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Published on Leave a comment on The Year in Review

It's fashionable for this time of year to give some reflections on the events of the last 12 months; seemingly every pundit/publication does it in some form or another. I won't buck the trend. What follows is a bit of a "highlight reel," plus the 3 things I'm watching closely for next year.

The Unexplained Explained

Recently we all had the opportunity to watch as a mystery outbreak unfolded in the Democratic Republic of Congo. Was it a novel pathogen set to launch a new pandemic or simply a localized outbreak of a known pathogen, complicated by poor health resources delaying accurate diagnosis and treatment? It took a little longer than I predicted to unravel everything, but we now have an answer from WHO as of December 27. That's still pretty quick, the original alert from the Panzi health zone in the Kwango province was November 29. I'm reassured that our global public health system is working well for outbreak detection.

The case definition used for investigation was fairly broad: "any person living in the Panzi health zone from September 2024 to date, presenting with fever, cough, body weakness, runny nose, with or without one of the following symptoms and signs: chills, headache, difficulty breathing, malnutrition, body aches." Here's an excerpt from the report:

"As of 16 December, laboratory results from a total of 430 samples indicated positive results for malaria, common respiratory viruses (Influenza A (H1N1, pdm09), rhinoviruses, SARS-COV-2, Human coronaviruses, parainfluenza viruses, and Human Adenovirus). While further laboratory tests are ongoing, together these findings suggest that a combination of common and seasonal viral respiratory infections and falciparum malaria, compounded by acute malnutrition led to an increase in severe infections and deaths, disproportionally affecting children under five years of age."

In other words, it was a combination of known pathogens already present in the area, layered on a background of falciparum malaria and malnutrition: a perfect storm. Let's hope the added health resources will dampen the outbreak in this very rural, isolated region of the DRC. Nutritional support is particularly needed.

WHO 2024

The WHO published its look back at 2024, including "highlights, breakthroughs and challenges." Many countries achieved milestones in either elimination or significant decreases of a number of diseases, including human African trypanosomiasis, leprosy, lymphatic filariasis, trachoma, malaria, measles, and mother-to-child transmission of HIV, syphilis, and hepatitis B. Their Expanded Programme on Immunization celebrated its 50th anniversary this year, with an estimated 154 million deaths prevented, most of them infants.

WRIS

CDC took a bit of a holiday break this week, so the level of detail in reports is less. However, Winter Respiratory Infection Season is officially High nationally.

The big 3 (covid, influenza, and RSV) all are increasing at this point. I'm hoping they don't peak at the same time and cause big logjams in healthcare settings.

What I'm Watching For

Mpox

In spite of the few cases in North America, Asia, and Europe, mpox is still primarily an African problem. As we know, however, no communicable disease in one area is just a problem limited to that area - international spread is always a few contacts away. In that regard, I found a recent review/opinion article enlightening.

Of interest, smallpox (vaccinia virus) vaccine protects against mpox infection. Our success in eliminating smallpox and subsequent cessation of smallpox vaccination led to a new population susceptible to mpox infection. A major hurdle to control the outbreaks will be vaccinia virus vaccine testing and distribution to high risk populations.

Avian Influenza

The influenza A H5N1 viruses now circulating in birds (both domestic poultry and wild birds) and dairy cows is the most likely source of a new pandemic, but fortunately the risk is still very remote especially if the public health system can keep on top of tracking infections and characterizing variants.

In the past week we learned that feeding your cat raw pet food derived from poultry is not a good idea, it resulted in 1 cat death in Oregon. I think most of us could have predicted that. One thing for cat owners to keep in mind is that the current avian flu, while still causing some respiratory symptoms in felines, is noteworthy for neurologic symptoms.

Also this week we learned about the mutation found in the hemagluttinin gene segment in the Louisiana human patient with severe avian flu illness. This is the H1 part of the virus which is important for attachment to respiratory epithelial cells. Mutations in this area can increase the effectiveness of spread in humans. However, it is completely expected that a human infected with the virus and experiencing severe disease would develop these types of viral mutations. What would be more concerning is if an isolate from a bird or cow developed such mutations, because of the potential for wider spread.

