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Published on Leave a comment on All Politics is Local

U.S. Representative Tip O'Neill popularized this phrase in the early 1980s, but perhaps it lost its meaning in later years. Has that changed? Infectious diseases, on the other hand, are most certainly not local.

Infectious Diseases Abroad

Any ripple in communicable infectious diseases in one locale inevitably affects others in far-away locations. Last week saw a number of ripples.

(Not) Measles in American Samoa

Yes, I'm aware that American is a US territory, but it certainly qualifies as far-away.

In 2023, health authorities in American Samoa went on a wild goose chase based on non-recommended testing practices of a suspected case, resulting in a large expenditure of time and money with no benefit. I'm not faulting Samoan practitioners, they had to deal with a lack of available testing resources in the setting of an island rocked by a deadly measles outbreak a few years ago; that outbreak had been fueled in part by prominent anti-vaccination proponents. This recent episode should serve to remind us of proper use of measles diagnostic testing which relies most prominently on use only for individuals who fulfill proper case definitions.

The above report was in last week's MMWR which also contained a WHO measles update. Here's a comparison of 2000 and 2023 measles cases and deaths (note North America is not included in these numbers.)

Severe Avian Influenza in Canada?

Last week Canadian officials confirmed that a critically ill teenager is infected with influenza A H5N1. The source is still unknown, and no close contacts are known to be infected. It's been very tough to get details about the patient's illness, but after going through a transcript of a British Columbia health official's briefing on November 12, it seems that the previously healthy child presented with typical H5N1 symptoms of conjunctivitis, cough, and fever, but then several days later had deterioration. That sequence of events, a sort of biphasic illness, is classic for secondary bacterial complications of influenza. Influenza virus infection of any type can be complicated by secondary bacterial processes, including sepsis and toxic shock syndrome, usually several days after initial flu symptoms begin. Canadian authorities haven't provided any more details, but I wouldn't be surprised if this is what's going on. I'm hoping it was recognized quickly and his healthcare team can return this person to normal health.

Along these lines, NASEM just issued a new publication detailing research priorities for avian influenza A H5N1 readiness. Some of this is already happening, and I hope funding priorities will continue to support planning.

Mpox Update

Last week WHO updated the status of the mpox outbreaks across Africa, a mixture of good news and bad news. Priorities are delivering vaccine to those at risk and implementing newer PCR testing for mpox just approved by the AfricaCDC. Also this past week we learned of the first mpox clade 1 case in the US, occurring in a traveler returning from Africa.

Number Needed to Vaccinate for Covid in the UK

I've mentioned in previous posts that the UK recommends many fewer groups for covid vaccination than we do in the US, primarily because of cost considerations. Last week the UK's Joint Commission on Vaccination and Immunization gave us a bit of a closer look at how those decisions are made with some NNV calculations. NNV (along with its cousin Number Needed to Treat for medication) are a good way to explain "bang for the buck." NNV simply refers to the number of individuals needed to vaccinate to prevent one additional case of the infection, compared to no vaccination. It depends on many variables including the rate of the disease and the number of susceptible individuals in the community and the vaccine effectiveness. Also, NNVs vary with the outcome of interest, such as infection versus hospitalization versus death. It's increasingly harder to calculate NNVs for covid vaccine because of asymptomatic infections and less widespread testing being performed.

The JCVI didn't give us NNVs for all age groups, but they did provide a close look at pregnant people and infants under 3 months of age, the latter group of course not eligible for vaccination and dependent on maternal immunity passed to them transplacentally. I had to dig into attachments to the reports, but here's the bottom line: NNV to prevent hospitalization of a pregnant person is "just under 2000" and "around 300,000" to prevent severe hospitalization. I couldn't find a definition of severe hospitalization but from the context it appears to be something more than overnight observation but less than ICU admission.

For infants < 3 months of age, NNVs (for maternal vaccination) were "under 500" for any hospitalization, "just over 13,000" for severe hospitalization, "almost 190,000" for ICU admission, and ranged from 380,000 to 1.5 million for mortality, the latter extremely hard to calculate due to rarity of the outcome. (But we're all thankful that it is rare.)

