Bird flu has been in the headlines, accompanied by the usual extremes of concern levels. The past few weeks reminded me of Alfred Hitchcock's 1963 movie "The Birds," especially a diner scene where an elderly (my age?) amateur ornithologist (Ethel Griffies as Mrs. Bundy) attempts to explain why the "brain pan" size of a crow or blackbird makes any organized attack on humans impossible. The discussion is interrupted by another customer declaring the end of the world, interspersed with background shouts of orders for blood marys and fried chicken with baked potatoes.
Before we get to bird, a few other items of note.
Dengue Update
Maybe things aren't quite as bad, with a downward trend now apparent in the Americas.
The bulk of this atypical seasonality increase is from the Andean and Southern Cone regions of South America. Brazil by far leads the way, and Argentina, Peru, and Paraguay are in a second tier by numbers of cases. Here's a numbers breakdown for last week and for the calendar year as a whole:
Don't Dismiss Covid
Yes, the current variants and immunity levels in the US seem to result mostly in mild disease and numbers continue to trend downward, but we are seeing well over a thousand deaths per month from covid in the US. It is still a devastating disease.
No outbreaks in new jurisdictions in the US in the past week; Illinois and Florida still account for most of the cases this calendar year.
Highly Pathogenic Avian Influenza (HPAI)
The name itself is pretty ominous, cue those eery bird sounds from the movie. The biggest event last week was the confirmation of a case of influenza A H5N1 infection in a man from Texas, almost certainly acquired from the dairy cows he worked with. He was treated with oseltamivir and apparently is doing well. CDC issued a health advisory through their Health Alert Network last week, including a lot of good advice and helpful links. People who are around birds or dairy animals should take care; this includes those with backyard chicken flocks. The public health messaging has been pretty consistent: no cause for alarm, and certainly no reason to avoid dairy products or eggs at your local store (assuming the dairy products are pasteurized). FDA has a great Q&A page on this.
Note however that we have pockets of these viruses throughout the US, including in wild mammals.
We can be reassured that all of these strains are being tracked and sequenced worldwide through the Global Influenza Surveillance & Response System (GSAID). Scroll down at that link to watch an animation of the geographic spread of influenza A H5Nx viruses worldwide over the past few decades.
We have several antiviral therapies available, and vaccine prototypes are ready to enter mass production if necessary. So far, none of these strains seem well adapted for human-to-human spread, but if that happened it would be a major event that would cause much more concern. I'm also watching to see if this appears in pig populations, since swine flu viruses have been seen in the past to foreshadow human spread. Pigs have similar flu viral receptors to humans, so spread in pigs can be seen prior to a jump to humans. Thankfully, many of the events that facilitate spread among different animal species also are associated with lower virulence, so clinical impact is minimal.
Don't Look Up (Without Your Eclipse Glasses)
Yes, I know it's yet another movie. Just be careful with tomorrow's eclipse.
I actually had to pull out the lawnmower this week, to cut some weedy grass running amok in the yard. Nonetheless, I'm buoyed by the approach of the vernal equinox next Tuesday, the official start of spring. Winter will be done, and with it the winter respiratory viruses. They will reliably be replaced with spring respiratory viruses.
Here's a look at the pediatric infectious disease news the past week.
Details on the Failed GSK RSV Vaccine Trial
We've known for about a year that GlaxoSmithKline's RSV vaccine trial in pregnant people was stopped due to safety concerns: a higher rate of preterm births in the vaccine group compared to placebo. Now we have more details, similar to what was reported to FDA and shared in various meetings. Preterm birth rate was 6.8% (237 of 3494 infants) in the vaccine group and 4.9% (86/1739) in the placebo group; it was statistically significant. Neonatal mortality was higher in the vaccine group, 0.4% versus 0.2%, but did not reach statistical significance.
On the other hand, vaccine effectiveness was pretty good:
The currently approved maternal RSV vaccine from Pfizer also had a hint of a safety signal for preterm birth, less so than the GSK product, and these signals combined resulted in the Pfizer vaccine being approved for a later time in gestation, at 32 weeks at the earliest. Postmarketing surveillance is ongoing. Perhaps the most difficult part of assessing this safety signal is whether it is real or not. We are lacking a key factor in making this assessment: biologic plausibility, i.e. the mechanism by which these vaccines might cause preterm birth. Without that, it is still possible this represents just a chance observation. From my perspective, I would still encourage RSV vaccination for pregnant people as well as nirsevimab therapy for at risk infants born to unvaccinated mothers. We have time for more discussions of any new data prior to our next RSV season this fall.
