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Tag: RSV

Published on Leave a comment on Super Sunday

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. 😉

Published on Leave a comment on Measles in My Backyard

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.

Published on Leave a comment on Seeing Spots Before Your Eyes?

Washington, DC, had a record high temperature 1 day during our heat wave this past week, and I suppose if you glanced at the sun you might see some spots for a few seconds. But of course I'm referring to different spots in this post.

Measles

I'm probably the only person who has read all of my blog posts over time, so you're forgiven if you don't realize I'm in broken record mode here. I can't count the number of times I've warned providers to be on the lookout for measles cases, and now we are facing a global decline in immunization rates that probably puts us at greatest risk since the modern-day measles vaccine was available in 1968 (the original Enders vaccine appeared in 1963). We've enjoyed some low numbers in the US recently, but that appears to be changing with 9 cases (from Georgia, Missouri, New Jersey, and Pennsylvania) reported to CDC so far this month.

CDC released an alert last week mentioning 23 US cases between December 1 and January 23.

I won't review everything about diagnosis of measles, the CDC website alert is a good resource with links to other sites, but I do want to highlight a few helpful nuances that aren't often mentioned. First, measles is fairly unique among exanthematous infections in that the prodrome interval, the time between onset of first symptoms and appearance of the rash, is long, usually a few days. Most infectious diseases accompanied by rash have very little or no time between onset of symptoms and appearance of the rash, with erythema infectiosum being a notable exception but not easily confused with measles clinically.

The measles prodrome consists of a febrile illness with cough, coryza, conjunctivitis, and Koplik's spots. You can find pictures of Koplik's spots everywhere on the web, but in my experience as an old geezer who has seen many cases of measles in children, they aren't that easy to see or photograph. Therefore, the photos available in textbooks and on line are skewed towards the most obvious. One needs to do a careful oral exam looking for gray or bluish-gray or white fine spots (almost sandpapery) anywhere on the buccal mucosa; the inside of the lower lip is particularly helpful. If you're not sure, find an old geezer clinician to confirm.

In the absence of Koplik spots, or if you don't see the child until the rash appears and the Koplik spots have resolved, pay close attention to the history. Specifically ask for a day-to-day accounting of symptoms; if you feel the parent or patient can recall reliably, noting at least a 2-3 day lag between the onset of high fever, cough, rhinorrhea, and conjunctivitis before the rash appears can be strongly suggestive of measles; the absence of this lag is against the diagnosis. Other alarms to increase your suspicion would be lack of 2 measles immunizations, international travel, and/or exposure to a suspected measles case.

"It ain't what they call you.....

..... it's what you answer to." - attributed to W.C. Fields, though I can't verify the origin.

I thought of Mr. Fields when I heard about administration errors involving the adult RSV vaccine (brand names Abrysvo and Arexvy) given to children and pregnant people. From my viewpoint, it was an accident waiting to happen, due to a name.

In order to speed payment allowance by the Vaccines for Children and other programs, the long-acting monoclonal antibody nirsevimab was officially designated a vaccine. Strictly speaking I guess this is correct: antibody administration is a form of passive immunization. However, the true RSV vaccines are intended only for adults with high risk conditions or for pregnant people to help protect newborns after birth. It was inevitable that confusion would ensue. The notice provides almost no details but does state that most administrations to young infants were "nonserious." Infants who wrongly received an adult RSV vaccine should be considered unprotected and still receive nirsevimab.

WHO Fans the Covid Mask/Distancing Controversy

WHO riled a lot of public health experts with its recent guidance for infection control in healthcare facilities. The main controversial elements involve recommendations to use physical barriers such as plastic windows for areas where patients first present (rated as conditional recommendation, very low certainty of evidence); maintaining a physical distance of at least 1 meter between people ("good practice statement"); and not sufficiently highlighting superiority of respirators (e.g. N95 masks) for general care - this particularly angered those who favor the aerosol, rather than droplet, mode of transmission for SARS-CoV-2. In general it seemed that the WHO panel carried over some details for infection control that do not have strong evidence for use and in some cases (plastic barriers) may be contradicted by other studies.