The risk for widespread human A H5N1 infections is still extremely low. I'll be watching in 2025 for any evidence of human-to-human transmission as well as any significant changes in the virus circulating in the wild animal kingdom. Again, I'm reassured that surveillance is allowing for rapid sequencing of human isolates. I hope that resources continue to be available to track this virus in animal and human populations.

SARS-CoV-2

Covid remains a wild card. It has perhaps the highest mutation rate of any virus causing human disease, it has yet to develop a true seasonality like other coronaviruses making it difficult to plan vaccination recommendations, and infections are still relatively frequent plus underreported due to lack of resources for testing, public apathy, and misinformation/disinformation fueling political decision-making. In short, we're in big trouble if another new variant appears with significantly greater pathogenicity and infectivity.

WHO published another year in review on covid that included a big overview of what's happened since 2020. They do note that our tracking systems worldwide are diminished compared to earlier in the pandemic, so recent data are likely to be significant underestimates. In the post-pandemic phase, we all need to transition from the type of extensive pandemic case tracking into a more sustainable surveillance system similar to what we do for influenza.

I was surprised to see some areas blank for what's going on the US, perhaps due to delayed reporting, and I was also a bit overwhelmed trying to decide what graphs to display here; if you're interested I'd suggest perusing the document itself. First, I've copied a quick highlight summary:

  • While there are periodic waves of COVID-19 in some countries, SARS-CoV-2, the virus that causes COVID-19,
    largely circulates without clear seasonality and continues to infect, cause severe acute disease and post
    COVID-19 condition.
  • The impact of COVID-19 has varied by country depending on the circulating variants, national policies,
    capacities to respond and access to countermeasures.
  • WHO’s ability to monitor circulation, severity, virus evolution and impact is challenged by reduced
    surveillance, testing, sequencing, limited integration into longer term infectious disease prevention and
    control programs, and reporting, as Member States adapt from crisis management to longer term prevention
    and control of COVID-19.
  • Changes to COVID-19 surveillance over the past five years have been consistent and expected, adapting to
    the changing landscape of the pandemic. Many Member States are transitioning from comprehensive case
    reporting to integrating SARS-CoV-2 monitoring into existing respiratory disease and infectious diseases
    surveillance systems. This is an important step towards sustainable infectious disease surveillance,
    monitoring and risk assessment. At the present time, the integration of SARS-CoV-2 into existing influenza
    surveillance systems is variable across regionsranging from 41% in countries from the Western Pacific Region
    to 96% in countries in the European Region.

Here's a great overview of the past few years on a global level.

Even with more inaccuracies in tracking recently, it's nice to see how far we've come in lowering cases and deaths.

Here's a look at deaths by age group, but what isn't apparent in the graph is that mortality rates in infants are comparable to mortality in 20-45-year-olds. Another advertisement for vaccination of pregnant people, who themselves are in high risk group.

And here's the crazy lack of seasonality expressed as percentage of positive tests. I might be tempted to see a trend towards winter seasonality, but remember these data include the southern hemisphere and thus we should see a biphasic pattern if/when seasonality develops.

And lastly a look at how far our variants have drifted over time.

Auld Lang Syne

My apologies to Scotsman Robert Burns, but I must turn to Londoner (with Scottish heritage) Sir Rod Stewart for my favorite version of the song at Stirling Castle in Scotland, complete with bagpipes.

Wishing everyone a Safe and Happy New Year. See you next year.

Published on Leave a comment on All Politics is Local

U.S. Representative Tip O'Neill popularized this phrase in the early 1980s, but perhaps it lost its meaning in later years. Has that changed? Infectious diseases, on the other hand, are most certainly not local.

Infectious Diseases Abroad

Any ripple in communicable infectious diseases in one locale inevitably affects others in far-away locations. Last week saw a number of ripples.

(Not) Measles in American Samoa

Yes, I'm aware that American is a US territory, but it certainly qualifies as far-away.