Waterborne Disease Outbreaks Associated With Drinking Water
I'm a big fan of CDC's Surveillance summaries, and this one published last week is of interest. The report concerns 214 outbreaks from 2015-2020. I wasn't thrilled to see my home state represented prominently.
Outbreaks occurred year-round, and biofilm exposures predominated.
In case you aren't familiar with biofilm-associated outbreaks, here's the quick explanation from the text:
"...microbial communities that attach to moist surfaces (e.g., water pipes) and provide protection and nutrients for many different types of pathogens, including Legionella and NTM [non-tuberculous mycobacteria]... Biofilm can grow when water becomes stagnant or disinfectant residuals are depleted, resulting in pathogen growth... Furthermore, biofilm pathogens are difficult to control because of their resistance to water treatment processes (e.g., disinfection)... Exposure to biofilm pathogens can occur through contact with, ingestion of, or aerosol inhalation of contaminated water from different fixtures (e.g., showerheads) and devices (e.g., humidifiers)..."
Not to minimize the severity of these events, but I couldn't help thinking about a whole new version of Hitchcock's Psycho shower scene based on this.
Legionella was by far the most common pathogen. The report has detail on every outbreak by year and location, as well as a listing of contributing factors. It's a great roadmap for future prevention.
Measles (Again)
It seems like I could devote every week's post entirely to measles and not run out of things to say. Here's the current US situation.
As I've stated previously, it's the sheer number of unconnected sites that concerns me now. Let's put this into some perspective.
As of March 14, we have 58 cases reported from 17 jurisdictions. In all of 2023, we had the same number, 58, reported from 20 jurisdictions in the US. So, we're way ahead of the game for recent years, but we're also not breaking any records compared to pre-pandemic times.
Looking more closely at the 2 biggest years recently, the 2014 (and somewhat 2015) numbers had a large contribution from a single site, Disneyland. More impressively, the 1274 measles cases in 2019, the highest number in the US since 1992, largely involved orthodox Jewish communities in New York - relatively epidemiologically isolated communities with very low immunization rates. A CDC update in fall 2019 (I couldn't find a final tally) stated that 75% of cases for the entire country that year originated from these communities.
Fingers crossed that we don't eclipse the 2019 figures this year, but with reduced vaccination rates and already widespread measles transmission occurring, it doesn't look good. We're just now coming to the spring break and summer travel season - importation of measles from travelers has been a large contributor to US measles outbreaks in the past.
Pediatric Covid ICU Admissions
A recent report of registry data from 55 hospitals during the first almost 2 years of the pandemic showed that about 8% children <21 years of age admitted to intensive care with covid had immunocompromising conditions (ICC). Secondary bacterial infection was more common (9.5% versus 7.3%) and mortality (11.4% versus 4.6%) was higher in the ICC group.
That Pesky Flu
The map is getting a little greener, apropos of springtime. Note in the link you can animate the map to show progression from the fall to the current week.
Better seen here, we did experience a little pause in our decrease of ILI, now headed down but at 3.7% still above the official "epidemic is over" mark of 2.9% for this year.
Any Chipmunk Sightings?
My 2024 Farmer's Almanac says that the real harbinger of spring in the eastern US is the appearance of the eastern chipmunk (Tamias striatus) above ground. As opposed to their squirrel brethren, chipmunks at my house don't bother my bird feeder, so I'm OK with them. I learned that although they stay below ground for the winter, they aren't true hibernators but rather experience torpor. They may sleep for several days in their bedrooms, followed by a trip to the underground pantry for snacks. Sounds like a good plan for retirement.
It was a busy week for infectious diseases, not in the sense of more outbreaks but rather more epidemiologic and vaccine data that point to better health for the future.
The big topic of the week was the Advisory Council on Immunization Practices regular February 2-day meeting. In retrospect, pediatric healthcare providers won't have any major new recommendations to work with; those are likely coming following the next meeting the end of June. I wasn't able to view as much of the meeting as I had hoped, patient care interfered a bit, but I did review all the presentations for those that I missed hearing live. Let's dive in.
