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Published on Leave a comment on My Hebdomadal Habit

One of the many reasons I love to read is to discover new words to add to my vocabulary. Reading Colin Dexter reminds me of the need to keep a dictionary close by.

WRIS

The US Winter Respiratory Infection Season hasn't started yet; activity is low to minimal everywhere.

Note that the map above is a new twist from CDC: rather than "Influenza-Like Illness" activity, this reflects all acute respiratory illness by not requiring fever in the definition. So, it probably picks up more of all those other respiratory viruses out there. For the 2 graphs below, just use the same link above and scroll down.

Percentage of ED visits due to the "big 3" viruses is minimal, with covid dropping dramatically.

Since I'm trying to figure out the best timing for my own flu shot, I looked at influenza A wastewater tracking:

Only Rhode Island makes it to moderate activity, all the others with data are minimal or low. Probably the key part of the map above is the number of hatched/limited coverage states. For example, New York flu A wastewater activity only includes Albany and Rochester, not much help to the New York City folks.

Given the WRIS lull, clinicians might be interested in a recent CDC overview of covid and flu management. I couldn't log on to the live presentation but reviewed the slides and took the test for (free) CME credit. The presentation was well done, I recommend it as a good review.

Forbear the Bear (Meat)

Not that long ago (5/24/24 post) I relayed a CDC report about a 2022 trichinellosis outbreak linked to frozen Canadian bear meat. Less than 5 months later, CDC is telling us about another one, this time from 2023 at a single "feast" in North Carolina. It doesn't have as much detail as the earlier report, we don't know much about the food preparation methods and none of the ill persons returned for confirmatory lab testing. It certainly sounds like trichinellosis, however; in addition to a nonspecific febrile illness, 9 of the 10 probable cases reported facial swelling which for me is a T. spiralis infection clue.

I visited a number of wild game/hunting sites to see what advice consumers of bear meat might see. Most sites correctly cautioned hunters to cook bear meat to at least 165 F internal temperature, but a few did not. Also, many mentioned other wild game meats that taste better than bear meat. I won't be ordering bear meat anytime soon, but if you are drawn to the experience check out the CDC web site or this advice from Massachusetts that also includes recipes!

Travel to Rwanda?

Last week I mentioned the Marburg virus outbreak in Rwanda, and this past week CDC upgraded a travel alert for the area which has caused quite a kerfuffle. Rwanda now has a CDC level 3 travel alert status, meaning that nonessential travel to the area should be reconsidered. Three days after the CDC advisory, WHO pushed back. WHO believes that travel restrictions will be ineffective in controlling the outbreak plus may prove harmful to local economies and serve as a disincentive for sharing of public health data from those countries, harming control efforts. These are valid concerns; choosing the proper course of action probably requires something approaching the wisdom of Solomon.

Also, an experimental Marburg vaccine has made its way to Rwanda, now primarily being used and studied in health care providers who form the bulk of new cases, plus other high risk individuals. This study is of extreme importance, and I'm hopeful that we'll see good data eventually.

OED

For a brief moment in my past, I longed to have a complete print version of the Oxford English Dictionary at my elbow. It was short-lived: the standard version comes in 20 volumes and now lists for $1000+. A bargain is the "compact" version at about half that price; it is a "photo reduction" of the original, with 9 pages of the original on each single page. It comes with its own magnifying glass.

It's a lot easier to just look at the online OED to find out that hebdomadal means "weekly." I also learned that it's not commonly used, fewer than 0.01 occurrences per million words in modern written English. Maybe I've now bumped that up to 0.02.

Dexter's Inspector Morse character, in his second installment entitled Last Seen Wearing, mentions his "regular hebdomadal debate" when faced with his weekly dilemma of whether to purchase the more cultured Sunday Times versus the coarse News of the World at the newsstand. I can see parallels to my own cultural preferences in literature, music, and art. However, the hebdomadal part of my habits clearly is this blog. Any further resemblance to Inspector Morse ends here though; he is a true, albeit fictional, polymath who happens to be a detective. I am a real-life physician who happens to have diverse interests, like most of us.

Published on Leave a comment on Winding Down (Again)

After one failed retirement attempt, I'm trying again. I just entered a new phase to decrease my coverage of inpatient telemedicine services at regional hospitals and, if demand isn't increasing terribly, I'll phase out completely. In the meantime, I'm revving up for watching the Winter Respiratory Infection Season (WRIS).

