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Published on Leave a comment on Autumn Has Broken ….

Leaves are everywhere, including still attached to trees and waiting to further increase my workload. I'm starting to plan my leaf management strategy; when to clear the gutters, waiting for the county to post its leaf collection dates, reflecting on my love/hate relationship with my garden rakes.

... But Still Waiting on WRIS

Covid is as quiescent as it ever gets, flu and RSV still low but hints of increase. I'll enjoy it while I can. As always, CDC has resources to look specifically at activity in your region.

Potpourri

In spite of the relative calm in infectious diseases, I found plenty of tidbits last week. I'll start with some good news.

WHO Declares Egypt Malaria-Free

The news release commented that this is the culmination of 100 years worth of effort. Forty-four countries and one territory have achieved this certification worldwide, which requires demonstration that malaria transmission from local Anopheles mosquitoes has been stopped for 3 consecutive years. In the WHO Eastern Mediterranean region, only 2 other countries, UAE and Morocco, have achieved this landmark. Given that some of our earliest evidence of malaria in humans comes from studies of ancient Egyptian mummies, it's pretty amazing to see a 6-thousand-plus year trend ended.

Mpox Age Distribution

A recent study from Burundi highlights a trend in recent mpox cases in the region, now seeming to cluster in children disproportionately. Here's the breakdown:

The authors state they could not identify reasons for this unusual age distribution, and I expect we'll hear more about that. They also noted that cases were more severe in individuals 15 years of age and older.

Community Acquired Pneumonia Due to Avian Chlamydia abortus in the Netherlands

One more cause of zoonotic pneumonia to add to our lists, based on this new report. Dutch investigators provide a convincing story for an infection cluster in 1 family, including 1 person with severe pneumonia, occurring in late 2022. This novel avian strain was first reported in 2021, and I suspect we'll be seeing more reports of this organism now with perhaps evidence that human infections have been occurring for some time. I'm especially anxious to hear more about the spectrum of clinical disease, hoping that this is mostly a mild pneumonia.

Iquitos Virus

Just as I was starting to get a feel for Oropouche virus (OROV) disease, now I need to learn about a close cousin (IQTV) that was found to cause infection in a traveler returning from Ecuador. Under the category of more than I needed to know, these viruses are part of the Simbu group of about 20 bunyaviruses including the amazingly named Madre de Dios virus. The traveler in the case report returned after a 10-day trip to Ecuador where he experienced many insect bites and presented with fever, chills, sweats, headache, pain with eye movement, and rash. He was thought to have OROV infection, but he fortuitously presented for care in Atlanta where his samples landed at the CDC and further testing revealed the true culprit to be IQTV. The traveler did not require hospitalization and recovered uneventfully.

Hold the Onions

The only way to have avoided hearing about this month's E. coli O157:H7 outbreak linked to Big Macs is to be completely cut off from all news and social media sources. It is centered in Colorado but also present in several neighboring and nearby states. As of the latest update on October 25, the case total is 75 with 22 hospitalizations and 1 death spread over 13 states.

CDC hasn't yet provided any detail about range of symptoms in this outbreak, but presumably the more severe cases represent instances of hemolytic-uremic syndrome. Although O157:H7 and HUS is classically associated with contaminated ground meat, that source didn't seem to make sense in this outbreak. All of these fast food chains have automated cooking methods that would reliably kill bacterial pathogens; it is conceivable the equipment could break down in one restaurant, but not particularly plausible for so many sites occurring at once. The hunt changed to uncooked foods with raw onions now the presumptive culprit.

These circumstances reminded me of a child with no travel history that I diagnosed with typhoid fever decades ago. It was eventually traced to the shrimp salad at a local McDonald's restaurant, prepared by a modern-day Typhoid Mary.

ACIP Meeting

I'd be totally remiss if I didn't mention the regular meeting of CDC's Advisory Council on Immunization Practices last week. However, most of the newsworthy items concerned adult vaccinations (e.g. lowering the recommended age for pneumococcal vaccines). They did approve the 2025 child and adult immunization schedules The final version is not yet available, but you can look at the drafts. Note that a second dose of covid vaccine will be recommended for immunocompromised and high risk children adults 6 months after the fall vaccination. Also see ongoing tweaks to the meningococcal vaccine recommendations appearing on slide 27.

