Once again I find myself, an ostensibly tech-savvy individual,* faced with manually resetting the time on 11 clocks and appliances in my house. Only my phone, laptops, and tablet appear to have joined the 21st century by self-correcting to eastern standard time. Of course, if our country had truly joined the 21st century, we wouldn't be making this twice yearly switch in the first place.
My election anxiety is somewhat mollified by focusing on infectious diseases, so you can categorize the following as therapeutic in nature.
WRIS
Still not much going on, though I was intrigued that my state of residence is 1 of only 2 to show up with moderate respiratory illness activity last week.
I'm pretty impressed by how quiet the SARS-CoV-2 front is. However, it's still around, and we can expect to see a resurgence sometime.
The fact that influenza has not yet appeared might indicate we are returning to a more "normal" flu season. The graph below shows how different the prior 3 flu seasons were from pre-pandemic experiences, where last year had a very early peak and 2020-21 and 2021-22 had very low and atypical peaks. (Apologies for CDC's labelling here, but if you stare at it long enough you can pick out which line goes with which year.)
New Development in Bird Flu
The so-called highly pathogenic avian flu H5N1 cropping up in dairy and poultry farms and in wild bird populations has been in the news for many months now. It still seems to be a mild illness in humans, most of whom have direct exposure to these farms. Only 41 humans have confirmed infections in 2024 so far. What's a bit noteworthy this week is that the virus may now have shown up in pigs. USDA officials reported probable swine cases at a backyard farm in Oregon where poultry, cows, and pigs all mingle. The farm itself has no role in commercial production of any foods, so it isn't a risk to others. What is of slight concern is the fact that pigs are involved. Pigs have a special place in influenza science because they have both human and avian flu receptors in their respiratory tracts, making the chance for a recombination event to occur if they happen to be infected with human and avian viruses at the same time. Most of the time this doesn't cause creation of a new pandemic strain, and I wouldn't hit the panic button at all now. Actually I'm surprised it took this long for swine infection to be found. The affected animals were all euthanized and multiple studies are ongoing, so I'm sure we'll hear more about this.
Polio
The news isn't great as both wild and vaccine-variant polio cases continue to be reported. This Global Polio Eradication Initiative map is a good summary.
No new cases have been reported in Gaza, with just the 1 case confirmed so far. The interrupted vaccination campaign in northern Gaza restarted this week.
Dengue Still Going Strong
I was browsing the CDC dengue page this week; infections are still plentiful.
Puerto Rico has the greatest number by far, but note that we have had autochthonous (locally acquired without travel to endemic areas) dengue in the mainland US (California with 11 cases, Florida with 49).
*
Can I really claim to be tech-savvy? I think so. I have an advanced degree in educational technology with classes that included instruction in networks and the various hardware involved; the fact that my schooling ended in 2008 shouldn't disqualify me. Also, this past week I restored to full health our K-cup brewing machine that became confused and wouldn't deliver the appropriate coffee volumes or allow the correct menu choices in its buttons. I guess in the interest of full disclosure, when I couldn't find a satisfactory replacement brewer online, my astute intervention was reading the instruction manual, realizing that I hadn't ever de-scaled the device in the approximately 90 years I've owned it, and made it new again using only a low-tech tool (vinegar).
In spite of my skills with technology and vinegar, I'll be performing my semiannual time resets for the foreseeable future; I could never part with my grandfather's clock.
The one or two regular readers of this blog know that I'm a favorite companion at outdoor summer activities, not because of my scintillating conversational repartee but rather due to my fabulous mosquto/gnat magnet properties. No one near me needs to worry about bug bites; all those bloodsuckers are feasting on me. One morning this week I gathered a couple dozen bites in a very short time and have been scratching ever since. I've been waiting for symptoms of West Nile virus infection, nothing so far. Meanwhile, another vector-borne disease may have worse consequences than previously known.
But first, ...
Covid Summer Surge
In spite of many breathless news reports, this is still nothing to get worked up about, other than for high-risk individuals to consider returning to masking in crowded indoor spaces and employing other mitigation strategies. Some of the lay reports seem to forget that wastewater levels are not the same as actual infections. Wastewater covid detections might be decreasing, especially in the West.
Percentage of emergency department visits due to Covid, one rough measure of clinical illness, is increasing though still at low levels.
