measles

Seeing Spots Before Your Eyes?

Bud WiedermannJanuary 28, 2024January 28, 2024Leave a comment

Washington, DC, had a record high temperature 1 day during our heat wave this past week, and I suppose if you glanced at the sun you might see some spots for a few seconds. But of course I'm referring to different spots in this post.

I'm probably the only person who has read all of my blog posts over time, so you're forgiven if you don't realize I'm in broken record mode here. I can't count the number of times I've warned providers to be on the lookout for measles cases, and now we are facing a global decline in immunization rates that probably puts us at greatest risk since the modern-day measles vaccine was available in 1968 (the original Enders vaccine appeared in 1963). We've enjoyed some low numbers in the US recently, but that appears to be changing with 9 cases (from Georgia, Missouri, New Jersey, and Pennsylvania) reported to CDC so far this month.

CDC released an alert last week mentioning 23 US cases between December 1 and January 23.

I won't review everything about diagnosis of measles, the CDC website alert is a good resource with links to other sites, but I do want to highlight a few helpful nuances that aren't often mentioned. First, measles is fairly unique among exanthematous infections in that the prodrome interval, the time between onset of first symptoms and appearance of the rash, is long, usually a few days. Most infectious diseases accompanied by rash have very little or no time between onset of symptoms and appearance of the rash, with erythema infectiosum being a notable exception but not easily confused with measles clinically.

The measles prodrome consists of a febrile illness with cough, coryza, conjunctivitis, and Koplik's spots. You can find pictures of Koplik's spots everywhere on the web, but in my experience as an old geezer who has seen many cases of measles in children, they aren't that easy to see or photograph. Therefore, the photos available in textbooks and on line are skewed towards the most obvious. One needs to do a careful oral exam looking for gray or bluish-gray or white fine spots (almost sandpapery) anywhere on the buccal mucosa; the inside of the lower lip is particularly helpful. If you're not sure, find an old geezer clinician to confirm.

In the absence of Koplik spots, or if you don't see the child until the rash appears and the Koplik spots have resolved, pay close attention to the history. Specifically ask for a day-to-day accounting of symptoms; if you feel the parent or patient can recall reliably, noting at least a 2-3 day lag between the onset of high fever, cough, rhinorrhea, and conjunctivitis before the rash appears can be strongly suggestive of measles; the absence of this lag is against the diagnosis. Other alarms to increase your suspicion would be lack of 2 measles immunizations, international travel, and/or exposure to a suspected measles case.

"It ain't what they call you.....

..... it's what you answer to." - attributed to W.C. Fields, though I can't verify the origin.

I thought of Mr. Fields when I heard about administration errors involving the adult RSV vaccine (brand names Abrysvo and Arexvy) given to children and pregnant people. From my viewpoint, it was an accident waiting to happen, due to a name.

In order to speed payment allowance by the Vaccines for Children and other programs, the long-acting monoclonal antibody nirsevimab was officially designated a vaccine. Strictly speaking I guess this is correct: antibody administration is a form of passive immunization. However, the true RSV vaccines are intended only for adults with high risk conditions or for pregnant people to help protect newborns after birth. It was inevitable that confusion would ensue. The notice provides almost no details but does state that most administrations to young infants were "nonserious." Infants who wrongly received an adult RSV vaccine should be considered unprotected and still receive nirsevimab.

WHO Fans the Covid Mask/Distancing Controversy

WHO riled a lot of public health experts with its recent guidance for infection control in healthcare facilities. The main controversial elements involve recommendations to use physical barriers such as plastic windows for areas where patients first present (rated as conditional recommendation, very low certainty of evidence); maintaining a physical distance of at least 1 meter between people ("good practice statement"); and not sufficiently highlighting superiority of respirators (e.g. N95 masks) for general care - this particularly angered those who favor the aerosol, rather than droplet, mode of transmission for SARS-CoV-2. In general it seemed that the WHO panel carried over some details for infection control that do not have strong evidence for use and in some cases (plastic barriers) may be contradicted by other studies.

