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Tag: SARS-CoV2

Published on Leave a comment on Chocolate Bunnies

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.

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 Lull or Spike – What Will Winter Break Look Like This Year?

We continue forward into winter respiratory illness season, and I find myself wondering again how it will compare to prepandemic winter seasons. At that time, my annual wish had been that influenza and RSV peak activity would not coincide; if they did, healthcare facilities faced an overload. Now, covid is thrown into that same mix. Furthermore, in the prepandemic winter school breaks that occurred in the midst of flu season often seemed to put a pause in flu transmission that carried over into January. In today's world of infectious diseases, will this still be true, or could the increased travel and crowding result in a spike of respiratory infections? Perhaps we'll know in another month.

Bad Omen for Mpox?

Last week CDC released a Health Alert Network post about a new outbreak of mpox in the Democratic Republic of Congo (DRC). Although it is happening in a country far away from the US and not a common travel destination, I believe it's worth taking note of. It could impact health around the world, including in the US. To me this is more noteworthy than the respiratory illness surge in China that I mentioned last week because it may impact the US directly. The current DRC outbreak is a different clade of mpox that is potentially more virulent and could spread worldwide. We all remember the 2022-23 outbreak resulting in mpox becoming endemic in the US and a particular hazard for men who have sex with men.

The previous outbreak was caused by clade 2 mpox, generally endemic in western Africa. The new DRC outbreak is clade 1 that historically has been more common in central Africa and may cause more serious infections generally including higher mortality. What is different in the DRC now is that human to human transmission has been documented, included sexually-transmitted disease. So far clade 1 has not been seen in the US, and the alert mentions that none of the 150 US isolates from 2023 undergoing testing (a 12% sampling) have been clade 1. It is likely that the same countermeasures that have been effective for the clade 2 outbreak, including vaccine and antiviral therapy such as tecovirimat, brincidofovir, and vaccinia immune globulin, will be effective for clade 1 disease. Now is a good time for healthcare providers to brush up on clinical diagnosis of mpox and counsel high risk individuals to seek vaccination.

Remember Eleanor

For most of my career I have kept and updated a list of Bud's Laws, now a compilation of 10 aphorisms designed to trigger recall of some key bits of medical knowledge for clinicians. One of them is "Remember Eleanor" to trigger the fact that tuberculosis has many clinical presentations, some outside of the usual fever, pneumonia scenario. The Eleanor in the aphorism refers to Eleanor Roosevelt who died of tuberculosis in the 1960s. Her physicians had been treating her for aplastic anemia; TB was finally diagnosed when it was too late for treatment to be effective (plus she apparently had drug-resistant TB!). Whether her physicians actually misdiagnosed her aplastic anemia or the steroids they administered for that just reactivated latent TB isn't clear to me.

A recent MMWR report of neonatal death following failure to diagnose mother with active TB is a heartbreaker. Mother did have risk factors for tuberculosis and concerning symptoms of insufficient weight gain and hyperemesis dismissed as due to pregnancy, plus chronic cough written off as gastroesophageal reflux. Mother wasn't evaluated for TB until her newborn became seriously ill in the third week of life, ultimately developing septic shock and dying at 6 weeks of age.

TB diagnosis is always easier in retrospect; please keep it in mind especially for individuals with risk factors.

Respiratory Virus Tracking

Clearly CDC is messing with me. Their cutoff for weekly data summary is Friday, but they don't post the updates until the following Monday. So, my blog post on Sunday will be a week off.

Still, nothing is going to change too much in a week to alter clinical practice during winter respiratory illness season. Here's a few details from the latest CDC graphics.

Remember that the graphic above will capture other illnesses besides flu, but it's a pretty good indicator for flu season. RSV hospitalizations in the 0 - 4 year age group still appears to be rising nationally.

Percent positivity of RSV tests may have peaked already, too early to be certain but that could be a good sign.

Covid wastewater levels continue to be high and rising.

Note that you can visit this site and see a breakdown by regions of the country; currently the Midwest has the highest levels.

Managing Mild Pneumonia in Children

I welcome comments to this blog and I answer them routinely - unfortunately subscribers don't get an email notice when I do so, you'll need to keep track of comments when you are looking at the site.

