RSV – Page 3 – Pediatric Infection Connection

Are You an Owl or a Lark?

Bud WiedermannMarch 10, 2024March 10, 2024Leave a comment

Another round of Daylight Saving Time. I came across a new article suggesting that potential harms of DST depend on your individual chronotype, or, more simply, whether you are an owl or a lark. I definitely fall into the lark category. More on this later, but let's dive into what's been happening in pediatric infectious diseases the past week.

New IDSA Laboratory Test Guidelines

Just out is an updated guideline from the Infectious Diseases Society of America. It might be my favorite guideline of all time, but at 244 pages I recognize it's not for everyone. Let me mention a couple items that I notice some frontline healthcare providers may not know about but are important to avoid misleading test results (a garbage-in-garbage-out scenario).

First concerns the use of swabs, starting on page 8 of the pdf guideline document. Always use a swab for sampling throats, conjunctiva, superficial wounds (aerobic culture only), some nose, nasopharynx, and vaginal testing, and sometimes in special circumstances related to institutional- or manufacturer-related instructions for the product. Never use a swab for surgical tissue - submit the tissue itself making sure it doesn't dry out before processing. The same applies for "respiratory fluids and secretions, endophthalmitis and keratitis, nasal sinus, otitis media, biopsy, abscess fluid, fungal and acid-fast bacilli specimens, formed stool, epiglottitis, diarrheal illness, and when anaerobes are suspected opt for tissue or fluid in anaerobic transport... Never submit a swab for analysis that has been dipped into a fluid or exudate. Send an adequate volume of the fluid or exudate instead." There's also an in-between situation where larger volume sampling isn't feasible, such as with an open wound (at least obtain a needle aspirate of leading edge).

The second pertains to urine specimens, the bane of my existence when consulting on possible UTI based on specimens that have sat around for considerable time before processing, such as placed in a lab collection box in an outpatient setting. Some key points, starting on page 119: "Urine collected for culture should not be kept at room temperature for more than 30 minutes. Hold at refrigerator temperatures or utilize a preservative tube if not processed by the laboratory within 30 minutes." The authors also mention the perils of relying on urinalysis because techniques have not been standardized and often require subjective interpretation. Especially if you are dealing with a child with possible UTI, obtain a good mid-stream voided or catheterized urine specimen and, again, don't let it sit at room temperature too long before analysis.

Different considerations arise when sampling urine for sexually transmitted infection - here, the first portion of urine voided is best for detecting pathogens by nucleic antigen amplification testing.

Speaking of Throat Swabs

The biggest problem in diagnosis of streptococcal pharyngitis is performing throat testing in children highly unlikely to have streptococcal pharyngitis. In this setting, a positive result is much more likely to represent a clinically-irrelevant carrier state and result in unnecessary antibiotic exposure for the child. Some heavy hitters in the group A streptococcal world published a review on this recently, but unfortunately it is not available without subscription to the journal. The authors describe differences in GAS testing between the US and Europe, compare and contrast rapid antigen detection and NAAT testing, and again mention situations where testing should not be performed: children less than 3 years of age unless known exposure, children with signs of viral infection including cough, runny nose, or hoarseness, and absence of "bona fide" clinical suspicion for strep throat if you use a clinical scoring system such as Centor or McIsaac.

Nirsevimab Worked Liked We Hoped

Nirsevimab effectiveness was 90% in preventing hospitalization for RSV infection in infants during their first RSV season, according to CDC data on 699 hospitalized infants. This is actually at the upper end of the confidence interval from prior clinical trials.

AI for Otitis Media

I seem to be on a track of personal banes of my existence as a consultant; misdiagnosis of acute OM is near the top. Although I don't see any of us being replaced by artificial intelligence anytime soon, a new report has some glimmer of hope that it might help us with AOM. It uses a not-yet-available iPhone app with an otoscope; you can use voice to control when to take a photo. Watch the video (at the link to the article, not in the screenshot below) to get an idea of what's involved. It's not nearly ready for prime time, but stay tuned.

Is Covid a Risk for Development of Autoimmune Rheumatologic Inflammatory Disorders?

This study of millions of adult patients from Korea and Japan utilizing a claims database would suggest that it is, with adjusted hazard ratios around 1.25 - 1.3. So far this is just an association and does not determine causality. Also, genetic risks for autoimmune disorders differ in Asian versus US populations (think Kawasaki Disease), so the results may not be broadly applicable.

