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Tag: avian influenza

Published on Leave a comment on Onward Through the Fog

Or haze, or just blackness. It's a beautiful sunny day in Maryland, but cancellation of the FDA's VRBAC meeting to discuss next fall's flu vaccine composition makes things a lot hazier. More on that later.

Covid Vaccination Protective Against Post-Covid Conditions in Children

This is a report from a multicenter study of children 5-17 years of age, originally enrolled July 2021-September 2022 and then followed longitudinally. The cohort was surveyed from December 2022 through May 2023, with questions about a variety of symptoms lumped under Post-Covid Conditions (PCC) detailed in the footnotes below.

The lower odds ratios of PCC in vaccinated children is impressive. The study's strengths are its prospective design, but the fact that they are relying on survey results, as opposed to specific follow-up encounters to determine signs and symptoms, is a bit of a weakness. Other longitudinal studies are ongoing with longitudinal in-person evaluations, so we'll eventually have better data. Also, this study doesn't tell us anything about benefits of ongoing covid immunizations in children. I've previously mentioned other studies suggesting benefit to children from ongoing immunizations.

Measles

The outbreak in Texas with probable spillover to New Mexico continues. Here's the latest from CDC in their February 28 report. Be aware there is a time lag from when cases are reported by states to when they are included in CDC numbers.

I was hoping the West Texas outbreak wouldn't result in large numbers of cases given the relatively rural and smallish population involved; we aren't yet approaching the 2019 New York outbreak that occurred in a densely populated community.

The Texas authorities' update from Friday tallies 146 cases, and New Mexico shows 9 cases. Five of the NM cases were 18+ years of age and 4 children 5-17 years old. Texas HHS also reports a large exposure area for a measles case in San Antonio and surrounding area. I think it's interesting to look at the sites and consider the immense resources needed to track down and protect exposed people.

WHO Soldiers On

The polio vaccination program in Gaza sounds like it was very successful: 603,000 children under 10 years of age were immunized over a 5-day period, aided by the cease-fire that I hope will continue.

New World Screwworm

Apologies, I think I've mentioned this topic once before but can't find it in a search of my posts. This disease is a form of myiasis, and the recent news is that it's getting closer to the US with new data at the end of last year showing the fly (Cochliomyia hominivorax) appeared in Mexico. The previous "barrier" to creeping closer to the US was the Darrien Pass in Panama, which you may recall from various immigration discussions in the lay press.

Now new efforts are underway to release sterile flies in Mexico, an established method to control the population. The USDA has a helpful document explaining the history. In endemic countries this is mostly a concern for livestock and other animals, but we humans also can be affected; it is very painful, beyond unpleasant, and gross, requiring manual extraction of the fly larvae from soft tissue. Here's the history in the US, at least as of late 2016 following the finding of the flies in Florida, resulting in a sterilized fly release for control.

Avian Flu

A lot of back and forth in the lay press about influenza A H5N1. My take on the bottom line is that there is nothing substantive that is new. I'm still watching closely for more concerning trends including extensive infection in pigs (where conversion to a strain with greater ability to infect humans is more of a risk) and any evidence of human-to-human transmission.

USDA monitoring is ongoing, with of course many infections in wild and domestic birds, cattle, and other mammals including a flurry of domestic cat infections recently. The map below is current as of February 26.

Our new agriculture secretary has released a plan for avian flu control. It is advertised as a means to lower egg prices which is fine, but we won't see any impact on that soon. I'm just glad we're seeing some movement to get a handle on this. The more H5N1 circulates in any animal, the more likely we'll see a new strain with greater potential to sicken humans.

In the meantime, I might try to steal my wife's oatmeal stash a few mornings a week.

Hooray for MMWR!

Not only does this week's edition look like the old days, it even included a sensitive topic for the current political administration: HPV vaccine.