This past week I received a comment from Dr. Rebecca Carlisle who practices mostly in a pediatric urgent care setting. I thought it was worth answering in a regular post because it brings up an issue I think most pediatric practitioners are facing now. She wrote, "I’ve been seeing a lot of kids-ages 4 to young adults with terrible sounding lungs-wheezing/rales-not really responding to nebs. I’ve been chalking it up to “viral pna” but a couple times have started Azithro (one of my least favorite medicines bec I think it’s overused in the adult population).... Your post mentions that tx doesn’t usually help, but maybe in early illness? Any elaboration on that and should I be trying more Azithro, never Azithro?"

It would be great if we had a guideline that helps us with managing pediatric community acquired pneumonia (CAP). Of course we did have one from the Infectious Diseases Society of America, but it was written in 2011 and has been archived, meaning it is no longer accurate. They are working on a new guideline, too late to help us now. WHO also has a guideline but that is geared for managing CAP in resource-poor countries and not that helpful for a US population.

Regardless of whether we have current guidelines or not, probably the most important consideration in management of mild CAP in children is knowing what pathogens are circulating in your community. In the midst of flu season. rapid testing for influenza should be obtained if treatment is considered, whether it be for mycoplasma, other bacteria, or influenza. Azithromycin likely is still the drug of choice in this age group, given that mycoplasma is more common in the slightly older child and it may have some activity against pneumococcus, depending on local resistance patterns.

The real problem with azithromycin in this circumstance is that it may have little to no effect on the course of mycoplasma lower respiratory disease. Randomized placebo-controlled trials in children from decades ago showed no difference between erythromycin treatment and placebo outcomes. A 2015 Cochrane review reinforced this: "In most studies, clinical response did not differ between children randomised to a macrolide antibiotic and children randomised to a non‐macrolide antibiotic. In one controlled study (of children with recurrent respiratory infections, whose acute LRTI was associated with Mycoplasma, Chlamydia or both, by polymerase chain reaction and/or paired sera) 100% of children treated with azithromycin had clinical resolution of their illness compared to 77% not treated with azithromycin at one month." The authors called for high-quality RCTs to answer the question, but the problem is that, since mycoplasma LRTI is self-limited, the sample size needed for a definitive study is quite large, probably prohibitively expensive unless a pharmaceutical company comes out with a new macrolide where future sales might warrant investment in such a trial.

For now, chest radiographs aren't indicated for mild pediatric CAP, and diagnostic testing should be limited to treatable infections such as influenza or for situations where elderly or immunosuppressed close contacts could benefit from knowledge of the child's infection. Azithromycin treatment of mild CAP in the school-aged child probably should be the exception rather than the rule. It's not a never event, just something to be considered based on the child/family individual concerns. Just my opinion.

TB in Literature

Speaking of Eleanor, probably your holiday vacation reading list isn't full of books about TB, not a particularly uplifting topic. My favorite TB novel by far is Thomas Mann's The Magic Mountain, but it does require a bit of diligence to make it through. If you're interested in a shorter novel where TB is featured, think about Penelope Fitzgerald's The Blue Flower. Her other 8 novels are all great as well.

Published on Leave a comment on Happy St. Martin’s Day

I was thumbing through my Farmer's Almanac this morning and noticed a mention of "Indian summer" for November 12. That's not a great term to use nowadays, so I'm opting for the European version called St. Martin's summer or day. I never bothered to see what these terms really meant, but I've learned it represents a period officially from November 11 to November 20 where we experience unseasonably warm weather. We've certainly had that recently, though November 11 and 12 in Maryland is back to cool fall weather.

Miscellaneous Vaccine News

I have no idea what a "miscellaneous" vaccine is, I was just desperate for something to title this section.