In 2023, health authorities in American Samoa went on a wild goose chase based on non-recommended testing practices of a suspected case, resulting in a large expenditure of time and money with no benefit. I'm not faulting Samoan practitioners, they had to deal with a lack of available testing resources in the setting of an island rocked by a deadly measles outbreak a few years ago; that outbreak had been fueled in part by prominent anti-vaccination proponents. This recent episode should serve to remind us of proper use of measles diagnostic testing which relies most prominently on use only for individuals who fulfill proper case definitions.

The above report was in last week's MMWR which also contained a WHO measles update. Here's a comparison of 2000 and 2023 measles cases and deaths (note North America is not included in these numbers.)

Severe Avian Influenza in Canada?

Last week Canadian officials confirmed that a critically ill teenager is infected with influenza A H5N1. The source is still unknown, and no close contacts are known to be infected. It's been very tough to get details about the patient's illness, but after going through a transcript of a British Columbia health official's briefing on November 12, it seems that the previously healthy child presented with typical H5N1 symptoms of conjunctivitis, cough, and fever, but then several days later had deterioration. That sequence of events, a sort of biphasic illness, is classic for secondary bacterial complications of influenza. Influenza virus infection of any type can be complicated by secondary bacterial processes, including sepsis and toxic shock syndrome, usually several days after initial flu symptoms begin. Canadian authorities haven't provided any more details, but I wouldn't be surprised if this is what's going on. I'm hoping it was recognized quickly and his healthcare team can return this person to normal health.

Along these lines, NASEM just issued a new publication detailing research priorities for avian influenza A H5N1 readiness. Some of this is already happening, and I hope funding priorities will continue to support planning.

Mpox Update

Last week WHO updated the status of the mpox outbreaks across Africa, a mixture of good news and bad news. Priorities are delivering vaccine to those at risk and implementing newer PCR testing for mpox just approved by the AfricaCDC. Also this past week we learned of the first mpox clade 1 case in the US, occurring in a traveler returning from Africa.

Number Needed to Vaccinate for Covid in the UK

I've mentioned in previous posts that the UK recommends many fewer groups for covid vaccination than we do in the US, primarily because of cost considerations. Last week the UK's Joint Commission on Vaccination and Immunization gave us a bit of a closer look at how those decisions are made with some NNV calculations. NNV (along with its cousin Number Needed to Treat for medication) are a good way to explain "bang for the buck." NNV simply refers to the number of individuals needed to vaccinate to prevent one additional case of the infection, compared to no vaccination. It depends on many variables including the rate of the disease and the number of susceptible individuals in the community and the vaccine effectiveness. Also, NNVs vary with the outcome of interest, such as infection versus hospitalization versus death. It's increasingly harder to calculate NNVs for covid vaccine because of asymptomatic infections and less widespread testing being performed.

The JCVI didn't give us NNVs for all age groups, but they did provide a close look at pregnant people and infants under 3 months of age, the latter group of course not eligible for vaccination and dependent on maternal immunity passed to them transplacentally. I had to dig into attachments to the reports, but here's the bottom line: NNV to prevent hospitalization of a pregnant person is "just under 2000" and "around 300,000" to prevent severe hospitalization. I couldn't find a definition of severe hospitalization but from the context it appears to be something more than overnight observation but less than ICU admission.

For infants < 3 months of age, NNVs (for maternal vaccination) were "under 500" for any hospitalization, "just over 13,000" for severe hospitalization, "almost 190,000" for ICU admission, and ranged from 380,000 to 1.5 million for mortality, the latter extremely hard to calculate due to rarity of the outcome. (But we're all thankful that it is rare.)

Just for comparison, NNV for flu vaccine to prevent 1 additional outpatient visit or 1additional hospitalization in children 6 - 59 months of age ranged from 12 - 42 and about 1000 - 7000, respectively, in one study.

