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Month: February 2025

Published on Leave a comment on End of an Icon?

What happens when a prominent public figure who thinks he knows everything about everything finds himself in a position to control an important public institution? It's another brave new world we'll need to endure as best we can.

Of course I'm speaking about the Broccoli family ceding creative control of the iconic James Bond franchise to Amazon/MGM, i.e. Jeff Bezos. I shudder at the possibilities of another billionaire-induced stream of havoc.

Er, no. What I'm really referring to is the postponement of this week's meeting of CDC's Advisory Council on Immunization Practices. I had detailed last week that it was scheduled for February 26-28 as one of the three planned meetings this year; the dates are selected well in advance and had been planned through 2027. Not any more, apparently.

These meetings, with the entire public invited to view in real time, were among the most transparent of all healthcare meetings in our country. I'm not sure what public comment accommodations were needed; comments had been requested via the Federal Register as per standard practice, and the draft agenda already included the usual times for live public comments prior to all votes. The concern is that RFK, Jr., will overhaul committee membership to install new members to carry out his anti-science doctrine. The website promises that the ACIP workgroups will still present their findings, but I'm concerned the votes could look much different by the time that happens.

Coupled with potential new rules for FDA and research funding, we could end up with no progress in vaccine development and increasing vaccine hesitancy in the general public. At worst, we may lose access to currently available safe and effective vaccines. The ACIP could cease to be a reliable partner for our nation's health. Private organizations, including the American Academy of Family Physicians, the American Academy of Pediatrics, and the American College of Physicians, among others, may need to step forward to fill the vacuum of discussion and recommendations.

As I step down from my soap box, Ambrose Bierce reminds me, "Speak when you are angry and you will make the best speech you will ever regret.”

Good News Department

After my Debbie Downer impersonation above (did you watch SNL's 50th Anniversary show?), I'm thankful I saw more positives than negatives this past week.

MMWR is Back in Form

The February 20th issue looked a lot more like a typical edition. It had 4 topics and didn't appear to be skimping/censoring information. Of course the biggest news from an infectious diseases standpoint is the report of 2 exclusively indoor pet cats from 2 separate households in Michigan who died from avian flu. Owners of both cats were workers on dairy farms. The cats never had direct exposure to the farms.

The investigation was somewhat limited by incomplete testing. The most logical conclusion is that these 2 episodes represent passage of the virus from humans to cats.

Polio Vaccination Resumes in Gaza

WHO reports another round of polio vaccination is ongoing now in the Gaza strip after wastewater monitoring recently showed a poliovirus spike. Almost 600,000 children under 10 years of age have been identified to receive vaccination through February 26.

Low Dose Yellow Fever Vaccine Produces Similar Seroconversion Rates

At first glance, this might not seem that important to those outside of the yellow fever world. However, yellow fever vaccine is in short supply at a time when this hemorrhagic fever virus is surging in many parts of the world, including the Americas. Investigators published a non-inferiority randomized, double-blind controlled trial of standard dose (13,803 IU) compared to lower doses of 1000, 500, or 250 U administered to adults in Uganda and Kenya.

Using a lower vaccine dose vastly increases the number of people residing in high-risk countries who can be vaccinated. Note that in addition to 29 African countries, 13 countries in Central and South America have some risk of yellow fever transmission.

Listeria Outbreak Linked to Frozen Shakes

Mostly these nutritional supplements are used in long-term care facilities. I haven't noticed any of these products in my local grocery stores. Last Friday FDA reported on the outbreak that first came to light in November 2024 and covers 21 states across the country. Thirty-eight individuals have been infected, resulting in 37 hospitalizations and 11 deaths. The high morbidity and mortality probably relate to the high-risk populations residing in these facilities. If you visit one a nursing home it's worth a mention to the staff to make sure they are aware.

Measles

I'm afraid that reports of vaccine-preventable diseases will increase in the current regulatory and cultural climate. Friday's update from Texas Health and Human Services now lists the total number at a whopping 90 cases, and if news reports are to be believed this is significantly under-reported due to high rates of home schooled children affected. Added to this are 9 cases just across the border in New Mexico, though news reports state there is no known contact to infected individuals in Texas. That seems to be a very unlikely coincidence.

Last week I mentioned that I thought the CDC needed to update their measles tracking page more frequently than monthly, and they listened to me! Now we have updates every Friday.

