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Tag: RSV

Published on Leave a comment on Rounding the Corner?

First, some of you may notice I'm posting unusually late for my regular Sunday routine. I wish I could say it was because I was out all night partying New Year's Eve, but anyone who knows me would realize that's a total fabrication. The truth of the matter is that I've been locked out of my blog account all day and unable to reach anyone at GWU to help me, but now all of a sudden my access reappeared. So, I'm writing this at night in case the Gods of Blog decide to exile me again tomorrow.

We have definitely entered a new phase of the pandemic. I know this because the "A" section of the January 1, 2023 Washington Post (yes, I still get the home-delivered version of our local newspaper) had no original news articles about anything related to medical aspects of covid or the other respiratory viruses circulating. The only acknowledgement that this could still be newsworthy was an editorial bemoaning the situation in China.

Let's dive in.

Tripledemic Tracking

RSV

Continued good news from RSV-NET, further definite decrease in RSV activity nationally.

As you can see from the green line, things appear to be coming down to less drastic levels this year.

Influenza

FLUVIEW also has good news.

We have a very definite downward trend on the red line for this year, very encouraging.

COVID-19

The news is not as good with our old friend covid.

The weekly cases don't show a surge, but percent positivity continues to rise.

In the meantime, a new variant appears to be taking over, particularly in the northeast and mid-Atlantic US.

Those big blue pieces of pie represent XBB.1.5, a subvariant in the omicron BA.2 lineage. It has exploded in the last couple of weeks. It likely has similar immune evasion properties as other recent subvariants, but too early to determine if it has increased ability to cause more severe disease.

What does all of this mean for the future of the tripledemic? That again would require an accurate crystal ball, but hey it's a new year, so why not stick my neck out? With the consistent downward trends in RSV and influenza, I think the tripledemic is over. I do not expect a rebound for either flu or RSV this winter because it's already run through most of the susceptibles who now have considerable immunity. I can't say the same for covid, however, because changing variants are still able to infect those who have been recently infected or immunized. The good news is that pre-existing infection and/or vaccination with boosting likely protects somewhat against severe disease, at least for a number of months, but not so much against new infection. So, I think covid will continue to increase though I doubt at levels we saw last winter, unless a more formidable variant appears.

Long Covid News

We still know very little about long covid, but what is increasingly apparent is that we need to have adequate control groups of uninfected people and people infected with other viruses for comparison. A recent example is an article just accepted for publication in Clinical Infectious Diseases. Long covid is likely a mixture of symptoms resulting from direct organ damage from the virus, such as severe pneumonia or cardiac or renal disease, along with some more poorly understood entities such as "brain fog" and other "myalgic encephalitis" symptoms that are known to follow multiple different types of infections. I am hopeful that the many longitudinal studies that are ongoing will shed more light on this confusing grab-bag of illnesses.

Another Effective Oral Anti-Covid Drug?

I was encouraged by the NEJM article showing non-inferiority of VV116 to Paxlovid, with fewer side effects. Development of resistance to antiviral agents is an ongoing concern for any antiviral treatment, so having more options is always preferable. Let's hope more studies support its efficacy.

It Could Have Been Worse

I came across a somewhat uplifting presentation about Epidemics That Didn't Happen. Take a few minutes to look at it; public health principles, when followed, actually work!

If You'll Be Rounding the Corner With Me, How About Doing It With a Silly Walk?

Every year at this time I enjoy reading the Christmas issue of the BMJ which contains some real but tongue-in-cheek research studies. I was particularly drawn to the study alleging to show the health benefits of the "silly walk" shown in the Monty Python skit in 1970. Try it out - it will bring a smile to your face, and we could all use more of that in 2023.

I wish everyone a safe, healthy, and fun 2023!

Published on Leave a comment on Happy Holidays

Whether you celebrate Christmas, Hanukkah, Kwanzaa, or any number of winter solstice/festival of light ceremonies like Saturnalia, Dong Zhi, Sah-e Yalda, or Shalako (the list of holidays this time of year is quite long), or choose to celebrate nothing at all, I hope you will take advantage of a few days away from work to relax and reflect.