A new vaccine to prevent chikungunya virus infection was approved by the FDA this week for individuals 18 years and older at increased risk for infection with this mosquito-borne pathogen. It is a live virus vaccine. As with most arboviral illnesses these days, the vector range is expanding as our climate warms, and transmission has occurred within the US. Still, most infections in US residents are acquired via travel to more endemic areas such as Africa, southeast Asia, and Central and South America. The clinical illness is similar to dengue fever and mostly is a miserable but self-limited illness. However, elderly are at risk for complications, principally chronic joint disease. Newborns also are at risk for more severe disease, including death, and it is unknown whether the vaccine virus could be transmitted to the fetus. The package insert includes precautions for use in pregnant people. The main study supporting approval appeared a few months ago and looked primarily at side effects and antibody response, not actual vaccine efficacy. One big caveat, the manufacturer is required to conduct post-marketing studies to ensure that vaccine recipients do not develop a worse form of chikungunya after becoming infected; this is a possibility though not highly likely. For now, I'd consider this mostly as an option for older individuals at very high risk for infection. Most other US residents should wait for further information about the vaccine, but it's good we have this option available.

This past week also saw publication of new data from Singapore about benefits to newborns of covid vaccination of mothers during pregnancy. It was a cohort study, which is a study design slightly more prone to inaccuracies than are randomized controlled trials, but it did show about 40% efficacy in preventing infection in newborns when their mothers were vaccinated during pregnancy. Of interest, pre-pregnancy vaccination of mothers was not effective in preventing newborn infection. The study covered the period from January, 2022, through March 2023. This is yet another reason to encourage covid vaccination for pregnant people, along with pertussis and RSV vaccination. The benefits do extend to their children.

Unfortunately, we also have some disappointing vaccine news in the category of missed opportunities. First, 2 studies from the CDC demonstrated poor influenza vaccine uptake by healthcare providers. In the first report, flu vaccination rates for HCP in acute care hospitals fell from 88.6 - 90.7% in the years 2017-2020 down to 85.9% in 2020-2021 and 81.1% in 2021-2022. We all know that the pandemic made it difficult to access regular health care for many people, but these are workers in acute care hospitals who didn't have that excuse. The second study looked at a broader range of HCP during the 2022-2023 flu season and showed 81.0% flu vaccination rates in acute care hospital employees and a shocking (to me) 47.1% rate for nursing home employees. Up to date covid vaccination status rates were even more depressing: 17.2% and 22.8% in acute care hospitals and nursing homes, respectively. I can understand why some people may choose not to receive these vaccines, but HCP do have a responsibility to protect those for whom they provide care. (IMHO; I'll get off my soap box now.)

Also in the Debbie Downer category, CDC reported that vaccine exemptions for kindergarteners increased for the 2022-2023 school year. The rogues' gallery includes 10 states (Alaska, Arizona, Hawaii, Idaho, Michigan, Nevada, North Dakota, Oregon, Utah, and Wisconsin) having exemption rates above 5%. Idaho easily came out on "top" with a 12.1% exemption rate. The reasons for high exemption rates are complex, note that the list of states doesn't necessarily follow political lines. States that make it more difficult for parents to apply for non-medical, aka philosophical, exemptions have lower exemption rates overall. An oldie but goodie study also stressed that exemption rates vary within a state, and small hot spots with high exemption rates can fuel outbreaks of vaccine-preventable diseases.

Missed Opportunities to Prevent Congenital Syphilis

The CDC was very busy this past week! Another report looked at missed opportunities for prevention of congenital syphilis in 2022. Looking at the 3761 cases of congenital syphilis reported that year, almost 90% of birth parents received inadequate management. This included no or nontimely testing (36.8% of parents) and no or nondocumented (11.2%) or inadequate (39.7%) treatment. I'm hoping our public health infrastructure can be shored up to lower cases of congenital syphilis, now at a 30-year high.

Tripledemic Update

Rather than showing yet another RSV-NET graph, where data are somewhat delayed anyway, I thought I'd mention a bit more about that system. It is set up in 14 states covering about 8% of the US population. Here's what the distribution and data collection looks like:

I'm not sure why (Veteran's Day?) but FLUVIEW did not update this past week, so nothing new to report there. Wastewater covid levels reported by Biobot remain lowish.

