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Month: August 2024

Published on Leave a comment on One More Time This Summer

Summer is supposed to be the slowest season in my line of work, but it doesn't seem like it. I've had trouble keeping up with everything, including some old news that I just found out about today. Maurice Williams died on August 5. If that name doesn't ring a bell, stay tuned. Here's what's up for this last post of the summer.

Mpox

It looks like we can add Gabon to the list of countries with exported mpox, this in a 30-year-old man who had stayed in Uganda for 2 weeks. The notice doesn't state whether or not this is clade I, but given that it appears to have been acquired in Uganda there is a good chance that it is. The latest WHO news was posted on August 22, the same day we heard from the CDC about the US response.

By no means is this the next pandemic, but we are seeing global spread of the clade I strain via travelers. Most important is ensuring affected African countries receive adequate vaccine supplies soon. In the US, persons in high risk groups also should be vaccinated.

Measles Check-In

Oregon is the latest state in the measles outbreak spotlight. Nationally the cases are percolating along at a steady rate.

West Nile Virus

In my post last July 28, I was halfway kidding about waiting for symptoms of West Nile virus after all my mosquito bites. West Nile is in "full swing" in Europe currently. Now I see in today's Washington Post that Tony Fauci is back home after a 6-day hospitalization for West Nile infection. Although he is 83 years of age, that's a long hospitalization and I hope he didn't have serious neurologic or other complications. I wish him a speedy recovery.

A little trivia piece I discovered years ago, did you know West Nile virus was tried as a cancer treatment in the early 1950's? Research on using flaviviruses as oncolytic agents continues. Unfortunately the lead investigator of that 50's study is mostly remembered for a serious ethical breach, injecting tumor cells into prisoners to study tumor immunology.

Timing is Everything

I have a complicated plan for how I'm going to time when I get my flu and covid vaccines in the coming weeks, based on travel plans and guessing about peak flu season. At my age, waning immunity following vaccination could be clinically significant.

This brings me to an interesting study in the BMJ trying to define optimal timing for influenza vaccination in young children. It utilized data from an administrative database in the US for timing of vaccination of over 800,000 children ages 2-5 years during several flu seasons. Bottom line, it looked like October was optimal. I wouldn't necessarily alter plans based on this study; every flu season has slightly different timing. It's probably a better plan to just vaccinate when you can, whether it be at regular checkups or flu vaccine events on evenings and weekends.

Holding My Breath on Polio

I'm still hoping polio doesn't break loose in Gaza, but I'd be more hopeful if vaccine could be distributed there. WHO has full plans in place to distribute the relatively new novel oral polio vaccine type 2 (nOPV2) to about 640,000 children under 10 years of age in 2 campaigns separated by a month. Wastewater monitoring suggests this is the strain that caused the case recently detected in a child in Gaza; we're still waiting for confirmation from a regional lab in Lebanon. Now we just need an effective ceasefire to allow this and other humanitarian aid to be implemented.

Covid

The big news was the not surprising FDA approval and emergency use authorization of the KP.2-based mRNA vaccines from Pfizer and Moderna. Novavax approval is still pending due to a longer manufacturing process. As I've said many times, if one looks at the level of individuals, it's pretty clear that vaccination benefits outweigh risks for every age group. New interim recommendations are available from the CDC.

Here's a quick look at a few disease activity indicators over the past year:

Wastewater hasn't changed much nationally.

Regionally, only the Northeast seems to be rising, though still lower than most other regions.

We'll see what happens with covid (and measles) now that schools are starting back again.

In the midst of all this, we have a new study on long covid in children. It was a multicenter prospective cohort study of about 900 younger children and 4500 adolescents, most with covid infection but some not infected who served as controls. The report is loaded with data and complexities; I'm sure everyone in the field is looking it over closely.

It's tough to summarize the findings succinctly, but perhaps you can enlarge the figure below to see details. The darker color shades are the more prominent symptoms in each cluster. Clustering of types of symptoms varied between adolescents (12-17 years) and school-age children (6-11 years). I'm very happy to see this type of analysis; it is possible that different clusters have different pathogenetic mechanisms suggesting different treatment approaches. Clusters in the younger children were in the neurocognitive, pain, and GI domains, whereas loss of smell or taste, pain, and fatigue/malaise were highlighted for the adolescents.

This study won't change clinical practice immediately, but it is a major step forward in providing a framework to base treatment studies.