Tripledemic Tracking

Let's check the latest stats from CDC.

RSV

The hospitalization rate graph looks pretty similar to last week on RSV-NET, the final endpoint is for data ending December 17. As indicated in the inset, recent data likely suffer from reporting lag. Still, overall good news.

I'm hoping our community of RSV-susceptible individuals is very low now, such that we won't see a rebound later. Note that we usually have 2 strains of RSV circulating every year, RSV A and RSV B, so in theory it is possible to be infected twice in a season. In the past this has occurred only rarely.

Influenza

Influenza likewise continues to decline nationally as per FLUVIEW, though still at a high level.

The lay press has a lot of buzz about flu increasing because of holiday travel, but I'd remind folks that sometimes with early flu seasons in the past, we've actually seen a big decline in infections because kids are out of school. Again, still plenty of flu around, and with 3 strains circulating still important and not at all too late to get vaccinated.

COVID-19

The CDC's weekly data update is on holiday, but daily updates occurred last on December 23 and I could access a graph similar to last week that tracked through December 21.

Rates continue to increase in general. If you aren't already, indoor masking would be prudent now. I continue to be appalled by the low booster vaccination rates in people who have already received the primary covid vaccine series.

Invasive Group A Streptococcal (iGAS) Infection

I've been following this topic in my myriad of listservs since early reports appeared from the Netherlands last spring, but now the lay press has raised an alarm likely in response to CDC weighing in. The problem is still very uncommon and only sporadically cropping up, but it's worth reviewing what's going on.

CDC issued a Health Alert Advisory (HAN) on December 22 documenting increased reporting of iGAS cases this fall; these include entities such as scarlet fever, cellulitis and necrotizing fasciitis, mastoiditis and sinusitis, retropharyngeal abscess, pneumonia/empyema, and streptococcal toxic shock syndrome. What isn't clear is whether this is something unusual or just the expected number during streptococcal season in a year when we are back to mostly "full contact" among people in our communities. Certainly the large number of respiratory viral infections bear some blame; iGAS is well known to follow viral infections. A few clinical caveats for healthcare providers as well as parents:

A biphasic illness, meaning a respiratory infection/fever followed by a few days of relative well-being and then return of illness with high fever and other symptoms, is a classic red flag for bacterial superinfection following viral illness. That is a time to seek care and pay close attention to consideration of iGAS.

Streptococcal skin infections occur much less frequently since the advent of varicella vaccine. But, given the drop-off in regular childhood vaccines, we likely have a much larger group of children non-immune to varicella. Beware iGAS superimposed on varicella.

Group A streptococcal pneumonia and empyema can be severe. Back in my days as inpatient teaching attending I referred to this as Henson's disease (not to be confused with Hansen's disease, aka leprosy) because this is what killed puppeteer Jim Henson. (I note that his Wikipedia entry has a confusing entry about his final illness, including blaming Disney negotiations for his illness!)

Necrotizing fasciitis is especially dangerous. It is a deeper skin and soft tissue infection than is simple cellulitis and can progress very rapidly to cause extensive tissue destruction and death. One possible clinical clue for healthcare providers is that the degree of pain at the site seems out of proportion to the skin appearance. Quick intervention with both antibiotic therapy and surgical resection can be life-saving.

Speaking of antibiotics, pediatric healthcare providers are aware of the amoxicillin suspension shortage nationwide, ongoing for many months now. AAP has a nice list of alternatives.

Cherish Diversity

Too often recently, the cultural and other differences among us are used instead as excuses for persecution. Wouldn't it be nice if we could all just cherish our diversity and use it to build rather than tear down communities? Have a wonderful holiday of your choice!

Published on Leave a comment on Potpourri

It's that time of year for various types of potpourri, either simmering on the stove or in dried form. I also realized a need for my own infection potpourri, I have so many topics to catch up on. Here goes.

The "Tripledemic"

You wouldn't know it from the news, but there is reason to be optimistic now even with covid cases surging.

