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Month: March 2025

Published on Leave a comment on I’m So TSAD

But don't worry, I've embarked on a treatment regimen for my Trusted Site Adjustment Disorder. My TSAD was triggered by all the changes to virtually all the organizations I've relied upon in the past to supply me with reliable information. Will cdc.gov and fda.gov information suffer further hits to transparency and lack of bias? I'm TSAD about all this, but I'll continue to plod through.

Once again, measles dominates the pediatric infectious diseases news, but I did find a couple of other areas of note this past week.

Mpox

WHO (at least they continue to function while facing decreased US funding) published a new report March 28, and it's not good news. (The text of the report is noted that the slight downturn in the African Region the past couple months likely represents lower levels of testing and reporting in the Democratic Republic of Congo, rather than a true decrease.)

Funding cuts for mpox control, including vaccine testing and treatment development, will cause even higher numbers in all regions in the coming years.

COVID-19

While we are in sort of a lull, I think it's useful to see what our somewhat baseline level of infection looks like. Here's a snapshot of the past 3 months' mortality, currently about 2/100,000 population over that time period.

Wastewater levels of SARS-CoV-2 remain low generally, with some geographic variation.

Two items of note here. Wastewater and other monitoring has been voluntary, up to individual jurisdictions, as shown by the large swaths of the country with no wastewater monitoring sites. Secondly, funding for such efforts have just been cut, so look for wastewater monitoring data to decrease substantially for all pathogens.

ACIP is Back!

A bit of good news, the regular meeting of the Advisory Committee on Immunization Practices, previously scheduled for February 26-28, is now on the docket for April 15 and 16. I compared the draft agenda for the newly scheduled meeting to that of the original meeting, and they are similar though total time for the meeting has been shortened by a few hours. No major topics were deleted, though some of the subtopics were changed. The section on flu vaccines is much shorter, with no votes scheduled, presumably related to the cancellation of the FDA VRBPAC meeting on the topic and subsequent selection of vaccine strains by FDA personnel without panel discussion. I'm most interested in the 1 topic that was added, "measles epidemiology and outbreaks," with a 30 minute presentation by 1 CDC employee. I'm planning to view as much of the meeting as I can, schedule permitting.

Measles

The beat goes on, we are clearly in this for the long term. Here's the latest from CDC as of March 27:

I found this map from the NY Times helpful in showing relationships of the Texas outbreak to the rest of the country.

I don't think I've mentioned much about various clades and genotypes of measles, but it's important to understand at a basic level to see how epidemiologists link various outbreaks together. CDC provides a detailed discussion that I'll attempt to summarize. Measles virus consists of 8 different clades, A through H, based on hemagglutinin and nucleoprotein (H and N) genes - similar to influenza A categorization. For example, the measles vaccine strains are members of clade A. Within each clade are different genotypes. with the Texas-origin outbreak being D8. So, those "yellow" states are connected by their D8 similarities.

Kansas is the latest developing hot spot, so I visited their health department's web site which is enormous and takes some digging. To save you that digging, they report 23 cases so far this year, the majority coming in March.

I couldn't find numbers for vaccination status, but here's the age breakdown.

WHO is concerned about measles in the US. They reminded travelers coming into the US to check and update their measles vaccine status prior to travel.

In case you missed it, I want to draw your attention to the Comments section in the right-hand margin of this blog where Dr. Michael Schwartz posed a very timely question last week about whether it's time to offer measles vaccination to children prior to the recommended 2nd dose at age 4-6 years. I attempted to answer the question but mostly punted to say to follow your local health department's guidance.

Measles Deep Dive #3

I'm hoping this is my last deep dive; this one is devoted to vitamin A. WHO recommends routine vitamin A supplementation for all children 6-59 months of age in regions where vitamin A deficiency is a public health problem, defined as "prevalence of night blindness is 1% or higher in children 24–59 months of age or where the prevalence of vitamin A deficiency (serum retinol 0.70 µmol/l or lower) is 20% or higher in infants and children 6–59 months of age)." A recently updated Cochrane Systematic Review did conclude that routine vitamin A supplementation in high risk settings was associated with overall benefit in high risk countries. Needless to say, the US population would not be included in that high risk category.

In terms of vitamin A specifically for measles, I'll mention just a few studies. I still keep a yellowed print copy of a randomized, double-blind, placebo controlled trial of almost 200 hospitalized children with measles in South Africa that showed lowered mortality with vitamin A.

Another study of similar size in Tanzania found similar results.

