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Tag: COVID-19 vaccine booster

Published on Leave a comment on Seeing Spots Before Your Eyes?

Washington, DC, had a record high temperature 1 day during our heat wave this past week, and I suppose if you glanced at the sun you might see some spots for a few seconds. But of course I'm referring to different spots in this post.

Measles

I'm probably the only person who has read all of my blog posts over time, so you're forgiven if you don't realize I'm in broken record mode here. I can't count the number of times I've warned providers to be on the lookout for measles cases, and now we are facing a global decline in immunization rates that probably puts us at greatest risk since the modern-day measles vaccine was available in 1968 (the original Enders vaccine appeared in 1963). We've enjoyed some low numbers in the US recently, but that appears to be changing with 9 cases (from Georgia, Missouri, New Jersey, and Pennsylvania) reported to CDC so far this month.

CDC released an alert last week mentioning 23 US cases between December 1 and January 23.

I won't review everything about diagnosis of measles, the CDC website alert is a good resource with links to other sites, but I do want to highlight a few helpful nuances that aren't often mentioned. First, measles is fairly unique among exanthematous infections in that the prodrome interval, the time between onset of first symptoms and appearance of the rash, is long, usually a few days. Most infectious diseases accompanied by rash have very little or no time between onset of symptoms and appearance of the rash, with erythema infectiosum being a notable exception but not easily confused with measles clinically.

The measles prodrome consists of a febrile illness with cough, coryza, conjunctivitis, and Koplik's spots. You can find pictures of Koplik's spots everywhere on the web, but in my experience as an old geezer who has seen many cases of measles in children, they aren't that easy to see or photograph. Therefore, the photos available in textbooks and on line are skewed towards the most obvious. One needs to do a careful oral exam looking for gray or bluish-gray or white fine spots (almost sandpapery) anywhere on the buccal mucosa; the inside of the lower lip is particularly helpful. If you're not sure, find an old geezer clinician to confirm.

In the absence of Koplik spots, or if you don't see the child until the rash appears and the Koplik spots have resolved, pay close attention to the history. Specifically ask for a day-to-day accounting of symptoms; if you feel the parent or patient can recall reliably, noting at least a 2-3 day lag between the onset of high fever, cough, rhinorrhea, and conjunctivitis before the rash appears can be strongly suggestive of measles; the absence of this lag is against the diagnosis. Other alarms to increase your suspicion would be lack of 2 measles immunizations, international travel, and/or exposure to a suspected measles case.

"It ain't what they call you.....

..... it's what you answer to." - attributed to W.C. Fields, though I can't verify the origin.

I thought of Mr. Fields when I heard about administration errors involving the adult RSV vaccine (brand names Abrysvo and Arexvy) given to children and pregnant people. From my viewpoint, it was an accident waiting to happen, due to a name.

In order to speed payment allowance by the Vaccines for Children and other programs, the long-acting monoclonal antibody nirsevimab was officially designated a vaccine. Strictly speaking I guess this is correct: antibody administration is a form of passive immunization. However, the true RSV vaccines are intended only for adults with high risk conditions or for pregnant people to help protect newborns after birth. It was inevitable that confusion would ensue. The notice provides almost no details but does state that most administrations to young infants were "nonserious." Infants who wrongly received an adult RSV vaccine should be considered unprotected and still receive nirsevimab.

WHO Fans the Covid Mask/Distancing Controversy

WHO riled a lot of public health experts with its recent guidance for infection control in healthcare facilities. The main controversial elements involve recommendations to use physical barriers such as plastic windows for areas where patients first present (rated as conditional recommendation, very low certainty of evidence); maintaining a physical distance of at least 1 meter between people ("good practice statement"); and not sufficiently highlighting superiority of respirators (e.g. N95 masks) for general care - this particularly angered those who favor the aerosol, rather than droplet, mode of transmission for SARS-CoV-2. In general it seemed that the WHO panel carried over some details for infection control that do not have strong evidence for use and in some cases (plastic barriers) may be contradicted by other studies.

Note that much of the controversy involves how much weight to give transmission simulation studies - e.g. distances that SARS-CoV-2 travels under experimental conditions rather than real-world evidence which is much more difficult to come by. It's hard for an individual medical practice to make these decisions on their own, best to abide by state or local health department guidance.

Spring Covid Vaccination?