Just for comparison, NNV for flu vaccine to prevent 1 additional outpatient visit or 1additional hospitalization in children 6 - 59 months of age ranged from 12 - 42 and about 1000 - 7000, respectively, in one study.

Novavax Combination Covid-Flu Vaccine Study Allowed to Resume

I mention this item mostly to show how well our vaccine safety oversight is working. This study was paused when 1 phase 2 study participant developed what was initially diagnosed as motor neuropathy (with concern for Guillain-Barre syndrome) but then turned out to be amyotrophic lateral sclerosis, not an inflammatory disorder plausibly related to vaccination. This is one of many mechanisms for detecting evaluating rare events after vaccination. Novavax now can proceed with phase 3 studies.

E. coli O157:H7 Outbreak Numbers Grow ...

... but not related to ongoing infection, simply reflecting a delay in case reporting/verification. CDC and FDA report we are now up to 104 cases spread over 14 states. Of the 98 persons with more detailed information available, 34 were hospitalized and 4 developed hemolytic-uremic syndrome. "Of the 81 people interviewed, 80 (99%) report eating at McDonald's. Seventy-five people were able to remember specific menu items they ate at McDonald's. 63 of 75 people (84%) reported a menu item containing fresh slivered onions."

The case map strongly resembles the distribution map for the suspected onions which are now out of the food chain.

In the meantime, we have another E. coli O157:H7 outbreak, this time associated with carrots. [Correction added 11/18/24: this outbreak is due to E. coli O121, not O157:H7 as originally stated.]

I have a feeling I'm going to be washing my salad items more carefully for a while!

WRIS

The winter season still hasn't started, so I'm reduced to browsing the wastewater maps, all updated through November 14 and current through November 9. Here is maybe a look at things to come. First, here's covid:

Now flu (wastewater only tracks influenza A):

Last but not least, RSV:

I'm a Throwback

When I started practicing medicine, implicit in my professional obligations was the duty to do my best to treat anyone who presented to me, without regard to their backgrounds including race, gender, sex, legal status, and, I guess must be said in today's world, political affiliation. Having practiced in Washington, DC for over 40 years, that last category came up frequently as I encountered parents who were elected officials and/or involved in jobs in the political realm. In keeping with that sentiment, I'll still be keeping politics out of this blog and restrict my pontification to infectious diseases. I'll also avoid commenting on various conspiracy theories and other wild ideas emanating from individuals with no scientific basis for their claims. I will, however, comment on any proposed policies related to pediatric infectious diseases where scientific analysis can enlighten the discussion. Nuff said for now.

Published on Leave a comment on A Modest Proposal

Quite an eventful week! In general, I try to keep politics out of my commentary, though I fell short of this goal in my February 25, 2024, post where I blasted the Surgeon General of Florida; that may be the only time I've singled out an individual in a negative manner in this blog. Now, I find that his name is being mentioned as the next Secretary of Health and Human Services. All of this reminded me of an almost 300-year-old pamphlet.

But first a bit of the other health news from last week.

Mayaro Virus

In spite of my voracious appetite for medical knowledge, the list of viruses I've never heard of is lengthy. Now my list is one item shorter due to a new report. Mayaro virus is another of the arthropod-transmitted alphaviruses prevalent in parts of South America, causing a febrile illness with severe arthralgias very similar to its cousin Chikungunya virus. Primates serve as a reservoir with the primary vector the mosquito Haemagogus janthinomys. If like me you are a bit shaky on some elements of South American geography and history, Suriname is a former Dutch colony located just north of Brazil and has territorial disputes (in light green) with neighboring countries.

Measles in Vietnam

Vietnam is introducing earlier measles vaccines to try to stem an epidemic. In this WHO Western Pacific region report, you can see Vietnam is going the wrong way in measles incidence. Like the rest of the world, we all "enjoyed" a pandemic period where many traditional infectious diseases transmitted by respiratory routes showed significant declines due to non-pharmaceutical interventions, only to now reappear in greater numbers. For measles, Vietnam showed an incidence of 7.4/million population in 2020, dropping to 0.3 in 2022 but now back up to 7.1/million in 2024.

