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.
As summer approaches, infectious diseases travel risks are growing. Now more than ever it's important to check recommendations for protection.
But first, I had an interesting couple of days listening to a large chunk of the ACIP meetings this past week. I was pleasantly surprised that it went pretty well with minimal evidence of adverse effects of cost cutting and no evidence of lack of transparency or significant censorship. I'll give my take on the big picture of ACIP as well as some of the important discussions and decisions that impact child healthcare. I tried to distill the meeting points to essentials, but it's still long-winded. Apologies.
Advisory Committee on Immunization Practices Meeting April 15-16, 2025
The original meeting scheduled for February was planned to last 2 1/2 days but was shortened to 2 days, and it was jam-packed and fast-moving. Eleven different vaccine topics were on the agenda: mpox, Lyme disease, influenza, COVID-19, pneumococcal, HPV, CMV, meningococcal, RSV adult vaccines, RSV maternal/pediatric vaccines, and chikungunya. There was also a brief presentation on the measles outbreaks. The only votes taking place were for meningococcal, RSV adult, and chikungunya vaccines. Others may have votes at the regular June meeting if the specific products being discussed are approved by FDA as seems likely next month for a few products. All the slides are available at https://www.cdc.gov/acip/meetings/presentation-slides-april-15-16-2025.html.
General
Most importantly, ACIP still exists and appears relatively unscathed. The presentations contained a lot of information, sometimes a little too quickly for adequate digestion by those unfamiliar with minutiae of specific vaccine immunology. I did feel there was adequate time for discussion and questions from committee members. A few things I was particularly looking for:
Evidence of Funding and Personnel Cuts - This appeared minimally, maybe just with respect to AV support. There were 2 instances in the streaming where lack of AV support stalled the meeting briefly.
Conflicts of Interest - ACIP and CDC have always been very strict about this. In the past, some of the members had worked on vaccine trials, but with new members appointed last year (well before the presidential election), it seems that fewer members have that background. All were required, as usual, to state any COIs up front. None had any noteworthy conflicts, but a few members did abstain from certain individual votes based on some potential appearance of COIs, for example having some involvement with a vaccine a decade previously, or serving on a data safety monitoring board for a vaccine in the distant past. I wondered if those individuals were bending over backwards to avoid any opportunity for lay press and politicians to falsely claim they had COIs.
Membership - A couple new committee members were added, nothing controversial to my eye. I was also intrigued to see a new nonvoting ex officio member representing the FDA, Dr. Hoag. Usually the FDA representative is someone directly involved with reviewing vaccines and is an expert in both FDA regulations and all aspects of vaccines. In contrast, Dr. Hoag is a political appointee with a background in sports medicine and epidemiology.
DEI and "Wokeness" - One of the standard evaluation measures used by the CDC/ACIP is an "Evidence to Recommendations" assessment that includes 7 domains: (is the disease) a public health problem; benefits and harms of vaccination; values (of the target population); acceptability (to key stakeholders); resource use; equity; and feasibility. I was particularly worried about whether the important equity domain would survive, and I'm happy to report that it did. In terms of wokeness, I did see that CDC presentations used the term pregnant "women" rather than pregnant "people." Also, Dr. Hoag used the term "monkeypox" for mpox, perhaps just a slip for someone who hasn't been involved with mpox at all.
Public Comment Session - As for most meetings, 30-minute public comment sessions provide an opportunity for 10 individuals to speak for 3 minutes each. If more than 10 people apply to comment, the speakers are chosen by lottery which was the case for the single public comment session on April 16. Usually the speakers are a large mix - some from organizations and some individuals, some pro-vaccination and some anti-vaxxers, some well-informed and some misguided. The mix was very different this time around: all 10 speakers were very clearly in the pro-vaccine camp. Two were even from the same organization. For this to have resulted from a lottery process implies that the overwhelming number of applicants were pro-vaccine. I haven't heard about any unified effort to flood the ACIP public comment applications, but I suspect that the dramatic changes in HHS and CDC served to activate a large backlash from people who recognize the value of vaccines; after all, they do represent the majority of the US population.
