Skip to content

Tag: COVID-19 vaccine

Published on Leave a comment on “The horror! The horror!”*

Well, not really horror stories, but it was a slow week for epidemics that allowed me to finish two somewhat disturbing pieces of literature. First, the news.

I'm pleased to report nothing particularly new on the measles front, so I won't bother with the recitation of statistics and graphs. Based on the measles incubation period, it appears we are out of the woods from the Chicago clusters thanks to excellent public health interventions. The Florida school issue hasn't surfaced again though we are still lacking accurate descriptions of how it was managed - did un-immunized children isolate at home, were catch-up immunizations administered?

A Few Covid Updates

This past week the World Health Organization Technical Advisory Group on COVID-19 Vaccine Composition (TAG-CO-VAC if you're attracted to cumbersome acronyms) advised use of a monovalent JN.1 variant vaccine for the next iteration. Although the WHO TAG-CO-VAC doesn't make official recommendations for the US, none of these discussions occur in a vacuum and I expect the FDA VRBPAC to come to the same conclusion when they meet on the subject on May 16. The CDC/ACIP likely will rule on this in late June, in time for potential fall booster recommendations.

The most recent variant tracking in the US largely shows JN.1 and its offspring as predominant.

Here's the latest family tree in the US showing the.relationships of the currently circulating variants.

Also noteworthy is a change in hospital covid reporting. As of May 1, hospitals no longer are required to report covid hospitalizations. Although efforts are underway to go back to mandatory reporting, for now all hospital reporting is voluntary which will likely mean no reporting for many institutions. So, don't try to compare future covid hospitalization rates to prior data. It would be another apples and oranges comparison.

Lessons From Quality Improvement

This month's issue of Pediatrics contained some QI articles. They are worthwhile reading for the QI aspects, but I think many front-line pediatric healthcare providers might want to compare their own practices to the standards used in two of the studies concerning infectious diseases.

The first of the studies involved standards for management of well-appearing febrile infants ages 8 to 60 days in emergency departments. Parenthetically, I'm in awe of the authors for pulling off a multi-institutional research study in the midst of the pandemic. I barely had time to breath during some of those months.

The authors looked at multiple outcomes, and I won't go into the actual QI processes themselves. Here are the primary measures they sought to improve (remember these are all well-appearing infants):

  • 90% of infants 29–60 d with normal inflammatory markers (and either a negative UA or a positive UA) DO NOT have CSF obtained 
  • 90% of infants 29–60 d with normal inflammatory markers and negative UA discharged from the ED 
  • 90% of infants 29–60 d with normal inflammatory markers and negative UA DO NOT receive antibiotics 
  • 90% of infants 8–60 d with negative cultures have appropriate discharge from the hospital within 36 h from the time blood cultures were received by the laboratory 

How does your local ED or practice compare?

The second article also was hospital-focused and carried out during pandemic peaks. It dealt with minimizing unnecessary antibiotic use in common pediatric infections for children above 60 days of age. Again, many outcomes were examined, but think about these in your own practice:

  • Antibiotic duration for community-acquired pneumonia < 10 days
  • Antibiotic duration for UTI < 10 days
  • Antibiotic duration for skin and soft tissue infections < 5 days

The above durations for CAP and UTI probably are too long. It would be difficult to justify therapy beyond 7 days for these entities assuming good clinical response, and courses as short as 5 days have been suggested.

There's a lot more to these studies that I haven't mentioned. Please look at them if you manage these types of patients in your practice.

Of Cows and Cats

Bird flu, primarily influenza A H5N1, continues to surprise us. Let me state up front, however, there is no reason to be overly concerned about consumption of pasteurized dairy products or getting rid of your pet cat. People who ingest unpasteurized dairy or have close contact with cows or chickens (including those backyard coops) need to be cautious.

The count of bird flu in wild mammals continues to expand:

Genetic testing of dairy cow milk samples and of 2 cats who died at the dairy farm strongly suggests transmission of influenza A H5N1 from cows to cats. The cats had ingested unpasteurized milk at the farm. The cows were only mildly ill, but the cats had severe neurologic symptoms due to the virus. This report concerns only a few animals but at the least suggests that humans could be at risk for infection from unpasteurized dairy products.

