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Tag: COVID-19

Published on Leave a comment on Spring is … Springing

I actually had to pull out the lawnmower this week, to cut some weedy grass running amok in the yard. Nonetheless, I'm buoyed by the approach of the vernal equinox next Tuesday, the official start of spring. Winter will be done, and with it the winter respiratory viruses. They will reliably be replaced with spring respiratory viruses.

Here's a look at the pediatric infectious disease news the past week.

Details on the Failed GSK RSV Vaccine Trial

We've known for about a year that GlaxoSmithKline's RSV vaccine trial in pregnant people was stopped due to safety concerns: a higher rate of preterm births in the vaccine group compared to placebo. Now we have more details, similar to what was reported to FDA and shared in various meetings. Preterm birth rate was 6.8% (237 of 3494 infants) in the vaccine group and 4.9% (86/1739) in the placebo group; it was statistically significant. Neonatal mortality was higher in the vaccine group, 0.4% versus 0.2%, but did not reach statistical significance.

On the other hand, vaccine effectiveness was pretty good:

The currently approved maternal RSV vaccine from Pfizer also had a hint of a safety signal for preterm birth, less so than the GSK product, and these signals combined resulted in the Pfizer vaccine being approved for a later time in gestation, at 32 weeks at the earliest. Postmarketing surveillance is ongoing. Perhaps the most difficult part of assessing this safety signal is whether it is real or not. We are lacking a key factor in making this assessment: biologic plausibility, i.e. the mechanism by which these vaccines might cause preterm birth. Without that, it is still possible this represents just a chance observation. From my perspective, I would still encourage RSV vaccination for pregnant people as well as nirsevimab therapy for at risk infants born to unvaccinated mothers. We have time for more discussions of any new data prior to our next RSV season this fall.

Waterborne Disease Outbreaks Associated With Drinking Water

I'm a big fan of CDC's Surveillance summaries, and this one published last week is of interest. The report concerns 214 outbreaks from 2015-2020. I wasn't thrilled to see my home state represented prominently.

Outbreaks occurred year-round, and biofilm exposures predominated.

In case you aren't familiar with biofilm-associated outbreaks, here's the quick explanation from the text:

"...microbial communities that attach to moist surfaces (e.g., water pipes) and provide protection and nutrients for many different types of pathogens, including Legionella and NTM [non-tuberculous mycobacteria]... Biofilm can grow when water becomes stagnant or disinfectant residuals are depleted, resulting in pathogen growth... Furthermore, biofilm pathogens are difficult to control because of their resistance to water treatment processes (e.g., disinfection)... Exposure to biofilm pathogens can occur through contact with, ingestion of, or aerosol inhalation of contaminated water from different fixtures (e.g., showerheads) and devices (e.g., humidifiers)..."

Not to minimize the severity of these events, but I couldn't help thinking about a whole new version of Hitchcock's Psycho shower scene based on this.

Legionella was by far the most common pathogen. The report has detail on every outbreak by year and location, as well as a listing of contributing factors. It's a great roadmap for future prevention.

Measles (Again)

It seems like I could devote every week's post entirely to measles and not run out of things to say. Here's the current US situation.

As I've stated previously, it's the sheer number of unconnected sites that concerns me now. Let's put this into some perspective.

As of March 14, we have 58 cases reported from 17 jurisdictions. In all of 2023, we had the same number, 58, reported from 20 jurisdictions in the US. So, we're way ahead of the game for recent years, but we're also not breaking any records compared to pre-pandemic times.

Looking more closely at the 2 biggest years recently, the 2014 (and somewhat 2015) numbers had a large contribution from a single site, Disneyland. More impressively, the 1274 measles cases in 2019, the highest number in the US since 1992, largely involved orthodox Jewish communities in New York - relatively epidemiologically isolated communities with very low immunization rates. A CDC update in fall 2019 (I couldn't find a final tally) stated that 75% of cases for the entire country that year originated from these communities.

Fingers crossed that we don't eclipse the 2019 figures this year, but with reduced vaccination rates and already widespread measles transmission occurring, it doesn't look good. We're just now coming to the spring break and summer travel season - importation of measles from travelers has been a large contributor to US measles outbreaks in the past.