Note that much of the controversy involves how much weight to give transmission simulation studies - e.g. distances that SARS-CoV-2 travels under experimental conditions rather than real-world evidence which is much more difficult to come by. It's hard for an individual medical practice to make these decisions on their own, best to abide by state or local health department guidance.

Spring Covid Vaccination?

Canada released guidance for covid vaccination this spring, advocating for an additional dose of the XBB.1.5 vaccine recommended last fall. I'd look for the US to make similar recommendations soon. ACIP has a regular meeting scheduled February 28-29, but no agenda is yet available. FDA doesn't have anything scheduled, and they may not need a separate advisory committee meeting for this.

WRIS

In general we seem to be trending downward with our winter respiratory infections, but still lots of runny noses, coughs, and more around.

For RSV I still look primarily at hospitalization rates in young children, the purple line in the graph below, because I think it's the most accurate gauge of RSV. I suspect almost all of these hospitalized children are tested for RSV and flu. The rate clearly is trending down, it's looking like we won't replicate the horrible RSV season of last year.

Influenza-like illness seems to be cooling off as well, as seen in FLUView. Note this measurement includes respiratory illnesses mimicking flu so could be any respiratory virus; there are many more ways to look at flu activity in general, all with their own inaccuracies. In the past I have found this map to be representative of what I've seen clinically in my practice areas.

Covid wastewater (I've said before why I prefer this qualitative measurement) continues to trend downward, and levels are below that seen last year.

All told this is good news for those of you trying to manage your packed patient waiting rooms. Let's just hope you don't have a case of measles sitting in there somewhere!

Do You Even Know What a Broken Record Sounds Like?

I used this term when I said I was sounding like a broken record for repeating over and over my warnings about measles. I harp (pun intended) on this because measles is the most contagious infectious disease known and most younger clinicians in the US have never seen a case, meaning it can be missed easily. However, those same clinicians might never have heard a broken record either. Vinyl records made a bit of a comeback recently but even I no longer have a turntable to play vinyl records; I do have a few moldy vinyl albums from the 1960s and 70s. I'm occasionally tempted to purchase a good turntable, but I have no place for it and it's yet another diversionary rabbit hole I don't need. I ain't gonna call out the name vinyl around here.

Published on Leave a comment on Snow at Last

It was an exciting week for me. We had our first tangible amount of snow in 2 years. Last year, I paid big bucks (to me, but I'm a skinflint) to recondition my 30-year old snowblower that refused to start. However, it sat dormant through last winter, and I never tried it out to see if it actually worked. Happily, it performed well this week.

Most of the infectious disease newsworthiness still centers around covid and WRIS*, with one exception.

Oh Deer!

Like most other teen boys growing up in South Texas in the 1960s, I learned to hunt. Once I harangued my father to take me deer hunting, something he abhorred, but like the dutiful father he was he finally acquiesced. I shot a deer, clean kill instantly, but it was a terrible experience. The end of my hunting career. Still, I have no fondness for deer, especially the ones who eat my wife's painstakingly planted vegetation around the yard.

This new article gives me one more reason to despise deer. Investigators from various agencies in Michigan report 4 new cases of Mycobacterium bovis disease linked to deer exposure and include 3 older cases already reported. Of the 7 individuals, 3 were deer hunters, 1was a taxidermist, 1 handled a sick fawn, and 2 were immunocompromised, had no known animal contact, and had close contact with each other.

I found it most interesting that hunters may voluntarily submit deer heads for M. bovis testing in this part of Michigan since 1995. Since that time, 993 of 349,445 (about 0.3%) specimens have tested positive (and those hunters were advised to discard the venison from those animals). Deer-hunters and -lovers should take note.

Another Oral Covid Medication

Researchers in China reported results of a phase 2/3 randomized, double-blind, placebo controlled trial of a new protease inhibitor, simnotrelvir, combined with ritonavir, for treatment of mild to moderate covid illness in 1208 adults within 72 hours of symptom onset. The treatment group had significantly lessened time to sustained resolution of symptoms (180 hours vs. 216 hours) and decreased viral load on day 5 of treatment. Rebound was studied in a subset of subjects and was similar in the 2 groups.

