ID Consult

I read a few articles recently that raised my concern about a laissez faire attitude regarding treatment and prevention of infectious disease and lack of a broader understanding of why we treat our patients.
 

Strep throat

Let’s start with group A streptococcal pharyngitis – strep throat. There are at least five reasons to treat strep throat with antibiotics.

Lest we forget, there is the prevention of acute rheumatic fever! Of course, acute rheumatic fever is rare in high-income countries like the United States, but we have had outbreaks in the past and we will have outbreaks in the future. All it takes is circulation of rheumatogenic strains and susceptible hosts.

Also, antibiotic treatment may prevent acute post-streptococcal glomerulonephritis, although that benefit is somewhat controversial.

Antibiotic treatment may prevent development of another controversial, nonsuppurative streptococcal complication, namely, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS).

Second, group A strep causes suppurative complications such as acute otitis media, peritonsillar abscess, mastoiditis, and sepsis, among others, and antibiotic treatment reduces those risks. Group A strep can cause impetigo, cellulitis, necrotizing fasciitis (flesh-eating disease), and toxic shock syndrome; antibiotics reduce those risks.

Third, while strep throat is a self-limited infection in terms of symptoms, it has been clearly shown that antibiotics cause symptoms to resolve more quickly. I must confess that it galls me when pundits suggest that reducing symptoms of any infectious disease by a day or 2 doesn’t matter for children, when adults with even mild symptoms rush to a clinician with hopes of treatment to shorten illness by a day.

Fourth, antibiotics shorten contagion. In fact, treatment in the morning of an office visit can allow a child to return to school the next day.¹

Lastly on this topic, if a clinician had a positive strep culture or rapid test on a patient and did not treat with antibiotics, which is not the standard of care, and that patient went on to a nonsuppurative or suppurative complication, then what?

I am not advocating wholesale antibiotic treatment of all sore throats because antibiotics carry risks from use. Most sore throats are not strep throats. The first step is the examination to decide if a strep test is warranted. There are clinical scoring systems available. But the essence of the clinical criteria relies on age of child (strep is mostly seen in 5- to 15-year-olds), season (not summer), known exposure to strep, absence of rhinorrhea, absence of cough, presence of rapid onset of symptoms, usually with fever, and moderate to severe redness, often with exudates. Gratefully, in the United States, we have rapid strep tests that are covered by insurance. This is not the case even in many other high-income countries and certainly, generally, not available at all in moderate to low income countries. With a rapid test, a point-of-care microbiologic diagnosis can be made with reasonable accuracy. Antibiotic treatment should be reserved for patients with positive laboratory confirmation of Group A streptococci, either by rapid test or culture.
 

Ear infections

Next, let’s address treatment of acute otitis media – ear infections. There are at least six reasons to treat ear infections with antibiotics. Worldwide, the No. 1 cause of acquired deafness in children today is ear infections. This is rarely seen in the United States because we rarely have patients with chronic suppurative otitis media since antibiotics are typically prescribed.

Second, ear infections have suppurative complications such as mastoiditis, labyrinthitis, malignant otitis, brain abscess, sepsis, and meningitis. The World Health Organization attributes 20,000 deaths per year to complications from ear infections.

Third, ear infections can lead to eardrum rupture and subsequent chronic middle ear drainage.

Fourth, untreated otitis more often progresses to a nonsuppurative complication – a cholesteatoma.

Fifth, while earache is a self-limited illness, antibiotics shorten the acute symptoms by a day or 2 and lessen the duration of middle ear effusion after infection that can cause temporary hearing loss. Once again, as a child advocate, I would point out that pain from an ear infection is often severe and the lingering effects of a middle ear effusion are annoying to say the least.

Lastly on this topic, if a clinician makes the diagnosis of an ear infection in a patient and does not treat with antibiotics, the decision should be within the guidelines of the standard of care as described by the American Academy of Pediatrics² with decision-making based on patient age and severity of symptoms.

I am not advocating wholesale antibiotic treatment of all ear pain or presumed ear pain. With this clinical condition we currently do not have a diagnostic test, and therein lies the conundrum. Most acute otitis media occurs among children age 6-24 months old, and this leads most clinicians to overdiagnose the infection. A child in that age group is nonverbal and in the context of a viral upper respiratory illness the symptoms of acute otitis media overlap completely with those of a viral URI. Therefore, an adequate examination is necessary. Confronted with an irritable child who is uncooperative with a challenging otoscopic examination, an ear canal with wax blocking an adequate view of the tympanic membrane, and a parent in a hurry to get back to work or home, the inclination is to observe a “little bit of redness” and prescribe unnecessary antibiotics. Even though redness is not a good diagnostic indicator, whereas a full or bulging eardrum is for the diagnosis of acute otitis media, I shudder at how often I see in a medical record a description of redness of the eardrum and no comment on the fullness that occurs when an authentic infection is most likely.

I could extend this column discussing acute sinusitis and cough illnesses as they are two other conditions associated with infection where antibiotics have their important place and where antibiotics are also overused. Instead, I will end by summarizing my viewpoint that judicious antibiotic use is of high importance for prevention of antibiotic resistance at the individual patient level and the community level. However, we should not become complacent about the risks to untreated children experiencing common respiratory infections because there are many justifiable reasons to treat children as discussed here.

Dr. Pichichero is a specialist in pediatric infectious diseases, Center for Infectious Diseases and Immunology, and director of the Research Institute at Rochester (N.Y.) General Hospital. He has no conflicts of interest to disclose.

References

1. Schwartz RH et al. A reappraisal of the minimum duration of antibiotic treatment before approval of return to school for children with streptococcal pharyngitis. Pediatr Infect Dis J. 2015 Dec. doi: 10.1097/INF.0000000000000883.

2. Lieberthal AS et al. The diagnosis and management of acute otitis media. Pediatrics. 2013 Mar. doi: 10.1542/peds.2012-3488.

I read a few articles recently that raised my concern about a laissez faire attitude regarding treatment and prevention of infectious disease and lack of a broader understanding of why we treat our patients.
 

Strep throat

Let’s start with group A streptococcal pharyngitis – strep throat. There are at least five reasons to treat strep throat with antibiotics.

Lest we forget, there is the prevention of acute rheumatic fever! Of course, acute rheumatic fever is rare in high-income countries like the United States, but we have had outbreaks in the past and we will have outbreaks in the future. All it takes is circulation of rheumatogenic strains and susceptible hosts.

Also, antibiotic treatment may prevent acute post-streptococcal glomerulonephritis, although that benefit is somewhat controversial.

Antibiotic treatment may prevent development of another controversial, nonsuppurative streptococcal complication, namely, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS).

Second, group A strep causes suppurative complications such as acute otitis media, peritonsillar abscess, mastoiditis, and sepsis, among others, and antibiotic treatment reduces those risks. Group A strep can cause impetigo, cellulitis, necrotizing fasciitis (flesh-eating disease), and toxic shock syndrome; antibiotics reduce those risks.

Third, while strep throat is a self-limited infection in terms of symptoms, it has been clearly shown that antibiotics cause symptoms to resolve more quickly. I must confess that it galls me when pundits suggest that reducing symptoms of any infectious disease by a day or 2 doesn’t matter for children, when adults with even mild symptoms rush to a clinician with hopes of treatment to shorten illness by a day.

Fourth, antibiotics shorten contagion. In fact, treatment in the morning of an office visit can allow a child to return to school the next day.¹

Lastly on this topic, if a clinician had a positive strep culture or rapid test on a patient and did not treat with antibiotics, which is not the standard of care, and that patient went on to a nonsuppurative or suppurative complication, then what?

I am not advocating wholesale antibiotic treatment of all sore throats because antibiotics carry risks from use. Most sore throats are not strep throats. The first step is the examination to decide if a strep test is warranted. There are clinical scoring systems available. But the essence of the clinical criteria relies on age of child (strep is mostly seen in 5- to 15-year-olds), season (not summer), known exposure to strep, absence of rhinorrhea, absence of cough, presence of rapid onset of symptoms, usually with fever, and moderate to severe redness, often with exudates. Gratefully, in the United States, we have rapid strep tests that are covered by insurance. This is not the case even in many other high-income countries and certainly, generally, not available at all in moderate to low income countries. With a rapid test, a point-of-care microbiologic diagnosis can be made with reasonable accuracy. Antibiotic treatment should be reserved for patients with positive laboratory confirmation of Group A streptococci, either by rapid test or culture.
 

Ear infections

Next, let’s address treatment of acute otitis media – ear infections. There are at least six reasons to treat ear infections with antibiotics. Worldwide, the No. 1 cause of acquired deafness in children today is ear infections. This is rarely seen in the United States because we rarely have patients with chronic suppurative otitis media since antibiotics are typically prescribed.

Second, ear infections have suppurative complications such as mastoiditis, labyrinthitis, malignant otitis, brain abscess, sepsis, and meningitis. The World Health Organization attributes 20,000 deaths per year to complications from ear infections.

Third, ear infections can lead to eardrum rupture and subsequent chronic middle ear drainage.

Fourth, untreated otitis more often progresses to a nonsuppurative complication – a cholesteatoma.

Fifth, while earache is a self-limited illness, antibiotics shorten the acute symptoms by a day or 2 and lessen the duration of middle ear effusion after infection that can cause temporary hearing loss. Once again, as a child advocate, I would point out that pain from an ear infection is often severe and the lingering effects of a middle ear effusion are annoying to say the least.

Lastly on this topic, if a clinician makes the diagnosis of an ear infection in a patient and does not treat with antibiotics, the decision should be within the guidelines of the standard of care as described by the American Academy of Pediatrics² with decision-making based on patient age and severity of symptoms.

I am not advocating wholesale antibiotic treatment of all ear pain or presumed ear pain. With this clinical condition we currently do not have a diagnostic test, and therein lies the conundrum. Most acute otitis media occurs among children age 6-24 months old, and this leads most clinicians to overdiagnose the infection. A child in that age group is nonverbal and in the context of a viral upper respiratory illness the symptoms of acute otitis media overlap completely with those of a viral URI. Therefore, an adequate examination is necessary. Confronted with an irritable child who is uncooperative with a challenging otoscopic examination, an ear canal with wax blocking an adequate view of the tympanic membrane, and a parent in a hurry to get back to work or home, the inclination is to observe a “little bit of redness” and prescribe unnecessary antibiotics. Even though redness is not a good diagnostic indicator, whereas a full or bulging eardrum is for the diagnosis of acute otitis media, I shudder at how often I see in a medical record a description of redness of the eardrum and no comment on the fullness that occurs when an authentic infection is most likely.

I could extend this column discussing acute sinusitis and cough illnesses as they are two other conditions associated with infection where antibiotics have their important place and where antibiotics are also overused. Instead, I will end by summarizing my viewpoint that judicious antibiotic use is of high importance for prevention of antibiotic resistance at the individual patient level and the community level. However, we should not become complacent about the risks to untreated children experiencing common respiratory infections because there are many justifiable reasons to treat children as discussed here.

Dr. Pichichero is a specialist in pediatric infectious diseases, Center for Infectious Diseases and Immunology, and director of the Research Institute at Rochester (N.Y.) General Hospital. He has no conflicts of interest to disclose.

References

1. Schwartz RH et al. A reappraisal of the minimum duration of antibiotic treatment before approval of return to school for children with streptococcal pharyngitis. Pediatr Infect Dis J. 2015 Dec. doi: 10.1097/INF.0000000000000883.

2. Lieberthal AS et al. The diagnosis and management of acute otitis media. Pediatrics. 2013 Mar. doi: 10.1542/peds.2012-3488.

I read a few articles recently that raised my concern about a laissez faire attitude regarding treatment and prevention of infectious disease and lack of a broader understanding of why we treat our patients.
 

Strep throat

Let’s start with group A streptococcal pharyngitis – strep throat. There are at least five reasons to treat strep throat with antibiotics.

Lest we forget, there is the prevention of acute rheumatic fever! Of course, acute rheumatic fever is rare in high-income countries like the United States, but we have had outbreaks in the past and we will have outbreaks in the future. All it takes is circulation of rheumatogenic strains and susceptible hosts.

Also, antibiotic treatment may prevent acute post-streptococcal glomerulonephritis, although that benefit is somewhat controversial.

Antibiotic treatment may prevent development of another controversial, nonsuppurative streptococcal complication, namely, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS).

Second, group A strep causes suppurative complications such as acute otitis media, peritonsillar abscess, mastoiditis, and sepsis, among others, and antibiotic treatment reduces those risks. Group A strep can cause impetigo, cellulitis, necrotizing fasciitis (flesh-eating disease), and toxic shock syndrome; antibiotics reduce those risks.

Third, while strep throat is a self-limited infection in terms of symptoms, it has been clearly shown that antibiotics cause symptoms to resolve more quickly. I must confess that it galls me when pundits suggest that reducing symptoms of any infectious disease by a day or 2 doesn’t matter for children, when adults with even mild symptoms rush to a clinician with hopes of treatment to shorten illness by a day.

Fourth, antibiotics shorten contagion. In fact, treatment in the morning of an office visit can allow a child to return to school the next day.¹

Lastly on this topic, if a clinician had a positive strep culture or rapid test on a patient and did not treat with antibiotics, which is not the standard of care, and that patient went on to a nonsuppurative or suppurative complication, then what?

I am not advocating wholesale antibiotic treatment of all sore throats because antibiotics carry risks from use. Most sore throats are not strep throats. The first step is the examination to decide if a strep test is warranted. There are clinical scoring systems available. But the essence of the clinical criteria relies on age of child (strep is mostly seen in 5- to 15-year-olds), season (not summer), known exposure to strep, absence of rhinorrhea, absence of cough, presence of rapid onset of symptoms, usually with fever, and moderate to severe redness, often with exudates. Gratefully, in the United States, we have rapid strep tests that are covered by insurance. This is not the case even in many other high-income countries and certainly, generally, not available at all in moderate to low income countries. With a rapid test, a point-of-care microbiologic diagnosis can be made with reasonable accuracy. Antibiotic treatment should be reserved for patients with positive laboratory confirmation of Group A streptococci, either by rapid test or culture.
 

Ear infections

Next, let’s address treatment of acute otitis media – ear infections. There are at least six reasons to treat ear infections with antibiotics. Worldwide, the No. 1 cause of acquired deafness in children today is ear infections. This is rarely seen in the United States because we rarely have patients with chronic suppurative otitis media since antibiotics are typically prescribed.

Second, ear infections have suppurative complications such as mastoiditis, labyrinthitis, malignant otitis, brain abscess, sepsis, and meningitis. The World Health Organization attributes 20,000 deaths per year to complications from ear infections.

Third, ear infections can lead to eardrum rupture and subsequent chronic middle ear drainage.

Fourth, untreated otitis more often progresses to a nonsuppurative complication – a cholesteatoma.

Fifth, while earache is a self-limited illness, antibiotics shorten the acute symptoms by a day or 2 and lessen the duration of middle ear effusion after infection that can cause temporary hearing loss. Once again, as a child advocate, I would point out that pain from an ear infection is often severe and the lingering effects of a middle ear effusion are annoying to say the least.

Lastly on this topic, if a clinician makes the diagnosis of an ear infection in a patient and does not treat with antibiotics, the decision should be within the guidelines of the standard of care as described by the American Academy of Pediatrics² with decision-making based on patient age and severity of symptoms.

