pandemic preparedness – Pediatric Infection Connection

Pumpkin Spice Season

Bud WiedermannOctober 19, 2025October 19, 2025Leave a comment

Pumpkin spice season is in high gear, even though winter viruses haven't taken off.

It's a mixed infectious diseases bag this week, led by the almost complete silence from CDC due to the government shutdown. I've attempted to navigate through various sources to put together what is, at best, a semi-accurate state of affairs in the US. I also include mention of 3 significant articles that appeared in the past week.

Nimble News

My predilection for alliteration notwithstanding, I found a lot of tidbits in the news that I thought would be best summarized with brief mentions and links.

WHO announced that the last hospitalized patient with Ebola virus infection in the Democratic Republic of the Congo has been discharged. This starts a 42-day (2 incubation periods) countdown to declaring the outbreak over.

On Monday WHO also announced that Maldives is the first country in the world to hit the trifecta, i.e. elimination of mother-to-child transmission of HIV, hepatitis B, and syphilis. That may not seem so difficult for a group of islands in the Indian ocean with a total population of about 500,000, but it does have a brisk tourist industry that certainly challenges disease containment efforts. Given current trends, don't look for the US to come close to this achievement in your lifetimes.

Along similar lines, I noticed that the AAP is expanding their congenital syphilis toolkit, with much of it available to individuals who are not AAP members.

Details are scarce, but it looks like California now has 2 or maybe 3 cases of autochthonous (locally acquired without travel) cases of the clade 1 mpox that cropped up in Africa recently. The individuals are from Los Angeles and Long Beach and reportedly aren't connected to one another. This isn't unexpected; in fact, I'm mostly surprised that it took so long. Presumably California health authorities will provide updates in the coming weeks.

Speaking of autochthonous transmission, New York now has reported a case of locally-acquired chikungunya infection. Again, not a big surprise. Watch out for those tiger (Aedes albopicutus) mosquitoes, especially in the eastern half of the US.

First reported by the Wall Street Journal and then picked up by multiple news organizations (I can't supply a link, subscription required). a collection of "blue" states and a territory (California, Colorado, Connecticut, Delaware, Guam, Hawaii, Illinois, Maryland, Massachusetts, New Jersey, New York, North Carolina, Oregon, Rhode Island and Washington) have set up a consortium "to monitor disease outbreaks, establish public health policy guidance, prepare for pandemics and buy vaccines and other supplies." This was in response to CDC bailing on these duties. Effectiveness of this group will be constrained both by federal funding cuts as well as the fact that it (so far) lacks bipartisan membership.

Perhaps more futile as far as the US is concerned is a new report from the Global Preparedness Monitoring Board mapping strategies for pandemic preparedness for the future. In the past, even with more "pandemic-preparedness-friendly" US administrations, these types of reports have mostly been unheeded and forgotten.

WRIS

As best as I can determine, the winter respiratory infection season has yet to get underway. I'm mostly relying on Yale's POPHIVE resource, but it was last updated on October 6. Individual healthcare providers may be better served by consulting their local or state health departments.

Measles

South Carolina, specifically Spartanburg, seems to be the up-and-coming hotspot to watch. Thankfully CDC is still updating their case numbers, most recently on October 15. The official case count is 1596, which will lag from individual state reporting. Here's the current map:

Previously I had mentioned using the Johns' Hopkins county-level measles tracker, but I noticed a possible discrepancy in their reporting of a large number of imported measles cases in the twin cities area of Minnesota which was not reflected in the Minnesota state health department number which indicated these cases were locally-acquired. Possibly the discrepancy is due to different timing of reporting cases, but I'll continue to be wary of the Hopkins site even though the county-level data are more useful than statewide numbers.

