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Published on Leave a comment on Onward Through the Fog

Or haze, or just blackness. It's a beautiful sunny day in Maryland, but cancellation of the FDA's VRBAC meeting to discuss next fall's flu vaccine composition makes things a lot hazier. More on that later.

Covid Vaccination Protective Against Post-Covid Conditions in Children

This is a report from a multicenter study of children 5-17 years of age, originally enrolled July 2021-September 2022 and then followed longitudinally. The cohort was surveyed from December 2022 through May 2023, with questions about a variety of symptoms lumped under Post-Covid Conditions (PCC) detailed in the footnotes below.

The lower odds ratios of PCC in vaccinated children is impressive. The study's strengths are its prospective design, but the fact that they are relying on survey results, as opposed to specific follow-up encounters to determine signs and symptoms, is a bit of a weakness. Other longitudinal studies are ongoing with longitudinal in-person evaluations, so we'll eventually have better data. Also, this study doesn't tell us anything about benefits of ongoing covid immunizations in children. I've previously mentioned other studies suggesting benefit to children from ongoing immunizations.

Measles

The outbreak in Texas with probable spillover to New Mexico continues. Here's the latest from CDC in their February 28 report. Be aware there is a time lag from when cases are reported by states to when they are included in CDC numbers.

I was hoping the West Texas outbreak wouldn't result in large numbers of cases given the relatively rural and smallish population involved; we aren't yet approaching the 2019 New York outbreak that occurred in a densely populated community.

The Texas authorities' update from Friday tallies 146 cases, and New Mexico shows 9 cases. Five of the NM cases were 18+ years of age and 4 children 5-17 years old. Texas HHS also reports a large exposure area for a measles case in San Antonio and surrounding area. I think it's interesting to look at the sites and consider the immense resources needed to track down and protect exposed people.

WHO Soldiers On

The polio vaccination program in Gaza sounds like it was very successful: 603,000 children under 10 years of age were immunized over a 5-day period, aided by the cease-fire that I hope will continue.

New World Screwworm

Apologies, I think I've mentioned this topic once before but can't find it in a search of my posts. This disease is a form of myiasis, and the recent news is that it's getting closer to the US with new data at the end of last year showing the fly (Cochliomyia hominivorax) appeared in Mexico. The previous "barrier" to creeping closer to the US was the Darrien Pass in Panama, which you may recall from various immigration discussions in the lay press.

Now new efforts are underway to release sterile flies in Mexico, an established method to control the population. The USDA has a helpful document explaining the history. In endemic countries this is mostly a concern for livestock and other animals, but we humans also can be affected; it is very painful, beyond unpleasant, and gross, requiring manual extraction of the fly larvae from soft tissue. Here's the history in the US, at least as of late 2016 following the finding of the flies in Florida, resulting in a sterilized fly release for control.

Avian Flu

A lot of back and forth in the lay press about influenza A H5N1. My take on the bottom line is that there is nothing substantive that is new. I'm still watching closely for more concerning trends including extensive infection in pigs (where conversion to a strain with greater ability to infect humans is more of a risk) and any evidence of human-to-human transmission.

USDA monitoring is ongoing, with of course many infections in wild and domestic birds, cattle, and other mammals including a flurry of domestic cat infections recently. The map below is current as of February 26.

Our new agriculture secretary has released a plan for avian flu control. It is advertised as a means to lower egg prices which is fine, but we won't see any impact on that soon. I'm just glad we're seeing some movement to get a handle on this. The more H5N1 circulates in any animal, the more likely we'll see a new strain with greater potential to sicken humans.

In the meantime, I might try to steal my wife's oatmeal stash a few mornings a week.

Hooray for MMWR!

Not only does this week's edition look like the old days, it even included a sensitive topic for the current political administration: HPV vaccine.

HPV was strikingly effective in lowering the rate of cervical precancers in young women (the solid blue lines below) as well as in women in their late twenties. The fact that the current administration allowed them to publish these results is encouraging; HPV vaccine has been a target as well as a source of income (from lawsuits) for RFK Jr. in the past.