I am not advocating wholesale antibiotic treatment of all ear pain or presumed ear pain. With this clinical condition we currently do not have a diagnostic test, and therein lies the conundrum. Most acute otitis media occurs among children age 6-24 months old, and this leads most clinicians to overdiagnose the infection. A child in that age group is nonverbal and in the context of a viral upper respiratory illness the symptoms of acute otitis media overlap completely with those of a viral URI. Therefore, an adequate examination is necessary. Confronted with an irritable child who is uncooperative with a challenging otoscopic examination, an ear canal with wax blocking an adequate view of the tympanic membrane, and a parent in a hurry to get back to work or home, the inclination is to observe a “little bit of redness” and prescribe unnecessary antibiotics. Even though redness is not a good diagnostic indicator, whereas a full or bulging eardrum is for the diagnosis of acute otitis media, I shudder at how often I see in a medical record a description of redness of the eardrum and no comment on the fullness that occurs when an authentic infection is most likely.

I could extend this column discussing acute sinusitis and cough illnesses as they are two other conditions associated with infection where antibiotics have their important place and where antibiotics are also overused. Instead, I will end by summarizing my viewpoint that judicious antibiotic use is of high importance for prevention of antibiotic resistance at the individual patient level and the community level. However, we should not become complacent about the risks to untreated children experiencing common respiratory infections because there are many justifiable reasons to treat children as discussed here.

Dr. Pichichero is a specialist in pediatric infectious diseases, Center for Infectious Diseases and Immunology, and director of the Research Institute at Rochester (N.Y.) General Hospital. He has no conflicts of interest to disclose.

References

1. Schwartz RH et al. A reappraisal of the minimum duration of antibiotic treatment before approval of return to school for children with streptococcal pharyngitis. Pediatr Infect Dis J. 2015 Dec. doi: 10.1097/INF.0000000000000883.

2. Lieberthal AS et al. The diagnosis and management of acute otitis media. Pediatrics. 2013 Mar. doi: 10.1542/peds.2012-3488.

In July 2023, nirsevimab (Beyfortus), a monoclonal antibody, was approved by the Food and Drug Administration for the prevention of respiratory syncytial virus (RSV) disease in infants and children younger than 2 years of age. On Aug. 3, 2023, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention recommended routine use of it for all infants younger than 8 months of age born during or entering their first RSV season. Its use is also recommended for certain children 8-19 months of age who are at increased risk for severe RSV disease at the start of their second RSV season. Hearing the approval, I immediately had a flashback to residency, recalling the multiple infants admitted each fall and winter exhibiting classic symptoms including cough, rhinorrhea, nasal flaring, retractions, and wheezing with many having oxygen requirements and others needing intubation. Only supportive care was available.

RSV is the leading cause of infant hospitalizations. Annually, the CDC estimates there are 50,000-80,000 RSV hospitalizations and 100-300 RSV-related deaths in the United States in persons younger than 5 years of age. While premature infants have the highest rates of hospitalization (three times a term infant) about 79% of hospitalized children younger than 2 years have no underlying medical risks.¹ The majority of children will experience RSV as an upper respiratory infection within the first 2 years of life. However, severe disease requiring hospitalization is more likely to occur in premature infants and children younger than 6 months; children younger than 2 with congenital heart disease and/or chronic lung disease; children with severe cystic fibrosis; as well as the immunocompromised child and individuals with neuromuscular disorders that preclude clearing mucous secretions or have difficulty swallowing.

Palivizumab (Synagis), the first monoclonal antibody to prevent RSV in infants was licensed in 1998. Its use was limited to infants meeting specific criteria developed by the American Academy of Pediatrics. Only 5% of infants had access to it. It was a short-acting agent requiring monthly injections, which were very costly ($1,661-$2,584 per dose). Eligible infants could receive up to five injections per season. Several studies proved its use was not cost beneficial.

What are the advantages of nirsevimab? It’s a long-acting monoclonal antibody. Only one dose is required per season. Costs will significantly diminish. It is recommended for all infants younger than 8 months of age born during RSV season. Those children 8-19 months at risk for severe RSV disease can receive it prior to the start of their second RSV season. During RSV season (October 1 to March 31), the initial dose should be administered to newborns just prior to hospital discharge. Older infants and newborns who did not receive it prior to hospital discharge can receive it at their medical home. Newborns should receive it within the first week of life. It is covered by the Vaccine for Children Program. Simultaneous administration with routine childhood immunizations is recommended. Finally, RSV season may vary in tropical areas (Southern Florida, Puerto Rico. etc.) and Alaska. The timing of nirsevimab administration should be based on local RSV activity provided by state and local authorities.

In addition, the FDA approved an RSV vaccine (Abrysvo) for use in adults at least 60 years of age and in pregnant women at 32-36 weeks’ gestation. The latter is administered to prevent lower respiratory tract infection in infants from birth to 6 months. Recommendations have been published for administration in nonpregnant adults. Specific information is forthcoming in terms timing of administration of nirsevimab in infants whose mothers receive Abrysvo.

RSV season is quickly approaching. Detailed recommendations for administration and FAQ questions related to nirsevimab and palivizumab can be found at https://www.aap.org or https://www.cdc.gov/vaccines/hcp/acip-recs/index.html.
 

Influenza

So, what about influenza? Vaccine composition has been tweaked to match the circulating viruses but the recommended age for annual routine administration remains unchanged. All persons at least 6 months of age should be vaccinated. Children between 6 months and 8 years need two doses at least 4 weeks apart when receiving vaccine for the first time. Immunizing everyone in the household is encouraged especially if there are household contacts at risk for developing severe disease, including infants too young to be vaccinated. Keep in mind children may be coinfected with multiple viruses. Adams and colleagues reviewed the prevalence of coinfection of influenza and Sars-CoV-2 in persons younger than 18 years reported to three CDC surveillance platforms during the 2021-2022 season.² Thirty-two of 575 hospitalized (6%) coinfections were analyzed and 7 of 44 (16%) deaths. Compared with patients without coinfections, the coinfected patients were more likely to require mechanical ventilation (13% vs. 4%) or CPAP (16% vs. 6%). Only 4 of 23 who were influenza vaccine eligible were vaccinated. Of seven coinfected children who died, none had received influenza vaccine and only one received an antiviral. Only 5 of 31 (16%) infected only with influenza were vaccinated.³

Influenza activity was lower than usual during the 2021-2022 season. However, this report revealed underuse of both influenza vaccine and antiviral therapy, both of which are routinely recommended.
 

COVID-19

What’s new with COVID-19? On Sept. 12, 2023, ACIP recommended that everyone at least 6 months of age receive the 2023-2024 (monovalent, XBB containing) COVID-19 vaccines. Children at least 5 years of age need one dose and those younger need one or two doses depending on the number of doses previously received. Why the change? Circulating variants continue to change. There is a current uptick in cases including hospitalizations (7.7%) and deaths (4.5%) and it’s just the beginning of the season.⁴ Symptoms, risk groups and complications have not changed. The primary goal is to prevent infection, hospitalization, long term complications, and death.

We are now armed with the most up-to-date interventions to help prevent the acquisition of these three viruses. Our next step is recommending and delivering them to our patients.
 

Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She reported no relevant financial disclosures.

References

1.Suh M et al. J Infect Dis. 2022;226(Suppl 2):S154-36. doi: 10.1093/infdis/jiac120.

2. Adams K et al. MMWR Morb Mortal Wkly Rep. 2022;71:1589-96. doi: http://dx.doi.org/10.15585/mmwr.mm7150a4.

3. Pingali C et al. MMWR Morb Mortal Wkly Rep. 2023 Aug 25;72:912-9. doi: http://dx.doi.org/10.15585/mmwr.mm7234a3.

4. CDC Covid Data Tracker.

In July 2023, nirsevimab (Beyfortus), a monoclonal antibody, was approved by the Food and Drug Administration for the prevention of respiratory syncytial virus (RSV) disease in infants and children younger than 2 years of age. On Aug. 3, 2023, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention recommended routine use of it for all infants younger than 8 months of age born during or entering their first RSV season. Its use is also recommended for certain children 8-19 months of age who are at increased risk for severe RSV disease at the start of their second RSV season. Hearing the approval, I immediately had a flashback to residency, recalling the multiple infants admitted each fall and winter exhibiting classic symptoms including cough, rhinorrhea, nasal flaring, retractions, and wheezing with many having oxygen requirements and others needing intubation. Only supportive care was available.

RSV is the leading cause of infant hospitalizations. Annually, the CDC estimates there are 50,000-80,000 RSV hospitalizations and 100-300 RSV-related deaths in the United States in persons younger than 5 years of age. While premature infants have the highest rates of hospitalization (three times a term infant) about 79% of hospitalized children younger than 2 years have no underlying medical risks.¹ The majority of children will experience RSV as an upper respiratory infection within the first 2 years of life. However, severe disease requiring hospitalization is more likely to occur in premature infants and children younger than 6 months; children younger than 2 with congenital heart disease and/or chronic lung disease; children with severe cystic fibrosis; as well as the immunocompromised child and individuals with neuromuscular disorders that preclude clearing mucous secretions or have difficulty swallowing.

Palivizumab (Synagis), the first monoclonal antibody to prevent RSV in infants was licensed in 1998. Its use was limited to infants meeting specific criteria developed by the American Academy of Pediatrics. Only 5% of infants had access to it. It was a short-acting agent requiring monthly injections, which were very costly ($1,661-$2,584 per dose). Eligible infants could receive up to five injections per season. Several studies proved its use was not cost beneficial.

What are the advantages of nirsevimab? It’s a long-acting monoclonal antibody. Only one dose is required per season. Costs will significantly diminish. It is recommended for all infants younger than 8 months of age born during RSV season. Those children 8-19 months at risk for severe RSV disease can receive it prior to the start of their second RSV season. During RSV season (October 1 to March 31), the initial dose should be administered to newborns just prior to hospital discharge. Older infants and newborns who did not receive it prior to hospital discharge can receive it at their medical home. Newborns should receive it within the first week of life. It is covered by the Vaccine for Children Program. Simultaneous administration with routine childhood immunizations is recommended. Finally, RSV season may vary in tropical areas (Southern Florida, Puerto Rico. etc.) and Alaska. The timing of nirsevimab administration should be based on local RSV activity provided by state and local authorities.

In addition, the FDA approved an RSV vaccine (Abrysvo) for use in adults at least 60 years of age and in pregnant women at 32-36 weeks’ gestation. The latter is administered to prevent lower respiratory tract infection in infants from birth to 6 months. Recommendations have been published for administration in nonpregnant adults. Specific information is forthcoming in terms timing of administration of nirsevimab in infants whose mothers receive Abrysvo.

RSV season is quickly approaching. Detailed recommendations for administration and FAQ questions related to nirsevimab and palivizumab can be found at https://www.aap.org or https://www.cdc.gov/vaccines/hcp/acip-recs/index.html.
 

Influenza

So, what about influenza? Vaccine composition has been tweaked to match the circulating viruses but the recommended age for annual routine administration remains unchanged. All persons at least 6 months of age should be vaccinated. Children between 6 months and 8 years need two doses at least 4 weeks apart when receiving vaccine for the first time. Immunizing everyone in the household is encouraged especially if there are household contacts at risk for developing severe disease, including infants too young to be vaccinated. Keep in mind children may be coinfected with multiple viruses. Adams and colleagues reviewed the prevalence of coinfection of influenza and Sars-CoV-2 in persons younger than 18 years reported to three CDC surveillance platforms during the 2021-2022 season.² Thirty-two of 575 hospitalized (6%) coinfections were analyzed and 7 of 44 (16%) deaths. Compared with patients without coinfections, the coinfected patients were more likely to require mechanical ventilation (13% vs. 4%) or CPAP (16% vs. 6%). Only 4 of 23 who were influenza vaccine eligible were vaccinated. Of seven coinfected children who died, none had received influenza vaccine and only one received an antiviral. Only 5 of 31 (16%) infected only with influenza were vaccinated.³

Influenza activity was lower than usual during the 2021-2022 season. However, this report revealed underuse of both influenza vaccine and antiviral therapy, both of which are routinely recommended.
 

COVID-19

What’s new with COVID-19? On Sept. 12, 2023, ACIP recommended that everyone at least 6 months of age receive the 2023-2024 (monovalent, XBB containing) COVID-19 vaccines. Children at least 5 years of age need one dose and those younger need one or two doses depending on the number of doses previously received. Why the change? Circulating variants continue to change. There is a current uptick in cases including hospitalizations (7.7%) and deaths (4.5%) and it’s just the beginning of the season.⁴ Symptoms, risk groups and complications have not changed. The primary goal is to prevent infection, hospitalization, long term complications, and death.

We are now armed with the most up-to-date interventions to help prevent the acquisition of these three viruses. Our next step is recommending and delivering them to our patients.
 

Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She reported no relevant financial disclosures.

References

1.Suh M et al. J Infect Dis. 2022;226(Suppl 2):S154-36. doi: 10.1093/infdis/jiac120.

2. Adams K et al. MMWR Morb Mortal Wkly Rep. 2022;71:1589-96. doi: http://dx.doi.org/10.15585/mmwr.mm7150a4.

3. Pingali C et al. MMWR Morb Mortal Wkly Rep. 2023 Aug 25;72:912-9. doi: http://dx.doi.org/10.15585/mmwr.mm7234a3.

4. CDC Covid Data Tracker.

In July 2023, nirsevimab (Beyfortus), a monoclonal antibody, was approved by the Food and Drug Administration for the prevention of respiratory syncytial virus (RSV) disease in infants and children younger than 2 years of age. On Aug. 3, 2023, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention recommended routine use of it for all infants younger than 8 months of age born during or entering their first RSV season. Its use is also recommended for certain children 8-19 months of age who are at increased risk for severe RSV disease at the start of their second RSV season. Hearing the approval, I immediately had a flashback to residency, recalling the multiple infants admitted each fall and winter exhibiting classic symptoms including cough, rhinorrhea, nasal flaring, retractions, and wheezing with many having oxygen requirements and others needing intubation. Only supportive care was available.

RSV is the leading cause of infant hospitalizations. Annually, the CDC estimates there are 50,000-80,000 RSV hospitalizations and 100-300 RSV-related deaths in the United States in persons younger than 5 years of age. While premature infants have the highest rates of hospitalization (three times a term infant) about 79% of hospitalized children younger than 2 years have no underlying medical risks.¹ The majority of children will experience RSV as an upper respiratory infection within the first 2 years of life. However, severe disease requiring hospitalization is more likely to occur in premature infants and children younger than 6 months; children younger than 2 with congenital heart disease and/or chronic lung disease; children with severe cystic fibrosis; as well as the immunocompromised child and individuals with neuromuscular disorders that preclude clearing mucous secretions or have difficulty swallowing.

Palivizumab (Synagis), the first monoclonal antibody to prevent RSV in infants was licensed in 1998. Its use was limited to infants meeting specific criteria developed by the American Academy of Pediatrics. Only 5% of infants had access to it. It was a short-acting agent requiring monthly injections, which were very costly ($1,661-$2,584 per dose). Eligible infants could receive up to five injections per season. Several studies proved its use was not cost beneficial.

What are the advantages of nirsevimab? It’s a long-acting monoclonal antibody. Only one dose is required per season. Costs will significantly diminish. It is recommended for all infants younger than 8 months of age born during RSV season. Those children 8-19 months at risk for severe RSV disease can receive it prior to the start of their second RSV season. During RSV season (October 1 to March 31), the initial dose should be administered to newborns just prior to hospital discharge. Older infants and newborns who did not receive it prior to hospital discharge can receive it at their medical home. Newborns should receive it within the first week of life. It is covered by the Vaccine for Children Program. Simultaneous administration with routine childhood immunizations is recommended. Finally, RSV season may vary in tropical areas (Southern Florida, Puerto Rico. etc.) and Alaska. The timing of nirsevimab administration should be based on local RSV activity provided by state and local authorities.