Normally Vietnam recommends measles immunization at 9 months of age, but now this is being dropped to 6 months due to an increase in cases in younger age groups. (You'll need Google translate for this link.)

Computerized Radiograph Interpretation for TB?

Although this study was performed only in adults, I thought it was worth mentioning as a possible glimpse of the future. Investigators in Africa and southeast Asia looked at the performance of a computer program to interpret chest radiographs in about 1400 adults with cough > 2 weeks in duration and found the program to have significantly higher sensitivity than a relatively new blood test for host response gene activation in TB as well as superior to CRP. When trying to diagnose TB in resource-poor settings that may not have access to good molecular and other microbiologic methods for TB diagnosis, we need every tool available. I'll be interested to see how newer methods for TB diagnosis evolve.

More on Bird Flu

CDC reported that 7% of 115 dairy workers at farms known to have infected cows showed serologic evidence of influenza A H5N1 infection. Four of the 8 seropositive workers did not recall having any respiratory signs or symptoms since the cows were first noted to be sick. This rate wasn't terribly different from the 60% of those with no illness history in the seronegative group. Given that H5N1 so far seems to be a mild illness in humans, the finding of asymptomatic infection isn't surprising. Clearly we need a lot more data on human illness in these and other settings.

Benefits of Quadrivalent Meningococcal Vaccine

Of our recommended vaccines, meningococcal vaccine probably has the lowest "return on investment." Meningococcal disease is relatively rare but comes with very high morbidity and mortality when it does occur. This modeling study estimated the number of cases of invasive meningococcal disease in 11-23 year-olds prevented by vaccination during the period 2005-2021. One always needs to take modeling studies with a grain of salt because they by necessity make a lot of assumptions. The authors did a good job of trying to look at all possibilities. They concluded that "vaccination averted an estimated 16 (95% CrI, 8-31) deaths among adolescents aged 11 to 15 years and 38 (95% CrI, 19-75) deaths among those aged 16 to 23 years." I guess those are small numbers when compared to the entire US population, but this is still a meaningful benefit.

WRIS

Things are still relatively quiet, though with regional variations.

I did happen to note that wastewater levels of RSV are very high in Maryland, so maybe that will be the first pathogen to increase in my region.

Make America Healthy Again

I feel like the MAHA acronym was one of the nicer-sounding political slogans to appear recently. However, the fact that it was popularized by a notorious pseudo-science fringer concerns me for what might lie behind MAHA. That made me recall a short treatise by Jonathan Swift (of Gulliver's Travels fame) that I came across a long time ago. I read it again a few times this week, and this highly satirical essay entitled "A Modest Proposal" is worth 10 or 15 minutes of your time. I think it is best read without knowing where the narrator is going, so I'll give you a SPOILER ALERT. You can read the original document in the link now, before reading what I write below, or you can just forego the surprise and keep on with my take below.

The narrator beings with an "objective" view of the problem, in 18th century Ireland, of the economic woes of a large section of the populace. He particularly hones in on the difficulties that parents in lower economic strata have in providing for their children. After going through some numbers assumptions that we can only guess at the accuracy, he decides that Ireland has about 120,000 children born to impoverished parents annually. How can the country solve this problem? He offers his modest proposal, or "humble solution:" It's a sudden turn in tone, to say the least.

"I have been assured by a very knowing American of my acquaintance in London, that a young healthy child well nursed, is, at a year old, a most delicious nourishing and wholesome food, whether stewed, roasted, baked, or boiled; and I make no doubt that it will equally serve in a fricasee, or a ragoust."

Yes, Mr. Swift in his satirical essay is proposing cannibalism as a solution to poor families trying to raise their children. He goes on to describe various details of preparation and serving.

MAHA sounds OK now, but I fear of this becoming another modest proposal. I'll withhold my judgment until we see more details of the plan.