While we wait for official pronouncements, you can find a summary of all the meeting recommendations here.

Published on Leave a comment on Information, Knowledge, and Wisdom

I regularly read Ron Charles's Washington Post Friday Book Club newsletter, always chock full of interesting topics and writers I haven't yet explored. This Friday he included a quote from controversial (accused of plagiarism) Turkish author and activist Elif Shafak

“... we are living in a world in which there is way too much information, but little knowledge and even less wisdom.… As we scroll up and down, more out of habit than out of anything else, we have no time to process what we see. No time to absorb or reflect or feel. Hyper-information gives us the illusion of knowledge. For true knowledge to be attained we need to slow down. We need cultural spaces, literary festivals, an open and honest intellectual exchange.”

This blog is my attempt to machete a trail through all the various forms of information and provide some bridge to knowledge and wisdom by providing links to reliable original sources. Speaking of which, we are now in the midst of ID Week, probably the most prestigious annual infectious diseases research conference, and many of my regular ID feeds are filled with reports of presentations. However, I virtually never include these reports in this blog, because there is no way via these abstracts to look for potential flaws or limitations in the research, and it is well known that research meeting presentation findings often change dramatically by the time they are published in a peer-reviewed journal, if they are ever published at all.

WRIS

Still pretty quiet on the Winter Respiratory Infection Season, with some hints of beginnings of influenza and RSV increasing. Perhaps the only item of interest is an increase in Mycoplasma pneumoniae activity, probably just a regular wave that tends to happen with this pathogen, though delayed somewhat due to pandemic mitigation strategies. It's not a reportable disease, so it's hard to find good data on incidence over time. As most providers know, this is a self-limited illness that produces generally mild illness (so-called walking pneumonia) and usually not worth diagnosing or treating. Because of its self-limited nature, it's been difficult to demonstrate any benefit of antibiotic treatment compared to placebo, and I doubt we'll see any placebo-controlled randomized trials in the near future.

Compared to last winter, CDC is predicting a 54% chance of a similar combined peak of respiratory illnesses, with a 28% chance of a lower peak and 18% chance of a higher peak.

Infectious Complications of Hurricanes

These tend to get less coverage than do the more obvious loss of life and property destruction occurring immediately during a natural disaster, but the Florida Department of Health is now reporting on a surge in cases of necrotizing fasciitis due to Vibrio vulnificus, a known salt and brackish water pathogen. Here are the numbers:

As a reminder, individuals with immunodeficiencies, but also particularly including chronic liver or renal disease, are at high risk for V. vulnificus complications. CDC has a good summary.

Conjunctivitis

Researchers in Colorado looked at about 200 children with acute conjunctivitis compared to a similar number of children who were either healthy or had URI without conjunctival involvement. Long story short, they found no benefit of ophthalmic ointment treatment, but did see a 20% incidence of antibiotic side effects. The study itself didn't replicate real-world situations for providers; for example, they employed broad spectrum PCR testing looking for a large number of bacteria and viruses. The study doesn't give us much direction for practical approaches to this problem but does serve as a reminder to limit topical and other antibiotic use in acute conjunctivitis in children,

Outpatient Infant Botulism?

I would never have thought of this, I've only been called for hospitalized children with infant botulism. It turns out, though, that there are rare instances of milder disease managed as outpatients. A team reviewing the California Department of Public Health data from 1976 - 2021 found 17 of 4372 cases (0.4%) were outpatients. (Note that California cases account for about 1/3 of all US infant botulism cases.) Here's the breakdown of clinical findings.

The median age at onset of symptoms was 20 weeks, with a range of 6 - 55 weeks. Only 1 child had been exposed to honey.

