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Tag: myocarditis

Published on Leave a comment on Is It or Isn’t It?

The Democratic Republic of Congo has been back in the news, this time not for mpox but for a mystery illness in an isolated, rural region of the country. Varying numbers of fatalities have been noted, but solid facts are sorely lacking. I am reminded of how early outbreak news percolates and changes; odds are low but not zero that this is a serious, new pathogen. Meanwhile, we can discuss several new publications that are on more solid scientific footing.

Vaccine Effectiveness Updates

Two manuscripts accepted for publication provided new information on VE measurements, one concerning influenza and the other looking at covid vaccines in young children.

CDC, along with other investigators, published an analysis of influenza VE for the 2023-24 flu season. For that year, the vaccine strains were well-matched for what eventually circulated in the US. The most common strain circulating was A H5N1pdm2009. Looking just at the pediatric population, VE in preventing hospitalizations and urgent care/ED visits was very good in all age groups as shown below: 58% for both outcomes overall, though with a wider confidence interval for hospitalizations since these were less common events.

The covid vaccine article is quite complex, involving investigators at multiple sites and listing 35 identified authors! Sadly it doesn't have any nice tables/figures that allow a short summary. I see 2 categories of take-home messages from the data: 1) as always, VE depends on which outcome you're looking at; 2) covid vaccines aren't that effective at preventing infection, but do help significantly in preventing complications of infection.

This multi-center study is actually a grouping of 3 cohorts (total 614 subjects) of children who had longitudinally-collected data including weekly sampling during the period of omicron variant circulation, 9/19/22 - 4/30/23. Variants were verified by genetic sequencing of about half the strains. Antibody studies and history questionnaires at study entry were utilized to determine evidence of prior infection. Here are the numbers from the study:

  1. Children with prior infection had less chance of both infection and symptomatic infection than did those without prior infection: Hazard Ratio [HR]: 0.28 [95%CI: 0.16-0.49] and HR: 0.21 [95%CI: 0.08-0.54. This was true regardless of timing of prior infection.
  2. Children with prior infection AND vaccination also had lower hazard ratios: HR: 0.31 [95%CI: 0.13-0.77], compared to those who were unvaccinated with no prior infection.
  3. The one slightly unique finding in this study is as follows: "There was no difference in risk of infection or symptomatic COVID-19 by vaccination status alone, regardless of timing of vaccination or manufacturer type. However, naïve participants vaccinated with Pfizer-BioNTech were more likely to be infected and experience symptomatic COVID-19 compared to naïve and unvaccinated participants (HR: 2.59 [95%CI: 1.27-5.28]), whereas participants with evidence of prior infection and who were vaccinated with Pfizer-BioNTech were less likely to be infected (HR: 0.22 [95%CI: 0.05-0.95])." In other words, vaccination didn't do very well at preventing infection.

This study is very complex but also very rigorous; I can't do it justice in a small summary. The major limitation is the relatively low sample size, meaning that the investigators couldn't do much in the way of subgroup analysis to try to look at other variables. Relatively few children received the bivalent Pfizer vaccine, so it's very hard to interpret specific differences between Pfizer and Moderna vaccines. Also, the small sample size precluded any assessment of complication risks following natural infection, one of the big advantages for being vaccinated.

Does Nirsevimab Prevent Other Infections Besides RSV?

According to another new study, the answer is "sort of." Investigators looked at around 3000 infants randomized 2:1 to receive either nirsevimab or placebo and then followed with respiratory swab PCR testing. The pictorial bottom line:

Not mentioned in the pictorial summary is that the cumulative incidence of rhinovirus/enterovirus coinfections was lower in the nirsevimab group, leading to my "sort of" conclusion.

The important bottom line of the study, however, is that no replacement infections appeared. Replacement infections refer to the concern that once an infectious agent is greatly reduced by preventive measures, another pathogen will take its place, lessening the impact of the preventive measure. This was a concern for Hib vaccine early on, but no other meningitic pathogens arose. Later, the same concern arose for pneumococcal vaccination. There is evidence that replacement pneumococcal serotypes started to become more common, but the overall rates of pneumococcal infections still declined significantly. This is why we're still trying to add other pneumococcal serotypes to newer conjugate vaccines.

