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Published on Leave a comment on Welcome to Our 10th Month!

The first of the month happens to fall on a Sunday, the day I put together my weekly post. I am transiently aware that the root word for December derives from the number 10 yet persists as the name of what is now our 12th month. Having nothing better to do while trying to digest my Thanksgiving excess of wonderful food, I decided to refresh my memory as to how this rather bizarre nomenclature has persisted.

Meanwhile, the CDC had a nice Thanksgiving recess and thus will not have any new updates on the winter respiratory infection activity until December 2. I can only report anecdotally that RSV season is in full swing in the Washington, DC, metropolitan area, with little in the way of influenza or covid cases. Still, there is lots to talk about from last week.

A Rare Mention of Early Phase Studies

I don't often mention results from phase 1 or phase 2 human trials; the studies are important but the findings aren't immediately transferable to clinical practice. Generally we need to wait for phase 3 trials to be completed so that we know how effective the intervention is likely to be. However, I couldn't hold myself back from these 2 reports because of the novel approaches and the likelihood that they represent what the future will look like.

The first report is of bacteriophage therapy for infections caused by multiply-resistant bacteria. Clinicians may recall that bacteriophages are viruses that exclusively infect bacterial cells and can destroy them. Bacteriophage use for treating infections resistant to all known antibiotics isn't new, it's being used by most tertiary medical institutions for the past few years at least. It requires painstaking hunting for a bacteriophage that is effective for the particular patient's infecting bacterium. What was enlightening to me was how CRISPR technology was used in this phase 2 trial to custom-design a bacteriophage, in this case for use in E. coli urinary tract infections. The resulting product is, unlike classical therapeutic bacteriophages, independent of the infecting organism's susceptibility pattern and can be used off-the-shelf, eliminating a patient-specific and very expensive, cumbersome, time-consuming search for an effective phage. Note, however, this still is a fairly cumbersome therapy. The actual treatment consisted of 2 days of intraurethral and 3 days of intravenous phage therapy, plus oral trimethoprim-sulfamethoxazole. The subjects were all adults and numbers were small, but relatively good responses were seen in the treatment groups.

A second part of the phase 2 trial is underway and one hopes we will see further results from this trial.

The other preliminary study is a phase 1 trial of a diphtheria antitoxin (DAT) developed as a monoclonal antibody. Currently DAT is an equine antibody and is in short supply worldwide. Having a ready supply of human monoclonal antibody could alleviate the shortage plus reduce the allergic reactions related to use of horse serum. In 41 adult subjects in this trial, the monoclonal product produced higher neutralizing antibody concentrations than that seen with the equine DAT and strongly suggests that it will be highly effective. Needless to say in our rapidly-advancing anti-vaccination environment, this could be an important advancement not just in resource-poor countries but also in the United States as well.

Tonsillectomy for PFAPA

Periodic Fever, Aphthous stomatitis, Pharyngitis, and cervical Adenopathy syndrome has been one of the dilemmas of my clinical practice for decades. It is likely a genetic periodic fever syndrome, but no precise gene mutation has yet been identified and thus there is no definitive diagnostic test available. PFAPA eventually resolves spontaneously with no known clinical sequelae. If all of the clinical components are present, the diagnosis is fairly easy, but likely there are variants of this syndrome, including those presenting with periodic fever alone. Tonsillectomy was effective in a randomized controlled trial but usually is employed only after other, simpler, therapies fail. Now we have an observational study on long-term (median 8.8 years) follow-up of 86 children in Sweden who underwent tonsillectomy for PFAPA. Entry criteria required periodic fever with at least 1 other finding of aphthous stomatitis, cervical lymphadenitis, or pharyngitis as part of their usual symptom complex. Here's the bottom line in (not pumpkin) pie format:

This information will be helpful in discussing treatment options, but it should be noted that, because this is a genetic disease that could have multiple gene variants, results may not be applicable to other populations beyond this Swedish cohort. The authors did not report the subjects' racial or ethnic backgrounds.

Parvovirus B19

Last week the CDC gave us a bolus of reports on parvovirus infections in MMWR. In a study of clinical and donor plasma testing in 2024, the percentage of samples showing positive parvo B19 antibody and/or PCR showed a significant jump. Below are the results for PCR testing of blood donor plasma.