HPV was strikingly effective in lowering the rate of cervical precancers in young women (the solid blue lines below) as well as in women in their late twenties. The fact that the current administration allowed them to publish these results is encouraging; HPV vaccine has been a target as well as a source of income (from lawsuits) for RFK Jr. in the past.

Last year's flu vaccine early estimates of effectiveness looked like a glass-half-empty versus -full in the lay press. The half-empty folks point to somewhat low effectiveness against all infections, but that's not the point. As with other respiratory virus vaccines, the main point of vaccination is preventing healthcare visits and serious outcomes. Here's the bottom line we should pay attention to: "Interim 2024–2025 seasonal influenza VE estimates were derived from four U.S. VE networks. Among children and adolescents, VE was 32%, 59%, and 60% in outpatient settings (three networks) and 63% and 78% against influenza-associated hospitalization (two networks). Among adults, VE was 36% and 54% in outpatient settings (two networks) and 41% and 55% against influenza-associated hospitalization (two networks)."

I'm in the half-full camp.

WRIS

I think we might really be headed down for winter respiratory infection season, largely due to a sustained decrease in influenza with no significant upswings in covid. RSV is almost out the door. Here's the latest from FluView.

That's not to say it's gone, however. We're definitely still in flu season in many areas of the country.

FDA Advisory Committees

I'm perplexed about why the FDA VRBPAC's scheduled meeting was cancelled. Supposedly the selection of next fall's flu vaccine composition will be done internally by the FDA, but one of the key advantages of the VRBPAC meetings was the chance for anyone, including the general public, to view the discussions in real time and get a better understanding of issues and risks/benefits.

I have a bit of personal experience to illuminate this. I've participated as a panel member on several FDA Advisory Committee meetings, though never anything to do with vaccines. Here are some key points that I can relate from first-hand experience.

  • I filled out an incredible number of forms about my potential conflicts of interest for every session. It was the equivalent of a paper strip search.
  • I spent many hours/days reviewing documents with a lot of raw data, both from FDA experts as well as from any pharmaceutical companies and device manufacturers. It was a very granular level of detail.
  • Every session included presentations by mostly lay public individuals given time to speak at the meeting. It was a broad representation: patients and relatives of patients who might benefit (or be harmed) by the product, other industry and association representatives, and yes, some pseudo-science/misinformation folks.
  • The discussion was very helpful; sometimes my mind changed as I learned from others.
  • All committee members explained their votes. The votes were not binding to the FDA, but I can't remember a situation where they didn't follow the vote for any of the committees I served on.
  • My exact recollection has faded, but I think at first I was reimbursed for lunch but later I wasn't. Everyone was reimbursed for travel and lodging when the meetings were held in person in the DC area. Of course, since I'm local that really didn't amount to much even if I submitted my gas mileage! In short, people serve on these committees for civic duty, not for any remuneration.

Now that meetings are virtual, there is not much reason to cancel them. The cost is born by the committee members; FDA and industry participants still need to do the same amount of work. I hope transparency in healthcare administration will return soon.

Paint It Black

This Stones' song came on my Pandora station just as I was wrapping up my first draft of this post. The sun isn't quite "blotted out from the sky" from the FDA VRBPAC and CDC ACIP postponements and cancellations, but it's enough to cast a shadow on my sunny day. Here's to brighter times.

Published on Leave a comment on End of an Icon?

What happens when a prominent public figure who thinks he knows everything about everything finds himself in a position to control an important public institution? It's another brave new world we'll need to endure as best we can.

Of course I'm speaking about the Broccoli family ceding creative control of the iconic James Bond franchise to Amazon/MGM, i.e. Jeff Bezos. I shudder at the possibilities of another billionaire-induced stream of havoc.

Er, no. What I'm really referring to is the postponement of this week's meeting of CDC's Advisory Council on Immunization Practices. I had detailed last week that it was scheduled for February 26-28 as one of the three planned meetings this year; the dates are selected well in advance and had been planned through 2027. Not any more, apparently.