Canada released guidance for covid vaccination this spring, advocating for an additional dose of the XBB.1.5 vaccine recommended last fall. I'd look for the US to make similar recommendations soon. ACIP has a regular meeting scheduled February 28-29, but no agenda is yet available. FDA doesn't have anything scheduled, and they may not need a separate advisory committee meeting for this.

WRIS

In general we seem to be trending downward with our winter respiratory infections, but still lots of runny noses, coughs, and more around.

For RSV I still look primarily at hospitalization rates in young children, the purple line in the graph below, because I think it's the most accurate gauge of RSV. I suspect almost all of these hospitalized children are tested for RSV and flu. The rate clearly is trending down, it's looking like we won't replicate the horrible RSV season of last year.

Influenza-like illness seems to be cooling off as well, as seen in FLUView. Note this measurement includes respiratory illnesses mimicking flu so could be any respiratory virus; there are many more ways to look at flu activity in general, all with their own inaccuracies. In the past I have found this map to be representative of what I've seen clinically in my practice areas.

Covid wastewater (I've said before why I prefer this qualitative measurement) continues to trend downward, and levels are below that seen last year.

All told this is good news for those of you trying to manage your packed patient waiting rooms. Let's just hope you don't have a case of measles sitting in there somewhere!

Do You Even Know What a Broken Record Sounds Like?

I used this term when I said I was sounding like a broken record for repeating over and over my warnings about measles. I harp (pun intended) on this because measles is the most contagious infectious disease known and most younger clinicians in the US have never seen a case, meaning it can be missed easily. However, those same clinicians might never have heard a broken record either. Vinyl records made a bit of a comeback recently but even I no longer have a turntable to play vinyl records; I do have a few moldy vinyl albums from the 1960s and 70s. I'm occasionally tempted to purchase a good turntable, but I have no place for it and it's yet another diversionary rabbit hole I don't need. I ain't gonna call out the name vinyl around here.

Published on Leave a comment on A Week of Autochthony

Last week I was struggling to come up with enough new items to fill the post; this week I'm wrestling to pare down the list of topics. We've had some more concerning news about autochthonous tropical infectious diseases cropping up, but before I turn to that....

Is Covid Coming Out of the Doldrums?

Lots of headlines about this in the past week, some more hysterical than others. Staying alert, not panic, is the appropriate response.

First to wastewater. Looking at the past 6 months in Biobot, every US region is trending up, notwithstanding a slight drop in the purple midwest region.

Now look at the same graph spread out over a longer time:

So yes, we've had an upward blip recently, but nothing as dramatic as what accompanied serious clinical outbreaks in the past.

The other hype is about newer variants. Fortunately, we're still talking about omicron and primarily from the XBB subvariant group. I'll turn to the UK's nice graphs to highlight; results are similar but not identical to the US.

This Sankey diagram gives you an idea of the relatedness of strains:

The key question is how well the proposed autumn covid vaccine, derived from XBB.1.5, works against these newer variants. The answer is based mostly on conjecture at this time, we have no peer-reviewed hard data yet. The best guess is that it will not protect much against infection itself, nor will prior natural immunity. However, for the more important protection against severe disease, hospitalization, or death, it is likely to have an impact. Jennifer Abassi, a medical news reporter for JAMA, published a nice discussion. CDC and IDSA recently posted a brief explanation. Also in the news the past few days has been a newer variant, BA.2.86, now seen in a few countries sporadically including the US. It's much too early to know if this will become prominent.

CDC published updated data about monovalent and bivalent vaccination in the 6-month to 4- or 5-year-old age groups that showed good effectiveness in protection against urgent and emergency care visits. Also important to note is that these are relatively uncommon events in this age group, which is why you see different recommendations for vaccination in the US versus the UK for example. Going from the last section of Table 2 in the article, rates of these care visits from 12/24/22 to 6/17/23 were 4.4% in the unvaccinated group versus 0.9% in those who had received at least one bivalent vaccine dose. With a little arithmetic, the number needed to vaccinate at this level to prevent one additional ED/urgent care visit is about 30.

Reason to Avoid Proton Pump Inhibitors

French investigators published a cohort study linking use of PPIs in children to higher risk of serious infections. It included over 600,000 children receiving PPIs and a similar number as a control group not receiving PPIs, followed for a few years. The risks for serious infections as well as a number of categories of infection types were significantly increased. Most of the children had significant comorbidities. This association has been known in adults for a long while and is likely based on a variety of PPI effects including elevated gastric pH and alteration of the GI microbiome. That's not to say PPIs shouldn't be used in children, but there is a clear risk that should be explained to parents.

