influenza – Page 8 – Pediatric Infection Connection

To Rake or Not To Rake

Bud WiedermannOctober 29, 2023October 29, 2023Leave a comment

A lot going on in the world of infectious diseases this past week, enough to challenge my ability to sort out and explain the key points. That's probably why my mind, and eyes, keep drifting to the window next to my desk. The neighborhood leaf pickup is coming any day now, and many leaves cover the ground. The number of fallen leaves is still far less than remain on the old maple tree just outside the window. Yes, it's too early to rake, I would just need to do it again in another week.

Here's my stab at summarizing recent ID events.

RSV and Nirsevimab Shortage

CDC issued a HAN (Health Alert Network) advisory statement on October 23 with a plan for prioritization of nirsevimab use in the face of limited supply.

I won't attempt to summarize everything here because the recommendations are detailed and depend highly on individual circumstances impacting nirsevimab access; please read the advisory. The 100 mg dose is the most severely restricted, and practitioners should not combine 2 50 mg doses to make up the difference because you are essentially depriving 2 younger/smaller children from access in order to treat 1 other child. Note that palivizumab (Synagis) is still available and is the go-to product for infants 8 - 19 months of age, the same as in previous RSV seasons.

At last week's Advisory Council on Immunization Practices (ACIP) meeting (see more below), the nirsevimab company representative completely avoided answering a request to provide details for the cause of the shortage, other than to invoke a supply versus demand problem. I'm hoping those details appear down the road so mistakes like this can be prevented in the future.

Remember COVID-19?

I hope nobody has forgotten, but never underestimate our short attention spans. Thankfully things are relatively calm compared to pandemic times.

I felt the lay press got things a bit wrong when reporting findings of a study by FDA and others regarding safety of monovalent covid vaccines given to children before early 2023 (i.e. NOT the current vaccines). Unfortunately the report has not been peer-reviewed, but it appears pretty sound from my brief reading. The risk of myocarditis/pericarditis in adolescent boys was pretty much the same as we've heard about all along. Also mentioned was seizure risk in younger children, and this part was over-hyped by some news agencies. The association merits further study, but currently is very uncertain: "...seizures/convulsions signals were detected following vaccination with BNT162b2 and mRNA-1273 in children aged 2-4/5 years. However, in a post-hoc sensitivity analysis, the seizures/convulsions signal was sensitive to background rates selection and was not observed when 2022 background rates were selected instead of 2020 rates." The exact numbers were 72 children with seizures, most fulfilling the case definition of febrile seizures, out of 429,119 doses administered to that age group. Thus, it is very close to the background rate of febrile seizures, without vaccination, in that population.

Tripledemic Status

Well, more like a weak monodemic now, with RSV still the only one of our RSV/Influenza/Covid triumvirate to appear in appreciable numbers in most places. RSV-NET shows some hospitalizations in young infants below, but note that hospitalizations are only the tip of the iceberg for infections.

FluView activity is similarly low in most locales.

Biobot wastewater tracking for covid remains low.

New Immunization Schedules for 2024

As mentioned above, the ACIP met October 25 and 26 to cover a variety of subjects and reveal proposed immunization schedules for 2024 which were approved. This approval is awaiting some tweaking and then final signoff by the CDC director. The new schedules will have many new options, which is both good and bad. It's always nice to have more choices, but at the same time those choices create new complexities that aren't easy to explain; CDC doesn't have a great track record for making recommendations understandable. Potential changes include vaccines for COVID-19, influenza, meningococcus, mpox, pneumococcus, polio, and RSV (monoclonal antibody and vaccine). Release is planned for January 2024, earlier than usual.

Pediatric healthcare providers should take note of proposed new mpox vaccine recommendations, now just applying to age 18 and older but likely to eventually include ages as young as 12 years once NIH trials are completed, perhaps as early as next year. Like most outbreaks/epidemics/pandemics, mpox has evolved from the 2022 epidemic into a 2023 endemic problem now at about 1-4 cases per week on average.