"No Good Songs Ever Came Out of the 1950s"

That probably inaccurate quote, heard when I switched my car's Sirius/XM to the 50's station, came from a musically-inclined and knowledgeable friend of mine. I'm pretty sure he uttered it just to get a rise out of me, which it did. IMHO, the 50's produced a lot of good songs and shouldn't be remembered just for some wacky West Nile virus studies.

The title of this week's post is a nod to Maurice Williams who wrote the song "Stay" in my birth year, 1953, but then put it on the shelf until he recorded it with the Zodiacs in 1959. It came out in 1960 and was a big hit at just 90 seconds in length. You may be more familiar with it from the 1977 cover with slightly altered lyrics by Jackson Browne, Rosemary Butler, and David Lindley (and the 9-minute mini-medley with "The Load Out") or from the 1987 movie "Dirty Dancing" that used the Williams original. Regardless of which of the couple dozen versions I listen to, this is one of those songs that always brings a smile to my face.

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Published on 2 Comments on “There never was a good war or a bad peace.”

This quote from a Benjamin Franklin letter written 241 years ago still rings true. It's not hard to list bad traits of war, but I find that sometimes we overlook war's contribution to infectious disease outbreaks. Now we're seeing yet another example of this that could expand if not controlled.

Last week revealed a bundle of things to mention, I've tried to trim the list as best I could.

Oropouche HAN

Now the CDC has jumped on the Oropouche virus bandwagon with a new alert via the Health Alert Network. Most useful to front line healthcare providers is an approach for when to consider Oropouche infection more likely:

  • Consider Oropouche virus infection in a patient who has been in an area with documented or suspected Oropouche virus circulation within 2 weeks of initial symptom onset (as patients may experience recurrent symptoms), and the following:
    • Abrupt onset of reported fever, headache, and one or more of the following: myalgia, arthralgia, photophobia, retroorbital/eye pain, or signs and symptoms of neuroinvasive disease (e.g., stiff neck, altered mental status, seizures, limb weakness, or cerebrospinal fluid pleocytosis); AND
    • No respiratory symptoms (e.g., cough, rhinorrhea, shortness of breath); AND
    • Tested negative for other possible diseases, in particular dengue. If strong suspicion of Oropouche virus disease exists based on the patient’s clinical features and history of travel to an area with virus circulation, do not wait for negative testing for other infections before contacting your state, tribal, local, or territorial health department.

As I've said previously, it's a clinical syndrome similar to dengue or chikungunya; note the absence of prominent respiratory symptoms. Cuba and Brazil travel has been associated with imported Oropouche in other countries; the disease is also experiencing a rise in Colombia, Peru, and Bolivia.

Mpox

Similarly, we now have mpox reported from Sweden in a traveler returning from an area of Africa where clade I disease has been active. Details are scant, but it was certainly only a matter of time before this happened. Clade I seems to have a higher mortality rate than the more common clade II variant, but it's hard to get precise numbers, much less whether anything is different about the clade Ib variant now being seen. Transmission epidemiology seems to be slightly different than the clade II epidemic of a couple years ago which stemmed primarily from men who have sex with men. In this year's clade I iteration, infections also are being spread by heterosexual encounters, usually via sex workers, and also within households. Young children and pregnant women are at highest risk for complications including fatal outcomes. Like most sexually transmitted infections, public health measures are hindered by infected people not being willing to disclose their sexual contacts. In the Democratic Republic of Congo, the epicenter of the clade I outbreak, homosexuality is not officially illegal but societal norms in the DRC are not favorable to LGBT individuals.

Effective mpox vaccines exist for preventive measures, but a recent press release from the NIH had discouraging news about antiviral therapy. Tecovirimat, aka TPOXX, had been useful in clade II disease. Now, in a placebo-controlled randomized trial of almost 600 mpox-infected subjects in the DRC, tecovirimat outcomes for mortality and for time to improvement were the same as with placebo recipients. I'd like to see the actual study results, but I tend to trust NIH press releases more than most others. CDC has a nice update and map.

Parvovirus B19 Alert

Parvo B19 infection isn't a notifiable disease in the US, so if concern has arisen it usually means something dramatic is going on. This week CDC issued a HAN notice about this infection. The disease is well known to pediatric healthcare providers and to many parents as erythema infectiosum or fifth disease. It's a minor illness unless a pregnant person is infected, with subsequent risk of miscarriage or severe fetal anemia and non-immune hydrops fetalis. Individuals with chronic hemolytic conditions are at risk for aplastic crisis and severe anemia, and immunocompromised people have higher risk of complications. Read more if you need a refresher.

