It was an exciting week for me. We had our first tangible amount of snow in 2 years. Last year, I paid big bucks (to me, but I'm a skinflint) to recondition my 30-year old snowblower that refused to start. However, it sat dormant through last winter, and I never tried it out to see if it actually worked. Happily, it performed well this week.
Most of the infectious disease newsworthiness still centers around covid and WRIS*, with one exception.
Oh Deer!
Like most other teen boys growing up in South Texas in the 1960s, I learned to hunt. Once I harangued my father to take me deer hunting, something he abhorred, but like the dutiful father he was he finally acquiesced. I shot a deer, clean kill instantly, but it was a terrible experience. The end of my hunting career. Still, I have no fondness for deer, especially the ones who eat my wife's painstakingly planted vegetation around the yard.
This new article gives me one more reason to despise deer. Investigators from various agencies in Michigan report 4 new cases of Mycobacterium bovis disease linked to deer exposure and include 3 older cases already reported. Of the 7 individuals, 3 were deer hunters, 1was a taxidermist, 1 handled a sick fawn, and 2 were immunocompromised, had no known animal contact, and had close contact with each other.
I found it most interesting that hunters may voluntarily submit deer heads for M. bovis testing in this part of Michigan since 1995. Since that time, 993 of 349,445 (about 0.3%) specimens have tested positive (and those hunters were advised to discard the venison from those animals). Deer-hunters and -lovers should take note.
Another Oral Covid Medication
Researchers in China reported results of a phase 2/3 randomized, double-blind, placebo controlled trial of a new protease inhibitor, simnotrelvir, combined with ritonavir, for treatment of mild to moderate covid illness in 1208 adults within 72 hours of symptom onset. The treatment group had significantly lessened time to sustained resolution of symptoms (180 hours vs. 216 hours) and decreased viral load on day 5 of treatment. Rebound was studied in a subset of subjects and was similar in the 2 groups.
We'll need to wait for further studies and FDA action to know whether this agent will become available in the US, but in general it's nice to have multiple options for covid management.
More Encouragement for Covid Vaccines
Two new studies added to the already large body of evidence confirming efficacy and safety of covid vaccines. First, a retrospective study using EMR data from multiple centers in the US showed lower rates of long covid in vaccinated children under 18 years of age: 4.5% in unvaccinated versus 0.7% in vaccinated, with some waning of protection over time. This is encouraging, but the study design itself is not optimal for measuring this type of effect. I'm waiting for prospective studies to give us a better handle on measuring this benefit.
Another group of investigators performed an extensive literature search to determine risks of various neuroimmunologic disorders, including Guillain-Barre syndrome, Bell palsy, myasthenia gravis, neuromyelitis optica spectrum disorders, multiple sclerosis and central demyelination, and myelin oligodendrocyte glycoprotein antibody-associated disease, following covid vaccination. This is a tough task since these illnesses exist at a low rate in the general population and mostly seem to be equally or more rare in vaccinated individuals.
The authors, after applying various quality methods to screen articles, ended up with 69 studies to include in the analysis. They present a ton of data, but distilling their remarks it does seem like the most evidence exists for an association between vaccination and GBS, especially for adenoviral vector vaccines but also for mRNA vaccines. Neither adenoviral nor SARS-CoV-2 natural infections have been convincingly linked to GBS so far, so this may be a true association. Bell palsy also showed a possible slight association following vaccination, but again these are exceedingly rare events. Worth the price of the article, or more since it is freely available, are the various discussions of limitations of these studies, compounded by the rarity of the conditions of interest. For example, individuals with mild GBS or Bell palsy may not seek medical attention, and this behavior might differ between vaccinated and unvaccinated persons. Other study problems such as publication bias, outcome reporting bias, and clinical heterogeneity also are mentioned by the investigators. I agree with the authors' conclusions that, given the unprecedented attention to covid vaccine safety, it is unlikely that rates of these rare conditions have been underestimated in vaccinated individuals, and vaccine benefits far outweigh any of these possible risks.
*WRIS
Winter Respiratory Infection Season plods along.
Influenza-like illness dropped a bit, uncertain if this will be sustained.
RSV hospitalizations continue to project downward:
Covid wastewater still hasn't approached levels of last winter; cases are down, but remember that case reporting methods have changed dramatically since last year and are more severely underreported now.
Overall a number of data sources suggest we may be turning the corner on WRIS, but still plenty of infections out there and definitely not too late for vaccination of eligible persons for any of these 3 pathogens.
One last note is a tip of the hat to Dr. Michael Schwartz, a frequent contributor to the Comments section of this blog. Last week he wrote "would you like to comment in your next post about California aligning COVID isolation recommendations with other respiratory illness ( most especially flu )? He referenced an order from the California Department of Public Health dated January 9. It specifically deals with covid and doesn't mention influenza directly and is mostly intended to redefine infectious periods for covid to conform with new data. It is short on references/links to source data. I was intrigued, however, to visit their mask advice page, and I think it's pretty helpful and might be useful to families who are confused about the different types of masks available.
In terms of Dr. Schwartz's request, he brings up an important practical point. In the midst of WRIS, much of the time we won't know which virus is causing a child's upper respiratory symptoms, and we need to use testing judiciously to inform treatment choices where indicated. Thus, it makes sense to have a general approach to URIs now. As any parent or pediatric healthcare provider knows, if you exclude every child from school every time they have a runny nose, our classrooms would be empty in the winter. However, in high risk circumstances such as contact with immunocompromised individuals, proper masking may help.
Also, I couldn't pass up sharing this facial hair guide for wearers of N95 and similar respirators:
So much for my plan to grow a wet noodle 'stache.
Snowy Times
Wallace Stevens wrote a famous poem called "The Snow Man," termed by one critic as the best short poem in the English language. I'm more drawn to his discussion of snow in "On the Way to the Bus." Unfortunately I can't find a copy of the latter poem freely available on the web and I would violate copyright laws by reproducing the complete piece here. So, I'll leave you with "The Snow Man," definitely not too shabby either.
One must have a mind of winter To regard the frost and the boughs Of the pine-trees crusted with snow; And have been cold a long time To behold the junipers shagged with ice, The spruces rough in the distant glitter Of the January sun; and not to think Of any misery in the sound of the wind, In the sound of a few leaves, Which is the sound of the land Full of the same wind That is blowing in the same bare place For the listener, who listens in the snow, And, nothing himself, beholds Nothing that is not there and the nothing that is.