Sapsicle

Happy 2026 to everyone! Let's hope for better things this year.

Yesterday I was briefly excited to think I had invented a new portmanteau; turns out many people before me had figured this out.

I had hoped to have the "new" website pretty much completed by now but hit a slight glitch for which I am waiting on outside technical help.

Last Week's Tidbits

Welder's Anthrax

I thought by now I had heard of everything in infectious diseases, but not surprisingly I was wrong. Perhaps I could be partially forgiven since it isn't a pediatric infection. Last week's MMWR informed me about a rare setting for anthrax infection - a welding worksite. The site was in Louisiana; 8 previous cases of welder's anthrax have been reported, interestingly all from Louisiana or Texas; 6 were fatal. The current individual survived, probably because he was "lucky" enough to have a positive blood culture for a bacterium in the Bacillus cereus group that produced B. anthracis-associated toxin genes. It sounds like the blood culture positivity was the key clue for his alert physician team to make the diagnosis and to administer the anthrax antitoxin monoclonal antibody obiltoxamab. The bacterial isolate was identified as B. tropicus by genetic methodology. I mention all this detail only to underline how complex the microbiology of Bacillus species is.

Welder's anthrax is a form of inhalational anthrax. The main reason I'm dinging myself for not knowing about the connection with welders is that I very heavily researched inhalational anthrax in 2001 when the postal letter anthrax cases appeared around the country, including in Washington, DC, where I was practicing. The earliest report of welder's anthrax, though not labelled as such, probably was in 1997.

Another Blow to Vaccination Policy

I don't recall seeing anything about this in the lay press, but the federal government is moving to limit data gathering that helps us track and control vaccine-preventable diseases in the US. Soon, states will no longer be required to report to CMS the numbers of children and pregnant people vaccinated; state officials can still do this, but it will be on a voluntary basis. Once data collection and reporting becomes voluntary, you can bet the data will dry up. A letter from CMS to state health officials spells everything out and appears to take effect for 2027 reporting.

"CMS is removing the following four measures related to pediatric and prenatal immunization status from the 2026 Child and Adult Core Sets.

• Prenatal Immunization Status: Age 21 and Older (PRS-AD)
• Childhood Immunization Status (CIS-CH)
• Immunizations for Adolescents (IMA-CH)
• Prenatal Immunization Status: Under Age 21 (PRS-CH)"

And that's not all. It appears that CMS will try to incentivize healthcare providers to discuss topics that serve to deter families from timely immunizations and to move away from using vaccination rates as a practice quality measure.

"In 2026 and beyond, CMS will explore options to facilitate the development of new vaccine measures that capture information about whether parents and families were informed about vaccine choices, vaccine safety and side effects, and alternative vaccine schedules. CMS plans to engage with stakeholders, including states, quality measure stewards, immunization registry managers, providers, and electronic health record vendors to learn how new measures could capture person and family preferences related to vaccines. CMS will also explore how religious exemptions for vaccinations can be accounted for in the data and the subsequent measures. CMS does not tie payment to performance on immunization quality measures in Medicaid and CHIP at the federal level. While states have flexibility and discretion to use quality measures in state developed value-based purchasing and payment incentive fee for service or managed care programs, CMS strongly discourages states from using immunization measures in payment arrangements."

Providers in states with governments that promote vaccine hesitancy and anti-vaccination views likely will be most affected by this new rule. I'd be surprised if any private insurance companies adopt this change in incentives.

For now, at least for influenza vaccination, we still have CDC's FluVaxView to consult. As an example, below is a comparison of vaccination rates among children in the higher risk age group of 6 months to <5 years.

The colors are a little hard to see, but note that rates have been dropping since the 2019-2020 flu season. The current 2025-2026 season is the incomplete light blue line near the bottom that appears to be trending similarly to recent years so far.

In spite of the great challenges of the covid pandemic, I became a little spoiled during that time. I relied on very robust disease monitoring systems that gave us access to detailed epidemiologic happenings very rapidly. That type of monitoring is extremely expensive and was unsustainable. As the pandemic settled into an endemic pattern, data became less reliable on 2 fronts: first, an exhausted and, in some cases angry, public withdrew from testing and healthcare seeking measures; second, public health funding was cut. Now we appear to be going beyond the logical extension of this trend by making it harder to collect even the bare minimum of reliable data for judging the effectiveness of vaccines.

WRIS and Measles

Speaking of flu season, we are definitely in it.

It's hard to know, but some of the patchiness may be due to poor reporting practices coupled with the usual holiday slowing of information. Laboratory confirmed influenza hospitalizations below may be a more reliable comparator among flu seasons. I'll be watching this year's red line to see if we exceed the recent high mark of last season's blue line.

RSV hospitalizations are below last year's numbers so far. Here's what it looks like for children 0-4 years of age.

Covid is increasing slightly but still at low levels.

Although not specifically a winter respiratory pathogen, pertussis has been in the news lately. However, numbers are below last year's. So far CDC has tallied 28,152 cases compared to a little over 43,000 last year. Pertussis tracking is affected by a number of factors not seen with other respiratory pathogens: 1) diagnosis is difficult especially in adults who mostly do not display typical whooping cough; 2) testing methodology is difficult - a jump in case numbers started in the 1990s when PCR testing became more widely available; 3) the switch from the whole cell vaccine to the less reactogenic acellular vaccine in the late 1990s resulted in earlier waning of immunity with an increase of pertussis cases in immunized school-aged children (though it was now available to adults who had not been recommended to receive the whole cell product); and 4) changes in case definitions.

We also expect a bit of sawtoothed spikes - when we have a heavier pertussis year, infants (the population most likely to be accurately diagnosed) have immunity from disease, so there's a dip in numbers while waiting for a new population of unexposed infants who get sick when their maternal vaccination antibody wanes.

We expected a bump in cases after the pandemic era and perhaps that is now in a plateau. However, it's still a bad number and will only worsen as vaccination rates of both mothers and infants fall.

Last but not least, measles soldiers on at a rate of about 50 new cases per week in the US. In a few weeks we will officially qualify as having lost our elimination status.

Icicles (not)

This week I was daydreaming, staring outside, when I saw a strange site. I quickly ran to the LSW* to tell her I saw icicles hanging from our large tree in the front yard. She cooly reminded me that the tree, a red maple (Acer rubrum) had been pruned recently, and the "icicles" were just frozen sap at the cut ends of the limbs. I should have figured that out, but then I was happy to invent a new name for this: sapcicle. Turns out this term is all over the web, I won't be able to patent it. One of the several sapsicles is indicated by the red arrow.

*For those new to this blog, this abbreviation refers to my long suffering wife.