Meanwhile, we have a little more clarity on one aspect of long covid. In one study, myalgic encephalitis/chronic fatigue syndrome in adults was no more common following covid than following an acute infection-like illness that was negative for covid. I've long been concerned that case definitions and studies haven't been focused on the heterogeneity of long covid. Fortunately, some studies are geared to looking at the ME/CFS cases separately from post-covid symptoms that might be related to end-organ damage persisting after severe pulmonary or other infection.
Avian Flu
Similarly, the highly pathogenic avian flu A H5N1 continues to crop up in dairy and poultry workers but doesn't seem to represent a broad risk to others, with no known human-to-human transmission. I neglected to mention last week some preliminary results from the seroprevalence study in Michigan dairy workers: none of 35 tested workers had antibody to the virus, suggesting that asymptomatic infections aren't common. However, we need a sample size larger than 35 to get a better handle on this.
Last week's MMWR contained a report supporting the impression that this particular avian flu strain in humans is a very mild disease.
Wash Your Parsley
Did you know that the FDA performs regular microbiologic surveillance sampling of foods? Last week they reported results from sampling of basil, parsley, and cilantro, 3 of my favorite herbs. Below are numbers for the prevalence of various pathogens in different herbs; 95% CI are in parentheses.
Herb
Cyclospora cayatenensis
Salmonella spp
Escherichia coli
Cilantro
9.2% (4.4-16.5)
2.8% (1.1-5.7)
0% (0-1.5)
Parsley
1.3% (0.5-2.6)
0.9 (0.4-1.8)
0.1% (0.4-1.8)
Basil
0% (0-2.6)
0.7 (0.1-2.7)
0.7% (0-1.4)
For comparison, grocery store Salmonella spp. contamination rates for chicken vary from about 8 to 24%, depending on the study.
Want Some Listeria With Your Liverwurst?
CDC has been investigating a Listeria outbreak linked to deli counter sliced foods, and now one brand of liverwurst tested positive for Listeria. It's possible that a single product could have contaminated slicing devices, causing Listeria to end up in other deli foods. I hope your favorite deli counter practices good cleansing practices for their slicing machines. If not, you might get a side of Listeria with other deli products too.
Ever Heard of Oropouche?
Probably not, unless you are an infectious disease nerd or familiar with the island of Trinidad or the Amazon basin. Oropouche virus (OROV) is still known by the old practice of using a geographic term to name it Now we have new attention focused on this virus, previously thought to cause a relatively harmless though uncomfortable febrile illness. It was first discovered on Trinidad in 1955, in a forest worker from Vega de Oropouche, Trinidad. OROV is endemic to the Amazon basin, and Brazil is seeing a big upsurge in Oropouche fever this year.
With that have come some troubling new reports. OROV is an arbovirus related to dengue, and it mostly causes an acute febrile illness with sometimes very painful myalgias, similar to dengue, zika, chikungunya, malaria, and similar infections. It is transmitted primarily by Culicoides paraensis, a biting midge, but also can be transmitted by other biting insects including Culex mosquitoes.
Last week the Brazilian health ministry confirmed 2 deaths from Oropouche fever, both in healthy young women. The clinical descriptions resemble dengue hemorrhagic fever. Also, the Pan American Health Organization is investigating possible vertical transmission of the virus from 2 infected mothers. One pregnancy resulted in miscarriage, the other with intrauterine fetal death. PAHO has issued guidelines for evaluating possible vertical transmission of OROV. These studies should help us understand if OROV is similar to Zika virus's ability to cause fetal malformations and other severe outcomes. [Note that you may need to activate Google Translate to read these links.]
Meanwhile, I haven't seen any C. paraensis around my house.even though they do range into the northern US, including Maryland. They are pretty tiny, can be less than a millimeter, so good chance I would miss them. I'm somewhat curious to know if I'm also a midge magnet, but really I'd rather not find out.
The title above is one of several great turns of phrase in the book I just finished reading, Edith Wharton's Age of Innocence. It refers to an episode where the protagonist was at a loss for words during a poignant encounter and presumably only later thought of something better to have said. I've been there.
Next Round for Covid Vaccine
The FDA's Vaccine and Related Biological Products Advisory Committee finally had their meeting last week; it had been postponed to give a little more time to see which way the new SARS-CoV-2 variants were headed. I was able to listen in on most of the meeting and have reviewed all the documents. The vote was unanimous to choose a monovalent JN.1-based vaccine for the next iteration, no surprise and in agreement with the recent WHO decision I discussed recently. (For those interested, there is quite a bit of international collaboration on these types of decisions. See the ICMRA posting about covid vaccines.) Still, there were some interesting updates on covid in general. I'll try to distill this down into the main takeaways.