RSV

RSV isn't a reportable disease in the US, so accurate tracking is tough. However, CDC's RSV-NET utilizes active reporting from 58 counties in 12 states (CA, CO, CT, GA, MD, MN, NM, OR, and TN) to give a partial picture:

The above is just one screenshot of many in this interactive display, but note the green bar representing the 2022-2023 season. It confirms what pediatricians in our area have been seeing for the past few weeks - RSV is way down. This needs to be tempered with the fact that current hospitalization rates now are in the same ballpark as peaks in the 2 prepandemic years, so there's still a lot of disease activity.

Although there is no guarantee we won't see another peak later on this winter, I would doubt it. We have probably run through the bulk of susceptible young children, so the remainder will be children born in the next few months. If their mothers were infected in this round, these newborns (except for the extreme prematures) will have benefit of maternal antibody. Also remember that, if studies go well, RSV vaccination for pregnant women and a longer-acting monoclonal antibody preventive treatment may be authorized or approved in 2023. (You can see I'm carried away by optimism today!)

Influenza

Similarly, we might be seeing a break in flu nationally, though like RSV and all other respiratory viruses, the disease activity can vary widely in different parts of the country. FLUVIEW shows us the picture from a few different angles. First is influenza-like illness, which can include other respiratory viruses besides influenza because it has a clinical definition without requiring diagnostic proof of influenza infection:

Note there is a clear downward trend for the (red) 2022-23 season, but also compare with the (green) 2019-20 season with multiple spikes that likely reflected the beginning of covid. However, there is additional evidence to suggest flu is waning when looking at the hospitalization rates for confirmed influenza (also from FLUVIEW).

The slope of red line, which shows cumulative hospitalization rates, is decreasing. Keeping fingers crossed, but still plenty worthwhile to get a flu vaccine for those who have procrastinated. We still have a ways to go with flu this winter.

COVID-19

Poor reporting of at-home test results and general apathy about all things covid mean our data aren't as reliable, but we're certainly seeing a surge this winter which is entirely expected.

The telling parts of the graph above are not only the somewhat tiny blip in weekly cases but more significantly the sharp increase in percentage of positive tests that likely spells at least a modest covid winter.

I'm hoping this winter won't look anything like last winter, but as usual it will depend on the variants.

The omicron subvariants BQ.1, BQ.1.1, and XBB will guide the next few months. They have certain advantages in terms of immune escape and growth but so far do not seem to be causing more severe disease. Human behaviors such as vaccine hesitancy and not restricting activities when having respiratory symptoms also are significant determinants for what the winter holds.

New MIS-C Case Definition

Along the lines of more good news, MIS-C has become increasingly uncommon in the omicron era.

Even last winter, MIS-C was not as common as in previous waves, and this trend is continuing now. The exact reasons aren't clear, likely a combination of previous infection, vaccine immunity, and perhaps genetics of the variants themselves. CDC recently modified the case definition to make it more accurate and easier to report; this will take effect in 2023. Check out a CDC webinar for the graph above and more information about MIS-C.

A More Accurate View of the Global Burden of the Pandemic

So, some degree of good news for covid. However, the overall status still is depressing. WHO estimates the cumulative burden of the pandemic to be almost 15 million excess deaths. Although we've all become somewhat numbed by large numbers, take a moment to let that sink in.

On the good news side, the Commonwealth Fund has estimated tremendous benefits from the first 2 years of covid vaccination in the US:

Covid Vaccine Updates

Speaking of covid vaccines, a few new items appeared recently. CDC released 2 reports showing relatively good efficacy of the bivalent boosters in preventing serious disease in adults. The studies are still preliminary and have a lot of limitations including not being able to control for individual behaviors such as use of therapeutic options like Paxlovid. One study looked at hospitalization rates in those 65 years and older and the other reported emergency department, urgent care, and hospitalization rates in immunocompetent adults.

One study of the Pfizer vaccine documented the benefit of booster dosing in the 5 - 11 year-old age group. This was during the delta and omicron periods but before the bivalent booster appeared.

