monkeypox

Big Week Ahead

Bud WiedermannJune 12, 2022Leave a comment

This past week was relatively quiet in infectious disease land, but next week could be a blockbuster.

COVID-19 Vaccines for Young Children

Unless you've been playing that head-in-the-sand game, you know that FDA and ACIP have meetings planned in the next few days to review data and make decisions and recommendations.

First up is the FDA VRBPAC meetings June 14 and 15. The first day will be devoted to discussion of the Moderna vaccine data for children 6 - 17 years of age. Both FDA and pharmaceutical company Moderna briefing documents were posted recently. I don't expect much controversy for authorization for this older age group based on FDA's briefing. Wednesday's session will cover both Pfizer and Moderna requests for EUA for vaccines for children under 5 and under 6, respectively. The briefing documents for Moderna cover this age group, but the Pfizer briefing documents aren't yet posted at the time I write this. Vaccine authorization for the younger children could be a little more controversial given the risk/benefit calculations and uncertainties about protection levels for omicron subvariants.

Then, the CDC/ACIP is scheduled to meet on June 17 and 18. The agenda isn't yet posted, but my educated guess is that they will discuss Moderna's vaccine on Friday and Pfizer's on Saturday, if either or both have been authorized by FDA. If the ACIP vote is favorable and Dr. Walensky approves, vaccines could be going into arms of children under 5 soon thereafter.

I'm certainly going to be tuned in to the live presentations as much as my schedule will permit. I'll try to summarize things in next week's post.

Local Monkeypox Follow-up

You recall I mentioned some questionable cases in Maryland in last week's post. I have some limited follow-up, all second- or third-hand so the true story might be slightly different. The first case was tested by Maryland DOH with negative results. I was surprised. I don't know what clinical follow-up has been done. For the second case that my colleague helped with over the phone, Maryland DOH decided not to test, said they would follow up with family in a few days, but so far have not contacted the family.

In the meantime, a third questionable case presented to our hospital and another of my colleagues saw the child and helped with collecting specimens. Although the clinical picture is not as strong for monkeypox, skin biopsies and several other samples were collected that will be very helpful for piecing this together. As the 3 of us shared ideas, the main alternative diagnoses for the first 2 cases would be a very unusual presentation of hand, foot, and mouth disease. The third child had enterovirus specimens collected so hoping that can help all of us in the DMV area manage these cases. Atypical hand/foot/mouth disease in the middle of a monkeypox watch? Stay tuned.

Don’t Bury Your Head in the Sand

Bud WiedermannJune 5, 2022Leave a comment

Yes, everyone is tired of worrying about COVID-19, and with rising cases across the US it's difficult to see evidence that the population in general is trying to be any more careful now that recommendations have replaced mandates. Pediatric healthcare providers still need to be vigilant.

Another Note on Monkeypox

No, it's not the next pandemic in terms of massive transmission like SARS-CoV-2, but it is a global problem. This past week I was involved with 2 events illustrating that front-line providers need to be prepared.

First I fielded emails and calls from a pediatric practice in Maryland. A toddler who had returned from a stay in West Africa had presented to the office with sores around the mouth. The clinical history including progression of lesions and associated symptoms, plus the rash appearance, was strongly suggestive of monkeypox in my assessment. How to go from there?

First step: ensure patient is medically stable, not needing emergent care, and child and parent are in an exam room with the door closed. Don't allow staff to enter without permission, and anyone who does need to enter must don gown, gloves, and mask, preferably N95 mask. Then, call for help/advice. I was able to help a bit by calling the Maryland DOH provider phone line, and after a few minute wait got a call back. The DOH took it from there and last I heard was going to arrange for sample collection at the family's home. The child and parent exited through the back door of the office, not through the waiting room. I don't know what happened subsequently, but I did provide the pediatrician with links to information about exposure management for the office staff, while they await word on whether preliminary evaluation determines that this is truly a monkeypox PUI (Person Under Investigation).

The second instance, 2 days later, was a text from one of my ID colleagues, again regarding a toddler in a pediatric office in Maryland. The photo looked very much like monkeypox to me, although the exact epidemiology and other details weren't available at that time. My colleague was planning to go through the same procedures as above.

I mention this not to alarm but to reinforce to providers to be prepared to act on this type of scenario. Have in mind how you would "phone a friend" for advice and be sure you know your local health department's provider access details. This will save you and your staff a lot of worry and ensure your patients and families get the care they need.

Omicron Subvariants Continue to Spread

I shouldn't be surprised by now, but it is quite remarkable how SARS-CoV-2 variants continue to evolve to evade prior immunity and spread so easily. Consider the most recent US data:

The BA.2.12.1 omicron subvariant quickly took over the landscape from its BA.2 parent.

In spite of all the US cases and rapid spread, we still aren't seeing a large uptick in hospitalizations:

The same seems to be true in South Africa, where BA.4 and BA.5 reign, and also in the UK. This at least is encouraging. Let's hope we continue to receive relatively good news about hospitalizations and deaths.