Balancing Simplicity With Individuality of Recommendations - This is nothing new, but it was even more evident at these presentations that CDC is trying to simplify vaccine recommendations, including harmonizing among various risk populations. They hope to improve on the problem that occurs when recommendations vary for different individuals and it becomes difficult to explain all that to healthcare providers as well as to the general public. I think we'll see even more of a move towards harmonizing recommendations among different risk groups and less advice to use shared clinical decision making. I'm a bit sad about that, it probably results from many folks being tired of hearing about vaccines in general plus clinicians feeling like they don't have the time to explain this to their patients. On the other hand, there is a movement to have less universal recommendations, such as for covid vaccination, with more emphasis on vaccinating high risk groups. See the covid section below for more information. The modern practice of medicine has always involved translating general results from studies of groups of individuals to use in a specific patient who may or may not exactly fit the subjects in a research study. That requires thought and time. The best clinicians find a way to understand the evidence behind vaccine recommendations and incorporate this into shared clinical decision making.
Mpox
The discussion revolved around approval for mpox vaccine in the 12-17 year old age group based on subsequent vaccine trials, a pretty straightforward question that was approved. I did find a few of the slides helpful in understanding the history and recent trends in the outbreaks. Both the clade 1 and clade 2 outbreaks are currently problematic.
Recommendations differ for outbreak versus routine vaccination strategies for adolescents and adults at risk for mpox.
Influenza
Regular readers will recall that the usual annual FDA VRBPAC meeting to choose the components of next year's flu vaccine was cancelled, and the strain choices were determined without advisory committee input. The ACIP discussion centered on home administration of FluMist, the live attenuated intranasal flu vaccine. The data are pretty good, but the devil is in the details - all kinds of regulatory and tracking details, including but not limited to the fact that some states won't allow prescriptions across state lines, so if you live in West Virginia but your primary care provider is in Maryland you might have trouble. Also, there can be lots of bumps in the road ensuring that the vaccine was in fact administered at home and logged into the individuals vaccine records. We're going to hear more about this in coming months, hopefully decided well before the next flu season.
COVID-19
This discussion probably got the biggest headlines. First, some general points.
Most of our population has immunity to covid, either by vaccine, infection, or both.
As the bottom statement indicates, vaccine effectiveness should focus as what the added benefit of vaccination is for a population with pre-existing immunity. Unfortunately, given the very small numbers of children receiving any covid vaccines recently coupled with the good news that events like hospitalization and deaths are relatively infrequent in children infected with SARS-CoV-2, we don't have enough data to make any VE estimates in the pediatric population. Here's the adult data:
CDC presenters noted that we experienced an increase in virus circulation in late summer 2024 just before the 2024-25 vaccines were approved and available. Natural infection during this time may have increased population immunity against the most recent strains and could have caused measured VE to be lower than if this surge had not occurred just before most people received the new vaccine.
As I've said in numerous other posts, if one looks at the impact of covid vaccination on individual pediatric patients, rather than at a population and cost-effectiveness level, the benefits of vaccination far outweigh the risks; but, it's relatively expensive to vaccinate all children, looking purely from a cost-effectiveness standpoint. Note that the cost-effectiveness studies for pediatric covid probably are similar to those seen for universal meningococcal vaccination for adolescents - small numbers of cases so higher cost of prevention, even for a more deadly infection like meningococcus.
Also, it's worth remembering that covid deaths in children are in the same ballpark as influenza-associated deaths in the US (no final data yet from this year's flu season).
Previously I've mentioned how the UK has a much more restrictive use of covid vaccines, coming from the population-based approach with the National Health Service paying for all recommended vaccines. One of the CDC presenters had a nice comparison of covid booster recommendations from around the world. I'm glad I don't have a child or grandchild living in Australia.
What is being considered is now changing the US recommendations to look more like these other countries, without a blanket recommendation for certain low-risk groups, including healthy children, while still allowing anyone who wishes to receive a vaccination. If this is ultimately the recommendation, it seems likely that the low-risk populations will have to pay out-of-pocket for the vaccine, disadvantaging our low income families and worsening health equity.
As you might surmise, my bias is still to recommend covid vaccines for healthy children.