In addition to the above, this MMWR issue also had 2 other parvo B19 reports focusing on high risk populations. Aplastic crises in sickle cell disease patients showed an upswing in an Atlanta children's healthcare organization:

Another report focusing on pregnant people in Minnesota this year showed increases across younger age groups:

Five laboratory-confirmed infections occurred in pregnant people at 13 - 20 weeks gestation, with the following characteristics:

Perhaps this is all part of the "immunity debt" catch-up we are seeing in so many infections occurring post-pandemic. Pregnant people often are infected by their own school-aged children. A good time for clinicians to brush up on parvovirus B19.

Cost Effectiveness of RSV Prevention

I've discussed how covid vaccination recommendations vary by country, such as the UK restricting vaccination of lower-risk groups due to cost concerns even though being vaccinated has lower risk of sequelae than with natural infection in these groups. Now we have some numbers for RSV prevention through maternal vaccination or with administration of monoclonal antibody to infants, courtesy of 2 CDC-funded analyses.

For maternal immunization during weeks 32-36 gestation, incorporating various estimates of newborn outcomes and maternal side effects from vaccination, vaccination of mothers year-round cost $396 280 per quality-adjusted life-year (QALY) saved. If vaccination were limited to the September through January period, the cost dropped to $163 513 per QALY saved. Changing various inputs to the model resulted in ranges from a net cost savings up to $800 000 per QALY saved.

For infant nirsevimab utilization using similar analyses and looking at single RSV season benefits in infants 0 - 7 months and 8 - 19 months of age, assuming half the US birth cohort received nirsevimab, cost savings were $153 517 per QALY saved. "Nirsevimab in the second season for children facing a 10-fold higher risk of hospitalization would cost $308 468 per QALY saved. Sensitivity analyses showed RSV hospitalization costs, nirsevimab cost, and QALYs lost from RSV disease were the most influential parameters with cost-effectiveness ratios between cost-saving and $323 788 per QALY saved."

Clearly the costs to society vary widely depending on what assumptions are made for effectiveness, outcome rates, and costs of product and hospitalizations, etc. As noted in the accompanying editorial, these costs are so high because the products themselves are very expensive, much more so than our other vaccines. If nirsevimab were to cost $50 instead of almost $500 per dose this would certainly be a net savings to society, but don't hold your breath for the cost to decrease anytime soon. Still, both of these products have very high clinical effectiveness, and pediatric healthcare providers should provide nirsevimab to all eligible infants whose mothers did not receive RSV vaccine during pregnancy.

Hiding in Plain Sight

Somewhere buried in the back of my mind is the fact that the word December contains the Latin root for 10, decem. This dates back to about 750 BCE and the calendar of Romulus, the first king of Rome. The calendar had only 10 months, starting with March and ending with December, with some sort of in-between period that became January and February during the reign of the next king, Numa Pompilius, who took over in 715 BCE. Various rearrangements appeared over the next few centuries. What I should have known but didn't, September, October, and November kept their names derived from the Latin names for numbers 7, 8, and 9. So, we're stuck with outdated names for 4 of our months that date back to use during a brief 50-year period occurring almost 3 centuries ago.

Also, I'd be remiss if I didn't report back to you about the Wiedermann Thanskgiving Massacree of 2024; thankfully, there was none. The most amazing thing that happened was that for the first time in modern history, not quite dating back to Romulus, I didn't make a written minute-by-minute oven and stove schedule for Thanksgiving day. Such activity was rendered moot largely because the 3 primary cooks (my sister-in-law, my wife, and me) were too organized from the start. It was a breeze, except for a brief cursing episode by yours truly when a new bird-carving technique proved to be less than desirable.

Happy 10th Month.

Published on Leave a comment on The Wiedermann Thanksgiving Massacree of 199?

Thanksgiving week has arrived, which for me means making checklists and time schedules and then revising them several times up until Thursday, at which point nothing happens according to schedule and I just go with the flow. It's also a time I remember the infamous Wiedermann Thanksgiving Massacree of 199? (I can't remember the exact year), with apologies to Arlo Guthrie.