New Streptococcal Pharyngitis Guidelines

Take special notice of this guidance from the Infectious Diseases Society of America because it is so long overdue and now recommends use of scoring systems for both adults and children with pharyngitis. The guideline is listed as "part 1" of the update, but I couldn't find any indication of when part 2 will be published. Here's an excerpt about use of scoring systems:

"In children and adults with sore throat, we suggest using a clinical scoring system to determine who should be tested for GAS (conditional recommendation, very low certainty of evidence) 

Remarks

High-risk individuals should be strongly considered for testing even if their clinical scores are low. Examples of high-risk individuals include those presenting with sore throat who have had household exposure to GAS (e.g., living or sleeping in the same indoor shared space as a person diagnosed with GAS infection), a history of a previous rheumatic fever diagnosis, or symptoms or signs suggestive of complicated local or systemic GAS infection (e.g., peritonsillar or retropharyngeal abscess, scarlet fever and/or toxic shock syndrome).
The panel recommends that a clinical scoring system be used as part of the evaluation of patients with sore throat. The principal utility of a scoring system is to identify patients with low probability of GAS pharyngitis, in whom further evaluation by diagnostic testing is unlikely to be helpful.
Given the lack of evidence favoring any particular scoring system, clinicians and patients may favor clinical scoring systems that do not include laboratory test(s).
The recommendation to use a scoring system does not apply to children under three years of age as GAS infection in this age group may not present with typical clinical features represented in these scoring systems.⁵ "

You will note that the recommendation is conditional with a very low certainty of evidence. In IDSA-speak, a conditional recommendation means that the majority of "informed" people would follow this recommendation, but "many" would not. Here is their Table 2 describing 3 scoring systems but recommending use of either Centor or McIsaac.

In the past my advice to frontline providers was against use of any particular scoring system, instead using the cluster of symptoms to make a judgment in individual cases. In general, the main focus should be on avoiding testing children with evidence of viral symptoms to decrease false positives due to detection of carrier states.

I predict we'll see some educational sessions from IDSA and AAP once the full guidelines are published.

1st Trimester Covid Vaccination Doesn't Cause Birth Defects

It's difficult/impossible to prove a negative, but this study adds reassurance that there is no suggestion of covid vaccination of pregnant women causing birth defects in their infants. It's a database study from France encompassing over 500,000 pregnancies; one-fourth of the infants were exposed to at least 1 covid vaccine dose during the first trimester. The results are reported in huge tables, too large for me to incorporate here. Suffice to say that there was no evidence of increased risk of major congenital malformations when correcting for maternal age, social deprivation, and folic acid consumption. The study did not include examination of stillbirths and terminated pregnancies because of difficulties identifying malformations in this population.

Fewer Ear Infections with RSV Vaccination

Also from France is a new report suggesting that RSV vaccination (maternal vaccination or infant nirsevimab) results in a lower risk of acute otitis media in infants. I was particularly intrigued because the study was carried out in a network of pediatric practices where practitioners where specifically trained to diagnose community-acquired infections. Based on the timing of implementation of these products in France, the post-immunization season of October 2024 - February 2025 was compared to the pre-immunization seasons, additionally accounting for non-pharmaceutical interventions during the covid pandemic. They also catalogued bronchiolitis and UTI diagnoses, the latter as sort of a negative control since RSV immunization shouldn't influence UTI rates.

Although the report included graphs, they're a little complicated so I'll just give you the takeaways. With over 70,000 AOM cases over the time period, the rates in children < 12 months of age decreased by about 23% with immunization, with no reductions seen in older children. Rates of bronchiolitis also decreased similarly in the younger children, but UTI rates were stable.

Don't Mess With My Espresso Drink

I'm proud to say I've never ordered a pumpkin spice-flavored drink at Starbucks, though I may have tested someone else's at some point. (I don't know why I should be proud of this, maybe just looking for something positive here.) I remain an espresso purist of sorts, now sipping a Bialetti "espresso" as I write these words. In researching the pumpkin spice craze more thoroughly, I discovered Starbucks started work on this flavored latte in 2003 with the original test sites being in Vancouver and Washington, DC - apparently I missed out on that focus group. Now everyone else has added this flavoring to their coffee menus.

I prefer my pumpkin in pies, though I usually go the lazy route with canned pumpkin rather than starting from scratch with the original fruit. For now, though, my pumpkin interactions focus more on jack-o-lanterns.

See you next week.

