wastewater tracking – Page 4 – Pediatric Infection Connection

Happy Holidays

Bud WiedermannDecember 24, 2023December 25, 2023Leave a comment

'Tis the season, both for holidays as well as for infectious diseases. Last week's publications featured a wide variety of articles of interest; I'll try to keep it short. As much as I focus on infectious diseases, now is prime time to spend with friends and family.

Multiplex Stool Testing in Gastroenteritis

Children with acute gastroenteritis presenting to one of five different children's hospitals' on site urgent care or emergency departments submitted stool specimens for multiplex PCR testing. The study plan was interesting. For the first approximately 100 subjects, stools were tested regardless of whether the test was ordered by their clinicians (after informed consent from parents, of course). Then there was an intervention period where clinicians received education about the test performance characteristics and clinical management of the infections that the PCR could detect. Regardless of whether or not you look at the article, you may find these educational materials of use in your practice. I did note that the study was funded by NIH but also by the company that manufactures the PCR tests, plus most of the authors were employees of or received outside funding from the manufacturer. This is important because of high risk of implicit bias affecting the report.

"Clinically relevant" pathogen detection rate rose from 2% in the pre-intervention period to 15% after intervention, and return visits decreased after the intervention. There was a trend towards appropriate treatment given post intervention, though not statistically significant.

Indiscriminate use of multiplex PCR assays in acute gastroenteritis has a great potential to cause unnecessary treatment, especially for C. difficile in young children where the carrier rate is so high. It's not surprising that targeted education would be helpful. Also, because the test cannot determine antibiotic resistance patterns, laboratories would be advised to provide reflex susceptibility testing for selected pathogens that might require antibiotic treatment and also have significant resistance rates.

Covid Morsels

A few tinsel-tinged tidbits about covid caught my eye this week. First of all, CDC had a couple reports both suggesting that rebound after Paxlovid treatment was not clinically significant and no different than after placebo treatment. The more substantial report was a closer look at viral RNA shedding from 2 randomized placebo-controlled trials, from both early and later in the pandemic, involving adults only. Rebound rates were about the same in the treatment and placebo groups, both around 6-8%.

We've seen a wide variety of reports about rebound after Paxlovid, but clearly the weight of evidence suggests that viral rebound after treatment does not result in severe disease and that rebound rates likely are not clinically significant from rebound rates in untreated patients. Rebound concerns should not be a factor in decision to treat with Paxlovid.

Also this past week, the WHO stated that antigen composition for covid vaccines should remain the same for now, i.e. based on the XBB lineage of omicron that continues to represent the vast majority of circulating strains worldwide. The BA.2.86 descendents, including JN.1, are rising but with no big concerns yet about greater virulence or significant lack of protection from the XBB.1.5 monovalent vaccines now in use. As I've stated in previous posts, I've not been commenting on emergence of new subvariants unless/until they are shown to have clinical relevance; so far JN.1 does not meet that threshold.

A multidisciplinary panel of infectious diseases, microbiology, and epidemiology experts published an exhaustive guideline for use of molecular diagnostic testing for covid 19. I struggled with how to summarize all the information, suffice to say that the methodology for guideline development and the evidence behind the recommendations are stated clearly. I'll just present the bottom line summary, but please dig into the article for details if you are interested. Note that, if you haven't already, it would be helpful to identify sites near you where nucleic acid amplification testing (NAAT) with quick turnaround of results is available.

A multinational group of investigators summarized reports of laboratory-acquired infections (LAIs) and accidental pathogen escape from laboratory settings (APELS) between 2000 and 2021. Sixteen APELS were reported and involved anthrax, SARS-CoV (the original), and polio (3 each); Brucella spp and foot and mouth disease virus (2 each); and single episodes of variola virus, Burkholderia pseudomallei, and influenza H5N1 virus escape. LAIs were much more common with a total of 94 reports involving over 300 infected individuals. LAIs more commonly involved Salmonella spp, Brucella spp, and vaccinia virus. Although the study doesn't answer the question of SARS-CoV-2 origin, it certainly can inform measures to prevent lab accidents in the future.

Winter Respiratory Illness Season

Cumulatively our winter respiratory illnesses are increasing. I'm interested to see what the holiday school breaks and travel will do to the epidemic curves. I've been trying very hard to streamline finding current data that also is broken down by location so I can see my own local trends; unfortunately I don't find a single best one-stop shopping site for this purpose.