In addition, the FDA approved an RSV vaccine (Abrysvo) for use in adults at least 60 years of age and in pregnant women at 32-36 weeks’ gestation. The latter is administered to prevent lower respiratory tract infection in infants from birth to 6 months. Recommendations have been published for administration in nonpregnant adults. Specific information is forthcoming in terms timing of administration of nirsevimab in infants whose mothers receive Abrysvo.

RSV season is quickly approaching. Detailed recommendations for administration and FAQ questions related to nirsevimab and palivizumab can be found at https://www.aap.org or https://www.cdc.gov/vaccines/hcp/acip-recs/index.html.
 

Influenza

So, what about influenza? Vaccine composition has been tweaked to match the circulating viruses but the recommended age for annual routine administration remains unchanged. All persons at least 6 months of age should be vaccinated. Children between 6 months and 8 years need two doses at least 4 weeks apart when receiving vaccine for the first time. Immunizing everyone in the household is encouraged especially if there are household contacts at risk for developing severe disease, including infants too young to be vaccinated. Keep in mind children may be coinfected with multiple viruses. Adams and colleagues reviewed the prevalence of coinfection of influenza and Sars-CoV-2 in persons younger than 18 years reported to three CDC surveillance platforms during the 2021-2022 season.² Thirty-two of 575 hospitalized (6%) coinfections were analyzed and 7 of 44 (16%) deaths. Compared with patients without coinfections, the coinfected patients were more likely to require mechanical ventilation (13% vs. 4%) or CPAP (16% vs. 6%). Only 4 of 23 who were influenza vaccine eligible were vaccinated. Of seven coinfected children who died, none had received influenza vaccine and only one received an antiviral. Only 5 of 31 (16%) infected only with influenza were vaccinated.³

Influenza activity was lower than usual during the 2021-2022 season. However, this report revealed underuse of both influenza vaccine and antiviral therapy, both of which are routinely recommended.
 

COVID-19

What’s new with COVID-19? On Sept. 12, 2023, ACIP recommended that everyone at least 6 months of age receive the 2023-2024 (monovalent, XBB containing) COVID-19 vaccines. Children at least 5 years of age need one dose and those younger need one or two doses depending on the number of doses previously received. Why the change? Circulating variants continue to change. There is a current uptick in cases including hospitalizations (7.7%) and deaths (4.5%) and it’s just the beginning of the season.⁴ Symptoms, risk groups and complications have not changed. The primary goal is to prevent infection, hospitalization, long term complications, and death.

We are now armed with the most up-to-date interventions to help prevent the acquisition of these three viruses. Our next step is recommending and delivering them to our patients.
 

Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She reported no relevant financial disclosures.

References

1.Suh M et al. J Infect Dis. 2022;226(Suppl 2):S154-36. doi: 10.1093/infdis/jiac120.

2. Adams K et al. MMWR Morb Mortal Wkly Rep. 2022;71:1589-96. doi: http://dx.doi.org/10.15585/mmwr.mm7150a4.

3. Pingali C et al. MMWR Morb Mortal Wkly Rep. 2023 Aug 25;72:912-9. doi: http://dx.doi.org/10.15585/mmwr.mm7234a3.

4. CDC Covid Data Tracker.

It’s “summertime and the livin’ is easy” according to the lyric from an old George Gershwin song. But sometimes, summer activities can lead to illnesses that can disrupt a child’s easy living.

Case: An otherwise healthy 11-year-old presents with four to five loose stools per day, mild nausea, excess flatulence, and cramps for 12 days with a 5-pound weight loss. His loose-to-mushy stools have no blood or mucous but smell worse than usual. He has had no fever, vomiting, rashes, or joint symptoms. A month ago, he went hiking/camping on the Appalachian Trail, drank boiled stream water. and slept in a common-use semi-enclosed shelter. He waded through streams and shared “Trail Magic” (soft drinks being cooled in a fresh mountain stream). Two other campers report similar symptoms.

Differential diagnosis: Broadly, we should consider bacteria, viruses, and parasites. But generally, bacteria are likely to produce more systemic symptoms and usually do not last 12 days. That said, this could be Clostridioides difficile, yet that seems unlikely because he is otherwise healthy and has no apparent risk factors. Salmonella spp., Campylobacter spp. and some Escherichia coli infections may drag on for more than a week but the lack of systemic symptoms or blood/mucous lowers the likelihood. Viral agents (rotavirus, norovirus, adenovirus, astrovirus, calicivirus, or sapovirus) seem unlikely because of the long symptom duration and the child’s preteen age.

The history and presentation seem more likely attributable to a parasite. Uncommonly detected protozoa include Microsporidium (mostly Enterocytozoon bieneusi) and amoeba. Microsporidium is very rare and seen mostly in immune compromised hosts, for example, those living with HIV. Amebiasis occurs mostly after travel to endemic areas, and stools usually contain blood or mucous. Some roundworm or tapeworm infestations cause abdominal pain and abnormal stools, but the usual exposures are absent. Giardia spp., Cryptosporidium spp., Cyclospora cayetanensis, and/or Cystoisospora belli best fit this presentation given his hiking/camping trip.
 

Workup. Laboratory testing of stool is warranted (because of weight loss and persistent diarrhea) despite a lack of systemic signs. Initially, bacterial culture, C. difficile testing, and viral testing seem unwarranted. The best initial approach, given our most likely suspects, is protozoan/parasite testing.

The Centers for Disease Control and Prevention recommends testing up to three stools collected on separate days.¹ Initially, stool testing for giardia and cryptosporidium antigens by EIA assays could be done as a point-of-care test. Such antigen tests are often the first step because of their ease of use, relatively low expense, reasonably high sensitivity and specificity, and rapid turnaround (as little as 1 hour). Alternatively, direct examination of three stools for ova and parasites (O&P) and acid-fast stain or direct fluorescent antibody testing can usually detect our main suspects (giardia, cryptosporidium, cyclospora, and cystoisospora) along with other less likely parasites.

Some laboratories, however, use syndromic stool testing approaches (multiplex nucleic acid panels) that detect over 20 different bacteria, viruses, and select parasites. Multiplex testing has yielded increased detection rates, compared with microscopic examination alone in some settings. Further, they also share ease-of-use and rapid turnaround times with parasite antigen assays while requiring less hands-on time by laboratory personnel, compared with direct microscopic examination. However, multiplex assays are expensive and more readily detect commensal organisms, so they are not necessarily the ideal test in all diarrheal illnesses.

Diagnosis. You decide to first order giardia and cryptosporidium antigen testing because you are highly suspicious that giardia is the cause, based on wild-water exposure, the presentation, and symptom duration. You also order full microscopic O&P examination because you know that parasites can “run in packs.” Results of testing the first stool are positive for giardia. Microscopic examination on each of three stools is negative except for giardia trophozoites (the noninfectious form) in stools two and three.

Giardia overview. Giardia is the most common protozoan causing diarrhea in the United States, is fecal-oral spread, and like Shigella spp., is a low-inoculum infection (ingestion of as few as 10-100 cysts). Acquisition in the United States has been estimated as being 75% from contaminated water (streams are a classic source.² Other sources are contaminated food (fresh produce is classic) and in some cases sexual encounters (mostly in men who have sex with men). Most detections are sporadic, but outbreaks can occur with case numbers usually below 20; 40% of outbreaks are attributable to contaminated water or food.³ Evaluating symptomatic household members can be important as transmission in families can occur.

After ingestion, the cysts uncoat and form trophozoites, which reside mostly in the small bowel (Figure), causing inflammation and altering gut membrane permeability, thereby reducing nutrient absorption and circulating amino acids. Along with decreased food intake, altered absorption can lead to weight loss and potentially reduce growth in young children. Some trophozoites replicate while others encyst, eventually passing into stool. The cysts can survive for months in water or the environment (lakes, swimming pools, and clear mountain streams). Giardia has been linked to beavers’ feces contaminating wild-water sources, hence the moniker “Beaver fever” and warnings about stream water related to wilderness hiking.⁴

CDC / Science Direct

Dr. Harrison is professor of pediatrics and pediatric infectious diseases at Children’s Mercy Hospital–Kansas City, Mo. Children’s Mercy Hospital receives grant funding to study two candidate RSV vaccines. The hospital also receives CDC funding under the New Vaccine Surveillance Network for multicenter surveillance of acute respiratory infections, including influenza, RSV, and parainfluenza virus. Email Dr. Harrison at [email protected].

References

1. Diagnosis and Treatment Information for Medical Professionals, Giardia, Parasites. CDC.

2. Krumrie S et al. Curr Res Parasitol Vector Borne Dis. 2022;2:100084. doi: 10.1016/j.crpvbd.2022.100084.

3. Baldursson S and Karanis P. Water Res. 2011 Dec 15. doi: 10.1016/j.watres.2011.10.013.

4. “Water on the Appalachian Trail” AppalachianTrail.com.

5. Giardiasis: Treatment and prevention. UpToDate.

6. Kimberlin D et al. Red Book: 2021-2024 Report of the Committee on Infectious Diseases (Itasca, Ill.: American Academy of Pediatrics, 2021. 32nd ed.) Giardia duodenalis infections. pp. 335-8; and p. 961 (Table 4.11).

It’s “summertime and the livin’ is easy” according to the lyric from an old George Gershwin song. But sometimes, summer activities can lead to illnesses that can disrupt a child’s easy living.

Case: An otherwise healthy 11-year-old presents with four to five loose stools per day, mild nausea, excess flatulence, and cramps for 12 days with a 5-pound weight loss. His loose-to-mushy stools have no blood or mucous but smell worse than usual. He has had no fever, vomiting, rashes, or joint symptoms. A month ago, he went hiking/camping on the Appalachian Trail, drank boiled stream water. and slept in a common-use semi-enclosed shelter. He waded through streams and shared “Trail Magic” (soft drinks being cooled in a fresh mountain stream). Two other campers report similar symptoms.

Differential diagnosis: Broadly, we should consider bacteria, viruses, and parasites. But generally, bacteria are likely to produce more systemic symptoms and usually do not last 12 days. That said, this could be Clostridioides difficile, yet that seems unlikely because he is otherwise healthy and has no apparent risk factors. Salmonella spp., Campylobacter spp. and some Escherichia coli infections may drag on for more than a week but the lack of systemic symptoms or blood/mucous lowers the likelihood. Viral agents (rotavirus, norovirus, adenovirus, astrovirus, calicivirus, or sapovirus) seem unlikely because of the long symptom duration and the child’s preteen age.

The history and presentation seem more likely attributable to a parasite. Uncommonly detected protozoa include Microsporidium (mostly Enterocytozoon bieneusi) and amoeba. Microsporidium is very rare and seen mostly in immune compromised hosts, for example, those living with HIV. Amebiasis occurs mostly after travel to endemic areas, and stools usually contain blood or mucous. Some roundworm or tapeworm infestations cause abdominal pain and abnormal stools, but the usual exposures are absent. Giardia spp., Cryptosporidium spp., Cyclospora cayetanensis, and/or Cystoisospora belli best fit this presentation given his hiking/camping trip.
 

Workup. Laboratory testing of stool is warranted (because of weight loss and persistent diarrhea) despite a lack of systemic signs. Initially, bacterial culture, C. difficile testing, and viral testing seem unwarranted. The best initial approach, given our most likely suspects, is protozoan/parasite testing.

The Centers for Disease Control and Prevention recommends testing up to three stools collected on separate days.¹ Initially, stool testing for giardia and cryptosporidium antigens by EIA assays could be done as a point-of-care test. Such antigen tests are often the first step because of their ease of use, relatively low expense, reasonably high sensitivity and specificity, and rapid turnaround (as little as 1 hour). Alternatively, direct examination of three stools for ova and parasites (O&P) and acid-fast stain or direct fluorescent antibody testing can usually detect our main suspects (giardia, cryptosporidium, cyclospora, and cystoisospora) along with other less likely parasites.

Some laboratories, however, use syndromic stool testing approaches (multiplex nucleic acid panels) that detect over 20 different bacteria, viruses, and select parasites. Multiplex testing has yielded increased detection rates, compared with microscopic examination alone in some settings. Further, they also share ease-of-use and rapid turnaround times with parasite antigen assays while requiring less hands-on time by laboratory personnel, compared with direct microscopic examination. However, multiplex assays are expensive and more readily detect commensal organisms, so they are not necessarily the ideal test in all diarrheal illnesses.

Diagnosis. You decide to first order giardia and cryptosporidium antigen testing because you are highly suspicious that giardia is the cause, based on wild-water exposure, the presentation, and symptom duration. You also order full microscopic O&P examination because you know that parasites can “run in packs.” Results of testing the first stool are positive for giardia. Microscopic examination on each of three stools is negative except for giardia trophozoites (the noninfectious form) in stools two and three.

Giardia overview. Giardia is the most common protozoan causing diarrhea in the United States, is fecal-oral spread, and like Shigella spp., is a low-inoculum infection (ingestion of as few as 10-100 cysts). Acquisition in the United States has been estimated as being 75% from contaminated water (streams are a classic source.² Other sources are contaminated food (fresh produce is classic) and in some cases sexual encounters (mostly in men who have sex with men). Most detections are sporadic, but outbreaks can occur with case numbers usually below 20; 40% of outbreaks are attributable to contaminated water or food.³ Evaluating symptomatic household members can be important as transmission in families can occur.

After ingestion, the cysts uncoat and form trophozoites, which reside mostly in the small bowel (Figure), causing inflammation and altering gut membrane permeability, thereby reducing nutrient absorption and circulating amino acids. Along with decreased food intake, altered absorption can lead to weight loss and potentially reduce growth in young children. Some trophozoites replicate while others encyst, eventually passing into stool. The cysts can survive for months in water or the environment (lakes, swimming pools, and clear mountain streams). Giardia has been linked to beavers’ feces contaminating wild-water sources, hence the moniker “Beaver fever” and warnings about stream water related to wilderness hiking.⁴

CDC / Science Direct

Dr. Harrison is professor of pediatrics and pediatric infectious diseases at Children’s Mercy Hospital–Kansas City, Mo. Children’s Mercy Hospital receives grant funding to study two candidate RSV vaccines. The hospital also receives CDC funding under the New Vaccine Surveillance Network for multicenter surveillance of acute respiratory infections, including influenza, RSV, and parainfluenza virus. Email Dr. Harrison at [email protected].

References

1. Diagnosis and Treatment Information for Medical Professionals, Giardia, Parasites. CDC.

2. Krumrie S et al. Curr Res Parasitol Vector Borne Dis. 2022;2:100084. doi: 10.1016/j.crpvbd.2022.100084.

3. Baldursson S and Karanis P. Water Res. 2011 Dec 15. doi: 10.1016/j.watres.2011.10.013.

4. “Water on the Appalachian Trail” AppalachianTrail.com.

5. Giardiasis: Treatment and prevention. UpToDate.

6. Kimberlin D et al. Red Book: 2021-2024 Report of the Committee on Infectious Diseases (Itasca, Ill.: American Academy of Pediatrics, 2021. 32nd ed.) Giardia duodenalis infections. pp. 335-8; and p. 961 (Table 4.11).

It’s “summertime and the livin’ is easy” according to the lyric from an old George Gershwin song. But sometimes, summer activities can lead to illnesses that can disrupt a child’s easy living.

Case: An otherwise healthy 11-year-old presents with four to five loose stools per day, mild nausea, excess flatulence, and cramps for 12 days with a 5-pound weight loss. His loose-to-mushy stools have no blood or mucous but smell worse than usual. He has had no fever, vomiting, rashes, or joint symptoms. A month ago, he went hiking/camping on the Appalachian Trail, drank boiled stream water. and slept in a common-use semi-enclosed shelter. He waded through streams and shared “Trail Magic” (soft drinks being cooled in a fresh mountain stream). Two other campers report similar symptoms.