Summer is (Un)officially Here

Bud WiedermannJune 8, 2025June 8, 2025Leave a comment

Yes, I know summer solstice is the official start of summer on June 20, but my self-centered slant counts the start of summer as when I finally break down and turn on my home air conditioning. That happened a few days ago when temperature hit the upper 80s, accompanied by high humidity.

Thankfully we survived another week with no major outbreaks, but a few things are smoldering.

GAO Report on Pandemic Preparedness

After every outbreak and pandemic, you can count on 2 things: finger-pointing and advice on preparedness to prevent past mistakes. Typically all is forgotten/unimplemented once the brouhaha calms and we all settle into our latest favorite TV shows or podcasts. Thus, we remain poorly prepared for the next challenge.

The Government Accounting Office convened an expert panel over 3 days in January, 2024, to develop recommendations for a coordinated national approach to diagnostic testing for pandemic pathogens. The report finally was released this past week with recommendations for the HHS Secretary.

Their Table 1 documenting 2 recent episodes involving diagnostic testing reminded me of its significant impact on my ability to provide high level service to my patients.

The GAO recommendations are sort of mom and apple pie stuff, very logical and thoughtful. I don't have high hopes it will go anywhere.

MIS-C Neurologic and Psychological Outcomes

A new study documented 2-year neurologic and psychologic outcomes of 95 children 5-20 years of age hospitalized with MIS-C between August 1, 2020, and August 31, 2021, at multiple sites in the US and Canada. A strength of the study was its longitudinal cohort design and use of sibling and community control children when available. The results were encouraging; although MIS-C children had more symptoms initially, by the 2-year follow-up the patients and controls were pretty similar. The article has a ton of data, please go to the source link for more details, but here's a quick snapshot of part of the results (note that higher numbers on the y-axis are worse outcomes for this particular test):

This is a relatively small but careful study that likely is valid for most MIS-C children, though please remember that young infants were not included.

Pertussis in the Americas

Whooping cough is definitely in the news, and on May 31 the Pan American Health Organization published an alert. I missed it that day, otherwise I would have included it last week. It provided numbers to back up what we already know, that pertussis is on the increase across the Americas. What I found most helpful were comparisons to pre-pandemic times because we all know that every infectious disease seems to be increased compared to the pandemic years. The figure below, adapted from WHO data, shows that in 2023 we had returned to pre-pandemic levels globally but did not see much rise in the Americas.

2025 vaccination coverage with 3 doses of DTP in the US isn't as bad as you might expect, though you can see in the footnote we have no data from the most recent 2 years.

In 2024 and 2025 the US is clearly back to pre-pandemic numbers of cases which usually are at least 10,000 annually. Washington, Oregon, and California have the most cases so far this year, and we've had 4 deaths nationally. It seems like 2025 will be more severe year for pertussis.

Clinician Attitudes Towards Earlier HPV Vaccination

You might recall I mentioned in my April 20 post about the ACIP meeting that there was controversy about making a recommendation to promote earlier administration of HPV vaccine at age 9-10 years; this is of course acceptable under current guidelines, but there was some pushback from some ACIP attendees that lumping the 9-10 age group with 11-12-year-old children for HPV vaccine would disrupt the the adolescent primary care visit schedule, plus would be less acceptable to parents.

Now comes a new survey of general pediatric healthcare providers and staff on HPV timing. It included 33 general pediatric practices in California and Colorado and was carried out between November, 2021, and April, 2022. It also included interviews with a subset of clinicians and office staff. A key point is that these practices were part of a study to implement earlier initiation of HPV vaccination; so, these study participants had actually gone through a change in HPV administration in their practices. This fact is helpful to provide real world evidence, but also is a potential source of bias.

It's hard to summarize everything from this report that included narrative statements by the providers and staff, but here's part of the results.

As you can see, the bulk of the respondents did not perceive a change in these parameters after switching to earlier HPV vaccination. I'm hoping this study will be included in any HPV vaccine discussion at ACIP later this month, but clearly this is a narrow sampling that may not apply to other practice settings.

Can't Get Away From Measles

This year's outbreak keeps percolating along without new major hot spots, but a couple of issues merit mention.