Parvovirus and Myocarditis

Last week I mentioned the reports about increase in parvovirus infections likely spurred by non-pharmaceutical measures to prevent respiratory pathogen spread during the pandemic. A spinoff of this kind of surge can be a surge in complications of these pathogens. I was intrigued by this report from Italy about parvoviral myocarditis, which is a slightly controversial topic. Etiology of viral myocarditis is difficult to determine without myocardial biopsy, and parvovirus myocarditis is particularly suspect because of older reports of parvoviral detection in cardiac tissue from individuals who never had concern for myocarditis. So, for an individual patient, it's hard to be certain of a parvoviral etiology for myocarditis even with a positive tissue biopsy. This post-pandemic surge may help clarify the situation.

Europe in general seemed to have an earlier surge in parvovirus infection than we did in the US, possibly because pandemic restrictions were lessened earlier there. Here is a breakdown of the Italian report by age and timing.

And a breakdown of how the diagnosis was made. Only 2 were with myocardial biopsy; blood PCR can persist positive for a long time after parvoviral infection. IgM serology always is suspect due to nonspecific factors. A matched control group without myocarditis to see rates of parvovirus IgM and blood PCR positivity would have been helpful.

Of course I'm hoping we don't see a surge of myocarditis cases soon. If cases do spike, it will be particularly tough to figure out if it happens during a covid surge.

Mycoplasma Complications Too?

Along similar lines, a study from Texas suggests that the Mycoplasma pneumoniae surge might be associated with a greater risk of complications. This is a retrospective review from a single institution documenting an increase in M. pneumoniae infections seen below the shaded section.

It's important to recognize, as the authors do, that this is a cohort skewed towards inpatients who had multiplex PCR testing. Also, mycoplasma PCR can persist positive for many weeks after infection (as do live organisms), so a positive PCR doesn't conclusively mean that the current illness is caused by mycoplasma. What was important and of some concern in the report is that 13 of the 41 children hospitalized with respiratory symptoms required ICU care. They also described 16 children with RIME (Reactive Infectious Mucocutaneous Eruption) with one of those children requiring ICU admission.

Avian Flu Updates

The news media (sometimes breathlessly) relayed new findings that a single mutation in influenza A H5N1 strains could increase adherence to human respiratory epithelium, increasing chances for greater infection rates in humans. I haven't yet bought into this panic.

Keep in mind that single mutations don't necessarily occur in isolation; often multiple mutations occur, some increasing virulence while others resulting in lower virulence. This in vitro study is an important contribution to our understanding of how avian flu might evolve and most importantly supports the need for close tracking of this agent in all animals, including humans.

Along those lines, I was please to hear that the US Department of Agriculture will implement mandatory milk testing nationwide for A H5N1. Previously this has been mostly a voluntary effort in the US. We still need much more monitoring for this agent in order to prepare for potential increase in human cases. Let's hope funding will be available to support these efforts.

WRIS

The winter respiratory infection season has begun, at least for RSV. We are now officially at moderate activity nationwide.

Influenza is increasing slowly with A H3N2 the most common subtype. COVID-19 projections are increasing, though not yet a big bump in clinical illness.

WHO to Help in the DRC

I figure I've been watching various feeds for outbreak alerts for about 30 years, starting with the ProMED service that still sends me at least a daily update. So, I've had early looks at these events, but also a slew of false alarms of new diseases that turned out to be mini-outbreaks of previously well-described illnesses. The latter are far more common than newly emerging infectious agents. So, I'm both watching closely but not overly concerned about the cluster of respiratory illnesses with significant mortality being reported from Kwango province (outlined in red) in rural southwestern DRC, bordering Angola.

Early reports suggest a predilection for children. The rural location with lack of medical facilities hinders any investigation. Also, this type of region, with close proximity of humans to many animal species, provides the potential for infectious agents to jump to other animal hosts. It appears the region now has appropriate support from WHO, and I would expect to hear more definitive information within the next several days, maybe in time for an update in my next post.

