Maybe chalk it up to old age. Last week I mentioned I'd be reporting on the ACIP meetings, not remembering that they are scheduled for the coming week, not last week.
Still, plenty going on to fill in with, including a strange case I've been investigating for a few weeks now.
New Adult C. difficile Fecal Transplant Guidelines
The American Gastroenterologic Association published new guidelines for use of fecal transplant in adults with C. difficile disease. Although the guidelines do not address pediatric issues they are still useful to consider. Looking at just the summary, fecal microbiota transplant therapy is being recommended for instances of recurrent disease in immunocompetent or mild/moderately immunocompromised individuals, as well as for severe or fulminant infections in individuals not responding to conventional therapy, Fecal transplant use is not recommended for those with certain underlying GI conditions such as ulcerative colitis, Crohn's disease, pouchitis, or irritable bowel syndrome, except as part of clinical trials. I noted that all of the recommendations were conditional with low or very low level of evidence.
Conflicting Nirsevimab Data
The headlines screamed that about 40% of eligible infants received nirsevimab prophylaxis for RSV infection, as of last month, which is much higher than I had thought based on reports and the shortage of the product. On closer examination, it may not be all that good. There are actually 2 sets of information that the CDC published. First is reporting of ongoing telephone surveys of households with infants under 8 months of age, asking if those infants have received nirsevimab or are planning to do so. That's where the 40% figure comes from. The second data source is an ongoing count of nirsevimab doses actually administered. The listing includes jurisdictional data up through December 2023. Here the highest rate is 20% (Alaska) with many states near zero. Presumably this latter count is more accurate than is self-reported survey data. Let's hope things improve next season, where it does appear that supply chain issues that caused so much disruption this season might be somewhat ameliorated.
Also on the nirsevimab front, I saw the first semi-detailed explanation of what went wrong with the supply chain last fall. You recall, and probably experienced, difficulty in receiving an adequate supply of nirsevimab to satisfy your patients' needs. The company simply didn't have enough stock on hand. This Wall Street Journal report offered more information. It seems that, as usual, it was a bad combination of multiple factors. First, the manufacturer underestimated demand. Second, pediatric healthcare providers initially delayed ordering the drug, not sure if third-party payers would cover the circa $500/dose price. When the feds decided in August to add the product to the Vaccines for Children program, it was already too late to reverse the trend for lower production targets. Production was ramped up eventually, and now some states have excess product available due to all the delays plus perhaps some practitioners not being aware of the availability. RSV is still around but clearly nearing the end of the season. Let's hope things go better for next RSV season.
Risk Stratification for Pediatric Covid
The Pediatric Infectious Diseases Society published new guidance related to covid management in children and adolescents, worth reading. In particular, I think the group did a great job explaining risk factors for poor outcomes from SARS-CoV-2 infection. This has been confusing, in part because we lacked data but also due to spillover from adult high risk conditions - I've noticed many practitioners citing adult risk factors for use in the pediatric population, and it's not quite applicable in all situations. Here's the quick breakdown:
Not All Telemedicine is Created Equal
I've been involved with telemedicine since well before the pandemic. It has its uses, and of course it also has limitations. However, some individuals providing so-called telemedicine services are doing more harm than good. I was saddened but not surprised at this article about providing antibiotic prescriptions via telemedicine. The authors searched for online platforms offering antibiotic prescriptions without real time physician examination or verification of patient details and then chose 2 platforms to query.
For the first platform, one "patient" was able to get a prescription for amoxicillin for "URI," answering a few yes/no questions asynchronously and being rewarded with the prescription in less than a half hour. Another "patient" insisted on being prescribed levofloxacin for cough and again was rewarded the prescription with little verification or pushback.
On the second platform, a "patient" with URI was given a link to choices of azithromycin, cefuroxime, amoxicillin, Augmentin, doxycycline, or levofloxacin. After choosing doxycycline the prescription was provided immediately.
These patients were actually some of the study authors, and they had real URI symptoms. They didn't fill the prescriptions and did recover uneventfully from their URIs. I had 2 immediate reactions after reading the article. First, I wanted to cry. Second, I wondered where these telemedicine "doctors" obtained their medical training.
I Told You So
Some people preface that comment with "I hate to say it, but..." Not me, I'll grab credit even if, as in this circumstance, I'm not unique in sounding the measles alarm. The most recent update shows 35 cases in the 15 US jurisdictions this year, as of February 24. This many cases scattered over so many jurisdictions bodes poorly, and the scariest is in a Florida elementary school.
Dr. Ladapo and Mr. .....?