Polio Updates

The second round of novel oral polio type 2 vaccinations have begun in Gaza, though I haven't heard much about ceasefires to help facilitate this critical second round. Meanwhile, this week the Global Polio Elimination Initiative had to bow to reality and revise plans and timeline for polio elimination worldwide. Now, the end of 2027 is the target for elimination of wild poliovirus infections, with end of 2029 for elimination of type 2 vaccine-derived polio. This will take significantly more funding, and the greater the risk of prolonged or new wars the less likely these targets will be achieved.

The DIKW Pyramid

I'm accustomed to using the evidence-based medicine pyramid for hierarchies of study design in medicine, but in researching Dr. Shafak's quote about wisdom I happened onto the Data, Information, Knowledge, and Wisdom pyramid. It doesn't appear to incorporate anything about the role of false or misleading data, so I'm not sure if it is a helpful model in our era. As artificial intelligence becomes more entrenched (it's impossible to remove that view from Google Chrome!), we need to be even more vigilant about our data sources.

HAL 9000 looks a lot like my doorbell. Yikes!

Published on Leave a comment on My Hebdomadal Habit

One of the many reasons I love to read is to discover new words to add to my vocabulary. Reading Colin Dexter reminds me of the need to keep a dictionary close by.

WRIS

The US Winter Respiratory Infection Season hasn't started yet; activity is low to minimal everywhere.

Note that the map above is a new twist from CDC: rather than "Influenza-Like Illness" activity, this reflects all acute respiratory illness by not requiring fever in the definition. So, it probably picks up more of all those other respiratory viruses out there. For the 2 graphs below, just use the same link above and scroll down.

Percentage of ED visits due to the "big 3" viruses is minimal, with covid dropping dramatically.

Since I'm trying to figure out the best timing for my own flu shot, I looked at influenza A wastewater tracking:

Only Rhode Island makes it to moderate activity, all the others with data are minimal or low. Probably the key part of the map above is the number of hatched/limited coverage states. For example, New York flu A wastewater activity only includes Albany and Rochester, not much help to the New York City folks.

Given the WRIS lull, clinicians might be interested in a recent CDC overview of covid and flu management. I couldn't log on to the live presentation but reviewed the slides and took the test for (free) CME credit. The presentation was well done, I recommend it as a good review.

Forbear the Bear (Meat)

Not that long ago (5/24/24 post) I relayed a CDC report about a 2022 trichinellosis outbreak linked to frozen Canadian bear meat. Less than 5 months later, CDC is telling us about another one, this time from 2023 at a single "feast" in North Carolina. It doesn't have as much detail as the earlier report, we don't know much about the food preparation methods and none of the ill persons returned for confirmatory lab testing. It certainly sounds like trichinellosis, however; in addition to a nonspecific febrile illness, 9 of the 10 probable cases reported facial swelling which for me is a T. spiralis infection clue.

I visited a number of wild game/hunting sites to see what advice consumers of bear meat might see. Most sites correctly cautioned hunters to cook bear meat to at least 165 F internal temperature, but a few did not. Also, many mentioned other wild game meats that taste better than bear meat. I won't be ordering bear meat anytime soon, but if you are drawn to the experience check out the CDC web site or this advice from Massachusetts that also includes recipes!

Travel to Rwanda?

Last week I mentioned the Marburg virus outbreak in Rwanda, and this past week CDC upgraded a travel alert for the area which has caused quite a kerfuffle. Rwanda now has a CDC level 3 travel alert status, meaning that nonessential travel to the area should be reconsidered. Three days after the CDC advisory, WHO pushed back. WHO believes that travel restrictions will be ineffective in controlling the outbreak plus may prove harmful to local economies and serve as a disincentive for sharing of public health data from those countries, harming control efforts. These are valid concerns; choosing the proper course of action probably requires something approaching the wisdom of Solomon.

Also, an experimental Marburg vaccine has made its way to Rwanda, now primarily being used and studied in health care providers who form the bulk of new cases, plus other high risk individuals. This study is of extreme importance, and I'm hopeful that we'll see good data eventually.

OED

For a brief moment in my past, I longed to have a complete print version of the Oxford English Dictionary at my elbow. It was short-lived: the standard version comes in 20 volumes and now lists for $1000+. A bargain is the "compact" version at about half that price; it is a "photo reduction" of the original, with 9 pages of the original on each single page. It comes with its own magnifying glass.

