measles – Page 2 – Pediatric Infection Connection

Winding Down (Again)

Bud WiedermannOctober 6, 2024October 6, 2024Leave a comment

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

WRIS

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

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

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

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

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

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

Two Viruses on the International Scene ...

Marburg Virus in Rwanda

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

Perinatal Chikungunya

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

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

... But Also Some International Success

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

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

Lower Vaccination Rates in US Kindergartners

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

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

How's Your Outpatient Antibiotic Prescribing Score?

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

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

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

November 5 is Fast Approaching

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

Invasive Species

Bud WiedermannSeptember 15, 2024September 15, 2024Leave a comment

Last week I outsmarted myself. The closing photo in the September 8 blog I was sure would result in at least 1 person calling me out; I was then going to follow up in this week's post to explain about invasive species. I guess I forgot to factor in the politeness of my audience in not wanting to berate me for mistakes. (This is a more preferable explanation than the alternative that no one even read that post!)

Still not much going on with our summer respiratory season. The percentage of ED visits due to covid continues to fall nationally.

However, covid wastewater levels in the western US plateaued or even increased a little.

Measles Still Here

It looks like we have settled into a persistent trickle of cases in the US. I'm still holding my breath hoping we can avoid another major outbreak this year. The official tally for 2024 now is 251 cases from 30 states and DC.

Not included in the totals above is a new case occurring in an unvaccinated student at Western Kentucky University, probably acquired during international travel. It looks like that person attended several public events over a few days in late August; with an incubation period of around 2 weeks, we should be hearing soon if secondary cases resulted from this person.

Meanwhile, the UK has reported a measles death in a "young person who was known to have other medical conditions." With 2465 confirmed measles cases so far this year, the UK is much worse off than we are in the US. Still, it's unsettling to hear about measles deaths in high income countries. The UK has had 1-5 deaths per year since 2019 but hasn't had double-digit death figures since 1988. Best estimates are that, even with the best medical care, 1-3/1000 children with measles will die.

A Couple Vaccine Updates

Nothing really new here, but it's easy to overlook important guidance with the flood of emails and other reminders we receive. First is the official statement from ACIP about Hib vaccination for American Indian and Alaskan Native infants. It is the follow up from an ACIP meeting last June. For both socioeconomic and biologic reasons, it's been clear for decades that this population has a very high rate of Hib disease and also a less robust response to most Hib vaccines compared to the general US population. The best Hib vaccine for this group is a conjugate using the Hib polysaccharide PRP joined to an outer membrane protein from Neisseria meningitidis. The OMP is a carrier protein that helps infants form antibody to PRP, the real protective antibody here. This is the basis for all conjugate vaccines; it fools the infant immune system into thinking it is seeing a protein antigen rather than a polysaccharide antigen; PRP and other polysaccharide antigens are not well recognized by infant immune systems - normal infants even fail to form antibody to PRP with natural Hib disease. Conjugate vaccines fool infant immune systems.

At any rate, for a long while we've only had 1 Hib vaccine with the PRP-OMP combo: PedvaxHIB. This summer we saw FDA approval of Vaxelis, a hexavalent vaccine with DTaP, IPV, HepB, and Hib, the latter using the PRP-OMP product. Vaxelis is now officially recommended as an option for the AI/AN infant population, as well as for other infants. The recommendation for the AI/AN group was made on the basis of a phase IV randomized study of Vaxelis versus PedvaxHIB showing good antibody formation in both groups. No effectiveness study was performed because this population didn't have enough Hib disease present at a background rate to determine any significant differences with a new vaccine - PedvaxHIB has worked very well for these children in the past, another vaccine success and cause for celebration.

A second vaccine update is just the recommendation, again from CDC, for the next round of covid vaccines recommended for everyone 6 months of age and older. Again, nothing new, but it's a good resource to have all that information in one document. The tables serve as a quick reference for many different situations.

Mosquito Invasion

Any ID physician worth their salt will obtain an extensive travel history when seeing patients. We are mostly looking for clues to diseases seen mostly in international travelers, such as typhoid fever and the vector-borne infections that include dengue, chikungunya, malaria, and others. However, sometimes the travel history is negative but the patient ends up having one of those exotic diseases, acquired locally in the US (aka autochthonous infection). Such is the case recently with autochthonous dengue fever cases in Los Angeles County, CA. These cases appear when there is an existing reservoir of infected people plus a reservoir of the vector. For dengue virus, the vector is the Aedes mosquito, specifically A. albopictus and A. aegypti, plentiful in much of California.