Last year's flu vaccine early estimates of effectiveness looked like a glass-half-empty versus -full in the lay press. The half-empty folks point to somewhat low effectiveness against all infections, but that's not the point. As with other respiratory virus vaccines, the main point of vaccination is preventing healthcare visits and serious outcomes. Here's the bottom line we should pay attention to: "Interim 2024–2025 seasonal influenza VE estimates were derived from four U.S. VE networks. Among children and adolescents, VE was 32%, 59%, and 60% in outpatient settings (three networks) and 63% and 78% against influenza-associated hospitalization (two networks). Among adults, VE was 36% and 54% in outpatient settings (two networks) and 41% and 55% against influenza-associated hospitalization (two networks)."

I'm in the half-full camp.

WRIS

I think we might really be headed down for winter respiratory infection season, largely due to a sustained decrease in influenza with no significant upswings in covid. RSV is almost out the door. Here's the latest from FluView.

That's not to say it's gone, however. We're definitely still in flu season in many areas of the country.

FDA Advisory Committees

I'm perplexed about why the FDA VRBPAC's scheduled meeting was cancelled. Supposedly the selection of next fall's flu vaccine composition will be done internally by the FDA, but one of the key advantages of the VRBPAC meetings was the chance for anyone, including the general public, to view the discussions in real time and get a better understanding of issues and risks/benefits.

I have a bit of personal experience to illuminate this. I've participated as a panel member on several FDA Advisory Committee meetings, though never anything to do with vaccines. Here are some key points that I can relate from first-hand experience.

  • I filled out an incredible number of forms about my potential conflicts of interest for every session. It was the equivalent of a paper strip search.
  • I spent many hours/days reviewing documents with a lot of raw data, both from FDA experts as well as from any pharmaceutical companies and device manufacturers. It was a very granular level of detail.
  • Every session included presentations by mostly lay public individuals given time to speak at the meeting. It was a broad representation: patients and relatives of patients who might benefit (or be harmed) by the product, other industry and association representatives, and yes, some pseudo-science/misinformation folks.
  • The discussion was very helpful; sometimes my mind changed as I learned from others.
  • All committee members explained their votes. The votes were not binding to the FDA, but I can't remember a situation where they didn't follow the vote for any of the committees I served on.
  • My exact recollection has faded, but I think at first I was reimbursed for lunch but later I wasn't. Everyone was reimbursed for travel and lodging when the meetings were held in person in the DC area. Of course, since I'm local that really didn't amount to much even if I submitted my gas mileage! In short, people serve on these committees for civic duty, not for any remuneration.

Now that meetings are virtual, there is not much reason to cancel them. The cost is born by the committee members; FDA and industry participants still need to do the same amount of work. I hope transparency in healthcare administration will return soon.

Paint It Black

This Stones' song came on my Pandora station just as I was wrapping up my first draft of this post. The sun isn't quite "blotted out from the sky" from the FDA VRBPAC and CDC ACIP postponements and cancellations, but it's enough to cast a shadow on my sunny day. Here's to brighter times.

Published on Leave a comment on End of an Icon?

What happens when a prominent public figure who thinks he knows everything about everything finds himself in a position to control an important public institution? It's another brave new world we'll need to endure as best we can.

Of course I'm speaking about the Broccoli family ceding creative control of the iconic James Bond franchise to Amazon/MGM, i.e. Jeff Bezos. I shudder at the possibilities of another billionaire-induced stream of havoc.

Er, no. What I'm really referring to is the postponement of this week's meeting of CDC's Advisory Council on Immunization Practices. I had detailed last week that it was scheduled for February 26-28 as one of the three planned meetings this year; the dates are selected well in advance and had been planned through 2027. Not any more, apparently.