Is It Time for Universal Screening for Congenital CMV?

Last week's MMWR reported on the first 12 months' experience with Minnesota's universal newborn screening program for cCMV; it began in February 2023. 184 of 60,115 (0.31%) newborns screened on a dried blood spot had positive CMV results. Note that screening dried blood spots is less sensitive than other methods; 3 infants with cCMV with negative blood spot results and were picked up by other means. Buried in the report was the interesting finding that of 11 infants with permanent hearing loss, 4 passed their hearing screening test as newborns. Clearly we need more than universal hearing screening to identify at-risk infants. I look forward to further outcome data on Minnesota's program.

Dinner at the Sick Restaurant (apologies to Anne Tyler)

I like to think of myself as an adventuresome diner, but probably I would have drawn the line at these 2 delicacies I found at ProMED, the listserv I've used for decades.

Chicken liver sashimi is a new one on me, but now linked to an outbreak of campylobacteriosis in Japan. (You'll need Google translate for this one.) Perhaps slightly less disgusting is the idea of smoked non-eviscerated fish. Recent testing found a commercial product potentially contaminated with botulinum spores; thankfully no clinical cases have been reported. I've eaten sardines from a can. They also are non-eviscerated, but apparently the fish reported this week were capelin and exceeded the length allowable for packaging non-eviscerated fish. The product was produced and distributed by a company in Florida.

Covid

Meanwhile, let's not forget about our old friend. National wastewater levels are still up.

Levels might be tapering off in some parts of the country.

Meanwhile, clinical indicators suggest we're going to be seeing increasing cases the next few weeks at least. Here's an example with percent test positivity from the same link as above. It's a little higher than it was a year ago, though it's difficult to compare time periods since different factors now drive test-seeking behavior.

Meanwhile, if we can believe news reports (the FDA can't disclose approvals ahead of time), the new KP.2 variant-based mRNA covid vaccines should be available later this week. The Novavax vaccine presumably will be ready a little later. Timing for when to get the new vaccine should be based on individual considerations, including immunocompromised state, travel plans, and other factors. However, trying to predict the amount of covid activity over the coming months is only slightly better informed than a roll of the dice. Here's the current forecast from CDC.

Polio in Gaza

Not that it's unexpected, but a case of polio has been reported in a 10-month-old child in Gaza. This child would have been born just near the start of the new war and presumably was never immunized. Breakdowns in the health system as well as with clean water and sanitation are ideal for a reappearance of polio; it hasn't been seen in Gaza in 25 years. The UN has called for a "polio pause" to allow vaccine distribution. I try to avoid political statements in this blog, and I won't change that now, but I think my old friend Ben Franklin had it right about war.

Batesian Mimicry

To end on a lighter note, when I first saw this term I immediately thought of Norman Bates and "Psycho," perhaps Hitchcock's most famous movie. But no, it's not (spoiler alert) Norman mimicking his mother. This refers to Henry Lewis Bates' 1862 publication on butterflies in the Amazon. For an easier read, try this Wikipedia page. It explains my astonished update in last week's post that the mysterious black butterfly in our garden was in fact a dark variant of the easily recognized tiger swallowtail. Apparently it is an example of Batesian mimicry whereby a vulnerable butterfly species develops the ability to mimic a less desirable (to predators) butterfly. In this case, the tiger swallowtail mimics the unpalatable and toxic pipevine swallowtail. I mentioned last week that I had probably forgotten a lot about what I learned about butterflies in my childhood. I certainly don't remember anything about Batesian mimicry or dark tiger swallowtails. Needless to say, I've been down a rabbit hole all week about this. When I went back to my 3 texts on butterflies, all mentioned the black variant in the tiger swallowtail section but not in the sections on black-colored swallowtails where I was looking. As you can see below taken from "Mimicry and the Swallowtails," they are very different but in fact have subtle similarities that escaped me.