Understandably in the past few years, this blog has drifted to the latest public health and epidemiologic trends, but I'm comforted by the fact that respiratory infections remain relatively calm and that this past week's publications allow me to focus more on recent original studies of interest to pediatric healthcare providers and the general public.

Macrolide-resistant Mycoplasma pneumoniae

I'm getting pretty tired of hearing about our resurgence of "walking pneumonia," but this article caught my eye. It's a report from North Dakota, and my interest wasn't in the fact that the investigators found evidence of macrolide resistance; that's nothing new. The bigger question is whether the resistance has major clinical significance. I've stated previously that, because Mycoplasma lower respiratory infection is largely a self-limited disease, it's difficult to know whether antibiotic treatment helps, and if it does, whether the amount of benefit is worth treating with antibiotics. The vast majority of "walking pneumonia" cases in children don't need any nasal swab or radiographic testing, nor any treatment.

The study was small, just based on 10 children of which 8 had macrolide resistance genes detected in their nasal swab assays. Six of them were said to have failed azithromycin treatment, though the authors didn't define treatment failure. Six of the patients who had fever and received doxycycline or levofloxacin became afebrile within 24-48 hours. Needless to say, this doesn't translate to great evidence that macrolide resistance is clinically important; it does point to the fact that we need randomized controlled trials to answer this question. Unfortunately, studies need funding, and this condition isn't likely to be profitable enough for funding from a pharmaceutical company. My only takeaway from the study is that further evaluation and treatment should be considered in children with possible pneumonia in whom symptoms worsen or fever persists more than a few days. Unfortunately, M. pneumoniae susceptibility testing isn't routinely available. For mild community-acquired pneumonia in children, amoxicillin is the treatment of choice, with azithromycin as a second-line agent. Switching to doxycycline or levofloxacin should be reserved for macrolide treatment failure, however that is defined.

Certainly we are having a banner year for mycooplasma respiratory infections, likely a combination of the normal mycoplasma surges we see every few years and lack of exposure during pandemic years. Which brings us to ...

Immune Debt

I really liked this new article that looked at the concept of a dose response effect in immune debt, i.e. that the magnitude of illness we see in rebounds of respiratory infections post-pandemic should be proportional to how much less frequent these infections were during the pandemic. The statistical methods in the study are somewhat beyond my expertise, but I mostly think the authors proved their point that lifting of non-pharmaceutical interventions (NPI) around the world seemed to be a point of increase for various respiratory infections. Here's a sample of the findings.

If this is all true, presumably we'll be back to the "old normal" of seasonal respiratory infections soon (barring another serious pandemic).

UTI Diagnosis

I must confesse my eyes rolled when I saw the title of this new study. Early in my career I was involved in UTI research. I've been very disappointed in analyses of UTI diagnosis in recent years because most of them seemed to ignore how variable accuracy of different UTI diagnostic laboratory methods are, even for something as basic as urinalysis. For example, it makes a big difference whether the number of white blood cells in urine is determined by machine (usually flow cytometry), manual counting by a lab technician with or without use of a hemocytometer, or just a urine leukocyte esterase dipstick. So, I was very pleasantly surprised that this group of investigators highlighted precisely those concerns. This was a study of around 4000 febrile children evaluated for UTI with urinalysis and culture, and the results showed that virtually all urinalysis components were poor at predicting a positive urine culture, defined as > 50,000 cfu/mL of a single pathogen in a catheterized urine specimen. The authors concluded that around 20% of children with febrile UTI could have normal urinalyses but also acknowledged how difficult it is to factor in asymptomatic bacteriuria (estimated rate 2%, but tough to assign an exact number) and specimen contamination. I don't think this study solves any of these issues, but it is an important contribution to our understanding of UTI diagnosis.

WRIS and Nowcasting

Last week CDC published a more detailed explanation of how the time-varying estimated reproductive number (Rt) can be used as an early warning for changes in respiratory pathogen transmission activity. This report is of interest mostly to true epidemiologic nerds, so of course I found it very enlightening. The authors did provide convincing evidence that this methodology has been working well recently.

We're not due for another respiratory illness outlook update from the CDC until mid-December, they only provide these every 2 months, but we remain mostly quiet. I suspect we'll see RSV and influenza hit pretty soon around the country. Again, you can check your own local illness and wastewater activity at the CDC' site.

