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Tag: chikungunya

Published on Leave a comment on Pumpkin Spice Season

Pumpkin spice season is in high gear, even though winter viruses haven't taken off.

It's a mixed infectious diseases bag this week, led by the almost complete silence from CDC due to the government shutdown. I've attempted to navigate through various sources to put together what is, at best, a semi-accurate state of affairs in the US. I also include mention of 3 significant articles that appeared in the past week.

Nimble News

My predilection for alliteration notwithstanding, I found a lot of tidbits in the news that I thought would be best summarized with brief mentions and links.

WHO announced that the last hospitalized patient with Ebola virus infection in the Democratic Republic of the Congo has been discharged. This starts a 42-day (2 incubation periods) countdown to declaring the outbreak over.

On Monday WHO also announced that Maldives is the first country in the world to hit the trifecta, i.e. elimination of mother-to-child transmission of HIV, hepatitis B, and syphilis. That may not seem so difficult for a group of islands in the Indian ocean with a total population of about 500,000, but it does have a brisk tourist industry that certainly challenges disease containment efforts. Given current trends, don't look for the US to come close to this achievement in your lifetimes.

Along similar lines, I noticed that the AAP is expanding their congenital syphilis toolkit, with much of it available to individuals who are not AAP members.

Details are scarce, but it looks like California now has 2 or maybe 3 cases of autochthonous (locally acquired without travel) cases of the clade 1 mpox that cropped up in Africa recently. The individuals are from Los Angeles and Long Beach and reportedly aren't connected to one another. This isn't unexpected; in fact, I'm mostly surprised that it took so long. Presumably California health authorities will provide updates in the coming weeks.

Speaking of autochthonous transmission, New York now has reported a case of locally-acquired chikungunya infection. Again, not a big surprise. Watch out for those tiger (Aedes albopicutus) mosquitoes, especially in the eastern half of the US.

First reported by the Wall Street Journal and then picked up by multiple news organizations (I can't supply a link, subscription required). a collection of "blue" states and a territory (California, Colorado, Connecticut, Delaware, Guam, Hawaii, Illinois, Maryland, Massachusetts, New Jersey, New York, North Carolina, Oregon, Rhode Island and Washington) have set up a consortium "to monitor disease outbreaks, establish public health policy guidance, prepare for pandemics and buy vaccines and other supplies." This was in response to CDC bailing on these duties. Effectiveness of this group will be constrained both by federal funding cuts as well as the fact that it (so far) lacks bipartisan membership.

Perhaps more futile as far as the US is concerned is a new report from the Global Preparedness Monitoring Board mapping strategies for pandemic preparedness for the future. In the past, even with more "pandemic-preparedness-friendly" US administrations, these types of reports have mostly been unheeded and forgotten.

WRIS

As best as I can determine, the winter respiratory infection season has yet to get underway. I'm mostly relying on Yale's POPHIVE resource, but it was last updated on October 6. Individual healthcare providers may be better served by consulting their local or state health departments.

Measles

South Carolina, specifically Spartanburg, seems to be the up-and-coming hotspot to watch. Thankfully CDC is still updating their case numbers, most recently on October 15. The official case count is 1596, which will lag from individual state reporting. Here's the current map:

Previously I had mentioned using the Johns' Hopkins county-level measles tracker, but I noticed a possible discrepancy in their reporting of a large number of imported measles cases in the twin cities area of Minnesota which was not reflected in the Minnesota state health department number which indicated these cases were locally-acquired. Possibly the discrepancy is due to different timing of reporting cases, but I'll continue to be wary of the Hopkins site even though the county-level data are more useful than statewide numbers.

New Streptococcal Pharyngitis Guidelines

Take special notice of this guidance from the Infectious Diseases Society of America because it is so long overdue and now recommends use of scoring systems for both adults and children with pharyngitis. The guideline is listed as "part 1" of the update, but I couldn't find any indication of when part 2 will be published. Here's an excerpt about use of scoring systems:

"In children and adults with sore throat, we suggest using a clinical scoring system to determine who should be tested for GAS (conditional recommendation, very low certainty of evidence)  