RSV Already in Florida

Florida is now seeing RSV infections in some jurisdictions. This isn't too surprising; Florida has a very different seasonal epidemiology than does most of the US:

It remains to be seen how RSV seasonality will stabilize in the post-pandemic/isolation era. A group in the Netherlands recently reported a switch to year-round transmission during the pandemic.

Along similar lines, a US study showed that ICU admissions for RSV consisted primarily of infants without risk factors; the study does have significant limitations. Findings may reflect the lack of partial RSV immunity conferred by prior RSV exposure of both mothers and infants.

It's still time to plan for use of monoclonal antibody and, if approved, maternal RSV vaccination. AAP and ACIP have a nice discussion available. Lots of logistical hurdles remain.

Autochthonous Malaria and Dengue

I posted about autochthonous malaria in Florida and Texas on July 2 and 9, and on autochthonous dengue fever in Arizona on 11/20/22. See the July 2 post for more about the definition of autochthonous infections.

Now we have a report of 11 autochthonous dengue cases in Florida. Closer to home, we've had a report of 1 case of autochthonous P. falciparum in a Maryland resident in the National Capital Area region. Falciparum malaria is significantly more dangerous than the vivax forms reported in Florida and Texas. Very little information was provided, but the letter does have links to good clinical information sites.

Autochthonous infections are tricky to diagnose given the lack of travel history to an endemic area. Climate change has expanded the geographic range of many insect vectors of disease. All clinicians should be aware of these diseases when evaluating febrile patients.

As a final note, my web wanderings about autochthony taught me something new about the term. Sadly, it has been used in a negative political (and racist) sense. An "autochthonous" flag protest disrupted a 2014 soccer match between Serbia and Albania.

Published on Leave a comment on A Late Summer Breeze?

Those pandemic doldrums may be lifting, but it's difficult to determine in today's post-pandemic era of reduced reporting. First, a look at a couple other things from a slow week in the world of infections.

ProMED Still Going Strong

I mentioned last week that my most cherished web site, ProMED, had some internal turmoil that threatened its existence. I don't know if the disagreements have been solved, but their postings have continued. Here's an example from last night's email of topics:

ProMED Digest, Vol 107, Issue 221

1. PRO/AH/EDR> Anthrax - Indonesia (07): (JT) cattle
2. PRO/AH/EDR> Crimean-Congo hem. fever - Asia (22): Afghanistan
3. PRO/EDR> Pertussis update (21): USA (NY)
4. PRO/AH/EDR> Canine influenza - North America (08): USA (OK) RFI
5. PRO/AH/EDR> Listeriosis - Americas (05): (USA) kosher ice cream, recall
6. PRO/EDR> Leishmaniasis, Americas (10): Brazil (MG)
7. PRO/AH/EDR> Leptospirosis - Italy: (VN) swimming, river
8. PRO/EDR> Measles update (36): Sweden, cruise ship
9. PRO/EDR> Meningitis, meningococcal - Norway: (VF) fatal, ex Greece
10. PRO/AH/EDR> Newcastle disease - Poland (02): (PD) poultry, spread
11. PRO/AH/EDR> Anthrax - USA (07): (ND) cattle
12. PRO/AH/EDR> Lumpy skin disease - Asia (11): Indonesia ex Australia, cattle, disputed, RFI
13. PRO/EDR> Measles update (37): South Sudan (WH) fatal, children
14. PRO/AH/EDR> Avian influenza (129): Americas (Argentina) sea lion, HPAI H5
15. PRO/AH/EDR> Echarate virus - Peru: (JU) new variant
16. PRO/AH/EDR> Eastern equine encephalitis - North America (05): USA (NC)
17. PRO/AH/EDR> Brucellosis - Paraguay (01): (AS) veterinary school, RFI
18. PRO/AH/EDR> Crimean-Congo hem. fever - Asia (23): Iraq
19. PRO/AH/EDR> West Nile virus (12): USA (NM, DE)
20. PRO/EDR> Pertussis update (22): Canada (SK)

It's a longer list than most of their posts. I couldn't remember what the Echarate virus (ECHV)was, so I looked deeper at that one. Turns out ECHV is a Phlebovirus, a genus of viruses that can cause nonspecific febrile illnesses in humans. It is transmitted primarily by sandflies, mosquitoes, and ticks. Echarate is the capital city of the Echarate District in Peru. One of the many reasons to use insect repellant.