Beware Studies Based on Administrative Data

This is one of my pet peeves: not the studies themselves, but how too much importance seems to be given to them in the lay press (bolstered by academic organizations seeking to get their names in the news). A new study shows how variable results can be from these databases, using the example of invasive bacterial infections in febrile infants. It's easy to imagine how any system based on diagnosis codes entered into various databases could lead to classification errors, but this report provides an excellent example to keep in mind. Any study using an administrative database should evaluate accuracy of diagnoses on a subset of patients to give some evaluation of the accuracy of their results (IMHO).

New 2025 Vaccination Schedules Published

The information isn't new, just based on prior FDA and ACIP deliberations mostly happening over the summer, but now we have the colorful schedules to use. The AAP has a quick summary of changes.

Happy Thanksgiving!

I have so much to be thankful for this year, and I hope not to repeat the Wiedermann Thanksgiving Massacree of maybe 30 years ago. I won't explain in full; it's too painful to spend anything like the 18 minutes, 34 seconds that Arlo Guthrie took to explain his Alice's Restaurant Thanksgiving Massacree of 1965. (Restaurant namesake Alice Brock died a few days ago.) The short version is that my attempt to create the perfect turkey gravy ended badly in an oil slick of glass shards in the kitchen. Why I'm still allowed to have any Thanksgiving responsibilities at all is a prime example of my wife's incredible powers of forgiveness.

We'll be hosting a relatively small gathering at our place this year. My duties are limited to turkey, gravy, and drinks. Starting today I'll have my checklists made out, separated into daily tasks. Thursday itself will have a well-choreographed timeline to include oven and stove use times in our smallish kitchen. As I said at the start, these scraps of paper will bear little resemblance to how the meal actually unfolds.

I won't go into detail about all the food-borne illnesses linked to turkey dinners, but please make good use of your food thermometer and follow guidelines.

And, speaking of Arlo, some of you might be interested in his live recording of "Amazing Grace" with Pete Seeger in 1993 (around the time of the Wiedermann Massacree!). It's 13 minutes of music and meanderings still meaningful in today's world.

Published on Leave a comment on A Modest Proposal

Quite an eventful week! In general, I try to keep politics out of my commentary, though I fell short of this goal in my February 25, 2024, post where I blasted the Surgeon General of Florida; that may be the only time I've singled out an individual in a negative manner in this blog. Now, I find that his name is being mentioned as the next Secretary of Health and Human Services. All of this reminded me of an almost 300-year-old pamphlet.

But first a bit of the other health news from last week.

Mayaro Virus

In spite of my voracious appetite for medical knowledge, the list of viruses I've never heard of is lengthy. Now my list is one item shorter due to a new report. Mayaro virus is another of the arthropod-transmitted alphaviruses prevalent in parts of South America, causing a febrile illness with severe arthralgias very similar to its cousin Chikungunya virus. Primates serve as a reservoir with the primary vector the mosquito Haemagogus janthinomys. If like me you are a bit shaky on some elements of South American geography and history, Suriname is a former Dutch colony located just north of Brazil and has territorial disputes (in light green) with neighboring countries.

Measles in Vietnam

Vietnam is introducing earlier measles vaccines to try to stem an epidemic. In this WHO Western Pacific region report, you can see Vietnam is going the wrong way in measles incidence. Like the rest of the world, we all "enjoyed" a pandemic period where many traditional infectious diseases transmitted by respiratory routes showed significant declines due to non-pharmaceutical interventions, only to now reappear in greater numbers. For measles, Vietnam showed an incidence of 7.4/million population in 2020, dropping to 0.3 in 2022 but now back up to 7.1/million in 2024.

Normally Vietnam recommends measles immunization at 9 months of age, but now this is being dropped to 6 months due to an increase in cases in younger age groups. (You'll need Google translate for this link.)

Computerized Radiograph Interpretation for TB?

Although this study was performed only in adults, I thought it was worth mentioning as a possible glimpse of the future. Investigators in Africa and southeast Asia looked at the performance of a computer program to interpret chest radiographs in about 1400 adults with cough > 2 weeks in duration and found the program to have significantly higher sensitivity than a relatively new blood test for host response gene activation in TB as well as superior to CRP. When trying to diagnose TB in resource-poor settings that may not have access to good molecular and other microbiologic methods for TB diagnosis, we need every tool available. I'll be interested to see how newer methods for TB diagnosis evolve.