Now we just need to improve our dismal covid vaccination rates! The AAP provided a guide for busy practices trying to figure out which vials to use for which circumstances, and CDC provided a nice webinar (I learned several things) about discussing vaccine hesitancy. I urge all healthcare providers to look at it.

Happy Birthday Louis!

Whenever I spoke about ancient (i.e. older than 5 years) history of infectious diseases, trainees always assumed I was speaking from personal experience. Let me be clear: Louis Pasteur was not a contemporary of mine. A very happy 200th birthday to Louis on December 27. Several editorials in the December 17 Lancet marked this milestone. The proponent of the germ theory of disease and developer of the first rabies vaccine likely could still teach us a few things about handling today's pandemic.

Also, I can't leave the subject of birthdays without noting my wife's birthday this week. She is considerably younger than Louis. Happy Birthday to Pam!

Published on Leave a comment on Too Much Ado About Nothing?

This will be a short post this week, not really that much new information going on in the world of pediatric infectious diseases. That's not to say pediatric healthcare providers aren't super busy, but the new information being published/promulgated isn't earth shattering. This again reminded me how important it is to avoid listening too closely to those who may tend towards sensationalizing health news without focusing on what's important. How do healthcare providers and the lay public sort through all the information?

A case in point is the recent wave of respiratory viral infections taxing pediatric healthcare settings. I've seen too many news reports touching on RSV but failing to give parents and families enough information on warning signs for more severe disease. I suspect this contributes to a lot of unnecessary visits to urgent care and emergency rooms for children with mild respiratory disease. Fortunately there are a few online resources that demonstrate the specific breathing signs that could warrant escalating to medical intervention.

We also need to be cognizant of the type of information being presented. For example, a Pfizer press release about antibody formation following the new bivalent covid vaccine. First, these are data announced by a for-profit company and not subject to any peer review. It is essentially an advertisement. Also, remember that these are just numbers, what we really want to know is how it protects against severe disease, and we don't have that data yet. Also, we'd like to know how it protects against new covid variants, not older ones. I'm not saying to ignore the information, it is important in understanding the immune response of bivalent vaccines. Just consider the source and the practical relevance of the data.

My last example, and then I'll try to silence my curmudgeonly comments for the week, is a recent report suggesting that individuals with more side effects following covid vaccination may be more likely to have higher antibody responses. Overall the studies on this particular subject have shown mixed results, and furthermore virtually everyone develops good immune responses regardless of whether they experience side effects or not. Again, monitoring this type of information is very important, it could lead to better understanding of how to improve vaccines, but it's not anything that would help anyone decide their own level of protection.

Shakespeare's play to which I referred in my title contains warning of sorts about the dangers of mis/disinformation. How did he know we'd be dealing with covid 400 years later?

Published on Leave a comment on A Failure to Communicate

Regular blog readers know I've taken a few months respite from posting to get my newly retired status figured out (still working on that) and deciding whether to continue blogging (affirmative, as indicated by this posting).

Even before the COVID-19 pandemic I was struck by how poorly we healthcare providers communicate risks, benefits, and management choices to each other and to our patients. We haven't done a good job of communicating the uncertainties inherent in medical science and practice; for multiple reasons, the pandemic has transformed this communication gap into a wide chasm. I'll be trying harder to be an effective communicator, not only to pediatric healthcare providers as before but also to patients, families, and the public in general.

The title of this post comes from the 1967 movie "Cool Hand Luke" starring Paul Newman and depicting the lives of jailers and inmates in the Deep South shortly after World War II. Having never watched the movie in its entirety before, I forced myself to do so recently. More on that later.

Bivalent COVID-19 Vaccines for 5-year-olds and Up

I hope all pediatric healthcare providers are now well aware that both Pfizer-BioNTech (ages 5 and up) and Moderna (ages 6 and up) bivalent vaccines are authorized for booster doses. Note that the bivalent part of the terminology just means it contains proteins from both the original strain of the SARS-CoV-2 virus that appeared in late 2019 as well that from the more recent omicron variants BA.4 and BA.5 that have some ability to evade the immune protection of the original vaccine.

