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.