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Tag: influenza

Published on Leave a comment on Happy World Leprosy Day!

I'm not sure I'd put this in the same celebratory category as a new year's event (January 29 is Vietnamese new year and Chinese new year for 2025), but it is noteworthy. WHO publicizes this day, and it might surprise some in the US that we had 369 new US cases detected in 2023, including 4 children. Here's a global map:

Leprosy still is one of the most stigmatized diseases in the world, fed by rumor and superstition. WHO is a good source for factual information. Speaking of WHO ...

US Quits WHO - What Does This Mean?

Well, this executive order doesn't mean anything immediately, assuming the new administration doesn't somehow violate the agreement for giving a year's notice to WHO before leaving. The US is obligated to pay for 2025. I have no direct experience with WHO, but it is well-known to be a large bureaucracy with the usual ponderous systems that this brings. I did find some better information from one of the many information sources I read, this one written by epidemiologist Dr. Katelyn Jetelina. She previously worked at WHO in Geneva, and her January 23 post provides more insight into how the loss of US funding for WHO might impact world health. She documents many problems with the WHO, but also provides a stark look at what the loss of US funds could portend. The US is the largest donor to WHO.

I'm hoping cooler heads will prevail and this exit won't go through.

MMWR Disappears

I've been subscribing to CDC's Morbidity and Mortality Weekly Report for more than 40 years, way back to when the paper copy came to me in snail mail every week. The communications embargo for health information, detailed in a memo by the acting Secretary for HHS, put a hold until February 1 on federal agencies issuing any information that hasn't been reviewed by a presidential appointee. The memo does allow for exceptions that include critical information, again requiring some sort of political appointee approval.

The MMWR isn't particularly controversial in my mind. I read it every week, but I suspect most healthcare providers don't keep it on their nightstands, or whatever that equivalent is in today's digital world. As of now, the current issue is listed as January 16, with nothing about a January 23 edition. Presumably we will miss January 30 as well.

I'm not so worried about this now, I'm sure we'd hear if we need to take any urgent action with bird flu or other emergency, but I am concerned about whether political censorship will affect the credibility of this information in the long run. I can still remember the chaos early in 2020 and the insistence by some of the value of hydroxychloroquine, ivermectin, and even bleach as effective treatments.

And, speaking of avian flu ...

Avian Flu Update (without CDC)

The Infectious Diseases Society of America broadcast a bird flu webinar, usually done in conjunction with CDC, but this time CDC wasn't mentioned in the title and none of the speakers had CDC appointments. I was able to attend the session in its entirety, and the recording and slides are available to everyone. In spite of the official CDC absence, the speakers were bona fide experts, and I learned several things.

The molecular difference between highly pathogenic avian influenza and low (not lowly) pathogenic strains (slide 6):

Recent global spread of HPAI by wild birds (slide 11):

Spread to dairy cows facilitated by excellent replication in mammary glands and transmission among cows mainly via milking machines (slide 16):

Experience in California suggests that conjunctival swabs may have higher yield of H5N1 than nasopharyngeal swabs (slide 37):

Remember that conjunctivitis is common (80%) in current human cases of H5N1 but is not a prominent feature of seasonal influenza.

Sequencing of strains from human cases in California suggest that the human cases arose by independent cattle-to-human infection events (slide 40), explained by the red dots below appearing in separate phylogenetic trees:

Also some discussion ensued about various testing options. The short version is that none of the tests are approved for conjunctival specimens, and the sensitivity of various tests to identify influenza A H5 is uncertain. Also unknown is whether testing costs in commercial labs would be covered by various insurance plans.

The penultimate presentation was by Bethany Boggess Alcauter, PhD, from the National Center for Farmworker Health. She provided a unique perspective that enlightened me greatly. It starts with slide 72. It was very clear that farmworkers have difficult jobs with little labor protections (below is slides 75-78):

One can easily imagine how tough it is to monitor and manage infections in these workers who now have the added burden of being more targeted for deportation.

A final presentation by Dr. Richard Webby from St. Jude Children's Research Hospital summed up in slides 86 and 87 the current understanding of H5N1 evolution and how difficult it will be to predict the future:

Antibiotics Can't Beat Cold Steel for Appendicitis

Moving away from various pandemic and political concerns for a moment, a new randomized controlled trial suggests that medical therapy alone is inferior to appendectomy (aka appendicectomy in the article) for management of uncomplicated appendicitis in children 5-16 years of age. This was a multinational study at 11 sites (2 in the US) that enrolled a little over 900 children with suspected non-perforated appendicitis.

