I learned this morning that the New Yorker followed my lead on asterisks from last week's post. The commentary by Dhruv Khullar highlights "the most notorious asterisk in modern public health" and uses examples from George Orwell to Joseph Stalin and Trofim Lysenko, the latter a sort of combination of our current HHS Secretary and leaders in FDA and ACIP. The commentary will appear in the December 8 print issue of the magazine. I won't sue the publisher for plagiarism, the article is much more entertaining than my post was.
In the meantime, I'm mostly trying to recover from my Thanksgiving gluttony and steel myself for the ACIP meeting this week.
ACIP Meeting December 4-5: What I'll Be Watching For
As of early Sunday afternoon, the meeting agenda is still the original, vague draft version that appeared on November 14. The topics include the general pediatric and adolescent vaccine schedules, "adjuvants and contaminants," and hepatitis B vaccine. There is a placeholder called "Votes" but nothing listed there.
It is unusual not to see a more detailed agenda posted this close to the actual ACIP meeting. It makes it more difficult for those kept in the dark to prepare for the meeting. Of course no slides or background materials have been posted; by itself this isn't unusual - sometimes this wan't posted until the evening before the meeting, but in the new ACIP era a few of the presentations are posted only after the meeting, greatly interfering with understanding the speaker's presentation.
Regardless of these uncertainties, what I'm most looking for is inclusion of details on how information was synthesized. To achieve transparency and allow for others to review conclusions, ACIP (and every other scientific body) needs to follow systematic processes to understand data. Prior to the recent meetings, this included standardized review processes such as the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology and the Evidence to Recommendations (EtR) framework. All of these documents remain on the CDC website but have been used sparingly or not at all in the last 2 ACIP meetings.
I hope to be able to virtually attend both days of the meetings and will report back next week.
Around the Globe
I've said it before and I'll say it again. We should care about outbreaks in far-away countries; these are real people who are suffering, in many cases because they don't have access to relatively simple public health tools and medications/vaccines that could prevent these outbreaks. For those in whom altruism is not at the forefront, remember that in this age of jet travel and plummeting vaccine coverage anyone anywhere can be personally affected by far-away outbreaks.
Enough soapbox oratory. I'll touch on 2 outbreak updates this week.
First, WHO's Weekly Epidemiological Record (volume 100, issue 48) has a measles update. Of course we don't need to journey beyond our own US borders to know that things aren't good, but a global view is helpful. Since 2000, the numbers of countries experiencing outbreaks fell for a while but now are increasing.
No surprise, the graph below shows vaccination works. Note the y-axis is in millions of deaths.
The WRISM section below has more details about the latest in the US.
WHO also had an update on cholera covering this calendar year so far. Cholera is a prime example of an infection that mostly wouldn't exist if proper sanitation measures were in place. Here's this year's geographic distribution. The one western hemisphere hotspot is Haiti.
The report goes into detail about specific regions and countries. The one piece of good news I found was that the supply of oral cholera vaccine is now at 7.9 million doses, a big improvement and above the emergency threshold of 5 million doses.
The Week's Articles of Interest
I guess I'm doing things in pairs this week, 2 articles caught my eye.
The first concerned one of the banes of my former clinical practice - recurrent staphylococcal skin and soft tissue infections. I don't know how many children and families I talked through decolonization protocols when I was in practice, but sometimes I felt like our time would be better spent if I just invented some sort of incantation ceremony for them. Now, we have results from a randomized controlled trial from investigators at Washington University to give us a little better definition of effectiveness of one approach to staphylococcal decolonization.
During the years 2015 - 2021, 196 index patients with a total of 623 household contacts underwent an initial 5-day decolonization regimen and then were randomized into 3 different 3-month decolonization regimens. The initial 5-day decolonization that everyone received consisted of twice daily nasal mupirocin and daily chlorhexidine body washes. Infants younger than 2 months were excluded from decolonization. The 3 randomization protocols were 3 months in length and included 1) periodic personal decolonization with twice weekly chlorhexidine body washes and nasal mupirocin on 5 consecutive days once monthly; 2) an environmental hygiene regimen with weekly bleach wipe-down of bathroom, kitchen, and electronic surfaces, weekly laundering of all bed lines, weekly replacement of kitchen sponges, and daily replacement of kitchen and bathroom tools with clean towels or use of disposable towels; and 3) the integrated approach combining all aspects of regimens 1 and 2. Samples to determine colonization were obtained and folllow-up was performed at 1, 3, 6, and 9 months, with the primary outcome targeted at 3 months. They monitored colonization rates, which I won't present here, as well as new episodes of infection.