These meetings, with the entire public invited to view in real time, were among the most transparent of all healthcare meetings in our country. I'm not sure what public comment accommodations were needed; comments had been requested via the Federal Register as per standard practice, and the draft agenda already included the usual times for live public comments prior to all votes. The concern is that RFK, Jr., will overhaul committee membership to install new members to carry out his anti-science doctrine. The website promises that the ACIP workgroups will still present their findings, but I'm concerned the votes could look much different by the time that happens.

Coupled with potential new rules for FDA and research funding, we could end up with no progress in vaccine development and increasing vaccine hesitancy in the general public. At worst, we may lose access to currently available safe and effective vaccines. The ACIP could cease to be a reliable partner for our nation's health. Private organizations, including the American Academy of Family Physicians, the American Academy of Pediatrics, and the American College of Physicians, among others, may need to step forward to fill the vacuum of discussion and recommendations.

As I step down from my soap box, Ambrose Bierce reminds me, "Speak when you are angry and you will make the best speech you will ever regret.”

Good News Department

After my Debbie Downer impersonation above (did you watch SNL's 50th Anniversary show?), I'm thankful I saw more positives than negatives this past week.

MMWR is Back in Form

The February 20th issue looked a lot more like a typical edition. It had 4 topics and didn't appear to be skimping/censoring information. Of course the biggest news from an infectious diseases standpoint is the report of 2 exclusively indoor pet cats from 2 separate households in Michigan who died from avian flu. Owners of both cats were workers on dairy farms. The cats never had direct exposure to the farms.

The investigation was somewhat limited by incomplete testing. The most logical conclusion is that these 2 episodes represent passage of the virus from humans to cats.

Polio Vaccination Resumes in Gaza

WHO reports another round of polio vaccination is ongoing now in the Gaza strip after wastewater monitoring recently showed a poliovirus spike. Almost 600,000 children under 10 years of age have been identified to receive vaccination through February 26.

Low Dose Yellow Fever Vaccine Produces Similar Seroconversion Rates

At first glance, this might not seem that important to those outside of the yellow fever world. However, yellow fever vaccine is in short supply at a time when this hemorrhagic fever virus is surging in many parts of the world, including the Americas. Investigators published a non-inferiority randomized, double-blind controlled trial of standard dose (13,803 IU) compared to lower doses of 1000, 500, or 250 U administered to adults in Uganda and Kenya.

Using a lower vaccine dose vastly increases the number of people residing in high-risk countries who can be vaccinated. Note that in addition to 29 African countries, 13 countries in Central and South America have some risk of yellow fever transmission.

Listeria Outbreak Linked to Frozen Shakes

Mostly these nutritional supplements are used in long-term care facilities. I haven't noticed any of these products in my local grocery stores. Last Friday FDA reported on the outbreak that first came to light in November 2024 and covers 21 states across the country. Thirty-eight individuals have been infected, resulting in 37 hospitalizations and 11 deaths. The high morbidity and mortality probably relate to the high-risk populations residing in these facilities. If you visit one a nursing home it's worth a mention to the staff to make sure they are aware.

Measles

I'm afraid that reports of vaccine-preventable diseases will increase in the current regulatory and cultural climate. Friday's update from Texas Health and Human Services now lists the total number at a whopping 90 cases, and if news reports are to be believed this is significantly under-reported due to high rates of home schooled children affected. Added to this are 9 cases just across the border in New Mexico, though news reports state there is no known contact to infected individuals in Texas. That seems to be a very unlikely coincidence.

Last week I mentioned that I thought the CDC needed to update their measles tracking page more frequently than monthly, and they listened to me! Now we have updates every Friday.

We haven't broken any records yet, here's hoping Texas officials get this under control soon.

WRIS

It's nice to see the influenza-like illness curve head down this past week, but it could bounce up again like it's done before.