First, a brief research letter gives us some information about county-level, rather than state-level, MMR vaccine coverage. The US outbreaks in past years have pretty much been centered around unvaccinated pockets of children, such as a geographically defined religious community in New York City in 2019 and the Texas outbreak this year in another vaccine-averse, relatively isolated religious community. These examples just point out that it's the small pockets of extremely low MMR vaccine coverage that can trigger major outbreaks; knowing the percentage of children who have received 2 doses of MMR vaccine in a state doesn't accurately account for smaller, under-immunized, communities.

The investigators collected county-level data from state health department websites and compared pre- (2017-2018) to post- (2023-2024) pandemic coverage with 2 doses of MMR vaccine. Of course by using state data they encountered different methods for data collection and reporting, so it's a bit of apples and oranges. Furthermore, 13 states aren't included in any of the analyses for a variety of reasons: "Alaska, Arkansas, Delaware, Idaho, Mississippi, Nebraska, New Hampshire, Ohio, and West Virginia are excluded because they do not report county level vaccination data. Georgia, Indiana and Montana are excluded because they only report 1-dose MMR vaccination rates for children aged 19-35 months, which does not align with our focus on 2-dose MMR rates in this analysis. Illinois was excluded because it reports a compliance rate spanning preschool through grade 12, and preschoolers are considered compliant with only 1-dose MMR administered." Here's what's left for the report.

Don't be confused by lighter color shades. The states entirely gray are those with no data; the counties in white are those with the lowest vaccination coverage. I'll be interested to look at this map when our next measles hot spot appears.

The second measles twist concerns congenital measles. Yes, it is possible for a mother with acute measles to pass rubeola virus to the baby prior to delivery. I was reminded about this when I saw a sad statement from the Canadian Chief Medical Officer of Health about the death of a newborn probably due to congenital measles. Remember, Canada is having an even tougher year with measles than we are in the US.

The CMO of Health did not provide much detail about the child, reportedly due to privacy concerns. Congenital rubeola is one of the few measles features I've never seen personally. If you want to learn more, I found an open access case report.

Summer Reading

To put off some chores I need to do, I decided to count up the number of books stacked in my "to be read" pile; I'm up to 52 after a recent buying flurry. I think my stack has ranged from 20 to 80 most of the time. I just finished Philip K. Dick's Martian Time-Slip, a fun book for those who can tolerate his perspectives on life and reality. Psychiatrists in particular would love this one. Now I've started John Banville's The Lock-Up. He's a difficult author for me to read because he writes such beautiful sentences I can't skim over anything for fear of missing out on another perfect rendering of the English language. It's a short book that likely will take me as long to get through as one twice its length.

Less Illness, More Chatter 2

Bud WiedermannMay 26, 2024May 26, 20242 Comments

We've had a slow week of infectious diseases events, but that hasn't slowed down the chatter and noise. I've tried to distill out the more important topics this week.

The Covid Front

Even though US tracking systems have been greatly dismantled in many states, I can still safely say we are in a lull. Naturally, thoughts turn to predicting the next surge and how to mitigate it.

I mentioned in my May 5 post that the FDA's Vaccines and Related Biological Products Advisory Committee meeting to decide on composition of the next iteration of covid vaccine would be held on May 16 and likely would make the same decision as the WHO already has, using the JN.1 variant. However, they suddenly postponed this meeting to June 5. FDA didn't offer an explanation for the postponement, but the last-minute change leads me to suspect that they wanted a little more time to think about newer variants with possible significant differences in immune-escape properties. Here's a deeper dive into that.

