBB sublineage. The vaccine manufacturers have a fair amount of preliminary data on immunogenicity of XBB-containing vaccines. Results suggest good safety signals and good neutralizing antibody activity against currently circulating XBB strains. Less data are available for memory B- and T-cell responses to these vaccines, and nothing substantial so far on XBB vaccination of children. Work continues, and we should see more about pediatric XBB vaccination in the next month or 2.
A very important part of the presentation has to do with cross-reactivity of antibody among the various XBB strains that were tested. Because of this, a monovalent vaccine with any XBB strain is likely to be effective against these closely related sublineages. Since among other reasons all 3 companies had the most experience with the XBB.1.5 vaccine and can readily ramp up vaccine production for this product, the VRBPAC members unanimously voted to go this route and the FDA officially signed off on this recommendation. Next up is a discussion at the ACIP meeting on June 23, but don't expect any vote or final recommendations at this session. That should come a bit later. In particular, we will need guidance on pediatric use, combined use with other vaccines such as for influenza and RSV, and whether to recommend for all or just for certain high-risk populations.
Last week I perhaps dissed the CDC's use of color in their depiction of variants, but now I need to acknowledge I was wrong. The most recent MMWR had some nice graphics. The graph below not only shows the colorful distribution of variants but also the relatively low numbers of cases recently (with the caveat that testing in general is less now than in 2022).
As can be seen, we have been in an omicron world for some time, with XBB now in charge.
Quickly, a few other covid notables from last week:
- A new monoclonal antibody product on the horizon
- Myocarditis associated with pediatric SARS-CoV-2 infection can be severe (note not a vaccine study)
- Metformin might have role in treatment (overweight or obese adults)
- Stopping routine admission covid testing associated with increased covid infections in a few UK hospitals
Juneteenth
Perhaps not what you would have guessed, but my home state of Texas was the first to make Juneteenth a permanent state holiday, in 1980, which was decades before most of the rest of the country. I left Texas in 1984 and parts of it now are unrecognizable to me, but it's easy to understand why that state was out in front on Juneteenth. The original event was June 19, 1865, in Galveston, TX, when Union troops arrived and finally enacted the January 1, 1863, Emancipation Proclamation and freed slaves in Texas. In my childhood, unless you kept yourself under a rock, if you lived in Texas you knew about Juneteenth.
Happy Father's Day to all fathers out there, and to everyone please use Juneteenth to reflect on its many lessons that continue to challenge us to do better.
The now quiescent ancestral strain was named SARS- CoV- 2 both because of the similarity of the lower respiratory disease to that of the previously discovered SARS virus and the similarity of the viruses.
In your opinion, should the XBB strains still be grouped in the SARS- CoV family or would it be more helpful to develop a new family name that deemphasizes the severity of the usual clinical case. ?
The short answer to your question is that I don't have an opinion, that would require knowledge way above my pay grade! But, the entire covid nomenclature is terribly confusing. I'll try to give some details about how this all unfolded.
Searching back through this blog I think the last time I mentioned nomenclature was on February 20, 2022. Recall this was just after our big surge of omicron infections that winter. I mentioned that omicron was first designated by the WHO as a "variant of concern" on November 26, 2021. We've come a long way since then, needless to say.
PANGOLIN (Phylogenetic Assignment of Named Global Outbreak Lineages) is a software tool developed in early 2020 to classify genetic lineages of SARS-CoV-2. The problem has been that this complicated nomenclature with letters and numbers interspersed with periods is just too difficult to remember. PANGO started abbreviating some of the number strings with letters of the alphabet, but even this became confusing. When we had another big surge with a new variant, the Greek alphabet was adopted and that variant was named alpha. Various options have been discussed for when/if we run out of Greek letters to use.
The best summary of all this that I can find is an article from the Atlantic by Sarah Zhang published in April 2022. She describes the PANGO designation as being used for variants that "simply exist," in contrast to the Greek letter system to designate epidemiologic importance. From that perspective, I think the current XBB recombinants fall into the former category; thankfully they haven't yet caused a major surge. Regardless, the WHO is in charge of all this nomenclature and I doubt they'll be asking my opinion!