Differential diagnosis: Broadly, we should consider bacteria, viruses, and parasites. But generally, bacteria are likely to produce more systemic symptoms and usually do not last 12 days. That said, this could be Clostridioides difficile, yet that seems unlikely because he is otherwise healthy and has no apparent risk factors. Salmonella spp., Campylobacter spp. and some Escherichia coli infections may drag on for more than a week but the lack of systemic symptoms or blood/mucous lowers the likelihood. Viral agents (rotavirus, norovirus, adenovirus, astrovirus, calicivirus, or sapovirus) seem unlikely because of the long symptom duration and the child’s preteen age.

The history and presentation seem more likely attributable to a parasite. Uncommonly detected protozoa include Microsporidium (mostly Enterocytozoon bieneusi) and amoeba. Microsporidium is very rare and seen mostly in immune compromised hosts, for example, those living with HIV. Amebiasis occurs mostly after travel to endemic areas, and stools usually contain blood or mucous. Some roundworm or tapeworm infestations cause abdominal pain and abnormal stools, but the usual exposures are absent. Giardia spp., Cryptosporidium spp., Cyclospora cayetanensis, and/or Cystoisospora belli best fit this presentation given his hiking/camping trip.
 

Workup. Laboratory testing of stool is warranted (because of weight loss and persistent diarrhea) despite a lack of systemic signs. Initially, bacterial culture, C. difficile testing, and viral testing seem unwarranted. The best initial approach, given our most likely suspects, is protozoan/parasite testing.

The Centers for Disease Control and Prevention recommends testing up to three stools collected on separate days.¹ Initially, stool testing for giardia and cryptosporidium antigens by EIA assays could be done as a point-of-care test. Such antigen tests are often the first step because of their ease of use, relatively low expense, reasonably high sensitivity and specificity, and rapid turnaround (as little as 1 hour). Alternatively, direct examination of three stools for ova and parasites (O&P) and acid-fast stain or direct fluorescent antibody testing can usually detect our main suspects (giardia, cryptosporidium, cyclospora, and cystoisospora) along with other less likely parasites.

Some laboratories, however, use syndromic stool testing approaches (multiplex nucleic acid panels) that detect over 20 different bacteria, viruses, and select parasites. Multiplex testing has yielded increased detection rates, compared with microscopic examination alone in some settings. Further, they also share ease-of-use and rapid turnaround times with parasite antigen assays while requiring less hands-on time by laboratory personnel, compared with direct microscopic examination. However, multiplex assays are expensive and more readily detect commensal organisms, so they are not necessarily the ideal test in all diarrheal illnesses.

Diagnosis. You decide to first order giardia and cryptosporidium antigen testing because you are highly suspicious that giardia is the cause, based on wild-water exposure, the presentation, and symptom duration. You also order full microscopic O&P examination because you know that parasites can “run in packs.” Results of testing the first stool are positive for giardia. Microscopic examination on each of three stools is negative except for giardia trophozoites (the noninfectious form) in stools two and three.

Giardia overview. Giardia is the most common protozoan causing diarrhea in the United States, is fecal-oral spread, and like Shigella spp., is a low-inoculum infection (ingestion of as few as 10-100 cysts). Acquisition in the United States has been estimated as being 75% from contaminated water (streams are a classic source.² Other sources are contaminated food (fresh produce is classic) and in some cases sexual encounters (mostly in men who have sex with men). Most detections are sporadic, but outbreaks can occur with case numbers usually below 20; 40% of outbreaks are attributable to contaminated water or food.³ Evaluating symptomatic household members can be important as transmission in families can occur.

After ingestion, the cysts uncoat and form trophozoites, which reside mostly in the small bowel (Figure), causing inflammation and altering gut membrane permeability, thereby reducing nutrient absorption and circulating amino acids. Along with decreased food intake, altered absorption can lead to weight loss and potentially reduce growth in young children. Some trophozoites replicate while others encyst, eventually passing into stool. The cysts can survive for months in water or the environment (lakes, swimming pools, and clear mountain streams). Giardia has been linked to beavers’ feces contaminating wild-water sources, hence the moniker “Beaver fever” and warnings about stream water related to wilderness hiking.⁴

CDC / Science Direct

Dr. Harrison is professor of pediatrics and pediatric infectious diseases at Children’s Mercy Hospital–Kansas City, Mo. Children’s Mercy Hospital receives grant funding to study two candidate RSV vaccines. The hospital also receives CDC funding under the New Vaccine Surveillance Network for multicenter surveillance of acute respiratory infections, including influenza, RSV, and parainfluenza virus. Email Dr. Harrison at [email protected].

References

1. Diagnosis and Treatment Information for Medical Professionals, Giardia, Parasites. CDC.

2. Krumrie S et al. Curr Res Parasitol Vector Borne Dis. 2022;2:100084. doi: 10.1016/j.crpvbd.2022.100084.

3. Baldursson S and Karanis P. Water Res. 2011 Dec 15. doi: 10.1016/j.watres.2011.10.013.

4. “Water on the Appalachian Trail” AppalachianTrail.com.

5. Giardiasis: Treatment and prevention. UpToDate.

6. Kimberlin D et al. Red Book: 2021-2024 Report of the Committee on Infectious Diseases (Itasca, Ill.: American Academy of Pediatrics, 2021. 32nd ed.) Giardia duodenalis infections. pp. 335-8; and p. 961 (Table 4.11).

A 4-year-old male presented to an urgent care center with a 2-week history of runny nose and cough. The treating clinician suspected a postviral cough, but the child’s mother was unconvinced. Testing for SARS-CoV-2, influenza, and respiratory syncytial virus performed earlier in the week at the pediatrician’s office was negative. At the mother’s insistence, an expanded respiratory panel was ordered and revealed a surprising result: Bordetella parapertussis.

Just like B. pertussis, B. parapertussis can cause a prolonged cough illness characterized by coughing paroxysms, whoop, and posttussive emesis. Testing is the only way to reliably distinguish between the two infections. In general, disease due to B. parapertussis tends to be milder than typical pertussis and symptoms usually don’t last as long. In one study, 40% of people with B. parapertussis had no symptoms. B. parapertussis does not produce pertussis toxin and this may affect disease severity. Rarely, children can be coinfected with both B. pertussis and B. parapertussis.

The burden of B. parapertussis in the United States is not well described because only pertussis cases caused by B. pertussis are reportable to the Centers for Disease Control and Prevention. Nevertheless, some states include cases in public reporting and outbreaks have been reported. Historically, disease has been cyclical, with peaks in cases every 4 years and no seasonality.

This year, some communities are currently seeing an increase in B. parapertussis cases. Through June 11 of this year, 40 cases of B. parapertussis and no cases of B. pertussis have been identified at Norton Healthcare in Louisville, Ky. For comparison, one case of B. parapertussis was reported in 2022 and no cases were reported in 2021. Chatter on infectious diseases listservs suggests that clinicians in other communities are also seeing an increase in cases.

According to Andi Shane, MD, MPH, chief of the division of pediatric infectious diseases at Emory University and Children’s Healthcare of Atlanta, an unusually high number of children with B. parapertussis were identified in the Atlanta area this spring. “Fortunately, most children had mild illness and of these, only a few required admission to the hospital,” Dr. Shane said.

Back at the urgent care center, the clinician on duty called the patient’s mom to discuss the diagnosis of B. parapertussis. By the time the test result was available, the patient was asymptomatic. The clinician advised that antibiotic therapy was not indicated.

Treatment recommendations diverge for B. pertussis and B. parapertussis and this is a point of emphasis for clinicians. Treatment of B. pertussis during the catarrhal phase may ameliorate disease. Treatment initiated after the catarrhal phase has little impact on symptoms but may reduce spread to others. In most cases, treatment isn’t recommended for B. parapertussis. It is not clear how well antibiotics work against this organism. Macrolides such as erythromycin and azithromycin that are used to treat pertussis may have some activity, along with trimethoprim-sulfamethoxazole and ciprofloxacin. According to the American Academy of Pediatrics, treatment is usually reserved for individuals at risk for more severe disease, including infants, especially those less than 6 months of age, the elderly, and immunocompromised persons. Prophylactic antibiotic therapy is not recommended for most persons exposed to B. parapertussis, although some public health experts also recommend treatment of B. parapertussis-infected people in contact with young infants and others are risk for severe disease.

In recent epidemiologic reports, patients with B. parapertussis infection had received age-appropriate vaccination for pertussis, suggesting that available pertussis vaccines offer little to no protection against this disease. The best prevention strategies are similar to those that are effective against other illness spread by respiratory droplets. Sick people should stay at home and cover their coughs when around others. Everyone should practice good hand hygiene.

Are you seeing increased cases of B. parapertussis in your community? Email me at [email protected].

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She is a member of the AAP’s Committee on Infectious Diseases and one of the lead authors of the AAP’s Recommendations for Prevention and Control of Influenza in Children, 2022-2023. The opinions expressed in this article are her own. Dr. Bryant discloses that she has served as an investigator on clinical trials funded by Pfizer, Enanta and Gilead. Email her at [email protected].

A 4-year-old male presented to an urgent care center with a 2-week history of runny nose and cough. The treating clinician suspected a postviral cough, but the child’s mother was unconvinced. Testing for SARS-CoV-2, influenza, and respiratory syncytial virus performed earlier in the week at the pediatrician’s office was negative. At the mother’s insistence, an expanded respiratory panel was ordered and revealed a surprising result: Bordetella parapertussis.

Just like B. pertussis, B. parapertussis can cause a prolonged cough illness characterized by coughing paroxysms, whoop, and posttussive emesis. Testing is the only way to reliably distinguish between the two infections. In general, disease due to B. parapertussis tends to be milder than typical pertussis and symptoms usually don’t last as long. In one study, 40% of people with B. parapertussis had no symptoms. B. parapertussis does not produce pertussis toxin and this may affect disease severity. Rarely, children can be coinfected with both B. pertussis and B. parapertussis.

The burden of B. parapertussis in the United States is not well described because only pertussis cases caused by B. pertussis are reportable to the Centers for Disease Control and Prevention. Nevertheless, some states include cases in public reporting and outbreaks have been reported. Historically, disease has been cyclical, with peaks in cases every 4 years and no seasonality.

This year, some communities are currently seeing an increase in B. parapertussis cases. Through June 11 of this year, 40 cases of B. parapertussis and no cases of B. pertussis have been identified at Norton Healthcare in Louisville, Ky. For comparison, one case of B. parapertussis was reported in 2022 and no cases were reported in 2021. Chatter on infectious diseases listservs suggests that clinicians in other communities are also seeing an increase in cases.

According to Andi Shane, MD, MPH, chief of the division of pediatric infectious diseases at Emory University and Children’s Healthcare of Atlanta, an unusually high number of children with B. parapertussis were identified in the Atlanta area this spring. “Fortunately, most children had mild illness and of these, only a few required admission to the hospital,” Dr. Shane said.

Back at the urgent care center, the clinician on duty called the patient’s mom to discuss the diagnosis of B. parapertussis. By the time the test result was available, the patient was asymptomatic. The clinician advised that antibiotic therapy was not indicated.

Treatment recommendations diverge for B. pertussis and B. parapertussis and this is a point of emphasis for clinicians. Treatment of B. pertussis during the catarrhal phase may ameliorate disease. Treatment initiated after the catarrhal phase has little impact on symptoms but may reduce spread to others. In most cases, treatment isn’t recommended for B. parapertussis. It is not clear how well antibiotics work against this organism. Macrolides such as erythromycin and azithromycin that are used to treat pertussis may have some activity, along with trimethoprim-sulfamethoxazole and ciprofloxacin. According to the American Academy of Pediatrics, treatment is usually reserved for individuals at risk for more severe disease, including infants, especially those less than 6 months of age, the elderly, and immunocompromised persons. Prophylactic antibiotic therapy is not recommended for most persons exposed to B. parapertussis, although some public health experts also recommend treatment of B. parapertussis-infected people in contact with young infants and others are risk for severe disease.

In recent epidemiologic reports, patients with B. parapertussis infection had received age-appropriate vaccination for pertussis, suggesting that available pertussis vaccines offer little to no protection against this disease. The best prevention strategies are similar to those that are effective against other illness spread by respiratory droplets. Sick people should stay at home and cover their coughs when around others. Everyone should practice good hand hygiene.

Are you seeing increased cases of B. parapertussis in your community? Email me at [email protected].

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She is a member of the AAP’s Committee on Infectious Diseases and one of the lead authors of the AAP’s Recommendations for Prevention and Control of Influenza in Children, 2022-2023. The opinions expressed in this article are her own. Dr. Bryant discloses that she has served as an investigator on clinical trials funded by Pfizer, Enanta and Gilead. Email her at [email protected].

A 4-year-old male presented to an urgent care center with a 2-week history of runny nose and cough. The treating clinician suspected a postviral cough, but the child’s mother was unconvinced. Testing for SARS-CoV-2, influenza, and respiratory syncytial virus performed earlier in the week at the pediatrician’s office was negative. At the mother’s insistence, an expanded respiratory panel was ordered and revealed a surprising result: Bordetella parapertussis.

Just like B. pertussis, B. parapertussis can cause a prolonged cough illness characterized by coughing paroxysms, whoop, and posttussive emesis. Testing is the only way to reliably distinguish between the two infections. In general, disease due to B. parapertussis tends to be milder than typical pertussis and symptoms usually don’t last as long. In one study, 40% of people with B. parapertussis had no symptoms. B. parapertussis does not produce pertussis toxin and this may affect disease severity. Rarely, children can be coinfected with both B. pertussis and B. parapertussis.

The burden of B. parapertussis in the United States is not well described because only pertussis cases caused by B. pertussis are reportable to the Centers for Disease Control and Prevention. Nevertheless, some states include cases in public reporting and outbreaks have been reported. Historically, disease has been cyclical, with peaks in cases every 4 years and no seasonality.

This year, some communities are currently seeing an increase in B. parapertussis cases. Through June 11 of this year, 40 cases of B. parapertussis and no cases of B. pertussis have been identified at Norton Healthcare in Louisville, Ky. For comparison, one case of B. parapertussis was reported in 2022 and no cases were reported in 2021. Chatter on infectious diseases listservs suggests that clinicians in other communities are also seeing an increase in cases.

According to Andi Shane, MD, MPH, chief of the division of pediatric infectious diseases at Emory University and Children’s Healthcare of Atlanta, an unusually high number of children with B. parapertussis were identified in the Atlanta area this spring. “Fortunately, most children had mild illness and of these, only a few required admission to the hospital,” Dr. Shane said.

Back at the urgent care center, the clinician on duty called the patient’s mom to discuss the diagnosis of B. parapertussis. By the time the test result was available, the patient was asymptomatic. The clinician advised that antibiotic therapy was not indicated.

Treatment recommendations diverge for B. pertussis and B. parapertussis and this is a point of emphasis for clinicians. Treatment of B. pertussis during the catarrhal phase may ameliorate disease. Treatment initiated after the catarrhal phase has little impact on symptoms but may reduce spread to others. In most cases, treatment isn’t recommended for B. parapertussis. It is not clear how well antibiotics work against this organism. Macrolides such as erythromycin and azithromycin that are used to treat pertussis may have some activity, along with trimethoprim-sulfamethoxazole and ciprofloxacin. According to the American Academy of Pediatrics, treatment is usually reserved for individuals at risk for more severe disease, including infants, especially those less than 6 months of age, the elderly, and immunocompromised persons. Prophylactic antibiotic therapy is not recommended for most persons exposed to B. parapertussis, although some public health experts also recommend treatment of B. parapertussis-infected people in contact with young infants and others are risk for severe disease.