The range of these mosquitoes have been increasing the past few decades at least, mostly due to warming of our climate. The last extensive study of Aedes presence in the US was in 2017, summarized by CDC.

As one of those people who seem to be particularly tasty for mosquitoes, I find it interesting (and depressing) that we have about 200 different species of mosquitoes in the US. I'm not terribly comforted by the fact that only about a dozen of these can transmit those infections we worry about. Besides the Aedes genus, we also need to worry about Anopheles and Culex mosquitoes.

Of these, it is Aedes that is the most versatile in transmitting disease to humans, implicated in Cache Valley virus disease, chikungunya, dengue, eastern equine encephalitis, La Crosse encephalitis, and zika infections. Anopholes can spread Cache Valley virus, and Culex are implicated in eastern equine encephalitis, St. Louis encephalitis, and Oropouche virus, though midges more commonly spread the Oropouche. Other viruses such as Jamestown Canyon virus can be spread by many different species of mosquitoes and vary with time of year and location.

As our global temperatures have warmed, the mosquito season has lengthened; in many locations mosquitoes are out and about throughout the year. Also, the idea that high altitudes are safer from mosquito-borne infections is becoming invalid in many parts of the world, including the US. It wasn't the altitude per se that mosquitoes didn't like, it was the cool weather which now is warming.

I realize that for many of you this is already too much mosquito information, but if you want more visit Arbonet.

More Invasion

Getting back to last week's post, I had mentioned that my wife was outside working hard to clear our back yard of poison ivy while I was indoors typing leisurely. It turned out she didn't find any poison ivy. The photo I placed at the end of the post wasn't poison ivy but rather a portion of the massive porcelain-berry plant she removed instead. While poison ivy is a native plant, not invasive but still hated, porcelain-berry is a horribly invasive vine deliberately introduced into the US for its attractiveness but quickly discovered to spread indiscriminately, eliminating native vegetation in its path. It is the plant world equivalent of pod people.

One More Time This Summer

Bud WiedermannAugust 25, 2024August 25, 2024Leave a comment

Summer is supposed to be the slowest season in my line of work, but it doesn't seem like it. I've had trouble keeping up with everything, including some old news that I just found out about today. Maurice Williams died on August 5. If that name doesn't ring a bell, stay tuned. Here's what's up for this last post of the summer.

Mpox

It looks like we can add Gabon to the list of countries with exported mpox, this in a 30-year-old man who had stayed in Uganda for 2 weeks. The notice doesn't state whether or not this is clade I, but given that it appears to have been acquired in Uganda there is a good chance that it is. The latest WHO news was posted on August 22, the same day we heard from the CDC about the US response.

By no means is this the next pandemic, but we are seeing global spread of the clade I strain via travelers. Most important is ensuring affected African countries receive adequate vaccine supplies soon. In the US, persons in high risk groups also should be vaccinated.

Measles Check-In

Oregon is the latest state in the measles outbreak spotlight. Nationally the cases are percolating along at a steady rate.

West Nile Virus

In my post last July 28, I was halfway kidding about waiting for symptoms of West Nile virus after all my mosquito bites. West Nile is in "full swing" in Europe currently. Now I see in today's Washington Post that Tony Fauci is back home after a 6-day hospitalization for West Nile infection. Although he is 83 years of age, that's a long hospitalization and I hope he didn't have serious neurologic or other complications. I wish him a speedy recovery.

A little trivia piece I discovered years ago, did you know West Nile virus was tried as a cancer treatment in the early 1950's? Research on using flaviviruses as oncolytic agents continues. Unfortunately the lead investigator of that 50's study is mostly remembered for a serious ethical breach, injecting tumor cells into prisoners to study tumor immunology.

Timing is Everything

I have a complicated plan for how I'm going to time when I get my flu and covid vaccines in the coming weeks, based on travel plans and guessing about peak flu season. At my age, waning immunity following vaccination could be clinically significant.