Here's the summary of all their findings for the most important outcome, skin and soft tissue infections. "Index patients and
household contacts with SSTI in the past year assigned to the Integrated-Approach had a lower cumulative SSTI incidence at 6-months(p=0.04) and 9-months(p=0.04) compared to the PeriodicPersonal and Environmental-Hygiene combined group."
If you struggle with advising these families, this article will help you and them decide on options to prevent infections.
The second study dealt with the problems in use of trimethroprim-sulfamethoxazole in adolescents and young adults with respiratory infection. It's a retrospective cohort study from Canada covering the years 2003-2023 and should at least make you think twice about using tmp/smx for respiratory illness in this patient population.
Compared to amoxicillin and oral cephalosporins, use of tmp/smx was associated with higher rates of serious outcomes.
In my practice I never (maybe there was a rare exception) recommended tmp/smx for treating outpatient pneumonia. However, because these outcomes are very rare, the absolute risk (indicated by RD above) is pretty small. Both the retrospective cohort study design and the small absolute differences in outcomes somewhat hinder the certainty of the outcome estimates, which is why I would put this in the "think twice" before using tmp/smx rather than strongly advising abandonment of tmp/smx for this purpose.
WRISM
On a national average, winter respiratory infection season hasn't started, but there is a bit of regional variation.
We are in for a bad flu season, although the reasons for that have been obfuscated by some of the lay press reports (IMHO). The primary reason we are in for a bad one is that the primary strain circulating is influenza A H3N2, which almost always causes more severe illness than does the other influenza A strain circulating in recent years, H1N1. Some lay press reports have hyped the AH3N2 clade K variant prominent in Europe and elsewhere which may be somewhat less covered by our current vaccine. However, this past week we have a preliminary report from England, which is experiencing an early start to their flu season, about vaccine effectiveness against this variant strain during the period September 29 to November 2, 2025. VE in preventing ED visits and hospitalizations was actually pretty good for children and adolescents infected with influenza A generally and with AH3N2 in particular. It is likely that the majority of the H3N2 infections in England during this period were subclade K.
Note the wide confidence intervals due to low numbers available for analysis this early in the flu season. Also included in the report was a brief mention of immunized ferret antisera reactivity with subclade K virus strains that showed significant decreases, but apparently not severe enough to eliminate VE at least in this preliminary analysis.
So, we likely will have a more severe flu season in the US this winter because AH3N2 will be the predominant strain. The low vaccination rates will add to the problem. Please encourage flu vaccination.
Also on the flu horizon, I was saddened to learn that the adult with underlying risk factors who was infected with influenza AH5N5 did not survive. There is now further evidence to suggest that he acquired his infection from his/her backyard domestic bird flock. CDC still has good advice for backyard poultry safety.
Last but not least, the latest on measles in the US. We're now up to 1798 cases.
It's almost certain the US will join Canada in losing its measles elimination status. Our steady flow of new infections isn't going to stop before the end of January when we will have a year's worth of ongoing endemic transmission, which is the elimination certification criterion used by WHO.
Soapbox Oratory
I'm not happy with getting up on my soapbox about political issues in this blog - I'm not a politician; in fact, I'd make a terrible politician because I don't like to cherry-pick information, obscure nuances, and reduce my message to catchy soundbites. I'll be challenged to hold myself in check for the next ACIP meeting.
In the meantime, I dug a little deeper into the origin of the soapbox term. It started in the late 19th century with snake oil salesmen and others fashioning speaking platforms from the wooden boxes used for packaging wholesale goods for delivery to retailers. I learned that the golden age of Soapbox Oratory was the period just before World War I.
Unfortunately, my dogfood delivery box does not function well as a speaking platform. Maybe that's a sign I should get off my soapbox.
