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Tag: measles

Published on Leave a comment on Super Sunday

I've been a Super Bowl addict I think from Super Bowl I, persisting in spite of the fact that the NFL has done very little to limit head trauma and chronic traumatic encephalopathy. I'm usually tied to the Super Bowl screen almost continuously because I like to pay particular attention to the national anthem (more on that later) and to all the commercials. For Super Bowl LVIII I'll unfortunately need to grimace and grit my teeth when the Kansas City fans do their insensitive tomahawk chopping and war hooping.

As I rush to finish my long list of chores for today I somehow need to cull through this week's list of 16 blog topic ideas to post something with low soporific properties. Here goes.

I'm Beginning to Really Worry About Measles

It's difficult to find a central, accurate source of data, but it seems to me that an unprecedented level of sites around the world are experiencing high numbers of measles cases. Coupled with robust international travel, declining vaccine rates, and very high contagion, the US population could have a major resurgence.

An editorial in the BMJ last week (unfortunately freely available only to those with a subscription) re-sounded the alarm. The impetus was a new outbreak in the West Midlands, but really the problem has been sweeping Europe for at least a year. They quote other sources citing over 42,000 cases in European Union countries from January to November 2023, with 5 fatalities. Ireland, which had only a few measles cases in 2022 and 2023, reported the death of a middle-aged man who had visited Birmingham; no further details such as underlying risk factors are available presently. Our northern neighbors in Montreal report a measles case in an unimmunized child, likely acquired on a trip to Africa. The child's age isn't mentioned but he was apparently school-aged since a school is one of multiple sites where health authorities are trying to track down contacts.

I came across an updated measles website from the Infectious Diseases Society of America that I think is pretty helpful, including several links to other sites. Look at the Facts link for a good discussion of common measles misconceptions. And, please, please, please make sure all your eligible pediatric patients are immunized.

Speaking of Vaccine-Preventable Diseases

Diphtheria has killed 130 Somali children in the last 3 months, according to a news report. Antitoxin availability in the country is very limited. Diphtheria continues to pop up in resource-poor countries with ever-present risk of imported and then locally-acquired cases appearing in the US.

"Silent" ARF

A new study carried out in Sudan informed me about the existence of "silent" acute rheumatic fever. The investigators performed handheld echocardiography testing on 400 febrile children 3-18 years of age who did not have a definite etiology for their fever. Of 281 children who had no clinical features of ARF, 44 had evidence of rheumatic heart disease on echocardiogram. This is an interesting diagnostic intervention that could prove practical for use in high risk ARF countries, but costs and training could be significant barriers.

Thankfully we don't have much of a rheumatic fever problem in the US, likely because most endemic US group A streptococcal strains are unlikely to trigger ARF. However, imported strains certainly pose a risk, and evaluation of any suspected ARF case should take into account travel history/country of origin.

More on Treatment of Hearing Loss in Congenital CMV Infection

Last week I mentioned a small phase 2 study of late, short course treatment for children with hearing loss likely due to congenital CMV infection; it didn't work. Now this week we have a report of a small phase 3 study in the Netherlands. It was an unusual circumstance where a randomized trial was converted to a non-randomized trial because the original trial floundered due to lack of enrollment; most parents wanted their children to receive treatment. In the new study, children with hearing loss but otherwise clinically silent congenital CMV infection received either 6 weeks of oral valganciclovir (n=25) or no treatment (n=15). They were followed until 18-22 months of age, and the treatment group had less hearing deterioration than did the control group. Not the cleanest study but a better design overall than was the US study, and it did find evidence of benefit. This also points out the great difficulty in conducting these trials; even though congenital CMV infection is very common and virtually all US infants are screened for hearing loss, it's very difficult to enroll and follow-up these children in randomized double-blind placebo-controlled trials. We still don't have a definitive answer on treatment benefits for isolated hearing loss in congenital CMV, but I hope the investigators don't give up trying.

Alaskapox

No, I didn't make up that word, it's a real orthopoxvirus that can rarely infect humans mostly in, you guessed it, Alaska. Only 7 human cases are known to exist, but the most recent one, in an immunocompromised man, was fatal. The report also is striking for how long it took to diagnose him. The virus mainly infects small mammals (voles, shrews) with no known human-to-human transmission so far. However, there is no reason it wouldn't be spread from another human, just like other viruses (smallpox, cowpox, Mpox) in the same family.

Photo from https://health.alaska.gov/dph/Epi/id/SiteAssets/Pages/Alaskapox/Alaskapox-FAQ.pdf.