Prior studies have suggested antibiotic therapy alone is an acceptable management pathway, and I suspect we haven't heard the last on this issue. For now I'd go with surgical intervention as the better alternative.

WRIS

With the muzzle on federal authorities releasing new data, I was interested to see what my usual information sites had available to me this week to monitor winter respiratory viral infection activity. I'm happy to report that the CDC's Respiratory Illnesses Data Channel was updated on Friday as per usual.

The NREVSS Dashboard also was updated (the cutoff date is January 17, but this diagram has additional data compared to last week's report).

I'm not subscribing to any crystal ball methods for predicting how WRIS will progress; I've seen some intimations that covid will be mild this winter, but I worry that some folks are trying to fit covid into a seasonal virus pattern which so far we've learned is not true.

Any bets on whether we'll see MMWR this week?

Happy Year of the Snake! Sức khỏe dồi dào

https://chus.vn/year-of-the-snake/

Published on Leave a comment on Tick Tock

I have little to no use for social media although I do understand that many in the US see TikTok as a valuable source of entertainment and income. When I had a blog with the AAP I was "forced" to sign up for a Facebook account but never used it. I already spend a lot of time tracking new data from multiple, more reliable, sources. Do I sound like a typical boomer?

The darkening of US TikTok access, presumably to be restored in a day, is but one of many striking events this coming week. I'll be watching closely to see what happens with our public health infrastructure and pandemic preparedness over the coming months and years.

Avian Influenza

Six months ago, or even 3 months ago, I never would have thought I'd be discussing the H5N1 situation so prominently. Although we still have no evidence of human-to-human transmission, which would be a game-changer, looking at how our leaders respond to this potential threat is a bellwether for our public health infrastructure will protect us going forward.

Here's the current status:

Our public health infrastructure has given us some important steps in the past week.

  • The FDA announced that cat and dog food manufacturers "consider H5N1 in food safety plans." The wording isn't clear to me, considering something is not the same as a requirement, but wording later in the document suggests it is requiring manufacturers to reassess how their unpasteurized raw products could place pets and their owners at risk for H5N1; transmission to pets from such products has been documented already. The webpage also contains a useful list of publications.
  • CDC issued a new advisory asking hospitals to accelerate subtyping of influenza A infections in hospitalized patients, particularly for these with severe illness where the high viral loads increase the possibility of mutation and recombination events that could increase virulence and transmissibility. This shouldn't be too difficult for hospitals - many multiplex test platforms include testing for influenza A H1 and H3, the seasonal strains, so a patient testing positive for influenza A and negative for H1 and H3 needs prompt followup to test for H5. H5 testing is not as widely available and would require help from public health labs. This advisory is very timely and important particularly as we see co-circulation of seasonal influenza with avian influenza.
  • CDC also reiterated their guidance for use of combination therapy (oseltamivir plus baloxavir) for some human infections with H5N1, mainly for immunocompromised patients but also to be considered for hospitalized patients.

All of this surveillance requires resources (i.e. money); let's hope the new administration recognizes that. As an aside, I noted that the UK is embarking on a large pandemic response exercise as preparation for future outbreaks.

Protect Your Hispanic Patients

OK, one more semi-political comment and then I'll get off my soap box. Dr. Danielle Ofri, a primary care doctor in NYC, wrote a nice opinion piece in the NY Times last week (requires subscription or a free account to read). With the uncertain threats of coming deportations, she notes that "fear alone can keep patients from seeking care." Not only is this harmful for individual patients and families, it will be incredibly expensive if individuals delay healthcare visits and we are faced with treating illnesses at a later stage in disease. One state (sadly, my place of birth) requires public hospitals to ask about US residence status, a rather chilling deterrent to seeking care, but patients are not required to answer. Dr. Ofri recommends those providers making the latter point clear first, before asking the question.

Consequences of in utero Zika Infection

A new article from investigators in Brazil found that children born to mothers infected with Zika virus during pregnancy demonstrated increased rates of neurodevelopmental delay even when they did not have evidence of the congenital Zika syndrome. The risk was significantly higher for infants born to mothers infected during the first trimester of pregnancy.