In recent epidemiologic reports, patients with B. parapertussis infection had received age-appropriate vaccination for pertussis, suggesting that available pertussis vaccines offer little to no protection against this disease. The best prevention strategies are similar to those that are effective against other illness spread by respiratory droplets. Sick people should stay at home and cover their coughs when around others. Everyone should practice good hand hygiene.

Are you seeing increased cases of B. parapertussis in your community? Email me at [email protected].

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She is a member of the AAP’s Committee on Infectious Diseases and one of the lead authors of the AAP’s Recommendations for Prevention and Control of Influenza in Children, 2022-2023. The opinions expressed in this article are her own. Dr. Bryant discloses that she has served as an investigator on clinical trials funded by Pfizer, Enanta and Gilead. Email her at [email protected].

In this column, I will describe the results of a recently published study from my group.¹ We sought to profile Streptococcus pneumoniae (pneumococcus), Haemophilus influenzae (Hflu) and Moraxella catarrhalis (Mcat) in the nasopharynx among 13-valent pneumococcal conjugate vaccine (PCV13)-immunized children, with a focus on the first 6 months of life. The rationale was to provide heretofore unreported contemporary data in a highly PCV13-immunized, community-based child population in the United States. A secondary objective was to assess nasopharyngeal bacterial density because higher density associates with greater likelihood of progression to infection. Thirdly, the serotype distribution and antibiotic susceptibility of pneumococci among children seen in primary care settings in the United States had not been evaluated for strains circulating among infants less than 6 months old and they may differ from strains recovered from older children. Therefore, comparisons were made within the same cohort of children to later child age time points.

Risk factors identified

The study was prospective and collected from a cohort of 101 children in Rochester, N.Y., during 2018-2020. Nasopharyngeal swabs were taken for study at age 1, 2 and 3 weeks, then 1, 2, 4, 6, 9, 12, 15, 18 and 24 months. All children had received PCV13 vaccine according to the Centers for Disease Control and Prevention recommended schedule.

We found two significant risk factors in the first 6 months of life for detection of nasopharyngeal colonization of pneumococcus, Hflu, and Mcat. They were daycare attendance and one or more siblings aged 1-5 years at home.

Colonization by one or more of the three bacteria was detected in only 5% of infants before age 2 months. None of the five children attended daycare but all five had young siblings at home. Pneumococcal colonization was detected in 12%, Hflu in 3%, and Mcat in 21% of nasopharyngeal swabs collected during the first 6 months of life. Nasopharyngeal colonization with the bacteria increased rapidly between age 4 and 6 months of life, coincident with infants going to daycare and other social interaction opportunities. Bacterial density of pneumococcus, Hflu, and Mcat during the first 6 months of life was significantly lower in the nasopharynx compared with bacterial density when samples were collected during child age 7-24 months.

The prevalent pneumococcal serotypes in children up to 6 months old were 23B (17%), 22F (13%), 15B/C (11%), 16F (9%), and 21 (7%), 19F (7%), which differed from those isolated from children age 7-24 months, where serotypes 35B (15%), 21 (10%), 15B (9%), and 23B (7%), 23A (7%) were most commonly observed. Antibiotic resistance among isolates did not significantly differ in comparisons between infants younger than 6 months versus 7- to 24-month-olds.
 

What is the clinical significance?

Colonization of the nasopharynx is a necessary first step in infection pathogenesis (Figure).

Michael Pichichero, MD

In a prior study of a different cohort of 358 prospectively-enrolled children, we sought associations between physician-attended illness visits and bacterial colonization in the first 5 years of life.² We showed that early age of first colonization with pneumococcus, Hflu, and Mcat was associated with respiratory infection proneness and asthma among the children.

Multiple demographic and risk factors may contribute to early life and high-density colonization that in turn may increase risk of infections. High densities and early life pneumococcal colonization in low/middle-income countries might impact PCV responses by induction of immunity tolerance. While it is appealing to study new vaccines in low/middle-income populations with high infection incidence, there are reasons that infection incidence is higher compared with high-income countries like the United States, among them may be early life nasopharyngeal colonization and density of colonization.

Prevalent pneumococcal serotype appear to differ with age. The most common serotypes in the first 6 months of life for the children were 23B> 22F> 16F and 21=19F, but in children 7-24 months, serotypes 35B> 21>15B>23A=23B were most commonly observed. This difference might be due to the impact of antibiotics.³ Pneumococci expressing serotypes 22F and 16F were oxacillin susceptible and antibiotic exposure in the first 6 months of life is very uncommon in our study cohorts. In contrast, all pneumococci expressing 35B capsule were oxacillin resistant and in our cohorts antibiotic exposures are common among 7- to 24-month-olds.

In conclusion, we determined that children in the first 6 months of life seen in pediatric primary care settings in Rochester, N.Y., have very low prevalence and low-density colonization of pneumococcus, Hflu, and Mcat compared with 7- to 24-month olds. Our results may explain the significantly lower rates of infections caused by pneumococci, Hflu, and Mcat in infants younger than 6 months old compared with low/middle-income countries.
 

Dr. Pichichero is a specialist in pediatric infectious diseases, Center for Infectious Diseases and Immunology, and director of the Research Institute at Rochester (N.Y.) General Hospital. He has no conflicts of interest to disclose.

References

1. Kaur R and Pichichero M. Colonization, density, and antibiotic resistance of Streptococcus pneumoniae, Haemophilus Influenzae, and Moraxella catarrhalis among PCV13 vaccinated infants in the first six months of life in Rochester, New York. J Pediatric Infect Dis Soc. 2023 Apr 18;12(3):135-42.

2. Chapman T et al. Nasopharyngeal colonization with pathobionts is associated with susceptibility to respiratory illnesses in young children. PLoS One. 2020 Dec 11;15(12):e0243942. doi: 10.1371/journal.pone.0243942.

3. Chapman TJ et al. Antibiotic use and vaccine antibody levels. Pediatrics 2022 May 1;149(5):e2021052061. doi: 10.1542/peds.2021-052061.

In this column, I will describe the results of a recently published study from my group.¹ We sought to profile Streptococcus pneumoniae (pneumococcus), Haemophilus influenzae (Hflu) and Moraxella catarrhalis (Mcat) in the nasopharynx among 13-valent pneumococcal conjugate vaccine (PCV13)-immunized children, with a focus on the first 6 months of life. The rationale was to provide heretofore unreported contemporary data in a highly PCV13-immunized, community-based child population in the United States. A secondary objective was to assess nasopharyngeal bacterial density because higher density associates with greater likelihood of progression to infection. Thirdly, the serotype distribution and antibiotic susceptibility of pneumococci among children seen in primary care settings in the United States had not been evaluated for strains circulating among infants less than 6 months old and they may differ from strains recovered from older children. Therefore, comparisons were made within the same cohort of children to later child age time points.

Risk factors identified

The study was prospective and collected from a cohort of 101 children in Rochester, N.Y., during 2018-2020. Nasopharyngeal swabs were taken for study at age 1, 2 and 3 weeks, then 1, 2, 4, 6, 9, 12, 15, 18 and 24 months. All children had received PCV13 vaccine according to the Centers for Disease Control and Prevention recommended schedule.

We found two significant risk factors in the first 6 months of life for detection of nasopharyngeal colonization of pneumococcus, Hflu, and Mcat. They were daycare attendance and one or more siblings aged 1-5 years at home.

Colonization by one or more of the three bacteria was detected in only 5% of infants before age 2 months. None of the five children attended daycare but all five had young siblings at home. Pneumococcal colonization was detected in 12%, Hflu in 3%, and Mcat in 21% of nasopharyngeal swabs collected during the first 6 months of life. Nasopharyngeal colonization with the bacteria increased rapidly between age 4 and 6 months of life, coincident with infants going to daycare and other social interaction opportunities. Bacterial density of pneumococcus, Hflu, and Mcat during the first 6 months of life was significantly lower in the nasopharynx compared with bacterial density when samples were collected during child age 7-24 months.

The prevalent pneumococcal serotypes in children up to 6 months old were 23B (17%), 22F (13%), 15B/C (11%), 16F (9%), and 21 (7%), 19F (7%), which differed from those isolated from children age 7-24 months, where serotypes 35B (15%), 21 (10%), 15B (9%), and 23B (7%), 23A (7%) were most commonly observed. Antibiotic resistance among isolates did not significantly differ in comparisons between infants younger than 6 months versus 7- to 24-month-olds.
 

What is the clinical significance?

Colonization of the nasopharynx is a necessary first step in infection pathogenesis (Figure).

Michael Pichichero, MD

In a prior study of a different cohort of 358 prospectively-enrolled children, we sought associations between physician-attended illness visits and bacterial colonization in the first 5 years of life.² We showed that early age of first colonization with pneumococcus, Hflu, and Mcat was associated with respiratory infection proneness and asthma among the children.

Multiple demographic and risk factors may contribute to early life and high-density colonization that in turn may increase risk of infections. High densities and early life pneumococcal colonization in low/middle-income countries might impact PCV responses by induction of immunity tolerance. While it is appealing to study new vaccines in low/middle-income populations with high infection incidence, there are reasons that infection incidence is higher compared with high-income countries like the United States, among them may be early life nasopharyngeal colonization and density of colonization.

Prevalent pneumococcal serotype appear to differ with age. The most common serotypes in the first 6 months of life for the children were 23B> 22F> 16F and 21=19F, but in children 7-24 months, serotypes 35B> 21>15B>23A=23B were most commonly observed. This difference might be due to the impact of antibiotics.³ Pneumococci expressing serotypes 22F and 16F were oxacillin susceptible and antibiotic exposure in the first 6 months of life is very uncommon in our study cohorts. In contrast, all pneumococci expressing 35B capsule were oxacillin resistant and in our cohorts antibiotic exposures are common among 7- to 24-month-olds.

In conclusion, we determined that children in the first 6 months of life seen in pediatric primary care settings in Rochester, N.Y., have very low prevalence and low-density colonization of pneumococcus, Hflu, and Mcat compared with 7- to 24-month olds. Our results may explain the significantly lower rates of infections caused by pneumococci, Hflu, and Mcat in infants younger than 6 months old compared with low/middle-income countries.
 

Dr. Pichichero is a specialist in pediatric infectious diseases, Center for Infectious Diseases and Immunology, and director of the Research Institute at Rochester (N.Y.) General Hospital. He has no conflicts of interest to disclose.

References

1. Kaur R and Pichichero M. Colonization, density, and antibiotic resistance of Streptococcus pneumoniae, Haemophilus Influenzae, and Moraxella catarrhalis among PCV13 vaccinated infants in the first six months of life in Rochester, New York. J Pediatric Infect Dis Soc. 2023 Apr 18;12(3):135-42.

2. Chapman T et al. Nasopharyngeal colonization with pathobionts is associated with susceptibility to respiratory illnesses in young children. PLoS One. 2020 Dec 11;15(12):e0243942. doi: 10.1371/journal.pone.0243942.

3. Chapman TJ et al. Antibiotic use and vaccine antibody levels. Pediatrics 2022 May 1;149(5):e2021052061. doi: 10.1542/peds.2021-052061.

In this column, I will describe the results of a recently published study from my group.¹ We sought to profile Streptococcus pneumoniae (pneumococcus), Haemophilus influenzae (Hflu) and Moraxella catarrhalis (Mcat) in the nasopharynx among 13-valent pneumococcal conjugate vaccine (PCV13)-immunized children, with a focus on the first 6 months of life. The rationale was to provide heretofore unreported contemporary data in a highly PCV13-immunized, community-based child population in the United States. A secondary objective was to assess nasopharyngeal bacterial density because higher density associates with greater likelihood of progression to infection. Thirdly, the serotype distribution and antibiotic susceptibility of pneumococci among children seen in primary care settings in the United States had not been evaluated for strains circulating among infants less than 6 months old and they may differ from strains recovered from older children. Therefore, comparisons were made within the same cohort of children to later child age time points.

Risk factors identified

The study was prospective and collected from a cohort of 101 children in Rochester, N.Y., during 2018-2020. Nasopharyngeal swabs were taken for study at age 1, 2 and 3 weeks, then 1, 2, 4, 6, 9, 12, 15, 18 and 24 months. All children had received PCV13 vaccine according to the Centers for Disease Control and Prevention recommended schedule.

We found two significant risk factors in the first 6 months of life for detection of nasopharyngeal colonization of pneumococcus, Hflu, and Mcat. They were daycare attendance and one or more siblings aged 1-5 years at home.

Colonization by one or more of the three bacteria was detected in only 5% of infants before age 2 months. None of the five children attended daycare but all five had young siblings at home. Pneumococcal colonization was detected in 12%, Hflu in 3%, and Mcat in 21% of nasopharyngeal swabs collected during the first 6 months of life. Nasopharyngeal colonization with the bacteria increased rapidly between age 4 and 6 months of life, coincident with infants going to daycare and other social interaction opportunities. Bacterial density of pneumococcus, Hflu, and Mcat during the first 6 months of life was significantly lower in the nasopharynx compared with bacterial density when samples were collected during child age 7-24 months.

The prevalent pneumococcal serotypes in children up to 6 months old were 23B (17%), 22F (13%), 15B/C (11%), 16F (9%), and 21 (7%), 19F (7%), which differed from those isolated from children age 7-24 months, where serotypes 35B (15%), 21 (10%), 15B (9%), and 23B (7%), 23A (7%) were most commonly observed. Antibiotic resistance among isolates did not significantly differ in comparisons between infants younger than 6 months versus 7- to 24-month-olds.
 

What is the clinical significance?

Colonization of the nasopharynx is a necessary first step in infection pathogenesis (Figure).

Michael Pichichero, MD

In a prior study of a different cohort of 358 prospectively-enrolled children, we sought associations between physician-attended illness visits and bacterial colonization in the first 5 years of life.² We showed that early age of first colonization with pneumococcus, Hflu, and Mcat was associated with respiratory infection proneness and asthma among the children.

Multiple demographic and risk factors may contribute to early life and high-density colonization that in turn may increase risk of infections. High densities and early life pneumococcal colonization in low/middle-income countries might impact PCV responses by induction of immunity tolerance. While it is appealing to study new vaccines in low/middle-income populations with high infection incidence, there are reasons that infection incidence is higher compared with high-income countries like the United States, among them may be early life nasopharyngeal colonization and density of colonization.

Prevalent pneumococcal serotype appear to differ with age. The most common serotypes in the first 6 months of life for the children were 23B> 22F> 16F and 21=19F, but in children 7-24 months, serotypes 35B> 21>15B>23A=23B were most commonly observed. This difference might be due to the impact of antibiotics.³ Pneumococci expressing serotypes 22F and 16F were oxacillin susceptible and antibiotic exposure in the first 6 months of life is very uncommon in our study cohorts. In contrast, all pneumococci expressing 35B capsule were oxacillin resistant and in our cohorts antibiotic exposures are common among 7- to 24-month-olds.

In conclusion, we determined that children in the first 6 months of life seen in pediatric primary care settings in Rochester, N.Y., have very low prevalence and low-density colonization of pneumococcus, Hflu, and Mcat compared with 7- to 24-month olds. Our results may explain the significantly lower rates of infections caused by pneumococci, Hflu, and Mcat in infants younger than 6 months old compared with low/middle-income countries.
 

Dr. Pichichero is a specialist in pediatric infectious diseases, Center for Infectious Diseases and Immunology, and director of the Research Institute at Rochester (N.Y.) General Hospital. He has no conflicts of interest to disclose.