WRIS

Nothing strikingly new or concerning on the covid, influenza, and RSV fronts, according to CDC. Respiratory illnesses, wastewater levels, and ED visits are pretty flat or decreasing most places. Florida is starting to show an increase in RSV; typically that region starts sooner than the rest of the country. Of course all viral activity varies geographically, and you can look at your own region with CDC's interactive program at that link.

I admit to having some personal interest in following this closely now. I'm trying to figure out timing of my flu vaccine; as a septuagenerian I may have more rapid waning of immunity after vaccination than do younger generations, plus preliminary data from the Southern Hemisphere suggests a slightly lower flu vaccine effectiveness this year. The key term here is preliminary. These estimates are based on very low sample sizes, and estimates always change once the full season can be evaluated.

Speaking of vaccines, the UK provided a more straightforward guidance for covid vaccination this year. The eligibility groups are pretty limited:

During the 2024 autumn campaign the following groups should be offered a COVID-19 vaccine:

  • all adults aged 65 years and over including individuals aged 64 who will have their 65th birthday before the campaign ends (31st March 2025)
  • residents in a care home for older adults
  • individuals aged 6 months and over who are in a clinical risk group, as defined in tables 3 and 4 of the Green Book chapter 14a

As I've mentioned before, the UK with its National Health Service relies heavily on cost effectiveness analyses, leading to a more restricted target population than in the US.

Two Viruses on the International Scene ...

Marburg Virus in Rwanda

Marburg activity in Rwanda is increasing, and the CDC sent out an advisory last week. Marburg virus is another of the hemorrhagic fever flaviviruses, like Ebola; it has a high fatality rate. As in other hemorrhagic fever virus outbreaks, healthcare workers are at high risk if they are not careful with exposure to blood and body fluids. Most of us remember the spread of Ebola to the US, and already there's been a scare in Hamburg, Germany, but the ill traveler returning from Rwanda tested negative. The name comes from the German city of Marburg which was one of the sites (the others were Frankfurt, Germany, and Belgrade in what is now Serbia) of laboratory outbreaks of the illness in 1967, linked to African green monkeys imported from Uganda. Let's hope efforts to contain the infection are successful, but it's a tough task in low-resource regions.

Perinatal Chikungunya

A new study from Brazil suggests a relatively high rate of transmission of this virus from pregnant people to their newborn infants. The study period covered the years 2016 - 2020. Here's the summary numbers:

Symptoms in infected infants included, in addition to rash and fever, some more severe conditions like DIC, vesiculobullous eruption, seizure and encephalitis, and respiratory failure. It was both a retrospective and prospective case series, and I learned a new term: ambispective!

... But Also Some International Success

The WHO recently declared Brazil has successfully eliminated lymphatic filariasis as a public health problem, a major milestone. The only countries successful previously with filariasis were Malawi and Togo in the WHO African region; Egypt and Yemen in the Eastern Mediterranean region; Bangladesh, Maldives, Sri Lanka, and Thailand in the South-East Asian region; and Cambodia, Cook Islands, Kiribati, Lao People's Democratic Republic, Marshall Islands, Niue, Pilau, Tonga, Vanuatu, Viet Nam, and Wallis and Futuna in the Western Pacific region. Time to dig out that world map!

Filariasis is one of 20 Neglected Tropical Diseases targeted by WHO for improved control by 2030.

Lower Vaccination Rates in US Kindergartners

CDC updated vaccine coverage rates for the 2023-2024 year and, no surprise, it's dropping. The decrease may be driven at least in part by an increase in non-medical exemptions. This news doesn't bode well for future outbreaks of vaccine-preventable diseases, but the clinical impact is largely determined by geographic distributions at the community level. The site has a lot of data, worth some browsing, but here's a quick look at MMR coverage by state for 2023-2024:

Any state that isn't the darkest blue has high risk for outbreaks. Even within the dark blue states any pockets of poor vaccine coverage, such as communities or schools that have high rates of vaccine-averse parents, could see outbreaks.

How's Your Outpatient Antibiotic Prescribing Score?