More on CWD

Last week I mentioned chronic wasting disease spreading in cervids in the US, with a tongue-in-cheek (pun intended) caution about eating venison; cooking does not inactive prion-mediated disease. Now comes a new report from Norway showing CWD prion detection in muscle tissue from moose, red deer, and reindeer. Pass on cervid meat ingestion in Scandinavia!

New Vaccine Education Resource for Clinicians

Well, maybe not so new, but I just found out it's available to anyone. The Pediatric Infectious Disease Society Foundation has a large number of educational modules available to all who register. Check it out if you're interested.

WRIS

Our winter respiratory infection season plods along. I've been somewhat amused with news reports about surges in human metapneumovirus infections, which of course happens every winter. However, no one is mentioning the common cold coronavirus infections (HCOV) that are just a common now as HMPV. Here's a quick look at percent positive tests nationally, also searchable by region. HCOV is a little higher than HMPV; I guess HCOV is the Rodney Dangerfield of winter respiratory viruses.

My Bucket Lists

I have many bucket lists, none of them in writing, but this past week a new report brought to mind the bucket list I'm most ashamed of. It's my infectious diseases bucket list, a mental listing of infections I hope to see during my lifetime. It's shameful because it requires someone to be sick in order for me to cross off a list item. One of the biggies on the list is seal finger. I'm guessing most readers have never heard of it.

Researchers in Denmark and Australia reported a rather severe episode of seal finger caused by Mycoplasma phocimorsus associated with a cat scratch. This 54-year-old Danish woman developed tendinous panaritium (I had to look that up, it's basically a paronychia/whitlow/felon with contiguous spread) several days following a cat scratch, but then it progressed to very extensive infection requiring multiple extensive surgical procedures. I don't think it's a misprint in the article that stated she developed all this in 2013; likely the delay in reporting depended on new methodology. The authors seem to be the same team that originally discovered in 2023 that this organism was associated with seal finger. The unusual element in the current case report is its association with a cat scratch, I think only reported a couple times previously. The authors of the current report state that their patient's isolate appears to be a different Mycoplasma species than what was detected in the other 2 reports.

Courtesy of BBC News. The Royal Society for the Prevention of Cruelty to Animals recommends observing seals from a distance of no less than 100 meters.

Published on Leave a comment on Settling Into Winter

I'd been spared from most snow shoveling due to mild winters the past few years. Fortunately, this week I discovered that my outdated acetaminophen still seems to work.

Artificial Intelligence for Pediatric Infectious Disease Diagnosis

Investigators at Baylor College of Medicine (bias alert: my alma mater) developed an interesting method to distinguish the covid-associated Multisystem Inflammatory Syndrome in Children (MIS-C) from endemic typhus, the latter enjoying a bit of a resurgence in south Texas. The rest of us don't have reason very often to consider these 2 entities together since endemic typhus (aka murine or flea-borne typhus) is pretty rare in the US beyond southern California, southern Texas, and Hawaii. However, the results from this preliminary study serve as a proof-of-concept model for other diseases. The methodology is very complex, to say the least. Briefly, they looked at electronic medical record data over a 2-year period for anyone being tested for Rickettsia typhi, the etiologic agent for endemic typhus, or having a rheumatology consult request for MIS-C. All of the typhus-positive patients and a subset of MIS-C patients were included in a preliminary dataset for the AI modeling. A large number of patient variables were tested in an iterative process to come up with a preliminary scoring system which was then validated on another MIS-C patient set. The final scoring system included 15 variables: age of patient, duration of fever, height of fever, highest heart rate, neutrophil to lymphocyte ratio, AST, ALT, sodium, troponin, BNP, fibrinogen, epidemiologic link to COVID-19 case, antecedent illness, conjunctivitis, and rash. The authors claimed their scoring system correctly classified all 220 patients in their training dataset (100% accuracy) and was 99% accurate in the 160-patient MIS-C cohort used as the validation dataset. Of course we still need further evidence that this works well in other settings and institutions. I hope the AI and machine learning process itself, so far published only as a preprint, can be applied to other clinical situations.

