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Tag: COVID-19

Published on Leave a comment on Rounding the Corner?

First, some of you may notice I'm posting unusually late for my regular Sunday routine. I wish I could say it was because I was out all night partying New Year's Eve, but anyone who knows me would realize that's a total fabrication. The truth of the matter is that I've been locked out of my blog account all day and unable to reach anyone at GWU to help me, but now all of a sudden my access reappeared. So, I'm writing this at night in case the Gods of Blog decide to exile me again tomorrow.

We have definitely entered a new phase of the pandemic. I know this because the "A" section of the January 1, 2023 Washington Post (yes, I still get the home-delivered version of our local newspaper) had no original news articles about anything related to medical aspects of covid or the other respiratory viruses circulating. The only acknowledgement that this could still be newsworthy was an editorial bemoaning the situation in China.

Let's dive in.

Tripledemic Tracking

RSV

Continued good news from RSV-NET, further definite decrease in RSV activity nationally.

As you can see from the green line, things appear to be coming down to less drastic levels this year.

Influenza

FLUVIEW also has good news.

We have a very definite downward trend on the red line for this year, very encouraging.

COVID-19

The news is not as good with our old friend covid.

The weekly cases don't show a surge, but percent positivity continues to rise.

In the meantime, a new variant appears to be taking over, particularly in the northeast and mid-Atlantic US.

Those big blue pieces of pie represent XBB.1.5, a subvariant in the omicron BA.2 lineage. It has exploded in the last couple of weeks. It likely has similar immune evasion properties as other recent subvariants, but too early to determine if it has increased ability to cause more severe disease.

What does all of this mean for the future of the tripledemic? That again would require an accurate crystal ball, but hey it's a new year, so why not stick my neck out? With the consistent downward trends in RSV and influenza, I think the tripledemic is over. I do not expect a rebound for either flu or RSV this winter because it's already run through most of the susceptibles who now have considerable immunity. I can't say the same for covid, however, because changing variants are still able to infect those who have been recently infected or immunized. The good news is that pre-existing infection and/or vaccination with boosting likely protects somewhat against severe disease, at least for a number of months, but not so much against new infection. So, I think covid will continue to increase though I doubt at levels we saw last winter, unless a more formidable variant appears.

Long Covid News

We still know very little about long covid, but what is increasingly apparent is that we need to have adequate control groups of uninfected people and people infected with other viruses for comparison. A recent example is an article just accepted for publication in Clinical Infectious Diseases. Long covid is likely a mixture of symptoms resulting from direct organ damage from the virus, such as severe pneumonia or cardiac or renal disease, along with some more poorly understood entities such as "brain fog" and other "myalgic encephalitis" symptoms that are known to follow multiple different types of infections. I am hopeful that the many longitudinal studies that are ongoing will shed more light on this confusing grab-bag of illnesses.

Another Effective Oral Anti-Covid Drug?

I was encouraged by the NEJM article showing non-inferiority of VV116 to Paxlovid, with fewer side effects. Development of resistance to antiviral agents is an ongoing concern for any antiviral treatment, so having more options is always preferable. Let's hope more studies support its efficacy.

It Could Have Been Worse

I came across a somewhat uplifting presentation about Epidemics That Didn't Happen. Take a few minutes to look at it; public health principles, when followed, actually work!

If You'll Be Rounding the Corner With Me, How About Doing It With a Silly Walk?

Every year at this time I enjoy reading the Christmas issue of the BMJ which contains some real but tongue-in-cheek research studies. I was particularly drawn to the study alleging to show the health benefits of the "silly walk" shown in the Monty Python skit in 1970. Try it out - it will bring a smile to your face, and we could all use more of that in 2023.

I wish everyone a safe, healthy, and fun 2023!

Published on Leave a comment on Happy Holidays

Whether you celebrate Christmas, Hanukkah, Kwanzaa, or any number of winter solstice/festival of light ceremonies like Saturnalia, Dong Zhi, Sah-e Yalda, or Shalako (the list of holidays this time of year is quite long), or choose to celebrate nothing at all, I hope you will take advantage of a few days away from work to relax and reflect.