Note that much of the controversy involves how much weight to give transmission simulation studies - e.g. distances that SARS-CoV-2 travels under experimental conditions rather than real-world evidence which is much more difficult to come by. It's hard for an individual medical practice to make these decisions on their own, best to abide by state or local health department guidance.

Spring Covid Vaccination?

Canada released guidance for covid vaccination this spring, advocating for an additional dose of the XBB.1.5 vaccine recommended last fall. I'd look for the US to make similar recommendations soon. ACIP has a regular meeting scheduled February 28-29, but no agenda is yet available. FDA doesn't have anything scheduled, and they may not need a separate advisory committee meeting for this.

WRIS

In general we seem to be trending downward with our winter respiratory infections, but still lots of runny noses, coughs, and more around.

For RSV I still look primarily at hospitalization rates in young children, the purple line in the graph below, because I think it's the most accurate gauge of RSV. I suspect almost all of these hospitalized children are tested for RSV and flu. The rate clearly is trending down, it's looking like we won't replicate the horrible RSV season of last year.

Influenza-like illness seems to be cooling off as well, as seen in FLUView. Note this measurement includes respiratory illnesses mimicking flu so could be any respiratory virus; there are many more ways to look at flu activity in general, all with their own inaccuracies. In the past I have found this map to be representative of what I've seen clinically in my practice areas.

Covid wastewater (I've said before why I prefer this qualitative measurement) continues to trend downward, and levels are below that seen last year.

All told this is good news for those of you trying to manage your packed patient waiting rooms. Let's just hope you don't have a case of measles sitting in there somewhere!

Do You Even Know What a Broken Record Sounds Like?

I used this term when I said I was sounding like a broken record for repeating over and over my warnings about measles. I harp (pun intended) on this because measles is the most contagious infectious disease known and most younger clinicians in the US have never seen a case, meaning it can be missed easily. However, those same clinicians might never have heard a broken record either. Vinyl records made a bit of a comeback recently but even I no longer have a turntable to play vinyl records; I do have a few moldy vinyl albums from the 1960s and 70s. I'm occasionally tempted to purchase a good turntable, but I have no place for it and it's yet another diversionary rabbit hole I don't need. I ain't gonna call out the name vinyl around here.

Lots of Thanks This Year

Bud WiedermannNovember 19, 2023November 19, 2023Leave a comment

I didn't have any trouble thinking of things to be thankful for this Thanksgiving-time. That might seem odd given the horrific events on the world stage now, and I don't mean to minimize that, but gratitude can coexist with dismay.

First, let's get caught up on this week's ID happenings.

Disappointing Measles News

Measles is probably the most easily transmissible human infection known; a high level (probably 95%) of population immunity is needed to prevent outbreaks. Not surprisingly, a breakdown in immunization rates during the COVID-19 pandemic likely is to blame for increases in measles cases worldwide, as reported last week by the CDC. Concomitant with a decrease in measles-containing vaccine coverage from 86 to 81%, measles cases increased 18% (7.8 million to 9.2 million) worldwide from 2021 to 2022; deaths increased from 96,000 to 136,200. Still, and here's the thankful part, vaccination likely prevented 57 million measles deaths from 2000 to 2022. Here's hoping we can get our global immunization campaigns back on track.

2024 CDC Recommended Immunization Schedules Are Available

Even earlier than advertised, CDC has posted the 2024 immunization schedules. Primary care providers should study these closely due to some complex changes, particularly for pneumococcal and meningococcal vaccines. The AAP has posted a summary of key changes (click on the PDF link). As an aside, I'm a bit irked by what CDC and others call "shared clinical decision-making." Here's CDC's tool for SCDM for meningococcal group B vaccine:

I'm not a primary care provider, but I don't see a lot of help for busy frontline practitioners here. What we really need are more details about choices parents and patients need to consider. Specifically, what are the risks of not getting the vaccine versus those being vaccinated? As stated in the table, meningococcal B infections are relatively rare in the US, so vaccination isn't going to prevent much disease or mortality even with a highly fatal infection. The risks are different depending on individual circumstances. Are frontline providers supposed to have these numbers at their fingertips? Maybe the CDC or AAP will provide them. (Or, if not, maybe I will!)