We still have only one known human infection related to dairy cows in the US, but now we have more details about that case. As reported earlier, this dairy farm worker had mild symptoms consisting of pain and redness of the right eye. Especially given the perhaps mild and atypical presentation of influenza in this instance, more testing of asymptomatic dairy workers and other high risk individuals is needed.

I had mentioned in previous posts I'm trying to monitor USDA updates on this situation, but so far most have just clogged my inbox with irrelevant notices. I did receive one relevant alert that at least told me someone is watching out for us. Due to concerns about bird flu in the Chiba prefecture in Japan, imports of live birds as well as bird products and byproducts are prohibited. In case you are thinking about bringing back some bird souvenirs from Chiba, please be aware:

"Processed avian products and byproducts, including eggs and egg products, for personal use originating from or transiting a restricted prefecture and entering in passenger baggage must:  

  • have a thoroughly cooked appearance; or 
  • be shelf-stable as a result of APHIS-approved packaging and cooking (i.e., packaged in a hermetically sealed container and cooked by a commercial method after such packing to produce an article that is shelf stable without refrigeration); or  
  • be accompanied by an APHIS import permit and/or government certification confirming that the products or byproducts were treated in accordance with APHIS requirements. 

Unprocessed avian products and byproducts for personal use or in passenger baggage originating from or transiting a restricted prefecture will not be permitted to enter the United States. This includes hunter harvested, non-fully finished avian trophies and meat."

Reliable information on bird flu is increasing. It seems very likely that pasteurization effectively inactivates live H5N1 from dairy products and that these influenza strains remain susceptible to commonly available antiviral agents used for influenza. But, I still have questions:

  • What is the range of symptoms of avian flu infection in a wide range of animals, including humans?
  • How common is asymptomatic infection in various species?
  • What is the specificity and sensitivity of commonly-used influenza detection methods for influenza A H5N1?

For now, even though we are beyond our winter flu season, anyone with flu-like illness should be tested for influenza and also asked about exposure risks involving domestic or wild animals or ingestion of unpasteurized dairy products. Look to the CDC website for guidance.

My Disturbing Week

My wife abandoned reading Ian McEwan's latest novel, Lessons, due to its unsettling content in its early pages. Nonetheless, I decided to slog through this nearly 500-page tome and found I couldn't put it down. It was truly disturbing, including depictions of abuse of the young male protagonist that were hard to read. Ultimately, though, I found the novel very thought-provoking in spite of the fact that the protagonist wasn't very likable and seemed to respond passively to much of his life events. These events were shaped by a series of historical occurrences that also were meaningful to me: World War II (before my time, but still significant) the Cuban missile crisis in the 1960s, the fall of the Berlin wall, the September 11 attack, and more recently the January 6 attack, among others.

About a week ago I happened to watch Apocalypse Now Redux, the longer version of the 1979 movie about the Vietnam War which itself was a take on Joseph Conrad's Heart of Darkness. The longer movie version added more uncomfortable scenes to the already unsettling original. As a boy I had read at least 3 of Conrad's novels plus maybe a few short stories, but never Heart of Darkness. It's really a novella, just under 150 pages, and I felt compelled to read it this week. I loved it, as I do most of Contrad's works. More than that, I was astounded at how deftly the novella was transplanted from the late 19th century into late 1960s Vietnam. How did it not win the academy award for best adapted screenplay? (That was Kramer vs. Kramer.) I found myself waiting to see if the 19th century Kurtz would have the same *final utterance as in the movie version. You'll need to read the book to find out!

My Respite Week

Given the slow times in infectious diseases (now I've jinxed myself) and a busy week of other activities in front of me, I'm planning to skip a Sunday post for Mother's Day. Barring any major events, I'll see you next on May 19.

Published on Leave a comment on Is There More to Life Than Infectious Diseases?

Well of course there is, that's why I try to sprinkle my weekly posts with comments on bird feeders, squirrels, novels I've been reading, and other escapades. This past week I happened upon a former colleague of mine who has taken this to new levels, much to my enjoyment.

We seem to be free of serious infectious diseases drama in the past week, unless you are a dairy cow.