Because of this, and the fact that a highly effective and safe vaccine is available, the new guidelines likely will recommend immunization for those at high risk:

Gay, bisexual, and other men who have sex with men, transgender or nonbinary people who
in the past 6 months have had one of the following:

A new diagnosis of ≥ 1 sexually transmitted disease
More than one sex partner
Sex at a commercial sex venue
Sex in association with a large public event in a geographic area where mpox
transmission is occurring
Sexual partners of persons with the risks described in above
Persons who anticipate experiencing any of the above

We will also see new recommendations for pneumococcal vaccine now that a 20-valent pneumococcal conjugate vaccine is approved. PCV13 will phase out and infant immunization will include just PCV15 or PCV20. The 23-valent pneumococcal vaccine also will phase out, except perhaps for a stockpile kept for use in immunologic diagnostic testing.

Covid vaccination will be a little easier for young children, with clarifications for which vaccines to use for children undergoing age transitions in the midst of vaccine cycle as well as greater allowance for interchangeability of vaccines (e.g. administering Pfizer vaccine when previous vaccine was Moderna) for children 6 months through 4 years of age:

COVID-19 vaccine doses from the same manufacturer should be administered whenever recommended. In the following circumstances, an age-appropriate COVID-19 vaccine from a different manufacturer may be administered:

Same vaccine not available at the vaccination site at the time of the clinic visit
Previous dose unknown
Person would otherwise not receive a recommended vaccine dose
Person starts but unable to complete a vaccination series with the same COVID-19 vaccine due to a contraindication

The changes for meningococcal vaccination are the most confusing. A pentavalent vaccine was approved recently by FDA for use as a 2-dose regimen for ages 10 through 25 years. The confounding factor for meningococcal vaccination is that the disease is relatively uncommon, particularly for serogroup B where we see only a handful of cases annually. Furthermore, vaccine immunity wanes fairly quickly following group B vaccination, and we are potentially faced with healthcare offices needing to stock 3 different meningococcal vaccines to cover all circumstances. Here are the current recommendations for meningococcal vaccination:

Here's a look at the serogroup distribution by age (June 2023 ACIP meeting, presentation 3 slide 9 for meningococcus):

How best to add in the pentavalent vaccine? Just using that vaccine alone isn't a good idea. Trying to incorporate immunization against group B into the current schedule that starts at age 11 is likely too early to be effective. ACIP has been struggling for several months to come up with a plan for meningococcal vaccination that takes into account the relative rarity of the disease as well as the need to provide a pragmatic plan that can be implemented in diverse healthcare settings. They focused on 3 policy questions that were debated by working groups over the past several months:

PICO 2 was deemed unfavorable for a variety of reasons. We are left with deciding how best to use the pentavalent vaccine for situations 1 and 3, knowing that stocking 3 different meningococcal vaccine products may not be feasible for many practice settings. I expect continued tweaking of the options before we see the final guidelines in January, but it appears that routine immunization will still be recommended at age 11-12 years with second dose at 16 years. Group B vaccination options will variously allow use of the monovalent or pentavalent products, but it may be that the pentavalent product will be recommended for a slightly different age range (16 - 23 years) than what was approved by FDA (10 - 25 years). Regardless, the Menactra vaccine (covering groups A, C, W, Y) will be withdrawn so at least some simplification there.

A concluding disclaimer to this section: all we have now from ACIP are proposed changes. They are not approved and very likely will undergo some changes before we see them in print. Please don't act on the above until we have the updated guidelines from CDC.

Staring Out the Window Again

You can perhaps understand my tendency to wander after reading the section above. The meningococcal vaccination options are almost endless, and I didn't necessarily agree with the way the discussions were going at the ACIP meeting.

The title of this posting is a lame riff on Shakespeare, and his Sonnet 73 mentions leaves prominently. However, it is primarily a poem about aging and I didn't necessarily want to be reminded of that! I found a more playful ode to autumn in a poem by James Whitcomb Riley; he has a children's hospital named after him although he was a very complex individual who suffered from alcoholism and wasn't exactly a model citizen. His poems often are written with a child-like voice and lend themselves well to reading aloud.

"But the air’s so appetizin’; and the landscape through the haze

Of a crisp and sunny morning of the airly autumn days

Is a pictur’ that no painter has the colorin’ to mock—

When the frost is on the punkin and the fodder’s in the shock."

Yellow Jack in the US? Are You Kidding Me?

Bud WiedermannOctober 22, 2023October 22, 2023Leave a comment

It's nice to be back after my brief website repair hiatus. Please let me know if you have any problems or have any suggestions for the website. I'll continue to work on design issues.