HPV
Again no votes on the human papillomavirus vaccine, but a lot of discussion and confusing options for what's to come which could involve changing to just 1 vaccine dose being routinely recommended. First, some really good news for VE. If you compare the prevalence of the 2 HPV genotypes represented, the HPV vaccine has resulted in a dramatic decrease over the past 10 years.
I'll spare you the tremendous amount of modeling studies that were discussed and just focus on conclusions that basically came down strongly in favor of switching to a single dose vaccine schedule, even using a worst-case scenario model for vaccine efficacy and duration of protection. Also, if the 1-dose protocol wasn't working, ongoing monitoring by CDC would allow for new mitigation strategies before vaccine strain prevalence and new cervical cancers appeared.
However, here's where another concern about budget cuts appeared. One of the committee members asked whether CDC will still be able to collect this data going forward, and the answer was a non-reassuring yes, "as far as we know."
A good deal of time was spent on the harmonization of recommendations, particularly with respect to the "adolescent platform" of regular visits and how a proposed recommendation that lumped 9-10 year-olds into the recommendation with the current 11-12 yo start of HPV vaccinations would disrupt this platform of adolescent primary care visits. There seemed to be large differences of opinion among stakeholders here. Expect a vote at the June ACIP meeting.
Measles
No new data here, but yet another comment on resources when discussing trying to get the various outbreaks under control. A CDC member stated they were "scraping to find resources" to handle things.
Meningococcus
By far the most complicated, with a new pentavalent vaccine on the launching pad and a multitude of discussion about how this could be accomplished without asking primary care practices to stock up to 5 different meningococcal vaccines. A key take-home for primary care providers: groups A, C, W, and Y vaccines are interchangeable, but meningococcal B vaccines are not - you really need to give a second dose of meningococcal B vaccine using the same manufacturer as the first, for both pentavalent and monovalent products. So, we potentially will have 2 pentavalent vaccines containing group B plus 2 monovalent group B vaccines. This is a potential nightmare for private practices in terms of stocking vaccines, and a potential problem for managing college outbreaks where one needs very accurate vaccine records to know which group B vaccine to use for at-risk students. Most colleges require this information up front, certainly it isn't very feasible to find missing information in a timely manner during a meningococcal outbreak in a college dorm.
I'd expect some new wording for meningococcal vaccines to be approved at the next (June) ACIP meeting, likely a simpler, harmonized recommendation.
Other discussions centered around another quadrivalent conjugate vaccine for high-risk infants, likely to be approved by FDA next month. The ACIP plans to discuss at the June meeting if FDA approval is granted.
Next Steps
The votes need to be approved by CDC, usually a task carried out by the FDA Director. However, this spot is vacant, filled only by an acting director who is not participating in any formal duties. It looks like the approvals, if they occur, will emanate from a higher bureaucratic level.
More Measles Milestones
But certainly nothing to celebrate. In the US, we ended the week at a round number, 800 confirmed cases; 11% have been hospitalized.
We are up to 25 jurisdictions reporting cases, and a total of 10 outbreaks (defined as 3 or more connected cases). Still no signs of slowing down.
Texas alone is up to 596 cases including 36 added in the past week. It seems likely the US will surpass the 2019 total of 1274 cases, which was the highest since the US was declared measles free in 2000. Meanwhile, Canada might be in even worse shape, largely due to measles in Ontario. They are up to 880 cases this year, although this total includes 132 probable but not yet confirmed cases. It is already the highest total since Canada was certified free of endemic measles transmission in 1998.
Measles is problematic in almost the entire world now. For travel in Canada and the US, check destinations to determine whether early vaccination for infants and children is warranted.
Yellow Jack is Back - New Warning
Last week CDC upgraded their traveler warning for South America to Level 2 - Practice Enhanced Precautions. Colombia reports 75 cases with 34 deaths since September 2024, likely an undercount, and new areas of Bolivia and Peru now have yellow fever cases reported. I worry that travelers and clinicians can't keep up with new yellow fever vaccine recommendations, it's confusing and changing.
For clinicians unsure about clinical findings of yellow fever, the CDC Yellow Book is an excellent resource. (It's called the Yellow Book because the original print version had a yellow cover; now it's mostly black.)