ACIP
The Council discussed 9 different topics, but only 3 involved voting: COVID-19 vaccines (vote in favor of a spring vaccine for some high-risk people), Chikungunya vaccine (vote for use in some US adult travelers and in laboratory workers), Td vaccine availability for those with contraindications to receiving pertussis vaccine (discussion followed by a vote regarding the Vaccines for Children progam), influenza vaccines, polio vaccines, RSV vaccines for adults, meningococcal vaccines, pneumococcal vaccines, and the new Vaxelis combined product for diphtheria, tetanus, pertussis, polio, Hib, and hepatitis B. I'll expand on just a few of these topics. (Note all of the graphs/figures below are from the ACIP web site presentation slide link for the February meeting.)
RSV
We saw the most up-to-date representation of RSV epidemiology, showing that the epidemic curve for this year looks a lot like prepandemic years (see last presentation in RSV session).
A good part of the discussion centered on risk of Guillain-Barre syndrome following vaccine, compared to risks of GBS in the baseline population. Both are rare events, but I think at this point it is reasonable to conclude that GBS is a rare risk of RSV vaccination, though not enough to outweigh benefits for high risk populations.
A quick look at the benefits versus GBS risks for adults > 60 years of age (Melgar presentation from RSV session):
Note risks might vary with vaccine type - hard to know with rare events and large confidence intervals, plus both in the ballpark of background GBS numbers.
Influenza
This session was interesting for me to see a preliminary assessment of vaccine effectiveness for the 2023-2024 flu season. I'll just show you an overview of VE in the pediatric population; note that multiple methodologies are used to measure VE. (See slides from Frutos presentation in the influenza section.)
This is good VE for flu, certainly the CDC and WHO were on track for choosing the best combination of strains for this season. Look for the vote for next season's vaccine composition in June.
Meningococcal Vaccines
The focus of the discussion was how best to incorporate meningococcal B vaccine now that we have an approved combination vaccine containing this serogroup. Here are the main options discussed, from the 1st Schillie presentation:
The issues are complex, primarily due to 3 factors. First, meningococcal group B infections are extremely rare; traditional cost-effectiveness models show that meningococcal B vaccination in the US is by far the most expensive vaccine; very few cases are prevented due to the rarity of infection. Second, vaccination at age 11-12 risks significant waning of immunity by the age for peak meningococcal disease in adolescents; it might make sense to move the first dose to a later age. (The main argument against this is the confusion caused by eliminating the long-standing practice for vaccination at age 11-12, perhaps lowering overall vaccine acceptance.) Third, it is clear that not all meningococcal disease risk in adolescents is equal: college attendance is prime, but there are other behavioral risk factors (1st Schillie presentation):
The discussion was mainly to hear input from all stakeholders and then go back to the drawing board. Expect a vote on this at the June meeting - it will greatly impact your summer vaccine guidance for adolescents and young adults.
COVID Vacines
This section of the meetings seemed to garner the most publicity. Of course most of the results presented dealt with adults, given the relatively lower risk for bad outcomes in children plus low rates of vaccinations. Most helpful I thought were the discussions about covid VE in recent months looking at the fall monovalent vaccine.
These are great numbers. Also mentioned was the fact that waning of efficacy hasn't been seen yet, but that could just be a result of not having enough time to pass since the fall vaccine. Other good news is that in vitro studies suggest that the current monovalent vaccine is likely to protect against newer variants.
Special situation for people ages 65 years and older: People ages 65 years and older should receive 1 additional dose of any updated (2023–2024 Formula) COVID-19 vaccine (i.e., Moderna, Novavax, Pfizer-BioNTech) at least 4 months following the previous dose of updated (2023–2024 Formula) COVID-19 vaccine. For initial vaccination with Novavax COVID-19 Vaccine, the 2-dose series should be completed before administration of the additional dose.
That "should" wording was the subject of much debate, finally choosing this wording more for simplicity of recommendations. The gnashing of teeth came about for a good reason - people in the lower end of this age population who do not have underlying risk factors will have less benefit from a spring vaccine because rates of bad outcomes in the post-pandemic period are lower.