We haven't broken any records yet, here's hoping Texas officials get this under control soon.

WRIS

It's nice to see the influenza-like illness curve head down this past week, but it could bounce up again like it's done before.

Hospitalizations for confirmed influenza infections also trended down.

Mortality is the highest we've seen since the pandemic. The numbers below include 86 pediatric deaths.

On a national level, covid and RSV aren't doing much, though even low levels result in significant disease.

Bernarr Macfadden

Yeah, I never heard of him either, but opinion columnist Jessica Grose at the NY Times brought him to my attention as a precursor/dopelganger for RFK, Jr. Unfortunately Macfadden's Wikipedia article has too many poorly documented statements to recommend, but what I can verify is that he was a weight-lifter who liked to be photographed showing his muscles (and most of his body) and founded various health movements. A charismatic individual, his influence was prominent from the early 1900s through World War II. He had no medical background. He championed raw milk and denounced white bread and pharmaceutical agents including vaccines. His "movement" reportedly had prominent adherents including Franklin Roosevelt and Rudolph Valentino. Eerily familiar.

As a distraction, I found myself wondering how Jeff Bezos would tilt his newfound power to influence the future of James Bond. I know just the person to play the next villain.

Courtesy of YouTube

Published on Leave a comment on The Kennedy Era

Readers of past postings know I try to avoid politics in this blog. Today's post represents a complete failure to achieve that goal. I have followed RFK Jr.'s statements and writings about vaccines and public health for many years. His brand of pseudo-science is incomprehensible to me and anyone who understands biology and scientific methodology. His confirmation as HHS Secretary last week marks a sea change in the American health system; although he spouts some worthwhile targets to improve public health, in his new position he poses a grave public health threat for infectious diseases in particular. Regardless of any specific vaccine or other policies he might introduce, his mere confirmation as HHS Secretary may serve to further normalize anti-vax sentiment and likely will increase rates of vaccine refusal. Welcome to the new Dark Ages, though I doubt it will last several centuries like the last one. More on this later.

The Global Watch

A number of things to be aware of globally, though none immediately troublesome for the US.

Marburg Outbreak in Tanzania

This outbreak of a viral hemorrhagic fever disease (similar to Ebola) was declared about a month ago. Ten cases (2 confirmed, 8 suspected) have been identified, all fatal. Now, the 281 contacts of those 10 cases have passed the 21-day incubation period and remain well, very reassuring. However, WHO still rates the risk at the national level as high, given that the locale, Kangera, is a major regional transportation hub to other countries. Risk for global spread is still low.

Ebola (Sudan virus) Outbreak in Uganda

AfricaCDC reports that the vaccine trial is underway now in 7 of the 8 planned sites. Disease activity seems relatively stable, though the weekly reports tend to lag with last update posted from February 10.

PPE for VHF

With every viral hemorrhagic fever outbreak, healthcare providers comprise a prominent number of infected individuals. This occurred even in the US when 2 American nurse providers were infected during the 2014 importation from travelers. It's a good time to remember precautions to prevent VHF spread in healthcare settings, also a bit confusing since different guidelines apply according to whether the suspected patient is clinically stable or unstable. Front line providers need to contact their friendly local ID or infection control practitioner for help as soon as a suspected VHF case is encountered. Remember to obtain a good travel history.

mpox

In WHO's February 13 situation report, clade Ib mpox remains primarily in the DRC, Rwanda, and Uganda. MMWR just reported confirmation of a case of Ib infection in California from November 2024, in a traveler returning from east Africa. More on MMWR later.

Measles Again!

No surprise, but we have new outbreaks in the US, presumptively heavily related to cases in unvaccinated persons who were old enough to have received 2 doses of MMR vaccine.

A February 14 update from the Texas Department of State Health Services lists a total of 48 cases in the South Plains region, with age distribution of 13 cases in 0-4 year-olds, 29 in school-aged children (5-17 yo), 5 18 and older, and 1 with age unknown. Digging through the data from their spreadsheet links, MMR coverage in 2023-24 in the Seminole ISD (apparently the epicenter of the outbreak) is an appallingly low 82%. In Gaines County, home of 42 of the outbreak cases, the rate of "Conscientious Exemptions" for vaccine administration for children rose from 7.45% in 2013-14 to 17.62% in 2023-24. Even the earlier rate is super-high. Gaines County is the red box below.

