Yes, I know summer solstice is the official start of summer on June 20, but my self-centered slant counts the start of summer as when I finally break down and turn on my home air conditioning. That happened a few days ago when temperature hit the upper 80s, accompanied by high humidity.
Thankfully we survived another week with no major outbreaks, but a few things are smoldering.
GAO Report on Pandemic Preparedness
After every outbreak and pandemic, you can count on 2 things: finger-pointing and advice on preparedness to prevent past mistakes. Typically all is forgotten/unimplemented once the brouhaha calms and we all settle into our latest favorite TV shows or podcasts. Thus, we remain poorly prepared for the next challenge.
The Government Accounting Office convened an expert panel over 3 days in January, 2024, to develop recommendations for a coordinated national approach to diagnostic testing for pandemic pathogens. The report finally was released this past week with recommendations for the HHS Secretary.
Their Table 1 documenting 2 recent episodes involving diagnostic testing reminded me of its significant impact on my ability to provide high level service to my patients.
The GAO recommendations are sort of mom and apple pie stuff, very logical and thoughtful. I don't have high hopes it will go anywhere.
MIS-C Neurologic and Psychological Outcomes
A new study documented 2-year neurologic and psychologic outcomes of 95 children 5-20 years of age hospitalized with MIS-C between August 1, 2020, and August 31, 2021, at multiple sites in the US and Canada. A strength of the study was its longitudinal cohort design and use of sibling and community control children when available. The results were encouraging; although MIS-C children had more symptoms initially, by the 2-year follow-up the patients and controls were pretty similar. The article has a ton of data, please go to the source link for more details, but here's a quick snapshot of part of the results (note that higher numbers on the y-axis are worse outcomes for this particular test):
This is a relatively small but careful study that likely is valid for most MIS-C children, though please remember that young infants were not included.
Pertussis in the Americas
Whooping cough is definitely in the news, and on May 31 the Pan American Health Organization published an alert. I missed it that day, otherwise I would have included it last week. It provided numbers to back up what we already know, that pertussis is on the increase across the Americas. What I found most helpful were comparisons to pre-pandemic times because we all know that every infectious disease seems to be increased compared to the pandemic years. The figure below, adapted from WHO data, shows that in 2023 we had returned to pre-pandemic levels globally but did not see much rise in the Americas.
2025 vaccination coverage with 3 doses of DTP in the US isn't as bad as you might expect, though you can see in the footnote we have no data from the most recent 2 years.
In 2024 and 2025 the US is clearly back to pre-pandemic numbers of cases which usually are at least 10,000 annually. Washington, Oregon, and California have the most cases so far this year, and we've had 4 deaths nationally. It seems like 2025 will be more severe year for pertussis.
Clinician Attitudes Towards Earlier HPV Vaccination
You might recall I mentioned in my April 20 post about the ACIP meeting that there was controversy about making a recommendation to promote earlier administration of HPV vaccine at age 9-10 years; this is of course acceptable under current guidelines, but there was some pushback from some ACIP attendees that lumping the 9-10 age group with 11-12-year-old children for HPV vaccine would disrupt the the adolescent primary care visit schedule, plus would be less acceptable to parents.
Now comes a new survey of general pediatric healthcare providers and staff on HPV timing. It included 33 general pediatric practices in California and Colorado and was carried out between November, 2021, and April, 2022. It also included interviews with a subset of clinicians and office staff. A key point is that these practices were part of a study to implement earlier initiation of HPV vaccination; so, these study participants had actually gone through a change in HPV administration in their practices. This fact is helpful to provide real world evidence, but also is a potential source of bias.
It's hard to summarize everything from this report that included narrative statements by the providers and staff, but here's part of the results.
As you can see, the bulk of the respondents did not perceive a change in these parameters after switching to earlier HPV vaccination. I'm hoping this study will be included in any HPV vaccine discussion at ACIP later this month, but clearly this is a narrow sampling that may not apply to other practice settings.
Can't Get Away From Measles
This year's outbreak keeps percolating along without new major hot spots, but a couple of issues merit mention.
First, a brief research letter gives us some information about county-level, rather than state-level, MMR vaccine coverage. The US outbreaks in past years have pretty much been centered around unvaccinated pockets of children, such as a geographically defined religious community in New York City in 2019 and the Texas outbreak this year in another vaccine-averse, relatively isolated religious community. These examples just point out that it's the small pockets of extremely low MMR vaccine coverage that can trigger major outbreaks; knowing the percentage of children who have received 2 doses of MMR vaccine in a state doesn't accurately account for smaller, under-immunized, communities.
The investigators collected county-level data from state health department websites and compared pre- (2017-2018) to post- (2023-2024) pandemic coverage with 2 doses of MMR vaccine. Of course by using state data they encountered different methods for data collection and reporting, so it's a bit of apples and oranges. Furthermore, 13 states aren't included in any of the analyses for a variety of reasons: "Alaska, Arkansas, Delaware, Idaho, Mississippi, Nebraska, New Hampshire, Ohio, and West Virginia are excluded because they do not report county level vaccination data. Georgia, Indiana and Montana are excluded because they only report 1-dose MMR vaccination rates for children aged 19-35 months, which does not align with our focus on 2-dose MMR rates in this analysis. Illinois was excluded because it reports a compliance rate spanning preschool through grade 12, and preschoolers are considered compliant with only 1-dose MMR administered." Here's what's left for the report.
Don't be confused by lighter color shades. The states entirely gray are those with no data; the counties in white are those with the lowest vaccination coverage. I'll be interested to look at this map when our next measles hot spot appears.
The second measles twist concerns congenital measles. Yes, it is possible for a mother with acute measles to pass rubeola virus to the baby prior to delivery. I was reminded about this when I saw a sad statement from the Canadian Chief Medical Officer of Health about the death of a newborn probably due to congenital measles. Remember, Canada is having an even tougher year with measles than we are in the US.
The CMO of Health did not provide much detail about the child, reportedly due to privacy concerns. Congenital rubeola is one of the few measles features I've never seen personally. If you want to learn more, I found an open access case report.
Summer Reading
To put off some chores I need to do, I decided to count up the number of books stacked in my "to be read" pile; I'm up to 52 after a recent buying flurry. I think my stack has ranged from 20 to 80 most of the time. I just finished Philip K. Dick's Martian Time-Slip, a fun book for those who can tolerate his perspectives on life and reality. Psychiatrists in particular would love this one. Now I've started John Banville's The Lock-Up. He's a difficult author for me to read because he writes such beautiful sentences I can't skim over anything for fear of missing out on another perfect rendering of the English language. It's a short book that likely will take me as long to get through as one twice its length.