Novavax Combination Covid-Flu Vaccine Study Allowed to Resume

I mention this item mostly to show how well our vaccine safety oversight is working. This study was paused when 1 phase 2 study participant developed what was initially diagnosed as motor neuropathy (with concern for Guillain-Barre syndrome) but then turned out to be amyotrophic lateral sclerosis, not an inflammatory disorder plausibly related to vaccination. This is one of many mechanisms for detecting evaluating rare events after vaccination. Novavax now can proceed with phase 3 studies.

E. coli O157:H7 Outbreak Numbers Grow ...

... but not related to ongoing infection, simply reflecting a delay in case reporting/verification. CDC and FDA report we are now up to 104 cases spread over 14 states. Of the 98 persons with more detailed information available, 34 were hospitalized and 4 developed hemolytic-uremic syndrome. "Of the 81 people interviewed, 80 (99%) report eating at McDonald's. Seventy-five people were able to remember specific menu items they ate at McDonald's. 63 of 75 people (84%) reported a menu item containing fresh slivered onions."

The case map strongly resembles the distribution map for the suspected onions which are now out of the food chain.

In the meantime, we have another E. coli O157:H7 outbreak, this time associated with carrots. [Correction added 11/18/24: this outbreak is due to E. coli O121, not O157:H7 as originally stated.]

I have a feeling I'm going to be washing my salad items more carefully for a while!

WRIS

The winter season still hasn't started, so I'm reduced to browsing the wastewater maps, all updated through November 14 and current through November 9. Here is maybe a look at things to come. First, here's covid:

Now flu (wastewater only tracks influenza A):

Last but not least, RSV:

I'm a Throwback

When I started practicing medicine, implicit in my professional obligations was the duty to do my best to treat anyone who presented to me, without regard to their backgrounds including race, gender, sex, legal status, and, I guess must be said in today's world, political affiliation. Having practiced in Washington, DC for over 40 years, that last category came up frequently as I encountered parents who were elected officials and/or involved in jobs in the political realm. In keeping with that sentiment, I'll still be keeping politics out of this blog and restrict my pontification to infectious diseases. I'll also avoid commenting on various conspiracy theories and other wild ideas emanating from individuals with no scientific basis for their claims. I will, however, comment on any proposed policies related to pediatric infectious diseases where scientific analysis can enlighten the discussion. Nuff said for now.

Published on Leave a comment on Autumn Has Broken ….

Leaves are everywhere, including still attached to trees and waiting to further increase my workload. I'm starting to plan my leaf management strategy; when to clear the gutters, waiting for the county to post its leaf collection dates, reflecting on my love/hate relationship with my garden rakes.

... But Still Waiting on WRIS

Covid is as quiescent as it ever gets, flu and RSV still low but hints of increase. I'll enjoy it while I can. As always, CDC has resources to look specifically at activity in your region.

Potpourri

In spite of the relative calm in infectious diseases, I found plenty of tidbits last week. I'll start with some good news.

WHO Declares Egypt Malaria-Free

The news release commented that this is the culmination of 100 years worth of effort. Forty-four countries and one territory have achieved this certification worldwide, which requires demonstration that malaria transmission from local Anopheles mosquitoes has been stopped for 3 consecutive years. In the WHO Eastern Mediterranean region, only 2 other countries, UAE and Morocco, have achieved this landmark. Given that some of our earliest evidence of malaria in humans comes from studies of ancient Egyptian mummies, it's pretty amazing to see a 6-thousand-plus year trend ended.

Mpox Age Distribution

A recent study from Burundi highlights a trend in recent mpox cases in the region, now seeming to cluster in children disproportionately. Here's the breakdown:

The authors state they could not identify reasons for this unusual age distribution, and I expect we'll hear more about that. They also noted that cases were more severe in individuals 15 years of age and older.

Community Acquired Pneumonia Due to Avian Chlamydia abortus in the Netherlands

One more cause of zoonotic pneumonia to add to our lists, based on this new report. Dutch investigators provide a convincing story for an infection cluster in 1 family, including 1 person with severe pneumonia, occurring in late 2022. This novel avian strain was first reported in 2021, and I suspect we'll be seeing more reports of this organism now with perhaps evidence that human infections have been occurring for some time. I'm especially anxious to hear more about the spectrum of clinical disease, hoping that this is mostly a mild pneumonia.