Avian Flu

Initially only previewed in news reports and even now lacking details, one thing is clear: influenza A H5N1 infection in US dairy cows is much more widespread than previously revealed. We were surprised by this because asymptomatic infection is common and cow testing was only being performed in symptomatic animals. (This is reminiscent of the early days of covid!) The FDA and Department of Agriculture both report finding positive avian flu PCR tests in 1 out of 5 samples of pasteurized milk tested, although I can't find details about the total numbers and the geographic distribution of milk samples tested.

Of course, a positive PCR merely means that nucleic acid has been detected. It is highly likely that pasteurization inactivates H5N1 virus, and preliminary reports from FDA suggest this is true. Again, details are not available, but certainly no cause for panic about drinking pasteurized milk.

The take-home messages are clear: 1) H5N1 infection is highly prevalent in US dairy cow herds if 20% of all milk samples are PCR positive; 2) there is even more reason now to avoid ingestion of unpasteurized dairy products; and 3) USDA, FDA, and CDC are performing poorly in providing transparency and detailed evidence to the public. They say they are working on this, let's hope we see the fruits of that labor in the coming few weeks.

And, to give our federal agencies some credit, CDC has a spiffed-up web site for avian flu now, with weekly updates. Here's a quick view for the week ending April 20:

Note that this site deals only with human disease. If you want to get more on dairy cattle, you'll need to go to the USDA site. Here you can realize how geographically widespread the situation is.

USDA now has new guidelines for testing dairy cattle being transported interstate. Perhaps testing needs to be expanded beyond just interstate transport.

Covid Calm

Covid activity continues to fall, and weekly deaths now appear to be consistently less than 1000 even considering there is significant reporting delay for covid deaths. The vast majority are in the elderly.

Two new studies appeared highlighting covid vaccine side effects in children. One was a prospective cohort study utilizing insurance databases that likely carried some risk of classification errors because the authors did not perform any medical records review for verification. The study confirmed the known risks for myocarditis or pericarditis for ages 12 - 17 years with the Pfizer vaccine. Also, they found a possible safety signal for seizure occurring following both Pfizer and Moderna vaccination in 2 - 4 or 5 year-old children. This is pretty iffy; as they explained in the body of the text, it may simply be an artifact of how they defined the baseline seizure rate as a comparison number. This is worthy of further study, but in my opinion not something that should be put on the list of definite side effects yet.

The other study was a massive (3.9 million children) look at covid cases in California from 4/1/20 through 2/27/23, again using an administrative database. The article has too many explanatory graphs to show here, but the bottom line from the authors' predictive models suggests that vaccination prevented about 146,000 covid cases in 12 - 15 year-olds, 230,000 cases in 5 - 11 year-olds, and 168 hospitalizations in 6 - 59 month-olds. The authors did not find any association of vaccination with numbers of cases in the youngest age group, possibly because the numbers of vaccinated children were too small during the study period.

Our friends across the pond reported on various covid features from this past winter, November 2023 through March 2024. Results are based on self-reported data from a longitudinal survey study. Here are the main points:

  • An estimated 3.3% (2 million) of people living in private households in England and Scotland were experiencing self-reported long COVID (symptoms continuing for more than four weeks after a confirmed or suspected coronavirus (COVID-19) infection that were not explained by something else).
  • Long COVID symptoms adversely affected the day-to-day activities of 1.5 million people (74.7% of those with self-reported long COVID), with 381,000 (19.2% of those with self-reported long COVID) reporting that their ability to undertake their day-to-day activities had been "limited a lot".
  • Those in the youngest (aged 3 to 17 years) and oldest (65 years and over) age groups were the least likely to test positive for COVID-19 during the study period.
  • Those who have had a vaccination since September 2023 were less likely to test positive in the early waves of the study period (1 and 2); in later waves of the study period (3 and 4) there was no statistical difference.
  • Participants in the oldest and youngest age groups who did test positive in the study period were also less likely to report symptoms consistent with "influenza-like illness" compared with those in the middle age groups.

It's hard to find such recent data. I think this gives us a good peek at the future, assuming we don't have some major change in virus virulence or transmissibility.