New Syphilis Testing Guidance

CDC released new recommendations for laboratory testing for syphilis, good timing given our terrible syphilis epidemic in the US. It is highly technical, so mostly of interest to laboratorians and syphilis geeks like me. Some of the illustrations and graphs are useful for everyone. Here is a nice quick view of lab test results in various syphilis stages:

And an explanation of the prozone effect, very important and something that I've found not all hospital clinical lab personnel understand. It appears mostly with RPR testing, where very high antibody levels cause a false negative result unless the assay is run at higher dilutions.

WRIS

Not a whole lot new with the Winter Respiratory Infection Season.

Investigators in France reported that rhinovirus infection in infants was a major contributor to bronchiolitis hospitalizations pre- and during the pandemic. Here's an example of ventilator use for RSV and rhinovirus during 2019 - 2020.

From a practical standpoint we have a tough time sorting this out with commercially-available testing. PCR testing for rhinovirus uses primers that include most enteroviruses, so you will always see these results combined as rhinovirus/enterovirus with no way to separate out which is which. The problem is compounded because most enteroviruses normally persist in the body and in nasal secretions weeks to months after the clinical illness resolves. So, a positive rhino/enterovirus test might reflect an infection that a) occurred months previously, and b) could have been asymptomatic (90+% of enteroviral infections are asymptomatic). Often we can guess rhinoviruses are active if we see a mid-winter bump in rhino/entero positivity, since the usual enterovirus epidemic peak is late summer/early fall.

Of note, the French investigators did not provide details of the PCR assay used in their study, so we are left trusting the journal editors that it did reliably distinguish rhinoviruses from enteroviruses.

RSV is pretty clearly on the way out, though still causing a lot of illness nationwide. The decline is present in all 7 monitoring sites.

Influenza also is declining, with a couple caveats.

First, we are starting to see a higher percentage of influenza B isolates now. This typically happens near the end of flu season, but it could also produce a secondary bump in infections. Second, local and regional flu levels are quite variable - what's true for Maryland is completely different in New Mexico. Also, I've never been a fan of presenting city-level (NYC, DC) data in the same context as state data - a classic apples and oranges comparison.

Covid wastewater data continue to be encouraging.

We also have a few new updates on the covid scene. The UK released their spring vaccine recommendations which are to offer vaccine (usually mRNA XBB.1.5 vaccine unless not suitable for an individual) to adults 75 years of age and older, residents in adult care homes for older people, and anyone 6 months of age or older fulfilling their definition of immunosuppression.

I was pleased to see an update on trying to get a handle on Postacute Sequelae of SARS-CoV-2 in Children (PASC), though as I read through it I still felt it was a difficult jumble of clinical syndromes that make it hard to develop practical management advice anytime soon. Here's an overview of their conceptual model:

I applaud the investigators for continuing to slog through this and I do expect to see concrete advice sometime in the future, not only for PASC but perhaps for all those other post-infections syndromes currently lumped into the myalgic encephalomyelitis/chronic fatigue syndrome wastebasket.

Birdhouse Update

I'm sure everyone has been waiting to hear the latest update in my birdhouse squirrel-proofing adventures. I'm happy to say the birds are back, but so far no squirrels are stealing the birdseed! I did notice one dastardly Scurius representative sitting on the large branch from which the birdhouse was suspended, but it never made an attempt to jump. We'll see how long this holds up.

White-breasted nuthatch enjoying the sun and safflower seeds, unmolested by squirrels.

Super Bowl VIII

Yes, I'm aware it's now LVIII, but much of my Super Bowl roots go back to the one 50 years ago where I happened to be employed selling beer in the stands. I didn't make much money; I was assigned to the Vikings side of the stadium, and they got blown out by the Dolphins and quit buying. I also didn't see much of the game itself due to walking up and down the stands, yelling "cold beer" and looking for raised hands.

I was required to show up several hours before kickoff time, and the stadium was virtually empty. One person on the field that morning happened to be one of my personal heroes, the country singer Charley Pride. (As an ironic note to me, he died of covid complications at age 86, in the first year of the pandemic and before vaccine availability.)

Pride was really the only Black person to have broken through as a country music star at the time, and he was practicing singing the national anthem which he would do at the start of the game. When he finished practicing I walked down to the field level and he was kind enough to chat with me a few minutes. He autographed my flimsy paper vender tag, now lost somewhere during my many moves.

As you can tell, I haven't lost that 50-year-old wonderful memory. Kiss an angel good mornin' if you have a chance. 😉

Published on Leave a comment on Measles in My Backyard

Well, not exactly, and directionally it's more like my front yard. On February 1 the Maryland Department of Health issued a press release of a measles case in a recent international traveler who resides in my Maryland county, listing an apartment complex with my same home zip code as a site of potential exposure. Details are lacking, and I do note the DOH still hasn't sent a notice to Maryland licensed physicians. Keeping my fingers crossed there are no secondary cases.