Tripledemic Tracking

Let's check the latest stats from CDC.

RSV

The hospitalization rate graph looks pretty similar to last week on RSV-NET, the final endpoint is for data ending December 17. As indicated in the inset, recent data likely suffer from reporting lag. Still, overall good news.

I'm hoping our community of RSV-susceptible individuals is very low now, such that we won't see a rebound later. Note that we usually have 2 strains of RSV circulating every year, RSV A and RSV B, so in theory it is possible to be infected twice in a season. In the past this has occurred only rarely.

Influenza

Influenza likewise continues to decline nationally as per FLUVIEW, though still at a high level.

The lay press has a lot of buzz about flu increasing because of holiday travel, but I'd remind folks that sometimes with early flu seasons in the past, we've actually seen a big decline in infections because kids are out of school. Again, still plenty of flu around, and with 3 strains circulating still important and not at all too late to get vaccinated.

COVID-19

The CDC's weekly data update is on holiday, but daily updates occurred last on December 23 and I could access a graph similar to last week that tracked through December 21.

Rates continue to increase in general. If you aren't already, indoor masking would be prudent now. I continue to be appalled by the low booster vaccination rates in people who have already received the primary covid vaccine series.

Invasive Group A Streptococcal (iGAS) Infection

I've been following this topic in my myriad of listservs since early reports appeared from the Netherlands last spring, but now the lay press has raised an alarm likely in response to CDC weighing in. The problem is still very uncommon and only sporadically cropping up, but it's worth reviewing what's going on.

CDC issued a Health Alert Advisory (HAN) on December 22 documenting increased reporting of iGAS cases this fall; these include entities such as scarlet fever, cellulitis and necrotizing fasciitis, mastoiditis and sinusitis, retropharyngeal abscess, pneumonia/empyema, and streptococcal toxic shock syndrome. What isn't clear is whether this is something unusual or just the expected number during streptococcal season in a year when we are back to mostly "full contact" among people in our communities. Certainly the large number of respiratory viral infections bear some blame; iGAS is well known to follow viral infections. A few clinical caveats for healthcare providers as well as parents:

A biphasic illness, meaning a respiratory infection/fever followed by a few days of relative well-being and then return of illness with high fever and other symptoms, is a classic red flag for bacterial superinfection following viral illness. That is a time to seek care and pay close attention to consideration of iGAS.

Streptococcal skin infections occur much less frequently since the advent of varicella vaccine. But, given the drop-off in regular childhood vaccines, we likely have a much larger group of children non-immune to varicella. Beware iGAS superimposed on varicella.

Group A streptococcal pneumonia and empyema can be severe. Back in my days as inpatient teaching attending I referred to this as Henson's disease (not to be confused with Hansen's disease, aka leprosy) because this is what killed puppeteer Jim Henson. (I note that his Wikipedia entry has a confusing entry about his final illness, including blaming Disney negotiations for his illness!)

Necrotizing fasciitis is especially dangerous. It is a deeper skin and soft tissue infection than is simple cellulitis and can progress very rapidly to cause extensive tissue destruction and death. One possible clinical clue for healthcare providers is that the degree of pain at the site seems out of proportion to the skin appearance. Quick intervention with both antibiotic therapy and surgical resection can be life-saving.

Speaking of antibiotics, pediatric healthcare providers are aware of the amoxicillin suspension shortage nationwide, ongoing for many months now. AAP has a nice list of alternatives.

Cherish Diversity

Too often recently, the cultural and other differences among us are used instead as excuses for persecution. Wouldn't it be nice if we could all just cherish our diversity and use it to build rather than tear down communities? Have a wonderful holiday of your choice!

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Published on 2 Comments on Collateral Damage

Of course covid hasn't gone away, we are entering a period of increased activity in the US now. (Note that reported new cases showed a slight decline, but hospitalizations are up; this likely reflects poor reporting of new infections.) If no new significantly different variants emerge, I don't think we'll see anything like last winter's covid surge. Individuals can now report home test results anonymously; if used extensively it would provide better understanding of disease activity.

