My soon-to-be daughter-in-law recently gave me a bird feeder - not just any bird feeder, but a smart one that has a camera connected to my wifi that takes photos and videos of any birds that show up. I had my first visitors this morning, a few days after I stocked it with birdseed.
In the meantime, winter is here.
WRIS
A lot going on with our Winter Respiratory Infection Season, including some new items.
CDC issued new (or actually old) guidance for use of the long-acting monoclonal antibody nirsevimab for preventing RSV infection in young infants. The change was prompted by the announcement of greater availability of nirsevimab because the manufacturer released an additional 230,000 doses this month. Previously the guidance had indicated that the product should be prioritized for just a subset of infants at higher risk, but now recommendations are to go back to the original plan to administer to all infants less than 8 months of age as well as to infants 8-19 months of age with high risk conditions:
- Children who have chronic lung disease of prematurity who required medical support (chronic corticosteroid therapy, diuretic therapy, or supplemental oxygen) any time during the 6-month period before the start of the second RSV season
- Children with severe immunocompromise
- Children with cystic fibrosis who have severe disease
- American Indian and Alaska Native children
If supply is still limited in your particular area, then prioritization should be used as before. Still a bit vague but very important are all the nuances for ordering, administering, and being reimbursed for the product.
Along that same line, RSV may have peaked nationally.
Even with some good news about RSV slowing down, there's still plenty to go around. Also, influenza continues to drive a lot of healthcare usage for all ages around the country. Here is the percentage of emergency department visits due to the various respiratory infections:
Be aware that this site allows you to look just at your local jurisdiction - here is Maryland:
Covid
This week covid deserves a separate heading with a few new twists. Wastewater tracking once again has accurately predicted a surge in infections.
The JN.1 variant has increased rapidly and is projected to be the predominant covid strain in the US, but without any indication (yet) that it has increased virulence.
This might be a good time to review a bit about variants and also some recent covid findings. Variant nomenclature is confusing to me, I can only imagine how the general public sees this. Here is an evolutionary tree from the same CDC weblink as above.
The nomenclature is from the Pango system, but most people are more familiar with the WHO classification: the delta variant (remember those horrible days?) is B.1.617.2 near the left of the diagram. Omicron is represented in both BA.1 and BA.2. Now here's the important part when we consider new variants, immune-escape, and vaccines: JN.1 has developed on the BA.2 side, just like XBB but on a different branch of the tree. Remember that our current vaccines are based on XBB. As I've mentioned previously, XBB vaccine antibody seems to neutralize JN.1 pretty well in the test tube, but all vaccine (and natural infection) immunity declines significantly within a few months after vaccination or immunization. I would still expect the current vaccine to be pretty good for protecting against severe disease with JN.1 infection.
Although near and dear to my heart, I don't usually talk about old folks in this blog. However, a study of old folks in the Netherlands lends support to the idea that current vaccines are effective against new variants. Without going into details, you can see this study has very recent data and show excellent effectiveness for hospitalization and ICU admission for old folks. It's likely this benefit translates to the younger population that of course has lower rates of hospitalization overall.
Another recent study sheds some light on a question I've been wondering about for some time, namely how common asymptomatic covid infection might be in the omicron era. You might recall that one of the early surprises in 2020 was that asymptomatic infection was both common and very important for viral spread. That made the pandemic much more difficult to control. Now we have data from Hong Kong where rather unique epidemiologic circumstances prevailed. With a population of 7.5 million, Hong Kong officials had still had managed to prevent covid spread very effectively prior to the omicron era, with only about 0.5% of the population having been infected. That ended in early 2022, but it also offered researchers an opportunity to look at rates of asymptomatic infection during the omicron period because virtually none of the population had been infected previously. Using antibody testing, they estimated that 16% of the population was infected during the first 6 months of 2022 and that the percentage of asymptomatic cases was at least 42% (taken from those with reported SARS-CoV-2 infections) and possibly as high as 72% (looking at combined reported and unreported infections). Wow. That doesn't necessarily mean we would have those same rates of asymptomatic infection in the US where we've had a very different epidemiologic curve over the years, but I think it's likely we have a lot of asymptomatic covid surrounding us now.
Some good news about long covid, AKA PCC (post-COVID-19 condition) in children. This Canadian study looked at pediatric emergency department data and found that PCC was present in only 0.67% at the12-month follow-up periods in children testing positive for SARS-CoV-2. That's not the only good news part of this; the rate in a control group of children testing negative for covid was 0.16%, suggesting once again that other infections can trigger some of these long term symptoms. We have NIH-funded studies in the US ongoing now, with good control groups, that should go a long way in giving us guidance for managing PCC as well as other long-term conditions triggered by infections.
The Tipping Point
FDA officials, including Peter Marks who is the director of CBER, recently published a viewpoint article about a vaccination tipping point, i.e. the fact that vaccine hesitancy issues have resulted in a severe decrease in immunization coverage, opening us up to major outbreaks soon. I mention this both because it perfectly supports my views expressed in recent weeks but also it gives me a chance to give credit where credit is due. The term "tipping point," as applied here, often has been credited to Malcolm Gladwell. However, his popularization of the term in a sociologic context earlier this century should go to Morton Grodzins who first adapted this for use in explaining racial integration of neighborhoods in the middle of the 20th century. I'm hoping Gladwell credited him.
In Case You Missed These
Two other articles caught my eye this past week. First is a quality improvement article about shortening treatment duration for children with community acquired pneumonia and skin and soft tissue infections. If you're one of those practitioners who still treats these for 10 days (because we have 10 fingers), check it out.
Secondly, I was attracted to a report about variation in rates of how primary pediatric providers use pediatric subspecialty consultations. Although not the main focus of the report, I was most drawn to the mention that the top 2 conditions for using a pediatric infectious diseases specialist were positive tuberculin skin test and inactive tuberculosis. This jives with my personal experience and certainly points to opportunities to lessen use of subspecialty health care. Multiple resources exist for managing latent tuberculosis infection, including the AAP's Red Book, the CDC, and UCSF's Pediatric TB Resource Page.
For the Birds
My first video stars at the bird feeder were a white-breasted nuthatch, maybe a tufted titmouse (looks a lot like the nuthatch, I couldn't figure it out), and a house finch. When I received the bird feeder, I immediately wondered how best to avoid attracting squirrels and other rodents. I did a bit of web searching and then journeyed to my local bird authorities at the Woodend Nature Sanctuary who of course turned out to be the most helpful. I armed my feeder with capsaicin-treated safflower seeds, not a favorite of squirrels and the like, plus birds can't taste the hot pepper. So far the birds seem to like it.
As for me, it appears I've fallen down another rabbit hole, similar to my butterfly fascination. My wanderings have now included a look at how climate change is affecting our bird populations, as projected by the Audubon Society (apologies for using his name, now controversial, but the Society hasn't yet changed it) in their field guide.
Here is how things will change for the white-breasted nuthatch's winter range with a 1.5 C increase in temperature.
For the tufted titmouse
and the house finch
With more severe temperature increases, the ranges are altered more dramatically. I still hope for some action that will reverse these trends.