References

1. Kaur R and Pichichero M. Colonization, density, and antibiotic resistance of Streptococcus pneumoniae, Haemophilus Influenzae, and Moraxella catarrhalis among PCV13 vaccinated infants in the first six months of life in Rochester, New York. J Pediatric Infect Dis Soc. 2023 Apr 18;12(3):135-42.

2. Chapman T et al. Nasopharyngeal colonization with pathobionts is associated with susceptibility to respiratory illnesses in young children. PLoS One. 2020 Dec 11;15(12):e0243942. doi: 10.1371/journal.pone.0243942.

3. Chapman TJ et al. Antibiotic use and vaccine antibody levels. Pediatrics 2022 May 1;149(5):e2021052061. doi: 10.1542/peds.2021-052061.

What do green monkeys, fruit bats, and python caves all have in common? All have been implicated in outbreaks as transmission sources of the rare but deadly Marburg virus. Marburg virus is in the same Filoviridae family of highly pathogenic RNA viruses as Ebola virus, and similarly can cause a rapidly progressive and fatal viral hemorrhagic fever.

In the first reported Marburg outbreak in 1967, laboratory workers in Marburg and Frankfurt, Germany, and in Belgrade, Yugoslavia, developed severe febrile illnesses with massive hemorrhage and multiorgan system dysfunction after contact with infected African green monkeys imported from Uganda. Since the first discovery of Marburg virus, there have been over 14 Marburg virus disease (MVD) outbreaks worldwide with nearly 600 cases and case fatality rates of 23%-90%.

The majority of MVD outbreaks have occurred in sub-Saharan Africa, and primarily in three African countries: Angola, the Democratic Republic of Congo, and Uganda. In sub-Saharan Africa, these sporadic outbreaks have had high case fatality rates (up to 80%-90%) and been linked to human exposure to the oral secretions or urinary/fecal droppings of Egyptian fruit bats (Rousettus aegyptiacus), the animal reservoir for Marburg virus. These exposures have primarily occurred among miners or tourists frequenting bat-infested mines or caves, including Uganda’s python cave, where Centers for Disease Control and Prevention investigators have conducted ecological studies on Marburg-infected bats. Person-to-person transmission occurs from direct contact with the blood or bodily fluids of an infected person or contact with a contaminated object (for example, unsterilized needles and syringes in a large nosocomial outbreak in Angola).

On April 6, 2023, the CDC issued a Health Advisory for U.S. clinicians and public health departments regarding two separate MVD outbreaks in Equatorial Guinea and Tanzania. These first-ever MVD outbreaks in both West and East African countries appear to be epidemiologically unrelated. As of March 24, 2023, in Equatorial Guinea, a total of 15 confirmed cases, including 11 deaths, and 23 probable cases, all deceased, have been identified in multiple districts since the outbreak declaration in February 2023. In Tanzania, a total of eight cases, including five deaths, have been reported among villagers in a northwest region since the outbreak declaration in March 2023. While so far cases in the Tanzania MVD outbreak have been epidemiologically linked, in Equatorial Guinea some cases have no identified epidemiological links, raising concern for ongoing community spread.

To date, no cases in these outbreaks have been reported in the United States or outside the affected countries. Overall, the risk of MVD in nonendemic countries, like the United States, is low but there is still a risk of importation. As of May 2, 2023, CDC has issued a Level 2 travel alert (practice enhanced precautions) for Marburg in Equatorial Guinea and a Level 1 travel watch (practice usual precautions) for Marburg in Tanzania. Travelers to these countries are advised to avoid nonessential travel to areas with active outbreaks and practice preventative measures, including avoiding contact with sick people, blood and bodily fluids, dead bodies, fruit bats, and nonhuman primates. International travelers returning to the United States from these countries are advised to self-monitor for Marburg symptoms during travel and for 21 days after country departure. Travelers who develop signs or symptoms of MVD should immediately self-isolate and contact their local health department or clinician.

So, how should clinicians manage such return travelers? In the setting of these new MVD outbreaks in sub-Saharan Africa, what do U.S. clinicians need to know? Clinicians should consider MVD in the differential diagnosis of ill patients with a compatible exposure history and clinical presentation. A detailed exposure history should be obtained to determine if patients have been to an area with an active MVD outbreak during their incubation period (in the past 21 days), had concerning epidemiologic risk factors (for example, presence at funerals, health care facilities, in mines/caves) while in the affected area, and/or had contact with a suspected or confirmed MVD case.

Clinical diagnosis of MVD is challenging as the initial dry symptoms of infection are nonspecific (fever, influenza-like illness, malaise, anorexia, etc.) and can resemble other febrile infectious illnesses. Similarly, presenting alternative or concurrent infections, particularly in febrile return travelers, include malaria, Lassa fever, typhoid, and measles. From these nonspecific symptoms, patients with MVD can then progress to the more severe wet symptoms (for example, vomiting, diarrhea, and bleeding). Common clinical features of MVD have been described based on the clinical presentation and course of cases in MVD outbreaks. Notably, in the original Marburg outbreak, maculopapular rash and conjunctival injection were early patient symptoms and most patient deaths occurred during the second week of illness progression.

Supportive care, including aggressive fluid replacement, is the mainstay of therapy for MVD. Currently, there are no Food and Drug Administration–approved antiviral treatments or vaccines for Marburg virus. Despite their viral similarities, vaccines against Ebola virus have not been shown to be protective against Marburg virus. Marburg virus vaccine development is ongoing, with a few promising candidate vaccines in early phase 1 and 2 clinical trials. In 2022, in response to MVD outbreaks in Ghana and Guinea, the World Health Organization convened an international Marburg virus vaccine consortium which is working to promote global research collaboration for more rapid vaccine development.

In the absence of definitive therapies, early identification of patients with suspected MVD is critical for preventing the spread of infection to close contacts. Like Ebola virus–infected patients, only symptomatic MVD patients are infectious and all patients with suspected MVD should be isolated in a private room and cared for in accordance with infection control procedures. As MVD is a nationally notifiable disease, suspected cases should be reported to local or state health departments as per jurisdictional requirements. Clinicians should also consult with their local or state health department and CDC for guidance on testing patients with suspected MVD and consider prompt evaluation for other infectious etiologies in the patient’s differential diagnosis. Comprehensive guidance for clinicians on screening and diagnosing patients with MVD is available on the CDC website at https://www.cdc.gov/vhf/marburg/index.html.

Dr. Appiah (she/her) is a medical epidemiologist in the division of global migration and quarantine at the CDC. Dr. Appiah holds adjunct faculty appointment in the division of infectious diseases at Emory University, Atlanta. She also holds a commission in the U.S. Public Health Service and is a resident advisor, Uganda, U.S. President’s Malaria Initiative, at the CDC.

What do green monkeys, fruit bats, and python caves all have in common? All have been implicated in outbreaks as transmission sources of the rare but deadly Marburg virus. Marburg virus is in the same Filoviridae family of highly pathogenic RNA viruses as Ebola virus, and similarly can cause a rapidly progressive and fatal viral hemorrhagic fever.

In the first reported Marburg outbreak in 1967, laboratory workers in Marburg and Frankfurt, Germany, and in Belgrade, Yugoslavia, developed severe febrile illnesses with massive hemorrhage and multiorgan system dysfunction after contact with infected African green monkeys imported from Uganda. Since the first discovery of Marburg virus, there have been over 14 Marburg virus disease (MVD) outbreaks worldwide with nearly 600 cases and case fatality rates of 23%-90%.

The majority of MVD outbreaks have occurred in sub-Saharan Africa, and primarily in three African countries: Angola, the Democratic Republic of Congo, and Uganda. In sub-Saharan Africa, these sporadic outbreaks have had high case fatality rates (up to 80%-90%) and been linked to human exposure to the oral secretions or urinary/fecal droppings of Egyptian fruit bats (Rousettus aegyptiacus), the animal reservoir for Marburg virus. These exposures have primarily occurred among miners or tourists frequenting bat-infested mines or caves, including Uganda’s python cave, where Centers for Disease Control and Prevention investigators have conducted ecological studies on Marburg-infected bats. Person-to-person transmission occurs from direct contact with the blood or bodily fluids of an infected person or contact with a contaminated object (for example, unsterilized needles and syringes in a large nosocomial outbreak in Angola).

On April 6, 2023, the CDC issued a Health Advisory for U.S. clinicians and public health departments regarding two separate MVD outbreaks in Equatorial Guinea and Tanzania. These first-ever MVD outbreaks in both West and East African countries appear to be epidemiologically unrelated. As of March 24, 2023, in Equatorial Guinea, a total of 15 confirmed cases, including 11 deaths, and 23 probable cases, all deceased, have been identified in multiple districts since the outbreak declaration in February 2023. In Tanzania, a total of eight cases, including five deaths, have been reported among villagers in a northwest region since the outbreak declaration in March 2023. While so far cases in the Tanzania MVD outbreak have been epidemiologically linked, in Equatorial Guinea some cases have no identified epidemiological links, raising concern for ongoing community spread.

To date, no cases in these outbreaks have been reported in the United States or outside the affected countries. Overall, the risk of MVD in nonendemic countries, like the United States, is low but there is still a risk of importation. As of May 2, 2023, CDC has issued a Level 2 travel alert (practice enhanced precautions) for Marburg in Equatorial Guinea and a Level 1 travel watch (practice usual precautions) for Marburg in Tanzania. Travelers to these countries are advised to avoid nonessential travel to areas with active outbreaks and practice preventative measures, including avoiding contact with sick people, blood and bodily fluids, dead bodies, fruit bats, and nonhuman primates. International travelers returning to the United States from these countries are advised to self-monitor for Marburg symptoms during travel and for 21 days after country departure. Travelers who develop signs or symptoms of MVD should immediately self-isolate and contact their local health department or clinician.

So, how should clinicians manage such return travelers? In the setting of these new MVD outbreaks in sub-Saharan Africa, what do U.S. clinicians need to know? Clinicians should consider MVD in the differential diagnosis of ill patients with a compatible exposure history and clinical presentation. A detailed exposure history should be obtained to determine if patients have been to an area with an active MVD outbreak during their incubation period (in the past 21 days), had concerning epidemiologic risk factors (for example, presence at funerals, health care facilities, in mines/caves) while in the affected area, and/or had contact with a suspected or confirmed MVD case.

Clinical diagnosis of MVD is challenging as the initial dry symptoms of infection are nonspecific (fever, influenza-like illness, malaise, anorexia, etc.) and can resemble other febrile infectious illnesses. Similarly, presenting alternative or concurrent infections, particularly in febrile return travelers, include malaria, Lassa fever, typhoid, and measles. From these nonspecific symptoms, patients with MVD can then progress to the more severe wet symptoms (for example, vomiting, diarrhea, and bleeding). Common clinical features of MVD have been described based on the clinical presentation and course of cases in MVD outbreaks. Notably, in the original Marburg outbreak, maculopapular rash and conjunctival injection were early patient symptoms and most patient deaths occurred during the second week of illness progression.

Supportive care, including aggressive fluid replacement, is the mainstay of therapy for MVD. Currently, there are no Food and Drug Administration–approved antiviral treatments or vaccines for Marburg virus. Despite their viral similarities, vaccines against Ebola virus have not been shown to be protective against Marburg virus. Marburg virus vaccine development is ongoing, with a few promising candidate vaccines in early phase 1 and 2 clinical trials. In 2022, in response to MVD outbreaks in Ghana and Guinea, the World Health Organization convened an international Marburg virus vaccine consortium which is working to promote global research collaboration for more rapid vaccine development.

In the absence of definitive therapies, early identification of patients with suspected MVD is critical for preventing the spread of infection to close contacts. Like Ebola virus–infected patients, only symptomatic MVD patients are infectious and all patients with suspected MVD should be isolated in a private room and cared for in accordance with infection control procedures. As MVD is a nationally notifiable disease, suspected cases should be reported to local or state health departments as per jurisdictional requirements. Clinicians should also consult with their local or state health department and CDC for guidance on testing patients with suspected MVD and consider prompt evaluation for other infectious etiologies in the patient’s differential diagnosis. Comprehensive guidance for clinicians on screening and diagnosing patients with MVD is available on the CDC website at https://www.cdc.gov/vhf/marburg/index.html.

Dr. Appiah (she/her) is a medical epidemiologist in the division of global migration and quarantine at the CDC. Dr. Appiah holds adjunct faculty appointment in the division of infectious diseases at Emory University, Atlanta. She also holds a commission in the U.S. Public Health Service and is a resident advisor, Uganda, U.S. President’s Malaria Initiative, at the CDC.

What do green monkeys, fruit bats, and python caves all have in common? All have been implicated in outbreaks as transmission sources of the rare but deadly Marburg virus. Marburg virus is in the same Filoviridae family of highly pathogenic RNA viruses as Ebola virus, and similarly can cause a rapidly progressive and fatal viral hemorrhagic fever.

In the first reported Marburg outbreak in 1967, laboratory workers in Marburg and Frankfurt, Germany, and in Belgrade, Yugoslavia, developed severe febrile illnesses with massive hemorrhage and multiorgan system dysfunction after contact with infected African green monkeys imported from Uganda. Since the first discovery of Marburg virus, there have been over 14 Marburg virus disease (MVD) outbreaks worldwide with nearly 600 cases and case fatality rates of 23%-90%.

The majority of MVD outbreaks have occurred in sub-Saharan Africa, and primarily in three African countries: Angola, the Democratic Republic of Congo, and Uganda. In sub-Saharan Africa, these sporadic outbreaks have had high case fatality rates (up to 80%-90%) and been linked to human exposure to the oral secretions or urinary/fecal droppings of Egyptian fruit bats (Rousettus aegyptiacus), the animal reservoir for Marburg virus. These exposures have primarily occurred among miners or tourists frequenting bat-infested mines or caves, including Uganda’s python cave, where Centers for Disease Control and Prevention investigators have conducted ecological studies on Marburg-infected bats. Person-to-person transmission occurs from direct contact with the blood or bodily fluids of an infected person or contact with a contaminated object (for example, unsterilized needles and syringes in a large nosocomial outbreak in Angola).

On April 6, 2023, the CDC issued a Health Advisory for U.S. clinicians and public health departments regarding two separate MVD outbreaks in Equatorial Guinea and Tanzania. These first-ever MVD outbreaks in both West and East African countries appear to be epidemiologically unrelated. As of March 24, 2023, in Equatorial Guinea, a total of 15 confirmed cases, including 11 deaths, and 23 probable cases, all deceased, have been identified in multiple districts since the outbreak declaration in February 2023. In Tanzania, a total of eight cases, including five deaths, have been reported among villagers in a northwest region since the outbreak declaration in March 2023. While so far cases in the Tanzania MVD outbreak have been epidemiologically linked, in Equatorial Guinea some cases have no identified epidemiological links, raising concern for ongoing community spread.

To date, no cases in these outbreaks have been reported in the United States or outside the affected countries. Overall, the risk of MVD in nonendemic countries, like the United States, is low but there is still a risk of importation. As of May 2, 2023, CDC has issued a Level 2 travel alert (practice enhanced precautions) for Marburg in Equatorial Guinea and a Level 1 travel watch (practice usual precautions) for Marburg in Tanzania. Travelers to these countries are advised to avoid nonessential travel to areas with active outbreaks and practice preventative measures, including avoiding contact with sick people, blood and bodily fluids, dead bodies, fruit bats, and nonhuman primates. International travelers returning to the United States from these countries are advised to self-monitor for Marburg symptoms during travel and for 21 days after country departure. Travelers who develop signs or symptoms of MVD should immediately self-isolate and contact their local health department or clinician.