It's a lot easier to just look at the online OED to find out that hebdomadal means "weekly." I also learned that it's not commonly used, fewer than 0.01 occurrences per million words in modern written English. Maybe I've now bumped that up to 0.02.

Dexter's Inspector Morse character, in his second installment entitled Last Seen Wearing, mentions his "regular hebdomadal debate" when faced with his weekly dilemma of whether to purchase the more cultured Sunday Times versus the coarse News of the World at the newsstand. I can see parallels to my own cultural preferences in literature, music, and art. However, the hebdomadal part of my habits clearly is this blog. Any further resemblance to Inspector Morse ends here though; he is a true, albeit fictional, polymath who happens to be a detective. I am a real-life physician who happens to have diverse interests, like most of us.

Published on Leave a comment on Winding Down (Again)

After one failed retirement attempt, I'm trying again. I just entered a new phase to decrease my coverage of inpatient telemedicine services at regional hospitals and, if demand isn't increasing terribly, I'll phase out completely. In the meantime, I'm revving up for watching the Winter Respiratory Infection Season (WRIS).

WRIS

Nothing strikingly new or concerning on the covid, influenza, and RSV fronts, according to CDC. Respiratory illnesses, wastewater levels, and ED visits are pretty flat or decreasing most places. Florida is starting to show an increase in RSV; typically that region starts sooner than the rest of the country. Of course all viral activity varies geographically, and you can look at your own region with CDC's interactive program at that link.

I admit to having some personal interest in following this closely now. I'm trying to figure out timing of my flu vaccine; as a septuagenerian I may have more rapid waning of immunity after vaccination than do younger generations, plus preliminary data from the Southern Hemisphere suggests a slightly lower flu vaccine effectiveness this year. The key term here is preliminary. These estimates are based on very low sample sizes, and estimates always change once the full season can be evaluated.

Speaking of vaccines, the UK provided a more straightforward guidance for covid vaccination this year. The eligibility groups are pretty limited:

During the 2024 autumn campaign the following groups should be offered a COVID-19 vaccine:

  • all adults aged 65 years and over including individuals aged 64 who will have their 65th birthday before the campaign ends (31st March 2025)
  • residents in a care home for older adults
  • individuals aged 6 months and over who are in a clinical risk group, as defined in tables 3 and 4 of the Green Book chapter 14a

As I've mentioned before, the UK with its National Health Service relies heavily on cost effectiveness analyses, leading to a more restricted target population than in the US.

Two Viruses on the International Scene ...

Marburg Virus in Rwanda

Marburg activity in Rwanda is increasing, and the CDC sent out an advisory last week. Marburg virus is another of the hemorrhagic fever flaviviruses, like Ebola; it has a high fatality rate. As in other hemorrhagic fever virus outbreaks, healthcare workers are at high risk if they are not careful with exposure to blood and body fluids. Most of us remember the spread of Ebola to the US, and already there's been a scare in Hamburg, Germany, but the ill traveler returning from Rwanda tested negative. The name comes from the German city of Marburg which was one of the sites (the others were Frankfurt, Germany, and Belgrade in what is now Serbia) of laboratory outbreaks of the illness in 1967, linked to African green monkeys imported from Uganda. Let's hope efforts to contain the infection are successful, but it's a tough task in low-resource regions.

Perinatal Chikungunya

A new study from Brazil suggests a relatively high rate of transmission of this virus from pregnant people to their newborn infants. The study period covered the years 2016 - 2020. Here's the summary numbers:

Symptoms in infected infants included, in addition to rash and fever, some more severe conditions like DIC, vesiculobullous eruption, seizure and encephalitis, and respiratory failure. It was both a retrospective and prospective case series, and I learned a new term: ambispective!