The CDC measles page is updated only monthly, perhaps not frequently enough given the current situation. And, speaking of the CDC ...

Interesting Week Ahead for the CDC

I'll be watching closely this week. MMWR seems to be back, but with fewer topics per issue. I looked at the 2024 content, and only about 10% of the weekly publications had less than 4 topics. Both issues following the "publication pause" had only 2 articles each.

More telling, the Advisory Council on Immunization Practices is scheduled to meet on February 26-28. The draft agenda was released on January 19, and I'll be interested to see if the topics change. Currently on the schedule are votes on meningococcal, chikungunya, and influenza vaccines plus further discussion on maternal and pediatric RSV vaccines on Wednesday. These are not particularly high profile targets for the anti-vaccination lobby or for anti-DEI issues. However, part of the discussion process for vaccines at ACIP meetings has been an "Evidence to Recommendations" portion that normally includes a section on equity. I wonder whether this will change. Thursday's draft agenda includes perhaps more controversial subjects of HPV and mpox vaccines, due the relationship of these infections to spread via sexual contact in different high risk groups. Thursday's discussion also touches on pneumococcal and adult RSV vaccines, plus a 5-minute blurb on Lyme disease vaccination that I'm wondering about. The meeting wraps up Friday morning with discussions on covid (!) and CMV vaccines. I hope to attend much of the meetings and I'll report back next week.

This week's New England Journal of Medicine included a Perspective written by 3 former editors-in-chief of MMWR plus a former director for one of CDC's Centers. It was entitled "The Consequences of Silencing the 'Voice of CDC.'" Clearly the authors carry some implicit bias in favor of the CDC, but the article was enlightening. They repeated the reports I heard that the February 6 issue suppressed a discussion on H5N1 influenza (may have related to spread between cats and humans), which is concerning. I was interested to learn a bit of history: MMWR first appeared in 1961, during my lifetime but in a period when my interests fell more along the lines of Tinkertoys and butterflies. Currently I am one of 147,000 electronic subscribers to MMWR. CDC shares titles and brief summaries of reports with the Office of the Assistant Secretary for Public Affairs at HHS to alert them of content, but the authors were not aware of any time the reports had been altered or censored by the executive branch.

The authors went on to mention how rapid publication in MMWR helped public health management, citing the initial descriptions of what was eventually AIDS, outbreaks of foodborne illness related to hamburger contaminated with E. coli O157:H7, and anthrax related to intentional distribution of anthrax spores. I was a practicing pediatric ID physician during all of these outbreaks and still remember reading MMWR and changing my practice to account for new disease situations.

In addition to the evolving VHF situation in Africa mentioned previously, we need ongoing high-level surveillance for avian flu and for the large outbreak of tuberculosis in Kansas. With regard to the former, we did hear some information in MMWR this week: new serologic evidence of H5N1 infection in veterinarians providing care for cattle but with no known link to infected herds, suggesting more widespread cow infection than has been detected so far.

As an aside, since I do most of the grocery shopping in my household, I discovered the USDA has egg market reports. If you need some distraction from hand-wringing, you can track how many 30-dozen egg cases are moving around in your region each weekday!

WRIS

I'm thinking I don't need to tell any front line healthcare provider that influenza season is in full swing and is the one prominent player in our winter respiratory infection season at the moment.

More concerning is that illness severity is quite high.

Virtually all circulating strains are influenza A, and avian flu is not contributing to this with still just a handful of human cases detected in the US. Not too late to vaccinate.

My Test Grade Was 3

Please pardon my error last week in inviting readers to take the "How Ignorant Am I?" online quiz, not realizing it required subscription access. The quiz itself is based on a 1950 publication by statistician and weather forecaster Glenn W. Brier, updated in the Nature article you probably can't access. Briefly, the new quiz consists of 5 questions covering percentage of water in human body parts, timing of publication of genetic theories, planet size, number of atoms in common molecules, and melting points of precious metals; in short, scientifically based but nothing recently discovered. The kicker to the quiz is that it's not just whether you provide the correct answer, but that you quantify your confidence in the answer you provided. The scoring system is weighted such that failure (getting the wrong answer but thinking you are correct) is punished more severely than rewarding success (just getting the right answer). Here's the scoring interpretation: "If you ended up with a negative total, you did worse than a complete ignoramus who just answered 5 to every question" [5 indicates you had no idea which answer was correct, resulting in a score of zero if you answered 5 for all questions]. "People who actually know a lot, or are extremely lucky, get higher scores." (The highest possible score, getting all answers correct and being absolute certain of your answers, is 125.). So, my score of 3 isn't great, with a consolation prize that "Those with an awareness of their own doubts ... might end up with a small positive score." The main point of the quiz was " ... to train forecasters to be less over-confident, and have insight into their own thought processes." Applies to weather forecasters and possibly to healthcare providers as well!