So, how should clinicians manage such return travelers? In the setting of these new MVD outbreaks in sub-Saharan Africa, what do U.S. clinicians need to know? Clinicians should consider MVD in the differential diagnosis of ill patients with a compatible exposure history and clinical presentation. A detailed exposure history should be obtained to determine if patients have been to an area with an active MVD outbreak during their incubation period (in the past 21 days), had concerning epidemiologic risk factors (for example, presence at funerals, health care facilities, in mines/caves) while in the affected area, and/or had contact with a suspected or confirmed MVD case.

Clinical diagnosis of MVD is challenging as the initial dry symptoms of infection are nonspecific (fever, influenza-like illness, malaise, anorexia, etc.) and can resemble other febrile infectious illnesses. Similarly, presenting alternative or concurrent infections, particularly in febrile return travelers, include malaria, Lassa fever, typhoid, and measles. From these nonspecific symptoms, patients with MVD can then progress to the more severe wet symptoms (for example, vomiting, diarrhea, and bleeding). Common clinical features of MVD have been described based on the clinical presentation and course of cases in MVD outbreaks. Notably, in the original Marburg outbreak, maculopapular rash and conjunctival injection were early patient symptoms and most patient deaths occurred during the second week of illness progression.

Supportive care, including aggressive fluid replacement, is the mainstay of therapy for MVD. Currently, there are no Food and Drug Administration–approved antiviral treatments or vaccines for Marburg virus. Despite their viral similarities, vaccines against Ebola virus have not been shown to be protective against Marburg virus. Marburg virus vaccine development is ongoing, with a few promising candidate vaccines in early phase 1 and 2 clinical trials. In 2022, in response to MVD outbreaks in Ghana and Guinea, the World Health Organization convened an international Marburg virus vaccine consortium which is working to promote global research collaboration for more rapid vaccine development.

In the absence of definitive therapies, early identification of patients with suspected MVD is critical for preventing the spread of infection to close contacts. Like Ebola virus–infected patients, only symptomatic MVD patients are infectious and all patients with suspected MVD should be isolated in a private room and cared for in accordance with infection control procedures. As MVD is a nationally notifiable disease, suspected cases should be reported to local or state health departments as per jurisdictional requirements. Clinicians should also consult with their local or state health department and CDC for guidance on testing patients with suspected MVD and consider prompt evaluation for other infectious etiologies in the patient’s differential diagnosis. Comprehensive guidance for clinicians on screening and diagnosing patients with MVD is available on the CDC website at https://www.cdc.gov/vhf/marburg/index.html.

Dr. Appiah (she/her) is a medical epidemiologist in the division of global migration and quarantine at the CDC. Dr. Appiah holds adjunct faculty appointment in the division of infectious diseases at Emory University, Atlanta. She also holds a commission in the U.S. Public Health Service and is a resident advisor, Uganda, U.S. President’s Malaria Initiative, at the CDC.

When most families hear the word rabies, they envision a dog foaming at the mouth and think about receiving multiple painful, often intra-abdominal injections. However, the epidemiology of rabies has changed in the United States. Postexposure prophylaxis (PEP) may not always be indicated and for certain persons preexposure prophylaxis (PrEP) is available and recommended.

Rabies is a Lyssavirus that is transmitted through saliva most often from the bite or scratch of an infected animal. Sometimes it’s via direct contact with mucous membranes. Although rare, cases have been described in which an undiagnosed donor passed the virus via transplant to recipients and four cases of aerosolized transmission were documented in two spelunkers and two laboratory technicians working with the virus. Worldwide it’s estimated that rabies causes 59,000 deaths annually.

CDC

Most cases (98%) are secondary to canine rabies. Prior to 1960, dogs were the major reservoir in the United States; however, after introduction of leash laws and animal vaccination in 1947, there was a drastic decline in cases caused by the canine rabies virus variant (CRVV). By 2004, CRVV was eliminated in the United States.

However, the proportion of strains associated with wildlife including raccoons, skunks, foxes, bats, coyotes, and mongoose now account for most of the cases in humans. Wildlife rabies is found in all states except Hawaii. Between 1960 and 2018, 89 cases were acquired in the United States and 62 (70%) were from bat exposure. Dog bites acquired during international travel were the cause of 36 cases.

Once signs and symptoms of disease develop there is no treatment. Regardless of the species variant, rabies virus infection is fatal in over 99% of cases. However, disease can be prevented with prompt initiation of PEP, which includes administration of rabies immune globulin (RIG) and rabies vaccine. Let’s look at a few different scenarios.

1. A delivery person is bitten by your neighbor’s dog while making a delivery. He was told to get rabies vaccine. What should we advise?

Canine rabies has been eliminated in the United States. However, unvaccinated canines can acquire rabies from wildlife. In this situation, you can determine the immunization status of the dog. Contact your local/state health department to assist with enforcement and management. Bites by cats and ferrets should be managed similarly.

Healthy dog:

1. Observe for 10 days.

2. PEP is not indicated unless the animal develops signs/symptoms of rabies. Then euthanize and begin PEP.

Dog appears rabid or suspected to be rabid:

1. Begin PEP.

2. Animal should be euthanized. If immunofluorescent test is negative discontinue PEP.

Dog unavailable:

Contact local/state health department. They are more familiar with rabies surveillance data.

2. Patient relocating to Malaysia for 3-4 years. Rabies PrEP was recommended but the family wants your opinion before receiving the vaccine. What would you advise?

Canine rabies is felt to be the primary cause of rabies outside of the United States. Canines are not routinely vaccinated in many foreign destinations, and the availability of RIG and rabies vaccine is not guaranteed in developing countries. As noted above, dog bites during international travel accounted for 28% of U.S. cases between 1960 and 2018.

In May 2022 recommendations for a modified two-dose PrEP schedule was published that identifies five risk groups and includes specific timing for checking rabies titers. The third rabies dose can now be administered up until year 3 (Morb Mortal Wkly Rep. 2022 May 6;71[18]:619-27). For individuals relocating to countries where CRVV is present, I prefer the traditional three-dose PrEP schedule administered between 21 and 28 days. However, we now have options. If exposure occurs any time after completion of a three-dose PrEP series or within 3 years after completion of a two-dose PrEP series, RIG would not be required. All patients would receive two doses of rabies vaccine (days 0, 3). If exposure occurs after 3 years in a person who received two doses of PrEP who did not have documentation of a protective rabies titer (> 5 IU/mL), treatment will include RIG plus four doses of vaccine (days 0, 3, 7, 14).

For this relocating patient, supporting PrEP would be strongly recommended.

3. A mother tells you she sees bats flying around her home at night and a few have even gotten into the home. This morning she saw one in her child’s room. He was still sleeping. Is there anything she needs to do?

Bats have become the predominant source of rabies in the United States. In addition to the cases noted above, three fatal cases occurred between Sept. 28 and Nov. 10, 2021, after bat exposures in August 2021 (MMWR Morb Mortal Wkly Rep. 2022 Jan 7;71:31-2). All had recognized contact with a bat 3-7 weeks prior to onset of symptoms and died 2-3 weeks after symptom onset. One declined PEP and the other two did not realize the risk for rabies from their exposure or did not notice a scratch or bite. Bites from bats may be small and unnoticed. Exposure to a bat in a closed room while sleeping is considered an exposure. Hawaii is the only state not reporting rabid bats.

PEP is recommended for her child. She should identify potential areas bats may enter the home and seal them in addition to removal of any bat roosts.

4. A parent realizes a house guest has been feeding raccoons in the backyard. What’s your response?

While bat rabies is the predominant variant associated with disease in the United States, as illustrated in Figure 1, other species of wildlife including raccoons are a major source of rabies. The geographic spread of the raccoon variant of rabies has been limited by oral vaccination via bait. In the situation noted here, the raccoons have returned because food was being offered thus increasing the families chance of a potential rabies exposure. Wildlife including skunks, raccoons, coyotes, foxes, and mongooses are always considered rabid until proven negative by laboratory testing.

CDC

You recommend to stop feeding wildlife and never to approach them. Have them contact the local rabies control unit and/or state wildlife services to assist with removal of the raccoons. Depending on the locale, pest control may be required at the owners expense. Inform the family to seek PEP if anyone is bitten or scratched by the raccoons.

As per the Centers for Disease Control and Prevention, about 55,000 residents receive PEP annually with health-associated expenditures including diagnostics, prevention, and control estimated between $245 and $510 million annually. Rabies is one of the most fatal diseases that can be prevented by avoiding contact with wild animals, maintenance of high immunization rates in pets, and keeping people informed of potential sources including bats. One can’t determine if an animal has rabies by looking at it. Rabies remains an urgent disease that we have to remember to address with our patients and their families. For additional information go to www.CDC.gov/rabies.

Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She has no relevant financial disclosures.

When most families hear the word rabies, they envision a dog foaming at the mouth and think about receiving multiple painful, often intra-abdominal injections. However, the epidemiology of rabies has changed in the United States. Postexposure prophylaxis (PEP) may not always be indicated and for certain persons preexposure prophylaxis (PrEP) is available and recommended.

Rabies is a Lyssavirus that is transmitted through saliva most often from the bite or scratch of an infected animal. Sometimes it’s via direct contact with mucous membranes. Although rare, cases have been described in which an undiagnosed donor passed the virus via transplant to recipients and four cases of aerosolized transmission were documented in two spelunkers and two laboratory technicians working with the virus. Worldwide it’s estimated that rabies causes 59,000 deaths annually.

CDC

Most cases (98%) are secondary to canine rabies. Prior to 1960, dogs were the major reservoir in the United States; however, after introduction of leash laws and animal vaccination in 1947, there was a drastic decline in cases caused by the canine rabies virus variant (CRVV). By 2004, CRVV was eliminated in the United States.

However, the proportion of strains associated with wildlife including raccoons, skunks, foxes, bats, coyotes, and mongoose now account for most of the cases in humans. Wildlife rabies is found in all states except Hawaii. Between 1960 and 2018, 89 cases were acquired in the United States and 62 (70%) were from bat exposure. Dog bites acquired during international travel were the cause of 36 cases.

Once signs and symptoms of disease develop there is no treatment. Regardless of the species variant, rabies virus infection is fatal in over 99% of cases. However, disease can be prevented with prompt initiation of PEP, which includes administration of rabies immune globulin (RIG) and rabies vaccine. Let’s look at a few different scenarios.

1. A delivery person is bitten by your neighbor’s dog while making a delivery. He was told to get rabies vaccine. What should we advise?

Canine rabies has been eliminated in the United States. However, unvaccinated canines can acquire rabies from wildlife. In this situation, you can determine the immunization status of the dog. Contact your local/state health department to assist with enforcement and management. Bites by cats and ferrets should be managed similarly.

Healthy dog:

1. Observe for 10 days.

2. PEP is not indicated unless the animal develops signs/symptoms of rabies. Then euthanize and begin PEP.

Dog appears rabid or suspected to be rabid:

1. Begin PEP.

2. Animal should be euthanized. If immunofluorescent test is negative discontinue PEP.

Dog unavailable:

Contact local/state health department. They are more familiar with rabies surveillance data.

2. Patient relocating to Malaysia for 3-4 years. Rabies PrEP was recommended but the family wants your opinion before receiving the vaccine. What would you advise?

Canine rabies is felt to be the primary cause of rabies outside of the United States. Canines are not routinely vaccinated in many foreign destinations, and the availability of RIG and rabies vaccine is not guaranteed in developing countries. As noted above, dog bites during international travel accounted for 28% of U.S. cases between 1960 and 2018.

In May 2022 recommendations for a modified two-dose PrEP schedule was published that identifies five risk groups and includes specific timing for checking rabies titers. The third rabies dose can now be administered up until year 3 (Morb Mortal Wkly Rep. 2022 May 6;71[18]:619-27). For individuals relocating to countries where CRVV is present, I prefer the traditional three-dose PrEP schedule administered between 21 and 28 days. However, we now have options. If exposure occurs any time after completion of a three-dose PrEP series or within 3 years after completion of a two-dose PrEP series, RIG would not be required. All patients would receive two doses of rabies vaccine (days 0, 3). If exposure occurs after 3 years in a person who received two doses of PrEP who did not have documentation of a protective rabies titer (> 5 IU/mL), treatment will include RIG plus four doses of vaccine (days 0, 3, 7, 14).

For this relocating patient, supporting PrEP would be strongly recommended.

3. A mother tells you she sees bats flying around her home at night and a few have even gotten into the home. This morning she saw one in her child’s room. He was still sleeping. Is there anything she needs to do?

Bats have become the predominant source of rabies in the United States. In addition to the cases noted above, three fatal cases occurred between Sept. 28 and Nov. 10, 2021, after bat exposures in August 2021 (MMWR Morb Mortal Wkly Rep. 2022 Jan 7;71:31-2). All had recognized contact with a bat 3-7 weeks prior to onset of symptoms and died 2-3 weeks after symptom onset. One declined PEP and the other two did not realize the risk for rabies from their exposure or did not notice a scratch or bite. Bites from bats may be small and unnoticed. Exposure to a bat in a closed room while sleeping is considered an exposure. Hawaii is the only state not reporting rabid bats.

PEP is recommended for her child. She should identify potential areas bats may enter the home and seal them in addition to removal of any bat roosts.

4. A parent realizes a house guest has been feeding raccoons in the backyard. What’s your response?

While bat rabies is the predominant variant associated with disease in the United States, as illustrated in Figure 1, other species of wildlife including raccoons are a major source of rabies. The geographic spread of the raccoon variant of rabies has been limited by oral vaccination via bait. In the situation noted here, the raccoons have returned because food was being offered thus increasing the families chance of a potential rabies exposure. Wildlife including skunks, raccoons, coyotes, foxes, and mongooses are always considered rabid until proven negative by laboratory testing.

CDC

You recommend to stop feeding wildlife and never to approach them. Have them contact the local rabies control unit and/or state wildlife services to assist with removal of the raccoons. Depending on the locale, pest control may be required at the owners expense. Inform the family to seek PEP if anyone is bitten or scratched by the raccoons.

As per the Centers for Disease Control and Prevention, about 55,000 residents receive PEP annually with health-associated expenditures including diagnostics, prevention, and control estimated between $245 and $510 million annually. Rabies is one of the most fatal diseases that can be prevented by avoiding contact with wild animals, maintenance of high immunization rates in pets, and keeping people informed of potential sources including bats. One can’t determine if an animal has rabies by looking at it. Rabies remains an urgent disease that we have to remember to address with our patients and their families. For additional information go to www.CDC.gov/rabies.

Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She has no relevant financial disclosures.

When most families hear the word rabies, they envision a dog foaming at the mouth and think about receiving multiple painful, often intra-abdominal injections. However, the epidemiology of rabies has changed in the United States. Postexposure prophylaxis (PEP) may not always be indicated and for certain persons preexposure prophylaxis (PrEP) is available and recommended.

Rabies is a Lyssavirus that is transmitted through saliva most often from the bite or scratch of an infected animal. Sometimes it’s via direct contact with mucous membranes. Although rare, cases have been described in which an undiagnosed donor passed the virus via transplant to recipients and four cases of aerosolized transmission were documented in two spelunkers and two laboratory technicians working with the virus. Worldwide it’s estimated that rabies causes 59,000 deaths annually.

CDC

Most cases (98%) are secondary to canine rabies. Prior to 1960, dogs were the major reservoir in the United States; however, after introduction of leash laws and animal vaccination in 1947, there was a drastic decline in cases caused by the canine rabies virus variant (CRVV). By 2004, CRVV was eliminated in the United States.