I won't attempt to cover all the issues in pediatric infectious diseases appearing during the hiatus. Needless to say, at lot happened, mostly old news by now. Some newer things I won't mention because they appear only in abstract form at national meetings, such as this month's ID Week (Infectious Diseases Society of America and other ID groups) and the American Society for Tropical Medicine and Hygiene. I have seen dramatic changes from the time data are presented at a meeting, which can be preliminary and incomplete, to the final publication or lack thereof. I've become averse to propagating that type of information source.

Yellow jack is another name for yellow fever; it takes its name from the yellow nautical flag that alerted others that yellow fever was on board. A variation of this flag is still used today to alert other ships about health issues on board. You might want to brush up on your yellow fever knowledge now, keep reading if you're intrigued.

Nirsevimab Supply Chain Flop

This isn't news to any practicing primary pediatric healthcare provider. The supply of the newly-approved long-acting monoclonal antibody preparation to prevent RSV infection for all infants has hit a major snag: demand has far outstripped supply. Maybe we will eventually hear the true story of what happened, but basically we are dealing with a single manufacturer who couldn't produce enough product. Even some hospitals aren't able to get a supply to administer to newborns at the time of discharge.

The AAP has a nice RSV page that healthcare providers may find useful, as well as an October 17 webinar with practical strategies. Remember that maternal RSV vaccination at 32-36 weeks gestation is another option to encourage; talk to preganant people visiting your practices. Palivizumab (Synagis) is still available for high risk infants.

Tripledemic Update

We're certainly not anywhere close to a tripledemic at present. Only RSV seems to be on a significant upswing:

Flu season hasn't yet started for most of the country. COVID-19 disease is much more difficult to track now that our tracking methods have changed so dramatically from the pandemic area. I look to wastewater reports as the most consistent indicator over time, and they suggest that we did not have a big spike this fall.

Future Pandemic Preparedness

The Journal of Infectious Diseases finally got around to publishing a supplement on vaccine and monoclonal antibody development for potential future viral pandemic pathogens. It was put together from presentations at a meeting in 2021. Here's a quick overview of the types of pathogens considered:

Comparison of pandemic potential and countermeasures for viral families known to infect humans. Viral families were categorized as having either low/moderate or high pandemic potential and low/moderate or high levels of existing resources and countermeasures. Cross-comparison revealed 10 viral families with high pandemic potential and low/moderate existing resources or countermeasures upon which the National Institute of Allergy and Infectious Diseases will focus its pandemic preparedness activities. Asterisks denote existing vaccine solutions for some viruses in that family; boldface type, potential vaccine solutions for the entire virus family; shaded box, viral families chosen for prototype pathogen selection.

I'm sure many of these names except for Coronaviridae are unrecognizable to most physicians, and several at best are vague even for infectious diseases specialists. Orthomyxoviridae include influenza viruses. Let's hope research funding comes through for the entities in that lower right box.

Yellow Fever

You probably haven't thought much about yellow fever unless you've considered travel to an endemic area, either for yourself or for patients in your practice. We have an effective vaccine available, but it is a live virus vaccine. Risks for vaccine side effects increase with age greater than 60; I actually received yellow fever vaccine for travel when I was in this high risk group; more on that later.

A recent Perspective essay in this week's New England Journal of Medicine raised the possibility of yellow fever reappearing in the US, particularly in the southeastern United States. This is already a problem with other mosquito-borne infections like dengue, chikungunya, and Zika viruses. (Note these are in the family Flaviviridae, also included in the gray box above.) The vectors for yellow fever, Aedes aegypti and A. albopictus, are well represented in the US, and their range is increasing as our climate warms.

Yellow fever is endemic in some parts of South America and Africa, and its range appears to be spreading in recent years. (The maps below are a few years old, updated WHO country recommendations usually are published in November.)

Diagnosing yellow fever without a travel history will be very difficult in most instances. In about 85% of those infected, the clinical presentation is a self-limited, nonspecific febrile illness with chills, myalgia, headache, and some GI symptoms lasting about 3 days. An unlucky 15% have a more biphasic presentation with the second stage appearing after around 48 hours of improvement and characterized by more severe symptoms including jaundice, renal failure, coagulopathy, and other life-threatening problems. At that stage the diagnosis might occur to an astute provider and diagnostic testing can be obtained. No specific antiviral therapy is available.

