Washington, DC, had a record high temperature 1 day during our heat wave this past week, and I suppose if you glanced at the sun you might see some spots for a few seconds. But of course I'm referring to different spots in this post.
Measles
I'm probably the only person who has read all of my blog posts over time, so you're forgiven if you don't realize I'm in broken record mode here. I can't count the number of times I've warned providers to be on the lookout for measles cases, and now we are facing a global decline in immunization rates that probably puts us at greatest risk since the modern-day measles vaccine was available in 1968 (the original Enders vaccine appeared in 1963). We've enjoyed some low numbers in the US recently, but that appears to be changing with 9 cases (from Georgia, Missouri, New Jersey, and Pennsylvania) reported to CDC so far this month.
CDC released an alert last week mentioning 23 US cases between December 1 and January 23.
I won't review everything about diagnosis of measles, the CDC website alert is a good resource with links to other sites, but I do want to highlight a few helpful nuances that aren't often mentioned. First, measles is fairly unique among exanthematous infections in that the prodrome interval, the time between onset of first symptoms and appearance of the rash, is long, usually a few days. Most infectious diseases accompanied by rash have very little or no time between onset of symptoms and appearance of the rash, with erythema infectiosum being a notable exception but not easily confused with measles clinically.
The measles prodrome consists of a febrile illness with cough, coryza, conjunctivitis, and Koplik's spots. You can find pictures of Koplik's spots everywhere on the web, but in my experience as an old geezer who has seen many cases of measles in children, they aren't that easy to see or photograph. Therefore, the photos available in textbooks and on line are skewed towards the most obvious. One needs to do a careful oral exam looking for gray or bluish-gray or white fine spots (almost sandpapery) anywhere on the buccal mucosa; the inside of the lower lip is particularly helpful. If you're not sure, find an old geezer clinician to confirm.
In the absence of Koplik spots, or if you don't see the child until the rash appears and the Koplik spots have resolved, pay close attention to the history. Specifically ask for a day-to-day accounting of symptoms; if you feel the parent or patient can recall reliably, noting at least a 2-3 day lag between the onset of high fever, cough, rhinorrhea, and conjunctivitis before the rash appears can be strongly suggestive of measles; the absence of this lag is against the diagnosis. Other alarms to increase your suspicion would be lack of 2 measles immunizations, international travel, and/or exposure to a suspected measles case.
"It ain't what they call you.....
..... it's what you answer to." - attributed to W.C. Fields, though I can't verify the origin.
I thought of Mr. Fields when I heard about administration errors involving the adult RSV vaccine (brand names Abrysvo and Arexvy) given to children and pregnant people. From my viewpoint, it was an accident waiting to happen, due to a name.
In order to speed payment allowance by the Vaccines for Children and other programs, the long-acting monoclonal antibody nirsevimab was officially designated a vaccine. Strictly speaking I guess this is correct: antibody administration is a form of passive immunization. However, the true RSV vaccines are intended only for adults with high risk conditions or for pregnant people to help protect newborns after birth. It was inevitable that confusion would ensue. The notice provides almost no details but does state that most administrations to young infants were "nonserious." Infants who wrongly received an adult RSV vaccine should be considered unprotected and still receive nirsevimab.
WHO Fans the Covid Mask/Distancing Controversy
WHO riled a lot of public health experts with its recent guidance for infection control in healthcare facilities. The main controversial elements involve recommendations to use physical barriers such as plastic windows for areas where patients first present (rated as conditional recommendation, very low certainty of evidence); maintaining a physical distance of at least 1 meter between people ("good practice statement"); and not sufficiently highlighting superiority of respirators (e.g. N95 masks) for general care - this particularly angered those who favor the aerosol, rather than droplet, mode of transmission for SARS-CoV-2. In general it seemed that the WHO panel carried over some details for infection control that do not have strong evidence for use and in some cases (plastic barriers) may be contradicted by other studies.
Note that much of the controversy involves how much weight to give transmission simulation studies - e.g. distances that SARS-CoV-2 travels under experimental conditions rather than real-world evidence which is much more difficult to come by. It's hard for an individual medical practice to make these decisions on their own, best to abide by state or local health department guidance.
Spring Covid Vaccination?
Canada released guidance for covid vaccination this spring, advocating for an additional dose of the XBB.1.5 vaccine recommended last fall. I'd look for the US to make similar recommendations soon. ACIP has a regular meeting scheduled February 28-29, but no agenda is yet available. FDA doesn't have anything scheduled, and they may not need a separate advisory committee meeting for this.
WRIS
In general we seem to be trending downward with our winter respiratory infections, but still lots of runny noses, coughs, and more around.
For RSV I still look primarily at hospitalization rates in young children, the purple line in the graph below, because I think it's the most accurate gauge of RSV. I suspect almost all of these hospitalized children are tested for RSV and flu. The rate clearly is trending down, it's looking like we won't replicate the horrible RSV season of last year.
Influenza-like illness seems to be cooling off as well, as seen in FLUView. Note this measurement includes respiratory illnesses mimicking flu so could be any respiratory virus; there are many more ways to look at flu activity in general, all with their own inaccuracies. In the past I have found this map to be representative of what I've seen clinically in my practice areas.
Covid wastewater (I've said before why I prefer this qualitative measurement) continues to trend downward, and levels are below that seen last year.
All told this is good news for those of you trying to manage your packed patient waiting rooms. Let's just hope you don't have a case of measles sitting in there somewhere!
Do You Even Know What a Broken Record Sounds Like?
I used this term when I said I was sounding like a broken record for repeating over and over my warnings about measles. I harp (pun intended) on this because measles is the most contagious infectious disease known and most younger clinicians in the US have never seen a case, meaning it can be missed easily. However, those same clinicians might never have heard a broken record either. Vinyl records made a bit of a comeback recently but even I no longer have a turntable to play vinyl records; I do have a few moldy vinyl albums from the 1960s and 70s. I'm occasionally tempted to purchase a good turntable, but I have no place for it and it's yet another diversionary rabbit hole I don't need. I ain't gonna call out the name vinyl around here.