Remarks 

  1. High-risk individuals should be strongly considered for testing even if their clinical scores are low. Examples of high-risk individuals include those presenting with sore throat who have had household exposure to GAS (e.g., living or sleeping in the same indoor shared space as a person diagnosed with GAS infection), a history of a previous rheumatic fever diagnosis, or symptoms or signs suggestive of complicated local or systemic GAS infection (e.g., peritonsillar or retropharyngeal abscess, scarlet fever and/or toxic shock syndrome). 
  2. The panel recommends that a clinical scoring system be used as part of the evaluation of patients with sore throat. The principal utility of a scoring system is to identify patients with low probability of GAS pharyngitis, in whom further evaluation by diagnostic testing is unlikely to be helpful.  
  3. Given the lack of evidence favoring any particular scoring system, clinicians and patients may favor clinical scoring systems that do not include laboratory test(s).   
  4. The recommendation to use a scoring system does not apply to children under three years of age as GAS infection in this age group may not present with typical clinical features represented in these scoring systems.5 "

You will note that the recommendation is conditional with a very low certainty of evidence. In IDSA-speak, a conditional recommendation means that the majority of "informed" people would follow this recommendation, but "many" would not. Here is their Table 2 describing 3 scoring systems but recommending use of either Centor or McIsaac.

In the past my advice to frontline providers was against use of any particular scoring system, instead using the cluster of symptoms to make a judgment in individual cases. In general, the main focus should be on avoiding testing children with evidence of viral symptoms to decrease false positives due to detection of carrier states.

I predict we'll see some educational sessions from IDSA and AAP once the full guidelines are published.

1st Trimester Covid Vaccination Doesn't Cause Birth Defects

It's difficult/impossible to prove a negative, but this study adds reassurance that there is no suggestion of covid vaccination of pregnant women causing birth defects in their infants. It's a database study from France encompassing over 500,000 pregnancies; one-fourth of the infants were exposed to at least 1 covid vaccine dose during the first trimester. The results are reported in huge tables, too large for me to incorporate here. Suffice to say that there was no evidence of increased risk of major congenital malformations when correcting for maternal age, social deprivation, and folic acid consumption. The study did not include examination of stillbirths and terminated pregnancies because of difficulties identifying malformations in this population.

Fewer Ear Infections with RSV Vaccination

Also from France is a new report suggesting that RSV vaccination (maternal vaccination or infant nirsevimab) results in a lower risk of acute otitis media in infants. I was particularly intrigued because the study was carried out in a network of pediatric practices where practitioners where specifically trained to diagnose community-acquired infections. Based on the timing of implementation of these products in France, the post-immunization season of October 2024 - February 2025 was compared to the pre-immunization seasons, additionally accounting for non-pharmaceutical interventions during the covid pandemic. They also catalogued bronchiolitis and UTI diagnoses, the latter as sort of a negative control since RSV immunization shouldn't influence UTI rates.

Although the report included graphs, they're a little complicated so I'll just give you the takeaways. With over 70,000 AOM cases over the time period, the rates in children < 12 months of age decreased by about 23% with immunization, with no reductions seen in older children. Rates of bronchiolitis also decreased similarly in the younger children, but UTI rates were stable.

Don't Mess With My Espresso Drink

I'm proud to say I've never ordered a pumpkin spice-flavored drink at Starbucks, though I may have tested someone else's at some point. (I don't know why I should be proud of this, maybe just looking for something positive here.) I remain an espresso purist of sorts, now sipping a Bialetti "espresso" as I write these words. In researching the pumpkin spice craze more thoroughly, I discovered Starbucks started work on this flavored latte in 2003 with the original test sites being in Vancouver and Washington, DC - apparently I missed out on that focus group. Now everyone else has added this flavoring to their coffee menus.

I prefer my pumpkin in pies, though I usually go the lazy route with canned pumpkin rather than starting from scratch with the original fruit. For now, though, my pumpkin interactions focus more on jack-o-lanterns.

See you next week.

Published on Leave a comment on A New Beginning?

In the past week, Tuesday to be exact, I caught a glimpse of what the new world of vaccines may look like. I'll spend the remainder of this post talking about what I saw. It's not that nothing else is happening in the infectious diseases world - Texas declared its large measles outbreak is finally over though global and western hemisphere countries still have big problems. Chikungunya is starting to look like a real global threat this year, rivaling a serious outbreak 20 years ago. So far, autochthonous chikungunya has been an uncommon event in the US, but look for that to change over the next few years (IMHO).

That said, let's examine Tuesday's events.

