I just watched a gentleman, probably close to my age, jog by my house. Current temperature is what should be a comfortable 79 degrees, but with humidity 87% the "feels like" temperature on my phone app is 82 and my real world experience walking the dog this morning I give a 4 on my 5-point uff da scale,* where 5 is completely miserable.
It's also been pretty steamy in the healthcare policy arena this past week. A group of medical and public health societies and an unnamed individual have filed a lawsuit against our HHS Secretary, FDA Commissioner, NIH Director, and CDC Acting Director seeking to overturn withdrawal of recommendations for covid vaccines. At about the same time, the HHS Secretary cancelled last week's meeting of the United States Preventive Services Task Force, a terrific group of 16 highly qualified medical and public health experts serving on a rotating voluntary basis under the auspices of the Agency for Healthcare Research and Policy. They publish recommendations for a variety of medical conditions; current work in progress includes statements on interventions for tobacco cessation in adults and vision screening in children ages 6 months to 5 years. So far in 2025 they had published 5 recommendation statements, including one for syphilis screening in pregnancy. The recommendations can in part determine insurance coverage for various tests and treatments. In general, the evidence bar to clear the USPSTF is pretty high; much of the time their recommendations serve to point out deficiencies in our knowledge base and provide direction for future study. Of course I'm wondering if USPSTF is headed for the same downhill trajectory we saw with ACIP - cancelled meetings followed by firing of experts who are then replaced with pseudo-scientists with an ax to grind.
Thankfully I found many intriguing topics to discuss this week. I picked a few.
High Consequence Infectious Diseases
This is an official designation in the UK, and I was interested to see a recent breakdown, especially noting infections that didn't qualify for HCID status. HCID definition includes an acute infectious disease that typically has a high case-fatality rate and may not have effective prophylaxis or treatment. HCID often are difficult to recognize and detect rapidly, have an ability to spread in the community and within healthcare settings, and require an enhanced individual, population and system response to ensure effective management. They are organized by mode of transmission as follows:
Contact HCIDs
- Argentine haemorrhagic fever (Junin virus)
- Bolivian haemorrhagic fever (Machupo virus)
- Crimean Congo haemorrhagic fever (CCHF)
- Ebola virus disease (EVD)
- Lassa fever
- Lujo virus disease
- Marburg virus disease (MARD)
- severe fever with thrombocytopaenia syndrome (SFTS)
Airborne HCIDs
- Andes virus infection (hantavirus)
- avian influenza A(H7N9) and A(H5N1)
- avian influenza A(H5N6) and A(H7N7) [H5N6 has not yet been reported to have human-to-human transmission]
- Middle East respiratory syndrome (MERS)
- Nipah virus infection
- pneumonic plague (Yersinia pestis)
- severe acute respiratory syndrome (SARS) [this is the original SARS from the early 2000's, no known cases since 2004]
Looking at the HCID definition, I think it's clear why SARS-CoV-2 wasn't on the list - we now have effective diagnostic tests, preventive measures, and treatments available. I was a little surprised not to see mpox in the list of contact HCIDs. The supporting evidence stated that mpox was "derogated" by the UK Advisory Committee on Dangerous Pathogens. Yes, I admit I had to look up the definition of derogation; it indicates an exemption or relaxation of a rule. Both COVID-19 and mpox are still significant threats to global health, but for UK purposes not having them on the HCID list means that they can be managed outside of designated HCID treatment centers.
Chagas Disease in Florida Kissing Bugs
Not a huge surprise, but now we have evidence of significant colonization of Florida triatomine bugs with Trypanosoma cruzi, the parasite that causes Chagas Disease. Various investigators and community programs collected 310 Triatoma sanguisuma bugs from 23 counties (mostly northern and central Florida) over the period 2013 - 2023. About 35% of the bugs were found in human dwellings, so this isn't just a phenomenon taking place in Florida wilderness. About 30% of the insects carried T. cruzi. The investigators also analyzed the blood sources. Mammals comprised 60% of the sources, ectothermic vertebrates (amphibians and reptiles) 37%, and cockroaches 2.5%. Importantly, humans represented 23% of the infected blood meals.
Just in case you have a Florida trip upcoming, here's the distribution though note that not all geographic areas of the state were sampled.
Probably more importantly, here's what the bugs look like. At left is an adult female and on the right are nymphal stages. The bars represent 2 mm for each photo.
Triatomes commonly are referred to as kissing bugs because they like to bite us on the face. Kissing bugs can be found in most US states, generally sparing the northernmost states.
Association of First Trimester UTI with Congenital Malformations
I was surprised I didn't see anything about this in the lay press, maybe I'm not watching enough TV. Previous studies have variously suggested an association with first trimester exposure of pregnant people to trimethoprim-sulfamethoxazole (TMP/SMX) or nitrofurantoin and subsequent congenital malformations in their newborn infants. Investigators from multiple institutions now have published a cohort study of around 70,000 pregnancies identified through a commercial insurance database to have received either TMP/SMX, nitrofurantoin, a fluoroquinolone (ciprofloxacin, levofloxacin, or ofloxacin), or a beta-lactam antibiotic to treat a UTI during the first trimester of pregnancy in the years 2006 - 2022.
Results suggested a higher risk with TMP/SMX exposure but not with nitrofurantoin for some cardiac defects and for cleft lip and cleft palate, when compared to mothers who received beta-lactam antibiotics for their UTI. Part of the data are shown below.
You can see at the right of the table that the 95% confidence intervals do not cross 1.0 for these 2 circumstances, indicating a statistically significant association. Also note, however, that the total number of events are a relatively small percentage of the total exposures. Still, these malformations carry significant morbidity. The American College of Obstetricians and Gynecologists cautions against use of TMP/SMX and nitrofurantoin in the first trimester of pregnancy. It's easier to understand why TMP/SMX might be able to cause malformations because both components inhibit folate metabolism. This study lends support to avoiding TMP/SMX in this setting.
Some Potpourri
Measles
You've probably seen a lot about US measles cases now surpassing 2019's total, so we now have to go back to 1992 to see a higher number of cases; this occurred while the US was still trying to implement 2nd doses of MMR for the 4 - 6 yo age group. Although new cases are reported every week, it's important to note that things have tapered off a bit, enough for the CDC to go back to just weekly case count reporting.
I'm holding my breath that we won't have another big outbreak somewhere, but MMR vaccine hesitancy is against us.
West Nile Virus Review
A nice one was published in JAMA last week, worth reading for a general refresher. Remember that most infections are asymptomatic. Symptomatic individuals usually experience a self-limited febrile illness, but the real fear is neuroinvasive disease.
The live link to the testing algorithm is here.
*Uff Da
Those who know me personally might wonder why I would appropriate a Norwegian term since my ancestry is most certainly not Scandinavian. I think I can claim some rights to the term. My long-suffering wife was born in Minnesota, and both sides of her family have Scandinavian roots. Furthermore, my mother was born and grew up in the Upper Peninsula of Michigan, a hotbed of former Scandinavian residents.
I survived several (6-month-long) summers in Houston, a hotbed of humidity, but I never became accustomed to it.
Looking forward to September.