Pediatric Covid ICU Admissions

A recent report of registry data from 55 hospitals during the first almost 2 years of the pandemic showed that about 8% children <21 years of age admitted to intensive care with covid had immunocompromising conditions (ICC). Secondary bacterial infection was more common (9.5% versus 7.3%) and mortality (11.4% versus 4.6%) was higher in the ICC group.

That Pesky Flu

The map is getting a little greener, apropos of springtime. Note in the link you can animate the map to show progression from the fall to the current week.

Better seen here, we did experience a little pause in our decrease of ILI, now headed down but at 3.7% still above the official "epidemic is over" mark of 2.9% for this year.

Any Chipmunk Sightings?

My 2024 Farmer's Almanac says that the real harbinger of spring in the eastern US is the appearance of the eastern chipmunk (Tamias striatus) above ground. As opposed to their squirrel brethren, chipmunks at my house don't bother my bird feeder, so I'm OK with them. I learned that although they stay below ground for the winter, they aren't true hibernators but rather experience torpor. They may sleep for several days in their bedrooms, followed by a trip to the underground pantry for snacks. Sounds like a good plan for retirement.

Published on Leave a comment on Another Strange Case of Dr. Jeckyll and Mr. Hyde

Maybe chalk it up to old age. Last week I mentioned I'd be reporting on the ACIP meetings, not remembering that they are scheduled for the coming week, not last week.

Still, plenty going on to fill in with, including a strange case I've been investigating for a few weeks now.

New Adult C. difficile Fecal Transplant Guidelines

The American Gastroenterologic Association published new guidelines for use of fecal transplant in adults with C. difficile disease. Although the guidelines do not address pediatric issues they are still useful to consider. Looking at just the summary, fecal microbiota transplant therapy is being recommended for instances of recurrent disease in immunocompetent or mild/moderately immunocompromised individuals, as well as for severe or fulminant infections in individuals not responding to conventional therapy, Fecal transplant use is not recommended for those with certain underlying GI conditions such as ulcerative colitis, Crohn's disease, pouchitis, or irritable bowel syndrome, except as part of clinical trials. I noted that all of the recommendations were conditional with low or very low level of evidence.

Conflicting Nirsevimab Data

The headlines screamed that about 40% of eligible infants received nirsevimab prophylaxis for RSV infection, as of last month, which is much higher than I had thought based on reports and the shortage of the product. On closer examination, it may not be all that good. There are actually 2 sets of information that the CDC published. First is reporting of ongoing telephone surveys of households with infants under 8 months of age, asking if those infants have received nirsevimab or are planning to do so. That's where the 40% figure comes from. The second data source is an ongoing count of nirsevimab doses actually administered. The listing includes jurisdictional data up through December 2023. Here the highest rate is 20% (Alaska) with many states near zero. Presumably this latter count is more accurate than is self-reported survey data. Let's hope things improve next season, where it does appear that supply chain issues that caused so much disruption this season might be somewhat ameliorated.

Also on the nirsevimab front, I saw the first semi-detailed explanation of what went wrong with the supply chain last fall. You recall, and probably experienced, difficulty in receiving an adequate supply of nirsevimab to satisfy your patients' needs. The company simply didn't have enough stock on hand. This Wall Street Journal report offered more information. It seems that, as usual, it was a bad combination of multiple factors. First, the manufacturer underestimated demand. Second, pediatric healthcare providers initially delayed ordering the drug, not sure if third-party payers would cover the circa $500/dose price. When the feds decided in August to add the product to the Vaccines for Children program, it was already too late to reverse the trend for lower production targets. Production was ramped up eventually, and now some states have excess product available due to all the delays plus perhaps some practitioners not being aware of the availability. RSV is still around but clearly nearing the end of the season. Let's hope things go better for next RSV season.

Risk Stratification for Pediatric Covid

The Pediatric Infectious Diseases Society published new guidance related to covid management in children and adolescents, worth reading. In particular, I think the group did a great job explaining risk factors for poor outcomes from SARS-CoV-2 infection. This has been confusing, in part because we lacked data but also due to spillover from adult high risk conditions - I've noticed many practitioners citing adult risk factors for use in the pediatric population, and it's not quite applicable in all situations. Here's the quick breakdown:

Not All Telemedicine is Created Equal

I've been involved with telemedicine since well before the pandemic. It has its uses, and of course it also has limitations. However, some individuals providing so-called telemedicine services are doing more harm than good. I was saddened but not surprised at this article about providing antibiotic prescriptions via telemedicine. The authors searched for online platforms offering antibiotic prescriptions without real time physician examination or verification of patient details and then chose 2 platforms to query.