A cross-sectional database study of about half a million antibiotic subscriptions in 2022 from Tennessee showed some interesting results. The investigators looked at both appropriateness of antibiotic choice and duration of treatment; only 31% of prescriptions were appropriate for both. Here's the quick look at optimal antibiotic choice by disease:

Here's what it looked like for duration of therapy. Standard durations reflect current guidelines, whereas contemporary durations are taken from more recent studies suggesting shorter courses are effective. The number of days in parentheses are the contemporary durations.

Again, another study worthy of browsing if you commonly prescribe antibiotics for these conditions.

November 5 is Fast Approaching

Although I'm trying to wind down my practice, it seems like my to-do list is twice as long now. We're all busy, but please don't forget to vote!

Published on Leave a comment on Melanerpes carolinus

I just returned from a mad dash to Orlando, FL. No, I wasn't paying Mickey and Minnie a visit, just putting in an almost cameo appearance at the American Academy of Pediatrics National Conference and Exhibition. Apparently they were desperate for speakers because they invited me to give a talk about how to approach reading journal articles. A few dozen attendees politely endured my presentation, but I, and I think even most of the attendees, had a fun time. I also got to chat with a few old friends, always nice.

Although the trip was nice, I was most excited about the notice I received from my bird feeder while I was away. More on that later.

Potpourri

I came across a smattering of unrelated items this past week, grouped here.

I think we could all use some good news from the Middle East now. The WHO announced that Jordan has become the first country in the world to be certified to have eliminated autochthonous (locally-acquired) leprosy. That is no mean feat and required tremendous efforts and resources both from the country of Jordan as well as the WHO. It has been over 20 years since they've had an autochthonous case in Jordan.

The CDC has sent out a notice about mpox prevention through their Health Alert Network. It's not new, but worth reviewing to understand risk groups and to remind us to ask about international travel plans of our patients.

I've deliberately avoided commenting on the possible person-to-person spread of influenza A H5N1 in Missouri, but it's been in the lay press. Close contacts of 1 confirmed case had illnesses that could be consistent with this form of bird flu, but we don't have any test results from the contacts. I just mention it to stress that this is an evolving story. It would be a change for this organism if human-to-human transmission is now common.

Vaccine News

A couple intriguing reports last week from the CDC via the weekly MMWR. First are survey results that give us a glimpse at what happened with childhood immunization rates during the pandemic. It should surprise no one that vaccination coverage at 24 months of age declined by a few percentage points from birth year 2018-19 to birth year 2020-2021. For the combined 7-dose series (doesn't include covid vaccination) the rate dropped from 70.1% to 66.9%. This just adds to the possibility for sustained epidemics especially if clusters of poorly immunized children are grouped together. Here's a list of the national data for the 2020-2021 birth year cohort:

The entire table was too large to put in everything here, but Montana had the lowest numbers followed by California at second worst. You can look up your state and region in the article.

The same MMWR also had some new data on covid in children under 6 months of age. It provides compelling rationale for maternal immunization. First, here's what age-associated covid hospitalization rates look like from the surveillance network:

Further data showed that infant hospitalization rates are higher than rates in the elderly (75 years and above). In a subset of 1148 infant records that underwent extensive review, 9 deaths were recorded. Overall 22% of the hospitalizations involved intensive care admissions. Looking just at the 1065 infants for whom maternal vaccination status was available, it appears that maternal vaccination during pregnancy could be an important preventive measure for severe infant covid illness.

Note the careful wording: "No record of maternal vaccination during pregnancy." This points to the fact that these records might have been incomplete or even wrong - the providers may have recorded information incorrectly, or the mother may have been mistaken about vaccination status and timing. I'm still impressed with the information, especially since these numbers are very recent, from the omicron period when virtually every adult had some sort of immunity either via natural infection, vaccination, or both. Maternal covid vaccination is important to protect both the pregnant person, itself a high risk group, as well as the infant who is too young to receive covid vaccine.

A New Antiviral for RSV?

A placebo-controlled, randomized, double-blind trial of a few hundred infants hospitalized for RSV in China suggests that a newer antiviral agent, ziresovir, might be an effective treatment.