The results are different when a high-income country is the study site, such as this relatively recent article from Italy. Given the very low mortality in such settings, a prospective randomized trial would require many thousands of enrollees to look at mortality differences. Instead, the Italian study addressed several other outcomes of interest. The Italian study was not truly randomized, since WHO had recommended vitamin A supplementation for children hospitalized with measles and a placebo group would not have been ethical. However, vitamin A wasn't available in all Italian jurisdictions, so some children could not receive it and thus comprised the "Standard Care" group.

As you can see, they found no statistically significant differences in these outcomes, although a few items almost reaching the "magic" p value of 0.05 favored the vitamin A group. Looking at the degree of differences in those categories, such as hematologic complications in the under-2 yo children or length of hospitalization, the clinical significance seems very small. The study has other limitations beyond its non-randomized nature, but so far it's the best we have that looks at a relatively non-resource poor country.

Here are the current CDC recommendations for use of vitamin A in children with measles:

"Under the supervision of a healthcare provider, vitamin A may be administered to infants and children in the United States with measles as part of supportive management. Under a physician's supervision, children with severe measles, such as those who are hospitalized, should be managed with vitamin A.

Also under physician supervision, if vitamin A is recommended, it should be administered immediately on diagnosis and repeated the next day for a total of 2 doses. Inappropriate dosing may lead to hypervitaminosis A. The recommended age-specific daily doses are:

  • 50,000 IU for infants younger than 6 months of age
  • 100,000 IU for infants 6–11 months of age
  • 200,000 IU for children 12 months of age and older"

A bigger issue now may be potential side effects of vitamin A use. Those risks aren't high if recommended doses are used but are more likely to develop with chronic use or in certain food fad instances. WHO, in an undated document with the most recent reference being 1999, gives a brief summary of clinical features of acute and chronic hypervitaminosis A. Clinicians should remember that isotretinoin (Accutane) has very high risks for causing fetal abnormalities if administrated to pregnant people, and other vitamin A products can do the same thing.

If a parent of a child with measles asked me to prescribe vitamin A I would do so, while also discouraging any chronic use of cod liver oil or over-the-counter vitamin A products.

I'm So TSAD

The one or two readers who might actually click on some of the links in my posts may have noticed my frequent reliance on Wikipedia. Is that site a reliable source of information?

Several years ago I taught a course in Evidence-Based Medicine at the GWU Graduate School of Education; the students were all medical professionals interested in improving their teaching skills. I heavily stressed the importance of helping students, trainees and practitioners to recognize how to quickly find trustworthy medical articles in web searches, and one exercise I used was a "race" to find the best articles for topics using either the traditional search in Pubmed using a PICO question versus a Google search in more standard language. During this time in the early 2000s the Google group always came out on top, but that would never happen with today's Google (and other search engines) use of sponsored sites and other commercially-oriented practices. I recently Googled my son's new NGO website using its exact name and couldn't find it. Turns out it didn't appear until page 4 of the search.

Wikipedia, even though virtually anyone can write or edit topics, retains its usefulness. If you want to dig paper, albeit using circular sourcing since it's a Wikipedia article, check out the references about Wikipedia's reliability. Misinformation is fairly quickly corrected in Wikipedia, especially for more commonly-visited topics.

OK, so I really made up this whole TSAD thing just so I could mention my delight in finding the original recording of the song "I'm So Glad," popularized by Cream (link to long version) and Deep Purple (after a 2:34 minute intro I could do without). Skip James recorded it in 1931, you can hear it on YouTube. Newspaper reports state that Cream provided James with royalties from their version that allowed him to pay for cancer surgery late in life.

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Published on 2 Comments on Ripple

I've had an ear worm all week after I heard the Grateful Dead's Ripple play on the radio. Little did I know it was a spooky foreshadowing for my weekend.

Meanwhile, measles is dominating the infectious diseases news, with only a few notable exceptions.

New Dengue Alert

CDC issued a new alert about dengue risk in the US. Not only are Puerto Rico and U.S. Virgin Islands hot spots for dengue acquisition, we continue to have significant spillover into the continental US, including in persons who haven't traveled to endemic areas. These autochthonous infections arise when enough of the local mosquito population becomes infected from travelers returning from endemic regions. Here's the map of total US dengue cases for 2025 so far:

Drilling down on the same website to look at just the autochthonous (locally acquired) cases:

Clearly just a handful of autochthonous cases, but spring has just started and summer is ahead, a good time for a reminder to practice good mosquito bite prevention measures. In 2024 we had a little over 10,000 dengue cases in the US, about 6500 of which were autochthonous, led by Puerto Rico. Florida, California, and Texas were the higher-risk states for locally acquired dengue in 2024.