For general virus surveillance besides covid and influenza, look at the CDC's National Respiratory and Enteric Virus Surveillance System (NREVSS). You can then click on links to 4 groups of respiratory viruses (including RSV) as well as to 2 enteric viruses, rotavirus and norovirus. Here's an example of the South Region's (which includes my area of DC, MD, and VA) most recent RSV detection activity:

The CDC's COVID Data Tracker provides an extensive view of various indicators of disease activity, though not of wastewater which is still available at the National Wastewater Surveillance System (see below). Here's a quick view of the Data Tracker's most recent headline:

Wastewater covid continues to rise nationally.

Last but not least, our old friend influenza continues to spread across the country:

Have Your Cake and Eat It Too

I did say at the start this was a time to balance my obsession with all things infectious and my desire to have fun times with family and friends during the holidays, and I'll mention one way to (almost) do both. The annual Christmas issue of the BMJ was released. It always contains a few tongue-in-cheek articles - real research but performed for silly premises. The only infectious diseases-related article this time around was a study of bacterial contamination of hospital coffee machines. Surprisingly to me, the level of true pathogens they found was pretty low. I'm helping with some baking today, fans of the Great British Bake Off will enjoy this article.

However you spend the holidays, please take time to enjoy friends and family.

Happy St. Martin’s Day

Bud WiedermannNovember 12, 2023November 12, 2023Leave a comment

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.

Good Will

Bud WiedermannAugust 27, 2023August 27, 2023Leave a comment

This past week I attended an event that led me to reflect on "good will," not necessarily referring to the "peace on earth ...." quote or to the San Antonio chapter of Goodwill Industries where my mother volunteered countless hours in the last century, but a more basic understanding. Its origins may be in the New Testament or in Middle English, but regardless it is pertinent today. More on that later.

Maternal RSV Vaccine Approved by FDA

The approval finally came through, as it turned out on the last day of FDA's deadline to make a decision based on the fast tracking and other priorities assigned to it by the FDA. The FDA advisory committee did not meet again prior to this decision, they had already reviewed the data at a previous meeting in May, and FDA did not release any updated scientific documents. Perhaps lost in the fine print is the important change in the approval. The original trials looked at vaccine administration to pregnant people at 24-36 weeks gestation, but the FDA approval narrows this to 32-36 weeks. This significant change is because of concerns about the vaccine causing premature delivery; the numbers in the published trials were very low, not enough to establish a cause/effect relationship and only answerable but post-marketing surveillance when a much larger number of pregnant people receive the vaccine. However, more concern than usual was expressed because another pharmaceutical company (GSK; the approved vaccine is from Pfizer) stopped their clinical trials in pregnant people for the same reason. Delaying the vaccine administration to 32 weeks gestation is a safety move; even if the vaccine causes a higher but extremely low risk of precipitating premature birth, the clinical consequences at 32+ weeks is small; infants born at that gestational age generally do very well. The down side is that narrowing the window for vaccination creates more logistic difficulties in ensuring pregnant people have the opportunity to receive the vaccine.

Next up will be an important meeting of ACIP/CDC to put together all the recommendations, including how to manage use of maternal vaccine and the long-acting monoclonal antibody to RSV, nirsevimab. Their next scheduled meeting is September 12, but so far the only current agenda item relates to covid vaccines.

A Curmudgeonly Jab at the Lay Press

At my age, what else do I have to do besides complain? I was annoyed by 2 items percolating through the lay press this past week.

BA.2.86

This new but relatively rare covid sublineage is popping up in every news feed there is. I've mentioned it before. Although it is present in only very low numbers, the pattern of mutations it carries suggests that it will be very effective at evading immunity from prior infection or vaccines, perhaps including the new XBB-derived vaccine to be available soon. Biobot helps put this in perspective. First, wastewater covid levels seem to have plateaued in the US and are still well below what we say in winter 2023.

Second, this variant doesn't even appear in wastewater data, although note the graph only reflects sequencing through the week of August 7.

In addition to following wastewater data, the next likely useful piece of information should be some in vitro data on ability of serum from study volunteers who received the new covid vaccine to neutralize newer variants, including BA.2.86. Given how long the assays take, we should see some information in September. A silver lining for all the publicity is that it could speed up the peer-review process for publication so we won't need to rely on non-peer-reviewed data. Look for a research letter in the New England Journal of Medicine relatively soon (just my prediction).