I guess the rural location is also a silver lining, with less risk for worldwide spread if this is in fact a new disease. I'll go out on a limb using past unknown outbreak experience and predict this won't be a new pathogen. Here's hoping.

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."

Published on Leave a comment on Is There More to Life Than Infectious Diseases?

Well of course there is, that's why I try to sprinkle my weekly posts with comments on bird feeders, squirrels, novels I've been reading, and other escapades. This past week I happened upon a former colleague of mine who has taken this to new levels, much to my enjoyment.

We seem to be free of serious infectious diseases drama in the past week, unless you are a dairy cow.

Avian Flu

Initially only previewed in news reports and even now lacking details, one thing is clear: influenza A H5N1 infection in US dairy cows is much more widespread than previously revealed. We were surprised by this because asymptomatic infection is common and cow testing was only being performed in symptomatic animals. (This is reminiscent of the early days of covid!) The FDA and Department of Agriculture both report finding positive avian flu PCR tests in 1 out of 5 samples of pasteurized milk tested, although I can't find details about the total numbers and the geographic distribution of milk samples tested.

Of course, a positive PCR merely means that nucleic acid has been detected. It is highly likely that pasteurization inactivates H5N1 virus, and preliminary reports from FDA suggest this is true. Again, details are not available, but certainly no cause for panic about drinking pasteurized milk.

The take-home messages are clear: 1) H5N1 infection is highly prevalent in US dairy cow herds if 20% of all milk samples are PCR positive; 2) there is even more reason now to avoid ingestion of unpasteurized dairy products; and 3) USDA, FDA, and CDC are performing poorly in providing transparency and detailed evidence to the public. They say they are working on this, let's hope we see the fruits of that labor in the coming few weeks.

And, to give our federal agencies some credit, CDC has a spiffed-up web site for avian flu now, with weekly updates. Here's a quick view for the week ending April 20:

Note that this site deals only with human disease. If you want to get more on dairy cattle, you'll need to go to the USDA site. Here you can realize how geographically widespread the situation is.

USDA now has new guidelines for testing dairy cattle being transported interstate. Perhaps testing needs to be expanded beyond just interstate transport.

Covid Calm

Covid activity continues to fall, and weekly deaths now appear to be consistently less than 1000 even considering there is significant reporting delay for covid deaths. The vast majority are in the elderly.

Two new studies appeared highlighting covid vaccine side effects in children. One was a prospective cohort study utilizing insurance databases that likely carried some risk of classification errors because the authors did not perform any medical records review for verification. The study confirmed the known risks for myocarditis or pericarditis for ages 12 - 17 years with the Pfizer vaccine. Also, they found a possible safety signal for seizure occurring following both Pfizer and Moderna vaccination in 2 - 4 or 5 year-old children. This is pretty iffy; as they explained in the body of the text, it may simply be an artifact of how they defined the baseline seizure rate as a comparison number. This is worthy of further study, but in my opinion not something that should be put on the list of definite side effects yet.

The other study was a massive (3.9 million children) look at covid cases in California from 4/1/20 through 2/27/23, again using an administrative database. The article has too many explanatory graphs to show here, but the bottom line from the authors' predictive models suggests that vaccination prevented about 146,000 covid cases in 12 - 15 year-olds, 230,000 cases in 5 - 11 year-olds, and 168 hospitalizations in 6 - 59 month-olds. The authors did not find any association of vaccination with numbers of cases in the youngest age group, possibly because the numbers of vaccinated children were too small during the study period.

Our friends across the pond reported on various covid features from this past winter, November 2023 through March 2024. Results are based on self-reported data from a longitudinal survey study. Here are the main points:

  • An estimated 3.3% (2 million) of people living in private households in England and Scotland were experiencing self-reported long COVID (symptoms continuing for more than four weeks after a confirmed or suspected coronavirus (COVID-19) infection that were not explained by something else).
  • Long COVID symptoms adversely affected the day-to-day activities of 1.5 million people (74.7% of those with self-reported long COVID), with 381,000 (19.2% of those with self-reported long COVID) reporting that their ability to undertake their day-to-day activities had been "limited a lot".
  • Those in the youngest (aged 3 to 17 years) and oldest (65 years and over) age groups were the least likely to test positive for COVID-19 during the study period.
  • Those who have had a vaccination since September 2023 were less likely to test positive in the early waves of the study period (1 and 2); in later waves of the study period (3 and 4) there was no statistical difference.
  • Participants in the oldest and youngest age groups who did test positive in the study period were also less likely to report symptoms consistent with "influenza-like illness" compared with those in the middle age groups.