Ignorance is Bliss versus Knowledge is Power
One might think that having my background in infectious diseases is helpful in planning travel. Or, if you side with my long-suffering wife, it might just be the bane of your existence. We have travel plans to various areas planned in the next several months. I'm not too worried about measles, we both had natural infection as children and I know that my measles IgG titer was very high a few years ago. Unfortunately vaccinations won't help us with the list of other infections to which our itinerary might expose us: Vibrio vulnificus, chronic wasting disease, Cryptococcus gattii, to name a few. Fortunately, none are very likely; I'll concentrate on sun protection and keeping well-hydrated.
It was a busy week for infectious diseases, not in the sense of more outbreaks but rather more epidemiologic and vaccine data that point to better health for the future.
The big topic of the week was the Advisory Council on Immunization Practices regular February 2-day meeting. In retrospect, pediatric healthcare providers won't have any major new recommendations to work with; those are likely coming following the next meeting the end of June. I wasn't able to view as much of the meeting as I had hoped, patient care interfered a bit, but I did review all the presentations for those that I missed hearing live. Let's dive in.
ACIP
The Council discussed 9 different topics, but only 3 involved voting: COVID-19 vaccines (vote in favor of a spring vaccine for some high-risk people), Chikungunya vaccine (vote for use in some US adult travelers and in laboratory workers), Td vaccine availability for those with contraindications to receiving pertussis vaccine (discussion followed by a vote regarding the Vaccines for Children progam), influenza vaccines, polio vaccines, RSV vaccines for adults, meningococcal vaccines, pneumococcal vaccines, and the new Vaxelis combined product for diphtheria, tetanus, pertussis, polio, Hib, and hepatitis B. I'll expand on just a few of these topics. (Note all of the graphs/figures below are from the ACIP web site presentation slide link for the February meeting.)
RSV
We saw the most up-to-date representation of RSV epidemiology, showing that the epidemic curve for this year looks a lot like prepandemic years (see last presentation in RSV session).
A good part of the discussion centered on risk of Guillain-Barre syndrome following vaccine, compared to risks of GBS in the baseline population. Both are rare events, but I think at this point it is reasonable to conclude that GBS is a rare risk of RSV vaccination, though not enough to outweigh benefits for high risk populations.
A quick look at the benefits versus GBS risks for adults > 60 years of age (Melgar presentation from RSV session):
Note risks might vary with vaccine type - hard to know with rare events and large confidence intervals, plus both in the ballpark of background GBS numbers.
Influenza
This session was interesting for me to see a preliminary assessment of vaccine effectiveness for the 2023-2024 flu season. I'll just show you an overview of VE in the pediatric population; note that multiple methodologies are used to measure VE. (See slides from Frutos presentation in the influenza section.)
This is good VE for flu, certainly the CDC and WHO were on track for choosing the best combination of strains for this season. Look for the vote for next season's vaccine composition in June.
Meningococcal Vaccines
The focus of the discussion was how best to incorporate meningococcal B vaccine now that we have an approved combination vaccine containing this serogroup. Here are the main options discussed, from the 1st Schillie presentation:
The issues are complex, primarily due to 3 factors. First, meningococcal group B infections are extremely rare; traditional cost-effectiveness models show that meningococcal B vaccination in the US is by far the most expensive vaccine; very few cases are prevented due to the rarity of infection. Second, vaccination at age 11-12 risks significant waning of immunity by the age for peak meningococcal disease in adolescents; it might make sense to move the first dose to a later age. (The main argument against this is the confusion caused by eliminating the long-standing practice for vaccination at age 11-12, perhaps lowering overall vaccine acceptance.) Third, it is clear that not all meningococcal disease risk in adolescents is equal: college attendance is prime, but there are other behavioral risk factors (1st Schillie presentation):
The discussion was mainly to hear input from all stakeholders and then go back to the drawing board. Expect a vote on this at the June meeting - it will greatly impact your summer vaccine guidance for adolescents and young adults.
COVID Vacines
This section of the meetings seemed to garner the most publicity. Of course most of the results presented dealt with adults, given the relatively lower risk for bad outcomes in children plus low rates of vaccinations. Most helpful I thought were the discussions about covid VE in recent months looking at the fall monovalent vaccine.