These meetings, with the entire public invited to view in real time, were among the most transparent of all healthcare meetings in our country. I'm not sure what public comment accommodations were needed; comments had been requested via the Federal Register as per standard practice, and the draft agenda already included the usual times for live public comments prior to all votes. The concern is that RFK, Jr., will overhaul committee membership to install new members to carry out his anti-science doctrine. The website promises that the ACIP workgroups will still present their findings, but I'm concerned the votes could look much different by the time that happens.

Coupled with potential new rules for FDA and research funding, we could end up with no progress in vaccine development and increasing vaccine hesitancy in the general public. At worst, we may lose access to currently available safe and effective vaccines. The ACIP could cease to be a reliable partner for our nation's health. Private organizations, including the American Academy of Family Physicians, the American Academy of Pediatrics, and the American College of Physicians, among others, may need to step forward to fill the vacuum of discussion and recommendations.

As I step down from my soap box, Ambrose Bierce reminds me, "Speak when you are angry and you will make the best speech you will ever regret.”

Good News Department

After my Debbie Downer impersonation above (did you watch SNL's 50th Anniversary show?), I'm thankful I saw more positives than negatives this past week.

MMWR is Back in Form

The February 20th issue looked a lot more like a typical edition. It had 4 topics and didn't appear to be skimping/censoring information. Of course the biggest news from an infectious diseases standpoint is the report of 2 exclusively indoor pet cats from 2 separate households in Michigan who died from avian flu. Owners of both cats were workers on dairy farms. The cats never had direct exposure to the farms.

The investigation was somewhat limited by incomplete testing. The most logical conclusion is that these 2 episodes represent passage of the virus from humans to cats.

Polio Vaccination Resumes in Gaza

WHO reports another round of polio vaccination is ongoing now in the Gaza strip after wastewater monitoring recently showed a poliovirus spike. Almost 600,000 children under 10 years of age have been identified to receive vaccination through February 26.

Low Dose Yellow Fever Vaccine Produces Similar Seroconversion Rates

At first glance, this might not seem that important to those outside of the yellow fever world. However, yellow fever vaccine is in short supply at a time when this hemorrhagic fever virus is surging in many parts of the world, including the Americas. Investigators published a non-inferiority randomized, double-blind controlled trial of standard dose (13,803 IU) compared to lower doses of 1000, 500, or 250 U administered to adults in Uganda and Kenya.

Using a lower vaccine dose vastly increases the number of people residing in high-risk countries who can be vaccinated. Note that in addition to 29 African countries, 13 countries in Central and South America have some risk of yellow fever transmission.

Listeria Outbreak Linked to Frozen Shakes

Mostly these nutritional supplements are used in long-term care facilities. I haven't noticed any of these products in my local grocery stores. Last Friday FDA reported on the outbreak that first came to light in November 2024 and covers 21 states across the country. Thirty-eight individuals have been infected, resulting in 37 hospitalizations and 11 deaths. The high morbidity and mortality probably relate to the high-risk populations residing in these facilities. If you visit one a nursing home it's worth a mention to the staff to make sure they are aware.

Measles

I'm afraid that reports of vaccine-preventable diseases will increase in the current regulatory and cultural climate. Friday's update from Texas Health and Human Services now lists the total number at a whopping 90 cases, and if news reports are to be believed this is significantly under-reported due to high rates of home schooled children affected. Added to this are 9 cases just across the border in New Mexico, though news reports state there is no known contact to infected individuals in Texas. That seems to be a very unlikely coincidence.

Last week I mentioned that I thought the CDC needed to update their measles tracking page more frequently than monthly, and they listened to me! Now we have updates every Friday.

We haven't broken any records yet, here's hoping Texas officials get this under control soon.

WRIS

It's nice to see the influenza-like illness curve head down this past week, but it could bounce up again like it's done before.

Hospitalizations for confirmed influenza infections also trended down.

Mortality is the highest we've seen since the pandemic. The numbers below include 86 pediatric deaths.

On a national level, covid and RSV aren't doing much, though even low levels result in significant disease.