For the first platform, one "patient" was able to get a prescription for amoxicillin for "URI," answering a few yes/no questions asynchronously and being rewarded with the prescription in less than a half hour. Another "patient" insisted on being prescribed levofloxacin for cough and again was rewarded the prescription with little verification or pushback.

On the second platform, a "patient" with URI was given a link to choices of azithromycin, cefuroxime, amoxicillin, Augmentin, doxycycline, or levofloxacin. After choosing doxycycline the prescription was provided immediately.

These patients were actually some of the study authors, and they had real URI symptoms. They didn't fill the prescriptions and did recover uneventfully from their URIs. I had 2 immediate reactions after reading the article. First, I wanted to cry. Second, I wondered where these telemedicine "doctors" obtained their medical training.

I Told You So

Some people preface that comment with "I hate to say it, but..." Not me, I'll grab credit even if, as in this circumstance, I'm not unique in sounding the measles alarm. The most recent update shows 35 cases in the 15 US jurisdictions this year, as of February 24. This many cases scattered over so many jurisdictions bodes poorly, and the scariest is in a Florida elementary school.

Dr. Ladapo and Mr. .....?

Dr. Josepah A. Ladapo sports both medical and public health degrees from Harvard, an internal medicine residency in Boston, followed by a faculty appointment at NYU. He than transitioned to a mostly research position at the University of Southern California before catching the eye of the Florida governor and becoming both Surgeon General for the state as well as a professor at the University of Florida. He's been on my radar for some bizarre pronouncements that made me want to look deeper.

Looking at his publication list in PubMed and scanning some of the articles, he clearly has good public health knowledge. Most of his publications center around aspects of cardiovascular disease in adults. He does have 3 relatively recent publications related to covid, but I'm deliberately not linking to them, or to his public statements in the past year, because they are either secondary to the conversation or so lacking in scientific merit as to be not worth your time.

His first covid-related publication was in 2021 and analyzed results of a Gallup poll carried out from July to December 2020 regarding adults' misconceptions about covid risk. Curiously, he published another analysis of this same poll in 2022, presenting some of the exact same data. Neither article referenced the other one and made me wonder whether this could be a case of duplicate publication. More importantly, though, why would covid perception data collected in late 2020 have any utility in 2022, unless the authors were analyzing changes over time (which they did not)?

His other covid-related publication from November 2021 was a multi-author effort (he was the 8th out of 12 authors) talking about future priorities in public health management of covid. I was very interested to see that vaccination was seen as the most important intervention given that Dr. Ladapo now disparages most use of covid vaccines, based on nonsensical arguments.

In the past year, Dr. Ladapo has been working actively to discourage covid vaccine use in most instances. You can see some rebuttal from FDA and CDC in early 2023 and separately from FDA more recently.

All of this made me wonder what gives with Dr. Ladapo. He seems to have had good training, and his prior publications show that he does have basic understanding of public health principles. How then to explain his response to a measles outbreak in a Florida elementary school? He left the decision to remain in school up to parents, and he did not encourage measles vaccination. At a minimum, unvaccinated children should be sent home to receive online education until their incubation periods expire. This could effectively stop the school outbreak and prevent further community spread. Every effort should be made to bring all children up to date with measles immunizations. This is pretty basic stuff.

According to news reports, the Manatee Bay Elementary School in Broward County, Florida, has documented several cases of measles. Details about immunization and travel status are lacking, but apparently there is no clear link to foreign travel identified. Remember that measles is the most easily spread infectious disease known. It is thought that at least 95% immunity needs to be present in a community to prevent sustained spread. The vaccination rate in Manatee Bay Elementary is 89.3%. Also, the incubation period is up to 3 weeks following exposure. So, if the outbreak isn't managed immediately, it can stretch on for weeks until every non-immune child is infected. By that time, spread outside the school is certainly likely. Apparently Dr. Lapado isn't concerned about that.