New AAP Guidelines for Influenza, RSV, and Covid Vaccines

These appeared Tuesday morning, an attempt to come up with reasonable guidance that the newly-anti-vax ACIP won't give us. It somewhat pre-empted the Vaccine Integrity Project data presented later that afternoon (see below), and I thought this was odd. It wasn't clear if the AAP Committee on Infectious Diseases considered the VIP data in their deliberations. The influenza vaccine information was pretty typical: a shorter summary of the policy itself, accompanied by a detailed technical report with references. It contained nothing controversial, but I was interested in how they approached the thimerosol issue given that ACIP has raised that as part of their overall vaccine deterrence strategy. Here's what AAP said about that: "The AAP continues to support the current WHO recommendations for use of thimerosal as a preservative in multiuse vials in the global vaccine supply. Thimerosal containing vaccines are not associated with an increased risk of autism spectrum disorder in children. Thimerosal from vaccines has not been linked to any neurologic condition...Therefore, to the extent permitted by state law, children should receive any available formulation of IIV rather than delaying vaccination while waiting for reduced-thimerosal content or thimerosal-free vaccines. IIV formulations that are free of even trace amounts of thimerosal are widely available..."

The RSV policy is pretty straightforward, not much new except for inclusion of clesrovimab as a second monoclonal antibody recently receiving FDA approval. They do not express a preference when choosing between nirsevimab and clesrovimab. Note that these monoclonal antibodies appear to be upcoming targets for the new ACIP membership based on ridiculous obfuscation of data already vetted by the "older, better" ACIP. (Thanks to an alert blog reader who notified me of a conspiracy-like posting about this that has been championed by an ACIP member. I won't dignify it with a link.)

The Covid vaccine policy looks to be the most recent and is clearly intended to correct blatant errors by ACIP (or, rather, the HHS Secretary himself) in taking pregnant people and healthy children 6-23 months of age off the list of eligible candidates. Here's a quick look at the recommendations for the younger kids:

"Infants and children 6 through 23 months of age are at high risk for severe COVID-19. The AAP recommends all infants and children in this age group who do not have contraindications* receive 2025-2026 COVID-19 vaccine, as follows:
o Those who are previously unvaccinated should receive an initial vaccine series.

  • COVID-19 vaccine contraindication includes a history of severe allergic reaction (eg, anaphylaxis) after a previous dose or to a component of the COVID-19 vaccine.
    o Those who are previously vaccinated but did not complete their initial vaccine series should complete their initial vaccine series.
    o Those who are previously vaccinated and completed their initial series should receive a single dose. This dose should be administered at least 8 weeks after the last dose was received.
    o Those with a previous asymptomatic infection or symptomatic disease caused by SARSCoV-2 should also receive COVID-19 vaccination."

All 3 of the policy statements contain solid recommendations and for now should serve as the best guidance for the fall vaccination strategies. Still up in the air, of course, is what covid vaccine(s) will be available in the US. ACIP still hasn't stated when their August/September meeting will take place.

One final note on the AAP documents. The policies for RSV and Covid prevention were a little different in that they were not accompanied by technical reports. I also noticed in the long list of contributors the new members of the SOID were mentioned, although they weren't in the influenza statements. (Note these new members were appointed recently as part of the regular rotation of members.) So, I assume the flu vaccine documents were created a few months ago and updated with the more recent thimerosol controversy, while RSV and Covid policies were cobbled together more recently. I hope we will eventually see technical reports for the RSV and covid statements.

VIP Presentation

I confess I wasn't expecting much from the long-awaited Vaccine Integrity Project's presentation on Tuesday afternoon, mostly because I didn't think they could say much in the allotted 90 minutes. I'm happy to say I was wrong, there was a lot of detail, though they did cheat and take an extra 20 minutes to get everything in. I was able to sit in on the entire meeting, furiously scribbling somewhat legible notes. You can watch the entire meeting and look at the slides and an executive summary on their website.

The structure of the VIP's research enlightened me about their focus. They essentially performed standard comprehensive literature searches for RSV, influenza, and covid prevention methods dating back to the last real ACIP updates. For RSV this period was from August 2024 to July 2025; for covid 6/24 - 7/25; and for influenza 8/23 - 7/25. The methodology is registered in PROSPERO, an industry standard for conducting systematic reviews. In total they found 17,602 references which after screeing narrowed down to 1406 selected for full text review. From here, 590 articles were included in the final analyses, including 62 randomized controlled trials. Here's the final breakdown (co-administration means administration of these vaccines with other vaccines.)