Encouraging Progress in Malaria Prevention

I don't usually mention phase 2 trials because they are often much removed from clinical applicability and might change significantly once phase 3 trials are completed. This study is cause for optimism, so I'll break my custom here. Investigators in Mali performed the trial, part of which looked at 225 children randomized in equal numbers to a long-acting monoclonal antibody against Plasmodium falciparum with low dose, high dose, and placebo groups. Infection and clinical malaria was much less in the treatment groups.

The antibody is administered subcutaneously, a plus in resource-poor environments. If further studies confirm efficacy, this could save many lives.

Measles

No new cases were reported in the past week, good news though we know there will be more eventually. Also, I've been looking for more reliable assessments of worldwide activity and found another resource for Europe, the European Centre for Disease Control and Prevention. Updates appear only monthly. Here's what the most recent report, February, looked like:

Romania is the major hot spot, but note that many popular tourist destinations are represented. Here are current CDC recommendations that apply for all international travel:

Fiddlin' Will

By a happy occurrence in my web wanderings, I discovered a former colleague of mine was performing with his band, the Goldbug Revival, at a Salvadoran restaurant near my home. I crossed paths briefly with Will Sears when he was an infectious diseases fellow at NIH; he is now a medical officer at NIAID. However, in his "spare time," he is an accomplished musician. I was thrilled to see him on the fiddle and his wife Sarah singing lead at the band's first live performance and Sarah's first performance in front of a microphone ever. They were excellent!

See you next week. I'll be listening to some John Prine music in the meantime, waiting for Goldbug Revival's first album to drop. Prine was an early covid victim, dying in April 2020.

Published on Leave a comment on Beautiful Beetles

I finished a wonderful novel last week; among other things, it reminded me of the beauty, complexity, and destructive forces in nature, certainly applicable to infections, pathogens, and vectors of disease.

The past week saw more publications than I could cover in depth (or that readers could tolerate, probably), so I had to narrow things down even more than I usually do. If you're feeling particularly adventuresome, some of the topics I excluded pertain to a new phase I Chlamydia vaccine trial that could prove to be a breakthrough eventually, more advice on use of the new pentavalent meningococcal vaccine, an in vitro study suggesting nasal epithelial properties account for less severe covid disease in children, and a tularemia outbreak in Utah beavers. I also left out the growing Salmonella outbreak linked to organic basil, though I did alert one of my sons who often shops at a store featuring the tainted product. Here's what made the cut this week.

Respiratory Disease Transmission is Not Binary

Most things in biology and medicine aren't binary, even if we tend to reduce our thinking to that level to simplify things. For example, most lab tests aren't just positive or negative, even though they are reported that way. The cutoff between those two choices are made to maximize specificity and sensitivity of the tests, but they don't necessarily work for all circumstances.

The World Health Organization provided an important new proposal for changing our longstanding terminology for spread of respiratory infections as either droplet or aerosol (airborne). It's just not that simple, as SARS-CoV-2 painfully taught us. I found I couldn't improve on WHO's explanation of the complexity of pathogen transmission through the air, so here it is verbatim with some highlights in red that are mine:

The following descriptors and stages have been defined by this extensively discussed consultation
to characterize the transmission of pathogens through the air (under typical circumstances):

  • Individuals infected with a pathogen, during the infectious stage of the disease (the source), can generate particles containing the pathogen, along with water and respiratory secretions. Such particles are herein described as potentially ‘infectious particles’.
  • These potentially infectious particles are carried by expired airflow, exit the infectious person’s mouth/nose through breathing, talking, singing, spitting, coughing or sneezing and enter the surrounding air. From this point, these particles are known as ‘infectious respiratory particles’ or IRPs.
  • IRPs exist in a wide range of sizes (from sub-microns to millimetres in diameter). The emitted IRPs are exhaled as a puff cloud (travelling first independently from air currents and then dispersed and diluted further by background air movement in the room).
  • IRPs exist on a continuous spectrum of sizes, and no single cut off points should be applied to distinguish smaller from larger particles, this allows to move away from the dichotomy of previous terms known as ‘aerosols’ (generally smaller particles) and ‘droplets’ (generally larger particles).
  • Many environmental factors influence the way IRPs travel through air, such as ambient air temperature, velocity, humidity, sunlight (ultraviolet radiation), airflow distribution within a space, and many other factors, and whether they retain viability and infectivity upon reaching other individuals.