It's hard to find such recent data. I think this gives us a good peek at the future, assuming we don't have some major change in virus virulence or transmissibility.

Encouraging Progress in Malaria Prevention

I don't usually mention phase 2 trials because they are often much removed from clinical applicability and might change significantly once phase 3 trials are completed. This study is cause for optimism, so I'll break my custom here. Investigators in Mali performed the trial, part of which looked at 225 children randomized in equal numbers to a long-acting monoclonal antibody against Plasmodium falciparum with low dose, high dose, and placebo groups. Infection and clinical malaria was much less in the treatment groups.

The antibody is administered subcutaneously, a plus in resource-poor environments. If further studies confirm efficacy, this could save many lives.

Measles

No new cases were reported in the past week, good news though we know there will be more eventually. Also, I've been looking for more reliable assessments of worldwide activity and found another resource for Europe, the European Centre for Disease Control and Prevention. Updates appear only monthly. Here's what the most recent report, February, looked like:

Romania is the major hot spot, but note that many popular tourist destinations are represented. Here are current CDC recommendations that apply for all international travel:

Fiddlin' Will

By a happy occurrence in my web wanderings, I discovered a former colleague of mine was performing with his band, the Goldbug Revival, at a Salvadoran restaurant near my home. I crossed paths briefly with Will Sears when he was an infectious diseases fellow at NIH; he is now a medical officer at NIAID. However, in his "spare time," he is an accomplished musician. I was thrilled to see him on the fiddle and his wife Sarah singing lead at the band's first live performance and Sarah's first performance in front of a microphone ever. They were excellent!

See you next week. I'll be listening to some John Prine music in the meantime, waiting for Goldbug Revival's first album to drop. Prine was an early covid victim, dying in April 2020.

Published on Leave a comment on Beautiful Beetles

I finished a wonderful novel last week; among other things, it reminded me of the beauty, complexity, and destructive forces in nature, certainly applicable to infections, pathogens, and vectors of disease.

The past week saw more publications than I could cover in depth (or that readers could tolerate, probably), so I had to narrow things down even more than I usually do. If you're feeling particularly adventuresome, some of the topics I excluded pertain to a new phase I Chlamydia vaccine trial that could prove to be a breakthrough eventually, more advice on use of the new pentavalent meningococcal vaccine, an in vitro study suggesting nasal epithelial properties account for less severe covid disease in children, and a tularemia outbreak in Utah beavers. I also left out the growing Salmonella outbreak linked to organic basil, though I did alert one of my sons who often shops at a store featuring the tainted product. Here's what made the cut this week.

Respiratory Disease Transmission is Not Binary

Most things in biology and medicine aren't binary, even if we tend to reduce our thinking to that level to simplify things. For example, most lab tests aren't just positive or negative, even though they are reported that way. The cutoff between those two choices are made to maximize specificity and sensitivity of the tests, but they don't necessarily work for all circumstances.

The World Health Organization provided an important new proposal for changing our longstanding terminology for spread of respiratory infections as either droplet or aerosol (airborne). It's just not that simple, as SARS-CoV-2 painfully taught us. I found I couldn't improve on WHO's explanation of the complexity of pathogen transmission through the air, so here it is verbatim with some highlights in red that are mine:

The following descriptors and stages have been defined by this extensively discussed consultation
to characterize the transmission of pathogens through the air (under typical circumstances):