Hospitalizations for confirmed influenza infections also trended down.

Mortality is the highest we've seen since the pandemic. The numbers below include 86 pediatric deaths.

On a national level, covid and RSV aren't doing much, though even low levels result in significant disease.

Bernarr Macfadden

Yeah, I never heard of him either, but opinion columnist Jessica Grose at the NY Times brought him to my attention as a precursor/dopelganger for RFK, Jr. Unfortunately Macfadden's Wikipedia article has too many poorly documented statements to recommend, but what I can verify is that he was a weight-lifter who liked to be photographed showing his muscles (and most of his body) and founded various health movements. A charismatic individual, his influence was prominent from the early 1900s through World War II. He had no medical background. He championed raw milk and denounced white bread and pharmaceutical agents including vaccines. His "movement" reportedly had prominent adherents including Franklin Roosevelt and Rudolph Valentino. Eerily familiar.

As a distraction, I found myself wondering how Jeff Bezos would tilt his newfound power to influence the future of James Bond. I know just the person to play the next villain.

Courtesy of YouTube

Published on Leave a comment on The Kennedy Era

Readers of past postings know I try to avoid politics in this blog. Today's post represents a complete failure to achieve that goal. I have followed RFK Jr.'s statements and writings about vaccines and public health for many years. His brand of pseudo-science is incomprehensible to me and anyone who understands biology and scientific methodology. His confirmation as HHS Secretary last week marks a sea change in the American health system; although he spouts some worthwhile targets to improve public health, in his new position he poses a grave public health threat for infectious diseases in particular. Regardless of any specific vaccine or other policies he might introduce, his mere confirmation as HHS Secretary may serve to further normalize anti-vax sentiment and likely will increase rates of vaccine refusal. Welcome to the new Dark Ages, though I doubt it will last several centuries like the last one. More on this later.

The Global Watch

A number of things to be aware of globally, though none immediately troublesome for the US.

Marburg Outbreak in Tanzania

This outbreak of a viral hemorrhagic fever disease (similar to Ebola) was declared about a month ago. Ten cases (2 confirmed, 8 suspected) have been identified, all fatal. Now, the 281 contacts of those 10 cases have passed the 21-day incubation period and remain well, very reassuring. However, WHO still rates the risk at the national level as high, given that the locale, Kangera, is a major regional transportation hub to other countries. Risk for global spread is still low.

Ebola (Sudan virus) Outbreak in Uganda

AfricaCDC reports that the vaccine trial is underway now in 7 of the 8 planned sites. Disease activity seems relatively stable, though the weekly reports tend to lag with last update posted from February 10.

PPE for VHF

With every viral hemorrhagic fever outbreak, healthcare providers comprise a prominent number of infected individuals. This occurred even in the US when 2 American nurse providers were infected during the 2014 importation from travelers. It's a good time to remember precautions to prevent VHF spread in healthcare settings, also a bit confusing since different guidelines apply according to whether the suspected patient is clinically stable or unstable. Front line providers need to contact their friendly local ID or infection control practitioner for help as soon as a suspected VHF case is encountered. Remember to obtain a good travel history.

mpox

In WHO's February 13 situation report, clade Ib mpox remains primarily in the DRC, Rwanda, and Uganda. MMWR just reported confirmation of a case of Ib infection in California from November 2024, in a traveler returning from east Africa. More on MMWR later.

Measles Again!

No surprise, but we have new outbreaks in the US, presumptively heavily related to cases in unvaccinated persons who were old enough to have received 2 doses of MMR vaccine.

A February 14 update from the Texas Department of State Health Services lists a total of 48 cases in the South Plains region, with age distribution of 13 cases in 0-4 year-olds, 29 in school-aged children (5-17 yo), 5 18 and older, and 1 with age unknown. Digging through the data from their spreadsheet links, MMR coverage in 2023-24 in the Seminole ISD (apparently the epicenter of the outbreak) is an appallingly low 82%. In Gaines County, home of 42 of the outbreak cases, the rate of "Conscientious Exemptions" for vaccine administration for children rose from 7.45% in 2013-14 to 17.62% in 2023-24. Even the earlier rate is super-high. Gaines County is the red box below.