Vaccination of Pregnant Persons

The timing worked out well for me, so I tuned in to a CDC COCA call on vaccination during pregnancy. The event recording and slides are available at their website. Virtually none of my patients have been pregnant people, but as with most pediatric healthcare providers it's been very common for parents of my patients to be pregnant at the time of their child's visit with me. So, pediatric providers have a role in encouraging vaccination for pregnant people.

No surprise, but uptake of the 3 vaccines with specific benefits during pregnancy (Tdap, influenza, covid) has been pretty poor lately:

The benefits of influenza and covid vaccines accrue to both the pregnant people, since those diseases are more severe during pregnancy, as well as to providing antibody to their newborns. Tdap vaccination is recommended for every pregnancy, regardless of prior immunization status, because pertussis protection wanes quickly over the year following vaccination and therefore is unlikely to provide newborn protection for a subsequent pregnancy. Tdap immunization specifically for pregnant people was first recommended in 2011 but excluded those who had prior Tdap vaccination; that was amended in 2012 to include all pregnant people regardless of prior vaccination.

Multiple studies have shown the effectiveness of this approach, seen above in the reduced rates in the less than 1 year-old group. Of course, the further sharp decline in recent years is related to pandemic isolation when rates dropped for multiple infectious diseases. We likely will see increases back to pre-pandemic levels or higher as we return to more normal societal interactions, so vaccination for all 3 conditions will become even more important.

At the time of this writing, we're still waiting on the FDA to make some sort of determination on RSV vaccination for pregnant people to protect their newborns, although the need for this intervention is attenuated by the recent approval and recommendations for nirsevimab, the long-acting anti-RSV monoclonal antibody for newborns.

Recommendations for how to guide pregnant people in their vaccine choices begins on slide 38 of the presentation, found at the link mentioned above.

'Demic Doldrums

At least one indicator suggests a significant change that could mean the summer calm of low covid rates is lifting. Still it's difficult to determine since almost all reporting has reduced. Even hospital reporting has changed post-pandemic, so case rates for hospitalizations and ED visits are less reliable. You can still see the upward trends, though still very low rates overall.

More significant, however, are new wastewater reports particularly in the upper Midwest. I've detailed previously that wastewater monitoring in the US is voluntary and very sketchy, but trends in this one region now approach last winter's numbers.

Again, time will tell whether this summer breeze ends our covid doldrums.

I think we've seen a bit too much hype about covid variants lately, specifically with the EG.5 (a descendent of XBB.1.9.2) that has appeared in both lay press and medical updates. Remember that overall this is based on relatively few viral samples tested and is very hard to predict for the future. Also, no hint yet that it produces more severe disease, it just has a growth advantage and effective immune escape properties compared to prior prominent variants.

Most important is that virtually everything going on now is in the XBB lineage which is included in the planned autumn covid vaccine dose. It should provide good protection against all of these.

A Tune Stuck in My Head

Speaking of summer breeze, given my age I immediately thought of the Seals and Crofts song of the same name listed as #20 in Rolling Stone's best summer songs. I hadn't realized it was also a hit for the Isley Brothers a couple years later.

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Published on 2 Comments on Happy Holidays!

I'm putting this post together on Father's Day, and tomorrow is Juneteenth, a holiday increasingly recognized in the US. Today two of my 3 sons are farther away than usual, one in Berlin, Germany, at the Special Olympics World Games and another working in healthcare in Mekele, Ethiopia. The third member of the triumvirate remains in the eastern US time zone.

Can anyone guess which state was the first to make Juneteenth a permanent state holiday?

Influenza Rising in Southern Hemisphere

The most recent World Health Organization update on influenza, published on June 12 with data current as of May 14, not surprisingly shows an uptick in flu activity in sections of the southern hemisphere. The influenza AH1N1 2009 pandemic strain and B Victoria lineages predominate, meaning we are likely in good shape from a vaccine standpoint for next winter in the US.

RSV and covid haven't increased to the same extent as flu in the south, for the most part.

Polio Vaccine for Travelers

'Tis the season for world travel, but I'm thinking many folks aren't aware of newer polio risks around the world. Spurred by the pandemic and various war zones, polio vaccination has waned. Also, as I've noted in the past we're seeing vaccine-derived polio disease via transmission from recipients of the oral live polio vaccine. The CDC continues to update polio vaccine recommendations for travelers. Twenty-nine countries around the world have circulating poliovirus, but in addition to the "usual suspects" the list now includes both Canada and the United Kingdom.