For people having trouble choosing among various mosquito repellants, scroll down to the Insect Repellent Bot on that same prevention page for an interactive discussion.

Cholera

WHO has raised the alarm about global cholera outbreaks. Cholera is tough to track, so the case counts probably represent significant undercounting. So far in 2025 WHO has tallied 70,488 cases and 808 deaths from cholera and acute watery diarrhea.

We have both effective vaccines and treatments, but still a very tough problem to control.

Measles Marches On

We are in for a long year of measles. The Texas/New Mexico/Oklahoma (I think I'll call it TeNMO) outbreak isn't slowing down, and control measures are hindered by likely underreporting with infected individuals not seeking medical attention. I was hoping the rural nature of the epicenter in Texas would limit spread, but travel and low vaccination rates are conspiring against us. Going forward I will focus mainly on CDC numbers as a whole, unless unique aspects about local infections warrant discussion. Remember that Texas and New Mexico are reporting case counts and other information regularly.

Here are current CDC data:

Measles Deep Dive #2

Last week I probably confused everyone about the measles reproductive number in Deep Dive #1. This week's dive addresses the measles risks for children under 12 months of age, before routine measles vaccination is recommended.

An offshoot of the Texas outbreak was an exposure of newborns in a hospital in Lubbock, Texas, to a mother admitted in labor who was found to have active measles. If the mothers of exposed infants had immunity through vaccination or natural infection, these other newborns likely are protected though I'm sure they underwent evaluation and immunoglobulin treatment. I've never seen a case of neonatal measles, probably because I've always practiced in an area where the vast majority of women of childbearing age have immunity. I was interested in an oldie-but-goodie article from Japan describing 7 children < 30 days of age who acquired measles from their mothers. Three developed pneumonia but thankfully all did well. The interesting part of the report was that the rash was atypical in 6 infants, appearing on the same day as the fever started (i.e. no 2-4 days of cough, coryza, conjunctivitis prodrome) and before the fever in 2. All had Koplik spots.

Travel season is upon us, and recommendations for vaccination for children as young as 6 months who plan international travel hasn't changed.

"Persons aged 6 months and older who will be traveling internationally to any country outside the United States who do not have presumptive evidence of immunity should be vaccinated with measles-containing vaccine if they are not already protected against measles, mumps, and rubella. Before any international travel—

  • Infants 6 through 11 months of age should receive 1 dose of MMR vaccine. Infants who get one dose of MMR vaccine before their first birthday should get 2 more doses according to the routinely recommended schedule.
    • The first dose should be given at 12 through 15 months of age and the second dose at 4 through 6 years of age.
    • The second dose can be administered earlier as long as at least 28 days have elapsed since the first dose.
  • People 12 months of age and older who will be traveling internationally should receive 2 doses of measles-containing vaccine;A unless they have other presumptive evidence of immunity against measles. The second dose should be administered no earlier than 28 days after the first dose."

Local health departments may recommend this early vaccine dose for infants 6-11 months of age who are deemed to be at risk from individual outbreaks as well, certainly pertinent to some areas of Texas and New Mexico at least.

As most primary care providers know, this early measles dose doesn't count as part of the routine 2-dose MMR vaccination; the early dose is sometimes called "dose 0" so that it won't be counted. Response to measles vaccine at 6 months of age isn't robust and can be inhibited further if maternal antibody is still present in the infant. However, data from around the world suggest that virtually no 6-month-olds will have detectable measles antibody. Here's a study from Belgium as an example:

This seems to be the case in resource-poor communities as well.

WRIS

I'm hoping this will be my last regular posting for this year's winter respiratory infection season. National levels of respiratory illness are low, as are most states.

Influenza-like illness continues to fall, though still above baseline. We still have some "red states."

I won't have a WRIS update until/unless something changes.

New Water Wonderland

Mid-week I had a plumber in the house to fix a problem with my shower water temperature and, while he was at it, fix a minor drainage problem in the basement. By Saturday I had a new wading pool in my basement, complete with ripples when I run water from anywhere in the house. I'm a very unhappy camper and hoping this gets fixed soon. The joys of home-owning.

Published on Leave a comment on Measles Out the Wazoo

My usual blog post routine is to scan all my journal and news feeds during the week and then over the weekend try to winnow that down to topics to include on Sunday. Try as I might, I can't seem to escape measles: 7 of my 11 surviving feeds deal with this annoying virus. I'll start with the non-rubeola topics first.