The CDC measles page is updated only monthly, perhaps not frequently enough given the current situation. And, speaking of the CDC ...

Interesting Week Ahead for the CDC

I'll be watching closely this week. MMWR seems to be back, but with fewer topics per issue. I looked at the 2024 content, and only about 10% of the weekly publications had less than 4 topics. Both issues following the "publication pause" had only 2 articles each.

More telling, the Advisory Council on Immunization Practices is scheduled to meet on February 26-28. The draft agenda was released on January 19, and I'll be interested to see if the topics change. Currently on the schedule are votes on meningococcal, chikungunya, and influenza vaccines plus further discussion on maternal and pediatric RSV vaccines on Wednesday. These are not particularly high profile targets for the anti-vaccination lobby or for anti-DEI issues. However, part of the discussion process for vaccines at ACIP meetings has been an "Evidence to Recommendations" portion that normally includes a section on equity. I wonder whether this will change. Thursday's draft agenda includes perhaps more controversial subjects of HPV and mpox vaccines, due the relationship of these infections to spread via sexual contact in different high risk groups. Thursday's discussion also touches on pneumococcal and adult RSV vaccines, plus a 5-minute blurb on Lyme disease vaccination that I'm wondering about. The meeting wraps up Friday morning with discussions on covid (!) and CMV vaccines. I hope to attend much of the meetings and I'll report back next week.

This week's New England Journal of Medicine included a Perspective written by 3 former editors-in-chief of MMWR plus a former director for one of CDC's Centers. It was entitled "The Consequences of Silencing the 'Voice of CDC.'" Clearly the authors carry some implicit bias in favor of the CDC, but the article was enlightening. They repeated the reports I heard that the February 6 issue suppressed a discussion on H5N1 influenza (may have related to spread between cats and humans), which is concerning. I was interested to learn a bit of history: MMWR first appeared in 1961, during my lifetime but in a period when my interests fell more along the lines of Tinkertoys and butterflies. Currently I am one of 147,000 electronic subscribers to MMWR. CDC shares titles and brief summaries of reports with the Office of the Assistant Secretary for Public Affairs at HHS to alert them of content, but the authors were not aware of any time the reports had been altered or censored by the executive branch.

The authors went on to mention how rapid publication in MMWR helped public health management, citing the initial descriptions of what was eventually AIDS, outbreaks of foodborne illness related to hamburger contaminated with E. coli O157:H7, and anthrax related to intentional distribution of anthrax spores. I was a practicing pediatric ID physician during all of these outbreaks and still remember reading MMWR and changing my practice to account for new disease situations.

In addition to the evolving VHF situation in Africa mentioned previously, we need ongoing high-level surveillance for avian flu and for the large outbreak of tuberculosis in Kansas. With regard to the former, we did hear some information in MMWR this week: new serologic evidence of H5N1 infection in veterinarians providing care for cattle but with no known link to infected herds, suggesting more widespread cow infection than has been detected so far.

As an aside, since I do most of the grocery shopping in my household, I discovered the USDA has egg market reports. If you need some distraction from hand-wringing, you can track how many 30-dozen egg cases are moving around in your region each weekday!

WRIS

I'm thinking I don't need to tell any front line healthcare provider that influenza season is in full swing and is the one prominent player in our winter respiratory infection season at the moment.

More concerning is that illness severity is quite high.

Virtually all circulating strains are influenza A, and avian flu is not contributing to this with still just a handful of human cases detected in the US. Not too late to vaccinate.