Published on Leave a comment on Super Bowl LIX

All of Taylor Swift's minions, along with much of the world, know that today is another Super Bowl event. This time the site is New Orleans, which brings to mind the recent FDA warning about norovirus contamination of oysters from Louisiana harvest area 3. If you're like me, you had to know exactly where this is.

The Superdome is sort of like a cruise ship. I wonder what a Super Bowl norovirus outbreak would look like, but hoping I don't find out.

More Measles to Start the Year

It looks like we have 2 measles clusters already this year, 1 in Gaines County, Texas, and the other in Fulton Country, Georgia. According to news reports, both are associated with unvaccinated children who were old enough to have been vaccinated. The CDC has incomplete information as of February 6, and I note that they have decreased the frequency of measles updates to monthly as of this year. The national tally is 14 cases so far, from Alaska, Georgia, New York City, Rhode Island, and Texas.
Six of the 14 cases were hospitalized.

And, speaking of the CDC ....

MMWR is Back ... Sort Of

After an unprecedented (isn't everything unprecedented these days?) 2 week hiatus, the Morbidity and Mortality Weekly Report Volume 73 number 3 appeared on February 6. Besides the delay, it was unusual in that it contained only 2 topics, both related to wildfires: PFAS levels in first responders to the 2023 Maui wildfire and emergency department use during the LA County wildfires. Not a thing about any infectious diseases, despite the fact we are in the midst of a heavy winter respiratory virus season. Presumably this is not the new normal, and I'm hoping we soon see a return to something resembling the old weekly MMWR.

WRIS

We do have some continuation of CDC data current enough for looking at our winter respiratory infection season. FluView is cooking along, and we can see that outpatient influenza-like illness is going strong.

Influenza hospitalizations are very high, similar to the 2017-18 flu season.

Mortality data lag actual cases, but we have already tallied 57 pediatric deaths this year, and I fear we'll top last year's number of 207. This past week we saw almost exclusively influenza A viruses, about evenly divided between H3N2 and H1N1pdm09 (the pandemic 2009 strain). Both are covered by the current vaccine.

Meanwhile, RSV season is mostly over, and we're still waiting to see if covid will spike this winter. Covid wastewater levels have been and remain high.

Avian Flu

Influenza A H5N1 continues to be widespread in the animal population. Probably the biggest news the past week is that the D.1.1 genotype, so far only present in birds, has now appeared in a dairy cattle herd in Nevada. Given how long H5N1 has been present in various animal populations in the US, this doesn't seem all that surprising to me. The main import is that the longer these strains hang around, the higher the chance for mutation or reassortment into a strain with the ability to infect and spread among humans.

Here's the February 6 USDA update on recent cattle cases; if you visit the site you can change the timeline and also look at alpaca or swine cases. I'm particularly watching the swine cases because that animal has the highest risk of developing a strain with greater ability to infect humans. (Only 1 pig has been known to be infected so far, in Oregon last October.) You can go to their main avian flu website to look at other animal populations.

Just to further confuse you, the official terminology for the predominantly bird strain is "highly pathogenic avian influenza (HPAI) H5N1 clade 2.3.4.4b, genotype D1.1," as opposed to the more common cattle strain of HPAI H5N1 clade 2.3.4.4b, genotype B3.13. Now you can bore your friends with this tidbit at tonight's Super Bowl party!

Infectious Disease Troubles in Africa

Two situations in Africa are looking increasingly concerning. The Democratic Republic of Congo is trying to deal with an mpox outbreak in the midst of widespread violence and war in the country. As we know from the song, war is good for absolutely nothing, and the DRC's ability to manage the mpox outbreak, already strained, is suffering.

The other African hotspot is in Uganda, experiencing an outbreak of Suban Ebola virus disease. Fortunately WHO is facilitating a candidate vaccine trial there which could be a breakthrough in controlling this particular virus. Mortality rates in prior outbreaks were 41-100% and are improved by availability of supportive care.