You can see the current CDC risk assessment here.

Tripledemic in Kentucky?

My second gripe is with the reporting on a supposed tripledemic resulting in school closures in Lee County, Kentucky, alleged to be caused by a combination of covid, influenza, and group A streptococcal infections. What seems to be missing in all the reports is how these etiologies were established. It sounds like it was just what parents or school staff were calling covid, flu, or strep, rather than based on careful testing.

It's a little early for influenza in Kentucky, not that it's impossible, but so far CDC data haven't shown it.

I didn't find anything about it on the Kentucky state flu site.

Group A strep infections aren't reliably reported, and the problem with GAS diagnoses is the relatively high carrier rate of the organism, around 10-15% in the pediatric population. So, if someone tests a child with a viral illness (e.g. rhinovirus/enterovirus, which is prominent this time of year), 10-15% will test positive for GAS.

More reliable but less relevant to Kentucky are recent data from England about GAS hospitalizations:

This may reflect changes in epidemiology during and after the pandemic, but I'm still skeptical of the characterization of etiologies for the Kentucky school illnesses. I hope we'll hear more eventually.

Fungus Amongus

I received a COCA Now notice from the CDC nicely summarizing concerning trends in fungal strains causing ringworm and nail infections. It may be that we are in the midst of rising rates of resistance to commonly-used antifungal medications to treat these diseases. A big problem for clinicians is that treatment response may be normally slow, requiring weeks to months of therapy, so it can take a long time to figure out if the infection isn't responding. Keep this in mind if you notice children with poor responses to treatment, and consider culture and susceptibility testing with a qualified lab.

Paxlovid Resistance

No surprise to anyone, but a new report characterizes nirmatrelvir (Paxlovid) resistance in an immunocompromised patient, exactly the sort of setting we'd expect to see for development of resistance. This isn't the first report of Paxlovid resistance, and it won't be the last. I wouldn't worry about it yet, but, like most treatments for infectious diseases, resistance becomes a problem sooner or later.

My Night in a Brewpub

Not one of my usual habitats, but this was for a good cause: a special meeting of the Greater Washington Infectious Diseases Society at a brewpub in Bethesda, MD. You won't find a web link for GWIDS, not because it's a secret society but because no one has gotten around to making one in the few decades of GWIDS' existence. It's a monthly meeting of adult and pediatric infectious diseases training programs in the DC area where fellows in training present challenging and usually obscure infection cases and try to stump the stars in attendance. Basically it is heaven for an infectious diseases nerd.

This meeting was our first in person since the pandemic began. It was special because Dr. Anthony Fauci, an annual speaker usually at the end of the year, was featured in what was supposed to be a fireside chat now transformed into a vatside chat. I moderated the session only because the first 50 or so choices for moderator weren't available. We gathered a list of questions from members prior to the meeting plus opened up for questions from the audience at the end. A good time was had by all, although I myself missed out on the refreshments.

One of the questions I asked, the only one I submitted, was for Dr. Fauci to help us understand the differences between the criticisms he received during the early days of the AIDS pandemic and the terrible threats he now receives from various covid crazies. (Three guys looking very muscular, with receivers in their ears and bulges under their coats, were the only non-GWIDS members present; Fauci came and went in one of those flashing-light black SUVs that disrupt traffic all over the DC area.)

In 1988, Larry Kramer, one of the earliest AIDS activists and a leader in the movement (also an accomplished playwright and author), published letters to Fauci in the Village Voice and the San Francisco Examiner. I read excerpts from those documents, and if you didn't know the context it would be perfectly reasonable to assume they were written recently. Kramer called him a murderer, an idiot, and a liar, among the repeatable epithets. I can't quote Dr. Fauci's response accurately, I wasn't taking notes, but the gist of his reply was that the AIDS and covid personal attacks, while sounding similar, are completely different. The difference boils down to Good Will.

AIDS protesters wanted to work to a solution; they were terribly critical of Fauci as a person as well as of policies of FDA and NIH. The end result was a revamping of the research and approval process for AIDS (and thus other treatments) that resulted in a quicker and more effective benefit to society. According to Fauci, those AIDS activists were motivated by good will and demonstrated willingness to collaborate on a solution. Nothing like that exists in today's Fauci demonization.