More on Bird Flu

CDC reported that 7% of 115 dairy workers at farms known to have infected cows showed serologic evidence of influenza A H5N1 infection. Four of the 8 seropositive workers did not recall having any respiratory signs or symptoms since the cows were first noted to be sick. This rate wasn't terribly different from the 60% of those with no illness history in the seronegative group. Given that H5N1 so far seems to be a mild illness in humans, the finding of asymptomatic infection isn't surprising. Clearly we need a lot more data on human illness in these and other settings.

Benefits of Quadrivalent Meningococcal Vaccine

Of our recommended vaccines, meningococcal vaccine probably has the lowest "return on investment." Meningococcal disease is relatively rare but comes with very high morbidity and mortality when it does occur. This modeling study estimated the number of cases of invasive meningococcal disease in 11-23 year-olds prevented by vaccination during the period 2005-2021. One always needs to take modeling studies with a grain of salt because they by necessity make a lot of assumptions. The authors did a good job of trying to look at all possibilities. They concluded that "vaccination averted an estimated 16 (95% CrI, 8-31) deaths among adolescents aged 11 to 15 years and 38 (95% CrI, 19-75) deaths among those aged 16 to 23 years." I guess those are small numbers when compared to the entire US population, but this is still a meaningful benefit.

WRIS

Things are still relatively quiet, though with regional variations.

I did happen to note that wastewater levels of RSV are very high in Maryland, so maybe that will be the first pathogen to increase in my region.

Make America Healthy Again

I feel like the MAHA acronym was one of the nicer-sounding political slogans to appear recently. However, the fact that it was popularized by a notorious pseudo-science fringer concerns me for what might lie behind MAHA. That made me recall a short treatise by Jonathan Swift (of Gulliver's Travels fame) that I came across a long time ago. I read it again a few times this week, and this highly satirical essay entitled "A Modest Proposal" is worth 10 or 15 minutes of your time. I think it is best read without knowing where the narrator is going, so I'll give you a SPOILER ALERT. You can read the original document in the link now, before reading what I write below, or you can just forego the surprise and keep on with my take below.

The narrator beings with an "objective" view of the problem, in 18th century Ireland, of the economic woes of a large section of the populace. He particularly hones in on the difficulties that parents in lower economic strata have in providing for their children. After going through some numbers assumptions that we can only guess at the accuracy, he decides that Ireland has about 120,000 children born to impoverished parents annually. How can the country solve this problem? He offers his modest proposal, or "humble solution:" It's a sudden turn in tone, to say the least.

"I have been assured by a very knowing American of my acquaintance in London, that a young healthy child well nursed, is, at a year old, a most delicious nourishing and wholesome food, whether stewed, roasted, baked, or boiled; and I make no doubt that it will equally serve in a fricasee, or a ragoust."

Yes, Mr. Swift in his satirical essay is proposing cannibalism as a solution to poor families trying to raise their children. He goes on to describe various details of preparation and serving.

MAHA sounds OK now, but I fear of this becoming another modest proposal. I'll withhold my judgment until we see more details of the plan.

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 Winding Down (Again)

After one failed retirement attempt, I'm trying again. I just entered a new phase to decrease my coverage of inpatient telemedicine services at regional hospitals and, if demand isn't increasing terribly, I'll phase out completely. In the meantime, I'm revving up for watching the Winter Respiratory Infection Season (WRIS).

WRIS

Nothing strikingly new or concerning on the covid, influenza, and RSV fronts, according to CDC. Respiratory illnesses, wastewater levels, and ED visits are pretty flat or decreasing most places. Florida is starting to show an increase in RSV; typically that region starts sooner than the rest of the country. Of course all viral activity varies geographically, and you can look at your own region with CDC's interactive program at that link.

I admit to having some personal interest in following this closely now. I'm trying to figure out timing of my flu vaccine; as a septuagenerian I may have more rapid waning of immunity after vaccination than do younger generations, plus preliminary data from the Southern Hemisphere suggests a slightly lower flu vaccine effectiveness this year. The key term here is preliminary. These estimates are based on very low sample sizes, and estimates always change once the full season can be evaluated.