Unfortunately immunocompromised and other high-risk individuals will need to weather this covid winter without much help from monoclonal antibody treatment and prevention strategies. Bebtelovimab is now unavailable for treatment due to poor neutralizing activity against current variants. Tixagevimab/cilgavimab (Evusheld) still is available for preventive management in very high-risk people due to lack of any other effective pharmacologic preventive measures, but Evusheld also is likely to be ineffective for the current variants.

Increasingly now our attention should also focus on what I call collateral damage, mainly through 2 mechanisms. First, the pandemic disrupted other respiratory virus transmission during its peak, meaning a lot of young children haven't seen our common respiratory viruses in their lifetimes. Also, a number of factors combined to lower general immunization rates across the globe. So, we have a large collection of non-immune people, including young children, at risk not only for covid but also for both common and previously rare (in high resource countries) infectious diseases.

The Mother of All Flu Seasons?

Well, no, but it's been tough and may last a bit longer. I haven't seen a flu map this bad in a long time (late October 2009, our pandemic year, is in the neighborhood; you can scroll back to see it at the same weblink).

Note that this map represents "influenza-like illness" activity, so likely includes some RSV and other respiratory infections as well.

Most of the influenza cases currently are H3N2 which is well-matched by this year's vaccine. It's still wise to provide flu vaccine to unimmunized children even if they have already had a documented influenza infection because both the 2009 pandemic strain of H1N1 as well as influenza B strains also are circulating and likely will increase later in the season. Olsetamivir is helpful for treatment of high-risk children with flu.

Be on the Lookout for Previously Rare Vaccine-Preventable Diseases

Measles probably represents our biggest risks for outbreaks and deaths worldwide, because of high transmission rate and severity of disease. It won't take much to see outbreaks in the US. Also, did you know England has already seen a diphtheria outbreak this year? The US is at risk as well. Pertussis is always around and could be more severe in the coming months; also watch out for more cases of otitis media (if poor pneumococcal vaccine rates), tetanus, and, as we've already seen, polio.

You Can Limit Collateral Damage

Pandemics and other times of upheaval have always affected immunization rates. However, I am struck by the degree of anti-vaccination campaigns and general misinformation we've seen in what should be an era of enlightenment and celebration of vaccine successes in the US. Frontline healthcare providers are an important countermeasure against this collateral damage. Don't miss an opportunity to reinforce this with your patients and families.

Published on Leave a comment on Yet Another Game Changer

The CDC appears to have answered my question in last week's post, at least partially. While we are by no means in the clear, the new transmission prevention guidelines signal a more logical approach to NPIs (non-pharmaceutical interventions) that fits the current stage of the pandemic. On the other hand, we did see some controversy about whether the CDC is purposely withholding data from the public.

Is the New Guidance Too Confusing?

The guidance for specific areas depends on both disease activity and healthcare capacity for that region which makes a lot of sense because we know we won't reach herd immunity. Prevention of severe disease, death, and healthcare rationing are primary goals. We've seen healthcare taxed beyond capacity trying to care for both COVID-19 patients as well as all the other population health needs. CDC has set up a site that gives a specific answer for a community's level of risk (high, medium, or low) and corresponding advice. Just look at the color of your area of interest in their map and you will have the quick answer.

Getting to the underlying data for the categorization is a little harder but not terribly imposing. For example, if you wanted to know what's going on in Montgomery County, MD, you'd see that as of February 27, 2022, community transmission is "substantial" with the case rate at 66/100,000 and percent of positive tests at 1.83%. 4.43% of inpatient beds and 8.42% of staffed ICU beds are occupied by COVID-19 positive patients. What this all means, going back to the main site link, is that Montgomery County is in the Low community risk level.