This brings me to an interesting study in the BMJ trying to define optimal timing for influenza vaccination in young children. It utilized data from an administrative database in the US for timing of vaccination of over 800,000 children ages 2-5 years during several flu seasons. Bottom line, it looked like October was optimal. I wouldn't necessarily alter plans based on this study; every flu season has slightly different timing. It's probably a better plan to just vaccinate when you can, whether it be at regular checkups or flu vaccine events on evenings and weekends.

Holding My Breath on Polio

I'm still hoping polio doesn't break loose in Gaza, but I'd be more hopeful if vaccine could be distributed there. WHO has full plans in place to distribute the relatively new novel oral polio vaccine type 2 (nOPV2) to about 640,000 children under 10 years of age in 2 campaigns separated by a month. Wastewater monitoring suggests this is the strain that caused the case recently detected in a child in Gaza; we're still waiting for confirmation from a regional lab in Lebanon. Now we just need an effective ceasefire to allow this and other humanitarian aid to be implemented.

Covid

The big news was the not surprising FDA approval and emergency use authorization of the KP.2-based mRNA vaccines from Pfizer and Moderna. Novavax approval is still pending due to a longer manufacturing process. As I've said many times, if one looks at the level of individuals, it's pretty clear that vaccination benefits outweigh risks for every age group. New interim recommendations are available from the CDC.

Here's a quick look at a few disease activity indicators over the past year:

Wastewater hasn't changed much nationally.

Regionally, only the Northeast seems to be rising, though still lower than most other regions.

We'll see what happens with covid (and measles) now that schools are starting back again.

In the midst of all this, we have a new study on long covid in children. It was a multicenter prospective cohort study of about 900 younger children and 4500 adolescents, most with covid infection but some not infected who served as controls. The report is loaded with data and complexities; I'm sure everyone in the field is looking it over closely.

It's tough to summarize the findings succinctly, but perhaps you can enlarge the figure below to see details. The darker color shades are the more prominent symptoms in each cluster. Clustering of types of symptoms varied between adolescents (12-17 years) and school-age children (6-11 years). I'm very happy to see this type of analysis; it is possible that different clusters have different pathogenetic mechanisms suggesting different treatment approaches. Clusters in the younger children were in the neurocognitive, pain, and GI domains, whereas loss of smell or taste, pain, and fatigue/malaise were highlighted for the adolescents.

This study won't change clinical practice immediately, but it is a major step forward in providing a framework to base treatment studies.

"No Good Songs Ever Came Out of the 1950s"

That probably inaccurate quote, heard when I switched my car's Sirius/XM to the 50's station, came from a musically-inclined and knowledgeable friend of mine. I'm pretty sure he uttered it just to get a rise out of me, which it did. IMHO, the 50's produced a lot of good songs and shouldn't be remembered just for some wacky West Nile virus studies.

The title of this week's post is a nod to Maurice Williams who wrote the song "Stay" in my birth year, 1953, but then put it on the shelf until he recorded it with the Zodiacs in 1959. It came out in 1960 and was a big hit at just 90 seconds in length. You may be more familiar with it from the 1977 cover with slightly altered lyrics by Jackson Browne, Rosemary Butler, and David Lindley (and the 9-minute mini-medley with "The Load Out") or from the 1987 movie "Dirty Dancing" that used the Williams original. Regardless of which of the couple dozen versions I listen to, this is one of those songs that always brings a smile to my face.

PPR

Bud WiedermannAugust 4, 2024August 4, 2024Leave a comment

You know things are slow in my world if I'm mentioning pestes des petits ruminants, aka goat plague, but it has been in the news lately and does have relevance to us. Spoiler alert, you don't need to break out the masks and gloves, the virus causing this disease has never been reported to infect humans.

First, let's touch on our (nearly) nonexistent summer respiratory infection season.

SRIS

We're talking primarily about covid and avian flu at the moment. Covid wastewater levels may be starting to level off, except in the southern US.

The clinical respiratory illness map is a beautiful sea of green (with a bit of light green in Alaska). I'm only showing this to remember fondly come next winter.

Not a lot to report on the avian flu front, with a continued sprinkling of new mild human illness in poultry/dairy workers and new outbreaks in flocks and herds. I was interested to see that CDC is making a $5 million investment to provide seasonal flu vaccine to at risk workers. Of course we want everyone eligible to vaccinate themselves against seasonal influenza, but the ulterior motive here is to lessen the chance that a human will be simultaneously infected with a seasonal flu strain along with the influenza A H5N1 avian strain. Such a situation could increase the likelihood of reassortment of the 2 strains to create a new virus that could cause more problems for us. This scenario is still a rare probability but worth preventive measures.