Published on Leave a comment on Fall Back

Once again I find myself, an ostensibly tech-savvy individual,* faced with manually resetting the time on 11 clocks and appliances in my house. Only my phone, laptops, and tablet appear to have joined the 21st century by self-correcting to eastern standard time. Of course, if our country had truly joined the 21st century, we wouldn't be making this twice yearly switch in the first place.

My election anxiety is somewhat mollified by focusing on infectious diseases, so you can categorize the following as therapeutic in nature.

WRIS

Still not much going on, though I was intrigued that my state of residence is 1 of only 2 to show up with moderate respiratory illness activity last week.

I'm pretty impressed by how quiet the SARS-CoV-2 front is. However, it's still around, and we can expect to see a resurgence sometime.

The fact that influenza has not yet appeared might indicate we are returning to a more "normal" flu season. The graph below shows how different the prior 3 flu seasons were from pre-pandemic experiences, where last year had a very early peak and 2020-21 and 2021-22 had very low and atypical peaks. (Apologies for CDC's labelling here, but if you stare at it long enough you can pick out which line goes with which year.)

New Development in Bird Flu

The so-called highly pathogenic avian flu H5N1 cropping up in dairy and poultry farms and in wild bird populations has been in the news for many months now. It still seems to be a mild illness in humans, most of whom have direct exposure to these farms. Only 41 humans have confirmed infections in 2024 so far. What's a bit noteworthy this week is that the virus may now have shown up in pigs. USDA officials reported probable swine cases at a backyard farm in Oregon where poultry, cows, and pigs all mingle. The farm itself has no role in commercial production of any foods, so it isn't a risk to others. What is of slight concern is the fact that pigs are involved. Pigs have a special place in influenza science because they have both human and avian flu receptors in their respiratory tracts, making the chance for a recombination event to occur if they happen to be infected with human and avian viruses at the same time. Most of the time this doesn't cause creation of a new pandemic strain, and I wouldn't hit the panic button at all now. Actually I'm surprised it took this long for swine infection to be found. The affected animals were all euthanized and multiple studies are ongoing, so I'm sure we'll hear more about this.

Polio

The news isn't great as both wild and vaccine-variant polio cases continue to be reported. This Global Polio Eradication Initiative map is a good summary.

No new cases have been reported in Gaza, with just the 1 case confirmed so far. The interrupted vaccination campaign in northern Gaza restarted this week.

Dengue Still Going Strong

I was browsing the CDC dengue page this week; infections are still plentiful.

Puerto Rico has the greatest number by far, but note that we have had autochthonous (locally acquired without travel to endemic areas) dengue in the mainland US (California with 11 cases, Florida with 49).

*

Can I really claim to be tech-savvy? I think so. I have an advanced degree in educational technology with classes that included instruction in networks and the various hardware involved; the fact that my schooling ended in 2008 shouldn't disqualify me. Also, this past week I restored to full health our K-cup brewing machine that became confused and wouldn't deliver the appropriate coffee volumes or allow the correct menu choices in its buttons. I guess in the interest of full disclosure, when I couldn't find a satisfactory replacement brewer online, my astute intervention was reading the instruction manual, realizing that I hadn't ever de-scaled the device in the approximately 90 years I've owned it, and made it new again using only a low-tech tool (vinegar).

In spite of my skills with technology and vinegar, I'll be performing my semiannual time resets for the foreseeable future; I could never part with my grandfather's clock.

Published on Leave a comment on Autumn Has Broken ….

Leaves are everywhere, including still attached to trees and waiting to further increase my workload. I'm starting to plan my leaf management strategy; when to clear the gutters, waiting for the county to post its leaf collection dates, reflecting on my love/hate relationship with my garden rakes.

... But Still Waiting on WRIS

Covid is as quiescent as it ever gets, flu and RSV still low but hints of increase. I'll enjoy it while I can. As always, CDC has resources to look specifically at activity in your region.

Potpourri

In spite of the relative calm in infectious diseases, I found plenty of tidbits last week. I'll start with some good news.