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Published on 2 Comments on Summer Sleuthing

Last week I mentioned I'd make a poor politician or salesman. I didn't mention other professions, but I wonder if I might have been a successful detective. I had a consult last week that took all of my sleuthing skills, a newborn exposed to maternal syphilis that required me to track down mother's history dating back to 2017 as well as a sibling who turned out to have been a patient of mine a few years ago - not the type of continuity of care I'm looking for. This newborn, like the sibling, will need IV penicillin treatment but most likely will be fine in the long run. The entire consult took me about 2 hours compared to my usual 1 hour. That's why pediatric ID docs are at the bottom end of physician reimbursement but also why I love the profession.

I've been involved in some other detective work recently, but first a review of what's bubbling up as summer is winding down.

More Oropouche Concerns

This is a stark example of today's world - no matter where an infectious disease outbreak occurs, it can affect all of us. The European Centre for Disease Prevention and Control has issued a travel alert for countries in Central and South America experiencing epidemic Oropouche virus disease. The EUCPC found 19 cases of Oropouche disease in European Union residents this year, all linked to travel to Cuba or Brazil. No such alert has been issued by the US CDC, but US citizens should take note.

Summer travel planning should include assessment of disease and other safety risks in foreign countries.

Mpox Redux

I had hoped mpox had settled into a mostly endemic situation in the US, which is in itself a defeat of sorts, but new concerns have arisen from the outbreak in the Democratic Republic of the Congo that could extend to the US. The CDC's Health Alert Network has issued a new alert as cases spill over from the DRC to neighboring Burundi, Rwanda, and Uganda. The clade involved, clade I, is more transmissible and perhaps has a higher mortality than the more common clade II. Risk of exportation to the US is still considered low due to infrequency of commercial air flights from these countries. The alert contains details for case management. Remember, at risk individuals (see below) should receive 2 doses of mpox vaccine.

Persons at risk:

  • Gay, bisexual, and other men who have sex with men, transgender or nonbinary people who in the past 6 months have had one of the following:
    • A new diagnosis of ≥1 sexually transmitted disease
    • More than one sex partner
    • Sex at a commercial sex venue
    • Sex in association with a large public event in a geographic area where mpox transmission is occurring
  • Sexual partners of persons with the risks described in above
  • Persons who anticipate experiencing any of the above

Benefits of Vaccination

Speaking of vaccinations and CDC, the latest MMWR included an article estimating benefits, both economic and clinical, of childhood vaccinations over the period 1994-2023. One always needs to be wary of this type of modeling which by its very nature requires analysis of large administrative databases that can have some errors. However, the study authors were very careful and listed 4 study limitations.

First, the analysis didn't include influenza, covid, or RSV vaccination; we can all agree that would result in an underestimation of benefits. They also felt that the recorded immunization rates could be an underestimate, which in turn would underestimate costs of the programs. Similarly, the cost estimates didn't include federal, state, or local program management costs or excise taxes. Their fourth limitation point was that they were unable to consider contributions of other factors like hygiene or social distancing which could have lowered disease rates independently of vaccines. So, of the 4 limitations, 3 could result in overstatement of vaccine benefit. With those caveats, here are their numbers:

That's over a million deaths prevented and over 2 trillion dollars in societal savings.

Sniffles Status

We're still talking covid here, with flu and RSV almost nonexistent. Here's the latest ED visit numbers from CDC.

I was hoping covid wastewater would start to level off, but it is rising in all parts of the US (same link as above).

So, expect more covid in the coming weeks. For now, it seems we are stuck with both summer/early fall and winter covid surges.

Hieronymus Bosch

Not the painter but rather the seriously flawed detective character created by Michael Connelly. Probably the same fondness I have for the detective-like nature of pediatric infectious diseases practice also draws me to (mostly) noir detective literature. This summer I decided to look into somewhat more recent (compared to 1920s-1950s) detective series. Colin Dexter's first book in the Inspector Morse series, Last Bus to Woodstock (1975) was enjoyable, and I'll probably continue to the next installment. Now I've started the first book in the Harry Bosch series, Black Echo (1992). Both books are littered with beautiful writing, such as this musing by Bosch: "The sky was the color of bleached jeans and the air was invisible and clean and smelled like fresh green peppers."