Certainly the risk can vary in settings within these countries, but primary care providers should remember to discuss vacation plans with families, not just out of interest but to make sure they are informed of any risks and where to find resources. Make sure all children are up to date on immunizations, including polio, and some adults may wish to receive a one-time killed polio vaccine booster if traveling to a high risk country.

'Demic Doldrums

Here in the US we continue with our low levels of SARS-CoV-2 circulation in most jurisdictions; now we rely primarily on ED visits and hospitalization rates for any early warning given our lack of other good community monitoring tools. The FDA VRBPAC group met on June 15 to advise on composition of the next covid vaccine, and I was able to attend most of the meeting including the important parts of the discussion sessions. All 3 US vaccine manufacturers (Moderna, Pfizer, and Novavax) presented data.

As most providers know, the XBB sublineages (XBB represents a recombination of omicron strains) now predominate; the ancestral strain has virtually disappeared from circulation in humans, as have all subsequent strains except for the omicron lineage. Without going into perhaps agonizing detail, most authorities agree that covid vaccines for the near future should focus on the XBB sublineage. The vaccine manufacturers have a fair amount of preliminary data on immunogenicity of XBB-containing vaccines. Results suggest good safety signals and good neutralizing antibody activity against currently circulating XBB strains. Less data are available for memory B- and T-cell responses to these vaccines, and nothing substantial so far on XBB vaccination of children. Work continues, and we should see more about pediatric XBB vaccination in the next month or 2.

A very important part of the presentation has to do with cross-reactivity of antibody among the various XBB strains that were tested. Because of this, a monovalent vaccine with any XBB strain is likely to be effective against these closely related sublineages. Since among other reasons all 3 companies had the most experience with the XBB.1.5 vaccine and can readily ramp up vaccine production for this product, the VRBPAC members unanimously voted to go this route and the FDA officially signed off on this recommendation. Next up is a discussion at the ACIP meeting on June 23, but don't expect any vote or final recommendations at this session. That should come a bit later. In particular, we will need guidance on pediatric use, combined use with other vaccines such as for influenza and RSV, and whether to recommend for all or just for certain high-risk populations.

Last week I perhaps dissed the CDC's use of color in their depiction of variants, but now I need to acknowledge I was wrong. The most recent MMWR had some nice graphics. The graph below not only shows the colorful distribution of variants but also the relatively low numbers of cases recently (with the caveat that testing in general is less now than in 2022).

As can be seen, we have been in an omicron world for some time, with XBB now in charge.

Quickly, a few other covid notables from last week:

Juneteenth

Perhaps not what you would have guessed, but my home state of Texas was the first to make Juneteenth a permanent state holiday, in 1980, which was decades before most of the rest of the country. I left Texas in 1984 and parts of it now are unrecognizable to me, but it's easy to understand why that state was out in front on Juneteenth. The original event was June 19, 1865, in Galveston, TX, when Union troops arrived and finally enacted the January 1, 1863, Emancipation Proclamation and freed slaves in Texas. In my childhood, unless you kept yourself under a rock, if you lived in Texas you knew about Juneteenth.

Happy Father's Day to all fathers out there, and to everyone please use Juneteenth to reflect on its many lessons that continue to challenge us to do better.

Published on Leave a comment on In the Spring, a Young Man’s Fancy Turns to Thoughts of … Ticks?

OK, I know I'm not a young man, but let me dream a little bit. March 20 is the first day of spring, actually starting at 5:24 PM EDT in the Northern Hemisphere. I was reminded of spring recently when my wife, who spends approximately 86% of her waking hours outdoors, noticed a tick crawling on her arm. In my warped world view I immediately think of tick-borne diseases.

But first, a couple updates.

Paxlovid Poised for Full Approval (for Adults)

FDA's Center for Drug Evaluation and Research Advisory Committee met on March 16 to consider newer data on Paxlovid, the oral combination of nirmatrelvir and ritonavir authorized for SARS-CoV-2 treatment in selected situations. It was no surprise to anyone that data were favorable and likely will lead to full approval for individuals meeting criteria who are 18 years of age or older, but don't expect any new changes for the pediatric population yet. You can view all the documents at the meeting document site. I was more interested in the data on rebound, and the meeting documents (I didn't tune in to the sessions) had a very balanced and nuanced assessment.

First of all, recognize that rebound really involves 2 issues: viral rebound, meaning the amount of virus present drops, then bounces back up; and symptom rebound, meaning symptoms improve and then return. Also, true rebound implies a period of improvement, followed by an increase in virus or symptoms. If there is no improvement, you can't really detect rebound per se.