No Hasty Pudding Again This Year

I'm starting to help plan a Thanksgiving menu for later this month, and I was reminded of another ill-named item, Indian pudding. It is similar to the British hasty pudding that uses wheat flour rather than cornmeal. I have a wonderful recipe, dated 1958, from the Durgin-Park Restaurant in Boston. Durgin-Park opened in 1742 and closed in 2019, and this dessert was an icon on their menu. The reasons I won't be having it again this year are multiple but include the fact that I'm the only one in my family who likes it and that it contains about 5000 calories per tablespoon (only slight exaggeration). I think I'll just change the name to Durgin-Park pudding for future reference.

Published on Leave a comment on I Should Have Listened to Myself

Last week I was a bit obsessed with all the leaves around my house, both on the ground and still in the trees. With a neighborhood leaf collection looming and many leaves still to fall, I decided not to rake that day. The next day I reversed my stance, which was a bad idea.

On the COVID Front

Although we aren't seeing much of a surge so far (see Tripledemic below), I did come across a few items to mention.

First, FDA issued an alert about potential dosage errors with the Moderna vaccine for children 6 months through 11 years of age. The standard dosage is 0.25 ml, but apparently the single dose vials contain "notably more" than this amount. So, if one draws up the entire contents of the single dose vial and administers it, the dose will be too high. Try as I might, I was unable to determine how much above 0.25 ml "notably more" is. So far the overdosage hasn't been shown to cause any harm. Please alert your staff to this.

On the topic of Multisystem Inflammatory Syndrome in Children, a prospective cohort study in the Netherlands suggests that MIS-C is lessening recently, possibly related to prior immunity. This fits with other reports, mostly anecdotal.

Finally, and consider this a very preliminary observation, researchers in China have noted an apparent increase in situs inversus diagnosed with prenatal ultrasound following lifting of covid restrictions in that country.

I'm advising caution in interpreting this study because 1) it is a short letter to the editor so methodologic details are a little sparse (supplementary online appendix helps); 2) funny things can happen when an epidemiologic blip is noticed that then triggers a look back - although the authors claim their protocols for performing sonography didn't change, all sorts of bias can affect the data in this setting; and 3) no one else has reported this association previously. I'm sure we'll see further refinement on this topic from these and other investigators in the coming months.

Some readers may have noticed I haven't mentioned anything about SARS-CoV2 variants for a while. They are still out there, changing rapidly as usual, but I won't comment much until/unless we see emergence of a variant dramatically different in its ability to alter epidemiology of disease, either by evasion of prior vaccine and infection immunity or with increased virulence.

New Infant Hepatitis C Screening Recommendations

CDC has issued new screening guidelines for infants born to mothers with hepatitis C, which should help identify infants at risk earlier. The entire document is very well written and informative. Expect updates to appear in the Red Book and from other organizations. Here is the bottom line for primary care providers, including a definition of perinatal exposure.

For a child not screened in early childhood:

Hepatitis C testing is a bit confusing to many providers; don't hesitate to seek assistance from your friendly neighborhood pediatric ID or GI provider!

Tripledemic Update

RSV continues, but we have yet to see any notable increases in flu or covid.

RSV-NET still shows an increase in hospitalizations nationally, ages 0-4 years shown in purple.

The FLUVIEW map is similar, though note this is tracking "influenza-like illness" which will be contaminated with other respiratory viral infections.

Biobot wastewater monitoring is at about the same level, still far below the January 2022 surge.

I continue to focus on wastewater data for SARS-CoV-2 due to the decrease and vast variability in tracking infections, hospitalizations, and deaths now compared to during the pandemic.

Autumn Thought

As I was finishing sweeping and raking leaves and carting them to the curb for pickup, a big wind came up. Within about 10 minutes, the areas I had just cleared looked exactly the same as before I started. The only change was that big maple tree outside my window now had significantly fewer leaves clinging to branches. At least I got a little exercise.

Langston Hughes, one of my 2 favorite American poets (Wallace Stevens being the other), wrote a short poem in 1921 entitled Autumn Thought:

Flowers are happy in summer.

In autumn they die and are blown away.

            Dry and withered,

Their petals dance on the wind

Like little brown butterflies.

And... Happy End of Daylight Savings Time!

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