Yellow fever vaccine is highly effective, and a single dose confers life-long immunity. It is relatively safe, but there are rare severe side effects. These severe reactions are 3- to 4-fold higher in vaccine recipients over 60 years of age:

Yellow fever vaccine associated neurologic disease (YEL-AND; mostly encephalitis, Guillain-Barre syndrome):

over 60 years of age = 2.2 cases per 100,000 doses of vaccine administered
less than 60 years of age = 0.8 cases per 100,000 doses of vaccine administered

Yellow fever vaccine associated viscerotropic disease (YEL-AVD; similar to severe infection itself with approximately 50% mortality):

over 60 years of age = 1.2 cases per 100,000 doses of vaccine administered
less than 60 years of age = 0.3 cases per 100,000 doses of vaccine administered

I was over 60 years of age when my travel to Ethiopia caused me to consider yellow fever vaccine. My reasoning wasn't based on the 3- to 4- fold increase in risk, which is a relative risk increase, but rather focused on the absolute risk. This is a topic I've revisited many times in this blog; it has immediately applicability to vaccination of any type but especially for COVID-19 and RSV now.

Adding together the risks for YEL-AND and YEL-AVD for the older population comes to 3.4 cases per 100,000 vaccinations, or 0.0034%. As a comparison, risk of airplane crash is about 1 in 11 million (o.oooo1%) and risk of being struck by lightening is 1 in a million or less (0.0001%). Of course these risks vary by how many miles you spend on airplanes and how often you are out walking around in thunderstorms. Weighing my yellow fever vaccine risks and benefits, I chose to receive the vaccine rather than not travel to Ethiopia where my specific yellow fever risk was very low because I was staying at high altitude for most of the time.

Speaking of Travel

I timed my blog hiatus with a major trip to the Umbria region of Italy. It was a hiking vacation through rural areas with occasional forays into medieval towns and was a wonderful experience. I'm still nursing a few minor musculoskeletal aches and pains - my muscles and joints aren't what they used to be.

In addition to beautiful churches, ruins, and the medieval towns, I was also surprised to see many unfamiliar butterfly species including this Hipparchia hermione example.

Hiatus

Bud WiedermannSeptember 10, 2023September 10, 2023Leave a comment

I've been thinking for a while about taking a break to reassess this blog. First, I'm not sure if the focus is optimal and whether this blog serves any unique function that isn't available elsewhere on the web. Second, I've not been happy with the design of the web site for some time, plus I've heard about problems with the subscription sign up widget not working now. I don't know that there is any good time for a pause, but now seems pretty good both from my schedule and from covid's (unpredictable) schedule.

I expect this may take at least a month or so - I want to work within the GWU system where my site is housed to look at tracking data and fixes available there, as well as to think about an entirely new site if I do decide to continue. I will provide an update post when I have a better idea of timing.

At the time I am writing this, we are all waiting for expected FDA approval of this fall's covid vaccines directed against the XBB lineage. ACIP has a meeting set for September 12 to discuss this, so I expect FDA's notice any second now! Also watch for the ACIP meeting on maternal RSV vaccination on September 22.

Nothing strikingly new on the variant front. Press releases from Pfizer and Moderna state their fall vaccines offer some immunity against BA.2.86 in addition to XBB lineages, and investigators have announced (on social media!) similar good news from in vitro studies. As usual, I'm waiting for actual data that I can assess myself.

Here is a quick update on noteworthy items from this week:

Influenza vaccine 2023 preliminary effectiveness in southern hemisphere looks very good, especially for kids. This bodes well for those who elect to receive flu vaccine for the upcoming season.

Covid variant BA.2.86 caused an outbreak in a nursing home in the East of England region of the UK - in the link, scroll down about 1/3 of the way. The attack rate was 86.6% (33 of 38 residents); so far 22 of the 33 positives have been sequenced and are BA.2.86. 29 of the 33 had received a spring covid vaccine booster. Only 1 resident required hospitalization. From the limited data presented, it appears that this very high risk population had relatively mild courses of illness.

During my hiatus, you may want to look at a few of those gazillion sites that I've found useful.