These are great numbers. Also mentioned was the fact that waning of efficacy hasn't been seen yet, but that could just be a result of not having enough time to pass since the fall vaccine. Other good news is that in vitro studies suggest that the current monovalent vaccine is likely to protect against newer variants.
Special situation for people ages 65 years and older: People ages 65 years and older should receive 1 additional dose of any updated (2023–2024 Formula) COVID-19 vaccine (i.e., Moderna, Novavax, Pfizer-BioNTech) at least 4 months following the previous dose of updated (2023–2024 Formula) COVID-19 vaccine. For initial vaccination with Novavax COVID-19 Vaccine, the 2-dose series should be completed before administration of the additional dose.
That "should" wording was the subject of much debate, finally choosing this wording more for simplicity of recommendations. The gnashing of teeth came about for a good reason - people in the lower end of this age population who do not have underlying risk factors will have less benefit from a spring vaccine because rates of bad outcomes in the post-pandemic period are lower.
Recommendations for younger people with moderate or severe immunocompromise have slightly different wording:
People ages 12–64 years who are moderately or severely immunocompromised may receive 1 additional dose of any updated (2023–2024 Formula) COVID-19 vaccine (i.e., Moderna, Novavax, Pfizer-BioNTech) at least 2 months after the last dose of updated (2023–2024 Formula) COVID-19 vaccine indicated in Table 2. Further additional doses may be administered, informed by the clinical judgement of a healthcare provider and personal preference and circumstances. Any further additional doses should be administered at least 2 months after the last updated (2023–2024 Formula) COVID-19 vaccine dose.
People ages 65 years and older who are moderately or severely immunocompromised should receive 1 additional dose of any updated (2023–2024 Formula) COVID-19 vaccine (i.e., Moderna, Novavax, Pfizer-BioNTech) at least 2 months after the last dose of updated (2023–2024 Formula) vaccine indicated in Table 2. Further additional doses may be administered, informed by the clinical judgement of a healthcare provider and personal preference and circumstances. Any further additional doses should be administered at least 2 months after the last updated (2023–2024 Formula) COVID-19 vaccine dose.
For all age groups, the dosage for the additional doses is as follows: Moderna, 0.5 mL/50 ug; Novavax, 0.5 mL/5 ug rS protein and 50 ug Matrix-M adjuvant; Pfizer-BioNTech, 0.3 mL/30 ug.
As an aside and not receiving much media attention, a new report showed that vaccine mandates didn't help and probably hurt. States with vaccine mandates didn't have higher covid vaccination rates and actually had lower covid booster uptake and flu vaccination rates. Yikes!
Nipah Virus
Never heard of it, or hard-pressed to find facts at the tip of your tongue? Most providers in the US don't need to know much about this bat-borne virus, but if you have any patients planning a trip to Bangladesh you may want to advise them not to consume raw date palm sap (not on my list of delicacies so far) and to stay away from pigs.
NiV gets its name from the village of Sugai Nipah in Malaysia, site of a 1999 outbreak highlighted by cases of encephalitis in pig farmers. Outbreaks typically occur in Bangladesh and India. Now, the World Health Organization reports that 2 individuals, including a 3-year-old girl, have died from the infection after consuming raw date palm sap. The sap likely was contaminated with fruit bat droppings laced with NiV. In addition to signs and symptoms of encephalitis, typical findings are those of nonspecific febrile illness. Diagnosis is difficult until/unless encephalitis findings appear. It's a relatively uncommon infection even in Bangladesh, but mortality is high.
Good Attitudes
It's a sign of our times that I was pleasantly surprised to see a vaccine attitude survey with good news. Investigators from RAND corporation, University of Iowa, and CDC performed an online survey of 1351 parents to assess their willingness to have their children 5-18 years of age receive a vaccine to prevent Lyme disease. About two-thirds of parents definitely or probably would vaccinate their children. The boldface numbers below show statistically significant predictors of willingness to have their children receive Lyme vaccine, with willingness of the parent to receive the vaccine the strongest predictor.
In case you were wondering, for the purposes of this survey the high incidence states were Connecticut, Delaware, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Virginia, Washington D.C. (yes, I don't need to be reminded it's not a state), West Virginia, and Wisconsin. They also looked at states characterized as "emerging" Lyme disease states (Iowa, Ohio, Illinois, Indiana, Michigan, North Carolina), but this group had a slightly lower rate of willingness than in high incidence states. Lyme vaccine trials in the pediatric and adult populations are ongoing, so don't be surprised if parents and children have this option in the next year or so.