Recommendations for younger people with moderate or severe immunocompromise have slightly different wording:
People ages 12–64 years who are moderately or severely immunocompromised may receive 1 additional dose of any updated (2023–2024 Formula) COVID-19 vaccine (i.e., Moderna, Novavax, Pfizer-BioNTech) at least 2 months after the last dose of updated (2023–2024 Formula) COVID-19 vaccine indicated in Table 2. Further additional doses may be administered, informed by the clinical judgement of a healthcare provider and personal preference and circumstances. Any further additional doses should be administered at least 2 months after the last updated (2023–2024 Formula) COVID-19 vaccine dose.
People ages 65 years and older who are moderately or severely immunocompromised should receive 1 additional dose of any updated (2023–2024 Formula) COVID-19 vaccine (i.e., Moderna, Novavax, Pfizer-BioNTech) at least 2 months after the last dose of updated (2023–2024 Formula) vaccine indicated in Table 2. Further additional doses may be administered, informed by the clinical judgement of a healthcare provider and personal preference and circumstances. Any further additional doses should be administered at least 2 months after the last updated (2023–2024 Formula) COVID-19 vaccine dose.
For all age groups, the dosage for the additional doses is as follows: Moderna, 0.5 mL/50 ug; Novavax, 0.5 mL/5 ug rS protein and 50 ug Matrix-M adjuvant; Pfizer-BioNTech, 0.3 mL/30 ug.
As an aside and not receiving much media attention, a new report showed that vaccine mandates didn't help and probably hurt. States with vaccine mandates didn't have higher covid vaccination rates and actually had lower covid booster uptake and flu vaccination rates. Yikes!
Nipah Virus
Never heard of it, or hard-pressed to find facts at the tip of your tongue? Most providers in the US don't need to know much about this bat-borne virus, but if you have any patients planning a trip to Bangladesh you may want to advise them not to consume raw date palm sap (not on my list of delicacies so far) and to stay away from pigs.
NiV gets its name from the village of Sugai Nipah in Malaysia, site of a 1999 outbreak highlighted by cases of encephalitis in pig farmers. Outbreaks typically occur in Bangladesh and India. Now, the World Health Organization reports that 2 individuals, including a 3-year-old girl, have died from the infection after consuming raw date palm sap. The sap likely was contaminated with fruit bat droppings laced with NiV. In addition to signs and symptoms of encephalitis, typical findings are those of nonspecific febrile illness. Diagnosis is difficult until/unless encephalitis findings appear. It's a relatively uncommon infection even in Bangladesh, but mortality is high.
Good Attitudes
It's a sign of our times that I was pleasantly surprised to see a vaccine attitude survey with good news. Investigators from RAND corporation, University of Iowa, and CDC performed an online survey of 1351 parents to assess their willingness to have their children 5-18 years of age receive a vaccine to prevent Lyme disease. About two-thirds of parents definitely or probably would vaccinate their children. The boldface numbers below show statistically significant predictors of willingness to have their children receive Lyme vaccine, with willingness of the parent to receive the vaccine the strongest predictor.
In case you were wondering, for the purposes of this survey the high incidence states were Connecticut, Delaware, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Virginia, Washington D.C. (yes, I don't need to be reminded it's not a state), West Virginia, and Wisconsin. They also looked at states characterized as "emerging" Lyme disease states (Iowa, Ohio, Illinois, Indiana, Michigan, North Carolina), but this group had a slightly lower rate of willingness than in high incidence states. Lyme vaccine trials in the pediatric and adult populations are ongoing, so don't be surprised if parents and children have this option in the next year or so.
Speaking of attitudes, take a look at AAP's new guidance for improving vaccine communication and uptake. It has an excellent literature review and describes various strategies that pediatric healthcare providers can use to improve vaccine acceptance. It is still true that different studies sometimes have reported different conclusions on how best to discuss vaccine hesitancy with parents, likely because it is very difficult to design studies that deal with such subjective issues in a uniform manner.
WRIS
Winter respiratory infection season is still chugging along, mostly due to influenza which is stubbornly persisting in scattered areas in the US. What a crazy patchwork!