The plan is to then share all their results with a number of professional societies; VIP apparently will leave construction of guidance documents to these societies, rather than make recommendations on their own.

Four VIP expert staff, along with Mike Osterholm, head of VIP and CIDRAP, presented their findings. Interspersed with the presentations were questions from a panel of 4 other individuals including the editor of the New England Journal of Medicine. The panel members asked great questions, I think they were excellent choices.

Dr. Caitlin Dugdale, an internist, discussed the publications regarding pregnancy; most focused on safety. Here are her conclusions from the collection of 34 recent articles in the review.

Note that Abrysvo is only recommended for administration at 32-36 weeks gestation, at a time when the preterm birth risk did not appear to be present. This preterm birth risk so far has been more associated with studies in low and middle income studies, raising the possibility that some confounding factor may be at play and that the vaccine eventually could be given earlier to pregnant people in high-resource countries. There were no studies on co-administration in pregnant people.

Another internist, Michael Albers, presented data on immunocompromised adults that you can view at the link at the top of this section.

The meat of the presentation for me was the new data on pediatric immunization by Dr. Marleen Harwah, a general pediatrician. She effectively presented the literature review but her answers to questions suggested to me she doesn't have a large clinical practice background nor familiarity with vaccine immunology and trial history; not a complaint, just that she didn't have that perspective to add. She described the results from a review of 69 studies, the majority dealing with VE.

For RSV prevention with nirsevimab, VE ranged from 64-95% against hospitalization in 13 studies and from 51-91% against ICU admission in 6 studies, for children <24 months of age.

Here is the final summary of the review:

Dr. Osterholm added his summary on the pediatric data in his executive summary: "There was a moderate volume of new data regarding the epidemiology of COVID-19, RSV, and influenza among children of all ages. Most notable were severe, sometimes fatal cases of influenza-associated encephalopathy in children, most of whom had not received age appropriate vaccination. Multiple studies provided new data demonstrating a protective effect of RSV (nirsevimab) and influenza immunization against medically-attended events and hospitalization. The review included several studies providing new data regarding the possible associations between COVID-19 vaccination and Guillain-Barré Syndrome (GBS) and myocarditis among children; no elevated safety concerns were identified. Additional pediatric vaccine effectiveness, safety studies, and co-administration analyses are ongoing."

What I can't show you (I didn't take any screenshots) was a preview of a wonderful data visualization tool that will be publicly available "soon." It's a highly interactive database that will allow anyone to do deep dives into the data, filtering for different pathogens. vaccines, and subpopulations, for example. It will definitely be my next rabbit hole dive.

Batesian Mimicry

Almost exactly a year ago, in posts of August 11 and 18, 2024, I revelled in my new knowledge and experience with Batesian mimicry surrounding Papilio glaucus, the tiger swallowtail butterfly, and its mimic the dark-form female. This summer has been a poor one for butterfly sightings in my butterfly garden, but yesterday I was excited to see both a typical tiger swallowtail and a dark-form female on the same New York ironweed (Vernonia noveboracensis). Unfortunately, my poor photographic skills combined with lepidopteral uncooperativeness means you'll need to use your imagination! (The standard tiger swallowtail is on the upper left of the bush, about at the level of the roof line. The dark-form female is lost in shadows farther down.)

It's a big stretch, but I wondered if the VIP presentation and the new AAP policies were forms of Batesian mimicry. Bates described this phenomenon as an attempt to disguise what would normally be a nice, palatable meal for a predator into another form that was less susceptible to attack. I'm sure those HHS predators will lash out at any new guidelines, but I hope VIP and medical societies will guard against vaccine extinction.

Published on Leave a comment on Federal Fiat Flurry

Last week's pronouncements and next week's events could tell us a great deal about the new landscape for FDA, NIH, CDC, and other federal healthcare agencies. Bated breath time.

Action on April 15-16 ACIP Votes Appears

You might recall that the ACIP finally met, a regular meeting postponed from February, and voted on some items. Usually the CDC director weighs in within a day or 2 to approve (or not) the recommendations. Unfortunately we don't have a CDC director, so the decision making was kicked higher up the food chain. Now, a month later, we have some movement on the meeting action items.