Read Tony's NY Times essay on Mr. Kramer and "loving difficult people," and take a little time to practice some good will.

Dog Days of Summer

Bud WiedermannJuly 16, 2023July 16, 2023Leave a comment

I've just returned from a wonderful family week at the beach to a steaming suburban DC and an annoying surprise at home. I'll just bask in my vacation afterglow and belatedly compose this post.

Bugs cont'd

I didn't think it was possible, but there are more mosquitos around my house now than before I left for vacation. Right on schedule, West Nile Virus infections are starting to heat up.

Hot off the presses, you can also add Texas to the list. Remember that although West Nile Virus is feared for its neurologic manifestations, most infections are either asymptomatic or result in a nonspecific febrile illness. The neurologic cases are the tip of the iceberg.

Hepatitis C - We're Missing the Mark in Public Awareness

A recent publication noted a big gap in delivery of care for hepatitis C, summarized below. I really like their cool poster-type depiction, check out the bottom line (at the bottom, of course).

Once again, our wonderful technologic advances in medicine are clouded by a failure to have them reach those who need them most.

More on Neonatal ECHOvirus Infections

The World Health Organization reported more cases of neonatal ECHO-11 infections in newborns, originally in France as discussed in these pages on June 4. Now WHO reports new cases from Croatia, Italy, Spain, Sweden, and the UK. No evidence so far that these events in different countries are connected; this might just reflect enhanced surveillance given the initial alert from France. The link above has a nice discussion of various aspects of the cases. Again, keep severe enteroviral disease in mind with any sick newborn in whom bacterial etiologies are not revealing.

'Demic Doldrums

Remember wastewater monitoring? It's not the greatest tool in the US due to the fact that monitoring is voluntary and leaves much of the US with no data. However, an epidemiologist at Johns Hopkins has been blogging on this and is predicting we are about to see an uptick in southern states. She admits the data are iffy, we'll know eventually if she is full of hot air or not.

Some interesting data appeared regarding maternal covid vaccination and newborn antibody levels. This was a small but well-studied group of 76 mothers who received an mRNA vaccine during pregnancy. Higher maternal antibody levels were seen in mothers who had systemic symptoms following the second vaccine dose, though all had good responses. Maternal transfer of IgG to infants was highest in those vaccinated in the second trimester. Breast milk IgG and IgA antibody to SARS-CoV-2 persisted about 5-6 months, just in time for the infants to start their own vaccine series! There were no significant adverse events in mothers or infants. Bottom line: since we don't know what covid will do in the future, pregnant persons would be well advised to get that new vaccine dose during their second trimester.

The US Government Accounting Office published some further recommendations for pandemic preparedness. I'm very glad these are appearing, but public interest and funding have cooled dramatically.

Also, I was pleased to see an analysis of journalistic coverage of preprint publication before and during the pandemic appearing (where else) but on the well-known preprint site BioRxiv. This coverage hit the boiling point during the pandemic but applied only to covid preprints, not to other scientific reports. Next up I hope we see some analysis of how many of those preprints never appeared in a peer-reviewed publication; some have attempted chart this already, but we probably need to wait another 2-3 years before passing judgement. I continue to worry that too much attention was focused on preprint postings during the pandemic; the blame for this is shared by journalists, scientists, and the universities and other organizations where the work was performed.

Lest we forget about flu, things aren't too bad worldwide but WHO did report some close-to-home hot spots in Costa Rica, Honduras, Nicaragua, and Panama.

My Astrologic Education

I always assumed the saying "dog days of summer" had something to do with a panting dog in the heat. I was barking up the wrong tree; now I've found out it originated with Hellinistic astrology. Officially, the dog days run from July 3 to August 11, according to the Farmer's Almanac.

I had a great time with my 3 sons and families at the beach, enough to keep me somewhat cool and calm after the thunderbolt of finding my air conditioner on the fritz when I returned home. Fortunately for my dog days, my house has 2 air conditioners. Until now, this was a complete mistake - our house could be handled by just one unit if only the ducts were all linked together. So, for now half the house is tolerable and I won't complain too much, at least until I get the bill from the air conditioning service.

Oh, and in case you haven't noticed, I've sprinkled weather- and temperature-related references and puns throughout this week's post. To keep your mind from sweating, see if you can find all of them. Answers in next week's post.