We'll need to wait for further studies and FDA action to know whether this agent will become available in the US, but in general it's nice to have multiple options for covid management.

More Encouragement for Covid Vaccines

Two new studies added to the already large body of evidence confirming efficacy and safety of covid vaccines. First, a retrospective study using EMR data from multiple centers in the US showed lower rates of long covid in vaccinated children under 18 years of age: 4.5% in unvaccinated versus 0.7% in vaccinated, with some waning of protection over time. This is encouraging, but the study design itself is not optimal for measuring this type of effect. I'm waiting for prospective studies to give us a better handle on measuring this benefit.

Another group of investigators performed an extensive literature search to determine risks of various neuroimmunologic disorders, including Guillain-Barre syndrome, Bell palsy, myasthenia gravis, neuromyelitis optica spectrum disorders, multiple sclerosis and central demyelination, and myelin oligodendrocyte glycoprotein antibody-associated disease, following covid vaccination. This is a tough task since these illnesses exist at a low rate in the general population and mostly seem to be equally or more rare in vaccinated individuals.

The authors, after applying various quality methods to screen articles, ended up with 69 studies to include in the analysis. They present a ton of data, but distilling their remarks it does seem like the most evidence exists for an association between vaccination and GBS, especially for adenoviral vector vaccines but also for mRNA vaccines. Neither adenoviral nor SARS-CoV-2 natural infections have been convincingly linked to GBS so far, so this may be a true association. Bell palsy also showed a possible slight association following vaccination, but again these are exceedingly rare events. Worth the price of the article, or more since it is freely available, are the various discussions of limitations of these studies, compounded by the rarity of the conditions of interest. For example, individuals with mild GBS or Bell palsy may not seek medical attention, and this behavior might differ between vaccinated and unvaccinated persons. Other study problems such as publication bias, outcome reporting bias, and clinical heterogeneity also are mentioned by the investigators. I agree with the authors' conclusions that, given the unprecedented attention to covid vaccine safety, it is unlikely that rates of these rare conditions have been underestimated in vaccinated individuals, and vaccine benefits far outweigh any of these possible risks.

*WRIS

Winter Respiratory Infection Season plods along.

Influenza-like illness dropped a bit, uncertain if this will be sustained.

RSV hospitalizations continue to project downward:

Covid wastewater still hasn't approached levels of last winter; cases are down, but remember that case reporting methods have changed dramatically since last year and are more severely underreported now.

Overall a number of data sources suggest we may be turning the corner on WRIS, but still plenty of infections out there and definitely not too late for vaccination of eligible persons for any of these 3 pathogens.

One last note is a tip of the hat to Dr. Michael Schwartz, a frequent contributor to the Comments section of this blog. Last week he wrote "would you like to comment in your next post about California aligning COVID isolation recommendations with other respiratory illness ( most especially flu )? He referenced an order from the California Department of Public Health dated January 9. It specifically deals with covid and doesn't mention influenza directly and is mostly intended to redefine infectious periods for covid to conform with new data. It is short on references/links to source data. I was intrigued, however, to visit their mask advice page, and I think it's pretty helpful and might be useful to families who are confused about the different types of masks available.

In terms of Dr. Schwartz's request, he brings up an important practical point. In the midst of WRIS, much of the time we won't know which virus is causing a child's upper respiratory symptoms, and we need to use testing judiciously to inform treatment choices where indicated. Thus, it makes sense to have a general approach to URIs now. As any parent or pediatric healthcare provider knows, if you exclude every child from school every time they have a runny nose, our classrooms would be empty in the winter. However, in high risk circumstances such as contact with immunocompromised individuals, proper masking may help.

Also, I couldn't pass up sharing this facial hair guide for wearers of N95 and similar respirators:

So much for my plan to grow a wet noodle 'stache.

Snowy Times

Wallace Stevens wrote a famous poem called "The Snow Man," termed by one critic as the best short poem in the English language. I'm more drawn to his discussion of snow in "On the Way to the Bus." Unfortunately I can't find a copy of the latter poem freely available on the web and I would violate copyright laws by reproducing the complete piece here. So, I'll leave you with "The Snow Man," definitely not too shabby either.