MIS-C Cardiac Follow-Up

Multisystem inflammatory syndrome in children (MIS-C) following covid infection is very uncommon currently, but we shouldn't forget about monitoring children as they recover from MIS-C. A group at Children's Hospital of Los Angeles reported that even children who did not have clinical cardiac involvement during their acute illness still had some evidence of cardiac injury at the 6-month followup period. Most of the report deals with laboratory, imaging, and other testing, but of the 69 patients evaluated at 8 weeks 15 had clinical symptoms such as chest pain, palpitations, exertional dyspnea, or fatigue. The rate of clinical symptoms was actually lower in the group with no initial myocardial injury, although the difference was not statistically significant. The bottom line: make sure all MIS-C patients have good cardiology followup.

Variations in Influenza Antiviral Use

A group from Vanderbilt reported wide variation in prescribing practice for influenza antivirals during the period 2010-2019 (so, not affected by the pandemic). It is an administrative database study, a study design type that has inherent inaccuracies due to how administrative data is collected. In general, however, a wide variation in practice is an indication that something isn't right. Guideline-concordant compliance was low, for example <40% in children less than 2 years of age, a high risk group. I would have liked to have seen how flu vaccine status affected antiviral use since vaccination greatly lowers risk for severe adverse outcomes, but apparently the database did not contain that information. This is another opportunity for shared clinical decision making with parents; what are the specific rates for infection, hospitalization, etc versus medication side effects (primarily vomiting with oseltamivir) for an individual child, based on their risk factors? That's what a frontline health provider needs when discussing whether to treat a child for influenza.

The "New Normal"

I mention this catchphrase only to bury it. Not only does it seem nonsensical to me, it also is beyond retirement age. Some might wish to apply this catchphrase to the upcoming winter season. I'm strangely thankful/hopeful for this because it now appears we may get to see what a typical respiratory virus season looks like in the post-pandemic era. We haven't seen any weird covid upticks early on, and RSV looks more typical so far without the very severe season we saw last year. Flu may be starting to increase, similar to pre-pandemic seasons. Of course, all of the respiratory virus seasons vary somewhat from year to year. Will covid settle into just another winter respiratory virus?

FLUVIEW is back in business, and the map is heating up especially in the South.

Remember that this is a map of "influenza-like illness" so can capture other respiratory viruses. However, covid wastewater tracking hasn't had much of an uptick.

RSV-NET continues to show increase primarily in younger children, not matching last year's peak but possibly similar to prepandemic waves.

Happy Thanksgiving

I was looking around for something uplifting and fun to mention and happened on "Thanksgiving" by Edgar Albert Guest. Here's an excerpt:

"Greetings fly fast as we crowd through the door

And under the old roof we gather once more

Just as we did when the youngsters were small;

Mother’s a little bit grayer, that’s all.

Father’s a little bit older, but still

Ready to romp an’ to laugh with a will.

Here we are back at the table again

Tellin’ our stories as women an’ men."

I had never read anything by Guest, but I was sold on him when I read his Wikipedia page. Anyone who merits mention by Edith Bunker from "All in the Family," Lemony Snicket, Mad Magazine, and Benny Hill is my kind of guy. Furthermore, Dorothy Parker of Algonquin Round Table fame had the best line: "I'd rather flunk my Wassermann test than read a poem by Edgar Guest." I think maybe she wasn't a fan, but at least she knows her 1950s syphilis testing.

Wishing everyone a Safe and Happy Thanksgiving.

Death Valley Days

Bud WiedermannFebruary 5, 2023February 5, 2023Leave a comment

I've had a wonderful week, just returned from a west coast swing to visit a son and also do some hiking in Death Valley. In the meantime, the infectious disease world soldiers on.

Winter Virus Update

We continue to see good news from RESP-NET, though again with the concern particularly with covid that we don't have accurate case tracking, likely resulting in underreporting. XBB.1.5, as expected, appears to be sweeping westward across the country and is by far the dominant variant east of the Mississippi.

