I've mentioned before that, whether I'm walking down the street or hiking in the wild, I can't help myself thinking of zoonotic diseases associated with every animal I see. Now I have a few more animals to add to my fauna paranoia list.
I'll be hand-wringing all this week that I won't be able to attend any of the ACIP meetings on September 18 and 19 due to other commitments. A draft agenda was posted September 12, and only 3 vaccines are being discussed: MMRV, hepatitis B, and covid. All have votes scheduled. As I said last week, I won't comment on the sessions until I've had a chance to review the recordings personally and make my own assessments; timing will depend on when CDC posts the recordings to their website.
In the meantime ...
Updates for Last Year's Flu Season
As they usually do around this time, investigators from CDC and around the country published more definitive data on hospitalizations associated with last year's flu season. As we all thought, it was fairly heavy compared to previous years (note the graph below includes all ages).
A little under one-third of these hospitalized flu patients had received a seasonal flu vaccine, on par with prior years. About 85% received antiviral medication, but the age group with the lowest treatment percentage, about 60%, were children 5 - 17 years of age. Once again, healthcare providers are presumably largely ignoring national guidelines for use of antiviral medications for influenza, though this detail is difficult to tease out from the database.
The discussion on limitations of the data was well done, typical of this influenza group, and bears listing their 5 points:
- influenza-associated hospitalizations rates might be underestimated because of clinician-driven influenza testing.
- influenza A subtype was missing for a median 56% (IQR 48%-64%; range 38%–72%) of patients, and the missingness could have been non-random. Thus the hospitalization rate estimates for A(H1N1)pdm09 and A(H3N2) subtypes derived from multiple imputation procedures using 3 predictor variables (site, age, month) are likely biased and should be interpreted cautiously.
- nonclinical factors, such as hospital admission thresholds, that might have resulted in changes in the number of hospitalizations, could not be measured.
- because influenza vaccination history is subject to more reporting delays than other outcomes in the analysis, 28.5% of hospitalized patients were missing this season’s influenza vaccination status.
- the FluSurv-NET catchment area represents 9% of the U.S. population and might not be generalizable to the entire U.S. population; hospitalization rates in this report represent the FluSurv-NET catchment area.
Consider the thoroughness of this report and its limitations while reading this next topic.
The MAHA Strategy Report
This was a follow up to the original 73-page MAHA Report from several weeks ago. The Strategy Report is only 20 pages and basically offers nothing helpful; it's just too vague and even rambling at times. I found the section on vaccines worrisome, given the leanings of the HHS Secretary. Here's the strategy plan for vaccines (page 10):
Vaccine Framework: The White House Domestic Policy Council and HHS will develop a framework focused on:
- Ensuring America has the best childhood vaccine schedule;
- Addressing vaccine injuries;
- Modernizing American vaccines with transparent, gold-standard science;
- Correcting conflicts of interest and misaligned incentives; and
- Ensuring scientific and medical freedom.
These points are exactly what has been the status quo all along, which of course signals that definitions of "best childhood vaccine schedule" and "gold-standard science" and all the other points will change, most likely to support predetermined endpoints to decrease vaccinations overall.
This report is in striking contrast to the 2024-25 flu hospitalization report I mentioned, which still represents CDC in partnership with other sites as an exemplar for public health.
Ciprofloxacin-Resistant Neisseria meningitidis
This past week I received a letter from the Maryland Department of Health informing clinicians that the state had exceeded the CDC's resistance criteria, and that ciprofloxacin should no longer be used for prophylaxis of meningococcal disease in close contacts of a case. Ciprofloxacin may still be utilized for prophylaxis in settings where it is known that the isolate from the contact source is susceptible to ciprofloxacin or is known to be a non-serogroup Y strain. Of course, usually we don't know this at the time we need to prescribe prophylaxis. Alternatives still include rifampin, ceftriaxone, or azithromycin.
Ideally all healthcare providers should be checking with local health department experts when managing someone exposed to an individual with meningococcal disease. Please don't reflexively prescribe ciprofloxacin without checking first.
Trying to Make Sense of COVID Data
Not only has FDA and ACIP thrown covid vaccine decision-making into complete chaos, it's also becoming harder to interpret covid infection trends. With less resources to track illness combined with less public interest in testing, prevention, and treatment, comparing rates now to those in the past becomes a comparison of apples to oranges. I continue to try still, so here's my latest dive into the national surveillance, with the caveat that regional variations can be considerable.
Early indicators are trending down...
... as are hospitalizations.
All this is good news, but it gets tough when one tries to trend over time, for the reasons stated above. COVID-NET has a fun (for me, anyway) interactive dashboard. Here's what things look like over the entirety of the pandemic and afterwards.
The light blue line represents current data; I don't doubt that numbers are greatly diminished, but take exact comparisons to earlier years with a grain of salt.
Also, here's what part of the pediatric age data for the 3 youngest age groups look like:
With the same caveats about comparing data from year to year, covid-associated hospitalizations in children were most pronounced in the first year of life. Rates for older children are even lower than for the 1 - 2 year-olds.
Alaskapox eMended
In another era, I had a blog for AAP called Evidence eMended where I took deep dives into understanding how to assess original research articles on general pediatric topics to help providers develop an approach to using such articles in everyday practice. AAP eventually ended the blog, and Pediatric Infection Connection was (re)born.
Now comes an emendation (I didn't make up that word) for Alaskapox. My post of 2/11/24 covered a report of the first fatality from this viral illness, in an immuncompromised person. This week, we now have more detail about the 6 of the 7 known cases of human Alaskapox infection, now termed borealpox as part of a general movement to get away from linking geographic communities to diseases. (A famous misuse of geographic tagging is the Spanish flu pandemic of 1918-20; for true accuracy, it should have been named the Kansas flu.)
I learned about the new borealpox name in a more detailed report on infections in humans and the animal reservoirs in Alaska which are mainly small mammals. Like most orthopoxviruses (e.g. smallpox, mpox) the characteristic lesion is on the skin; this new report contains the same lesion photos as in my 2024 post which were taken from a 2/9/24 State of Alaska Epidemiology Bulletin. If you ever find yourself wandering in the interior of Alaska, watch out for these small mammals.
Mode of transmission of borealpox to humans isn't known, but all the cases reported contact with dogs and cats (and in 1 case poultry as well) that had contact with voles and other small mammals. So, their pets may have transmitted the virus to their owners. Clearly these human infections are rare, but I expect future studies of humans and animals will expand our knowledge. If you're ever "travelin' .... where the winds hit heavy on the borderline" as Bob (with help from Johnny) said, keep your dog away from the voles.