... But Also Some International Success

The WHO recently declared Brazil has successfully eliminated lymphatic filariasis as a public health problem, a major milestone. The only countries successful previously with filariasis were Malawi and Togo in the WHO African region; Egypt and Yemen in the Eastern Mediterranean region; Bangladesh, Maldives, Sri Lanka, and Thailand in the South-East Asian region; and Cambodia, Cook Islands, Kiribati, Lao People's Democratic Republic, Marshall Islands, Niue, Pilau, Tonga, Vanuatu, Viet Nam, and Wallis and Futuna in the Western Pacific region. Time to dig out that world map!

Filariasis is one of 20 Neglected Tropical Diseases targeted by WHO for improved control by 2030.

Lower Vaccination Rates in US Kindergartners

CDC updated vaccine coverage rates for the 2023-2024 year and, no surprise, it's dropping. The decrease may be driven at least in part by an increase in non-medical exemptions. This news doesn't bode well for future outbreaks of vaccine-preventable diseases, but the clinical impact is largely determined by geographic distributions at the community level. The site has a lot of data, worth some browsing, but here's a quick look at MMR coverage by state for 2023-2024:

Any state that isn't the darkest blue has high risk for outbreaks. Even within the dark blue states any pockets of poor vaccine coverage, such as communities or schools that have high rates of vaccine-averse parents, could see outbreaks.

How's Your Outpatient Antibiotic Prescribing Score?

A cross-sectional database study of about half a million antibiotic subscriptions in 2022 from Tennessee showed some interesting results. The investigators looked at both appropriateness of antibiotic choice and duration of treatment; only 31% of prescriptions were appropriate for both. Here's the quick look at optimal antibiotic choice by disease:

Here's what it looked like for duration of therapy. Standard durations reflect current guidelines, whereas contemporary durations are taken from more recent studies suggesting shorter courses are effective. The number of days in parentheses are the contemporary durations.

Again, another study worthy of browsing if you commonly prescribe antibiotics for these conditions.

November 5 is Fast Approaching

Although I'm trying to wind down my practice, it seems like my to-do list is twice as long now. We're all busy, but please don't forget to vote!

Published on Leave a comment on Seeing You in September

This month always bring me back to The Happenings version of "See You in September;" I remember it fondly from my junior high school era. The Harvest Month often is a transition period from summer to fall/winter infections.

The Respiratory Infection Front

Right on schedule, the ACIP published its official flu vaccine recommendations. Nothing new in there, but it's a good one-stop shopping place for seasonal flu information. Things remain calm on the overall respiratory illness view, and covid may have reached its peak.

However, I'm still waiting for covid wastewater trends to start heading down in most areas of the country (same link as above). We may not be out of the woods yet.

Also note that the covid vaccine from Novavax was authorized by FDA this week. I'll be interested to see how effectiveness compares to that of the mRNA vaccines; Novavax targets a slightly earlier variant (JN.1) than the Pfizer and Moderna products which used KP.2. KP.2 is decreasing in prevalence in the US but still is more closely related to the current variants KP.3.1.1, KP.2.3, KP.3, and LB.1.

We have more longterm follow-up information about myocarditis and covid, looking at both vaccine- and natural infection-associated complications compared to other ("conventional") etiologies. It looked specifically at individuals 12-49 years of age hospitalized with myocarditis. Without going into great detail, it was clear that vaccine-associated complications were less common than with myocarditis associated with conventional or SARS-CoV-2 infection; however, confidence intervals were wide for several of the outcomes due to low numbers of events.

I was excited to see a new update from the HIVE (Household Influenza Vaccine Evaluation) program that has been monitoring households in Michigan since 2010 and was expanded to cover other respiratory infections in later years. The new update covers the years 2015-2022. (The watermark in the figures below signifies this is an accepted manuscript that hasn't yet appeared in the print journal.) Even though it's limited to southeast Michigan, it is valuable data because it is an ongoing active surveillance program in these volunteer households and gives us a glimpse of how the pandemic affected other virus epidemiology.

Far Away Challenges

Mpox continues to rage in the DRC and other areas of Africa, with exported cases appearing in far-flung countries. In addition to vaccine, these countries need better front line diagnostic tests. WHO has requested test manufacturers to apply for emergency approval.