Covid Immunologic Insights

A couple of articles released recently bring up some interesting findings. First, researchers at WHO and multiple other academic institutions around the world performed a systematic review and meta-regression looking at protection from prior infection with or without vaccination against omicron infection. Not surprisingly, protection against infection itself waned very rapidly, but hybrid immunity (combination of prior infection plus vaccination) was relatively long-lasting for protection against severe disease and hospitalization: better than 90% at 12 months following last vaccination or infection. This is somewhat supportive of the proposal for annual covid vaccine boosters, although in practice it will be exceptionally impractical to determine individual prior infection status.

The other article was a detailed analysis of clonal T-cell responses to asymptomatic or mild covid infection, comparing adults and children. It is highly technical, mostly of interest to basic scientists, but I was intrigued by the finding that children did not develop effective adaptive immune responses compared to adults. This has important ramifications for future vaccine development.

More Measles Mess

We are already seeing measles outbreaks around the country, mostly isolated/contained, but given the pandemic-associated drop in childhood vaccination coverage we should prepare to see more. Now, researchers at U. Penn have reported relatively high rates of negative measles serologic testing in parturient patients at 2 Philadelphia hospitals. About 20% lacked protective antibodies to measles, an important finding not only for these patients but also for their newborns. For the babies, it's a bit of mixed news because maternal antibody will block response to measles vaccine in the first 6 months of life but also means that these infants could be unprotected very early in life. The main caveat for interpretation is that measles antibody is only a surrogate of protection from infection and thus we can't assume directly that the 20% rate corresponds to true lack of protection.

20 Mule Team Borax

I have vague memories of a television show, Death Valley Days, from my early childhood. Or, should I say what I do remember are the commercials for 20 Mule Team Borax, a laundry detergent still available today. Its main ingredient is sodium tetraborate, very toxic if taken internally or even used as a topical soak/bath. It's a sad state of affairs that I wasn't surprised that borax is yet another toxic compound advocated for use in the covid era, this time by anti-vaxxers as a bath component to reverse the effects of covid vaccination. Bad idea.

Of course, kicking up the trail dust in Death Valley, I couldn't help but think about health risks and not just from tumbling 5000 feet down the Dante's View trail. Death Valley is coccidioidomycosis territory, so if I develop a respiratory illness within the incubation period (1-3 weeks), I'll remind my physician to keep it in the differential diagnosis!

Collateral Damage 2

Bud WiedermannDecember 4, 2022December 4, 20222 Comments

Of course covid hasn't gone away, we are entering a period of increased activity in the US now. (Note that reported new cases showed a slight decline, but hospitalizations are up; this likely reflects poor reporting of new infections.) If no new significantly different variants emerge, I don't think we'll see anything like last winter's covid surge. Individuals can now report home test results anonymously; if used extensively it would provide better understanding of disease activity.

Unfortunately immunocompromised and other high-risk individuals will need to weather this covid winter without much help from monoclonal antibody treatment and prevention strategies. Bebtelovimab is now unavailable for treatment due to poor neutralizing activity against current variants. Tixagevimab/cilgavimab (Evusheld) still is available for preventive management in very high-risk people due to lack of any other effective pharmacologic preventive measures, but Evusheld also is likely to be ineffective for the current variants.

Increasingly now our attention should also focus on what I call collateral damage, mainly through 2 mechanisms. First, the pandemic disrupted other respiratory virus transmission during its peak, meaning a lot of young children haven't seen our common respiratory viruses in their lifetimes. Also, a number of factors combined to lower general immunization rates across the globe. So, we have a large collection of non-immune people, including young children, at risk not only for covid but also for both common and previously rare (in high resource countries) infectious diseases.

The Mother of All Flu Seasons?

Well, no, but it's been tough and may last a bit longer. I haven't seen a flu map this bad in a long time (late October 2009, our pandemic year, is in the neighborhood; you can scroll back to see it at the same weblink).