  • Individuals infected with a pathogen, during the infectious stage of the disease (the source), can generate particles containing the pathogen, along with water and respiratory secretions. Such particles are herein described as potentially ‘infectious particles’.
  • These potentially infectious particles are carried by expired airflow, exit the infectious person’s mouth/nose through breathing, talking, singing, spitting, coughing or sneezing and enter the surrounding air. From this point, these particles are known as ‘infectious respiratory particles’ or IRPs.
  • IRPs exist in a wide range of sizes (from sub-microns to millimetres in diameter). The emitted IRPs are exhaled as a puff cloud (travelling first independently from air currents and then dispersed and diluted further by background air movement in the room).
  • IRPs exist on a continuous spectrum of sizes, and no single cut off points should be applied to distinguish smaller from larger particles, this allows to move away from the dichotomy of previous terms known as ‘aerosols’ (generally smaller particles) and ‘droplets’ (generally larger particles).
  • Many environmental factors influence the way IRPs travel through air, such as ambient air temperature, velocity, humidity, sunlight (ultraviolet radiation), airflow distribution within a space, and many other factors, and whether they retain viability and infectivity upon reaching other individuals.

WHO still proposes a somewhat binary system of IRP spread, with "airborne transmission/inhalation" denoting pathogens which can spread at both short and longer distances, depending on various factors, versus "direct deposition," e.g. someone sneezes on you. It still may be confusing, but this is an important attempt to get past somewhat misleading advice such as a establishing a standard 6-foot distance between persons waiting in line.

Children and Adolescents Likely Still Benefit From Covid Vaccination

CDC has an update on covid vaccine effectiveness and durability, looking at the original monovalent vaccines over the time period from mid-December 2021 to late October 2023. Two doses of vaccine were 52% (95% CI 33%-66%) effective against hospitalization in the 5 - 18 year-old age group if vaccines were received no more than 4 months prior to hospitalization. From 4 to 12 months, protection against hospitalization waned significantly to 19% (95% CI 2%-32%). The report doesn't mention children less than 5 years of age, I suspect because vaccine authorization occurred later, numbers vaccinated are too small, and hospitalization was too uncommon to give reliable numbers.

Vaccine Adverse Events: New Numbers and a Terrific Interactive Web Site

The National Academies of Science, Engineering, and Medicine published new reports on adverse events from covid vaccines as well as an assessment of shoulder injuries from all vaccine administrations. The reports are excellent, but I fell in love with their web site. The NASEM group used levels of evidence to summarize current knowledge about various vaccine adverse events. The categories are evidence that a) establishes a causal relationship; b) favors acceptance of a causal relationship; c) inadequate to accept or reject a causal relationship; or d) favors rejection of a causal relationship. (Certainly this is far from a binary categorization!)

For covid vaccination they looked at six categories of adverse events: cardiac and vascular, female infertility, hearing conditions, immune-mediated events, neurologic events, and sudden deaths. The interactive web site allows you to pick and choose among various topics and subtopics and vaccines. Here's what the portion on myocarditis looks like:

Here's a look at acute biceps tendinopathy from vaccine administration in general:

You can also access the pdf version of the report (note it is a pre-publication proof, could contain some typos) to look at the summary and/or more details.

A Significant Change for Syphilis Screening From ACOG

I'm thrilled to see new recommendations for syphilis screening of pregnant people from the American College of Obstetricians and Gynecologists. I feel like my practice is a congenital syphilis quagmire right now. This updated recommendation gets away from the risk-based approach for screening which has always been a bit vague and clearly less useful with the resurgence of syphilis in the US. Now, every pregnant person should have syphilis testing 3 times: at the first prenatal visit, during the third trimester, and at birth. Previously a pregnant person with good prenatal care could escape with being screened only once early in pregnancy, a practice that would miss recent infection or infection acquired later in pregnancy. They also remind us that 40% of congenital syphilis occurs in infants whose mothers did not receive prenatal care; syphilis screening should be considered for pregnant people at every interaction with the healthcare system, such as emergency or urgent care visits.

Fake News From USDA?