WHO still proposes a somewhat binary system of IRP spread, with "airborne transmission/inhalation" denoting pathogens which can spread at both short and longer distances, depending on various factors, versus "direct deposition," e.g. someone sneezes on you. It still may be confusing, but this is an important attempt to get past somewhat misleading advice such as a establishing a standard 6-foot distance between persons waiting in line.

Children and Adolescents Likely Still Benefit From Covid Vaccination

CDC has an update on covid vaccine effectiveness and durability, looking at the original monovalent vaccines over the time period from mid-December 2021 to late October 2023. Two doses of vaccine were 52% (95% CI 33%-66%) effective against hospitalization in the 5 - 18 year-old age group if vaccines were received no more than 4 months prior to hospitalization. From 4 to 12 months, protection against hospitalization waned significantly to 19% (95% CI 2%-32%). The report doesn't mention children less than 5 years of age, I suspect because vaccine authorization occurred later, numbers vaccinated are too small, and hospitalization was too uncommon to give reliable numbers.

Vaccine Adverse Events: New Numbers and a Terrific Interactive Web Site

The National Academies of Science, Engineering, and Medicine published new reports on adverse events from covid vaccines as well as an assessment of shoulder injuries from all vaccine administrations. The reports are excellent, but I fell in love with their web site. The NASEM group used levels of evidence to summarize current knowledge about various vaccine adverse events. The categories are evidence that a) establishes a causal relationship; b) favors acceptance of a causal relationship; c) inadequate to accept or reject a causal relationship; or d) favors rejection of a causal relationship. (Certainly this is far from a binary categorization!)

For covid vaccination they looked at six categories of adverse events: cardiac and vascular, female infertility, hearing conditions, immune-mediated events, neurologic events, and sudden deaths. The interactive web site allows you to pick and choose among various topics and subtopics and vaccines. Here's what the portion on myocarditis looks like:

Here's a look at acute biceps tendinopathy from vaccine administration in general:

You can also access the pdf version of the report (note it is a pre-publication proof, could contain some typos) to look at the summary and/or more details.

A Significant Change for Syphilis Screening From ACOG

I'm thrilled to see new recommendations for syphilis screening of pregnant people from the American College of Obstetricians and Gynecologists. I feel like my practice is a congenital syphilis quagmire right now. This updated recommendation gets away from the risk-based approach for screening which has always been a bit vague and clearly less useful with the resurgence of syphilis in the US. Now, every pregnant person should have syphilis testing 3 times: at the first prenatal visit, during the third trimester, and at birth. Previously a pregnant person with good prenatal care could escape with being screened only once early in pregnancy, a practice that would miss recent infection or infection acquired later in pregnancy. They also remind us that 40% of congenital syphilis occurs in infants whose mothers did not receive prenatal care; syphilis screening should be considered for pregnant people at every interaction with the healthcare system, such as emergency or urgent care visits.

Fake News From USDA?

Because of the avian flu concerns in the US, I've been trying for the first time to use alerts from the US Department of Agriculture on the status of avian influenza in wildlife and domesticated animals, including the recent importance of dairy animals. So far the alerts aren't telling me much, just clogging my in box with unhelpful information. So, I was a bit dismayed to see a recent NY Times article criticizing USDA transparency. Unfortunately the article requires a subscription, but it mentions an "obscure" USDA update (that I didn't receive) mentioning influenza A H5N1 further spreading among dairy cow herds and from there to poultry. More distressing to me is a claim in the Times article stating that asymptomatic infections have been discovered in a herd, but not yet reported by USDA; this is important since screening advice for dairy farmers currently is focused on symptoms in the cattle, with no screening of healthy-appearing cows. Perhaps USDA hasn't reported this asymptomatic infection possibility because it hasn't been verified, but one hopes they will be more transparent (and provide better updates) than they have so far. CDC learned a lot about public communication and transparency during the covid pandemic that should inform communications from USDA and other government agencies that we depend on.