My Test Grade Was 3

Please pardon my error last week in inviting readers to take the "How Ignorant Am I?" online quiz, not realizing it required subscription access. The quiz itself is based on a 1950 publication by statistician and weather forecaster Glenn W. Brier, updated in the Nature article you probably can't access. Briefly, the new quiz consists of 5 questions covering percentage of water in human body parts, timing of publication of genetic theories, planet size, number of atoms in common molecules, and melting points of precious metals; in short, scientifically based but nothing recently discovered. The kicker to the quiz is that it's not just whether you provide the correct answer, but that you quantify your confidence in the answer you provided. The scoring system is weighted such that failure (getting the wrong answer but thinking you are correct) is punished more severely than rewarding success (just getting the right answer). Here's the scoring interpretation: "If you ended up with a negative total, you did worse than a complete ignoramus who just answered 5 to every question" [5 indicates you had no idea which answer was correct, resulting in a score of zero if you answered 5 for all questions]. "People who actually know a lot, or are extremely lucky, get higher scores." (The highest possible score, getting all answers correct and being absolute certain of your answers, is 125.). So, my score of 3 isn't great, with a consolation prize that "Those with an awareness of their own doubts ... might end up with a small positive score." The main point of the quiz was " ... to train forecasters to be less over-confident, and have insight into their own thought processes." Applies to weather forecasters and possibly to healthcare providers as well!

Published on Leave a comment on Super Bowl LIX

All of Taylor Swift's minions, along with much of the world, know that today is another Super Bowl event. This time the site is New Orleans, which brings to mind the recent FDA warning about norovirus contamination of oysters from Louisiana harvest area 3. If you're like me, you had to know exactly where this is.

The Superdome is sort of like a cruise ship. I wonder what a Super Bowl norovirus outbreak would look like, but hoping I don't find out.

More Measles to Start the Year

It looks like we have 2 measles clusters already this year, 1 in Gaines County, Texas, and the other in Fulton Country, Georgia. According to news reports, both are associated with unvaccinated children who were old enough to have been vaccinated. The CDC has incomplete information as of February 6, and I note that they have decreased the frequency of measles updates to monthly as of this year. The national tally is 14 cases so far, from Alaska, Georgia, New York City, Rhode Island, and Texas.
Six of the 14 cases were hospitalized.

And, speaking of the CDC ....

MMWR is Back ... Sort Of

After an unprecedented (isn't everything unprecedented these days?) 2 week hiatus, the Morbidity and Mortality Weekly Report Volume 73 number 3 appeared on February 6. Besides the delay, it was unusual in that it contained only 2 topics, both related to wildfires: PFAS levels in first responders to the 2023 Maui wildfire and emergency department use during the LA County wildfires. Not a thing about any infectious diseases, despite the fact we are in the midst of a heavy winter respiratory virus season. Presumably this is not the new normal, and I'm hoping we soon see a return to something resembling the old weekly MMWR.

WRIS

We do have some continuation of CDC data current enough for looking at our winter respiratory infection season. FluView is cooking along, and we can see that outpatient influenza-like illness is going strong.

Influenza hospitalizations are very high, similar to the 2017-18 flu season.

Mortality data lag actual cases, but we have already tallied 57 pediatric deaths this year, and I fear we'll top last year's number of 207. This past week we saw almost exclusively influenza A viruses, about evenly divided between H3N2 and H1N1pdm09 (the pandemic 2009 strain). Both are covered by the current vaccine.

Meanwhile, RSV season is mostly over, and we're still waiting to see if covid will spike this winter. Covid wastewater levels have been and remain high.

Avian Flu

Influenza A H5N1 continues to be widespread in the animal population. Probably the biggest news the past week is that the D.1.1 genotype, so far only present in birds, has now appeared in a dairy cattle herd in Nevada. Given how long H5N1 has been present in various animal populations in the US, this doesn't seem all that surprising to me. The main import is that the longer these strains hang around, the higher the chance for mutation or reassortment into a strain with the ability to infect and spread among humans.