I am most interested to see what happens in those jurisdictions where states have made pre-emptive rulings about NPIs that may contradict CDC's guidance. How many of them will toe the new line? Also, will citizens comply when their community experiences an increase in risk and should increase precautions?

Transparency is Essential

I don't have a problem with CDC or other agencies not releasing data that could be inaccurate, but I do have a problem with withholding information because someone might misinterpret the data. Just as with any scientific study, the investigators are obligated to discuss what the results mean and the limitations of the study.

Let's look at the example of wastewater testing and compare the US to the UK. Wastewater testing can be extremely valuable for tracking disease hotspots and also for tracking variants. CDC reports 15-day data on their website. You can see trends and activity in different parts of the country, though I couldn't find any information about variant tracking.

The UK, on the other hand, offers much more extensive information about wastewater tracking in monthly reports, including variant percentages across the country. The country coverage is much more extensive than in the US, though I didn't see any data from Wales.

Here is a screenshot of sites covered by wastewater tracking in the US. Large swaths of the country are not represented:

Dots represent data collection sites, with colors showing percent change. Red is bad, dark blue good, other shades in between, and gray with no recent data.

In general I wouldn't worry as much about misinterpretation of CDC data as I would about deliberate misuse of data. An example of the latter has been an ongoing problem with use of the Vaccine Adverse Events Reporting System (VAERS) data during the pandemic. Virtually every pediatric healthcare provider knew well before the pandemic that VAERS could not provide information about causation - anyone can report any type of event as being associated with a vaccine, and the reports are publicly available. That didn't stop many bad actors from using the data to falsely support claims of harm from COVID-19 vaccines.

Published on Leave a comment on In the Clear?

I must admit a bit of surprise that so many "blue" states are relaxing NPIs (Non-Pharmaceutical Interventions) for the pandemic at a time when new case rates, while falling, are still quite high. Is this all too soon? Too late?

What Do the Models Predict?

Most of us don't have the mathematical background to critique the various pandemic models, but let's look a little closer at one of them. The Institute for Health Metrics and Evaluation (IHME) is an independent population health research organization based at the University of Washington. IHME was founded in 2007 and is one of my favorite sources for data and forecasting during the pandemic.

Let's look at their most recent data compiled February 17. This is a link I'd really encourage you to explore because as you will see the graphs are interactive. Although I've set the link to open for the view of the United States, you can search anywhere.

It's important to look at several different outcomes, especially in the omicron era, to get an accurate picture. We have lots of variability in healthcare seeking and testing behavior, plus as my wife reminded me most of those rapid home test results don't get reported to any public health authority. However, hospitalization rates are a reasonable assessment of what's going on plus focus on an outcome that we care about most. Here's a screen shot of IHME's current projection for hospital bed use in the US.

This is certainly encouraging, though projections will depend on what future variants have in store for us.

Variant Alphabet Soup

Writing in the BMJ, journalist Elisabeth Mahase reminds us that the World Health Organization first designated omicron a variant of concern on November 26, 2021. A lot has happened in the last 3 months. In Pango-speak (Phylogenetic Assignment of Named Global Outbreak lineages, a software tool) it is designated B.1.1.529.1, now BA.1 for short. It accounts for >90% of cases globally currently, including in the US. BA.1 seems to have increased transmissibility but lower severity, although as we've seen it can still stretch our healthcare resources beyond capacity. It exhibits immune escape in terms of infection, though vaccine and natural immunity still provide good to excellent protection against severe disease, depending on individual circumstances.

The subvariant BA.2 (B.1.1.529.2) is a bit in the spotlight now, comprising a few percent of US cases as we hold our breath to see if it precipitates another infection wave. BA.2 certainly has a faster replication rate than BA.1 and likely is more transmissible. Although cases have been reported throughout the world, it's still a bit early to judge relative severity.

BA.3 is much less common so far. Its spike protein mutations aren't that different from BA.1 and BA.2; much remains to be learned about its ability to spread and cause severe disease.

NPI relaxation across the US leads us into a new era of the pandemic. We'll see what this experiment reveals in the coming months.

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