That all aside, the bottom line (see page 70 of the pdf, slide 59) from all the analysis from FDA was that "...rebound ... is not clearly associated with PAXLOVID treatment, is not associated with severe disease outcomes, and likely reflects natural COVID-19 disease progression and/or technical variability in virology assessments." In other words, although data continue to be collected, for now we can forget about rebound influencing treatment decisions.

The analyses involved 3 different trials including the original trial for authorization plus some trials that were primarily pre- or during omicron circulation. Most importantly, all have shown good efficacy against disease progression and excellent safety profiles, but the numbers from the omicron era (EPIC-SR 2022) are still too small to provide any separate conclusions for current times. That's been a problem with covid all along - by the time we have solid data, we've moved on to a new variant.

For the rebound consideration, here is a summary slide for combined outcomes that gives you an idea of numbers of subjects studied. Note that in the original EPIC-HR trial there was no difference in symptomatic viral RNA rebound.

The meeting site has a ton of other interesting data. I've just highlighted some key aspects.

Also on a slightly related matter, FDA has authorized the Pfizer bivalent vaccine to be used as a booster dose for children ages 6 months through 4 years, joining authorization for the Moderna bivalent vaccine booster for similar ages. It's important to remember that the primary vaccine series for Pfizer is 3 doses and for Moderna is 2 doses, both using the monovalent vaccine. Now we need to wait for CDC/ACIP to weigh in with recommendations.

What we are witnessing is the start of incremental assessments that I hope will lead to use of whatever bi- or multi-valent vaccine might be proposed for next fall, ideally for both primary series and booster doses. If analyses support this change we'll live in a simpler world of covid vaccines for children.

Babesiosis

When was the last time you worried about babesiosis? It's not on the list of commonly encountered infections, but newer CDC data just published should at least put it on our radar. The report covers the years 2011-2019 and shows that the infection is still relatively rare. However, the low numbers might be misleading because the infection is not nationally reportable and often is asymptomatic or self-limited in healthy individuals so can go undetected.

In the 10 states where babesiosis was reportable over this time period (Connecticut, Maine, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Rhode Island, Vermont, and Wisconsin), numbers increased significantly in 8 (Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Rhode Island, and Vermont). Of further interest is that Maine, New Hampshire, and Vermont previously have not been considered to have endemic babesiosis. Clearly we need more states to make babesiosis case reporting mandatory, but I say this knowing that many states are decreasing their public health vigilance generally.

Here's the geographic picture, based on state of residence:

If you aren't too clear about the management of babesiosis, the CDC has excellent resources for healthcare providers and for the lay public. Remember that it is a parasite that infects red blood cells, similar to malaria. Signs and symptoms often are nonspecific (febrile flu-like illness) and thus very difficult to diagnose unless hemolytic anemia develops. Individuals with asplenia, immunodeficiency, and advanced age are at highest risk of severe outcomes.

Peripheral blood smear of Babesia infection:

Another problem with babesiosis management is that some individuals carry this diagnosis falsely, on the basis of unapproved laboratory testing and misguided (or worse) clinicians. I've spent much more of my time disproving Babesia diagnoses than in actually diagnosing and treating true cases. Most of the children and young adults in my practice who were misdiagnosed had prolonged fatigue or other symptoms that weren't suggestive of babesiosis. Consultation with a reputable pediatric infectious diseases specialist is wise if a babesiosis diagnosis is entertained. Avoid so-called practitioners ordering large batteries of non-FDA approved tests for patients with vague symptoms.

Alfred Lord Tennyson

Tennyson is perhaps best-known for his poem, Charge of the Light Brigade, describing the fateful Battle of Balaclava during the Crimean War (1854, not the current Ukraine/Russia war). Thinking about spring allowed me the pleasure of rereading another of his poems, Locksley Hall, first published in 1842. It was even more pleasurable for me because I opened my copy of the slightly more modern (1892) complete and unabridged The Works of Alfred Lord Tennyson printed by Macmillan Standard Library. It's a long poem, but the pertinent passages for spring are:

"In the Spring a fuller crimson comes upon the robin's breast;
In the Spring the wanton lapwing gets himself another crest;

In the Spring a livelier iris changes on the burnish'd dove;
In the Spring a young man's fancy lightly turns to thoughts of love."

I can see robins outside my window as I write this. Take a break, go outside, and enjoy spring. (But watch out for ticks!)

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