Iquitos Virus

Just as I was starting to get a feel for Oropouche virus (OROV) disease, now I need to learn about a close cousin (IQTV) that was found to cause infection in a traveler returning from Ecuador. Under the category of more than I needed to know, these viruses are part of the Simbu group of about 20 bunyaviruses including the amazingly named Madre de Dios virus. The traveler in the case report returned after a 10-day trip to Ecuador where he experienced many insect bites and presented with fever, chills, sweats, headache, pain with eye movement, and rash. He was thought to have OROV infection, but he fortuitously presented for care in Atlanta where his samples landed at the CDC and further testing revealed the true culprit to be IQTV. The traveler did not require hospitalization and recovered uneventfully.

Hold the Onions

The only way to have avoided hearing about this month's E. coli O157:H7 outbreak linked to Big Macs is to be completely cut off from all news and social media sources. It is centered in Colorado but also present in several neighboring and nearby states. As of the latest update on October 25, the case total is 75 with 22 hospitalizations and 1 death spread over 13 states.

CDC hasn't yet provided any detail about range of symptoms in this outbreak, but presumably the more severe cases represent instances of hemolytic-uremic syndrome. Although O157:H7 and HUS is classically associated with contaminated ground meat, that source didn't seem to make sense in this outbreak. All of these fast food chains have automated cooking methods that would reliably kill bacterial pathogens; it is conceivable the equipment could break down in one restaurant, but not particularly plausible for so many sites occurring at once. The hunt changed to uncooked foods with raw onions now the presumptive culprit.

These circumstances reminded me of a child with no travel history that I diagnosed with typhoid fever decades ago. It was eventually traced to the shrimp salad at a local McDonald's restaurant, prepared by a modern-day Typhoid Mary.

ACIP Meeting

I'd be totally remiss if I didn't mention the regular meeting of CDC's Advisory Council on Immunization Practices last week. However, most of the newsworthy items concerned adult vaccinations (e.g. lowering the recommended age for pneumococcal vaccines). They did approve the 2025 child and adult immunization schedules The final version is not yet available, but you can look at the drafts. Note that a second dose of covid vaccine will be recommended for immunocompromised and high risk children adults 6 months after the fall vaccination. Also see ongoing tweaks to the meningococcal vaccine recommendations appearing on slide 27.

While we wait for official pronouncements, you can find a summary of all the meeting recommendations here.

Published on Leave a comment on Melanerpes carolinus

I just returned from a mad dash to Orlando, FL. No, I wasn't paying Mickey and Minnie a visit, just putting in an almost cameo appearance at the American Academy of Pediatrics National Conference and Exhibition. Apparently they were desperate for speakers because they invited me to give a talk about how to approach reading journal articles. A few dozen attendees politely endured my presentation, but I, and I think even most of the attendees, had a fun time. I also got to chat with a few old friends, always nice.

Although the trip was nice, I was most excited about the notice I received from my bird feeder while I was away. More on that later.

Potpourri

I came across a smattering of unrelated items this past week, grouped here.

I think we could all use some good news from the Middle East now. The WHO announced that Jordan has become the first country in the world to be certified to have eliminated autochthonous (locally-acquired) leprosy. That is no mean feat and required tremendous efforts and resources both from the country of Jordan as well as the WHO. It has been over 20 years since they've had an autochthonous case in Jordan.

The CDC has sent out a notice about mpox prevention through their Health Alert Network. It's not new, but worth reviewing to understand risk groups and to remind us to ask about international travel plans of our patients.

I've deliberately avoided commenting on the possible person-to-person spread of influenza A H5N1 in Missouri, but it's been in the lay press. Close contacts of 1 confirmed case had illnesses that could be consistent with this form of bird flu, but we don't have any test results from the contacts. I just mention it to stress that this is an evolving story. It would be a change for this organism if human-to-human transmission is now common.