Speaking of attitudes, take a look at AAP's new guidance for improving vaccine communication and uptake. It has an excellent literature review and describes various strategies that pediatric healthcare providers can use to improve vaccine acceptance. It is still true that different studies sometimes have reported different conclusions on how best to discuss vaccine hesitancy with parents, likely because it is very difficult to design studies that deal with such subjective issues in a uniform manner.
WRIS
Winter respiratory infection season is still chugging along, mostly due to influenza which is stubbornly persisting in scattered areas in the US. What a crazy patchwork!
New Covid Isolation Guidelines
Maybe this has overshadowed everything in the news. I've discussed this recently in the blog and was expecting the new guidelines to come in April, but CDC bumped it up by a month. It incorporates new information about covid epidemiology, hospitalization rates, and outcomes with balancing for impacts on the economy and on school and work attendance into a comprehensive guideline for all respiratory infections. So, no longer do we have a specific number of days after covid diagnosis to remain out of school or work. The document has multiple links and is pretty complicated. The CDC's press release is a good summary, however. Note that vaccination is still stressed heavily, though I expect it will be ignored by the same hardcore group of antivaxxers. Here's the quick blurb:
"When people get sick with a respiratory virus, the updated guidance recommends that they stay home and away from others. For people with COVID-19 and influenza, treatment is available and can lessen symptoms and lower the risk of severe illness. The recommendations suggest returning to normal activities when, for at least 24 hours, symptoms are improving overall, and if a fever was present, it has been gone without use of a fever-reducing medication."
I am very much in favor of these new recommendations. Circumstances have changed, and we have learned a lot from management of the pandemic these past few years. I just hope our vaccination rate will improve and that people with any respiratory symptoms at all will be aware that they can pose a significant risk to others who may have circumstances putting them at high risk for hospitalization or death from respiratory viruses. Also, please note this only applies to community settings; there are no changes for healthcare settings.
Squirrel Redux
If I were superstitious, I wouldn't mention the fact that my neighborhood squirrels still have not attacked my newly-positioned bird feeder. I was bemused by an article in the Local Living section of the Washington Post last Thursday, clearly written by a squirrel lover. Squirrels do have value, and I have no desire to wipe them off the face of the earth. I just don't want them eating all my bird seed.
A friend of mine in South Carolina with an array of bird feeders and birds also has come to terms with squirrels, albeit somewhat differently than my crazy solution. He just monitors things, and when the squirrels reach a point that he feels they become a significant barrier to maintaining bird happiness and seed access, he uses a humane trap to collect squirrels and then release them far from his neighborhood. I won't disclose where he releases them, but it sounded like a good place for squirrels and unlikely to bother too many people. I wonder if any of them found their way back to him.
I was thumbing through my Farmer's Almanac this morning and noticed a mention of "Indian summer" for November 12. That's not a great term to use nowadays, so I'm opting for the European version called St. Martin's summer or day. I never bothered to see what these terms really meant, but I've learned it represents a period officially from November 11 to November 20 where we experience unseasonably warm weather. We've certainly had that recently, though November 11 and 12 in Maryland is back to cool fall weather.
Miscellaneous Vaccine News
I have no idea what a "miscellaneous" vaccine is, I was just desperate for something to title this section.
A new vaccine to prevent chikungunya virus infection was approved by the FDA this week for individuals 18 years and older at increased risk for infection with this mosquito-borne pathogen. It is a live virus vaccine. As with most arboviral illnesses these days, the vector range is expanding as our climate warms, and transmission has occurred within the US. Still, most infections in US residents are acquired via travel to more endemic areas such as Africa, southeast Asia, and Central and South America. The clinical illness is similar to dengue fever and mostly is a miserable but self-limited illness. However, elderly are at risk for complications, principally chronic joint disease. Newborns also are at risk for more severe disease, including death, and it is unknown whether the vaccine virus could be transmitted to the fetus. The package insert includes precautions for use in pregnant people. The main study supporting approval appeared a few months ago and looked primarily at side effects and antibody response, not actual vaccine efficacy. One big caveat, the manufacturer is required to conduct post-marketing studies to ensure that vaccine recipients do not develop a worse form of chikungunya after becoming infected; this is a possibility though not highly likely. For now, I'd consider this mostly as an option for older individuals at very high risk for infection. Most other US residents should wait for further information about the vaccine, but it's good we have this option available.