I wanted to understand how the Florida Surgeon General arrived at his decisions. His prior covid vaccine arguments contained a fatal flaw that I always look for to judge how well someone understands public health/vaccine data. This involves an understanding of the Vaccine Adverse Effects Reporting System (VAERS), one of many tools to monitor vaccine side effects in the US. It's a type of early warning system for rare events. It is structured so that anyone can report a potential adverse event as being related to a vaccine; for example, if my neighbor broke a leg skiing and had received a covid vaccine 2 months ago, he or she could report that event to VAERs. Clearly that doesn't prove that the vaccine caused a fractured femur. VAERS is just a way to monitor all potential vaccine problems. Dr. Lapado incorrectly used VAERS data to conclude that covid vaccines killed more people than it helped. No one who understands the structure of VAERS could possibly end up with that idea.

At a loss for understanding Dr. Lapado's logic, I can only suspect he must be having some Mr. Hyde moments. Either he has a dual personality due to some neuropsychological condition, or he is purposely misusing data to achieve political or personal goals. He clearly should know better. I'd love to spend 30 minutes with him to see where he falls on this spectrum. Or, maybe he knows of some unpublished data that refutes the current understanding of measles transmissibility and the role of antibody in providing protection; I'd hope he would have shared that.

WRIS

The Winter Respiratory Infection Season soldiers on. Given the length of this post and relative lack of any new data I'm not going to dive deeply into CDC or other numbers. Suffice to say RSV is still decreasing. flu is a mixed bag across the country, and covid is out there but not surging at the moment.

"Commingled Out of Good and Evil"

Robert Louis Stevenson's "Strange Case of Dr. Jekyll and Mr. Hyde" was one of my favorite books as a child, and it's loaded with great quotes like the one above. I don't like bashing another individual, and I'm also a natural skeptic always willing to entertain new theories based on new data. I just don't think Dr. Ladapo's management of this measles outbreak, or his covid vaccine views, make any sense. For the sake of all Floridians and others they may infect, I hope I'm wrong.

Nest week I'll report any exciting details from the ACIP meeting.

Published on Leave a comment on Did Tiger Woods Receive Flu Vaccine?

Famous golfer Tiger Woods couldn't complete the second round of a golf tournament this weekend due to influenza. Two questions came to my mind immediately, still not answered. But, we have a lot more than golf to discuss this week.

WRIS

I suspect we are a matter of weeks away before I can retire Winter Respiratory Infection Season as a weekly feature. RSV is much less of a factor now, and I won't be discussing much about RSV unless things change.

Influenza-like illness continues to fluctuate regionally, we're really seeing wide variations. I'll mention again that this tracking method will pick up not just influenza, but also other respiratory illnesses. However, pre-pandemic it was a pretty reliable gauge of influenza activity. I do note that Mr. Woods lives in Florida and the golf tournament is in California. He became ill Thursday night, so using the common incubation period for flu of 2-3 days he could have acquired this in California (if he was practicing there a few days before); however, the outer range for flu incubation period is 7 days, so all bets are off about where he met his virus. (Also, I'm not stalking him, I have no idea about his travel history.)

At this stage of flu season, it's worth a look at pediatric mortality numbers. It's a little less than, but similar to, last year. Also note there is a significant lag time in reporting and verifying influenza deaths, so some of these bars in previous weeks will rise.

Pediatric deaths continue to occur slightly more commonly in children without underlying medical conditions, and the 5-11 year age group is the most common. Unfortunately, no data for vaccine status is provided.

What about the covid scene? As usual, I'm still looking at wastewater data because the methodology for collecting and reporting this information hasn't changed as much as have the methods for reporting infections and deaths among the states.

Again, this is at most a qualitative descriptor, but nothing to suggest a new surge approaching. Wastewater activity is highest in the South.

I wish CDC would publish numbers of covid pediatric deaths like they do for influenza. They only report death rates per 100,000 by age, and of course they are very low for the pediatric population. The absolute numbers are somewhere in there, but on the CDC website it would require me to write my own search language in their database, and I'm too lazy to spend the time to figure that out.

I also took a look at CDC's covid vaccine rates by age, especially since they now have updated information regarding the fall XBB vaccine dose. It's pretty grim.