Happy Thanksgiving, et al 2

Bud WiedermannNovember 20, 2022November 20, 20222 Comments

We're hosting a relatively small Thanksgiving gathering this week, but that doesn't mean I won't go crazy with planning and implementation. My goals are to have all of the food on the table, reasonably warm (except for the salads), within 2 hours of the intended sit-down time. A secondary goal is to keep the turkey off the floor during carving.

I suspect most of you are unaware, but this Thanksgiving day also marks the first anniversary of the initial report of the omicron variant appearance in South Africa.

Since I Mentioned Variants

Usually I give the weekly JAMA Medical News section only a cursory glance, but one item last week, written by Rita Rubin, was particularly well done. She effectively summarized a lot of evidence and viewpoints to paint a picture of what a covid winter wave might look like, and why. In addition to addressing the importance of immune-evasion properties of newer subvariants, she also sorts through some of the confusion about variant nomenclature and points out limitations of our standard pandemic tracking data like case numbers and hospitalization rates. It's become a difficult number to grasp now that much of home testing results go unreported, whether positive or negative, and large swaths of the US population have given up testing altogether. Wastewater monitoring probably is our most reliable, although imperfect, early warning indicator for a winter covid wave now.

Maricopa County - More Than Vote Counting

Maricopa County in Arizona features prominently in our news nowadays, mostly as a hotbed of election fraud rumors and innuendo. More significant (IMHO) is the report last week of an autochthonous dengue case (acquired locally rather than during travel to an endemic area). Dengue, a virus transmitted via mosquito bite, is endemic in many parts of the world, and virtually all cases in US residents are acquired via travel to these areas. However, climate change has greatly affected the range of the mosquito vector. Until now, Florida is the only US jurisdiction that has seen autochthonous dengue transmission.

2022 US Dengue cases in US residents as of 11/2/22, all travel-associated except for Florida.

Mosquitoes of the Aedes species (Aedes aegypti is also known as the tiger mosquito) transmit dengue, as well as Zika, chikungunya, and other viruses. Their range now extends across much of the US, including into the DC area.

More on Paxlovid Rebound

We now have an early glimpse via non-peer-reviewed preprint publication of an observational study of the rebound rates of covid positivity and illness following treatment with the oral antiviral agent paxlovid, compared to infection in individuals who did not take paxlovid. This preliminary report contains information on 127 participants who received paxlovid and 43 who did not. It covers the time period from August 4 to November 1, 2022, so all during omicron activity.

Rebound for positive virus testing (these were antigen tests) was 14.2% (18/127) in the paxlovid group versus 9.3% (4/43) in the no treatment group. For clinical symptoms rebound, the rates were 18.9% and 9.3% in paxlovid and no treatment groups, respectively. Another interesting nugget I noticed was that 20% of individuals in both groups still had positive antigen tests on day 10 after first positive test.

This is very preliminary information with a small number of participants, so the exact rates and differences between the 2 groups could change dramatically as more data are analyzed. The observational study design in general (rather than a blinded randomized controlled trial) also has limitations that could skew results.

Note that participants were all 18 years of age or older. Still, this is the start of getting a better ballpark assessment of covid rebound with and without antiviral treatment. For now, in the absence of specific pediatric studies, it remains prudent that covid-infected non-hospitalized children ages 12 years and older with weight at least 40 kg and with the appropriate risks and clinical status should be offered paxlovid treatment.

We Should Be Thankful

RSV, flu, and covid continue to cause a lot of angst in the pediatric medical community, and we know that some of the outcomes of the original Thanksgiving aren't worthy of celebration. But, let's remember to be thankful for the covid vaccines and treatments we do have available. We just need to do a better job of implementing these interventions.

Sunday's Washington Post Food section article on Thanksgiving holiday horrors triggered some post-traumatic stress. I wish I had known they were looking for stories, I would have submitted my greasy drippings jar/glass shards into the gravy pot fiasco from a while back, I'm sure it would have qualified for inclusion. It was a classic too-much-rushing-to-process-the-turkey-pan-drippings-before-the-turkey-turned-cold-drill. We didn't have any turkey gravy that year, but now I've switched to a recipe with roasted turkey wings that I prepare on Wednesday and probably tastes better than the original. So, remember to be thankful for silver linings, and have a safe and happy holiday!

Tag: wastewater tracking