The Latest on Epidemiology (from Thornburg FDA presentation)
Current circulation of SARS-CoV-2 is relatively low. Although our reporting is not as reliable these days, looking just at percentage of positive covid tests in orange you can see we are in a lull now, though perhaps with a hint of an uptick. This is pretty similar to last summer when we saw a bit of a surge in summer into fall and winter. SARS-CoV-2 still has not come around to a winter seasonality seen with other coronaviruses of with influenza, making predictions for surges and vaccine composition very tough.
JN.1 lineages replaced XBB.1.5 lineages during winter 2023-2024. I like the depiction below because it's looking at normalized numbers of positive tests rather than a percentage of positive tests due to different variants. This gives a better appreciation of numbers of cases and shows that we are still talking about relatively low numbers compared to 2022.
Here's a closeup of the most recent part of the above slide showing that KP.2-like, KP.3, and other JN.1 derivatives are starting to take over, though still all at very low numbers.
The recent subvariants have very few differences from other JN.1-derived strains and antigenically are very similar. This has important meaning for vaccine choice - should it be the original JN.1 variant or one of these newer KP.2 or KP.3 type subvariants, currently at extremely low numbers? Look at the last 2 rows in the table below, showing that these newer subvariants have very few mutation differences from the earlier JN.1-like variants.
In a totally new and as yet unpublished CDC analysis, severity of JN.1 infections does not appear to be worse than earlier lineages. The trend was towards milder illness, though not statistically significantly different. Note these numbers are just for adults.
Vaccine Effectiveness in Children (from Link-Gelles FDA presentation)
This it tough to estimate because children generally have milder disease, plus so few children are vaccinated. Adult data is pretty favorable for VE; SGT failure is a faster method of testing and correlates will with JN.1 lineage strains. 2023-2024 VE drops a little with these strains compared to effectiveness against XBB lineage strains.
On the pediatric side, it's important to remember that the vast majority of US children have been infected with SARS-CoV-2 at some time in their lives - this has been apparent since late 2022.
So, it's important to determine any VE now in light of prior infection and vaccination. We can't rely on older estimates. Here's the best and latest estimates for VE in children who received vaccine in the past year. Confidence intervals are relatively wide, reflecting the small numbers able to be studied, but do show benefit in prevention of ED or urgent care use. VE wanes with time after vaccination as it does with all age groups, but there is clear benefit for covid vaccination of children.
David Wentworth, representing WHO, delivered a wonderful explanation of the complexities in choosing among current subvariants for vaccine inclusion. He had this great quote: "... antigenic evolution just speeds up waning immunity." The variant evolution we're seeing now is parallel, i.e. lots of different subvariants evolving on their own, in parallel, rather than one subvariant evolving into another, and then into another, etc. Parallel evolution is what XBB lineages did previously, and we're seeing it now in the JN.1 groups. The slide below demonstrates this process with a timeline on the X axis.
The dilemma in choosing composition of the next vaccine is that no one knows which way the very new subvariants will evolve in terms of antigenic similarity to earlier JN.1 strains. Currently, KP.2, KP.3, and JN.1.23 are within what is thought to be close proximity to JN.1 in terms of antigenic similarity and therefore a vaccine based on any of those likely will have cross-reactivity with one another, enough to provide protection. However, as illustrated by the arrows, it just isn't known how the offspring of the newer subvariants will evolve - will it be farther away from JN.1 and each other, or will it remain relatively stable?
No one can predict what next fall's or winter's subvariants will look like. Once they appear, new lab testing would need to be done, ideally using human serum containing antibody to the newer strains, which Wentworth stated would take about a month to produce. So, it's not something that can be turned around quickly.
Also, it bears mentioning that virtually all of the immunity studies involve neutralizing antibody. Antibody does correlate well with VE, but T-cell immunity also is important. We don't see as much data about this arm of the immune system because the studies are more difficult.