Note that the highest rate is only 13.4%, and when I dug down into more details, all the states except one were in single digits for pediatric populations receiving the updated vaccine. The best and only double-digit rate was Vermont at a dismal 13.4%.

On the other hand, one could argue that because rates of serious pediatric disease with covid are so low it isn't cost-effective to vaccinate children who do not have risk factors. In fact, that's what most countries have decided; the US is an outlier in offering covid vaccine to healthy children. Nonetheless, on an individual basis every child is better off being vaccinated than not, even given the low risk of death, long covid, MIS-C, etc.

Back in the somewhat good news arena, a recent article gave an overview of planning (and funding!) for research on better covid vaccines, monoclonal antibodies, and antiviral drugs that will not be subject to loss of effectiveness with new variants. It's called Project NexGen.

Lastly on the covid front, many of you probably heard about CDC plans to change isolation guidelines for the public to be more in line with what we do for flu and other respiratory viruses. So far it is just a draft, but it's targeted for release in April. It's not really based on any new findings about transmission rates or duration of infectivity, but rather I think an attempt at simplicity with the recognition that current guidelines aren't being followed by the majority of the public anyway. What I think is most important, and I hope the final guidelines will stress, is that guidelines should differ depending on the situation. For example, it's a very different calculus for children attending school than it is for those same children going to visit their 85-year-old grandma. The public needs to understand that different risks occur in different circumstances.

Measles

Hot off the presses, 4 children in a single elementary school in Florida developed measles. So far not much official from the Broward County health department, but I'm betting that none of them were fully immunized. Watch out for a large number of secondary cases in the coming weeks.

Changes in Prophylaxis for Meningococcal Disease

This was news from the previous week that I'm just mentioning now. Ciprofloxacin has been used for prophylaxis of meningococcal disease for several years, but recently some sectors are now seeing resistance to quinolones. So, if you are considering prophylaxis of a close contact of someone with meningococcal disease, you will need to contact your local health department immediately to see if the resistance rate meets criteria for choosing an alternative agent such as rifampin, ceftriaxone, or azithromycin.

Tiger's Third Degree

I look at everything through an infectious diseases eye, whether I'm walking down the street, reading the paper, or chasing squirrels from the bird feeder; I just can't stop myself. So, I have 2 questions for Tiger.

  1. Did you get a flu vaccine this year? I'm not a betting man, and I've already made one bet in this blog, but I'd guess not. He had fever and other symptoms the night before his Friday golf round, and then Friday morning still had fever and other symptoms but tried to play the round, making it through a few holes before feeling faint and ending up with IV rehydration therapy according to his official statement.
  2. And to follow up on the above thought, what were you thinking trying to play the round on Friday? Not only did you not meet any school or workplace criteria for participating, you exposed everyone close to you to influenza presumably without notifying them. Of course, this is the sort of "tough it out" mentality that I've been guilty of myself in the past, at least to the point of working when I had a mild cold because I thought myself too essential for my workplace or didn't want to shoulder my colleagues with covering me. I don't think Tiger needed the money for playing in the tournament, but he also was the host of this particular event and I'm sure many fans turned out primarily because he was playing, so that's a bit more pressure than in my workplace. Still, isn't it time we made a change in our behavior when we're sick? Take a moment to think about the impact your actions have on others.

Which brings me to a third question for Mr. Woods: Would you at least make a statement recognizing that you should not have tried to play on Friday, and also give a plug for flu vaccine even if you didn't receive one this year?

I'd bet big bucks that Tiger Woods doesn't read this blog, so, yes, I'm just blowing off steam.

Next week is the regular meeting of the ACIP, I"m hoping to view most of the 2-day meeting and have this be the focus of next week's blog.

Published on Leave a comment on Measles in My Backyard

Well, not exactly, and directionally it's more like my front yard. On February 1 the Maryland Department of Health issued a press release of a measles case in a recent international traveler who resides in my Maryland county, listing an apartment complex with my same home zip code as a site of potential exposure. Details are lacking, and I do note the DOH still hasn't sent a notice to Maryland licensed physicians. Keeping my fingers crossed there are no secondary cases.