Bernarr Macfadden

Yeah, I never heard of him either, but opinion columnist Jessica Grose at the NY Times brought him to my attention as a precursor/dopelganger for RFK, Jr. Unfortunately Macfadden's Wikipedia article has too many poorly documented statements to recommend, but what I can verify is that he was a weight-lifter who liked to be photographed showing his muscles (and most of his body) and founded various health movements. A charismatic individual, his influence was prominent from the early 1900s through World War II. He had no medical background. He championed raw milk and denounced white bread and pharmaceutical agents including vaccines. His "movement" reportedly had prominent adherents including Franklin Roosevelt and Rudolph Valentino. Eerily familiar.

As a distraction, I found myself wondering how Jeff Bezos would tilt his newfound power to influence the future of James Bond. I know just the person to play the next villain.

Courtesy of YouTube

Published on Leave a comment on Fall Back

Once again I find myself, an ostensibly tech-savvy individual,* faced with manually resetting the time on 11 clocks and appliances in my house. Only my phone, laptops, and tablet appear to have joined the 21st century by self-correcting to eastern standard time. Of course, if our country had truly joined the 21st century, we wouldn't be making this twice yearly switch in the first place.

My election anxiety is somewhat mollified by focusing on infectious diseases, so you can categorize the following as therapeutic in nature.

WRIS

Still not much going on, though I was intrigued that my state of residence is 1 of only 2 to show up with moderate respiratory illness activity last week.

I'm pretty impressed by how quiet the SARS-CoV-2 front is. However, it's still around, and we can expect to see a resurgence sometime.

The fact that influenza has not yet appeared might indicate we are returning to a more "normal" flu season. The graph below shows how different the prior 3 flu seasons were from pre-pandemic experiences, where last year had a very early peak and 2020-21 and 2021-22 had very low and atypical peaks. (Apologies for CDC's labelling here, but if you stare at it long enough you can pick out which line goes with which year.)

New Development in Bird Flu

The so-called highly pathogenic avian flu H5N1 cropping up in dairy and poultry farms and in wild bird populations has been in the news for many months now. It still seems to be a mild illness in humans, most of whom have direct exposure to these farms. Only 41 humans have confirmed infections in 2024 so far. What's a bit noteworthy this week is that the virus may now have shown up in pigs. USDA officials reported probable swine cases at a backyard farm in Oregon where poultry, cows, and pigs all mingle. The farm itself has no role in commercial production of any foods, so it isn't a risk to others. What is of slight concern is the fact that pigs are involved. Pigs have a special place in influenza science because they have both human and avian flu receptors in their respiratory tracts, making the chance for a recombination event to occur if they happen to be infected with human and avian viruses at the same time. Most of the time this doesn't cause creation of a new pandemic strain, and I wouldn't hit the panic button at all now. Actually I'm surprised it took this long for swine infection to be found. The affected animals were all euthanized and multiple studies are ongoing, so I'm sure we'll hear more about this.

Polio

The news isn't great as both wild and vaccine-variant polio cases continue to be reported. This Global Polio Eradication Initiative map is a good summary.

No new cases have been reported in Gaza, with just the 1 case confirmed so far. The interrupted vaccination campaign in northern Gaza restarted this week.

Dengue Still Going Strong

I was browsing the CDC dengue page this week; infections are still plentiful.

Puerto Rico has the greatest number by far, but note that we have had autochthonous (locally acquired without travel to endemic areas) dengue in the mainland US (California with 11 cases, Florida with 49).

*

Can I really claim to be tech-savvy? I think so. I have an advanced degree in educational technology with classes that included instruction in networks and the various hardware involved; the fact that my schooling ended in 2008 shouldn't disqualify me. Also, this past week I restored to full health our K-cup brewing machine that became confused and wouldn't deliver the appropriate coffee volumes or allow the correct menu choices in its buttons. I guess in the interest of full disclosure, when I couldn't find a satisfactory replacement brewer online, my astute intervention was reading the instruction manual, realizing that I hadn't ever de-scaled the device in the approximately 90 years I've owned it, and made it new again using only a low-tech tool (vinegar).