All 3 US vaccine manufacturers, Moderna, Pfizer, and Novavax, presented their new data at the meeting. They are developing and testing new vaccines "at risk," meaning the companies are making vaccines without funding currently, risking their own research and development dollars, hoping whatever they are working on will be recommended for the next covid vaccine rounds and allow them to recoup their investment. Moderna and Pfizer have both developed JN.1- and KP.2-based mRNA vaccines. Novavax, the adjuvanted protein-based vaccine, only developed a JN.1-based vaccine. The protein vaccine takes much longer to construct than do mRNA vaccines, about 6 months to get good data in all. So, if a KP.2 or other vaccine were recommended, Novavax would need to start over and wouldn't be ready until about December.
I don't usually like to use pharma slides to illustrate points, but this one from Pfizer isn't biased in favor of their product and I think nicely shows the current situation, including how closely related the newer subvariants are to JN.1.
In the discussion after the vote to have a monovalent JN.1-based vaccine, which could mean one based on KP.2, the majority of the group felt that using the JN.1 variant rather than KP.2 or another subvariant was the best route, both to allow Novavax to be ready this fall but also not to take a chance that fall and winter predominant subvariants might be more antigenically removed from KP.2 antigenically. All in all I felt this was the right choice, though I probably wouldn't have let Novavax's problems affect the decision; very few US residents have received Novavax in the past, though it is nice to have an alternative to mRNA vaccines available.
On June 7 the FDA formally recommended sticking with the JN.1 strain for this next vaccine round. Next step with be the CDC's Advisory Council on Immunization Practices meeting the end of this month, where the official seal of approval will be issued. I'm sure Moderna, Pfizer, and Novavax already are ramping up production.
NASEM Long Covid Report Available
Long covid remains a quagmire, lots of different symptoms, many of which are vague, and still no definite light shed on diagnosis and treatment of what is likely a heterogenous group of conditions requiring different approaches. The National Academies of Science, Engineering, and Medicine published their full report, available free online. I haven't gotten through all of it, it's pretty long, but it is of interest to those practitioners who see these patients. Most of the evidence is from adults, but it appears that pediatric patients tend to have a better prognosis, especially if improvements are occurring in the first year after onset. Note that a positive covid test is not required for diagnosis testing may not have been done at the time of the triggering infection and antigen or PCR tests will have reverted to negative by the time a long covid diagnosis is considered.
Doxycycline for Post-Exposure Prophylaxis of STIs
The official guidelines appeared this past week, although the gist of the recommendations had been floated previously. Particularly high risk groups are gay, bisexual, and other men who have sex with men and transgender women. The summary is very helpful for practitioners who may want to print out and post Box 1 and Box 2 in their workspaces. Note that the recommendations apply just to those high risk groups.
Summer Bugs!
Bugs in the sense of both insects and microbes. We now have more details about a new rickettsial agent, termed species C6269, that caused a Rocky Mountain Spotted Fever-like illness in 2 individuals in northern California last summer. Both had severe disease, were hospitalized and treated with doxycycline, and survived. As always, keep RMSF and other tick-borne diseases in mind during our warm months.
Speaking of bugs, our dog came down with a skin abscess, expertly debrided by her veterinarian. She is now enjoying chewable amoxicillin/clavulanate but is less thrilled with her "cone of shame." The vet had another bug concern, however. She didn't want the dog to spend much time outside - apparently it is also maggot season, and they love open dog wounds. The vet doesn't know I'm an ID doctor, and I was trying to come up with some clever comment on maggots but failed at that moment - belated eloquence of the inarticulate!
Courtesy of Wikipedia. Hope you aren't eating as you read this.
It's Easter time, when my thoughts turn to chocolate bunnies. Not only do they taste better than real bunnies (well, to think of it, I may have never tested a real bunny), but I have been unable to find any reports of tularemia transmitted from chocolate bunnies.
Although we are clearly beyond the peak of winter respiratory infection season, we still have plenty to think about from last week.
Covid Household Transmission From Asymptomatic Children
A prospective study showed a high secondary attack rate (SAR) for covid in households likely stemming from asymptomatically infected children. The study was well designed to try to answer this question, identifying asymptomatic children in Canada and the US who were tested for SARS-CoV-2 for either non-household contact with a known covid case or as part of routine hospital screening. The study covered a 15-month period, and results were analyzed according to viral variants predominating in the community at those times: 1/31/21 - 6/30/21 was predominantly alpha or mixed variants, 7/121 - 12/19/21 was delta, and 12/21/21 - 4/22/22 was omicron. The authors compared household SAR of SARS-CoV-2 positive children to rates of those who tested negative. There are many nuances to the study, but here's the bottom line:
SARs were higher with younger index cases (< 5yo versus 13 - <18 yo), if the index case eventually developed covid symptoms (versus continuing asymptomatic), and during delta and omicron time periods versus the interval when alpha/other variants predominated. If you have access to the full text of the article, skim the Methods section to get an idea of the tremendous amount of effort involved in collecting this kind of data.