The main endpoint is change in the "Wang score" which is a relatively unvalidated scoring scale for assessing RSV severity. You can see the decline in the score is a bit better with the treatment group compared to placebo, but is the change in score clinically important? As a still wet-behind-the-ears ID attending, I witnessed early studies of randomized, double-blind, placebo-controlled trials of aerosolized ribavirin for hospitalized infants with bronchiolitis; my boss, a renowned pediatric infectious diseases physician named Bill Rodriguez, headed up these multi-center studies. I witnessed potential pitfalls in using scoring systems for bronchiolitis, particularly the problem with intra- and inter-rater reliability in assessments: it's hard to be consistent with scoring when the events you're looking at are somewhat subjective. Also, the aerosolized ribavirin left a fine powder on the infants, difficult to disguise even when the nurse tried to remove it before the investigator did the scoring. So, it wasn't perfectly double-blinded, in some cases not blinded at all. At blinding wasn't a problem with ziresovir, which is administered orally. Aerosolized ribavirin did work, but ultimately the costs outweighed the benefits (plus some risk to providers of inhaling the medication if the patient room was not well-ventilated and potential for teratogenicity), so the practice didn't last long.

I'll wait to see more data about this intriguing new agent. In the meantime, remember we have very effective methods of preventing severe RSV disease in infants by either maternal vaccination or administration of long-acting monoclonal antibody (nirsevimab) to infants whose mothers were not immunized.

Crystal Ball Time

What's coming this winter, and how bad will it be? Don't place any big bets on the CDC's latest predictions, they have only low to moderate confidence with their model, but it's by far the best data we have.

Here goes: "CDC expects the upcoming fall and winter respiratory disease season will likely have a similar or lower number of combined peak hospitalizations due to COVID-19, influenza, and RSV compared to last season."

That's good news. The experts were moderately confident of predictions for individual infections, but it's not really possible to anticipate all of the variables that could change the predictions dramatically, such as immunization uptake. Of course, if a new covid variant arises with a very effective immune escape mechanism, no one will be betting and we'll be in for a bad time.

Here's some more tidbits:

For example, if our summer covid activity peaks early (which it seems to be doing), they predict a milder winter season than if covid continues to rise now.

If you're a nerd like me, you can look at their description of how they developed this prediction model.

For the Birds

Getting back to my bird feeder, regular readers will recall my travails discussed in prior posts, including battling squirrel seed raiders. Things have settled down now, and I seldom see new species, but the past 2 days I've had my first sightings of a red-bellied woodpecker. The first thing I noted from my feeder's video (still photo taken below) is that I don't see a prominent red belly.

Other views show the typical zebra-like striping on the wings - why not call it the zebra woodpecker? - and the Cornell app quickly identified its call as the red-bellied variety. As usual, I couldn't help but see what new woodpecker tidbits I could learn from the worlds of literature and music. My childhood and adolescent "career" playing tenor saxophone made me a fan of big band music, particularly of Glenn Miller, and I discovered he had recorded The Woodpecker Song. It's not that great in my opinion, but at least I learned something new. One of my other musical heroes, Chuck Berry, recorded a purely instrumental (with saxophone solo!) song called Woodpecker. My favorite find, though, was a new-to-me poet, Elizabeth Madox Roberts. She was a Kentucky-born daughter of a Confederate soldier, active as a poet and novelist in the late nineteenth and early twentieth centuries. She seems to have the largest numbers of poetry web sites extolling her virtues for poems about woodpeckers. Here's her poem The Woodpecker in its entirety:

The woodpecker pecked out a little round hole
And made him a house in the telephone pole.

One day when I watched he poked out his head,
And he had on a hood and a collar of red.

When the streams of rain pour out of the sky,
And the sparkles of lightning go flashing by,

And the big, big wheels of thunder roll,
He can snuggle back in the telephone pole.

2

Published on 2 Comments on Happy Autumnal Equinox

It's been an eventful week for me but relatively quiet in the world of infectious diseases. I've just returned from a week's trek in the semi-wilds of Colorado. You may recall that last week's post included a mention of mosquitoes and high altitudes, noting that climate warming has been accompanied by trends of more mosquitoes at those upper elevation. I'm happy to report that after spending the week in the great outdoors at 5000 - 10,000 feet I only had a few bites and didn't even touch my insect repellent.

Turning skyward, I was able to view the September 17 partial lunar eclipse from Mesa Verde National Park; sadly my antique cell phone camera was unable to capture it. This morning I consulted my trusted 2024 print edition of The Old Farmer's Almanac to remind myself of the difference between an equinox and a solstice. The earth's axis is tilted at 23.5 degrees from the perpendicular as it revolves around the sun, and the equinoxes occur when both northern and southern hemispheres equally face the sun. Northern hemisphere solstices occur when the North Pole is most tilted towards (winter) or away (summer) from the sun. I learned so much this week!