Another Tick-borne Virus

Speaking of vector-borne infections, now researchers in China report a novel virus from the Nairoviridae family was found to be a cause of febrile illness in 26 of 252 febrile patients tested in northeastern China. They named it XCV (Xue-Cheng Virus) after the geographic site. (IMHO, I wish we could get away from naming diseases according to a geographic site, it just encourages xenophobia.) They also found evidence that XCV caused cytopathic effect in vitro and was present in 3-6% of ticks in the area. They authors don't provide much clinical information about the cases, and a link to a supplementary appendix didn't contain any more details. Overall it does appear this is a new infectious pathogen.

If you never heard of nairoviruses, don't feel bad. Some infectious diseases physicians may be aware that Crimean-Congo hemorrhagic fever virus is the main human pathogen in this family.

Chronic Wasting Disease

I don't think I've ever mentioned CWD in these pages previously. It is a fatal neurodegenerative disease seen in cervids (deer, elk, moose, reindeer) and caused by an infectious prion. I've been watching reports about spread of CWD in the US and across the globe for many years. I mention it now because of the publication of a new report from CIDRAP concerning for potential for spillover into other species, including humans, similar to what has happened in humans with Creutzfeld-Jakob Disease, kuru, and bovine spongiform encephalopathy (mad cow disease). Here's the North American distribution of CWD.

CWD has been expanding in numbers and in geographic areas in the US the past 20 years, increasing the possibility of spillover into humans. The CWD prion can remain intact in the environment for years, and prions are not inactivated by cooking infected meat.

The report maps out several recommendations for monitoring this situation; the recommendations bullet list alone takes up 5 pages of the 102-page document. It's a good example of how to plan proactively, but of course implementation takes funding of public health endeavors.

Venison steak, anyone?

Good News in the Vaccine Department

Three quick comments on recent vaccine studies.

First, I was somewhat surprised to see a pretty good uptake of RSV prevention modalities for pregnant people and infants. In the 2023-24 RSV season in the Kaiser Permanente Northern California system, around 75% of at risk infants received protection either by maternal vaccination or nirsevimab administration after birth.

I'm hoping it is even better this season. Remember that Kaiser is a health system very well designed to deliver high rates of vaccinations and other preventive interventions to its subscribers. However, individual private medical practices can and should aim to achieve high rates of RSV prevention.

Another study provided more evidence that it is safe to administer 2-month vaccinations to hospitalized preterm infants. It was a randomized controlled trial of preterm (<33 weeks gestation) infants hospitalized at 3 NICUs and eligible for vaccination at 6 - 12 weeks of age. 223 babies were randomized to receive either 2-month vaccines or no vaccine and then monitored for 48 hours. The unvaccinated group of course could receive vaccines after this 2-day period. Although apnea was more common in the vaccinated group, it didn't appear to have any adverse effects.

The vaccines administered were PCV13, DTaP, HBV, IPV, and Hib.

The last vaccine study I'll mention is another estimate of flu vaccine effectiveness last year. Specifically, it looked at outpatients at least 8 months of age in 7 states that were part of a flu VE surveillance system. The target endpoint was outpatient visits with positive influenza testing. VE against any influenza illness was 41% (95% Confidence Interval [CI]: 32 to 49): 28% (95% CI: 13 to 40) against influenza A(H1N1)pdm09, 68% (95% CI: 59 to 76) against B/Victoria, and 30% (95% CI: 9 to 47) against A(H3N2). Protection was found in all age groups except for the 50-64-year-old group. Differences in age groups (and also related to influenza A subtypes) likely are related to imprinting, i.e. what flu strains people are exposed to early in life, but this study wasn't designed to answer this question.

WRIS

As we roll along in the winter respiratory infection season it's worth taking a look at where we are. CDC has some newer data for the "big 3" viruses in pictorial form. (See https://www.cdc.gov/flu-burden/php/data-vis/2024-2025.html, https://www.cdc.gov/rsv/php/surveillance/burden-estimates.html?ACSTrackingID=USCDC_2067-DM142871&ACSTrackingLabel=CDC%20Updates%20%7C%20New%20In-Season%20Estimates%20of%20COVID-19%20and%20RSV%20-%201%2F7%2F2024&deliveryName=USCDC_2067-DM142871, and https://www.cdc.gov/covid/php/surveillance/burden-estimates.html?ACSTrackingID=USCDC_2067-DM142871&ACSTrackingLabel=CDC%20Updates%20%7C%20New%20In-Season%20Estimates%20of%20COVID-19%20and%20RSV%20-%201%2F7%2F2024&deliveryName=USCDC_2067-DM142871.)