One must have a mind of winter
To regard the frost and the boughs
Of the pine-trees crusted with snow;

And have been cold a long time
To behold the junipers shagged with ice,
The spruces rough in the distant glitter

Of the January sun; and not to think
Of any misery in the sound of the wind,
In the sound of a few leaves,

Which is the sound of the land
Full of the same wind
That is blowing in the same bare place

For the listener, who listens in the snow,
And, nothing himself, beholds
Nothing that is not there and the nothing that is.

Published on Leave a comment on What About Me?

This week I realized covid shares a characteristic with my granddaughter. Sometimes, when she is the only child in a room full of adults taking about endless banalities, she interrupts us with a "What about me?" plea. Every week I gather potential topics for this blog from key medical journal email alerts, feeds from a few selected sources like CIDRAP, scanning the Washington Post, New York Times, and Wall Street Journal dailies, watching national news broadcasts when I can, and just generally keeping my eyes and ears open. I must see dozens of potential topics to include next week, and I bookmark a subset to reconsider at the end of the week.

This week I had a few more topics than usual, around 20, that I needed to winnow down. I quickly realized that all but 1 of them were related to covid. Try as I might to include topics on general infectious diseases, covid has succeeded in becoming the center of attention this week. I'll do my best to summarize a few of the pearls.

Covid Vaccine Updates

Pediatric healthcare providers can rejoice in some more good news: according to the AAP, Moderna has joined Pfizer in allowing free returns of unused covid vaccine doses, making it less financially risky for practices to order vaccine.

A few new studies confirm high vaccine effectiveness extending into the omicron era. First, a cohort study in 4 Nordic countries looked at mRNA covid vaccine effectiveness in adolescents completing 2 vaccine doses between approximately April 2021 and April 2023. A little over 500,000 subjects were included. Vaccine effectiveness against hospitalization was 72.6% (95% CI 62.5-82.7) with a suggestion that heterologous dosing (1 Pfizer dose and 1 Moderna dose) had slightly higher effectiveness at 86.0% (56.8-100). Similar numbers were seen when just the omicron time period was analyzed at follow-up periods of 6 and 12 months. It's important to note that hospitalizations were relatively rare, regardless of vaccine status, as expected in an adolescent population. (Norway isn't included below because too few hospitalizations occurred to allow for analysis.)

Another study looked at VE in US children (5-11 yo) and adolescents (12-20 yo), the latter group in both delta and omicron periods and the former group only during the omicron period (no vaccine was available for the younger group during the delta wave). It looked at a "real world" population, i.e. not part of a formal research study but rather examining vaccine usage as implemented after authorization/approval, using data available from 7 pediatric healthcare organizations. Again VE was high, For the Pfizer vaccine during the delta time period, VE against infection was 98.4% with narrow CI (those were the good-old days at least in this one feature, no covid vaccine has great VE against infection nowadays). During the early omicron period (up through November 2022), VE against infection was 74% in the younger children and 82% in the adolescents; durability of the protection was fairly stable over a 10-month follow-up period, although the CIs became very wide because so few events occurred.

Finally I'll mention a study in the "elderly" because it contains very recent data. In Denmark, VE reported as hazard ratios of the XBB variant-based vaccine (the one in use starting last fall) was highly effective against hospitalization in this older age group. Note the very short follow-up period, this information clearly is very preliminary and could change significantly as time passes.

Covid Epidemiology

The more interesting information about covid epidemiology this week comes from abroad. First, I loved this study from the UK because it used smartphone tracing technology, preserving confidentiality, to identify important determinants of covid transmission. A key finding was that the probability of person-to-person transmission increased with time, first linearly at 1.1% per hour of exposure but extending for several days. Household exposures were most likely to result in transmission. Distance played a role of course, but longer exposures at greater distances had about equal risk of transmission as shorter exposures at shorter distances. I could spend an entire blog post and more on this article. This information can provide excellent guidance for quarantining and distancing in the event of a large covid wave in the future. Remember that the original guidance earlier in the pandemic for distancing of 6 feet was mostly a best guess to prevent transmission, no great data to guide that advice.