Covid Vaccine and Birth Defects

Before you get anxious, no, there is no association between covid vaccination given to pregnant people in the first trimester of pregnancy (the most likely time for an exposure to cause a birth defect) and birth defects in their children. A report from UCSF looked at national insurance claims databases from August, 2021, through September, 2022. From about 78,000 pregnancies they identified 1248 newborns with major structural birth defects. Of those, 1049 occurred in unvaccinated people and 199 among vaccinated people. The rates were 160.6 and 156.4 per 10,000 live births for unvaccinated and vaccinated groups, respectively. Adjusted prevalence ratio was 0.96 with 95% CI 0.81-1.13. Here's a further breakdown.

There was no difference in rates by vaccine brand (Pfizer vs Moderna).

FDA Flu Vaccine Recommendations (without VRBPAC)

The FDA Center for Biologics Evaluation and Research published their recommendations for next year's influenza vaccine and, no surprise, it was in agreement with the WHO recommendations recently released. This will allow time for vaccine manufacturers, regardless of vaccine platform being used, to have vaccine supplies ready in time for our next flu season. Competent FDA and CDC experts were involved in the decision-making, joined this year by a presentation from the Department of Defense that mostly covered vaccine effectiveness estimates for this year's flu vaccine in military dependents.

What was missing from this gathering was the open public discussion of the choices via VRBPAC meeting. Having tuned in to a lot of these meetings over the years, I recognize this was a major loss for transparency of decision-making at a time when our country needs as much transparency as possible for vaccine and other public health matters. I don't think VRBPAC discussion would have altered the final decision. The slides are available at the link above, but it's a lot tougher to go through reams of slides without concomitant discussions as in the past.

Foodborne Ilness Surveillance Summary

I was glad to see that the CDC is still churning out some important information for us. This past week they released a study of contributing factors to foodborne disease outbreaks from 2014 through 2022. I thought it was interesting to see how they categorized types of contributing factors and how they changed over time, especially during pandemic years. They catalogued 2677 outbreaks that had recognized contributing factors over this time, with 1142 occurring in 2014-2016 and 1130 in 2017-2019 but only 405 in 2020-2022. It takes a crowd to produce an outbreak.

This is a large table but gives an idea of the main causes for bacterial and viral pathogens. Note that viral outbreaks were more likely to be linked to infectious food handlers rather than to environmental or animal sources.

WRIS

The big 3 (covid, flu, RSV) for our winter respiratory infection season all continue to decrease nationally, as of CDC's March 14 update. Respiratory activity averages out as "moderate" nationally. Flu continues to fall and seems to be on the way out, though still above baseline.

The map is starting to look more orangey-green.

Although looking at numbers of deaths from flu or covid is a bit misleading, due to significant time lags for deaths and reporting to occur, we are likely hovering at around 1000 per week each for flu and covid mortality.

I'll be very interested to see when our next covid surge will emerge. Clearly it still isn't behaving like a typical winter respiratory virus.

Measles

As I said, measles is hogging the infectious diseases limelight. Just so you know we are not alone in the US, WHO tells us Europe is at a 25-year high in measles cases: 127,350 in 2024, twice the number of cases in 2023 and the highest since 1997.

Closer to home, the New Mexico outbreak, really part of the Texas outbreak, is up to 35 cases (33 more likely associated with Texas cases across the border). Good ol' Texas now tallies 259 cases. Now Oklahoma reports 2 cases that were imported from contact with the Texas outbreak, though they have released few details. Here's a map from the NY Times showing these areas - if you don't have a subscription, you can create a free account for limited access. The map is a little confusing, Yoakum and Cochran are in Texas, not New Mexico.

More amazing to me is that this outbreak apparently has spread to western Chihuahua, Mexico, over 400 miles from Gaines County, TX. Apparently the link is between Mennonite communities in Mexico and Texas.

The combination of international travel and lower vaccination rates could mean a terrible year for measles globally.

Measles Deep Dive #1

Last week I promised to go into more depth with measles topics, but it has turned out to be so involved that I'm going to divide this up over the next few weeks. First I'll address the data on just how contagious measles really is.

Measles is definitely the most contagious infectious agent for humans. The key terminology for expressing this is the basic reproduction number, aka R0, which is the average number of secondary cases of disease arising from exposure to an index case in a completely susceptible population. In general, if R0 is greater than 1, each infected person can transmit the disease to more than 1 person and the disease can propagate in a population, If R0 is less than 1, transmission in that population cannot be maintained. R0 is particularly useful during an outbreak, such as now, when it can be used to estimate how many susceptible people in the outbreak would need to be vaccinated to stop transmission in the community.