Influenza is Still With Us

I've officially retired my WRIS (Winter Respiratory Infection Season) section. Really we're only waiting for flu to wind down, though we still have too many covid hospitalizations and deaths. Here's the most recent Fluview map, looking a little more encouraging:

In the meantime, the FDA VRBPAC met on March 5 to officially recommend trivalent vaccines for next fall. The disappearance of the B/Yamagata lineage means we won't need a quadrivalent vaccine as in past years. Next up is CDC/ACIP recommendation in June.

Medical Injustices in the Past

It was painful for me to read, but I highly recommend the NEJM series highlighting medical injustices and biases perpetuated in its publications. The current article is about eugenics. Apparently there were a few voices trying to speak up against these practices in the early part of the 20th century, but they were drowned out by the majority, many of them physicians. You don't need a subscription to the journal for this series.

My Inner Lark

On a lighter note, I was delighted to learn that I might not be at such high risk for adverse events of Daylight Saving Time. A recent study looked at the effects of the DST change on sleep and work productivity in 155 full-time workers in Germany utilizing survey methodology. The effects varied with individual chronotype; that is, the "owls" are those that tend to stay up and wake up later than "larks," the early to bed and early to rise group. There's actually a tool to determine chronotype! The study found that us larks are less affected by the shift to DST.

Lots of evidence exists that the DST shift is associated with harmful effects, from medical illness to car crashes to work productivity. However, this is an extremely messy phenomenon. We have good evidence that the shifts are associated with poor circadian rhythms, a biologic plausibility for harmful outcomes, but only an epidemiologic association with these bad outcomes. With too many factors that can't be controlled or accounted for, probably the only way we will know if DST is bad is if the bad outcomes lessen when we quit using DST. I recall 2 prior instances where an epidemiologic association was likely confirmed to be causal: the association of aspirin use with Reye Syndrome in children, and the association of infant sleeping position with Sudden Infant Death Syndrome. The aspirin industry fought against the concept, but Reye Syndrome essentially disappeared when aspirin use for symptom relief in young children ended. SIDS rates plummeted with the Back-to-Sleep programs.

I don't recall ever seeing a lark, but apparently a subspecies of horned lark inhabits Maryland. I guess I'll need to rise early to spy one.

From CornellLab All About Birds.

Another Strange Case of Dr. Jeckyll and Mr. Hyde

Bud WiedermannFebruary 25, 2024February 26, 2024Leave a comment

Maybe chalk it up to old age. Last week I mentioned I'd be reporting on the ACIP meetings, not remembering that they are scheduled for the coming week, not last week.

Still, plenty going on to fill in with, including a strange case I've been investigating for a few weeks now.

New Adult C. difficile Fecal Transplant Guidelines

The American Gastroenterologic Association published new guidelines for use of fecal transplant in adults with C. difficile disease. Although the guidelines do not address pediatric issues they are still useful to consider. Looking at just the summary, fecal microbiota transplant therapy is being recommended for instances of recurrent disease in immunocompetent or mild/moderately immunocompromised individuals, as well as for severe or fulminant infections in individuals not responding to conventional therapy, Fecal transplant use is not recommended for those with certain underlying GI conditions such as ulcerative colitis, Crohn's disease, pouchitis, or irritable bowel syndrome, except as part of clinical trials. I noted that all of the recommendations were conditional with low or very low level of evidence.

Conflicting Nirsevimab Data

The headlines screamed that about 40% of eligible infants received nirsevimab prophylaxis for RSV infection, as of last month, which is much higher than I had thought based on reports and the shortage of the product. On closer examination, it may not be all that good. There are actually 2 sets of information that the CDC published. First is reporting of ongoing telephone surveys of households with infants under 8 months of age, asking if those infants have received nirsevimab or are planning to do so. That's where the 40% figure comes from. The second data source is an ongoing count of nirsevimab doses actually administered. The listing includes jurisdictional data up through December 2023. Here the highest rate is 20% (Alaska) with many states near zero. Presumably this latter count is more accurate than is self-reported survey data. Let's hope things improve next season, where it does appear that supply chain issues that caused so much disruption this season might be somewhat ameliorated.

Also on the nirsevimab front, I saw the first semi-detailed explanation of what went wrong with the supply chain last fall. You recall, and probably experienced, difficulty in receiving an adequate supply of nirsevimab to satisfy your patients' needs. The company simply didn't have enough stock on hand. This Wall Street Journal report offered more information. It seems that, as usual, it was a bad combination of multiple factors. First, the manufacturer underestimated demand. Second, pediatric healthcare providers initially delayed ordering the drug, not sure if third-party payers would cover the circa $500/dose price. When the feds decided in August to add the product to the Vaccines for Children program, it was already too late to reverse the trend for lower production targets. Production was ramped up eventually, and now some states have excess product available due to all the delays plus perhaps some practitioners not being aware of the availability. RSV is still around but clearly nearing the end of the season. Let's hope things go better for next RSV season.