Oh, and I learned something new about the whole ostrich/head in sand thing. It turns out that is a complete myth, dating back to Pliny the Elder!

COVID Information Fatigue? Check Out These 2 New Outbreaks

Bud WiedermannMay 22, 2022Leave a comment

Good news this past week with FDA authorization of COVID-19 boosters for the 5-11 year olds, but don't take your eye off the more important issue of improving the primary vaccination series rate for this age group, currently sitting at a dismal 28%. An important take home from the ACIP meeting was continued evidence that the vaccine is safe in this age group with overall lower rates of myocarditis compared to adolescents and young adults. I'm still waiting optimistically for next month's meetings about vaccine in the youngest age groups.

In the meantime, my attention increasingly is focused on new outbreak developments.

In the late 1960s/early 1970s I had the amazing good fortune to spend a few summers working in a world-class virology research center, undoubtedly sowing the seeds for my future interests. I was basically a glorified research assistant helping a veterinarian studying herpesviruses, but I was also surrounded by other labs dealing with mysterious (to me, at the time) organisms. The monkeypox facility was nearby, a high level biosafety lab that required me to don full Andromeda Strain garb when I went in to borrow equipment.

Monkeypox, an orthopoxvirus and cousin to smallpox, usually occurs in residents in or travelers from the West African and Central African countries where it is endemic. Cases turn up in the US sporadically. However, now we are seeing small clusters of infected individuals turning up in many different countries - Spain, France, Belgium, Germany, Italy, Sweden, Portugal, UK, Canada, US, and Australia so far. We haven't seen anything like this before and it is likely we will see many more cases around the world. Current affected individuals have been predominantly young men with an overrepresentation of men who report sexual contact with other men. Early testing suggests these cases may involve the West African strain which has a lower mortality (about 1%) compared to the Central African clade (up to 10% mortality). An antiviral medication, tecovirimat, has FDA approval for treatment of smallpox and likely would be effective against monkeypox; the approval was based in part on animal studies of monkeypox. Vaccines against smallpox and monkeypox are likely to be effective in preventing disease, though I doubt we'll need that option in the US. Monkeypox is not highly contagious, it requires close contact. However, if you think you are dealing with a case, institute full infection control with gown, gloves and N95 mask protection while you are calling for assistance.

Monkeypox infection is fairly distinctive, usually with systemic symptoms of fever, chills, lymphadenopathy, and a vesicular or pustular rash. It may be confused with secondary syphilis, HSV, chancroid, or varicella zoster infection. The CDC website is useful. If you think you might be dealing with a child or adolescent with monkeypox, call me (or your nearest pediatric infectious diseases specialist).

More on Severe Hepatitis Cases

Investigations are ongoing attempting to uncover the etiology of clusters of severe hepatitis in young children in the US and worldwide. CDC provides weekly updates. Since I mentioned this last week, we don't have any breakthroughs yet. However, I've been working on a guide for clinicians to facilitate identification and evaluation of cases. I offer what I have so far to aid in evaluation at the front lines of care in office practices, urgent care, and emergency departments.

First, I made up a name for this: Pediatric Hepatitis of Unknown Etiology (PHUO). Certainly someone more clever than I will come up with a better acronym. Potential cases (termed Person Under Investigation, or PUI) currently are defined as children under 10 years of age with AST or ALT >500 U/L. If you are dealing with that, it's time to consult with a subspecialist, but the issue is how to get there in an efficient manner without testing every child who vomits once or twice. To do that, it's helpful to know what cases so far have looked like.

In a cluster of 9 cases of PHUO in Alabama, common symptoms were emesis (78%), diarrhea (67%), fever (56%), and fatigue (44%), with small numbers of upper respiratory symptoms, poor appetite, and dark urine. On exam, icterus/jaundice was present in most (89%) and hepatomegaly in 78%, with splenomegaly and hepatic encephalopathy also noted at presentation in small numbers. A detailed report from the United Kingdom noted similar numbers and mentioned pale stools in 50% of 450 cases under investigation. Two-thirds or more of the children in Alabama and the UK were under 5 years of age.

As you may deduce from the percentages, children seldom exhibited just one sign or symptom; multiple were present. A frontline provider evaluating a child with a compatible clinical picture as above should obtain further history for travel, environmental exposures (e.g. pesticides), family history of liver disease, and other details. Assuming the child shows no signs of liver failure such as mental status changes or bruising mandating immediate attention, it would be prudent to consider obtaining initial laboratory studies to include CBC with differential and comprehensive metabolic panel.

Consultation with a pediatric subspecialist may be helpful at any time, but if the initial evaluation meets PUI criteria then referral to a tertiary pediatric center should be made.

It's a hot afternoon ahead in beautiful downtown Silver Spring. Maybe I'll look for a good sci-fi movie on the tube. (That last word really dates me!)

Tag: monkeypox