New Covid Isolation Guidelines
Maybe this has overshadowed everything in the news. I've discussed this recently in the blog and was expecting the new guidelines to come in April, but CDC bumped it up by a month. It incorporates new information about covid epidemiology, hospitalization rates, and outcomes with balancing for impacts on the economy and on school and work attendance into a comprehensive guideline for all respiratory infections. So, no longer do we have a specific number of days after covid diagnosis to remain out of school or work. The document has multiple links and is pretty complicated. The CDC's press release is a good summary, however. Note that vaccination is still stressed heavily, though I expect it will be ignored by the same hardcore group of antivaxxers. Here's the quick blurb:
"When people get sick with a respiratory virus, the updated guidance recommends that they stay home and away from others. For people with COVID-19 and influenza, treatment is available and can lessen symptoms and lower the risk of severe illness. The recommendations suggest returning to normal activities when, for at least 24 hours, symptoms are improving overall, and if a fever was present, it has been gone without use of a fever-reducing medication."
I am very much in favor of these new recommendations. Circumstances have changed, and we have learned a lot from management of the pandemic these past few years. I just hope our vaccination rate will improve and that people with any respiratory symptoms at all will be aware that they can pose a significant risk to others who may have circumstances putting them at high risk for hospitalization or death from respiratory viruses. Also, please note this only applies to community settings; there are no changes for healthcare settings.
Squirrel Redux
If I were superstitious, I wouldn't mention the fact that my neighborhood squirrels still have not attacked my newly-positioned bird feeder. I was bemused by an article in the Local Living section of the Washington Post last Thursday, clearly written by a squirrel lover. Squirrels do have value, and I have no desire to wipe them off the face of the earth. I just don't want them eating all my bird seed.
A friend of mine in South Carolina with an array of bird feeders and birds also has come to terms with squirrels, albeit somewhat differently than my crazy solution. He just monitors things, and when the squirrels reach a point that he feels they become a significant barrier to maintaining bird happiness and seed access, he uses a humane trap to collect squirrels and then release them far from his neighborhood. I won't disclose where he releases them, but it sounded like a good place for squirrels and unlikely to bother too many people. I wonder if any of them found their way back to him.
Maybe chalk it up to old age. Last week I mentioned I'd be reporting on the ACIP meetings, not remembering that they are scheduled for the coming week, not last week.
Still, plenty going on to fill in with, including a strange case I've been investigating for a few weeks now.
New Adult C. difficile Fecal Transplant Guidelines
The American Gastroenterologic Association published new guidelines for use of fecal transplant in adults with C. difficile disease. Although the guidelines do not address pediatric issues they are still useful to consider. Looking at just the summary, fecal microbiota transplant therapy is being recommended for instances of recurrent disease in immunocompetent or mild/moderately immunocompromised individuals, as well as for severe or fulminant infections in individuals not responding to conventional therapy, Fecal transplant use is not recommended for those with certain underlying GI conditions such as ulcerative colitis, Crohn's disease, pouchitis, or irritable bowel syndrome, except as part of clinical trials. I noted that all of the recommendations were conditional with low or very low level of evidence.
Conflicting Nirsevimab Data
The headlines screamed that about 40% of eligible infants received nirsevimab prophylaxis for RSV infection, as of last month, which is much higher than I had thought based on reports and the shortage of the product. On closer examination, it may not be all that good. There are actually 2 sets of information that the CDC published. First is reporting of ongoing telephone surveys of households with infants under 8 months of age, asking if those infants have received nirsevimab or are planning to do so. That's where the 40% figure comes from. The second data source is an ongoing count of nirsevimab doses actually administered. The listing includes jurisdictional data up through December 2023. Here the highest rate is 20% (Alaska) with many states near zero. Presumably this latter count is more accurate than is self-reported survey data. Let's hope things improve next season, where it does appear that supply chain issues that caused so much disruption this season might be somewhat ameliorated.
Also on the nirsevimab front, I saw the first semi-detailed explanation of what went wrong with the supply chain last fall. You recall, and probably experienced, difficulty in receiving an adequate supply of nirsevimab to satisfy your patients' needs. The company simply didn't have enough stock on hand. This Wall Street Journal report offered more information. It seems that, as usual, it was a bad combination of multiple factors. First, the manufacturer underestimated demand. Second, pediatric healthcare providers initially delayed ordering the drug, not sure if third-party payers would cover the circa $500/dose price. When the feds decided in August to add the product to the Vaccines for Children program, it was already too late to reverse the trend for lower production targets. Production was ramped up eventually, and now some states have excess product available due to all the delays plus perhaps some practitioners not being aware of the availability. RSV is still around but clearly nearing the end of the season. Let's hope things go better for next RSV season.