Risk Stratification for Pediatric Covid

The Pediatric Infectious Diseases Society published new guidance related to covid management in children and adolescents, worth reading. In particular, I think the group did a great job explaining risk factors for poor outcomes from SARS-CoV-2 infection. This has been confusing, in part because we lacked data but also due to spillover from adult high risk conditions - I've noticed many practitioners citing adult risk factors for use in the pediatric population, and it's not quite applicable in all situations. Here's the quick breakdown:

Not All Telemedicine is Created Equal

I've been involved with telemedicine since well before the pandemic. It has its uses, and of course it also has limitations. However, some individuals providing so-called telemedicine services are doing more harm than good. I was saddened but not surprised at this article about providing antibiotic prescriptions via telemedicine. The authors searched for online platforms offering antibiotic prescriptions without real time physician examination or verification of patient details and then chose 2 platforms to query.

For the first platform, one "patient" was able to get a prescription for amoxicillin for "URI," answering a few yes/no questions asynchronously and being rewarded with the prescription in less than a half hour. Another "patient" insisted on being prescribed levofloxacin for cough and again was rewarded the prescription with little verification or pushback.

On the second platform, a "patient" with URI was given a link to choices of azithromycin, cefuroxime, amoxicillin, Augmentin, doxycycline, or levofloxacin. After choosing doxycycline the prescription was provided immediately.

These patients were actually some of the study authors, and they had real URI symptoms. They didn't fill the prescriptions and did recover uneventfully from their URIs. I had 2 immediate reactions after reading the article. First, I wanted to cry. Second, I wondered where these telemedicine "doctors" obtained their medical training.

I Told You So

Some people preface that comment with "I hate to say it, but..." Not me, I'll grab credit even if, as in this circumstance, I'm not unique in sounding the measles alarm. The most recent update shows 35 cases in the 15 US jurisdictions this year, as of February 24. This many cases scattered over so many jurisdictions bodes poorly, and the scariest is in a Florida elementary school.

Dr. Ladapo and Mr. .....?

Dr. Josepah A. Ladapo sports both medical and public health degrees from Harvard, an internal medicine residency in Boston, followed by a faculty appointment at NYU. He than transitioned to a mostly research position at the University of Southern California before catching the eye of the Florida governor and becoming both Surgeon General for the state as well as a professor at the University of Florida. He's been on my radar for some bizarre pronouncements that made me want to look deeper.

Looking at his publication list in PubMed and scanning some of the articles, he clearly has good public health knowledge. Most of his publications center around aspects of cardiovascular disease in adults. He does have 3 relatively recent publications related to covid, but I'm deliberately not linking to them, or to his public statements in the past year, because they are either secondary to the conversation or so lacking in scientific merit as to be not worth your time.

His first covid-related publication was in 2021 and analyzed results of a Gallup poll carried out from July to December 2020 regarding adults' misconceptions about covid risk. Curiously, he published another analysis of this same poll in 2022, presenting some of the exact same data. Neither article referenced the other one and made me wonder whether this could be a case of duplicate publication. More importantly, though, why would covid perception data collected in late 2020 have any utility in 2022, unless the authors were analyzing changes over time (which they did not)?

His other covid-related publication from November 2021 was a multi-author effort (he was the 8th out of 12 authors) talking about future priorities in public health management of covid. I was very interested to see that vaccination was seen as the most important intervention given that Dr. Ladapo now disparages most use of covid vaccines, based on nonsensical arguments.

In the past year, Dr. Ladapo has been working actively to discourage covid vaccine use in most instances. You can see some rebuttal from FDA and CDC in early 2023 and separately from FDA more recently.

All of this made me wonder what gives with Dr. Ladapo. He seems to have had good training, and his prior publications show that he does have basic understanding of public health principles. How then to explain his response to a measles outbreak in a Florida elementary school? He left the decision to remain in school up to parents, and he did not encourage measles vaccination. At a minimum, unvaccinated children should be sent home to receive online education until their incubation periods expire. This could effectively stop the school outbreak and prevent further community spread. Every effort should be made to bring all children up to date with measles immunizations. This is pretty basic stuff.

