Category: Uncategorized

Today's Morbidity and Mortality Weekly Report contained updates on the flu season just past. First of all, the report confirms what we already knew, that it was a fairly busy season. Pediatric deaths were high, total of 171 influenza-related deaths have been confirmed. When I looked back, this number is similar to the 2014-15 flu season. Sadly, of those fatal cases who would have been eligible to receive flu vaccine, only 22% had received at least 1 dose of vaccine. That's a real missed opportunity, since flu vaccine is significantly effective in preventing more severe illness.

Unusual for the season just ended was the fact that the severity of illness was high for all age groups, the first time that particular scenario has been noted since the CDC has applied new definitions for flu severity now dating back to 2003-4:

On another note, those of you who attended the most recent Montgomery County Pediatric Society meeting may recall my answer to an audience question about whether to use the new live attenuated influenza vaccine (LAIV4, aka FluMist) recently approved by FDA. You recall the previous iteration of this vaccine was removed from the market due to poor efficacy, particularly against the H1N1 2009 pandemic strain.

The newer product appears to produce higher antibody levels, but that's not the same as whether it has better efficacy; we will only know that when we see how it performs in the real world, in a year when we have more H1N1 activity than we had this past year.

The Advisory Council for Immunization Practice officially does not designate a preference for any of the types of flu vaccine over another. My response at the May meeting was that I wouldn't use it for my family members, and perhaps only to consider ordering it if you felt that you had families in your practice that would refuse the inactivated (injectable) vaccine; LAIV4 is better than no flu vaccine at all. It turns out my advice is more in keeping with AAP recommendations, now advising using LAIV4 as a "last resort."

This week's Morbidity and Mortality Weekly Report had a timely article summarizing outbreaks associated with treated recreational water over the time period 2000 - 2014. I'll share a few take home points.

A total of 493 outbreaks were reported over this time period, and 363 (74%) had a confirmed infectious etiology. Any guesses as to the number 1 identified infectious cause? If you said Cryptosporidium, you win the prize. Second place wasn't even close, more or less a tie between Legionella and Pseudomonas, with the latter manifest mostly by folliculitis and otitis externa. Hotels were implicated in about 1/3 of the outbreaks.

The report included a little informational poster with some fairly obvious but still important messages to the public:
1. Don't swim with diarrhea
2. Check the pool or hot tub inspection score (more on this below)
3. Don't swallow the water

I had never really looked into how public pools or hot tubs were regulated, but not surprisingly there are rules governing this with oversight by county/state health departments. I decided to try to find out pool inspection scores for some area hotels, and I had a lot of difficulty. Montgomery County Health Department's web page listed a bunch of regulations, but I couldn't see anything there about individual hotel reports. Needless to say, going to a hotel's website isn't likely to help anyone find out when the pool was last inspected, or how it scored. This seems to be true for most of the country. So, I guess if you're really concerned about your vacation spot's pool or hot tub health rating, you'd need to ask the hotel specifically. The CDC does help if you wanted to look at the sites responsible for outbreaks in the past, via this site.

My only swimming possibility this summer is a lake, not covered by the treated recreational water regulations. I'll just have to take my chances.

Tried any kratom? Now wouldn't be a good time to do so.

If you are like me, you're not familiar with kratom. I actually heard about it almost 2 years ago, in a CDC blurb about poisonings and overdoses with the substance. Now, however, it's associated with a new public health danger, salmonellosis due to S. Javiana, S. Okatie, and S. Thompson serotypes. CDC first publicized the outbreak last month, with illness onset as early as October 2017. Now, however, the outbreak is expanding to a total of 87 people in 35 states. The most recent states added including Maryland and West Virginia. Take a look at the current case count map.

Kratom's other name is Mitrabyna speciosa, a cousin of the coffee plant. It appears to be used as both a "natural" remedy as well as for recreational purposes for its opioid- and stimulant-like effects. If you happen to uncover any cases of salmonellosis, be sure to ask about kratom exposure. Also, at this time there is no common source supplier of the tainted kratom, so CDC is advising to avoid all use of this compound. (Not that anyone should be using it anyway!)

Influenza-like illness continues to drop nationally, as seen from the latest CDC data for the week ending March 3:

At Children's National we don't collect data in that manner, but our viral detection results for the week ending March 11 show a clear shift in influenza strains, now showing a predominance of influenza B. At our institution flu B is now about twice as common as flu A, which was the predominant strain earlier in the season. RSV is still hanging around from 2017, now at least as common as flu A detections.

In past years, this shift to influenza B has been typical for late in the flu season. However, we still have plenty of flu in the air, not too late to recommend influenza immunization for any children who missed it earlier in the year.