Note that the influenza numbers include 2 weeks longer than for RSV and covid. I did a quick calculation of death rates per illnesses for each, using the midpoint of the ranges: influenza 1.3 deaths/1000 illnesses, RSV 2.5, and covid 3.1. Of course these are all ballpark estimations but still show that infections with any of the big 3 are worth preventing.

Here's the most recent look from FluView, which captures respiratory illnesses other than influenza.

Still hoping that flu and RSV reach their peaks before covid ramps up.

Español en la Nieve

My shoveling activities were greatly enhanced by one of my new neighbors, a 3-year-old boy who just moved here from Colombia and only speaks Spanish. I'm forever embarrassed by the fact that the Spanish I've retained from my south Texas childhood can't be used in polite company, but my new friend was speaking his native tongue to me while we shoveled together. The upside if we have a heavy snow winter in Maryland is that I may develop new Spanish fluency!

Published on Leave a comment on Bye Bye Birdie?

Regular readers may recall my new infatuation with bird watching triggered by the gift of a video bird feeder from a daughter-in-law. In this era of avian influenza evolution, one might legitimately ask whether a septuagenarian should gown, glove, and mask when performing weekly seed replacement and monthly cleanings. The short answer is no; the birds at most bird feeders in the US are not displaying high rates of infection. I just won't be touching any dead fowl or starting a backyard chicken coop anytime soon.

Here's what I ran across this past week.

Managing the Febrile Infant

This is one of those conundrums that has plagued me since medical school in the late 1970s. It's not that we haven't made progress (GBS prophylaxis, for example), but we still lack reliable methods to distinguish which febrile newborns need empiric antibiotic therapy and which can be safely observed without antibiotics. The latest iteration in the discussion looked at prospectively-collected data from 2018-2023 on well-appearing febrile infants 8 - 60 days of age at a single center in Canada. The investigators were particularly interested in predictive data without using serum procalcitonin measurement. AAP Practice Guidelines recommend using PCT but also provide guidance for assessment if PCT measurements are not available in a timely manner.

From the sample of slightly less than 2000 infants the Canadian investigators developed a new decision rule, with some internal validation, to manage low-risk infants. The new rule maintained high sensitivity (and therefore high negative predictive value) while improving specificity from 51% to 84%, resulting in fewer infants receiving unnecessary therapy. The rule incorporated CRP, maximum temperature, and ANC. (IBI denotes Invasive Bacterial Infection.)

It's important to note, as the authors do, that this was a single center study. In general, it's wise to wait for validation from other sites (this was an urban tertiary care center) more similar to your own practice setting before implementing a new practice. Also, only 38 infants had IBI, not surprising since most fevers in infants are due to viral infections, but the low numbers of IBI cases might result in lower validity. This study, and any resultant guidelines, apply to a relatively healthy group; to qualify for the study, subjects had to be well-appearing, previously healthy infants of at least 37 weeks gestation. A number of standard exclusion criteria such as no prior antibiotics and no focal infections, underlying medical disorders, or other high risk factors for infection also were employed. This approach certainly could be an improvement to current guidelines, but 84% specificity is far from what I would want for ideal management of a frequent clinical problem.

Which IGRA Test is Better?

Testing for tuberculosis infection is at the top of diagnostic dilemmas that have plagued me for my entire career in medicine. Interferon gamma release assays are a big improvement over tuberculin skin testing primarily because they remove the error problems of application and interpretation of the skin test and are not affected by prior BCG vaccine administration. Aside from those circumstances, IGRAs have about the same sensitivity and specificity as skin testing.

A new study looked at discrepancies between the 2 main IGRA tests, Quantiferon and T-spot, in a multi-center US pediatric population. Subjects for this study were less than 15 years of age and had risk factors for TB infection, but were not thought to have active TB disease; in short, these were children being screened for latent tuberculosis infection. The rate of indeterminate test results was similar between the 2 tests, about 0.3%. However, the rate of positive tests was higher for Quantiferon than for T-spot.