According to news reports, the Manatee Bay Elementary School in Broward County, Florida, has documented several cases of measles. Details about immunization and travel status are lacking, but apparently there is no clear link to foreign travel identified. Remember that measles is the most easily spread infectious disease known. It is thought that at least 95% immunity needs to be present in a community to prevent sustained spread. The vaccination rate in Manatee Bay Elementary is 89.3%. Also, the incubation period is up to 3 weeks following exposure. So, if the outbreak isn't managed immediately, it can stretch on for weeks until every non-immune child is infected. By that time, spread outside the school is certainly likely. Apparently Dr. Lapado isn't concerned about that.

I wanted to understand how the Florida Surgeon General arrived at his decisions. His prior covid vaccine arguments contained a fatal flaw that I always look for to judge how well someone understands public health/vaccine data. This involves an understanding of the Vaccine Adverse Effects Reporting System (VAERS), one of many tools to monitor vaccine side effects in the US. It's a type of early warning system for rare events. It is structured so that anyone can report a potential adverse event as being related to a vaccine; for example, if my neighbor broke a leg skiing and had received a covid vaccine 2 months ago, he or she could report that event to VAERs. Clearly that doesn't prove that the vaccine caused a fractured femur. VAERS is just a way to monitor all potential vaccine problems. Dr. Lapado incorrectly used VAERS data to conclude that covid vaccines killed more people than it helped. No one who understands the structure of VAERS could possibly end up with that idea.

At a loss for understanding Dr. Lapado's logic, I can only suspect he must be having some Mr. Hyde moments. Either he has a dual personality due to some neuropsychological condition, or he is purposely misusing data to achieve political or personal goals. He clearly should know better. I'd love to spend 30 minutes with him to see where he falls on this spectrum. Or, maybe he knows of some unpublished data that refutes the current understanding of measles transmissibility and the role of antibody in providing protection; I'd hope he would have shared that.

WRIS

The Winter Respiratory Infection Season soldiers on. Given the length of this post and relative lack of any new data I'm not going to dive deeply into CDC or other numbers. Suffice to say RSV is still decreasing. flu is a mixed bag across the country, and covid is out there but not surging at the moment.

"Commingled Out of Good and Evil"

Robert Louis Stevenson's "Strange Case of Dr. Jekyll and Mr. Hyde" was one of my favorite books as a child, and it's loaded with great quotes like the one above. I don't like bashing another individual, and I'm also a natural skeptic always willing to entertain new theories based on new data. I just don't think Dr. Ladapo's management of this measles outbreak, or his covid vaccine views, make any sense. For the sake of all Floridians and others they may infect, I hope I'm wrong.

Nest week I'll report any exciting details from the ACIP meeting.

Did Tiger Woods Receive Flu Vaccine?

Bud WiedermannFebruary 18, 2024February 18, 2024Leave a comment

Famous golfer Tiger Woods couldn't complete the second round of a golf tournament this weekend due to influenza. Two questions came to my mind immediately, still not answered. But, we have a lot more than golf to discuss this week.

WRIS

I suspect we are a matter of weeks away before I can retire Winter Respiratory Infection Season as a weekly feature. RSV is much less of a factor now, and I won't be discussing much about RSV unless things change.

Influenza-like illness continues to fluctuate regionally, we're really seeing wide variations. I'll mention again that this tracking method will pick up not just influenza, but also other respiratory illnesses. However, pre-pandemic it was a pretty reliable gauge of influenza activity. I do note that Mr. Woods lives in Florida and the golf tournament is in California. He became ill Thursday night, so using the common incubation period for flu of 2-3 days he could have acquired this in California (if he was practicing there a few days before); however, the outer range for flu incubation period is 7 days, so all bets are off about where he met his virus. (Also, I'm not stalking him, I have no idea about his travel history.)

At this stage of flu season, it's worth a look at pediatric mortality numbers. It's a little less than, but similar to, last year. Also note there is a significant lag time in reporting and verifying influenza deaths, so some of these bars in previous weeks will rise.

Pediatric deaths continue to occur slightly more commonly in children without underlying medical conditions, and the 5-11 year age group is the most common. Unfortunately, no data for vaccine status is provided.

What about the covid scene? As usual, I'm still looking at wastewater data because the methodology for collecting and reporting this information hasn't changed as much as have the methods for reporting infections and deaths among the states.

Again, this is at most a qualitative descriptor, but nothing to suggest a new surge approaching. Wastewater activity is highest in the South.