I thought about that line as I was outside in the garden trying to figure out what species of butterfly was sampling the Joe-Pye-weed. I have a love of butterflies dating back to my childhood in south Texas, though I've forgotten almost everything I've learned from that time. We don't have nearly as many butterfly species in Maryland as in my home town, but it's still fun to watch and study them. This one black butterfly has been hanging around for several days; in fact, it's right outside my window now. Unfortunately I can't decide if it is the somewhat more common black swallowtail (Papilio polyxenes) or the rarer spicebush swallowtail (Papilio troilus). Real butterflies often don't look exactly like their pictures in reference materials. After several days and about 15 photos of different aspects of the wings and thorax, I decided to surrender and ask BAMONA (Butterflies and Moths of North America). I've submitted photos, dates, locations, and behavior details and now waiting on a reply from an expert. I'll let you know if they reply.

STOP THE PRESSES: BAMONA just sent me a reply, moments after my initial posting. It is a "dark-form female P. glaucus." For the uninitiated, this is the tiger swallowtail, but the picture below looks nothing like the typical tiger swallowtail. Also amazing, my iPhone identified the photo as P. glaucus, which I laughed as being another failure of artificial intelligence. You can bet I'll be reading more about this dark form butterfly.

Published on Leave a comment on PPR

You know things are slow in my world if I'm mentioning pestes des petits ruminants, aka goat plague, but it has been in the news lately and does have relevance to us. Spoiler alert, you don't need to break out the masks and gloves, the virus causing this disease has never been reported to infect humans.

First, let's touch on our (nearly) nonexistent summer respiratory infection season.

SRIS

We're talking primarily about covid and avian flu at the moment. Covid wastewater levels may be starting to level off, except in the southern US.

The clinical respiratory illness map is a beautiful sea of green (with a bit of light green in Alaska). I'm only showing this to remember fondly come next winter.

Not a lot to report on the avian flu front, with a continued sprinkling of new mild human illness in poultry/dairy workers and new outbreaks in flocks and herds. I was interested to see that CDC is making a $5 million investment to provide seasonal flu vaccine to at risk workers. Of course we want everyone eligible to vaccinate themselves against seasonal influenza, but the ulterior motive here is to lessen the chance that a human will be simultaneously infected with a seasonal flu strain along with the influenza A H5N1 avian strain. Such a situation could increase the likelihood of reassortment of the 2 strains to create a new virus that could cause more problems for us. This scenario is still a rare probability but worth preventive measures.

PPRV and Cousins

The virus that causes PPR is a morbillivirus, which should sound familiar to healthcare providers because that is the same genus as measles virus. You can learn more than you want to know about PPR from the article from which the figure below was lifted.

Morbilliviruses in general have the theoretical ability to be eradicated. In fact, one animal morbillivirus, rinderpest virus, already has been eradicated. PPR has been targeted for eradication by 2030, but a recent outbreak in Greece now threatens that with spread from Africa and the Middle East to the European Union. Infection has a very high fatality rate in goats, sheep, camels, and other ruminants that provide livelihoods to many. So, although PPRV doesn't infect humans, runinant infection is a major threat to livelihoods of those in these countries who depend on these animal industries. The World Organisation for Animal Health nicely summarizes eradication tools in place, let's hope the Greek outbreak doesn't set eradication plans back too far. (Also, if you're looking for a rabbit (only slight pun here) hole to fall down, check out WOAH's list of 207 animal diseases.)

The real reason I mention PPR is to draw attention to somewhat misleading measles pronouncements in the lay press this past week. NBC, among virtually every national news agency I could find, highlighted the CDC announcement that US measles cases have tripled this year compared to all of 2023. That's true but also misleading. I understand this helps get the message out that measles vaccination rates are low in many segments of society, but by using this relative increase in cases as a headline it overlooks the fact that the actual number of cases is still low, thank goodness. To its credit, the NBC link above did go on to give these details, but in our sound bite world that clarification is easily lost. Here's a bit more perspective from CDC.

From the same website, you can see how graphs can be used to stress a particular point - the perspective below would make us think everything is great. Just by expanding the date range, we can hardly see anything going on this year.

CDC regularly updates assessments of measles outbreak risk in the US. Currently they predict the most likely number of cases for 2024 will total 300, with a 4% risk of >1000 cases. Keep that in mind over the next 5 months.

Don't get me wrong, I'm all for increasing measles vaccination rates; however, I don't want to do this without presenting an accurate view of the data. I'd make a terrible salesperson or politician.

Unless otherwise indicated, the content and opinions expressed on this web site are those of the author(s). They are not endorsed by and do not necessarily reflect the views of the George Washington University.
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