Risk Stratification for Pediatric Covid
The Pediatric Infectious Diseases Society published new guidance related to covid management in children and adolescents, worth reading. In particular, I think the group did a great job explaining risk factors for poor outcomes from SARS-CoV-2 infection. This has been confusing, in part because we lacked data but also due to spillover from adult high risk conditions - I've noticed many practitioners citing adult risk factors for use in the pediatric population, and it's not quite applicable in all situations. Here's the quick breakdown:
Not All Telemedicine is Created Equal
I've been involved with telemedicine since well before the pandemic. It has its uses, and of course it also has limitations. However, some individuals providing so-called telemedicine services are doing more harm than good. I was saddened but not surprised at this article about providing antibiotic prescriptions via telemedicine. The authors searched for online platforms offering antibiotic prescriptions without real time physician examination or verification of patient details and then chose 2 platforms to query.
For the first platform, one "patient" was able to get a prescription for amoxicillin for "URI," answering a few yes/no questions asynchronously and being rewarded with the prescription in less than a half hour. Another "patient" insisted on being prescribed levofloxacin for cough and again was rewarded the prescription with little verification or pushback.
On the second platform, a "patient" with URI was given a link to choices of azithromycin, cefuroxime, amoxicillin, Augmentin, doxycycline, or levofloxacin. After choosing doxycycline the prescription was provided immediately.
These patients were actually some of the study authors, and they had real URI symptoms. They didn't fill the prescriptions and did recover uneventfully from their URIs. I had 2 immediate reactions after reading the article. First, I wanted to cry. Second, I wondered where these telemedicine "doctors" obtained their medical training.
I Told You So
Some people preface that comment with "I hate to say it, but..." Not me, I'll grab credit even if, as in this circumstance, I'm not unique in sounding the measles alarm. The most recent update shows 35 cases in the 15 US jurisdictions this year, as of February 24. This many cases scattered over so many jurisdictions bodes poorly, and the scariest is in a Florida elementary school.
Dr. Ladapo and Mr. .....?
Dr. Josepah A. Ladapo sports both medical and public health degrees from Harvard, an internal medicine residency in Boston, followed by a faculty appointment at NYU. He than transitioned to a mostly research position at the University of Southern California before catching the eye of the Florida governor and becoming both Surgeon General for the state as well as a professor at the University of Florida. He's been on my radar for some bizarre pronouncements that made me want to look deeper.
Looking at his publication list in PubMed and scanning some of the articles, he clearly has good public health knowledge. Most of his publications center around aspects of cardiovascular disease in adults. He does have 3 relatively recent publications related to covid, but I'm deliberately not linking to them, or to his public statements in the past year, because they are either secondary to the conversation or so lacking in scientific merit as to be not worth your time.
His first covid-related publication was in 2021 and analyzed results of a Gallup poll carried out from July to December 2020 regarding adults' misconceptions about covid risk. Curiously, he published another analysis of this same poll in 2022, presenting some of the exact same data. Neither article referenced the other one and made me wonder whether this could be a case of duplicate publication. More importantly, though, why would covid perception data collected in late 2020 have any utility in 2022, unless the authors were analyzing changes over time (which they did not)?
His other covid-related publication from November 2021 was a multi-author effort (he was the 8th out of 12 authors) talking about future priorities in public health management of covid. I was very interested to see that vaccination was seen as the most important intervention given that Dr. Ladapo now disparages most use of covid vaccines, based on nonsensical arguments.
In the past year, Dr. Ladapo has been working actively to discourage covid vaccine use in most instances. You can see some rebuttal from FDA and CDC in early 2023 and separately from FDA more recently.
All of this made me wonder what gives with Dr. Ladapo. He seems to have had good training, and his prior publications show that he does have basic understanding of public health principles. How then to explain his response to a measles outbreak in a Florida elementary school? He left the decision to remain in school up to parents, and he did not encourage measles vaccination. At a minimum, unvaccinated children should be sent home to receive online education until their incubation periods expire. This could effectively stop the school outbreak and prevent further community spread. Every effort should be made to bring all children up to date with measles immunizations. This is pretty basic stuff.