I wish CDC would publish numbers of covid pediatric deaths like they do for influenza. They only report death rates per 100,000 by age, and of course they are very low for the pediatric population. The absolute numbers are somewhere in there, but on the CDC website it would require me to write my own search language in their database, and I'm too lazy to spend the time to figure that out.

I also took a look at CDC's covid vaccine rates by age, especially since they now have updated information regarding the fall XBB vaccine dose. It's pretty grim.

Note that the highest rate is only 13.4%, and when I dug down into more details, all the states except one were in single digits for pediatric populations receiving the updated vaccine. The best and only double-digit rate was Vermont at a dismal 13.4%.

On the other hand, one could argue that because rates of serious pediatric disease with covid are so low it isn't cost-effective to vaccinate children who do not have risk factors. In fact, that's what most countries have decided; the US is an outlier in offering covid vaccine to healthy children. Nonetheless, on an individual basis every child is better off being vaccinated than not, even given the low risk of death, long covid, MIS-C, etc.

Back in the somewhat good news arena, a recent article gave an overview of planning (and funding!) for research on better covid vaccines, monoclonal antibodies, and antiviral drugs that will not be subject to loss of effectiveness with new variants. It's called Project NexGen.

Lastly on the covid front, many of you probably heard about CDC plans to change isolation guidelines for the public to be more in line with what we do for flu and other respiratory viruses. So far it is just a draft, but it's targeted for release in April. It's not really based on any new findings about transmission rates or duration of infectivity, but rather I think an attempt at simplicity with the recognition that current guidelines aren't being followed by the majority of the public anyway. What I think is most important, and I hope the final guidelines will stress, is that guidelines should differ depending on the situation. For example, it's a very different calculus for children attending school than it is for those same children going to visit their 85-year-old grandma. The public needs to understand that different risks occur in different circumstances.

Measles

Hot off the presses, 4 children in a single elementary school in Florida developed measles. So far not much official from the Broward County health department, but I'm betting that none of them were fully immunized. Watch out for a large number of secondary cases in the coming weeks.

Changes in Prophylaxis for Meningococcal Disease

This was news from the previous week that I'm just mentioning now. Ciprofloxacin has been used for prophylaxis of meningococcal disease for several years, but recently some sectors are now seeing resistance to quinolones. So, if you are considering prophylaxis of a close contact of someone with meningococcal disease, you will need to contact your local health department immediately to see if the resistance rate meets criteria for choosing an alternative agent such as rifampin, ceftriaxone, or azithromycin.

Tiger's Third Degree

I look at everything through an infectious diseases eye, whether I'm walking down the street, reading the paper, or chasing squirrels from the bird feeder; I just can't stop myself. So, I have 2 questions for Tiger.

Did you get a flu vaccine this year? I'm not a betting man, and I've already made one bet in this blog, but I'd guess not. He had fever and other symptoms the night before his Friday golf round, and then Friday morning still had fever and other symptoms but tried to play the round, making it through a few holes before feeling faint and ending up with IV rehydration therapy according to his official statement.
And to follow up on the above thought, what were you thinking trying to play the round on Friday? Not only did you not meet any school or workplace criteria for participating, you exposed everyone close to you to influenza presumably without notifying them. Of course, this is the sort of "tough it out" mentality that I've been guilty of myself in the past, at least to the point of working when I had a mild cold because I thought myself too essential for my workplace or didn't want to shoulder my colleagues with covering me. I don't think Tiger needed the money for playing in the tournament, but he also was the host of this particular event and I'm sure many fans turned out primarily because he was playing, so that's a bit more pressure than in my workplace. Still, isn't it time we made a change in our behavior when we're sick? Take a moment to think about the impact your actions have on others.

Which brings me to a third question for Mr. Woods: Would you at least make a statement recognizing that you should not have tried to play on Friday, and also give a plug for flu vaccine even if you didn't receive one this year?

I'd bet big bucks that Tiger Woods doesn't read this blog, so, yes, I'm just blowing off steam.

Next week is the regular meeting of the ACIP, I"m hoping to view most of the 2-day meeting and have this be the focus of next week's blog.

Super Sunday

Bud WiedermannFebruary 11, 2024February 11, 2024Leave a comment

I've been a Super Bowl addict I think from Super Bowl I, persisting in spite of the fact that the NFL has done very little to limit head trauma and chronic traumatic encephalopathy. I'm usually tied to the Super Bowl screen almost continuously because I like to pay particular attention to the national anthem (more on that later) and to all the commercials. For Super Bowl LVIII I'll unfortunately need to grimace and grit my teeth when the Kansas City fans do their insensitive tomahawk chopping and war hooping.