Last Summer's Vibrio vulnificus Flurry

CDC reported on last summer's burst of V. vulnificus infections across 3 states, a total of 11 severe cases occurring during heat waves in residents of Connecticut, New York, and North Carolina. Median age was 70, and 5 people died. Of the 10 with available information, all had at least 1 underlying risk factor for severe Vibrio infection, including diabetes (3), cancer (3), heart disease (3), history of alcoholism (3), and hematologic disease (2). While the clusters can't be blamed definitely on the heat, Vibrio growth is augmented in warm water; we may see an increase in Vibrio infections associated with climate change.

An impaired reticuloendothelial system (including liver disease from any cause) is a big risk factor; high risk individuals should be warned about avoiding contact with brackish water, salt water, and raw seafood (2 cases last summer had raw oysters as only known exposure).

Late Treatment for Congenital CMV

A new report from the Collaborative Antiviral Study Group reported on a phase 2 randomized, double-blind, placebo-controlled trial of 6 weeks of oral valganciclovir for infants 1 month to 3 years of age with congenital CMV infection and sensorineural hearing loss. Although the treatment group had much lower urine and salivary viral loads during treatment, there was no difference in hearing outcomes compared to the placebo group. Back to the drawing board.

Diphtheria in Africa

It looks like diphtheria is going to be a big problem for some time to come. WHO lists major diphtheria outbreaks in Nigeria (the most cases), Guinea, Niger, Mauritania, and South Africa. The cumulative total of suspected cases is 27,991 with 828 deaths. For those of you needing a little help with African geography, here's what it looks like:

So, this is not just clusters related geographically, but rather scattered throughout the continent. Cases were more prominent in the pediatric ages, and about a quarter of the cases were fully immunized. The numbers could be much higher given the difficulties in diagnosing diphtheria in resource-poor settings.

Bad E. coli in China

Although I'm never happy to hear about new virulent and resistant organisms, I was particularly unhappy about this news for a few reasons. First, it is a hypervirulent strain, apparently more likely to cause severe invasive infections. Second, it carries carbapenem resistance, often our last relatively safe resource in the antibiotic armamentarium for multiply resistant Gram negative bacteria. Worse is that 13% of these carbapenem-resistant organisms did not express a known carbapenem resistance gene, suggesting other perhaps new resistance mechanisms might be present. Lastly, these organisms caused a prolonged outbreak in a children's hospital.

You can see this outbreak occurred a few years ago, but I don't think we've heard the last of this.

WRIS

I'm looking forward to the week when I can retire a regular update on Winter Respiratory Infection Season. For now we have some encouragement but still too early to tell which way we're headed, especially with covid since our data sources are less reliable/predictive.

We seem to be over the hump with RSV season, still plenty out there but we tend not to see late rebounds with RSV.

Flu is a mixed bag depending on locale, but seems to be headed downward overall.

The covid wastewater report doesn't look too bad, either.

JN.1 is the predominant variant in most places now. I include a graph from the UK just because it's pretty.

We also have some other good news on the covid front: the fall vaccine seems to have high effectiveness (54%; 95% CI 46-60%) against development of symptomatic infection in immunocompetent adults. The study covered the time period September 2023 - January 2024 so is very recent and includes the time of JN.1 variant predominance.

Squirrel Wars 2.0

Speaking of my front yard, it is the new site of my war to keep squirrels away from my bird feeder, first mentioned in these pages on January 14. You recall that the capsaicin-laced safflower seeds, advertised as obnoxious to squirrels, turned out to be a delightful snack for those obnoxious rodents here. I tried to access research proven methods for preventing squirrels from eating all the bird food, but sadly there doesn't appear to be a trove of studies to guide me; in other words, no such thing as evidence-based squirrel medicine.

However, many sites mentioned trying to choose a site for a feeder that is beyond the reach of a typical squirrel's jumping prowess of 5 feet upward from the ground, 7 feet across, and 9 feet downward. After much thought, we selected a site in a large front yard tree. Armed with my long-suffering wife's long tree branch cutters and her assistance, 2 rickety ladders, slippery wire, packaging tape, and an autographed baseball from my youngest son's youth baseball team (circa 1990's, I was the official scorekeeper since I was too uncoordinated to be a coach), I succeeded in placing it in the perfect place with only minimal self-injury. Passersby seemed alternately amused and alarmed. If this works, I should get a MacArthur genius grant.

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.

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