In spite of my skills with technology and vinegar, I'll be performing my semiannual time resets for the foreseeable future; I could never part with my grandfather's clock.

Published on Leave a comment on Information, Knowledge, and Wisdom

I regularly read Ron Charles's Washington Post Friday Book Club newsletter, always chock full of interesting topics and writers I haven't yet explored. This Friday he included a quote from controversial (accused of plagiarism) Turkish author and activist Elif Shafak

“... we are living in a world in which there is way too much information, but little knowledge and even less wisdom.… As we scroll up and down, more out of habit than out of anything else, we have no time to process what we see. No time to absorb or reflect or feel. Hyper-information gives us the illusion of knowledge. For true knowledge to be attained we need to slow down. We need cultural spaces, literary festivals, an open and honest intellectual exchange.”

This blog is my attempt to machete a trail through all the various forms of information and provide some bridge to knowledge and wisdom by providing links to reliable original sources. Speaking of which, we are now in the midst of ID Week, probably the most prestigious annual infectious diseases research conference, and many of my regular ID feeds are filled with reports of presentations. However, I virtually never include these reports in this blog, because there is no way via these abstracts to look for potential flaws or limitations in the research, and it is well known that research meeting presentation findings often change dramatically by the time they are published in a peer-reviewed journal, if they are ever published at all.

WRIS

Still pretty quiet on the Winter Respiratory Infection Season, with some hints of beginnings of influenza and RSV increasing. Perhaps the only item of interest is an increase in Mycoplasma pneumoniae activity, probably just a regular wave that tends to happen with this pathogen, though delayed somewhat due to pandemic mitigation strategies. It's not a reportable disease, so it's hard to find good data on incidence over time. As most providers know, this is a self-limited illness that produces generally mild illness (so-called walking pneumonia) and usually not worth diagnosing or treating. Because of its self-limited nature, it's been difficult to demonstrate any benefit of antibiotic treatment compared to placebo, and I doubt we'll see any placebo-controlled randomized trials in the near future.

Compared to last winter, CDC is predicting a 54% chance of a similar combined peak of respiratory illnesses, with a 28% chance of a lower peak and 18% chance of a higher peak.

Infectious Complications of Hurricanes

These tend to get less coverage than do the more obvious loss of life and property destruction occurring immediately during a natural disaster, but the Florida Department of Health is now reporting on a surge in cases of necrotizing fasciitis due to Vibrio vulnificus, a known salt and brackish water pathogen. Here are the numbers:

As a reminder, individuals with immunodeficiencies, but also particularly including chronic liver or renal disease, are at high risk for V. vulnificus complications. CDC has a good summary.

Conjunctivitis

Researchers in Colorado looked at about 200 children with acute conjunctivitis compared to a similar number of children who were either healthy or had URI without conjunctival involvement. Long story short, they found no benefit of ophthalmic ointment treatment, but did see a 20% incidence of antibiotic side effects. The study itself didn't replicate real-world situations for providers; for example, they employed broad spectrum PCR testing looking for a large number of bacteria and viruses. The study doesn't give us much direction for practical approaches to this problem but does serve as a reminder to limit topical and other antibiotic use in acute conjunctivitis in children,

Outpatient Infant Botulism?

I would never have thought of this, I've only been called for hospitalized children with infant botulism. It turns out, though, that there are rare instances of milder disease managed as outpatients. A team reviewing the California Department of Public Health data from 1976 - 2021 found 17 of 4372 cases (0.4%) were outpatients. (Note that California cases account for about 1/3 of all US infant botulism cases.) Here's the breakdown of clinical findings.

The median age at onset of symptoms was 20 weeks, with a range of 6 - 55 weeks. Only 1 child had been exposed to honey.