Pertussis

Whooping cough was in the news recently, though really this is just a return to "normal" after the pandemic years. Here's the long view from CDC data.

On a more recent view, you can see the age breakdown.

I was involved in pertussis immunology and vaccine research very briefly in my career. I always like to mention an oldie-but-goodie article from 1992 showing that about one-quarter of UCLA college students with cough lasting longer than 5 days showed evidence of recent pertussis infection. It's a good reminder that pertussis in adults usually looks very different, and milder, than the classical whooping cough in infants. Diagnosis is difficult unless you think about pertussis as a possbility.

Maybe not so coincidentally with these news reports, the FDA VRBPAC meeting last Friday focused on using Controlled Human Infection Models (CHIMs) to try to develop a better pertussis vaccine. Yes, that's right, intentional infection of human volunteers to study various aspects of the disease. We need more information to improve pertussis control, given that our current acellular vaccines are less effective (but also with less side effects) than the predecessor whole cell vaccines. Large scale trials are difficult, expensive, and largely impractical in the present era, so it's time for new approaches. A group at the University of Southhampton in the UK presented some preliminary data from a CHIMs trial and also had a nice graph to put into perspective relative mortalities and contagiousness of pertussis compared to other pathogens:

The study itself was just a challenge study of human volunteers to determine the dose of organisms and the immunologic responses surrounding infection and colonization. It seems likely that these types of studies will be utilized more frequently in the future to improve our understanding of pertussis prevention.

Needless to say, I didn't join this meeting live, I was off the grid in Colorado, but I did skim through the recording and slides today. This wasn't a typical VRBPAC meeting where voting occurred, it was more of a discussion to guide future research.

More Wastewater

Speaking of returning to pre-pandemic levels of infection, I've been watching wastewater trends for enterovirus D68. You may recall that this was an enterovirus strain that figured prominently, but not exclusively, in outbreaks of acute flaccid myelitis that tended to occur in even-numbered years - pretty strange.

As you can see, the pandemic really ended this pattern, and nothing new is going on so far this year. However, wastewater numbers, at least for EV D68, have looked very different.

Will we see a blip upwards in AFM cases this year? I hope not.

More Colorado Learning

My landscape designer wife clued me in to the details of the quaking aspens, so named due to the fluttering of the leaves that have their own distinct sound. They are beautiful, both my wife and I wished we had better pictures to show you.

On another note, although I love to learn, one new factoid I happened upon was perhaps less exciting. Hiking at these altitudes, I learned that I'm not as young as I used to be!

Published on Leave a comment on Invasive Species

Last week I outsmarted myself. The closing photo in the September 8 blog I was sure would result in at least 1 person calling me out; I was then going to follow up in this week's post to explain about invasive species. I guess I forgot to factor in the politeness of my audience in not wanting to berate me for mistakes. (This is a more preferable explanation than the alternative that no one even read that post!)

Still not much going on with our summer respiratory season. The percentage of ED visits due to covid continues to fall nationally.

However, covid wastewater levels in the western US plateaued or even increased a little.

Measles Still Here

It looks like we have settled into a persistent trickle of cases in the US. I'm still holding my breath hoping we can avoid another major outbreak this year. The official tally for 2024 now is 251 cases from 30 states and DC.

Not included in the totals above is a new case occurring in an unvaccinated student at Western Kentucky University, probably acquired during international travel. It looks like that person attended several public events over a few days in late August; with an incubation period of around 2 weeks, we should be hearing soon if secondary cases resulted from this person.

Meanwhile, the UK has reported a measles death in a "young person who was known to have other medical conditions." With 2465 confirmed measles cases so far this year, the UK is much worse off than we are in the US. Still, it's unsettling to hear about measles deaths in high income countries. The UK has had 1-5 deaths per year since 2019 but hasn't had double-digit death figures since 1988. Best estimates are that, even with the best medical care, 1-3/1000 children with measles will die.