The major changes are about chikungunya vaccine, probably not a huge concern for most US frontliine pediatric providers but still important. On May 13, the HHS Secretary approved everything that was voted on, you can see the brief statement by scrolling down and opening the April 15-16 tab. I don't think the delay was a big deal, but note that we also have a lot of new concerns about chikungunya. CDC Travelers' Health raised to level 2 (practice enhanced precautions) the level of concern for chikungunya for travelers to certain areas in the Indian Ocean where outbreaks are occurring: Mauritius, Mayotte, Reunion, Somalia, and Sri Lanka. WHO put out some more details about Mayotte and Reunion.

(Also note FDA and CDC jointly put out a message on May 9 for people 60 years and older to avoid the live chikungunya vaccine - they can use the virus-like particle vaccine just recommended above. The issues with the live vaccine also were discussed at the April ACIP meeting, though from the discussion I had thought they were going to put the cutoff at age 65 rather than 60.)

Cloudy COVID Vaccine Future?

Remember last week I said I was trying to figure out when WHO was meeting to discuss the next iteration of covid vaccine composition? Turns out they met on May 15 and recommended that "... monovalent JN.1 or KP.2 vaccines remain appropriate vaccine antigens; monovalent LP.8.1 is a suitable alternative vaccine antigen." Basically what is circulating now isn't that different antigenically with what current vaccines contain, though the LP.8.1 variant might be slightly different and maybe a better choice for the fall.

Here's where things get murky, especially for those in the US. We are supposed to hear word from the FDA director about new regulations for vaccine approvals; I, and many others far more expert than I, are worried that we're going to see unnecessary hurdles for vaccine approvals that might be severely limiting financially to vaccine manufacturers and serve to slow all vaccine advances. Will the current mRNA vaccines need to undergo further testing? If LP.8.1 is used, will that require an onerous trial impossible to carry out in a few month time period?

We have some reason to be worried because of what has happened to the Novavax covid vaccine, which you will recall is a more traditional vaccine not utilizing mRNA technology. It was expected to be approved (elevating from emergency use authorization) by FDA this spring, but now FDA is requiring more information, some of which will require new trials, and we're not even talking about trials for children less than 12 years of age that seem to be on permanent hold. You can read the FDA approval letter that spells out all the studies. The vaccine presumably is still available, but approval delay may mean the vaccine wouldn't be covered by insurance except in very limited circumstances.

Remember MERS?

Enough of my hand-wringing about US healthcare policy trends. Middle Eastern Respiratory Syndrome, another virulent coronavirus infection first identified in 2012, now is again causing problems in Saudi Arabia. Nine new cases were reported between March 1 and April 21, the majority being healthcare workers exposed to a hospitalized person. Two of the nine, neither a healthcare worker, died; the remainder have recovered. It's a good reminder to all healthcare providers to pay attention to travel history and be careful. Hoping this won't develop into a major problem in Saudi Arabia - you can see what this has looked like over the past 13 years:

New World Screwworm

You'd need to go back to my post of March 2, 2025, to refresh your memory about this disgusting and painful disease. It's been creeping northwards and is a big threat to animals mostly. Now the USDA has stopped importation of live animals from south of the border to protect US animals (and people), because of screwworm detection in cattle within 700 miles of our border with Mexico.

Hepatitis A in California

This wouldn't seem like big news - hepatitis A is a big problem in high risk groups such as drug users and homeless people. It's disconcerting, however, that a new blip of hepatitis A in Los Angeles County is occurring in people without risk factors - about half of the cases.

I hope public health workers can figure this out quickly and eliminate any new source of hepatitis A in this community.

Measles

I feel a duty to keep reporting on this, though I think we are in for the long haul and (I hope) not any big new outbreaks to rival Texas. Here goes:

Per CDC, we are up to 1024 confirmed cases as of May 15. I think we are over the biggest hump for now.

I"m going to go out on a limb and start just posting monthly about measles, unless something noteworthy comes up in the meantime.

My Newest Feathered Friend

Speaking of limbs, or in this case deck railing, say hello to a new friend I met, the great crested flycatcher, aka Myiarchus crinitus.

The main reason my post is appearing Sunday night instead of early afternoon is that I was visiting family in South Carolina where I happened upon this creature. He (or she, I'm not sure) doesn't appear in the US (outside of the southernmost tip of Florida) except during breeding season. It mostly hangs out in Central and South America. Don't worry, birds don't harbor New World screwworm.

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 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.

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