Here's the February 6 USDA update on recent cattle cases; if you visit the site you can change the timeline and also look at alpaca or swine cases. I'm particularly watching the swine cases because that animal has the highest risk of developing a strain with greater ability to infect humans. (Only 1 pig has been known to be infected so far, in Oregon last October.) You can go to their main avian flu website to look at other animal populations.

Just to further confuse you, the official terminology for the predominantly bird strain is "highly pathogenic avian influenza (HPAI) H5N1 clade 2.3.4.4b, genotype D1.1," as opposed to the more common cattle strain of HPAI H5N1 clade 2.3.4.4b, genotype B3.13. Now you can bore your friends with this tidbit at tonight's Super Bowl party!

Infectious Disease Troubles in Africa

Two situations in Africa are looking increasingly concerning. The Democratic Republic of Congo is trying to deal with an mpox outbreak in the midst of widespread violence and war in the country. As we know from the song, war is good for absolutely nothing, and the DRC's ability to manage the mpox outbreak, already strained, is suffering.

The other African hotspot is in Uganda, experiencing an outbreak of Suban Ebola virus disease. Fortunately WHO is facilitating a candidate vaccine trial there which could be a breakthrough in controlling this particular virus. Mortality rates in prior outbreaks were 41-100% and are improved by availability of supportive care.

In the meantime, CDC's Health Alert Network issued an advisory for the Uganda outbreak, raising the travel precautions to a level 2 (practice enhanced precautions).

Does Probability Exist?

As I was trying to interpret the various weather predictions for icy roads in my area, I came across this great piece in Nature by David Spiegelhalter, an emeritus professor of statistics at the University of Cambridge, UK. It definitely appealed to the statistics nerd in me, but I think everyone, including people without a background in science, would learn from it. I especially enjoyed the "How ignorant am I?" quiz. You don't need any special background to take it, so try it out. Next week I'll reveal my score. [Note added: apparently I used my institutional access to see this article, it's not free content for everyone. My apologies to those who can't access it, I'll give more details about the quiz next week.]

What is the probability the Super Bowl will end in a tie? The rules don't allow that, so I guess it's as close to zero as you can get with any probability in this world.

BTW, Spiegelhalter's answer to whether probability exists was, "probably not - but it is useful to act as if it does." My kind of guy.

Published on Leave a comment on Happy World Leprosy Day!

I'm not sure I'd put this in the same celebratory category as a new year's event (January 29 is Vietnamese new year and Chinese new year for 2025), but it is noteworthy. WHO publicizes this day, and it might surprise some in the US that we had 369 new US cases detected in 2023, including 4 children. Here's a global map:

Leprosy still is one of the most stigmatized diseases in the world, fed by rumor and superstition. WHO is a good source for factual information. Speaking of WHO ...

US Quits WHO - What Does This Mean?

Well, this executive order doesn't mean anything immediately, assuming the new administration doesn't somehow violate the agreement for giving a year's notice to WHO before leaving. The US is obligated to pay for 2025. I have no direct experience with WHO, but it is well-known to be a large bureaucracy with the usual ponderous systems that this brings. I did find some better information from one of the many information sources I read, this one written by epidemiologist Dr. Katelyn Jetelina. She previously worked at WHO in Geneva, and her January 23 post provides more insight into how the loss of US funding for WHO might impact world health. She documents many problems with the WHO, but also provides a stark look at what the loss of US funds could portend. The US is the largest donor to WHO.

I'm hoping cooler heads will prevail and this exit won't go through.

MMWR Disappears

I've been subscribing to CDC's Morbidity and Mortality Weekly Report for more than 40 years, way back to when the paper copy came to me in snail mail every week. The communications embargo for health information, detailed in a memo by the acting Secretary for HHS, put a hold until February 1 on federal agencies issuing any information that hasn't been reviewed by a presidential appointee. The memo does allow for exceptions that include critical information, again requiring some sort of political appointee approval.