Vaccine News

A couple intriguing reports last week from the CDC via the weekly MMWR. First are survey results that give us a glimpse at what happened with childhood immunization rates during the pandemic. It should surprise no one that vaccination coverage at 24 months of age declined by a few percentage points from birth year 2018-19 to birth year 2020-2021. For the combined 7-dose series (doesn't include covid vaccination) the rate dropped from 70.1% to 66.9%. This just adds to the possibility for sustained epidemics especially if clusters of poorly immunized children are grouped together. Here's a list of the national data for the 2020-2021 birth year cohort:

The entire table was too large to put in everything here, but Montana had the lowest numbers followed by California at second worst. You can look up your state and region in the article.

The same MMWR also had some new data on covid in children under 6 months of age. It provides compelling rationale for maternal immunization. First, here's what age-associated covid hospitalization rates look like from the surveillance network:

Further data showed that infant hospitalization rates are higher than rates in the elderly (75 years and above). In a subset of 1148 infant records that underwent extensive review, 9 deaths were recorded. Overall 22% of the hospitalizations involved intensive care admissions. Looking just at the 1065 infants for whom maternal vaccination status was available, it appears that maternal vaccination during pregnancy could be an important preventive measure for severe infant covid illness.

Note the careful wording: "No record of maternal vaccination during pregnancy." This points to the fact that these records might have been incomplete or even wrong - the providers may have recorded information incorrectly, or the mother may have been mistaken about vaccination status and timing. I'm still impressed with the information, especially since these numbers are very recent, from the omicron period when virtually every adult had some sort of immunity either via natural infection, vaccination, or both. Maternal covid vaccination is important to protect both the pregnant person, itself a high risk group, as well as the infant who is too young to receive covid vaccine.

A New Antiviral for RSV?

A placebo-controlled, randomized, double-blind trial of a few hundred infants hospitalized for RSV in China suggests that a newer antiviral agent, ziresovir, might be an effective treatment.

The main endpoint is change in the "Wang score" which is a relatively unvalidated scoring scale for assessing RSV severity. You can see the decline in the score is a bit better with the treatment group compared to placebo, but is the change in score clinically important? As a still wet-behind-the-ears ID attending, I witnessed early studies of randomized, double-blind, placebo-controlled trials of aerosolized ribavirin for hospitalized infants with bronchiolitis; my boss, a renowned pediatric infectious diseases physician named Bill Rodriguez, headed up these multi-center studies. I witnessed potential pitfalls in using scoring systems for bronchiolitis, particularly the problem with intra- and inter-rater reliability in assessments: it's hard to be consistent with scoring when the events you're looking at are somewhat subjective. Also, the aerosolized ribavirin left a fine powder on the infants, difficult to disguise even when the nurse tried to remove it before the investigator did the scoring. So, it wasn't perfectly double-blinded, in some cases not blinded at all. At blinding wasn't a problem with ziresovir, which is administered orally. Aerosolized ribavirin did work, but ultimately the costs outweighed the benefits (plus some risk to providers of inhaling the medication if the patient room was not well-ventilated and potential for teratogenicity), so the practice didn't last long.

I'll wait to see more data about this intriguing new agent. In the meantime, remember we have very effective methods of preventing severe RSV disease in infants by either maternal vaccination or administration of long-acting monoclonal antibody (nirsevimab) to infants whose mothers were not immunized.

Crystal Ball Time

What's coming this winter, and how bad will it be? Don't place any big bets on the CDC's latest predictions, they have only low to moderate confidence with their model, but it's by far the best data we have.

Here goes: "CDC expects the upcoming fall and winter respiratory disease season will likely have a similar or lower number of combined peak hospitalizations due to COVID-19, influenza, and RSV compared to last season."

That's good news. The experts were moderately confident of predictions for individual infections, but it's not really possible to anticipate all of the variables that could change the predictions dramatically, such as immunization uptake. Of course, if a new covid variant arises with a very effective immune escape mechanism, no one will be betting and we'll be in for a bad time.