Particularly interesting was that the reasons for the higher positivity of Quantiferon wasn't evident. It did not vary with the child's age (note too few positives in the children younger than 2 years of age to be confident of those results), whether the tests were borderline positive, i.e. close to the cutoff for positivity, or reason for performing the TB screening test.

This report doesn't tell us which test is better in this setting. We can't determine false positive or false negative rates from the data, a problem with every study of latent TB infection because the subjects would need to be followed for years without receiving preventive treatment, clearly unethical. We still have a lot to learn about TB.

Norovirus in the News

I've seen a lot lately, and not just the usual cruise ship headlines. Due to how norovirus outbreaks are reported, it's hard to know if what we are seeing now is something highly different from pre-pandemic years, but let me remind everyone that norovirus is a winter disease.

Also, remember that alcohol-based hand sanitizer won't work for norovirus; use real soap and water for an extended scrub. Norovirus vaccines of various types are under development, including a recently-launched phase 3 trial in adults in the UK.

Are My Red M&Ms on the Way Out?

I'm really not branching out from infectious diseases commentary and won't pretend to be an expert on cancer-causing chemicals, but we've all seen the concerns about red dye #3 in foods in recent news reports. Maybe this is a bow to the new political administration and possible public health leadership. Regardless, from afar I'm confused about why a compound that is associated with cancer in laboratory animals, and is essentially a food cosmetic is still on the market.

Believe it or not, there is a pediatric infection connection with red food colorings. I first heard about this 1965-66 pediatric Salmonella outbreak at the Massachusetts General Hospital from a pediatric resident present at the time who later became one of my mentors. Summarizing a lot of data and leaving out my mentor's colorful anecdotes which may be embellished, the source of the outbreak was a red dye used for measuring intestinal transit time - give the dye capsule and watch for red-colored stools. The key component was carmine, derived from a cochineal insect Dactylopius coccus that produces the red pigment carminic acid. These insects are found primarily in Mexico and Central America, and processing at the time was found to be ineffective at killing Salmonella.

The food industry seems dependent on food colorings, but I'd prefer less additives that serve only to colorize my food.

WRIS

Some of my CDC tracking sites are still a bit behind due to the holidays, but we are certainly in full-blown Winter Respiratory Virus Season. The Influenza-Like Illness map is leaning towards the red end of the visible light spectrum (note CDC seems to have moved blue outside of its normal position in the spectrum!).

The drivers are primarily influneza A and RSV. Covid is low but rising, and covid wastewater monitoring suggests we'll see a significant uptick in the coming weeks.

Avian Influenza

This is still a low probability for concern but should be closely watched. This past week saw a more complete report of the case of severe avian flu in a Canadian teenager that reminded me how poorly news reports and press releases characterize specific cases. I had initially thought, based on news reports, that the severe disease might be due to secondary bacterial complications, but in fact this was just bad, high viral load, avian influenza. We now know that the child was an obese (BMI was "greater than 35") 13-year-old-girl, previously healthy except for mild asthma, who required intubation and ventilation, then ultimately ECMO, for survival. She first became ill on November 2, was seen in an emergency department with conjunctivitis and fever on November 4 and sent home, then admitted in respiratory distress on November 7 and transferred to an intensive care unit on November 8. She had multiple complications including renal failure requiring hemodialysis. She was off all oxygen therapy by December 18.

One additional concern in the report was the presence of a mutation in the hemagglutinin gene that might facilitate better adaptation to the human respiratory tract, similar to the Louisiana adult with severe avian flu infection. We need to keep a close watch in general on avian flu mutations in wildlife but also in humans, particularly those who have severe disease with high viral loads that facilitate mutations that increase human adaptation. Still, there is no evidence of human-to-human transmission which is the most reassuring finding at present.

I've been trying to monitor how the federal government is prioritizing avian flu. Last summer the USDA introduced a program to compensate poultry farmers for monetary loss due to avian flu infecting their flocks, and a proposed update was announced recently. I know that researchers at CDC, NIH and elsewhere are working hard on variant assessments and development of stockpiles of effective vaccines and alternative antiviral agents.