In practice, virtually no population is completely susceptible to measles, due to either natural infection or vaccination in the population. It's been estimated that a population would need to have a 95% measles vaccination rate to keep R0 under 1. If R0 is less than 1, it's easier to target close contacts of an index case of measles rather than worrying about a larger community.

R0 for measles is often given as 12-18, meaning a single infected person can transmit measles to 12-18 exposed susceptible people. This is far higher than for any other infectious agent. However, it's not that simple, as shown in a systematic review published in 2017. As a quick look, here's how R0 can be used to determine what coverage is needed to achieve herd immunity in a population. The blue-shaded area shows that about 95% vaccine coverage would be needed if R0 is in that 12-18 range. However, if R0 is 2 in a given population, herd immunity can be achieved with a 50% vaccination rate.

The investigators in that systematic review found a much wider range of R0 for measles in previous publications, both above and below that much-quoted 12-18 number:

R0 varied considerably by geographic location and time period studied:

If you're confused now, don't be. The basic reproduction number isn't all that basic. As the authors of the review explained very well, "...R0 is not an intrinsic value characteristic of a given pathogen, but rather describes the transmissibility of that pathogen within the specific population and setting under study." They go on to explain that R0 is a property of both sociodemographic factors that are different for every outbreak setting and the biology of the microbe itself, the latter having a relatively fixed set of properties. One size does not fit all. Your guess is as good as mine as to what R0 is for Gaines County, TX.

Let me also quickly mention a few other studies. First is a pretty amazing natural experiment of a measles outbreak in the divided cities of Texarkana, TX, and Texarkana, AR. (It's even the more amazing because it has only 1 author!). The outbreak occurred from June, 1970, through January, 1971. The natural experiment was that, although the 2 cities functioned as one both socially and economically, and residents regularly traveled back and forth to various businesses in both cities, they were governed by their own state regulations including separate public health departments and schools. On the Texas side, at the time there was no legal requirement for measles vaccination for entering school children nor ever any mass immunization campaign in Texarkana, TX. The state of Arkansas had required measles immunization for all school children. Estimations of immunity in children 1 to 9 years of age, from either natural infection or vaccination, were 57% on the Texas side and >95% on the Arkansas side. You can guess what happened with this outbreak. (For those of you who are geographically challenged, Texarkana, AR is in the dark blue, east of Texas.)

Probably most of you have heard that measles can persist in the air and be transmitted even 2 hours after the index case has left the area. A well-studied situation occurred in a pediatric practice in Georgia in 1981, where 4 children where infected by the source patient even though only 1 had had close contact with him or her. One infected child didn't even arrive at the practice until 1 hour after the index case had left. Again, one size doesn't fit all. You know the actual transmission would be affected by air exchange rates in an office, for example. Still, it's a useful number to use when trying to track and protect potential at-risk individuals. For those interested, a larger review of measles transmission in medical settings during the early 1980s is available.

Wazoo

Ever wonder where this less polite term our bodies' solid waste outlet came from? It appears to date back to a 1961 article in the California Pelican, a now-defunct humor magazine based at UC-Berkeley. I can't find any archive of this periodical online, but from now on I'll be keeping my eyes open in all the dusty used bookstores I visit.

Published on Leave a comment on Happy 5th Anniversary

March 11 marks the 5th anniversary of the World Health Organization declaring COVID-19 a pandemic. WHO had declared it a Public Health Emergency of International Concern (PHEIC) on January 30, 2020. I can't say I'll be celebrating this anniversary, but it did lead me to discover a new site: the CDC Museum COVID-19 Timeline. It's yet another rabbit hole for me to get lost in.

Wasteful Lab Tests

Two publications last week highlighted the developing science of diagnostic stewardship - increasing effective use of diagnostic tests and minimizing test ordering that does not help, or worse, harms, patients. First, a retrospective database study showed that respiratory pathogen panel (RPP) orders, already on the rise in pediatric hospitals, increased sharply during the pandemic but continue to be ordered at high levels even as the pandemic ended. The larger multiplex RPPs test for a number of pathogens for which there is no treatment and thus really no benefit to detecting those viruses for the vast majority of children. Also, most practitioners don't recognize that many respiratory pathogens (e.g. enteroviruses, adenoviruses, and Mycoplasma) can persist positive on these panels for weeks or months. largely because the pathogens themselves remain in our systems for a prolonged period though don't cause harm. Thus, positive tests can sometimes reflect something that happened 2 months ago and not have anything to do with the current illness being evaluated.

The authors found that respiratory testing overall seems to have remained quite high, at least through 2023, for both hospitalized children as well as for children seen in the ED but not hospitalized.