The MMWR isn't particularly controversial in my mind. I read it every week, but I suspect most healthcare providers don't keep it on their nightstands, or whatever that equivalent is in today's digital world. As of now, the current issue is listed as January 16, with nothing about a January 23 edition. Presumably we will miss January 30 as well.

I'm not so worried about this now, I'm sure we'd hear if we need to take any urgent action with bird flu or other emergency, but I am concerned about whether political censorship will affect the credibility of this information in the long run. I can still remember the chaos early in 2020 and the insistence by some of the value of hydroxychloroquine, ivermectin, and even bleach as effective treatments.

And, speaking of avian flu ...

Avian Flu Update (without CDC)

The Infectious Diseases Society of America broadcast a bird flu webinar, usually done in conjunction with CDC, but this time CDC wasn't mentioned in the title and none of the speakers had CDC appointments. I was able to attend the session in its entirety, and the recording and slides are available to everyone. In spite of the official CDC absence, the speakers were bona fide experts, and I learned several things.

The molecular difference between highly pathogenic avian influenza and low (not lowly) pathogenic strains (slide 6):

Recent global spread of HPAI by wild birds (slide 11):

Spread to dairy cows facilitated by excellent replication in mammary glands and transmission among cows mainly via milking machines (slide 16):

Experience in California suggests that conjunctival swabs may have higher yield of H5N1 than nasopharyngeal swabs (slide 37):

Remember that conjunctivitis is common (80%) in current human cases of H5N1 but is not a prominent feature of seasonal influenza.

Sequencing of strains from human cases in California suggest that the human cases arose by independent cattle-to-human infection events (slide 40), explained by the red dots below appearing in separate phylogenetic trees:

Also some discussion ensued about various testing options. The short version is that none of the tests are approved for conjunctival specimens, and the sensitivity of various tests to identify influenza A H5 is uncertain. Also unknown is whether testing costs in commercial labs would be covered by various insurance plans.

The penultimate presentation was by Bethany Boggess Alcauter, PhD, from the National Center for Farmworker Health. She provided a unique perspective that enlightened me greatly. It starts with slide 72. It was very clear that farmworkers have difficult jobs with little labor protections (below is slides 75-78):

One can easily imagine how tough it is to monitor and manage infections in these workers who now have the added burden of being more targeted for deportation.

A final presentation by Dr. Richard Webby from St. Jude Children's Research Hospital summed up in slides 86 and 87 the current understanding of H5N1 evolution and how difficult it will be to predict the future:

Antibiotics Can't Beat Cold Steel for Appendicitis

Moving away from various pandemic and political concerns for a moment, a new randomized controlled trial suggests that medical therapy alone is inferior to appendectomy (aka appendicectomy in the article) for management of uncomplicated appendicitis in children 5-16 years of age. This was a multinational study at 11 sites (2 in the US) that enrolled a little over 900 children with suspected non-perforated appendicitis.

Prior studies have suggested antibiotic therapy alone is an acceptable management pathway, and I suspect we haven't heard the last on this issue. For now I'd go with surgical intervention as the better alternative.

WRIS

With the muzzle on federal authorities releasing new data, I was interested to see what my usual information sites had available to me this week to monitor winter respiratory viral infection activity. I'm happy to report that the CDC's Respiratory Illnesses Data Channel was updated on Friday as per usual.

The NREVSS Dashboard also was updated (the cutoff date is January 17, but this diagram has additional data compared to last week's report).

I'm not subscribing to any crystal ball methods for predicting how WRIS will progress; I've seen some intimations that covid will be mild this winter, but I worry that some folks are trying to fit covid into a seasonal virus pattern which so far we've learned is not true.

Any bets on whether we'll see MMWR this week?

Happy Year of the Snake! Sức khỏe dồi dào

https://chus.vn/year-of-the-snake/
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