Polio Updates

The second round of novel oral polio type 2 vaccinations have begun in Gaza, though I haven't heard much about ceasefires to help facilitate this critical second round. Meanwhile, this week the Global Polio Elimination Initiative had to bow to reality and revise plans and timeline for polio elimination worldwide. Now, the end of 2027 is the target for elimination of wild poliovirus infections, with end of 2029 for elimination of type 2 vaccine-derived polio. This will take significantly more funding, and the greater the risk of prolonged or new wars the less likely these targets will be achieved.

The DIKW Pyramid

I'm accustomed to using the evidence-based medicine pyramid for hierarchies of study design in medicine, but in researching Dr. Shafak's quote about wisdom I happened onto the Data, Information, Knowledge, and Wisdom pyramid. It doesn't appear to incorporate anything about the role of false or misleading data, so I'm not sure if it is a helpful model in our era. As artificial intelligence becomes more entrenched (it's impossible to remove that view from Google Chrome!), we need to be even more vigilant about our data sources.

HAL 9000 looks a lot like my doorbell. Yikes!

Published on Leave a comment on I’m Optimistic

It was a busy week for infectious diseases, not in the sense of more outbreaks but rather more epidemiologic and vaccine data that point to better health for the future.

The big topic of the week was the Advisory Council on Immunization Practices regular February 2-day meeting. In retrospect, pediatric healthcare providers won't have any major new recommendations to work with; those are likely coming following the next meeting the end of June. I wasn't able to view as much of the meeting as I had hoped, patient care interfered a bit, but I did review all the presentations for those that I missed hearing live. Let's dive in.

ACIP

The Council discussed 9 different topics, but only 3 involved voting: COVID-19 vaccines (vote in favor of a spring vaccine for some high-risk people), Chikungunya vaccine (vote for use in some US adult travelers and in laboratory workers), Td vaccine availability for those with contraindications to receiving pertussis vaccine (discussion followed by a vote regarding the Vaccines for Children progam), influenza vaccines, polio vaccines, RSV vaccines for adults, meningococcal vaccines, pneumococcal vaccines, and the new Vaxelis combined product for diphtheria, tetanus, pertussis, polio, Hib, and hepatitis B. I'll expand on just a few of these topics. (Note all of the graphs/figures below are from the ACIP web site presentation slide link for the February meeting.)

RSV

We saw the most up-to-date representation of RSV epidemiology, showing that the epidemic curve for this year looks a lot like prepandemic years (see last presentation in RSV session).

A good part of the discussion centered on risk of Guillain-Barre syndrome following vaccine, compared to risks of GBS in the baseline population. Both are rare events, but I think at this point it is reasonable to conclude that GBS is a rare risk of RSV vaccination, though not enough to outweigh benefits for high risk populations.

A quick look at the benefits versus GBS risks for adults > 60 years of age (Melgar presentation from RSV session):

Note risks might vary with vaccine type - hard to know with rare events and large confidence intervals, plus both in the ballpark of background GBS numbers.

Influenza

This session was interesting for me to see a preliminary assessment of vaccine effectiveness for the 2023-2024 flu season. I'll just show you an overview of VE in the pediatric population; note that multiple methodologies are used to measure VE. (See slides from Frutos presentation in the influenza section.)

This is good VE for flu, certainly the CDC and WHO were on track for choosing the best combination of strains for this season. Look for the vote for next season's vaccine composition in June.

Meningococcal Vaccines

The focus of the discussion was how best to incorporate meningococcal B vaccine now that we have an approved combination vaccine containing this serogroup. Here are the main options discussed, from the 1st Schillie presentation:

The issues are complex, primarily due to 3 factors. First, meningococcal group B infections are extremely rare; traditional cost-effectiveness models show that meningococcal B vaccination in the US is by far the most expensive vaccine; very few cases are prevented due to the rarity of infection. Second, vaccination at age 11-12 risks significant waning of immunity by the age for peak meningococcal disease in adolescents; it might make sense to move the first dose to a later age. (The main argument against this is the confusion caused by eliminating the long-standing practice for vaccination at age 11-12, perhaps lowering overall vaccine acceptance.) Third, it is clear that not all meningococcal disease risk in adolescents is equal: college attendance is prime, but there are other behavioral risk factors (1st Schillie presentation):

The discussion was mainly to hear input from all stakeholders and then go back to the drawing board. Expect a vote on this at the June meeting - it will greatly impact your summer vaccine guidance for adolescents and young adults.