Our 39th President

I'd be very remiss if I didn't stop to comment on President Carter's passing. He certainly had an up-and-down stint during his 1 term as president, but his subsequent work in public health was phenomenal. Take a moment to review the public health accomplishments via the Carter Center. I hope our current and future leaders will take a page from his playbook as we deal with upcoming public health challenges.

Guinea worm disease is a major impediment to a farmer's ability to work. Dressed in his farming clothes, Nuru Ziblim, a Guinea worm health volunteer in Ghana, educates children on how to use pipe filters when they go to the fields with their families. Pipe filters, individual filtration devices worn around the neck, work similarly to a straw, allowing people to filter their water to avoid contracting Guinea worm disease while away from home. In May 2010, with Carter Center support, Ghana reported its last case of Guinea worm disease and announced it had stopped disease transmission a year later.

Location: Ghana | Date: February 2008 | Photo: The Carter Center/L. Gubb

Published on Leave a comment on The Year in Review

It's fashionable for this time of year to give some reflections on the events of the last 12 months; seemingly every pundit/publication does it in some form or another. I won't buck the trend. What follows is a bit of a "highlight reel," plus the 3 things I'm watching closely for next year.

The Unexplained Explained

Recently we all had the opportunity to watch as a mystery outbreak unfolded in the Democratic Republic of Congo. Was it a novel pathogen set to launch a new pandemic or simply a localized outbreak of a known pathogen, complicated by poor health resources delaying accurate diagnosis and treatment? It took a little longer than I predicted to unravel everything, but we now have an answer from WHO as of December 27. That's still pretty quick, the original alert from the Panzi health zone in the Kwango province was November 29. I'm reassured that our global public health system is working well for outbreak detection.

The case definition used for investigation was fairly broad: "any person living in the Panzi health zone from September 2024 to date, presenting with fever, cough, body weakness, runny nose, with or without one of the following symptoms and signs: chills, headache, difficulty breathing, malnutrition, body aches." Here's an excerpt from the report:

"As of 16 December, laboratory results from a total of 430 samples indicated positive results for malaria, common respiratory viruses (Influenza A (H1N1, pdm09), rhinoviruses, SARS-COV-2, Human coronaviruses, parainfluenza viruses, and Human Adenovirus). While further laboratory tests are ongoing, together these findings suggest that a combination of common and seasonal viral respiratory infections and falciparum malaria, compounded by acute malnutrition led to an increase in severe infections and deaths, disproportionally affecting children under five years of age."

In other words, it was a combination of known pathogens already present in the area, layered on a background of falciparum malaria and malnutrition: a perfect storm. Let's hope the added health resources will dampen the outbreak in this very rural, isolated region of the DRC. Nutritional support is particularly needed.

WHO 2024

The WHO published its look back at 2024, including "highlights, breakthroughs and challenges." Many countries achieved milestones in either elimination or significant decreases of a number of diseases, including human African trypanosomiasis, leprosy, lymphatic filariasis, trachoma, malaria, measles, and mother-to-child transmission of HIV, syphilis, and hepatitis B. Their Expanded Programme on Immunization celebrated its 50th anniversary this year, with an estimated 154 million deaths prevented, most of them infants.

WRIS

CDC took a bit of a holiday break this week, so the level of detail in reports is less. However, Winter Respiratory Infection Season is officially High nationally.

The big 3 (covid, influenza, and RSV) all are increasing at this point. I'm hoping they don't peak at the same time and cause big logjams in healthcare settings.

What I'm Watching For

Mpox

In spite of the few cases in North America, Asia, and Europe, mpox is still primarily an African problem. As we know, however, no communicable disease in one area is just a problem limited to that area - international spread is always a few contacts away. In that regard, I found a recent review/opinion article enlightening.

Of interest, smallpox (vaccinia virus) vaccine protects against mpox infection. Our success in eliminating smallpox and subsequent cessation of smallpox vaccination led to a new population susceptible to mpox infection. A major hurdle to control the outbreaks will be vaccinia virus vaccine testing and distribution to high risk populations.

Avian Influenza

The influenza A H5N1 viruses now circulating in birds (both domestic poultry and wild birds) and dairy cows is the most likely source of a new pandemic, but fortunately the risk is still very remote especially if the public health system can keep on top of tracking infections and characterizing variants.