According to news reports, the Manatee Bay Elementary School in Broward County, Florida, has documented several cases of measles. Details about immunization and travel status are lacking, but apparently there is no clear link to foreign travel identified. Remember that measles is the most easily spread infectious disease known. It is thought that at least 95% immunity needs to be present in a community to prevent sustained spread. The vaccination rate in Manatee Bay Elementary is 89.3%. Also, the incubation period is up to 3 weeks following exposure. So, if the outbreak isn't managed immediately, it can stretch on for weeks until every non-immune child is infected. By that time, spread outside the school is certainly likely. Apparently Dr. Lapado isn't concerned about that.
I wanted to understand how the Florida Surgeon General arrived at his decisions. His prior covid vaccine arguments contained a fatal flaw that I always look for to judge how well someone understands public health/vaccine data. This involves an understanding of the Vaccine Adverse Effects Reporting System (VAERS), one of many tools to monitor vaccine side effects in the US. It's a type of early warning system for rare events. It is structured so that anyone can report a potential adverse event as being related to a vaccine; for example, if my neighbor broke a leg skiing and had received a covid vaccine 2 months ago, he or she could report that event to VAERs. Clearly that doesn't prove that the vaccine caused a fractured femur. VAERS is just a way to monitor all potential vaccine problems. Dr. Lapado incorrectly used VAERS data to conclude that covid vaccines killed more people than it helped. No one who understands the structure of VAERS could possibly end up with that idea.
At a loss for understanding Dr. Lapado's logic, I can only suspect he must be having some Mr. Hyde moments. Either he has a dual personality due to some neuropsychological condition, or he is purposely misusing data to achieve political or personal goals. He clearly should know better. I'd love to spend 30 minutes with him to see where he falls on this spectrum. Or, maybe he knows of some unpublished data that refutes the current understanding of measles transmissibility and the role of antibody in providing protection; I'd hope he would have shared that.
WRIS
The Winter Respiratory Infection Season soldiers on. Given the length of this post and relative lack of any new data I'm not going to dive deeply into CDC or other numbers. Suffice to say RSV is still decreasing. flu is a mixed bag across the country, and covid is out there but not surging at the moment.
"Commingled Out of Good and Evil"
Robert Louis Stevenson's "Strange Case of Dr. Jekyll and Mr. Hyde" was one of my favorite books as a child, and it's loaded with great quotes like the one above. I don't like bashing another individual, and I'm also a natural skeptic always willing to entertain new theories based on new data. I just don't think Dr. Ladapo's management of this measles outbreak, or his covid vaccine views, make any sense. For the sake of all Floridians and others they may infect, I hope I'm wrong.
Nest week I'll report any exciting details from the ACIP meeting.
Famous golfer Tiger Woods couldn't complete the second round of a golf tournament this weekend due to influenza. Two questions came to my mind immediately, still not answered. But, we have a lot more than golf to discuss this week.
WRIS
I suspect we are a matter of weeks away before I can retire Winter Respiratory Infection Season as a weekly feature. RSV is much less of a factor now, and I won't be discussing much about RSV unless things change.
Influenza-like illness continues to fluctuate regionally, we're really seeing wide variations. I'll mention again that this tracking method will pick up not just influenza, but also other respiratory illnesses. However, pre-pandemic it was a pretty reliable gauge of influenza activity. I do note that Mr. Woods lives in Florida and the golf tournament is in California. He became ill Thursday night, so using the common incubation period for flu of 2-3 days he could have acquired this in California (if he was practicing there a few days before); however, the outer range for flu incubation period is 7 days, so all bets are off about where he met his virus. (Also, I'm not stalking him, I have no idea about his travel history.)
At this stage of flu season, it's worth a look at pediatric mortality numbers. It's a little less than, but similar to, last year. Also note there is a significant lag time in reporting and verifying influenza deaths, so some of these bars in previous weeks will rise.
Pediatric deaths continue to occur slightly more commonly in children without underlying medical conditions, and the 5-11 year age group is the most common. Unfortunately, no data for vaccine status is provided.
What about the covid scene? As usual, I'm still looking at wastewater data because the methodology for collecting and reporting this information hasn't changed as much as have the methods for reporting infections and deaths among the states.