Not shown in a nice graph but included in the text of the article, they found that testing for SARS-CoV-2 alone decreased during the post-pandemic period, but this was not accompanied by a decrease in use of the larger RPPs. They also estimated the costs of such testing: about $20 million in 2016, a high of $111 million in 2022, and $83 million in 2023. Remember, this is just for children's hospitals included in a national consortium. The true excess costs likely are much higher.

Another report focused on a new guideline for management of pneumonia in neurologically-impaired hospitalized children, based on expert panel opinions of different scenarios. It's a useful guidance document, but what I found most interesting was in the diagnostic stewardship realm. They recommended against routine use of procalcitonin, ESR, CRP and large panel respiratory viral testing. (Sorry, you'll need to access the article to see all the explanatory footnotes, just too large to include here.)

The World

There's a lot going on in the world of infectious diseases outside of the US, and of course sometimes those issues come home to us via international travel - it's inevitable.

Sudan Virus in Uganda

In the latest WHO outbreak news from March 8, Sudan virus hemorrhagic fever continues to be a problem in Uganda with 12 confirmed and 2 probable cases total since the outbreak started in late January. That doesn't sound like much, but underreporting is always a particular problem in resource-poor regions. The most recent case had symptom onset in mid-February. We have no proven vaccines or therapeutic agents for Sudan virus disease, but WHO began a vaccine trial using a ring vaccination model: vaccinating primary and secondary contacts of index patients to see if this presents spread to the larger community. A therapeutic agent trial also is being planned.

Poliovirus in European Wastewater

Last week's MMWR (yes, it's back in mostly fine form!) announced findings of a vaccine-derived strain of poliovirus type 2 surging in wastewater in some European countries; this is the strain that has produced paralytic disease in other countries. The particular strain originated in Nigeria and has spread to 21 other African countries. There are no known cases of clinical infection, but remember that paralytic polio occurs in only around 1% of those infected with the virus and it's very difficult to identify the asymptomatic and mildly symptomatic infected people without very costly tools.

This isn't a time for alarm or for closing borders, though I'm sure some will use this as an excuse to do so, but it bears watching as well as ensuring adequate immunization against polio. Of course the killed polio vaccine, used in the US and other countries where polio has been eradicated, does not carry the risk of spread of vaccine-derived virus known to occur with the live virus polio vaccines.

Unknown Agent(s) Causing Deaths in Democratic Republic of the Congo

WHO officials have been monitoring this situation in the DRC, still very unclear whether it is a single agent or just a cluster of multiple known agents causing deaths. I haven't mentioned this previously because it is still unexplained and most often will not result in any new information concerning for spread outside of a limited region. I'll swing back with an update when the situation is pinpointed.

Measles

I'm saddened that measles likely will be a regular feature in my posts for the next few weeks at least. On Friday, CDC issued an advisory through its Health Alert Network about the increasing numbers of measles cases in Texas and New Mexico. These areas are definitely not on my travel list, even though I know my measles antibody titers are high. The advisory has a lot of useful information and links for healthcare providers and the general public.

I was also pleased to see that Texas has accepted help from the CDC, although I learned this only through lay press announcements that CDC had posted the news on X, absolutely the last place I'd normally go for any useful information.

I didn't bother to read any of the 491 replies, not a good use of my time.

Here's the latest from CDC; note that the recent decrease in numbers isn't necessarily real, there is a lag time for reporting and verification of cases:

The official CDC total for 2025 is up to 222 cases. One death of an adult in New Mexico who tested positive for measles is still under investigation to see if measles was actually the cause of death or just coincidental. Apparently this person did not seek medical attention before death.

As bad as the outbreak numbers are, I think I was most dismayed by the rumors in the lay press that CDC has announced a new study of a linkage between autism spectrum disorder and the MMR vaccine. This is perhaps the best-studied association known to modern science, with reports of cumulative numbers of several million children across the globe showing no connection between MMR and ASD. Yet another study seems like wasteful spending and use of government workers' time!

I won't bother to go into depth with the studies, you can look at the CDC site for an excellent discussion and some key references (click on the tab for references 3,4,5,6). However, I did want to make a couple points about issues that anti-vaccination proponents misinterpret or deliberately ignore. First, these studies look a large numbers of children who received and did not receive MMR vaccine and present results for the group as a whole. It is impossible to prove that MMR vaccine could not have caused a particular child's ASD. You can think of it as analogous to a situation where one tries to see if a particular medication had caused a rare side effect in a child where that side effect was not previously known to cause the adverse event. About the only way to prove it caused the problem for that child is to wait for the side effect to go away and then re-challenge the child with the same medication and see if the adverse event recurs. There's no way to do that with a vaccine and ASD. Second, anti-vaxxers often misinterpret how various tracking systems for vaccine adverse events are collected and what the limitations of these databases can be. From my observations of past RFK's interpretations of vaccine safety reports, I expect that any new study that doesn't align with his views that MMR causes ASD will just be disregarded or twisted to change the results. I pity the CDC scientists forced to work on the new study.