As I rush to finish my long list of chores for today I somehow need to cull through this week's list of 16 blog topic ideas to post something with low soporific properties. Here goes.

I'm Beginning to Really Worry About Measles

It's difficult to find a central, accurate source of data, but it seems to me that an unprecedented level of sites around the world are experiencing high numbers of measles cases. Coupled with robust international travel, declining vaccine rates, and very high contagion, the US population could have a major resurgence.

An editorial in the BMJ last week (unfortunately freely available only to those with a subscription) re-sounded the alarm. The impetus was a new outbreak in the West Midlands, but really the problem has been sweeping Europe for at least a year. They quote other sources citing over 42,000 cases in European Union countries from January to November 2023, with 5 fatalities. Ireland, which had only a few measles cases in 2022 and 2023, reported the death of a middle-aged man who had visited Birmingham; no further details such as underlying risk factors are available presently. Our northern neighbors in Montreal report a measles case in an unimmunized child, likely acquired on a trip to Africa. The child's age isn't mentioned but he was apparently school-aged since a school is one of multiple sites where health authorities are trying to track down contacts.

I came across an updated measles website from the Infectious Diseases Society of America that I think is pretty helpful, including several links to other sites. Look at the Facts link for a good discussion of common measles misconceptions. And, please, please, please make sure all your eligible pediatric patients are immunized.

Speaking of Vaccine-Preventable Diseases

Diphtheria has killed 130 Somali children in the last 3 months, according to a news report. Antitoxin availability in the country is very limited. Diphtheria continues to pop up in resource-poor countries with ever-present risk of imported and then locally-acquired cases appearing in the US.

"Silent" ARF

A new study carried out in Sudan informed me about the existence of "silent" acute rheumatic fever. The investigators performed handheld echocardiography testing on 400 febrile children 3-18 years of age who did not have a definite etiology for their fever. Of 281 children who had no clinical features of ARF, 44 had evidence of rheumatic heart disease on echocardiogram. This is an interesting diagnostic intervention that could prove practical for use in high risk ARF countries, but costs and training could be significant barriers.

Thankfully we don't have much of a rheumatic fever problem in the US, likely because most endemic US group A streptococcal strains are unlikely to trigger ARF. However, imported strains certainly pose a risk, and evaluation of any suspected ARF case should take into account travel history/country of origin.

More on Treatment of Hearing Loss in Congenital CMV Infection

Last week I mentioned a small phase 2 study of late, short course treatment for children with hearing loss likely due to congenital CMV infection; it didn't work. Now this week we have a report of a small phase 3 study in the Netherlands. It was an unusual circumstance where a randomized trial was converted to a non-randomized trial because the original trial floundered due to lack of enrollment; most parents wanted their children to receive treatment. In the new study, children with hearing loss but otherwise clinically silent congenital CMV infection received either 6 weeks of oral valganciclovir (n=25) or no treatment (n=15). They were followed until 18-22 months of age, and the treatment group had less hearing deterioration than did the control group. Not the cleanest study but a better design overall than was the US study, and it did find evidence of benefit. This also points out the great difficulty in conducting these trials; even though congenital CMV infection is very common and virtually all US infants are screened for hearing loss, it's very difficult to enroll and follow-up these children in randomized double-blind placebo-controlled trials. We still don't have a definitive answer on treatment benefits for isolated hearing loss in congenital CMV, but I hope the investigators don't give up trying.

Alaskapox

No, I didn't make up that word, it's a real orthopoxvirus that can rarely infect humans mostly in, you guessed it, Alaska. Only 7 human cases are known to exist, but the most recent one, in an immunocompromised man, was fatal. The report also is striking for how long it took to diagnose him. The virus mainly infects small mammals (voles, shrews) with no known human-to-human transmission so far. However, there is no reason it wouldn't be spread from another human, just like other viruses (smallpox, cowpox, Mpox) in the same family.

Photo from https://health.alaska.gov/dph/Epi/id/SiteAssets/Pages/Alaskapox/Alaskapox-FAQ.pdf.

New Syphilis Testing Guidance

CDC released new recommendations for laboratory testing for syphilis, good timing given our terrible syphilis epidemic in the US. It is highly technical, so mostly of interest to laboratorians and syphilis geeks like me. Some of the illustrations and graphs are useful for everyone. Here is a nice quick view of lab test results in various syphilis stages:

And an explanation of the prozone effect, very important and something that I've found not all hospital clinical lab personnel understand. It appears mostly with RPR testing, where very high antibody levels cause a false negative result unless the assay is run at higher dilutions.