A report from the UK government summarizes a wealth of data as the following (see page 3 of the pdf in the link):

"... COVID-19 Omicron variant cases were most infectious around symptom onset and up to 5 days after, but could potentially be infectious for longer, especially for cases that are hospitalised, immunocompromised, or otherwise high risk. Three studies looked at transmission before symptom onset. These suggested that between a third and a half of transmission events occurred before symptom onset in the index case. However, while some studies included substantial numbers of cases, most studies included relatively few cases, and the majority of studies included cases with Omicron variant BA.1 and BA.2, with only a small number of studies reporting evidence from 2023."

This information can help inform your discussions with all those parents who wonder about transmission to high risk family members and whether to risk exposure for a special event. If you want more data than you (or I) can handle about what's going on in the UK with covid, see this link. The Excel files are massive but very interesting for those of you who want to take a deep dive.

The final mention of epidemiology is a source for concern and caution. The Pan American Health Organization, PAHO, that is the branch of the WHO overseeing public health in the Americas, reported on respiratory illness activity in the southern hemisphere which is now in summer season. The key take-home point here is that, although North American is driving a lot of the SARS-CoV-2 positivity now, there is significant covid illness in Central and South America. This implies that covid is not quite a winter respiratory virus, at least not yet.

Covid Bottom Lines

As we enter our 4th year of covid, I realized I've learned a few key lessons to be applied for the future:

  • It's difficult to compare illness rates and other outcomes in the US over the years, primarily because we aren't collecting information in the same way as we did early in the pandemic. Wastewater data are mostly obtained as they were before, but this is at best a qualitative data source.
  • Covid vaccines are the most closely studied and monitored in history with now over 5 billion people worldwide receiving at least one dose. Every credible study/report has confirmed that, regardless of age or underlying risk factors, vaccinated individuals will have better outcomes than being unaccinated and infected, even after being infected multiple times. This takes into account all adverse events following vaccination itself. For virtually every individual, vaccination is the better choice. From a public health perspective, vaccination of some low risk groups may not be cost effective. This is why the UK, for example, does not provide vaccine for some healthy children; UK health authorities have decided the money is better spent on other aspects of health care.
  • Although there are similarities, SARS-CoV-2 is not just like influenza virus. The mutation rate is much higher, meaning that we still face a faster moving target for new vaccine and therapeutic drug development. Also, as mentioned above, seasonality isn't yet clear. So far SARS-CoV-2 isn't just a winter respiratory virus.
  • Even though the omicron era seems to have brought less disease severity, SARS-CoV-2 is still a major killer, now at a rate of about 1500 deaths per week.

Please encourage everyone to be up-to-date on covid and all other vaccines.

WRIS

Winter Respiratory Infection Season clearly is still with us. I await more data to see if the winter school break resulted in fewer, greater, or had no effect on WRIS infection numbers. However, I did notice a report from China that provided evidence that school breaks lessened influenza transmission during the years 2015-2018.

RSV-NET: CDC is still projecting a downturn nationally, but too early to be certain of this.

FluView still shows significant influenza-like illness activity, at least as of a week ago. It's definitely not too late to be vaccinated.

And ... More What About Me

It's my blog, what could be a more pitiful plea for attention? So, speaking of me, note that the CDC published the 2024 adult immunization guide that not only includes old codgers such as yours truly but also extends down to 19 years of age.

One last bit, an update to my bird feeder adventures I mentioned last week. I had a great few days of multiple bird species sightings, followed by a squirrel invasion - those dastardly rodents cleaned out the birdseed supply in a couple days. I've now been researching squirrel deterrents, being careful to not actually hurt them although I admit to having occasional sciuricidal thoughts. It looks like I'll be moving the feeder and engaging in some high-wire techniques to squirrel-proof the new location, hoping I don't end up with a spectacular ladder fall and resultant visit to my local ER.

Unless otherwise indicated, the content and opinions expressed on this web site are those of the author(s). They are not endorsed by and do not necessarily reflect the views of the George Washington University.
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