ProMED - https://promedmail.org/

CIDRAP Newsletter - https://www.cidrap.umn.edu/newsletter

CDC COVID Data Tracker - https://covid.cdc.gov/covid-data-tracker/#datatracker-home

CDC Health Alert Network - https://emergency.cdc.gov/han/updates.asp

Biobot Network of Wastewater Treatment Plants (includes both covid and mpox) - https://biobot.io/data/?utm_source=substack&utm_medium=email

United Kingdom COVID notifications - https://www.gov.uk/email-signup?topic=/coronavirus-taxon

Remember that comparing covid numbers now to those from last winter or prior years can be very misleading because of dismantling of some tracking systems as well as unreported home testing and lack of testing in general. Even covid tracking for ED visits, hospitalizations, and deaths all are significantly changed. Probably only the wastewater methodology has remained similar over the few years, so I'm watching those trends more closely.

And one final optimistic note I picked up from David Brooks of the NY Times in his August 31 opinion piece (subscription required). The title was "People are More Generous Than You Think" and he referred to a scientific publication in a psychology journal that I found pretty surprising. For all I know he cherry-picked this article to come up with a heartening message, I didn't take the time to do a formal lit search and I certainly don't keep up with this subject matter.

In the study, almost 200 people in total, from 3 low-income and 4 high-income countries, were selected to receive $10,000 for whatever they wanted to use if for. The only strings attached were that they must report to the investigators how they used the money and they agreed to be randomized to either share their use of the money on Twitter or keep quiet about what they used it for. The investigators figured that the group publicizing this on Twitter would spend less of the money on themselves. That wasn't the case however. On average the individuals spent $6400 of the total on others, including $1700 on charitable donations. By and large, spending of those from lower income countries didn't differ that much from the higher income group, though the latter had slightly higher gifts to charity. The article really brightened my day, take a peek at it.

Take care and stay well,

Bud

Good Will

Bud WiedermannAugust 27, 2023August 27, 2023Leave a comment

This past week I attended an event that led me to reflect on "good will," not necessarily referring to the "peace on earth ...." quote or to the San Antonio chapter of Goodwill Industries where my mother volunteered countless hours in the last century, but a more basic understanding. Its origins may be in the New Testament or in Middle English, but regardless it is pertinent today. More on that later.

Maternal RSV Vaccine Approved by FDA

The approval finally came through, as it turned out on the last day of FDA's deadline to make a decision based on the fast tracking and other priorities assigned to it by the FDA. The FDA advisory committee did not meet again prior to this decision, they had already reviewed the data at a previous meeting in May, and FDA did not release any updated scientific documents. Perhaps lost in the fine print is the important change in the approval. The original trials looked at vaccine administration to pregnant people at 24-36 weeks gestation, but the FDA approval narrows this to 32-36 weeks. This significant change is because of concerns about the vaccine causing premature delivery; the numbers in the published trials were very low, not enough to establish a cause/effect relationship and only answerable but post-marketing surveillance when a much larger number of pregnant people receive the vaccine. However, more concern than usual was expressed because another pharmaceutical company (GSK; the approved vaccine is from Pfizer) stopped their clinical trials in pregnant people for the same reason. Delaying the vaccine administration to 32 weeks gestation is a safety move; even if the vaccine causes a higher but extremely low risk of precipitating premature birth, the clinical consequences at 32+ weeks is small; infants born at that gestational age generally do very well. The down side is that narrowing the window for vaccination creates more logistic difficulties in ensuring pregnant people have the opportunity to receive the vaccine.

Next up will be an important meeting of ACIP/CDC to put together all the recommendations, including how to manage use of maternal vaccine and the long-acting monoclonal antibody to RSV, nirsevimab. Their next scheduled meeting is September 12, but so far the only current agenda item relates to covid vaccines.

A Curmudgeonly Jab at the Lay Press

At my age, what else do I have to do besides complain? I was annoyed by 2 items percolating through the lay press this past week.

BA.2.86

This new but relatively rare covid sublineage is popping up in every news feed there is. I've mentioned it before. Although it is present in only very low numbers, the pattern of mutations it carries suggests that it will be very effective at evading immunity from prior infection or vaccines, perhaps including the new XBB-derived vaccine to be available soon. Biobot helps put this in perspective. First, wastewater covid levels seem to have plateaued in the US and are still well below what we say in winter 2023.

Second, this variant doesn't even appear in wastewater data, although note the graph only reflects sequencing through the week of August 7.

In addition to following wastewater data, the next likely useful piece of information should be some in vitro data on ability of serum from study volunteers who received the new covid vaccine to neutralize newer variants, including BA.2.86. Given how long the assays take, we should see some information in September. A silver lining for all the publicity is that it could speed up the peer-review process for publication so we won't need to rely on non-peer-reviewed data. Look for a research letter in the New England Journal of Medicine relatively soon (just my prediction).