Last Summer's Vibrio vulnificus Flurry

CDC reported on last summer's burst of V. vulnificus infections across 3 states, a total of 11 severe cases occurring during heat waves in residents of Connecticut, New York, and North Carolina. Median age was 70, and 5 people died. Of the 10 with available information, all had at least 1 underlying risk factor for severe Vibrio infection, including diabetes (3), cancer (3), heart disease (3), history of alcoholism (3), and hematologic disease (2). While the clusters can't be blamed definitely on the heat, Vibrio growth is augmented in warm water; we may see an increase in Vibrio infections associated with climate change.

An impaired reticuloendothelial system (including liver disease from any cause) is a big risk factor; high risk individuals should be warned about avoiding contact with brackish water, salt water, and raw seafood (2 cases last summer had raw oysters as only known exposure).

Late Treatment for Congenital CMV

A new report from the Collaborative Antiviral Study Group reported on a phase 2 randomized, double-blind, placebo-controlled trial of 6 weeks of oral valganciclovir for infants 1 month to 3 years of age with congenital CMV infection and sensorineural hearing loss. Although the treatment group had much lower urine and salivary viral loads during treatment, there was no difference in hearing outcomes compared to the placebo group. Back to the drawing board.

Diphtheria in Africa

It looks like diphtheria is going to be a big problem for some time to come. WHO lists major diphtheria outbreaks in Nigeria (the most cases), Guinea, Niger, Mauritania, and South Africa. The cumulative total of suspected cases is 27,991 with 828 deaths. For those of you needing a little help with African geography, here's what it looks like:

So, this is not just clusters related geographically, but rather scattered throughout the continent. Cases were more prominent in the pediatric ages, and about a quarter of the cases were fully immunized. The numbers could be much higher given the difficulties in diagnosing diphtheria in resource-poor settings.

Bad E. coli in China

Although I'm never happy to hear about new virulent and resistant organisms, I was particularly unhappy about this news for a few reasons. First, it is a hypervirulent strain, apparently more likely to cause severe invasive infections. Second, it carries carbapenem resistance, often our last relatively safe resource in the antibiotic armamentarium for multiply resistant Gram negative bacteria. Worse is that 13% of these carbapenem-resistant organisms did not express a known carbapenem resistance gene, suggesting other perhaps new resistance mechanisms might be present. Lastly, these organisms caused a prolonged outbreak in a children's hospital.

You can see this outbreak occurred a few years ago, but I don't think we've heard the last of this.

WRIS

I'm looking forward to the week when I can retire a regular update on Winter Respiratory Infection Season. For now we have some encouragement but still too early to tell which way we're headed, especially with covid since our data sources are less reliable/predictive.

We seem to be over the hump with RSV season, still plenty out there but we tend not to see late rebounds with RSV.

Flu is a mixed bag depending on locale, but seems to be headed downward overall.

The covid wastewater report doesn't look too bad, either.

JN.1 is the predominant variant in most places now. I include a graph from the UK just because it's pretty.

We also have some other good news on the covid front: the fall vaccine seems to have high effectiveness (54%; 95% CI 46-60%) against development of symptomatic infection in immunocompetent adults. The study covered the time period September 2023 - January 2024 so is very recent and includes the time of JN.1 variant predominance.

Squirrel Wars 2.0

Speaking of my front yard, it is the new site of my war to keep squirrels away from my bird feeder, first mentioned in these pages on January 14. You recall that the capsaicin-laced safflower seeds, advertised as obnoxious to squirrels, turned out to be a delightful snack for those obnoxious rodents here. I tried to access research proven methods for preventing squirrels from eating all the bird food, but sadly there doesn't appear to be a trove of studies to guide me; in other words, no such thing as evidence-based squirrel medicine.

However, many sites mentioned trying to choose a site for a feeder that is beyond the reach of a typical squirrel's jumping prowess of 5 feet upward from the ground, 7 feet across, and 9 feet downward. After much thought, we selected a site in a large front yard tree. Armed with my long-suffering wife's long tree branch cutters and her assistance, 2 rickety ladders, slippery wire, packaging tape, and an autographed baseball from my youngest son's youth baseball team (circa 1990's, I was the official scorekeeper since I was too uncoordinated to be a coach), I succeeded in placing it in the perfect place with only minimal self-injury. Passersby seemed alternately amused and alarmed. If this works, I should get a MacArthur genius grant.

Published on Leave a comment on Seeing Spots Before Your Eyes?

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.

Measles

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.

Published on Leave a comment on Lots of Thanks This Year

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.

Published on Leave a comment on Death Valley Days

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!

Unless otherwise indicated, the content and opinions expressed on this web site are those of the author(s). They are not endorsed by and do not necessarily reflect the views of the George Washington University.
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