A Couple Vaccine Updates

Nothing really new here, but it's easy to overlook important guidance with the flood of emails and other reminders we receive. First is the official statement from ACIP about Hib vaccination for American Indian and Alaskan Native infants. It is the follow up from an ACIP meeting last June. For both socioeconomic and biologic reasons, it's been clear for decades that this population has a very high rate of Hib disease and also a less robust response to most Hib vaccines compared to the general US population. The best Hib vaccine for this group is a conjugate using the Hib polysaccharide PRP joined to an outer membrane protein from Neisseria meningitidis. The OMP is a carrier protein that helps infants form antibody to PRP, the real protective antibody here. This is the basis for all conjugate vaccines; it fools the infant immune system into thinking it is seeing a protein antigen rather than a polysaccharide antigen; PRP and other polysaccharide antigens are not well recognized by infant immune systems - normal infants even fail to form antibody to PRP with natural Hib disease. Conjugate vaccines fool infant immune systems.

At any rate, for a long while we've only had 1 Hib vaccine with the PRP-OMP combo: PedvaxHIB. This summer we saw FDA approval of Vaxelis, a hexavalent vaccine with DTaP, IPV, HepB, and Hib, the latter using the PRP-OMP product. Vaxelis is now officially recommended as an option for the AI/AN infant population, as well as for other infants. The recommendation for the AI/AN group was made on the basis of a phase IV randomized study of Vaxelis versus PedvaxHIB showing good antibody formation in both groups. No effectiveness study was performed because this population didn't have enough Hib disease present at a background rate to determine any significant differences with a new vaccine - PedvaxHIB has worked very well for these children in the past, another vaccine success and cause for celebration.

A second vaccine update is just the recommendation, again from CDC, for the next round of covid vaccines recommended for everyone 6 months of age and older. Again, nothing new, but it's a good resource to have all that information in one document. The tables serve as a quick reference for many different situations.

Mosquito Invasion

Any ID physician worth their salt will obtain an extensive travel history when seeing patients. We are mostly looking for clues to diseases seen mostly in international travelers, such as typhoid fever and the vector-borne infections that include dengue, chikungunya, malaria, and others. However, sometimes the travel history is negative but the patient ends up having one of those exotic diseases, acquired locally in the US (aka autochthonous infection). Such is the case recently with autochthonous dengue fever cases in Los Angeles County, CA. These cases appear when there is an existing reservoir of infected people plus a reservoir of the vector. For dengue virus, the vector is the Aedes mosquito, specifically A. albopictus and A. aegypti, plentiful in much of California.

The range of these mosquitoes have been increasing the past few decades at least, mostly due to warming of our climate. The last extensive study of Aedes presence in the US was in 2017, summarized by CDC.

As one of those people who seem to be particularly tasty for mosquitoes, I find it interesting (and depressing) that we have about 200 different species of mosquitoes in the US. I'm not terribly comforted by the fact that only about a dozen of these can transmit those infections we worry about. Besides the Aedes genus, we also need to worry about Anopheles and Culex mosquitoes.

Of these, it is Aedes that is the most versatile in transmitting disease to humans, implicated in Cache Valley virus disease, chikungunya, dengue, eastern equine encephalitis, La Crosse encephalitis, and zika infections. Anopholes can spread Cache Valley virus, and Culex are implicated in eastern equine encephalitis, St. Louis encephalitis, and Oropouche virus, though midges more commonly spread the Oropouche. Other viruses such as Jamestown Canyon virus can be spread by many different species of mosquitoes and vary with time of year and location.

As our global temperatures have warmed, the mosquito season has lengthened; in many locations mosquitoes are out and about throughout the year. Also, the idea that high altitudes are safer from mosquito-borne infections is becoming invalid in many parts of the world, including the US. It wasn't the altitude per se that mosquitoes didn't like, it was the cool weather which now is warming.

I realize that for many of you this is already too much mosquito information, but if you want more visit Arbonet.

More Invasion

Getting back to last week's post, I had mentioned that my wife was outside working hard to clear our back yard of poison ivy while I was indoors typing leisurely. It turned out she didn't find any poison ivy. The photo I placed at the end of the post wasn't poison ivy but rather a portion of the massive porcelain-berry plant she removed instead. While poison ivy is a native plant, not invasive but still hated, porcelain-berry is a horribly invasive vine deliberately introduced into the US for its attractiveness but quickly discovered to spread indiscriminately, eliminating native vegetation in its path. It is the plant world equivalent of pod people.

Unless otherwise indicated, the content and opinions expressed on this web site are those of the author(s). They are not endorsed by and do not necessarily reflect the views of the George Washington University.
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