And, speaking of a waste of time, we now have a new CDC page listing all the conflicts of interest reports from ACIP members. I say this because the details have all been part of the public record and available at every ACIP meeting in the past, plus archived on the ACIP web site. I suspect this will be used as an excuse to remove members from the ACIP and replace them with less knowledgeable individuals who have never been involved with a vaccine trial.

All of this measles news caused me to unearth what's left of my old measles folder containing some very yellowed pages at this point. This coming week I'll go through some key articles on effect of vaccination rates on measles transmission, the reproductive numbers for measles, what we know about measles transmission in office settings (spoiler alert, it's not as much as you think), what vitamin A does and does not do for measles, and maybe some others. Stay tuned for my next post.

WRIS

At least we can end with some good news. The winter respiratory infection season continues to wind down, and without a big jump in covid so far. Both covid and RSV are low and decreasing; flu is still high but also continues to decrease.

That COVID Timeline Museum

Taking a stroll through the CDC's site wasn't that picturesque for me; in fact, there are no pictures or graphs beyond the same worn-out cartoon of the virus itself at the top. It did have a lot of words on a timeline, however, and I found myself trying to remember what was going through my mind at various times as the pandemic evolved. I wish I had kept a written journal, but I well recall that 5 years ago this month, among other concerns like grocery shopping, I was trying to research how to safely re-use N-95 masks in my clinical practice. We definitely had a shortage of those masks that prevented any single use options, and it was very time consuming to use other methods such as our hospital's limited supply of PAPRs (powered air-purifying respirators). US cases were still low in early March, 2020; here's a screenshot from the Museum:

Published on Leave a comment on Onward Through the Fog

Or haze, or just blackness. It's a beautiful sunny day in Maryland, but cancellation of the FDA's VRBAC meeting to discuss next fall's flu vaccine composition makes things a lot hazier. More on that later.

Covid Vaccination Protective Against Post-Covid Conditions in Children

This is a report from a multicenter study of children 5-17 years of age, originally enrolled July 2021-September 2022 and then followed longitudinally. The cohort was surveyed from December 2022 through May 2023, with questions about a variety of symptoms lumped under Post-Covid Conditions (PCC) detailed in the footnotes below.

The lower odds ratios of PCC in vaccinated children is impressive. The study's strengths are its prospective design, but the fact that they are relying on survey results, as opposed to specific follow-up encounters to determine signs and symptoms, is a bit of a weakness. Other longitudinal studies are ongoing with longitudinal in-person evaluations, so we'll eventually have better data. Also, this study doesn't tell us anything about benefits of ongoing covid immunizations in children. I've previously mentioned other studies suggesting benefit to children from ongoing immunizations.

Measles

The outbreak in Texas with probable spillover to New Mexico continues. Here's the latest from CDC in their February 28 report. Be aware there is a time lag from when cases are reported by states to when they are included in CDC numbers.

I was hoping the West Texas outbreak wouldn't result in large numbers of cases given the relatively rural and smallish population involved; we aren't yet approaching the 2019 New York outbreak that occurred in a densely populated community.

The Texas authorities' update from Friday tallies 146 cases, and New Mexico shows 9 cases. Five of the NM cases were 18+ years of age and 4 children 5-17 years old. Texas HHS also reports a large exposure area for a measles case in San Antonio and surrounding area. I think it's interesting to look at the sites and consider the immense resources needed to track down and protect exposed people.

WHO Soldiers On

The polio vaccination program in Gaza sounds like it was very successful: 603,000 children under 10 years of age were immunized over a 5-day period, aided by the cease-fire that I hope will continue.

New World Screwworm

Apologies, I think I've mentioned this topic once before but can't find it in a search of my posts. This disease is a form of myiasis, and the recent news is that it's getting closer to the US with new data at the end of last year showing the fly (Cochliomyia hominivorax) appeared in Mexico. The previous "barrier" to creeping closer to the US was the Darrien Pass in Panama, which you may recall from various immigration discussions in the lay press.