WRIS

Not a whole lot new with the Winter Respiratory Infection Season.

Investigators in France reported that rhinovirus infection in infants was a major contributor to bronchiolitis hospitalizations pre- and during the pandemic. Here's an example of ventilator use for RSV and rhinovirus during 2019 - 2020.

From a practical standpoint we have a tough time sorting this out with commercially-available testing. PCR testing for rhinovirus uses primers that include most enteroviruses, so you will always see these results combined as rhinovirus/enterovirus with no way to separate out which is which. The problem is compounded because most enteroviruses normally persist in the body and in nasal secretions weeks to months after the clinical illness resolves. So, a positive rhino/enterovirus test might reflect an infection that a) occurred months previously, and b) could have been asymptomatic (90+% of enteroviral infections are asymptomatic). Often we can guess rhinoviruses are active if we see a mid-winter bump in rhino/entero positivity, since the usual enterovirus epidemic peak is late summer/early fall.

Of note, the French investigators did not provide details of the PCR assay used in their study, so we are left trusting the journal editors that it did reliably distinguish rhinoviruses from enteroviruses.

RSV is pretty clearly on the way out, though still causing a lot of illness nationwide. The decline is present in all 7 monitoring sites.

Influenza also is declining, with a couple caveats.

First, we are starting to see a higher percentage of influenza B isolates now. This typically happens near the end of flu season, but it could also produce a secondary bump in infections. Second, local and regional flu levels are quite variable - what's true for Maryland is completely different in New Mexico. Also, I've never been a fan of presenting city-level (NYC, DC) data in the same context as state data - a classic apples and oranges comparison.

Covid wastewater data continue to be encouraging.

We also have a few new updates on the covid scene. The UK released their spring vaccine recommendations which are to offer vaccine (usually mRNA XBB.1.5 vaccine unless not suitable for an individual) to adults 75 years of age and older, residents in adult care homes for older people, and anyone 6 months of age or older fulfilling their definition of immunosuppression.

I was pleased to see an update on trying to get a handle on Postacute Sequelae of SARS-CoV-2 in Children (PASC), though as I read through it I still felt it was a difficult jumble of clinical syndromes that make it hard to develop practical management advice anytime soon. Here's an overview of their conceptual model:

I applaud the investigators for continuing to slog through this and I do expect to see concrete advice sometime in the future, not only for PASC but perhaps for all those other post-infections syndromes currently lumped into the myalgic encephalomyelitis/chronic fatigue syndrome wastebasket.

Birdhouse Update

I'm sure everyone has been waiting to hear the latest update in my birdhouse squirrel-proofing adventures. I'm happy to say the birds are back, but so far no squirrels are stealing the birdseed! I did notice one dastardly Scurius representative sitting on the large branch from which the birdhouse was suspended, but it never made an attempt to jump. We'll see how long this holds up.

White-breasted nuthatch enjoying the sun and safflower seeds, unmolested by squirrels.

Super Bowl VIII

Yes, I'm aware it's now LVIII, but much of my Super Bowl roots go back to the one 50 years ago where I happened to be employed selling beer in the stands. I didn't make much money; I was assigned to the Vikings side of the stadium, and they got blown out by the Dolphins and quit buying. I also didn't see much of the game itself due to walking up and down the stands, yelling "cold beer" and looking for raised hands.

I was required to show up several hours before kickoff time, and the stadium was virtually empty. One person on the field that morning happened to be one of my personal heroes, the country singer Charley Pride. (As an ironic note to me, he died of covid complications at age 86, in the first year of the pandemic and before vaccine availability.)

Pride was really the only Black person to have broken through as a country music star at the time, and he was practicing singing the national anthem which he would do at the start of the game. When he finished practicing I walked down to the field level and he was kind enough to chat with me a few minutes. He autographed my flimsy paper vender tag, now lost somewhere during my many moves.

As you can tell, I haven't lost that 50-year-old wonderful memory. Kiss an angel good mornin' if you have a chance. 😉

Measles in My Backyard

Bud WiedermannFebruary 4, 2024February 4, 2024Leave a comment

Well, not exactly, and directionally it's more like my front yard. On February 1 the Maryland Department of Health issued a press release of a measles case in a recent international traveler who resides in my Maryland county, listing an apartment complex with my same home zip code as a site of potential exposure. Details are lacking, and I do note the DOH still hasn't sent a notice to Maryland licensed physicians. Keeping my fingers crossed there are no secondary cases.