As you can see in this latest CDC variant report, the dark purple JN.1 proportion is decreasing, with KP.1 and KP.2 starting to expand. Both of those are in the JN. 1 lineage:

All of the JN and KP variants are informally called FLiRT variants, an easier shorthand than trying to remember all the letters and numbers. It stands for amino acid substitutions, in this case phenylalanine (F) substituted for leucine (L) in the 456 position (F456L) and arginine (R) to threonine (T) in the 346 position (R346T) in the spike protein genomic code. These 2 mutations are in antibody binding sites that neutralize the virus, and the mutations make SARS-CoV-2 less vulnerable to vaccine- and infection-acquired antibodies. A JN.1-derived vaccine likely would offer some protection, but perhaps by the June meeting we'll know a bit more about all of this. If they do recommend using KP.2 instead of JN.1 for example, I don't think there would be a significant delay in mRNA vaccine production by Pfizer and Moderna, but it might cause problems for other vaccine platforms such as the one used by Novavax, the other approved vaccine in the US which is an adjuvanted protein subunit vaccine. I'll be watching as much of the June 5 meeting as I can.

HPAI

Now we have a grand total of 2 people in the US infected this year with Highly Pathogenic Avian Influenza, along with a lot of cattle and other animals; a recent MMWR provides details. The new, improved CDC website has lots of helpful links. The second case, in Michigan, was similar to the first human case of A H5N1 infection in Texas - very mild illness with conjunctivitis as the primary symptom. This strikes me as very unusual for evolving epidemics in that usually the more severe cases are identified first because they are more likely to come to medical attention. Both of these cases were identified through surveillance of dairy workers which suggests to me that currently HPAI in humans is a very mild infection, possibly with high rates of asymptomatic infection. This is a good thing generally, but also problematic for tracking infection rates. The MMWR reports only 350 exposed dairy workers are being followed, a very small number. Ideally we'd have more tracking of cattle and dairy workers, regardless of illness or exposure to infected animals. Getting cooperation from dairy farms will be difficult, we're talking about livelihoods in an industry where a shutdown for a cow outbreak could send someone into bankruptcy.

I'm watching multiple feeds to keep up with all of this. A report in NEJM last week was encouraging - heat inactivation of spiked milk samples significantly lowered infectivity in mice fed the milk.

Also in the good news department, USDA reported preliminary findings on HPAI detection in muscle tissue of culled dairy cows. 95 of 96 samples tested so far were negative by PCR. Note that these were condemned animals, none of the meat entered the food supply.

On the somewhat negative side, more cattle herds have been hit with the virus, according to USDA.

Poultry outbreaks also continue with Minnesota registering more detections last week. Note that backyard flocks are not immune to HPAI.

On a slightly related topic, I was disappointed but not surprised to learn that the World Health Assembly, the decision body for the WHO, removed a pandemic preparedness treaty that was to be discussed at their meeting starting May 27. It appears that political considerations caused the cancellation; much misinformation is circulating, especially in the US. The treaty would help countries design programs for pandemic preparedness and in no way allows the WHO to control countries' own public health programs as claimed by some sources.

Potpourri

A scattering of reports might be interesting for readers. First, beware of undercooked bear meat. Six out of eight people who consumed undercooked, previously frozen black bear meat developed trichinellosis. Freezing doesn't kill Trichinella parasites. Beware the (undercooked) bear.

CDC released a Health Advisory Network alert for meningococcal disease in Saudi Arabia, although this is pretty much routine for this time of year during religious pilgrimage season. Travelers to the region should be immunized for meningococcal disease, which is more easily transmitted in the crowded situations during Islamic pilgrimages to Mecca.

Speaking of Noise

I'm pretty sure I've never mentioned this in the blog, probably because I'm so embarrassed, but I'm a 2-time harmonica school dropout. This last exit was due to a combination of my inability to master bending notes on the diatonic harmonica and the fact that my dog runs away from me every time when she hears my mellifluous tones. I've now solved the second problem by clearing a practice space in my trash-heap of a basement where the dog can't hear me, but bending will still be a challenge. It's a technique to hit notes that are in between standard notes; there are maybe hundreds of online instruction sites for how to form your mouth to do this, but basically it's just trial and error and takes several months for most people.

Graphic courtesy of Luke.

Maybe by announcing my intentions I'll be shamed into pulling it together this time and can return to harmonica school. I can't promise to report on my progress, especially if I have none!

Dog Days of Summer

Bud WiedermannJuly 16, 2023July 16, 2023Leave a comment

I've just returned from a wonderful family week at the beach to a steaming suburban DC and an annoying surprise at home. I'll just bask in my vacation afterglow and belatedly compose this post.