Here's some more tidbits:

For example, if our summer covid activity peaks early (which it seems to be doing), they predict a milder winter season than if covid continues to rise now.

If you're a nerd like me, you can look at their description of how they developed this prediction model.

For the Birds

Getting back to my bird feeder, regular readers will recall my travails discussed in prior posts, including battling squirrel seed raiders. Things have settled down now, and I seldom see new species, but the past 2 days I've had my first sightings of a red-bellied woodpecker. The first thing I noted from my feeder's video (still photo taken below) is that I don't see a prominent red belly.

Other views show the typical zebra-like striping on the wings - why not call it the zebra woodpecker? - and the Cornell app quickly identified its call as the red-bellied variety. As usual, I couldn't help but see what new woodpecker tidbits I could learn from the worlds of literature and music. My childhood and adolescent "career" playing tenor saxophone made me a fan of big band music, particularly of Glenn Miller, and I discovered he had recorded The Woodpecker Song. It's not that great in my opinion, but at least I learned something new. One of my other musical heroes, Chuck Berry, recorded a purely instrumental (with saxophone solo!) song called Woodpecker. My favorite find, though, was a new-to-me poet, Elizabeth Madox Roberts. She was a Kentucky-born daughter of a Confederate soldier, active as a poet and novelist in the late nineteenth and early twentieth centuries. She seems to have the largest numbers of poetry web sites extolling her virtues for poems about woodpeckers. Here's her poem The Woodpecker in its entirety:

The woodpecker pecked out a little round hole
And made him a house in the telephone pole.

One day when I watched he poked out his head,
And he had on a hood and a collar of red.

When the streams of rain pour out of the sky,
And the sparkles of lightning go flashing by,

And the big, big wheels of thunder roll,
He can snuggle back in the telephone pole.

Published on Leave a comment on Seeing You in September

This month always bring me back to The Happenings version of "See You in September;" I remember it fondly from my junior high school era. The Harvest Month often is a transition period from summer to fall/winter infections.

The Respiratory Infection Front

Right on schedule, the ACIP published its official flu vaccine recommendations. Nothing new in there, but it's a good one-stop shopping place for seasonal flu information. Things remain calm on the overall respiratory illness view, and covid may have reached its peak.

However, I'm still waiting for covid wastewater trends to start heading down in most areas of the country (same link as above). We may not be out of the woods yet.

Also note that the covid vaccine from Novavax was authorized by FDA this week. I'll be interested to see how effectiveness compares to that of the mRNA vaccines; Novavax targets a slightly earlier variant (JN.1) than the Pfizer and Moderna products which used KP.2. KP.2 is decreasing in prevalence in the US but still is more closely related to the current variants KP.3.1.1, KP.2.3, KP.3, and LB.1.

We have more longterm follow-up information about myocarditis and covid, looking at both vaccine- and natural infection-associated complications compared to other ("conventional") etiologies. It looked specifically at individuals 12-49 years of age hospitalized with myocarditis. Without going into great detail, it was clear that vaccine-associated complications were less common than with myocarditis associated with conventional or SARS-CoV-2 infection; however, confidence intervals were wide for several of the outcomes due to low numbers of events.

I was excited to see a new update from the HIVE (Household Influenza Vaccine Evaluation) program that has been monitoring households in Michigan since 2010 and was expanded to cover other respiratory infections in later years. The new update covers the years 2015-2022. (The watermark in the figures below signifies this is an accepted manuscript that hasn't yet appeared in the print journal.) Even though it's limited to southeast Michigan, it is valuable data because it is an ongoing active surveillance program in these volunteer households and gives us a glimpse of how the pandemic affected other virus epidemiology.

Far Away Challenges

Mpox continues to rage in the DRC and other areas of Africa, with exported cases appearing in far-flung countries. In addition to vaccine, these countries need better front line diagnostic tests. WHO has requested test manufacturers to apply for emergency approval.