Speaking of vaccines, the UK provided a more straightforward guidance for covid vaccination this year. The eligibility groups are pretty limited:

During the 2024 autumn campaign the following groups should be offered a COVID-19 vaccine:

  • all adults aged 65 years and over including individuals aged 64 who will have their 65th birthday before the campaign ends (31st March 2025)
  • residents in a care home for older adults
  • individuals aged 6 months and over who are in a clinical risk group, as defined in tables 3 and 4 of the Green Book chapter 14a

As I've mentioned before, the UK with its National Health Service relies heavily on cost effectiveness analyses, leading to a more restricted target population than in the US.

Two Viruses on the International Scene ...

Marburg Virus in Rwanda

Marburg activity in Rwanda is increasing, and the CDC sent out an advisory last week. Marburg virus is another of the hemorrhagic fever flaviviruses, like Ebola; it has a high fatality rate. As in other hemorrhagic fever virus outbreaks, healthcare workers are at high risk if they are not careful with exposure to blood and body fluids. Most of us remember the spread of Ebola to the US, and already there's been a scare in Hamburg, Germany, but the ill traveler returning from Rwanda tested negative. The name comes from the German city of Marburg which was one of the sites (the others were Frankfurt, Germany, and Belgrade in what is now Serbia) of laboratory outbreaks of the illness in 1967, linked to African green monkeys imported from Uganda. Let's hope efforts to contain the infection are successful, but it's a tough task in low-resource regions.

Perinatal Chikungunya

A new study from Brazil suggests a relatively high rate of transmission of this virus from pregnant people to their newborn infants. The study period covered the years 2016 - 2020. Here's the summary numbers:

Symptoms in infected infants included, in addition to rash and fever, some more severe conditions like DIC, vesiculobullous eruption, seizure and encephalitis, and respiratory failure. It was both a retrospective and prospective case series, and I learned a new term: ambispective!

... But Also Some International Success

The WHO recently declared Brazil has successfully eliminated lymphatic filariasis as a public health problem, a major milestone. The only countries successful previously with filariasis were Malawi and Togo in the WHO African region; Egypt and Yemen in the Eastern Mediterranean region; Bangladesh, Maldives, Sri Lanka, and Thailand in the South-East Asian region; and Cambodia, Cook Islands, Kiribati, Lao People's Democratic Republic, Marshall Islands, Niue, Pilau, Tonga, Vanuatu, Viet Nam, and Wallis and Futuna in the Western Pacific region. Time to dig out that world map!

Filariasis is one of 20 Neglected Tropical Diseases targeted by WHO for improved control by 2030.

Lower Vaccination Rates in US Kindergartners

CDC updated vaccine coverage rates for the 2023-2024 year and, no surprise, it's dropping. The decrease may be driven at least in part by an increase in non-medical exemptions. This news doesn't bode well for future outbreaks of vaccine-preventable diseases, but the clinical impact is largely determined by geographic distributions at the community level. The site has a lot of data, worth some browsing, but here's a quick look at MMR coverage by state for 2023-2024:

Any state that isn't the darkest blue has high risk for outbreaks. Even within the dark blue states any pockets of poor vaccine coverage, such as communities or schools that have high rates of vaccine-averse parents, could see outbreaks.

How's Your Outpatient Antibiotic Prescribing Score?

A cross-sectional database study of about half a million antibiotic subscriptions in 2022 from Tennessee showed some interesting results. The investigators looked at both appropriateness of antibiotic choice and duration of treatment; only 31% of prescriptions were appropriate for both. Here's the quick look at optimal antibiotic choice by disease:

Here's what it looked like for duration of therapy. Standard durations reflect current guidelines, whereas contemporary durations are taken from more recent studies suggesting shorter courses are effective. The number of days in parentheses are the contemporary durations.

Again, another study worthy of browsing if you commonly prescribe antibiotics for these conditions.

November 5 is Fast Approaching

Although I'm trying to wind down my practice, it seems like my to-do list is twice as long now. We're all busy, but please don't forget to vote!

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