This past week also saw publication of new data from Singapore about benefits to newborns of covid vaccination of mothers during pregnancy. It was a cohort study, which is a study design slightly more prone to inaccuracies than are randomized controlled trials, but it did show about 40% efficacy in preventing infection in newborns when their mothers were vaccinated during pregnancy. Of interest, pre-pregnancy vaccination of mothers was not effective in preventing newborn infection. The study covered the period from January, 2022, through March 2023. This is yet another reason to encourage covid vaccination for pregnant people, along with pertussis and RSV vaccination. The benefits do extend to their children.
Unfortunately, we also have some disappointing vaccine news in the category of missed opportunities. First, 2 studies from the CDC demonstrated poor influenza vaccine uptake by healthcare providers. In the first report, flu vaccination rates for HCP in acute care hospitals fell from 88.6 - 90.7% in the years 2017-2020 down to 85.9% in 2020-2021 and 81.1% in 2021-2022. We all know that the pandemic made it difficult to access regular health care for many people, but these are workers in acute care hospitals who didn't have that excuse. The second study looked at a broader range of HCP during the 2022-2023 flu season and showed 81.0% flu vaccination rates in acute care hospital employees and a shocking (to me) 47.1% rate for nursing home employees. Up to date covid vaccination status rates were even more depressing: 17.2% and 22.8% in acute care hospitals and nursing homes, respectively. I can understand why some people may choose not to receive these vaccines, but HCP do have a responsibility to protect those for whom they provide care. (IMHO; I'll get off my soap box now.)
Also in the Debbie Downer category, CDC reported that vaccine exemptions for kindergarteners increased for the 2022-2023 school year. The rogues' gallery includes 10 states (Alaska, Arizona, Hawaii, Idaho, Michigan, Nevada, North Dakota, Oregon, Utah, and Wisconsin) having exemption rates above 5%. Idaho easily came out on "top" with a 12.1% exemption rate. The reasons for high exemption rates are complex, note that the list of states doesn't necessarily follow political lines. States that make it more difficult for parents to apply for non-medical, aka philosophical, exemptions have lower exemption rates overall. An oldie but goodie study also stressed that exemption rates vary within a state, and small hot spots with high exemption rates can fuel outbreaks of vaccine-preventable diseases.
Missed Opportunities to Prevent Congenital Syphilis
The CDC was very busy this past week! Another report looked at missed opportunities for prevention of congenital syphilis in 2022. Looking at the 3761 cases of congenital syphilis reported that year, almost 90% of birth parents received inadequate management. This included no or nontimely testing (36.8% of parents) and no or nondocumented (11.2%) or inadequate (39.7%) treatment. I'm hoping our public health infrastructure can be shored up to lower cases of congenital syphilis, now at a 30-year high.
Tripledemic Update
Rather than showing yet another RSV-NET graph, where data are somewhat delayed anyway, I thought I'd mention a bit more about that system. It is set up in 14 states covering about 8% of the US population. Here's what the distribution and data collection looks like:
I'm not sure why (Veteran's Day?) but FLUVIEW did not update this past week, so nothing new to report there. Wastewater covid levels reported by Biobot remain lowish.
No Hasty Pudding Again This Year
I'm starting to help plan a Thanksgiving menu for later this month, and I was reminded of another ill-named item, Indian pudding. It is similar to the British hasty pudding that uses wheat flour rather than cornmeal. I have a wonderful recipe, dated 1958, from the Durgin-Park Restaurant in Boston. Durgin-Park opened in 1742 and closed in 2019, and this dessert was an icon on their menu. The reasons I won't be having it again this year are multiple but include the fact that I'm the only one in my family who likes it and that it contains about 5000 calories per tablespoon (only slight exaggeration). I think I'll just change the name to Durgin-Park pudding for future reference.