Dr. Josepah A. Ladapo sports both medical and public health degrees from Harvard, an internal medicine residency in Boston, followed by a faculty appointment at NYU. He than transitioned to a mostly research position at the University of Southern California before catching the eye of the Florida governor and becoming both Surgeon General for the state as well as a professor at the University of Florida. He's been on my radar for some bizarre pronouncements that made me want to look deeper.
Looking at his publication list in PubMed and scanning some of the articles, he clearly has good public health knowledge. Most of his publications center around aspects of cardiovascular disease in adults. He does have 3 relatively recent publications related to covid, but I'm deliberately not linking to them, or to his public statements in the past year, because they are either secondary to the conversation or so lacking in scientific merit as to be not worth your time.
His first covid-related publication was in 2021 and analyzed results of a Gallup poll carried out from July to December 2020 regarding adults' misconceptions about covid risk. Curiously, he published another analysis of this same poll in 2022, presenting some of the exact same data. Neither article referenced the other one and made me wonder whether this could be a case of duplicate publication. More importantly, though, why would covid perception data collected in late 2020 have any utility in 2022, unless the authors were analyzing changes over time (which they did not)?
His other covid-related publication from November 2021 was a multi-author effort (he was the 8th out of 12 authors) talking about future priorities in public health management of covid. I was very interested to see that vaccination was seen as the most important intervention given that Dr. Ladapo now disparages most use of covid vaccines, based on nonsensical arguments.
In the past year, Dr. Ladapo has been working actively to discourage covid vaccine use in most instances. You can see some rebuttal from FDA and CDC in early 2023 and separately from FDA more recently.
All of this made me wonder what gives with Dr. Ladapo. He seems to have had good training, and his prior publications show that he does have basic understanding of public health principles. How then to explain his response to a measles outbreak in a Florida elementary school? He left the decision to remain in school up to parents, and he did not encourage measles vaccination. At a minimum, unvaccinated children should be sent home to receive online education until their incubation periods expire. This could effectively stop the school outbreak and prevent further community spread. Every effort should be made to bring all children up to date with measles immunizations. This is pretty basic stuff.
According to news reports, the Manatee Bay Elementary School in Broward County, Florida, has documented several cases of measles. Details about immunization and travel status are lacking, but apparently there is no clear link to foreign travel identified. Remember that measles is the most easily spread infectious disease known. It is thought that at least 95% immunity needs to be present in a community to prevent sustained spread. The vaccination rate in Manatee Bay Elementary is 89.3%. Also, the incubation period is up to 3 weeks following exposure. So, if the outbreak isn't managed immediately, it can stretch on for weeks until every non-immune child is infected. By that time, spread outside the school is certainly likely. Apparently Dr. Lapado isn't concerned about that.
I wanted to understand how the Florida Surgeon General arrived at his decisions. His prior covid vaccine arguments contained a fatal flaw that I always look for to judge how well someone understands public health/vaccine data. This involves an understanding of the Vaccine Adverse Effects Reporting System (VAERS), one of many tools to monitor vaccine side effects in the US. It's a type of early warning system for rare events. It is structured so that anyone can report a potential adverse event as being related to a vaccine; for example, if my neighbor broke a leg skiing and had received a covid vaccine 2 months ago, he or she could report that event to VAERs. Clearly that doesn't prove that the vaccine caused a fractured femur. VAERS is just a way to monitor all potential vaccine problems. Dr. Lapado incorrectly used VAERS data to conclude that covid vaccines killed more people than it helped. No one who understands the structure of VAERS could possibly end up with that idea.
At a loss for understanding Dr. Lapado's logic, I can only suspect he must be having some Mr. Hyde moments. Either he has a dual personality due to some neuropsychological condition, or he is purposely misusing data to achieve political or personal goals. He clearly should know better. I'd love to spend 30 minutes with him to see where he falls on this spectrum. Or, maybe he knows of some unpublished data that refutes the current understanding of measles transmissibility and the role of antibody in providing protection; I'd hope he would have shared that.
WRIS
The Winter Respiratory Infection Season soldiers on. Given the length of this post and relative lack of any new data I'm not going to dive deeply into CDC or other numbers. Suffice to say RSV is still decreasing. flu is a mixed bag across the country, and covid is out there but not surging at the moment.
"Commingled Out of Good and Evil"
Robert Louis Stevenson's "Strange Case of Dr. Jekyll and Mr. Hyde" was one of my favorite books as a child, and it's loaded with great quotes like the one above. I don't like bashing another individual, and I'm also a natural skeptic always willing to entertain new theories based on new data. I just don't think Dr. Ladapo's management of this measles outbreak, or his covid vaccine views, make any sense. For the sake of all Floridians and others they may infect, I hope I'm wrong.
Nest week I'll report any exciting details from the ACIP meeting.