WHO Declares Egypt Malaria-Free

The news release commented that this is the culmination of 100 years worth of effort. Forty-four countries and one territory have achieved this certification worldwide, which requires demonstration that malaria transmission from local Anopheles mosquitoes has been stopped for 3 consecutive years. In the WHO Eastern Mediterranean region, only 2 other countries, UAE and Morocco, have achieved this landmark. Given that some of our earliest evidence of malaria in humans comes from studies of ancient Egyptian mummies, it's pretty amazing to see a 6-thousand-plus year trend ended.

Mpox Age Distribution

A recent study from Burundi highlights a trend in recent mpox cases in the region, now seeming to cluster in children disproportionately. Here's the breakdown:

The authors state they could not identify reasons for this unusual age distribution, and I expect we'll hear more about that. They also noted that cases were more severe in individuals 15 years of age and older.

Community Acquired Pneumonia Due to Avian Chlamydia abortus in the Netherlands

One more cause of zoonotic pneumonia to add to our lists, based on this new report. Dutch investigators provide a convincing story for an infection cluster in 1 family, including 1 person with severe pneumonia, occurring in late 2022. This novel avian strain was first reported in 2021, and I suspect we'll be seeing more reports of this organism now with perhaps evidence that human infections have been occurring for some time. I'm especially anxious to hear more about the spectrum of clinical disease, hoping that this is mostly a mild pneumonia.

Iquitos Virus

Just as I was starting to get a feel for Oropouche virus (OROV) disease, now I need to learn about a close cousin (IQTV) that was found to cause infection in a traveler returning from Ecuador. Under the category of more than I needed to know, these viruses are part of the Simbu group of about 20 bunyaviruses including the amazingly named Madre de Dios virus. The traveler in the case report returned after a 10-day trip to Ecuador where he experienced many insect bites and presented with fever, chills, sweats, headache, pain with eye movement, and rash. He was thought to have OROV infection, but he fortuitously presented for care in Atlanta where his samples landed at the CDC and further testing revealed the true culprit to be IQTV. The traveler did not require hospitalization and recovered uneventfully.

Hold the Onions

The only way to have avoided hearing about this month's E. coli O157:H7 outbreak linked to Big Macs is to be completely cut off from all news and social media sources. It is centered in Colorado but also present in several neighboring and nearby states. As of the latest update on October 25, the case total is 75 with 22 hospitalizations and 1 death spread over 13 states.

CDC hasn't yet provided any detail about range of symptoms in this outbreak, but presumably the more severe cases represent instances of hemolytic-uremic syndrome. Although O157:H7 and HUS is classically associated with contaminated ground meat, that source didn't seem to make sense in this outbreak. All of these fast food chains have automated cooking methods that would reliably kill bacterial pathogens; it is conceivable the equipment could break down in one restaurant, but not particularly plausible for so many sites occurring at once. The hunt changed to uncooked foods with raw onions now the presumptive culprit.

These circumstances reminded me of a child with no travel history that I diagnosed with typhoid fever decades ago. It was eventually traced to the shrimp salad at a local McDonald's restaurant, prepared by a modern-day Typhoid Mary.

ACIP Meeting

I'd be totally remiss if I didn't mention the regular meeting of CDC's Advisory Council on Immunization Practices last week. However, most of the newsworthy items concerned adult vaccinations (e.g. lowering the recommended age for pneumococcal vaccines). They did approve the 2025 child and adult immunization schedules The final version is not yet available, but you can look at the drafts. Note that a second dose of covid vaccine will be recommended for immunocompromised and high risk children adults 6 months after the fall vaccination. Also see ongoing tweaks to the meningococcal vaccine recommendations appearing on slide 27.

While we wait for official pronouncements, you can find a summary of all the meeting recommendations here.

Published on Leave a comment on Information, Knowledge, and Wisdom

I regularly read Ron Charles's Washington Post Friday Book Club newsletter, always chock full of interesting topics and writers I haven't yet explored. This Friday he included a quote from controversial (accused of plagiarism) Turkish author and activist Elif Shafak

“... we are living in a world in which there is way too much information, but little knowledge and even less wisdom.… As we scroll up and down, more out of habit than out of anything else, we have no time to process what we see. No time to absorb or reflect or feel. Hyper-information gives us the illusion of knowledge. For true knowledge to be attained we need to slow down. We need cultural spaces, literary festivals, an open and honest intellectual exchange.”