Note that this map represents "influenza-like illness" activity, so likely includes some RSV and other respiratory infections as well.

Most of the influenza cases currently are H3N2 which is well-matched by this year's vaccine. It's still wise to provide flu vaccine to unimmunized children even if they have already had a documented influenza infection because both the 2009 pandemic strain of H1N1 as well as influenza B strains also are circulating and likely will increase later in the season. Olsetamivir is helpful for treatment of high-risk children with flu.

Be on the Lookout for Previously Rare Vaccine-Preventable Diseases

Measles probably represents our biggest risks for outbreaks and deaths worldwide, because of high transmission rate and severity of disease. It won't take much to see outbreaks in the US. Also, did you know England has already seen a diphtheria outbreak this year? The US is at risk as well. Pertussis is always around and could be more severe in the coming months; also watch out for more cases of otitis media (if poor pneumococcal vaccine rates), tetanus, and, as we've already seen, polio.

You Can Limit Collateral Damage

Pandemics and other times of upheaval have always affected immunization rates. However, I am struck by the degree of anti-vaccination campaigns and general misinformation we've seen in what should be an era of enlightenment and celebration of vaccine successes in the US. Frontline healthcare providers are an important countermeasure against this collateral damage. Don't miss an opportunity to reinforce this with your patients and families.

A Lot of Irons in the Fire

Bud WiedermannMay 1, 2022Leave a comment

This week I'm very challenged to limit the number of topics to discuss; much of interest, though nothing earth-shattering. I'll focus on 2 non-COVID items while slipping in a couple more ideas.

Speaking of COVID-19, it's mostly a good news situation for the moment. I continue to watch developments in the UK and it does seem like their uptick in cases is tailing off without having seen a big increase in hospitalizations. I hope we'll see that trend continue in the US. At the same time, I'm keeping a watch on South Africa. Gauteng province, the first alert to omicron problems originally, now is experiencing an increase in cases and hospitalizations likely driven by BA.4 and BA.5 omicron subvariants. It is also spilling over to other provinces. Time will tell if this is the next new surge there and worldwide.

Also, a good news/bad news package from the FDA. Counterfeit at-home COVID-19 diagnostic tests have appeared, but there are ways to identify them. Also, we saw a tentative schedule for FDA-VRBPAC meetings to discuss vaccines for the youngest children. Data submission from Moderna and Prizer is not yet complete, but I certainly hope one or both of the products will fulfill criteria for authorization.

Be Careful Counting Your Chickens

We now have the first detection of human influenza A H5N1 infection, a "bird flu," in the United States. Not a huge deal from a public health perspective in terms of numbers of people at risk. However, I'm glad it got a little news coverage because clinicians need to be aware of this. Birds have been affected in 30 states so far and include both poultry farms and backyard flocks.

The take-home message for front-line healthcare providers is to remember to inquire about history of close exposure to birds, not just chickens but wild birds as well, in anyone with influenza-like illness. CDC has guidance for what to do.

Fulminant Hepatitis Update

We've had some updates this week, but still more questions than answers. UK scientists have provided us with more information about their cluster investigation, as has the CDC for the cluster in Alabama. The association between adenovirus 41 (a gastrointestinal, not respiratory, adenovirus type) is still just that. The focus so far is on younger, previously healthy children. Whether the adenovirus is causal, a cofactor with another environmental or infectious agent, or just an epiphenomenon remains to be seen. In the meantime, probably a good idea for pediatric healthcare providers to discuss potential hepatitis cases with a subspecialist.

One final iron to mention: summer travel. Travel is opening up worldwide, increasing chance for spread of many infections. I take this opportunity to remind practitioners about measles, now increasing in several places around the world. It is still the most highly contagious respiratory infection known, though I'm waiting for one of the SARS-CoV-2 variants to exceed that. This high transmission rate combined with its rather prolonged incubation period and infectivity prior to clinical symptoms make it easy to take off in a community. Currently with general immunization rates relatively low due to the pandemic, many US communities are at very high risk if measles is introduced. Stay vigilant.

Tag: measles