PPRV and Cousins

The virus that causes PPR is a morbillivirus, which should sound familiar to healthcare providers because that is the same genus as measles virus. You can learn more than you want to know about PPR from the article from which the figure below was lifted.

Morbilliviruses in general have the theoretical ability to be eradicated. In fact, one animal morbillivirus, rinderpest virus, already has been eradicated. PPR has been targeted for eradication by 2030, but a recent outbreak in Greece now threatens that with spread from Africa and the Middle East to the European Union. Infection has a very high fatality rate in goats, sheep, camels, and other ruminants that provide livelihoods to many. So, although PPRV doesn't infect humans, runinant infection is a major threat to livelihoods of those in these countries who depend on these animal industries. The World Organisation for Animal Health nicely summarizes eradication tools in place, let's hope the Greek outbreak doesn't set eradication plans back too far. (Also, if you're looking for a rabbit (only slight pun here) hole to fall down, check out WOAH's list of 207 animal diseases.)

The real reason I mention PPR is to draw attention to somewhat misleading measles pronouncements in the lay press this past week. NBC, among virtually every national news agency I could find, highlighted the CDC announcement that US measles cases have tripled this year compared to all of 2023. That's true but also misleading. I understand this helps get the message out that measles vaccination rates are low in many segments of society, but by using this relative increase in cases as a headline it overlooks the fact that the actual number of cases is still low, thank goodness. To its credit, the NBC link above did go on to give these details, but in our sound bite world that clarification is easily lost. Here's a bit more perspective from CDC.

From the same website, you can see how graphs can be used to stress a particular point - the perspective below would make us think everything is great. Just by expanding the date range, we can hardly see anything going on this year.

CDC regularly updates assessments of measles outbreak risk in the US. Currently they predict the most likely number of cases for 2024 will total 300, with a 4% risk of >1000 cases. Keep that in mind over the next 5 months.

Don't get me wrong, I'm all for increasing measles vaccination rates; however, I don't want to do this without presenting an accurate view of the data. I'd make a terrible salesperson or politician.

Red Book Renewal

Bud WiedermannMay 19, 2024May 19, 2024Leave a comment

The 33rd edition of the American Academy of Pediatrics' 2024-2027 Report of the Committee on Infectious Diseases, aka Red Book, arrived online (and on my doorstep) recently. This latest edition adds about 100 pages to the 32nd edition, even as many sections were combined or shortened. More than annual spring cleaning, this is a renewal effort for me that has become an enjoyable triennial task for me. Although the early pages provide a brief summary of changes (total 222) from the previous edition, I operationalize this by having the new Red Book at my side always, looking up every clinical situation I encounter in reading or in patient care. Not surprisingly, even after doing this for maybe the next year, I still won't remember everything, but I'll know when and where to look. Remember also that the Red Book advice is in many instances a set of consensus opinions that are subject to author bias, even with extensive review and editing. Nothing is etched in stone, and individual patient circumstances may require deviation from general recommendations.

In the meantime, let's look at what's been going on in pediatric infectious diseases recently; this isn't in the Red Book.

A New Look CDC Website

Our friends at CDC announced a new look to their website with a focus on reducing clutter and making access easier. After my first series of run-throughs, I think they are well on their way to that goal. It's worth your while to view their 2-minute YouTube video describing the changes.

Bird Flu News

Still no reason to increase fears of the next human pandemic, but plenty going on. The US Department of Agriculture (they should talk to their CDC colleagues about reducing website clutter and improving navigation!) updated beef safety with some new studies. First, USDA tested ground beef samples from stores in states known to have influenza A H5N1 present in cattle; all were negative by PCR, although they don't mention how many samples were tested. Second, they performed studies on cooking ground beef spiked with Highly Pathogenic Avian Influenza "surrogate" virus (they don't specify details or numbers). Cooking the burgers to medium (145 F) or well done (160 F) eliminated all live virus. Rare (120 F) cooking "substantially inactivated" the virus, whatever that means. I'm looking forward to results of another ongoing study of PCR testing of muscle samples from cows who were culled due to "systemic pathologies" which should go a long way in helping understand if there is any reasonable risk of transmission of H5N1 in raw beef.