This blog is my attempt to machete a trail through all the various forms of information and provide some bridge to knowledge and wisdom by providing links to reliable original sources. Speaking of which, we are now in the midst of ID Week, probably the most prestigious annual infectious diseases research conference, and many of my regular ID feeds are filled with reports of presentations. However, I virtually never include these reports in this blog, because there is no way via these abstracts to look for potential flaws or limitations in the research, and it is well known that research meeting presentation findings often change dramatically by the time they are published in a peer-reviewed journal, if they are ever published at all.

WRIS

Still pretty quiet on the Winter Respiratory Infection Season, with some hints of beginnings of influenza and RSV increasing. Perhaps the only item of interest is an increase in Mycoplasma pneumoniae activity, probably just a regular wave that tends to happen with this pathogen, though delayed somewhat due to pandemic mitigation strategies. It's not a reportable disease, so it's hard to find good data on incidence over time. As most providers know, this is a self-limited illness that produces generally mild illness (so-called walking pneumonia) and usually not worth diagnosing or treating. Because of its self-limited nature, it's been difficult to demonstrate any benefit of antibiotic treatment compared to placebo, and I doubt we'll see any placebo-controlled randomized trials in the near future.

Compared to last winter, CDC is predicting a 54% chance of a similar combined peak of respiratory illnesses, with a 28% chance of a lower peak and 18% chance of a higher peak.

Infectious Complications of Hurricanes

These tend to get less coverage than do the more obvious loss of life and property destruction occurring immediately during a natural disaster, but the Florida Department of Health is now reporting on a surge in cases of necrotizing fasciitis due to Vibrio vulnificus, a known salt and brackish water pathogen. Here are the numbers:

As a reminder, individuals with immunodeficiencies, but also particularly including chronic liver or renal disease, are at high risk for V. vulnificus complications. CDC has a good summary.

Conjunctivitis

Researchers in Colorado looked at about 200 children with acute conjunctivitis compared to a similar number of children who were either healthy or had URI without conjunctival involvement. Long story short, they found no benefit of ophthalmic ointment treatment, but did see a 20% incidence of antibiotic side effects. The study itself didn't replicate real-world situations for providers; for example, they employed broad spectrum PCR testing looking for a large number of bacteria and viruses. The study doesn't give us much direction for practical approaches to this problem but does serve as a reminder to limit topical and other antibiotic use in acute conjunctivitis in children,

Outpatient Infant Botulism?

I would never have thought of this, I've only been called for hospitalized children with infant botulism. It turns out, though, that there are rare instances of milder disease managed as outpatients. A team reviewing the California Department of Public Health data from 1976 - 2021 found 17 of 4372 cases (0.4%) were outpatients. (Note that California cases account for about 1/3 of all US infant botulism cases.) Here's the breakdown of clinical findings.

The median age at onset of symptoms was 20 weeks, with a range of 6 - 55 weeks. Only 1 child had been exposed to honey.

Polio Updates

The second round of novel oral polio type 2 vaccinations have begun in Gaza, though I haven't heard much about ceasefires to help facilitate this critical second round. Meanwhile, this week the Global Polio Elimination Initiative had to bow to reality and revise plans and timeline for polio elimination worldwide. Now, the end of 2027 is the target for elimination of wild poliovirus infections, with end of 2029 for elimination of type 2 vaccine-derived polio. This will take significantly more funding, and the greater the risk of prolonged or new wars the less likely these targets will be achieved.

The DIKW Pyramid

I'm accustomed to using the evidence-based medicine pyramid for hierarchies of study design in medicine, but in researching Dr. Shafak's quote about wisdom I happened onto the Data, Information, Knowledge, and Wisdom pyramid. It doesn't appear to incorporate anything about the role of false or misleading data, so I'm not sure if it is a helpful model in our era. As artificial intelligence becomes more entrenched (it's impossible to remove that view from Google Chrome!), we need to be even more vigilant about our data sources.

HAL 9000 looks a lot like my doorbell. Yikes!

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