On the polio front in Gaza, we've all heard the good news that there will be a pause in fighting to allow for vaccine administration, but it remains to be seen if this will really happen. Regardless, this will be an extremely difficult undertaking, targeting over 600,000 unprotected children in the region.

Bugs Transmitting Bugs

Healthcare providers and the general public are understandably reeling from all the information about various outbreaks of vector-borne infections. It's important to keep in mind 2 main points: 1) Nothing is happening this year that hasn't happened before in the US. This is the season for vector-borne viral infections. 2) Global warming has increased both the range of these vectors, introducing these infections to areas that haven't seen them in past years, and also increased the season length that these infections circulate. We could see increases in all these infections in coming years.

Here's a breakdown of some of the viruses being hyped in the news.

West Nile Virus

Approximately 70-80% of infections are asymptomatic. The most feared complication, neuroinvasive disease, occurs in <1% of all infections but has a 10% mortality and higher rates of permanent neurologic sequelae such as paralysis. So far in 2024, we have had 289 cases from 33 states in the US, with 195 being neuroinvasive (reflecting the fact that only the worst cases get tested for WNV, not any change in asymptomatic rates). Here are some maps for prior years in the US:

As of now, nothing out of the ordinary for West Nile disease in the US. But, it's pretty common if you recognize that we're only identifying maybe 1% of infections.

Dengue

Here the risk is very high in Puerto Rico, but otherwise mostly restricted to travelers from the current epidemic/endemic areas. Some border states, especially Florida, are more likely to see autochthonous (locally acquired) cases. The asymptomatic infection rate is about 75%; 5% of the symptomatic infections progress to severe dengue with capillary leak syndrome and/or hemorrhagic complications. IMPORTANT CLINICAL PEARL: severe dengue usually appears when things otherwise look good - start of afebrile phase after 2-7 days of the febrile phase. This is the time to be very vigilant if dengue is suspected. The slide below (#42 in the pdf) is taken from a wonderful IDSA/CDC Clinician Call webinar this past week, available at https://www.idsociety.org/globalassets/idsa/multimedia/clinician-call-slides--qa/8-28-2024-clinician-call.pdf and https://www.idsociety.org/multimedia/clinician-calls/cdcidsa-clinician-call-update-on-dengue--other-vector-borne-diseases/.

Here are some numbers from the main CDC website above.

For 2024, the only locally acquired cases in the US have been in Puerto Rico (2676 cases), US Virgin Islands (85), and Florida (21), though those numbers are certain to rise since the season isn't over and reporting in general is delayed. If you add in the travel-associated cases, we've seen a little over 4000 in the US.

Oropouche Virus

This is a relatively mild illness for the most part. The asymptomatic infection rate is around 40%, but 4% of those with symptoms will develop neuroinvasive disease. Now there is concern for vertical transmission in pregnant people, still not completely clear. Management guidelines for infants with possible intrauterine infection are updated and available.

Although I was aware of Oropouche virus previously, this is the first year I've ever heard of the term "sloth fever" which only applies if you acquire the infection in the jungle. This is a slide from that same IDSA/CDC webinar, slide 69 in the pdf.

Oropouche may be over with in South America now, and the main risk area remaining is Cuba. CDC reported 21 US cases in travelers returning from Cuba.

Eastern Equine Encephalitis

Saving the worst for last. It's very uncommon, but you definitely don't want EEE. The encephalitis picture occurs in <5% of those infected with EEE virus, but of those with encephalitis the mortality rate is 30%, and 50% of survivors have permanent sequelae.

We've had 4 cases in 2024 so far. Here's data from prior years:

This is a horrible disease. Certainly precautions such as mosquito spraying and personal protection from bites should be implemented in areas where the virus has been identified.

Earworms

Not wanting to end on a depressing note from the rare but severe EEE disease, I thought of earworms. I'm not referring to the real earworm infecting corn ears, nor RFK Jr.'s brain worm, but rather the more contemporary use of the term. Last week I went down the rabbit hole for the Maurice Williams song "Stay," and this entire past week I've been unable to get it out of my head. Maybe I'll replace it with "See You in September."

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