Because of the avian flu concerns in the US, I've been trying for the first time to use alerts from the US Department of Agriculture on the status of avian influenza in wildlife and domesticated animals, including the recent importance of dairy animals. So far the alerts aren't telling me much, just clogging my in box with unhelpful information. So, I was a bit dismayed to see a recent NY Times article criticizing USDA transparency. Unfortunately the article requires a subscription, but it mentions an "obscure" USDA update (that I didn't receive) mentioning influenza A H5N1 further spreading among dairy cow herds and from there to poultry. More distressing to me is a claim in the Times article stating that asymptomatic infections have been discovered in a herd, but not yet reported by USDA; this is important since screening advice for dairy farmers currently is focused on symptoms in the cattle, with no screening of healthy-appearing cows. Perhaps USDA hasn't reported this asymptomatic infection possibility because it hasn't been verified, but one hopes they will be more transparent (and provide better updates) than they have so far. CDC learned a lot about public communication and transparency during the covid pandemic that should inform communications from USDA and other government agencies that we depend on.

Measles

Only 4 new cases reported in the last week, hoping we stay in this lull for a good while.

Elm Beetle Romance

That novel I finished recently was Daniel Mason's North Woods; it's had mixed reviews but I thoroughly enjoyed it. The author happens to be a psychiatrist, and this recent offering from him is an entertaining look at the happenings in a house in rural Massachusetts over several centuries. I had a great chuckle from a brief description of Dutch elm disease complete with a steamy sex scene involving elm bark beetles. Maybe I need to get out more.

Published on Leave a comment on Eclipsed

Even though Maryland wasn't in the full eclipse path, I miraculously located my eclipse glasses and enjoyed Monday's event. It easily overshadowed last week's relatively quiet collection of infections.

Newer Covid Publications

CDC gave us more reassurance that cardiac events associated with covid vaccination are mild. For the period June 2021 - December 2022, investigators looked at Oregon death certificate data in adolescents and young adults (16 - 30 year-olds). They found 40 deaths, 3 of which occurred < 100 days following receipt of covid vaccine, a time period when vaccine-associated myocarditis/pericarditis occurs. Of those 3, 2 individuals had underlying disease (one had mitral stenosis associated with chronic respiratory failure, the other congestive heart failure due to hypertension, with comorbidities of morbid obesity, type 2 diabetes, and obstructive sleep apnea). The other person died of "undetermined natural cause" 45 days after vaccination; toxicology results showed aripiprazole, ritalinic acid, and trazodone, presumably medications the individual was receiving but apparently not definitively explaining a cause for death. To most scientists this is further good news, but I'm sure anti-vaxxers will somehow spin this as a negative. Below is the big picture:

German investigators reported success of a program using pooled SARS-CoV-2 PCR testing to allow children to remain in day care versus quarantining after covid exposure, which they termed a "test-to-stay" approach.

The investigators estimated that. over a 30-week period, they avoided between 7 and 20 days of quarantine per eligible child. The study was performed from March 2021 to April 2022, at a different state of immunity and variants than we are experiencing today but still helpful to strategize when we hit the next big outbreak.

More on Bird Flu/HPAI

Highly pathogenic avian influenza news has calmed down a bit, but the viruses are still out there. We are up to 21 dairy herds with outbreaks according to USDA:

As of April 10, CDC reports widespread detections in wild birds with sporadic outbreaks in poultry flocks, sporadic infections in mammals, and still just the 2 human infections.

Measles

Not as many new cases now, with Illinois and Florida retaining the dubious distinction as leading all states this year. The national total stands at 121.

CDC reported that most US measles outbreaks from 1/1/20 through 3/28/24 were triggered by unvaccinated US residents returning from foreign travel. This is a good reminder for frontline clinicians to advise people planning foreign travel this summer to ensure their families have not only up-to-date immunizations but also early measles immunization for infants and toddlers who otherwise have not received 2 doses of MMR.

I also happened upon a link for assessing measles outbreak risk in US communities. I resisted the temptation to copy the entire page here, please check out the link. Here's a few highlights:

So, about 29% of US communities are at risk for small or medium outbreaks, with 1% at risk for a large outbreak. Even within communities with the same vaccination coverage, outbreak risk can vary if they have pockets of unvaccinated people.

And a look at outbreak modeling risks for measles outbreaks after one measles case is introduced in a school, according to vaccine coverage rates. (Note these numbers apply for situations where no post-exposure preventive measures are instituted. Risks go down if established interventions are applied.)

Here's the latest (2022-23) geographic measles vaccine coverage data.

Fingers crossed for measles to continue to slow down, though I'm predicting another blip around travel season.

See you next week!

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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