Dengue in Puerto Rico
This past week Puerto Rico health authorities declared a public health emergency due to dengue, the first time this has happened in the territory since 2012. What I'm sure is alarming to those authorities, beyond the sheer number of cases (524) in 2024 so far, is that this isn't peak dengue season. As befitting the mosquito vector, cases tend to rise in the summer when it is wetter. See below, with my apologies for lack of English translation. You can click on the Week 10 report in the PR DOH Arboviral Diseases Weekly Report for the full document.
In other words, the worst may be yet to come. (The dashed red line is the epidemic threshold which is higher in summer/early fall weeks; August usually is the peak month for rain in Puerto Rico.) We can certainly expect cases in the mainland US, including in non-travelers living in Florida and other states that have experienced autochthonous dengue cases in the past.
Meningococcal Group Y Alert
CDC issued another HAN report about increasing cases of invasive meningococcal disease due to group Y, a phenomenon that has been noticed for a couple years now.
Note that the incidence rate is very low; this represents a relatively small number of cases but still quite significant given the severity of meningococcal disease. Now is a good time for frontline healthcare providers to read up about meningococcal disease in general including indications for vaccination and identification of high risk groups, especially for this outbreak: age 30-60 years, Black or African-American descent, and living with HIV; as well as the usual risk factors of close contact with a case, people at the age extremes, certain immunodeficiency diseases such as complement deficiencies, and some college settings. The HAN notice includes many useful links.
How's Your Ventilation?
CDC issued revised guidelines for indoor ventilation to help prevent respiratory virus transmission, including SARS-CoV-2. Take a look and maybe ask your friendly office landlord how your building stacks up.
Apparently I've missed it for a couple years, but CDC also has an interactive tool to see how changes in ventilation may improve viral particle clearance. I disappeared down that rabbit hole playing with it for about half an hour. Note the disclaimer at the top of the web page about some information needing updates, though I think it mostly concerns the old 6-feet social distancing and other recommendations rather than the tool itself. Here are results from a home with intermittent HVAC operation, uncertain filter rating, and running the HVAC system for 1 hour after a 4-hour period of gathering. Better results can be achieved with continuous HVAC operation (i.e. keep it on continuously during times of high occupancy), high MERV-rated (Minimal Efficiency Reporting Value) filter, use of HEPA (High Efficiency Particulate Air) cleaner, and other factors.
However, before you overhaul your home system or threaten your office landlord, note what this is really saying. The outcomes pertain to effectiveness of particle reduction in the air, which is different from measuring whether it lessens transmission of SARS-CoV-2, influenza, RSV, or other viruses. It makes sense that there would be some correlation, but until someone does a more definitive study comparing systems and actual viral infection rates, we don't really know to what degree ventilation efficiency changes infectious disease outcomes. Compare this with the study of secondary household transmission mentioned at the top today's post - a more difficult study design with results more directly related to clinical outcomes than just a study of airborne particles in a laboratory chamber. And, parenthetically, the household transmission study did not include individual home ventilation as a factor, so even those results are incomplete. This is complicated!
Measles Update
Measles marches on in the US and across the world. US cases continue to grow, now at 97 since January 1, fed in large part recently by outbreaks in Chicago: 21 new cases in the past week just in Chicago alone. Here are the latest US numbers and distribution from CDC:
In Search of Easter Candy
Once again my wife and I have used our granddaughter as an excuse to buy Easter candy. She's a picky eater, now the only chocolate bunny she will touch must be dark chocolate without any added flavorings or other adulterations. I applaud her good taste, but perhaps next year I'll do this shopping more than a few days prior to Easter Sunday. I had no trouble finding a multitude of milk chocolate bunnies, some with various additives including peanut butter, salted and unsalted caramel, marshmallow, and other ingredients that I might have considered inedible if presented separately from chocolate. Plain dark chocolate bunnies apparently are almost extinct, definitely at least a critically endangered species.
I should have kept track of my steps and car odometer for this year's chocolate bunny safari, though I doubt even the thousands of steps I tallied will offset my Easter candy ingestion.
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.
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.
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. 😉