Although we don't yet have peer-reviewed publications of the data leading to this authorization, know that it was based primarily on safety and antibody data, rather than a prolonged trial looking at how effective the boosters are in preventing severe COVID-19 disease in children - that information will take many more months to accumulate, and studies are ongoing as are studies in younger children.

At this point in the pandemic, the scientific data on the benefits of vaccination are clear. Compared to outcomes of natural infection with the SARS-CoV-2 virus, vaccines come out ahead for all age groups and risk factors, including for children. Of course, the magnitude of the benefit (bang for the buck) is greater for older individuals and those with underlying conditions leaving them at higher risk for COVID-19 complications. Risk for a poor outcome in a healthy child with COVID-19 disease is much lower than in an old geezer like me, for example. Still, it's a slam dunk from my perspective: every child eligible for vaccination should receive the primary series and available boosters. Reliable information is available from the CDC website. Vaccine Recipient Information also is available. 'Nuff said.

Variations on a Theme

Regardless of what COVID-19 variants are up to, we are in for a tough winter of respiratory virus illness, including for children. Our usual seasonal patterns have changed since the pandemic started, but maybe this season will be more normalized. We have already had a very busy enteroviral illness season; this virus usually peaks in August/September and came back with a vengeance recently. Influenza is ramping up mostly in the southern US but will soon involve the entire country, and respiratory syncytial virus (RSV) activity is already up - usually RSV is a late fall/winter virus. In the days before the pandemic every winter I (selfishly) hoped that RSV season would taper off before flu season started; if they came at the same time, we'd all be working overtime. Now, we're layering COVID-19 on top of all this. I strongly recommend annual influenza vaccine for everyone who is eligible.

Everything so far is pointing to an increase in COVID-19 cases this winter season. For example, cases in the United Kingdom and elsewhere in Europe are already rising, and with so many unvaccinated children out there all going back to school, we can expect a lot of SARS-CoV-2 transmission. How much, and how severe, are unanswered questions so far. In part this depends on the behavior of the so-called virus variants.

The graph at the right depicts the most recent CDC data for circulating variants of SARS-CoV-2, as of October 15, 2022. First, the good news. These are all subvariants of the omicron variant; this has been the case for several months (remember the delta variant?). Omicron seems to be a variant that causes less severe illness in general.

Now for the bad news. Some of these subvariants show early indications that they are resistant to some of the therapies now very helpful in managing or preventing infections. Secondly, some of those now increasing, like the dark blue BA.4.6, may not be prevented by the original COVID-19 vaccines. That's why there was a big push to produce the bivalent vaccines that include components that could be more effective for these newer subvariants. Again, everyone eligible for the bivalent COVID-19 booster should receive it.

The real concern is that we are waiting for the next major change in the virus that could portend something that could evade our existing treatments and vaccines and cause more severe disease. As long as we have humans being infected, this virus will continue to mutate; the more infections, the more mutations and the more likely we'll see a worse version of the virus come to the forefront.

But enough of this doom and gloom! Sometime, maybe about a year ago when it became clear that SARS-CoV-2 had incredible ability to produce new variants, I was reminded of the Goldberg Variations, a set of keyboard pieces written by J. S. Bach. Johann Gottlieb Goldberg studied under Bach and likely was the first person to perform Bach's variations. My favorite pianist playing these variations (not that I've sampled all the recordings) is Glenn Gould. It is my never-fail stress reliever, especially needed during pandemic times.

Cool Hand Luke

Retirement has given me more freedom to go down rabbit holes, and when I found out the "failure to communicate" quote came from this movie (though not present in the book from which it was adapted) I had to watch the full movie. I said at the start of this post that I had to force myself to watch the entire movie; the emotional and physical brutality depicted was a bit tough for me. However, I enjoyed performances of all the lead actors plus a few "hey, doesn't he look like ..." moments that I discovered were younger versions of future stars, their names buried in a long list of cast credits.

The quote itself, delivered by the great character actor Strother Martin in his role as prison warden, is: "What we've got here is failure to communicate." (It is #11 on the American Film Institute's list of 100 greatest American movie quotes.)

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