Again, this is at most a qualitative descriptor, but nothing to suggest a new surge approaching. Wastewater activity is highest in the South.
I wish CDC would publish numbers of covid pediatric deaths like they do for influenza. They only report death rates per 100,000 by age, and of course they are very low for the pediatric population. The absolute numbers are somewhere in there, but on the CDC website it would require me to write my own search language in their database, and I'm too lazy to spend the time to figure that out.
I also took a look at CDC's covid vaccine rates by age, especially since they now have updated information regarding the fall XBB vaccine dose. It's pretty grim.
Note that the highest rate is only 13.4%, and when I dug down into more details, all the states except one were in single digits for pediatric populations receiving the updated vaccine. The best and only double-digit rate was Vermont at a dismal 13.4%.
On the other hand, one could argue that because rates of serious pediatric disease with covid are so low it isn't cost-effective to vaccinate children who do not have risk factors. In fact, that's what most countries have decided; the US is an outlier in offering covid vaccine to healthy children. Nonetheless, on an individual basis every child is better off being vaccinated than not, even given the low risk of death, long covid, MIS-C, etc.
Back in the somewhat good news arena, a recent article gave an overview of planning (and funding!) for research on better covid vaccines, monoclonal antibodies, and antiviral drugs that will not be subject to loss of effectiveness with new variants. It's called Project NexGen.
Lastly on the covid front, many of you probably heard about CDC plans to change isolation guidelines for the public to be more in line with what we do for flu and other respiratory viruses. So far it is just a draft, but it's targeted for release in April. It's not really based on any new findings about transmission rates or duration of infectivity, but rather I think an attempt at simplicity with the recognition that current guidelines aren't being followed by the majority of the public anyway. What I think is most important, and I hope the final guidelines will stress, is that guidelines should differ depending on the situation. For example, it's a very different calculus for children attending school than it is for those same children going to visit their 85-year-old grandma. The public needs to understand that different risks occur in different circumstances.
Measles
Hot off the presses, 4 children in a single elementary school in Florida developed measles. So far not much official from the Broward County health department, but I'm betting that none of them were fully immunized. Watch out for a large number of secondary cases in the coming weeks.
Changes in Prophylaxis for Meningococcal Disease
This was news from the previous week that I'm just mentioning now. Ciprofloxacin has been used for prophylaxis of meningococcal disease for several years, but recently some sectors are now seeing resistance to quinolones. So, if you are considering prophylaxis of a close contact of someone with meningococcal disease, you will need to contact your local health department immediately to see if the resistance rate meets criteria for choosing an alternative agent such as rifampin, ceftriaxone, or azithromycin.
Tiger's Third Degree
I look at everything through an infectious diseases eye, whether I'm walking down the street, reading the paper, or chasing squirrels from the bird feeder; I just can't stop myself. So, I have 2 questions for Tiger.
Did you get a flu vaccine this year? I'm not a betting man, and I've already made one bet in this blog, but I'd guess not. He had fever and other symptoms the night before his Friday golf round, and then Friday morning still had fever and other symptoms but tried to play the round, making it through a few holes before feeling faint and ending up with IV rehydration therapy according to his official statement.
And to follow up on the above thought, what were you thinking trying to play the round on Friday? Not only did you not meet any school or workplace criteria for participating, you exposed everyone close to you to influenza presumably without notifying them. Of course, this is the sort of "tough it out" mentality that I've been guilty of myself in the past, at least to the point of working when I had a mild cold because I thought myself too essential for my workplace or didn't want to shoulder my colleagues with covering me. I don't think Tiger needed the money for playing in the tournament, but he also was the host of this particular event and I'm sure many fans turned out primarily because he was playing, so that's a bit more pressure than in my workplace. Still, isn't it time we made a change in our behavior when we're sick? Take a moment to think about the impact your actions have on others.
Which brings me to a third question for Mr. Woods: Would you at least make a statement recognizing that you should not have tried to play on Friday, and also give a plug for flu vaccine even if you didn't receive one this year?
I'd bet big bucks that Tiger Woods doesn't read this blog, so, yes, I'm just blowing off steam.
Next week is the regular meeting of the ACIP, I"m hoping to view most of the 2-day meeting and have this be the focus of next week's blog.