Measles

Only 4 new cases reported in the last week, hoping we stay in this lull for a good while.

Elm Beetle Romance

That novel I finished recently was Daniel Mason's North Woods; it's had mixed reviews but I thoroughly enjoyed it. The author happens to be a psychiatrist, and this recent offering from him is an entertaining look at the happenings in a house in rural Massachusetts over several centuries. I had a great chuckle from a brief description of Dutch elm disease complete with a steamy sex scene involving elm bark beetles. Maybe I need to get out more.

Published on Leave a comment on Eclipsed

Even though Maryland wasn't in the full eclipse path, I miraculously located my eclipse glasses and enjoyed Monday's event. It easily overshadowed last week's relatively quiet collection of infections.

Newer Covid Publications

CDC gave us more reassurance that cardiac events associated with covid vaccination are mild. For the period June 2021 - December 2022, investigators looked at Oregon death certificate data in adolescents and young adults (16 - 30 year-olds). They found 40 deaths, 3 of which occurred < 100 days following receipt of covid vaccine, a time period when vaccine-associated myocarditis/pericarditis occurs. Of those 3, 2 individuals had underlying disease (one had mitral stenosis associated with chronic respiratory failure, the other congestive heart failure due to hypertension, with comorbidities of morbid obesity, type 2 diabetes, and obstructive sleep apnea). The other person died of "undetermined natural cause" 45 days after vaccination; toxicology results showed aripiprazole, ritalinic acid, and trazodone, presumably medications the individual was receiving but apparently not definitively explaining a cause for death. To most scientists this is further good news, but I'm sure anti-vaxxers will somehow spin this as a negative. Below is the big picture:

German investigators reported success of a program using pooled SARS-CoV-2 PCR testing to allow children to remain in day care versus quarantining after covid exposure, which they termed a "test-to-stay" approach.

The investigators estimated that. over a 30-week period, they avoided between 7 and 20 days of quarantine per eligible child. The study was performed from March 2021 to April 2022, at a different state of immunity and variants than we are experiencing today but still helpful to strategize when we hit the next big outbreak.

More on Bird Flu/HPAI

Highly pathogenic avian influenza news has calmed down a bit, but the viruses are still out there. We are up to 21 dairy herds with outbreaks according to USDA:

As of April 10, CDC reports widespread detections in wild birds with sporadic outbreaks in poultry flocks, sporadic infections in mammals, and still just the 2 human infections.

Measles

Not as many new cases now, with Illinois and Florida retaining the dubious distinction as leading all states this year. The national total stands at 121.

CDC reported that most US measles outbreaks from 1/1/20 through 3/28/24 were triggered by unvaccinated US residents returning from foreign travel. This is a good reminder for frontline clinicians to advise people planning foreign travel this summer to ensure their families have not only up-to-date immunizations but also early measles immunization for infants and toddlers who otherwise have not received 2 doses of MMR.

I also happened upon a link for assessing measles outbreak risk in US communities. I resisted the temptation to copy the entire page here, please check out the link. Here's a few highlights:

So, about 29% of US communities are at risk for small or medium outbreaks, with 1% at risk for a large outbreak. Even within communities with the same vaccination coverage, outbreak risk can vary if they have pockets of unvaccinated people.

And a look at outbreak modeling risks for measles outbreaks after one measles case is introduced in a school, according to vaccine coverage rates. (Note these numbers apply for situations where no post-exposure preventive measures are instituted. Risks go down if established interventions are applied.)

Here's the latest (2022-23) geographic measles vaccine coverage data.

Fingers crossed for measles to continue to slow down, though I'm predicting another blip around travel season.

See you next week!

Published on Leave a comment on I’m Optimistic

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.

The official recommendations from CDC now state

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.

A downy woodpecker said hello to me last week.

Unless otherwise indicated, the content and opinions expressed on this web site are those of the author(s). They are not endorsed by and do not necessarily reflect the views of the George Washington University.
Viewing Message: 1 of 1.
 Notice

This site uses cookies to offer you a better browsing experience. Visit GW’s Website Privacy Notice to learn more about how GW uses cookies.