You can see the current CDC risk assessment here.

Tripledemic in Kentucky?

My second gripe is with the reporting on a supposed tripledemic resulting in school closures in Lee County, Kentucky, alleged to be caused by a combination of covid, influenza, and group A streptococcal infections. What seems to be missing in all the reports is how these etiologies were established. It sounds like it was just what parents or school staff were calling covid, flu, or strep, rather than based on careful testing.

It's a little early for influenza in Kentucky, not that it's impossible, but so far CDC data haven't shown it.

I didn't find anything about it on the Kentucky state flu site.

Group A strep infections aren't reliably reported, and the problem with GAS diagnoses is the relatively high carrier rate of the organism, around 10-15% in the pediatric population. So, if someone tests a child with a viral illness (e.g. rhinovirus/enterovirus, which is prominent this time of year), 10-15% will test positive for GAS.

More reliable but less relevant to Kentucky are recent data from England about GAS hospitalizations:

This may reflect changes in epidemiology during and after the pandemic, but I'm still skeptical of the characterization of etiologies for the Kentucky school illnesses. I hope we'll hear more eventually.

Fungus Amongus

I received a COCA Now notice from the CDC nicely summarizing concerning trends in fungal strains causing ringworm and nail infections. It may be that we are in the midst of rising rates of resistance to commonly-used antifungal medications to treat these diseases. A big problem for clinicians is that treatment response may be normally slow, requiring weeks to months of therapy, so it can take a long time to figure out if the infection isn't responding. Keep this in mind if you notice children with poor responses to treatment, and consider culture and susceptibility testing with a qualified lab.

Paxlovid Resistance

No surprise to anyone, but a new report characterizes nirmatrelvir (Paxlovid) resistance in an immunocompromised patient, exactly the sort of setting we'd expect to see for development of resistance. This isn't the first report of Paxlovid resistance, and it won't be the last. I wouldn't worry about it yet, but, like most treatments for infectious diseases, resistance becomes a problem sooner or later.

My Night in a Brewpub

Not one of my usual habitats, but this was for a good cause: a special meeting of the Greater Washington Infectious Diseases Society at a brewpub in Bethesda, MD. You won't find a web link for GWIDS, not because it's a secret society but because no one has gotten around to making one in the few decades of GWIDS' existence. It's a monthly meeting of adult and pediatric infectious diseases training programs in the DC area where fellows in training present challenging and usually obscure infection cases and try to stump the stars in attendance. Basically it is heaven for an infectious diseases nerd.

This meeting was our first in person since the pandemic began. It was special because Dr. Anthony Fauci, an annual speaker usually at the end of the year, was featured in what was supposed to be a fireside chat now transformed into a vatside chat. I moderated the session only because the first 50 or so choices for moderator weren't available. We gathered a list of questions from members prior to the meeting plus opened up for questions from the audience at the end. A good time was had by all, although I myself missed out on the refreshments.

One of the questions I asked, the only one I submitted, was for Dr. Fauci to help us understand the differences between the criticisms he received during the early days of the AIDS pandemic and the terrible threats he now receives from various covid crazies. (Three guys looking very muscular, with receivers in their ears and bulges under their coats, were the only non-GWIDS members present; Fauci came and went in one of those flashing-light black SUVs that disrupt traffic all over the DC area.)

In 1988, Larry Kramer, one of the earliest AIDS activists and a leader in the movement (also an accomplished playwright and author), published letters to Fauci in the Village Voice and the San Francisco Examiner. I read excerpts from those documents, and if you didn't know the context it would be perfectly reasonable to assume they were written recently. Kramer called him a murderer, an idiot, and a liar, among the repeatable epithets. I can't quote Dr. Fauci's response accurately, I wasn't taking notes, but the gist of his reply was that the AIDS and covid personal attacks, while sounding similar, are completely different. The difference boils down to Good Will.

AIDS protesters wanted to work to a solution; they were terribly critical of Fauci as a person as well as of policies of FDA and NIH. The end result was a revamping of the research and approval process for AIDS (and thus other treatments) that resulted in a quicker and more effective benefit to society. According to Fauci, those AIDS activists were motivated by good will and demonstrated willingness to collaborate on a solution. Nothing like that exists in today's Fauci demonization.