COVID Vacines

This section of the meetings seemed to garner the most publicity. Of course most of the results presented dealt with adults, given the relatively lower risk for bad outcomes in children plus low rates of vaccinations. Most helpful I thought were the discussions about covid VE in recent months looking at the fall monovalent vaccine.

These are great numbers. Also mentioned was the fact that waning of efficacy hasn't been seen yet, but that could just be a result of not having enough time to pass since the fall vaccine. Other good news is that in vitro studies suggest that the current monovalent vaccine is likely to protect against newer variants.

The official recommendations from CDC now state

Special situation for people ages 65 years and older: People ages 65 years and older should receive 1 additional dose of any updated (2023–2024 Formula) COVID-19 vaccine (i.e., Moderna, Novavax, Pfizer-BioNTech) at least 4 months following the previous dose of updated (2023–2024 Formula) COVID-19 vaccine. For initial vaccination with Novavax COVID-19 Vaccine, the 2-dose series should be completed before administration of the additional dose.

That "should" wording was the subject of much debate, finally choosing this wording more for simplicity of recommendations. The gnashing of teeth came about for a good reason - people in the lower end of this age population who do not have underlying risk factors will have less benefit from a spring vaccine because rates of bad outcomes in the post-pandemic period are lower.

Recommendations for younger people with moderate or severe immunocompromise have slightly different wording:

  • People ages 12–64 years who are moderately or severely immunocompromised may receive 1 additional dose of any updated (2023–2024 Formula) COVID-19 vaccine (i.e., Moderna, Novavax, Pfizer-BioNTech) at least 2 months after the last dose of updated (2023–2024 Formula) COVID-19 vaccine indicated in Table 2. Further additional doses may be administered, informed by the clinical judgement of a healthcare provider and personal preference and circumstances. Any further additional doses should be administered at least 2 months after the last updated (2023–2024 Formula) COVID-19 vaccine dose.
  • People ages 65 years and older who are moderately or severely immunocompromised should receive 1 additional dose of any updated (2023–2024 Formula) COVID-19 vaccine (i.e., Moderna, Novavax, Pfizer-BioNTech) at least 2 months after the last dose of updated (2023–2024 Formula) vaccine indicated in Table 2. Further additional doses may be administered, informed by the clinical judgement of a healthcare provider and personal preference and circumstances. Any further additional doses should be administered at least 2 months after the last updated (2023–2024 Formula) COVID-19 vaccine dose.
  • For all age groups, the dosage for the additional doses is as follows: Moderna, 0.5 mL/50 ug; Novavax, 0.5 mL/5 ug rS protein and 50 ug Matrix-M adjuvant; Pfizer-BioNTech, 0.3 mL/30 ug.

As an aside and not receiving much media attention, a new report showed that vaccine mandates didn't help and probably hurt. States with vaccine mandates didn't have higher covid vaccination rates and actually had lower covid booster uptake and flu vaccination rates. Yikes!

Nipah Virus

Never heard of it, or hard-pressed to find facts at the tip of your tongue? Most providers in the US don't need to know much about this bat-borne virus, but if you have any patients planning a trip to Bangladesh you may want to advise them not to consume raw date palm sap (not on my list of delicacies so far) and to stay away from pigs.

NiV gets its name from the village of Sugai Nipah in Malaysia, site of a 1999 outbreak highlighted by cases of encephalitis in pig farmers. Outbreaks typically occur in Bangladesh and India. Now, the World Health Organization reports that 2 individuals, including a 3-year-old girl, have died from the infection after consuming raw date palm sap. The sap likely was contaminated with fruit bat droppings laced with NiV. In addition to signs and symptoms of encephalitis, typical findings are those of nonspecific febrile illness. Diagnosis is difficult until/unless encephalitis findings appear. It's a relatively uncommon infection even in Bangladesh, but mortality is high.