On the polio front in Gaza, we've all heard the good news that there will be a pause in fighting to allow for vaccine administration, but it remains to be seen if this will really happen. Regardless, this will be an extremely difficult undertaking, targeting over 600,000 unprotected children in the region.

Bugs Transmitting Bugs

Healthcare providers and the general public are understandably reeling from all the information about various outbreaks of vector-borne infections. It's important to keep in mind 2 main points: 1) Nothing is happening this year that hasn't happened before in the US. This is the season for vector-borne viral infections. 2) Global warming has increased both the range of these vectors, introducing these infections to areas that haven't seen them in past years, and also increased the season length that these infections circulate. We could see increases in all these infections in coming years.

Here's a breakdown of some of the viruses being hyped in the news.

West Nile Virus

Approximately 70-80% of infections are asymptomatic. The most feared complication, neuroinvasive disease, occurs in <1% of all infections but has a 10% mortality and higher rates of permanent neurologic sequelae such as paralysis. So far in 2024, we have had 289 cases from 33 states in the US, with 195 being neuroinvasive (reflecting the fact that only the worst cases get tested for WNV, not any change in asymptomatic rates). Here are some maps for prior years in the US:

As of now, nothing out of the ordinary for West Nile disease in the US. But, it's pretty common if you recognize that we're only identifying maybe 1% of infections.

Dengue

Here the risk is very high in Puerto Rico, but otherwise mostly restricted to travelers from the current epidemic/endemic areas. Some border states, especially Florida, are more likely to see autochthonous (locally acquired) cases. The asymptomatic infection rate is about 75%; 5% of the symptomatic infections progress to severe dengue with capillary leak syndrome and/or hemorrhagic complications. IMPORTANT CLINICAL PEARL: severe dengue usually appears when things otherwise look good - start of afebrile phase after 2-7 days of the febrile phase. This is the time to be very vigilant if dengue is suspected. The slide below (#42 in the pdf) is taken from a wonderful IDSA/CDC Clinician Call webinar this past week, available at https://www.idsociety.org/globalassets/idsa/multimedia/clinician-call-slides--qa/8-28-2024-clinician-call.pdf and https://www.idsociety.org/multimedia/clinician-calls/cdcidsa-clinician-call-update-on-dengue--other-vector-borne-diseases/.

Here are some numbers from the main CDC website above.

For 2024, the only locally acquired cases in the US have been in Puerto Rico (2676 cases), US Virgin Islands (85), and Florida (21), though those numbers are certain to rise since the season isn't over and reporting in general is delayed. If you add in the travel-associated cases, we've seen a little over 4000 in the US.

Oropouche Virus

This is a relatively mild illness for the most part. The asymptomatic infection rate is around 40%, but 4% of those with symptoms will develop neuroinvasive disease. Now there is concern for vertical transmission in pregnant people, still not completely clear. Management guidelines for infants with possible intrauterine infection are updated and available.

Although I was aware of Oropouche virus previously, this is the first year I've ever heard of the term "sloth fever" which only applies if you acquire the infection in the jungle. This is a slide from that same IDSA/CDC webinar, slide 69 in the pdf.

Oropouche may be over with in South America now, and the main risk area remaining is Cuba. CDC reported 21 US cases in travelers returning from Cuba.

Eastern Equine Encephalitis

Saving the worst for last. It's very uncommon, but you definitely don't want EEE. The encephalitis picture occurs in <5% of those infected with EEE virus, but of those with encephalitis the mortality rate is 30%, and 50% of survivors have permanent sequelae.

We've had 4 cases in 2024 so far. Here's data from prior years:

This is a horrible disease. Certainly precautions such as mosquito spraying and personal protection from bites should be implemented in areas where the virus has been identified.

Earworms

Not wanting to end on a depressing note from the rare but severe EEE disease, I thought of earworms. I'm not referring to the real earworm infecting corn ears, nor RFK Jr.'s brain worm, but rather the more contemporary use of the term. Last week I went down the rabbit hole for the Maurice Williams song "Stay," and this entire past week I've been unable to get it out of my head. Maybe I'll replace it with "See You in September."

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