In the past week we learned that feeding your cat raw pet food derived from poultry is not a good idea, it resulted in 1 cat death in Oregon. I think most of us could have predicted that. One thing for cat owners to keep in mind is that the current avian flu, while still causing some respiratory symptoms in felines, is noteworthy for neurologic symptoms.

Also this week we learned about the mutation found in the hemagluttinin gene segment in the Louisiana human patient with severe avian flu illness. This is the H1 part of the virus which is important for attachment to respiratory epithelial cells. Mutations in this area can increase the effectiveness of spread in humans. However, it is completely expected that a human infected with the virus and experiencing severe disease would develop these types of viral mutations. What would be more concerning is if an isolate from a bird or cow developed such mutations, because of the potential for wider spread.

The risk for widespread human A H5N1 infections is still extremely low. I'll be watching in 2025 for any evidence of human-to-human transmission as well as any significant changes in the virus circulating in the wild animal kingdom. Again, I'm reassured that surveillance is allowing for rapid sequencing of human isolates. I hope that resources continue to be available to track this virus in animal and human populations.

SARS-CoV-2

Covid remains a wild card. It has perhaps the highest mutation rate of any virus causing human disease, it has yet to develop a true seasonality like other coronaviruses making it difficult to plan vaccination recommendations, and infections are still relatively frequent plus underreported due to lack of resources for testing, public apathy, and misinformation/disinformation fueling political decision-making. In short, we're in big trouble if another new variant appears with significantly greater pathogenicity and infectivity.

WHO published another year in review on covid that included a big overview of what's happened since 2020. They do note that our tracking systems worldwide are diminished compared to earlier in the pandemic, so recent data are likely to be significant underestimates. In the post-pandemic phase, we all need to transition from the type of extensive pandemic case tracking into a more sustainable surveillance system similar to what we do for influenza.

I was surprised to see some areas blank for what's going on the US, perhaps due to delayed reporting, and I was also a bit overwhelmed trying to decide what graphs to display here; if you're interested I'd suggest perusing the document itself. First, I've copied a quick highlight summary:

  • While there are periodic waves of COVID-19 in some countries, SARS-CoV-2, the virus that causes COVID-19,
    largely circulates without clear seasonality and continues to infect, cause severe acute disease and post
    COVID-19 condition.
  • The impact of COVID-19 has varied by country depending on the circulating variants, national policies,
    capacities to respond and access to countermeasures.
  • WHO’s ability to monitor circulation, severity, virus evolution and impact is challenged by reduced
    surveillance, testing, sequencing, limited integration into longer term infectious disease prevention and
    control programs, and reporting, as Member States adapt from crisis management to longer term prevention
    and control of COVID-19.
  • Changes to COVID-19 surveillance over the past five years have been consistent and expected, adapting to
    the changing landscape of the pandemic. Many Member States are transitioning from comprehensive case
    reporting to integrating SARS-CoV-2 monitoring into existing respiratory disease and infectious diseases
    surveillance systems. This is an important step towards sustainable infectious disease surveillance,
    monitoring and risk assessment. At the present time, the integration of SARS-CoV-2 into existing influenza
    surveillance systems is variable across regionsranging from 41% in countries from the Western Pacific Region
    to 96% in countries in the European Region.

Here's a great overview of the past few years on a global level.

Even with more inaccuracies in tracking recently, it's nice to see how far we've come in lowering cases and deaths.

Here's a look at deaths by age group, but what isn't apparent in the graph is that mortality rates in infants are comparable to mortality in 20-45-year-olds. Another advertisement for vaccination of pregnant people, who themselves are in high risk group.

And here's the crazy lack of seasonality expressed as percentage of positive tests. I might be tempted to see a trend towards winter seasonality, but remember these data include the southern hemisphere and thus we should see a biphasic pattern if/when seasonality develops.

And lastly a look at how far our variants have drifted over time.

Auld Lang Syne

My apologies to Scotsman Robert Burns, but I must turn to Londoner (with Scottish heritage) Sir Rod Stewart for my favorite version of the song at Stirling Castle in Scotland, complete with bagpipes.

Wishing everyone a Safe and Happy New Year. See you next year.

Unless otherwise indicated, the content and opinions expressed on this web site are those of the author(s). They are not endorsed by and do not necessarily reflect the views of the George Washington University.
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