Good Attitudes

It's a sign of our times that I was pleasantly surprised to see a vaccine attitude survey with good news. Investigators from RAND corporation, University of Iowa, and CDC performed an online survey of 1351 parents to assess their willingness to have their children 5-18 years of age receive a vaccine to prevent Lyme disease. About two-thirds of parents definitely or probably would vaccinate their children. The boldface numbers below show statistically significant predictors of willingness to have their children receive Lyme vaccine, with willingness of the parent to receive the vaccine the strongest predictor.

In case you were wondering, for the purposes of this survey the high incidence states were Connecticut, Delaware, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Virginia, Washington D.C. (yes, I don't need to be reminded it's not a state), West Virginia, and Wisconsin. They also looked at states characterized as "emerging" Lyme disease states (Iowa, Ohio, Illinois, Indiana, Michigan, North Carolina), but this group had a slightly lower rate of willingness than in high incidence states. Lyme vaccine trials in the pediatric and adult populations are ongoing, so don't be surprised if parents and children have this option in the next year or so.

Speaking of attitudes, take a look at AAP's new guidance for improving vaccine communication and uptake. It has an excellent literature review and describes various strategies that pediatric healthcare providers can use to improve vaccine acceptance. It is still true that different studies sometimes have reported different conclusions on how best to discuss vaccine hesitancy with parents, likely because it is very difficult to design studies that deal with such subjective issues in a uniform manner.

WRIS

Winter respiratory infection season is still chugging along, mostly due to influenza which is stubbornly persisting in scattered areas in the US. What a crazy patchwork!

New Covid Isolation Guidelines

Maybe this has overshadowed everything in the news. I've discussed this recently in the blog and was expecting the new guidelines to come in April, but CDC bumped it up by a month. It incorporates new information about covid epidemiology, hospitalization rates, and outcomes with balancing for impacts on the economy and on school and work attendance into a comprehensive guideline for all respiratory infections. So, no longer do we have a specific number of days after covid diagnosis to remain out of school or work. The document has multiple links and is pretty complicated. The CDC's press release is a good summary, however. Note that vaccination is still stressed heavily, though I expect it will be ignored by the same hardcore group of antivaxxers. Here's the quick blurb:

"When people get sick with a respiratory virus, the updated guidance recommends that they stay home and away from others. For people with COVID-19 and influenza, treatment is available and can lessen symptoms and lower the risk of severe illness. The recommendations suggest returning to normal activities when, for at least 24 hours, symptoms are improving overall, and if a fever was present, it has been gone without use of a fever-reducing medication."

I am very much in favor of these new recommendations. Circumstances have changed, and we have learned a lot from management of the pandemic these past few years. I just hope our vaccination rate will improve and that people with any respiratory symptoms at all will be aware that they can pose a significant risk to others who may have circumstances putting them at high risk for hospitalization or death from respiratory viruses. Also, please note this only applies to community settings; there are no changes for healthcare settings.

Squirrel Redux

If I were superstitious, I wouldn't mention the fact that my neighborhood squirrels still have not attacked my newly-positioned bird feeder. I was bemused by an article in the Local Living section of the Washington Post last Thursday, clearly written by a squirrel lover. Squirrels do have value, and I have no desire to wipe them off the face of the earth. I just don't want them eating all my bird seed.

A friend of mine in South Carolina with an array of bird feeders and birds also has come to terms with squirrels, albeit somewhat differently than my crazy solution. He just monitors things, and when the squirrels reach a point that he feels they become a significant barrier to maintaining bird happiness and seed access, he uses a humane trap to collect squirrels and then release them far from his neighborhood. I won't disclose where he releases them, but it sounded like a good place for squirrels and unlikely to bother too many people. I wonder if any of them found their way back to him.

A downy woodpecker said hello to me last week.

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