In the meantime, CDC's Health Alert Network issued an advisory for the Uganda outbreak, raising the travel precautions to a level 2 (practice enhanced precautions).

Does Probability Exist?

As I was trying to interpret the various weather predictions for icy roads in my area, I came across this great piece in Nature by David Spiegelhalter, an emeritus professor of statistics at the University of Cambridge, UK. It definitely appealed to the statistics nerd in me, but I think everyone, including people without a background in science, would learn from it. I especially enjoyed the "How ignorant am I?" quiz. You don't need any special background to take it, so try it out. Next week I'll reveal my score. [Note added: apparently I used my institutional access to see this article, it's not free content for everyone. My apologies to those who can't access it, I'll give more details about the quiz next week.]

What is the probability the Super Bowl will end in a tie? The rules don't allow that, so I guess it's as close to zero as you can get with any probability in this world.

BTW, Spiegelhalter's answer to whether probability exists was, "probably not - but it is useful to act as if it does." My kind of guy.

Published on Leave a comment on Hello Darkness

Earlier this morning, Punxsutawney Phil saw his shadow, guaranteeing 6 more weeks of winter darkness with about the same amount of scientific basis as what we might be facing with a darkened CDC and other federal agencies. The original executive order limiting information release from federal agencies was said to last until February 1, but a day later MMWR is still silent.

We have now missed 2 MMWR reports, and I haven't been able to find any update on when/if this valuable resource might reappear. FluView Interactive and other CDC sites have similar notices though apparently are publishing some updates, which I'll show in the WRIS section later. Meanwhile, the world goes on.

Niger Eliminates Onchocerciasis Transmission

WHO announced that Niger joined Colombia (2013), Ecuador (2014), Guatemala (2016) and Mexico (2015) in eliminating transmission of Onchocerca volvulus, the cause of "river blindness." This is a major achievement, and I hope that funding cuts don't hinder WHO's disease elimination programs significantly.

African Outbreaks with Worldwide Significance

Sudan Virus in Uganda

This virus is in the Ebola virus family, and now Uganda is facing a new outbreak mostly involving healthcare providers (so far). WHO is advising against instituting any travel advisories, but the US State Department has had a Level 3 travel advisory in place since October, 2024, unrelated to any infectious disease outbreaks. (I was interested to note that this State Department site had no disclaimers about revamping the web site.)

Many readers will remember how Ebola virus came to the US via international travel. Certainly this new outbreak is still low risk for international spread, but the possibility remains and reminds all of us how distant outbreaks can hit home.

mpox

A new report in NEJM nicely describes the ongoing mpox outbreak in the Democratic Republic of Congo and surrounding areas. As emphasized in the accompanying editorial, spread from household close contact is prominent, with children sometimes experiencing severe disease. Pediatric cases are further described in another report, and the accompanying editorial emphasizes the challenges in trying to manage the outbreak. If you really want to dig deep into the numbers, WHO has an update. International spread so far has been limited but could increase.

MIS-C Phenotypes

This article caught my eye, even though MIS-C is less of a concern in our current covid situation.

The figure below is complicated, but suffice to say the researchers identified 3 clinical clusters: respiratory (cluster 1 above), shock/cardiac (cluster 2), and mild disease (cluster 3).

WRIS

Winter respiratory infection season is in full swing. It's not exactly great timing to have confusion in CDC's information restrictions during what is likely the height of flu season, not to mention ongoing concerns about avian flu. Already we were dealing with less data after the pandemic ended, a reasonable plan given less urgency surrounding covid. However, I admit to being confused about what might be changing in other surveillance systems now, with nary a peep (pun intended) about how the new administration's executive orders affect disease surveillance.

For what it's worth, here's a little bit of what I can find. I'm guessing that nothing much had changed with data collection methods by January 25, the closing date for the numbers used below.

Total acute respiratory illness is high or very high in much of the country.

Influenza is the main driver.

The Sound of Silence

Paul Simon has criticized most of the early work of Simon and Garfunkel, but the song that begins with "Hello darkness, my old friend" apparently is an exception. He is quoted in a 2023 interview regarding The Sound of Silence, “Somehow that song has changed its meaning over the years. It’s different. That’s good luck for me that that happened, you know?” I agree.

People talking without speaking
People hearing without listening

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