Last Summer's Vibrio vulnificus Flurry

CDC reported on last summer's burst of V. vulnificus infections across 3 states, a total of 11 severe cases occurring during heat waves in residents of Connecticut, New York, and North Carolina. Median age was 70, and 5 people died. Of the 10 with available information, all had at least 1 underlying risk factor for severe Vibrio infection, including diabetes (3), cancer (3), heart disease (3), history of alcoholism (3), and hematologic disease (2). While the clusters can't be blamed definitely on the heat, Vibrio growth is augmented in warm water; we may see an increase in Vibrio infections associated with climate change.

An impaired reticuloendothelial system (including liver disease from any cause) is a big risk factor; high risk individuals should be warned about avoiding contact with brackish water, salt water, and raw seafood (2 cases last summer had raw oysters as only known exposure).

Late Treatment for Congenital CMV

A new report from the Collaborative Antiviral Study Group reported on a phase 2 randomized, double-blind, placebo-controlled trial of 6 weeks of oral valganciclovir for infants 1 month to 3 years of age with congenital CMV infection and sensorineural hearing loss. Although the treatment group had much lower urine and salivary viral loads during treatment, there was no difference in hearing outcomes compared to the placebo group. Back to the drawing board.

Diphtheria in Africa

It looks like diphtheria is going to be a big problem for some time to come. WHO lists major diphtheria outbreaks in Nigeria (the most cases), Guinea, Niger, Mauritania, and South Africa. The cumulative total of suspected cases is 27,991 with 828 deaths. For those of you needing a little help with African geography, here's what it looks like:

So, this is not just clusters related geographically, but rather scattered throughout the continent. Cases were more prominent in the pediatric ages, and about a quarter of the cases were fully immunized. The numbers could be much higher given the difficulties in diagnosing diphtheria in resource-poor settings.

Bad E. coli in China

Although I'm never happy to hear about new virulent and resistant organisms, I was particularly unhappy about this news for a few reasons. First, it is a hypervirulent strain, apparently more likely to cause severe invasive infections. Second, it carries carbapenem resistance, often our last relatively safe resource in the antibiotic armamentarium for multiply resistant Gram negative bacteria. Worse is that 13% of these carbapenem-resistant organisms did not express a known carbapenem resistance gene, suggesting other perhaps new resistance mechanisms might be present. Lastly, these organisms caused a prolonged outbreak in a children's hospital.

You can see this outbreak occurred a few years ago, but I don't think we've heard the last of this.

WRIS

I'm looking forward to the week when I can retire a regular update on Winter Respiratory Infection Season. For now we have some encouragement but still too early to tell which way we're headed, especially with covid since our data sources are less reliable/predictive.

We seem to be over the hump with RSV season, still plenty out there but we tend not to see late rebounds with RSV.

Flu is a mixed bag depending on locale, but seems to be headed downward overall.

The covid wastewater report doesn't look too bad, either.

JN.1 is the predominant variant in most places now. I include a graph from the UK just because it's pretty.

We also have some other good news on the covid front: the fall vaccine seems to have high effectiveness (54%; 95% CI 46-60%) against development of symptomatic infection in immunocompetent adults. The study covered the time period September 2023 - January 2024 so is very recent and includes the time of JN.1 variant predominance.

Squirrel Wars 2.0

Speaking of my front yard, it is the new site of my war to keep squirrels away from my bird feeder, first mentioned in these pages on January 14. You recall that the capsaicin-laced safflower seeds, advertised as obnoxious to squirrels, turned out to be a delightful snack for those obnoxious rodents here. I tried to access research proven methods for preventing squirrels from eating all the bird food, but sadly there doesn't appear to be a trove of studies to guide me; in other words, no such thing as evidence-based squirrel medicine.

However, many sites mentioned trying to choose a site for a feeder that is beyond the reach of a typical squirrel's jumping prowess of 5 feet upward from the ground, 7 feet across, and 9 feet downward. After much thought, we selected a site in a large front yard tree. Armed with my long-suffering wife's long tree branch cutters and her assistance, 2 rickety ladders, slippery wire, packaging tape, and an autographed baseball from my youngest son's youth baseball team (circa 1990's, I was the official scorekeeper since I was too uncoordinated to be a coach), I succeeded in placing it in the perfect place with only minimal self-injury. Passersby seemed alternately amused and alarmed. If this works, I should get a MacArthur genius grant.