Read Tony's NY Times essay on Mr. Kramer and "loving difficult people," and take a little time to practice some good will.

Dog Days of Summer

Bud WiedermannJuly 16, 2023July 16, 2023Leave a comment

I've just returned from a wonderful family week at the beach to a steaming suburban DC and an annoying surprise at home. I'll just bask in my vacation afterglow and belatedly compose this post.

Bugs cont'd

I didn't think it was possible, but there are more mosquitos around my house now than before I left for vacation. Right on schedule, West Nile Virus infections are starting to heat up.

Hot off the presses, you can also add Texas to the list. Remember that although West Nile Virus is feared for its neurologic manifestations, most infections are either asymptomatic or result in a nonspecific febrile illness. The neurologic cases are the tip of the iceberg.

Hepatitis C - We're Missing the Mark in Public Awareness

A recent publication noted a big gap in delivery of care for hepatitis C, summarized below. I really like their cool poster-type depiction, check out the bottom line (at the bottom, of course).

Once again, our wonderful technologic advances in medicine are clouded by a failure to have them reach those who need them most.

More on Neonatal ECHOvirus Infections

The World Health Organization reported more cases of neonatal ECHO-11 infections in newborns, originally in France as discussed in these pages on June 4. Now WHO reports new cases from Croatia, Italy, Spain, Sweden, and the UK. No evidence so far that these events in different countries are connected; this might just reflect enhanced surveillance given the initial alert from France. The link above has a nice discussion of various aspects of the cases. Again, keep severe enteroviral disease in mind with any sick newborn in whom bacterial etiologies are not revealing.

'Demic Doldrums

Remember wastewater monitoring? It's not the greatest tool in the US due to the fact that monitoring is voluntary and leaves much of the US with no data. However, an epidemiologist at Johns Hopkins has been blogging on this and is predicting we are about to see an uptick in southern states. She admits the data are iffy, we'll know eventually if she is full of hot air or not.

Some interesting data appeared regarding maternal covid vaccination and newborn antibody levels. This was a small but well-studied group of 76 mothers who received an mRNA vaccine during pregnancy. Higher maternal antibody levels were seen in mothers who had systemic symptoms following the second vaccine dose, though all had good responses. Maternal transfer of IgG to infants was highest in those vaccinated in the second trimester. Breast milk IgG and IgA antibody to SARS-CoV-2 persisted about 5-6 months, just in time for the infants to start their own vaccine series! There were no significant adverse events in mothers or infants. Bottom line: since we don't know what covid will do in the future, pregnant persons would be well advised to get that new vaccine dose during their second trimester.

The US Government Accounting Office published some further recommendations for pandemic preparedness. I'm very glad these are appearing, but public interest and funding have cooled dramatically.

Also, I was pleased to see an analysis of journalistic coverage of preprint publication before and during the pandemic appearing (where else) but on the well-known preprint site BioRxiv. This coverage hit the boiling point during the pandemic but applied only to covid preprints, not to other scientific reports. Next up I hope we see some analysis of how many of those preprints never appeared in a peer-reviewed publication; some have attempted chart this already, but we probably need to wait another 2-3 years before passing judgement. I continue to worry that too much attention was focused on preprint postings during the pandemic; the blame for this is shared by journalists, scientists, and the universities and other organizations where the work was performed.

Lest we forget about flu, things aren't too bad worldwide but WHO did report some close-to-home hot spots in Costa Rica, Honduras, Nicaragua, and Panama.

My Astrologic Education

I always assumed the saying "dog days of summer" had something to do with a panting dog in the heat. I was barking up the wrong tree; now I've found out it originated with Hellinistic astrology. Officially, the dog days run from July 3 to August 11, according to the Farmer's Almanac.

I had a great time with my 3 sons and families at the beach, enough to keep me somewhat cool and calm after the thunderbolt of finding my air conditioner on the fritz when I returned home. Fortunately for my dog days, my house has 2 air conditioners. Until now, this was a complete mistake - our house could be handled by just one unit if only the ducts were all linked together. So, for now half the house is tolerable and I won't complain too much, at least until I get the bill from the air conditioning service.

Oh, and in case you haven't noticed, I've sprinkled weather- and temperature-related references and puns throughout this week's post. To keep your mind from sweating, see if you can find all of them. Answers in next week's post.

Tag: influenza