Inspector Morse – Pediatric Infection Connection

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

WRIS

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

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

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

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

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

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

Forbear the Bear (Meat)

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

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

Travel to Rwanda?

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

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

OED

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

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

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

Last week I mentioned I'd make a poor politician or salesman. I didn't mention other professions, but I wonder if I might have been a successful detective. I had a consult last week that took all of my sleuthing skills, a newborn exposed to maternal syphilis that required me to track down mother's history dating back to 2017 as well as a sibling who turned out to have been a patient of mine a few years ago - not the type of continuity of care I'm looking for. This newborn, like the sibling, will need IV penicillin treatment but most likely will be fine in the long run. The entire consult took me about 2 hours compared to my usual 1 hour. That's why pediatric ID docs are at the bottom end of physician reimbursement but also why I love the profession.

I've been involved in some other detective work recently, but first a review of what's bubbling up as summer is winding down.

More Oropouche Concerns

This is a stark example of today's world - no matter where an infectious disease outbreak occurs, it can affect all of us. The European Centre for Disease Prevention and Control has issued a travel alert for countries in Central and South America experiencing epidemic Oropouche virus disease. The EUCPC found 19 cases of Oropouche disease in European Union residents this year, all linked to travel to Cuba or Brazil. No such alert has been issued by the US CDC, but US citizens should take note.

Summer travel planning should include assessment of disease and other safety risks in foreign countries.

Mpox Redux

I had hoped mpox had settled into a mostly endemic situation in the US, which is in itself a defeat of sorts, but new concerns have arisen from the outbreak in the Democratic Republic of the Congo that could extend to the US. The CDC's Health Alert Network has issued a new alert as cases spill over from the DRC to neighboring Burundi, Rwanda, and Uganda. The clade involved, clade I, is more transmissible and perhaps has a higher mortality than the more common clade II. Risk of exportation to the US is still considered low due to infrequency of commercial air flights from these countries. The alert contains details for case management. Remember, at risk individuals (see below) should receive 2 doses of mpox vaccine.

Persons at 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

Benefits of Vaccination

Speaking of vaccinations and CDC, the latest MMWR included an article estimating benefits, both economic and clinical, of childhood vaccinations over the period 1994-2023. One always needs to be wary of this type of modeling which by its very nature requires analysis of large administrative databases that can have some errors. However, the study authors were very careful and listed 4 study limitations.

First, the analysis didn't include influenza, covid, or RSV vaccination; we can all agree that would result in an underestimation of benefits. They also felt that the recorded immunization rates could be an underestimate, which in turn would underestimate costs of the programs. Similarly, the cost estimates didn't include federal, state, or local program management costs or excise taxes. Their fourth limitation point was that they were unable to consider contributions of other factors like hygiene or social distancing which could have lowered disease rates independently of vaccines. So, of the 4 limitations, 3 could result in overstatement of vaccine benefit. With those caveats, here are their numbers:

That's over a million deaths prevented and over 2 trillion dollars in societal savings.

Sniffles Status

We're still talking covid here, with flu and RSV almost nonexistent. Here's the latest ED visit numbers from CDC.

I was hoping covid wastewater would start to level off, but it is rising in all parts of the US (same link as above).

So, expect more covid in the coming weeks. For now, it seems we are stuck with both summer/early fall and winter covid surges.

Hieronymus Bosch

Not the painter but rather the seriously flawed detective character created by Michael Connelly. Probably the same fondness I have for the detective-like nature of pediatric infectious diseases practice also draws me to (mostly) noir detective literature. This summer I decided to look into somewhat more recent (compared to 1920s-1950s) detective series. Colin Dexter's first book in the Inspector Morse series, Last Bus to Woodstock (1975) was enjoyable, and I'll probably continue to the next installment. Now I've started the first book in the Harry Bosch series, Black Echo (1992). Both books are littered with beautiful writing, such as this musing by Bosch: "The sky was the color of bleached jeans and the air was invisible and clean and smelled like fresh green peppers."

I thought about that line as I was outside in the garden trying to figure out what species of butterfly was sampling the Joe-Pye-weed. I have a love of butterflies dating back to my childhood in south Texas, though I've forgotten almost everything I've learned from that time. We don't have nearly as many butterfly species in Maryland as in my home town, but it's still fun to watch and study them. This one black butterfly has been hanging around for several days; in fact, it's right outside my window now. Unfortunately I can't decide if it is the somewhat more common black swallowtail (Papilio polyxenes) or the rarer spicebush swallowtail (Papilio troilus). Real butterflies often don't look exactly like their pictures in reference materials. After several days and about 15 photos of different aspects of the wings and thorax, I decided to surrender and ask BAMONA (Butterflies and Moths of North America). I've submitted photos, dates, locations, and behavior details and now waiting on a reply from an expert. I'll let you know if they reply.

STOP THE PRESSES: BAMONA just sent me a reply, moments after my initial posting. It is a "dark-form female P. glaucus." For the uninitiated, this is the tiger swallowtail, but the picture below looks nothing like the typical tiger swallowtail. Also amazing, my iPhone identified the photo as P. glaucus, which I laughed as being another failure of artificial intelligence. You can bet I'll be reading more about this dark form butterfly.

Tag: Inspector Morse

My Hebdomadal Habit