Bugs cont'd

I didn't think it was possible, but there are more mosquitos around my house now than before I left for vacation. Right on schedule, West Nile Virus infections are starting to heat up.

Hot off the presses, you can also add Texas to the list. Remember that although West Nile Virus is feared for its neurologic manifestations, most infections are either asymptomatic or result in a nonspecific febrile illness. The neurologic cases are the tip of the iceberg.

Hepatitis C - We're Missing the Mark in Public Awareness

A recent publication noted a big gap in delivery of care for hepatitis C, summarized below. I really like their cool poster-type depiction, check out the bottom line (at the bottom, of course).

Once again, our wonderful technologic advances in medicine are clouded by a failure to have them reach those who need them most.

More on Neonatal ECHOvirus Infections

The World Health Organization reported more cases of neonatal ECHO-11 infections in newborns, originally in France as discussed in these pages on June 4. Now WHO reports new cases from Croatia, Italy, Spain, Sweden, and the UK. No evidence so far that these events in different countries are connected; this might just reflect enhanced surveillance given the initial alert from France. The link above has a nice discussion of various aspects of the cases. Again, keep severe enteroviral disease in mind with any sick newborn in whom bacterial etiologies are not revealing.

'Demic Doldrums

Remember wastewater monitoring? It's not the greatest tool in the US due to the fact that monitoring is voluntary and leaves much of the US with no data. However, an epidemiologist at Johns Hopkins has been blogging on this and is predicting we are about to see an uptick in southern states. She admits the data are iffy, we'll know eventually if she is full of hot air or not.

Some interesting data appeared regarding maternal covid vaccination and newborn antibody levels. This was a small but well-studied group of 76 mothers who received an mRNA vaccine during pregnancy. Higher maternal antibody levels were seen in mothers who had systemic symptoms following the second vaccine dose, though all had good responses. Maternal transfer of IgG to infants was highest in those vaccinated in the second trimester. Breast milk IgG and IgA antibody to SARS-CoV-2 persisted about 5-6 months, just in time for the infants to start their own vaccine series! There were no significant adverse events in mothers or infants. Bottom line: since we don't know what covid will do in the future, pregnant persons would be well advised to get that new vaccine dose during their second trimester.

The US Government Accounting Office published some further recommendations for pandemic preparedness. I'm very glad these are appearing, but public interest and funding have cooled dramatically.

Also, I was pleased to see an analysis of journalistic coverage of preprint publication before and during the pandemic appearing (where else) but on the well-known preprint site BioRxiv. This coverage hit the boiling point during the pandemic but applied only to covid preprints, not to other scientific reports. Next up I hope we see some analysis of how many of those preprints never appeared in a peer-reviewed publication; some have attempted chart this already, but we probably need to wait another 2-3 years before passing judgement. I continue to worry that too much attention was focused on preprint postings during the pandemic; the blame for this is shared by journalists, scientists, and the universities and other organizations where the work was performed.

Lest we forget about flu, things aren't too bad worldwide but WHO did report some close-to-home hot spots in Costa Rica, Honduras, Nicaragua, and Panama.

My Astrologic Education

I always assumed the saying "dog days of summer" had something to do with a panting dog in the heat. I was barking up the wrong tree; now I've found out it originated with Hellinistic astrology. Officially, the dog days run from July 3 to August 11, according to the Farmer's Almanac.

I had a great time with my 3 sons and families at the beach, enough to keep me somewhat cool and calm after the thunderbolt of finding my air conditioner on the fritz when I returned home. Fortunately for my dog days, my house has 2 air conditioners. Until now, this was a complete mistake - our house could be handled by just one unit if only the ducts were all linked together. So, for now half the house is tolerable and I won't complain too much, at least until I get the bill from the air conditioning service.

Oh, and in case you haven't noticed, I've sprinkled weather- and temperature-related references and puns throughout this week's post. To keep your mind from sweating, see if you can find all of them. Answers in next week's post.

Tag: pandemic preparedness