Now new efforts are underway to release sterile flies in Mexico, an established method to control the population. The USDA has a helpful document explaining the history. In endemic countries this is mostly a concern for livestock and other animals, but we humans also can be affected; it is very painful, beyond unpleasant, and gross, requiring manual extraction of the fly larvae from soft tissue. Here's the history in the US, at least as of late 2016 following the finding of the flies in Florida, resulting in a sterilized fly release for control.

Avian Flu

A lot of back and forth in the lay press about influenza A H5N1. My take on the bottom line is that there is nothing substantive that is new. I'm still watching closely for more concerning trends including extensive infection in pigs (where conversion to a strain with greater ability to infect humans is more of a risk) and any evidence of human-to-human transmission.

USDA monitoring is ongoing, with of course many infections in wild and domestic birds, cattle, and other mammals including a flurry of domestic cat infections recently. The map below is current as of February 26.

Our new agriculture secretary has released a plan for avian flu control. It is advertised as a means to lower egg prices which is fine, but we won't see any impact on that soon. I'm just glad we're seeing some movement to get a handle on this. The more H5N1 circulates in any animal, the more likely we'll see a new strain with greater potential to sicken humans.

In the meantime, I might try to steal my wife's oatmeal stash a few mornings a week.

Hooray for MMWR!

Not only does this week's edition look like the old days, it even included a sensitive topic for the current political administration: HPV vaccine.

HPV was strikingly effective in lowering the rate of cervical precancers in young women (the solid blue lines below) as well as in women in their late twenties. The fact that the current administration allowed them to publish these results is encouraging; HPV vaccine has been a target as well as a source of income (from lawsuits) for RFK Jr. in the past.

Last year's flu vaccine early estimates of effectiveness looked like a glass-half-empty versus -full in the lay press. The half-empty folks point to somewhat low effectiveness against all infections, but that's not the point. As with other respiratory virus vaccines, the main point of vaccination is preventing healthcare visits and serious outcomes. Here's the bottom line we should pay attention to: "Interim 2024–2025 seasonal influenza VE estimates were derived from four U.S. VE networks. Among children and adolescents, VE was 32%, 59%, and 60% in outpatient settings (three networks) and 63% and 78% against influenza-associated hospitalization (two networks). Among adults, VE was 36% and 54% in outpatient settings (two networks) and 41% and 55% against influenza-associated hospitalization (two networks)."

I'm in the half-full camp.

WRIS

I think we might really be headed down for winter respiratory infection season, largely due to a sustained decrease in influenza with no significant upswings in covid. RSV is almost out the door. Here's the latest from FluView.

That's not to say it's gone, however. We're definitely still in flu season in many areas of the country.

FDA Advisory Committees

I'm perplexed about why the FDA VRBPAC's scheduled meeting was cancelled. Supposedly the selection of next fall's flu vaccine composition will be done internally by the FDA, but one of the key advantages of the VRBPAC meetings was the chance for anyone, including the general public, to view the discussions in real time and get a better understanding of issues and risks/benefits.

I have a bit of personal experience to illuminate this. I've participated as a panel member on several FDA Advisory Committee meetings, though never anything to do with vaccines. Here are some key points that I can relate from first-hand experience.

  • I filled out an incredible number of forms about my potential conflicts of interest for every session. It was the equivalent of a paper strip search.
  • I spent many hours/days reviewing documents with a lot of raw data, both from FDA experts as well as from any pharmaceutical companies and device manufacturers. It was a very granular level of detail.
  • Every session included presentations by mostly lay public individuals given time to speak at the meeting. It was a broad representation: patients and relatives of patients who might benefit (or be harmed) by the product, other industry and association representatives, and yes, some pseudo-science/misinformation folks.
  • The discussion was very helpful; sometimes my mind changed as I learned from others.
  • All committee members explained their votes. The votes were not binding to the FDA, but I can't remember a situation where they didn't follow the vote for any of the committees I served on.
  • My exact recollection has faded, but I think at first I was reimbursed for lunch but later I wasn't. Everyone was reimbursed for travel and lodging when the meetings were held in person in the DC area. Of course, since I'm local that really didn't amount to much even if I submitted my gas mileage! In short, people serve on these committees for civic duty, not for any remuneration.

Now that meetings are virtual, there is not much reason to cancel them. The cost is born by the committee members; FDA and industry participants still need to do the same amount of work. I hope transparency in healthcare administration will return soon.

Paint It Black

This Stones' song came on my Pandora station just as I was wrapping up my first draft of this post. The sun isn't quite "blotted out from the sky" from the FDA VRBPAC and CDC ACIP postponements and cancellations, but it's enough to cast a shadow on my sunny day. Here's to brighter times.

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