Meanwhile, in the latest update there have been no new state detections in domestic livestock since April 24. Bird infections remain a major problem as judged from USDA's main avian influenza website.

FDA provided a little more detailed information than did USDA. They found no viable virus in 297 pasteurized dairy products tested and confirmed by egg inoculation studies which should be highly sensitive.

Things are improving, but more proactive testing, especially of asymptomatic wild and domestic animals and high-risk humans such as poultry and dairy workers, is needed to stay ahead of any epidemic trends.

MMWR Trifecta

I'm not a big horse-racing fan, though I did watch the Preakness this weekend. This week's (May 16) MMWR hit a trifecta for me in that 3 topics are worth mentioning, so here's a quick look.

Measles: We have a detailed report of the outbreak associated with the migrant shelter in Chicago, spread over February through April 2024. Here's the quick overview:

The key take-home points: 1) Most of the 57 cases occurred in unvaccinated individuals; 2) active case-finding and a mass vaccination campaign (882 residents were vaccinated) likely averted a larger disaster.

I wish we had similar reporting from the Florida public school outbreak, apparently managed very differently but we know nothing about what was done. I can still find only a March 8 update that sounds mostly like a political statement.

Clade I Mpox: This clade I outbreak continues in the Democratic Republic of Congo and, compared to the clade II strain that caused the global outbreak in 2022, this clade I seems more virulent, with higher morbidity and mortality than seen with clade II (this was known prior to this outbreak). Again, here's the big picture:

While the numbers appear to be trending downward in the latter dates on this graph, this could be due to delays in reporting.

Age distributions are alarming for pediatric healthcare providers though clearly are influenced by social factors present in the DRC and might not apply to any US cases if we do see global spread.

The Jynneos mpox vaccine is effective against both clades, and high-risk individuals in the US should be vaccinated. The newly revamped CDC mpox site is a good example of how they've improved the look and ease of navigation. Providers should access this again to be sure they have offered vaccine to those at risk.

Polio: This was an update on progress towards polio eradication and is a good news/bad news report. The good news is that wild-type polio infections appear to be decreasing over the period January 2022 to December 2023. Wild type polioviruses types 2 and 3 (WPV2 and WPV3) have been eradicated, and only WPV1 continues to circulate but just in Afghanistan and Pakistan. In 2023 there were only 12 cases of WPV1 identified, compared to 22 in 2022, a decrease even with more extensive sewage screening in 2023. The bad news is that circulating vaccine-derived polio (cVDPV) cases, from live polio vaccine, continues to be a problem. The number of cases decreased (881 in 2022 to 524 in 2023) but the number of countries affected increased from 24 to 32. The vast majority of these are cVDPV1 and cVDPV2. WHO has newer and more effective vaccination strategies to eliminate both wild and vaccine-derived strain infections, but implementation is difficult.

Books - Red and Other Colors

Regular readers of this blog know that I'm an avid reader. I'm not an avid book collector, however. I try to keep a relatively static number of books in the house, requiring donating old books to my neighborhood public library's used bookstore as I acquire new ones (my last trip to a used bookstore resulted in 11 additions to my sagging bookshelves). However, I'm now reminded that I have 3 collections that I don't recycle from my shelves.

First is the Red Book. I own all editions dating back to 1961, the 13th edition, plus the 6th edition of 1944. I've been unable to find the remaining 11 editions, probably because I'm not as adept at used bookstore searches as I am at PubMed searches. I'll keep trying. Three pediatric infectious diseases giants, Drs. Larry Pickering, Georges Peter, and Stan Shulman, wrote a nice review of Red Book history in 2013.

My other 2 non-recyclable book collections are very different. One is the Audrey/Maturin series of nautical novels by Patrick O'Brian. I also own several of his lesser works. I'm not sure why I hang on to all of those; perhaps it's because my initial attempt at reading one was quickly abandoned due to boredom. Years later I picked it up again and was hooked. My other collector fascination is the Parker noir series by Richard Stark, a pseudonym of Donald Westlake. I lack many in the series which I could easily buy as newly issued printings, but I prefer to prowl used bookstores for older copies. I haven't happened upon an old one in years, but hope springs eternal.

Tag: measles