However, the proportion of strains associated with wildlife including raccoons, skunks, foxes, bats, coyotes, and mongoose now account for most of the cases in humans. Wildlife rabies is found in all states except Hawaii. Between 1960 and 2018, 89 cases were acquired in the United States and 62 (70%) were from bat exposure. Dog bites acquired during international travel were the cause of 36 cases.

Once signs and symptoms of disease develop there is no treatment. Regardless of the species variant, rabies virus infection is fatal in over 99% of cases. However, disease can be prevented with prompt initiation of PEP, which includes administration of rabies immune globulin (RIG) and rabies vaccine. Let’s look at a few different scenarios.

1. A delivery person is bitten by your neighbor’s dog while making a delivery. He was told to get rabies vaccine. What should we advise?

Canine rabies has been eliminated in the United States. However, unvaccinated canines can acquire rabies from wildlife. In this situation, you can determine the immunization status of the dog. Contact your local/state health department to assist with enforcement and management. Bites by cats and ferrets should be managed similarly.

Healthy dog:

1. Observe for 10 days.

2. PEP is not indicated unless the animal develops signs/symptoms of rabies. Then euthanize and begin PEP.

Dog appears rabid or suspected to be rabid:

1. Begin PEP.

2. Animal should be euthanized. If immunofluorescent test is negative discontinue PEP.

Dog unavailable:

Contact local/state health department. They are more familiar with rabies surveillance data.

2. Patient relocating to Malaysia for 3-4 years. Rabies PrEP was recommended but the family wants your opinion before receiving the vaccine. What would you advise?

Canine rabies is felt to be the primary cause of rabies outside of the United States. Canines are not routinely vaccinated in many foreign destinations, and the availability of RIG and rabies vaccine is not guaranteed in developing countries. As noted above, dog bites during international travel accounted for 28% of U.S. cases between 1960 and 2018.

In May 2022 recommendations for a modified two-dose PrEP schedule was published that identifies five risk groups and includes specific timing for checking rabies titers. The third rabies dose can now be administered up until year 3 (Morb Mortal Wkly Rep. 2022 May 6;71[18]:619-27). For individuals relocating to countries where CRVV is present, I prefer the traditional three-dose PrEP schedule administered between 21 and 28 days. However, we now have options. If exposure occurs any time after completion of a three-dose PrEP series or within 3 years after completion of a two-dose PrEP series, RIG would not be required. All patients would receive two doses of rabies vaccine (days 0, 3). If exposure occurs after 3 years in a person who received two doses of PrEP who did not have documentation of a protective rabies titer (> 5 IU/mL), treatment will include RIG plus four doses of vaccine (days 0, 3, 7, 14).

For this relocating patient, supporting PrEP would be strongly recommended.

3. A mother tells you she sees bats flying around her home at night and a few have even gotten into the home. This morning she saw one in her child’s room. He was still sleeping. Is there anything she needs to do?

Bats have become the predominant source of rabies in the United States. In addition to the cases noted above, three fatal cases occurred between Sept. 28 and Nov. 10, 2021, after bat exposures in August 2021 (MMWR Morb Mortal Wkly Rep. 2022 Jan 7;71:31-2). All had recognized contact with a bat 3-7 weeks prior to onset of symptoms and died 2-3 weeks after symptom onset. One declined PEP and the other two did not realize the risk for rabies from their exposure or did not notice a scratch or bite. Bites from bats may be small and unnoticed. Exposure to a bat in a closed room while sleeping is considered an exposure. Hawaii is the only state not reporting rabid bats.

PEP is recommended for her child. She should identify potential areas bats may enter the home and seal them in addition to removal of any bat roosts.

4. A parent realizes a house guest has been feeding raccoons in the backyard. What’s your response?

While bat rabies is the predominant variant associated with disease in the United States, as illustrated in Figure 1, other species of wildlife including raccoons are a major source of rabies. The geographic spread of the raccoon variant of rabies has been limited by oral vaccination via bait. In the situation noted here, the raccoons have returned because food was being offered thus increasing the families chance of a potential rabies exposure. Wildlife including skunks, raccoons, coyotes, foxes, and mongooses are always considered rabid until proven negative by laboratory testing.

CDC

You recommend to stop feeding wildlife and never to approach them. Have them contact the local rabies control unit and/or state wildlife services to assist with removal of the raccoons. Depending on the locale, pest control may be required at the owners expense. Inform the family to seek PEP if anyone is bitten or scratched by the raccoons.

As per the Centers for Disease Control and Prevention, about 55,000 residents receive PEP annually with health-associated expenditures including diagnostics, prevention, and control estimated between $245 and $510 million annually. Rabies is one of the most fatal diseases that can be prevented by avoiding contact with wild animals, maintenance of high immunization rates in pets, and keeping people informed of potential sources including bats. One can’t determine if an animal has rabies by looking at it. Rabies remains an urgent disease that we have to remember to address with our patients and their families. For additional information go to www.CDC.gov/rabies.

Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She has no relevant financial disclosures.

Case: A 3-year-old girl presented to the emergency department after a brief seizure at home. She looked well on physical exam except for a fever of 103° F and thick rhinorrhea.

The intern on duty methodically worked through the standard list of questions. “Immunizations up to date?” she asked.

“Absolutely,” the child’s mom responded. “She’s had everything that’s recommended.”

“Including COVID-19 vaccine?” the intern prompted.

“No.” The mom responded with a shake of her head. “We don’t do that vaccine.”

That mom is not alone. 

COVID-19 vaccines for children as young as 6 months were given emergency-use authorization by the Food and Drug Administration in June 2022 and in February 2023, the Advisory Committee on Immunization Practices included COVID-19 vaccine on the routine childhood immunization schedule.

COVID-19 vaccines are safe in young children, and they prevent the most severe outcomes associated with infection, including hospitalization. Newly released data confirm that the COVID-19 vaccines produced by Moderna and Pfizer also provide protection against symptomatic infection for at least 4 months after completion of the monovalent primary series. 

In a Morbidity and Mortality Weekly Report released on Feb. 17, 2023, the Centers for Disease Control and Prevention reported the results of a test-negative design case-control study that enrolled symptomatic children tested for SARS-CoV-2 infection through Feb. 5, 2023, as part of the Increasing Community Access to Testing (ICATT) program.¹ ICATT provides SARS-CoV-2 testing to persons aged at least 3 years at pharmacy and community-based testing sites nationwide.

Two doses of monovalent Moderna vaccine (complete primary series) was 60% effective against symptomatic infection (95% confidence interval, 49%-68%) 2 weeks to 2 months after receipt of the second dose. Vaccine effectiveness dropped to 36% (95% CI, 15%-52%) 3-4 months after the second dose. Three doses of monovalent Pfizer-BioNTech vaccine (complete primary series) was 31% effective (95% CI, 7%-49%) at preventing symptomatic infection 2 weeks to 4 months after receipt of the third dose. A bivalent vaccine dose for eligible children is expected to provide more protection against currently circulating SARS-CoV-2 variants. 

Despite evidence of vaccine efficacy, very few parents are opting to protect their young children with the COVID-19 vaccine. The CDC reports that, as of March 1, 2023, only 8% of children under 2 years and 10.5% of children aged 2-4 years have initiated a COVID vaccine series. The American Academy of Pediatrics has emphasized that 15.0 million children between the ages of 6 months and 4 years have not yet received their first COVID-19 vaccine dose.

While the reasons underlying low COVID-19 vaccination rates in young children are complex, themes emerge. Socioeconomic disparities contributing to low vaccination rates in young children were highlighted in another recent MMWR article.² Through Dec. 1, 2022, vaccination coverage was lower in rural counties (3.4%) than in urban counties (10.5%). Rates were lower in Black and Hispanic children than in White and Asian children. 

According to the CDC, high rates of poverty in Black and Hispanic communities may affect vaccination coverage by affecting caregivers’ access to vaccination sites or ability to leave work to take their child to be vaccinated. Pediatric care providers have repeatedly been identified by parents as a source of trusted vaccine information and a strong provider recommendation is associated with vaccination, but not all families are receiving vaccine advice. In a 2022 Kaiser Family Foundation survey, parents of young children with annual household incomes above $90,000 were more likely to talk to their pediatrician about a COVID-19 vaccine than families with lower incomes.³Vaccine hesitancy, fueled by general confusion and skepticism, is another factor contributing to low vaccination rates. Admittedly, the recommendations are complex and on March 14, 2023, the FDA again revised the emergency-use authorization for young children. Some caregivers continue to express concerns about vaccine side effects as well as the belief that the vaccine won’t prevent their child from getting sick. 

Kendall Purcell, MD, a pediatrician with Norton Children’s Medical Group in Louisville, Ky., recommends COVID-19 vaccination for her patients because it reduces the risk of severe disease. That factored into her own decision to vaccinate her 4-year-old son and 1-year-old daughter, but she hasn’t been able to convince the parents of all her patients. “Some feel that COVID-19 is not as severe for children, so the risks don’t outweigh the benefits when it comes to vaccinating their children.” Back to our case: In the ED the intern reviewed the laboratory testing she had ordered. She then sat down with the mother of the 3-year-old girl to discuss the diagnosis: febrile seizure associated with COVID-19 infection. Febrile seizures are a well-recognized but uncommon complication of COVID-19 in children. In a retrospective cohort study using electronic health record data, febrile seizures occurred in 0.5% of 8,854 children aged 0-5 years with COVID-19 infection.⁴ About 9% of these children required critical care services. In another cohort of hospitalized children, neurologic complications occurred in 7% of children hospitalized with COVID-19.⁵ Febrile and nonfebrile seizures were most commonly observed.

“I really thought COVID-19 was no big deal in young kids,” the mom said. “Parents need the facts.”

The facts are these: Through Dec. 2, 2022, more than 3 million cases of COVID-19 have been reported in children aged younger than 5 years. While COVID is generally less severe in young children than older adults, it is difficult to predict which children will become seriously ill. When children are hospitalized, one in four requires intensive care. COVID-19 is now a vaccine-preventable disease, but too many children remain unprotected.

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She is a member of the AAP’s Committee on Infectious Diseases and one of the lead authors of the AAP’s Recommendations for Prevention and Control of Influenza in Children, 2022-2023. The opinions expressed in this article are her own. Dr. Bryant discloses that she has served as an investigator on clinical trials funded by Pfizer, Enanta, and Gilead. Email her at [email protected]. Ms. Ezell is a recent graduate from Indiana University Southeast with a Bachelor of Arts in English. They have no conflicts of interest.

References

1. Fleming-Dutra KE et al. Morb Mortal Wkly Rep. 2023;72:177-182.

2. Murthy BP et al. Morb Mortal Wkly Rep. 2023;72:183-9.

3. Lopes L et al. KFF COVID-19 vaccine monitor: July 2022. San Francisco: Kaiser Family Foundation, 2022.

4. Cadet K et al. J Child Neurol. 2022 Apr;37(5):410-5.

5. Antoon JW et al. Pediatrics. 2022 Nov 1;150(5):e2022058167.

Case: A 3-year-old girl presented to the emergency department after a brief seizure at home. She looked well on physical exam except for a fever of 103° F and thick rhinorrhea.

The intern on duty methodically worked through the standard list of questions. “Immunizations up to date?” she asked.

“Absolutely,” the child’s mom responded. “She’s had everything that’s recommended.”

“Including COVID-19 vaccine?” the intern prompted.

“No.” The mom responded with a shake of her head. “We don’t do that vaccine.”

That mom is not alone. 

COVID-19 vaccines for children as young as 6 months were given emergency-use authorization by the Food and Drug Administration in June 2022 and in February 2023, the Advisory Committee on Immunization Practices included COVID-19 vaccine on the routine childhood immunization schedule.

COVID-19 vaccines are safe in young children, and they prevent the most severe outcomes associated with infection, including hospitalization. Newly released data confirm that the COVID-19 vaccines produced by Moderna and Pfizer also provide protection against symptomatic infection for at least 4 months after completion of the monovalent primary series. 

In a Morbidity and Mortality Weekly Report released on Feb. 17, 2023, the Centers for Disease Control and Prevention reported the results of a test-negative design case-control study that enrolled symptomatic children tested for SARS-CoV-2 infection through Feb. 5, 2023, as part of the Increasing Community Access to Testing (ICATT) program.¹ ICATT provides SARS-CoV-2 testing to persons aged at least 3 years at pharmacy and community-based testing sites nationwide.

Two doses of monovalent Moderna vaccine (complete primary series) was 60% effective against symptomatic infection (95% confidence interval, 49%-68%) 2 weeks to 2 months after receipt of the second dose. Vaccine effectiveness dropped to 36% (95% CI, 15%-52%) 3-4 months after the second dose. Three doses of monovalent Pfizer-BioNTech vaccine (complete primary series) was 31% effective (95% CI, 7%-49%) at preventing symptomatic infection 2 weeks to 4 months after receipt of the third dose. A bivalent vaccine dose for eligible children is expected to provide more protection against currently circulating SARS-CoV-2 variants. 

Despite evidence of vaccine efficacy, very few parents are opting to protect their young children with the COVID-19 vaccine. The CDC reports that, as of March 1, 2023, only 8% of children under 2 years and 10.5% of children aged 2-4 years have initiated a COVID vaccine series. The American Academy of Pediatrics has emphasized that 15.0 million children between the ages of 6 months and 4 years have not yet received their first COVID-19 vaccine dose.

While the reasons underlying low COVID-19 vaccination rates in young children are complex, themes emerge. Socioeconomic disparities contributing to low vaccination rates in young children were highlighted in another recent MMWR article.² Through Dec. 1, 2022, vaccination coverage was lower in rural counties (3.4%) than in urban counties (10.5%). Rates were lower in Black and Hispanic children than in White and Asian children. 

According to the CDC, high rates of poverty in Black and Hispanic communities may affect vaccination coverage by affecting caregivers’ access to vaccination sites or ability to leave work to take their child to be vaccinated. Pediatric care providers have repeatedly been identified by parents as a source of trusted vaccine information and a strong provider recommendation is associated with vaccination, but not all families are receiving vaccine advice. In a 2022 Kaiser Family Foundation survey, parents of young children with annual household incomes above $90,000 were more likely to talk to their pediatrician about a COVID-19 vaccine than families with lower incomes.³Vaccine hesitancy, fueled by general confusion and skepticism, is another factor contributing to low vaccination rates. Admittedly, the recommendations are complex and on March 14, 2023, the FDA again revised the emergency-use authorization for young children. Some caregivers continue to express concerns about vaccine side effects as well as the belief that the vaccine won’t prevent their child from getting sick. 

Kendall Purcell, MD, a pediatrician with Norton Children’s Medical Group in Louisville, Ky., recommends COVID-19 vaccination for her patients because it reduces the risk of severe disease. That factored into her own decision to vaccinate her 4-year-old son and 1-year-old daughter, but she hasn’t been able to convince the parents of all her patients. “Some feel that COVID-19 is not as severe for children, so the risks don’t outweigh the benefits when it comes to vaccinating their children.” Back to our case: In the ED the intern reviewed the laboratory testing she had ordered. She then sat down with the mother of the 3-year-old girl to discuss the diagnosis: febrile seizure associated with COVID-19 infection. Febrile seizures are a well-recognized but uncommon complication of COVID-19 in children. In a retrospective cohort study using electronic health record data, febrile seizures occurred in 0.5% of 8,854 children aged 0-5 years with COVID-19 infection.⁴ About 9% of these children required critical care services. In another cohort of hospitalized children, neurologic complications occurred in 7% of children hospitalized with COVID-19.⁵ Febrile and nonfebrile seizures were most commonly observed.

“I really thought COVID-19 was no big deal in young kids,” the mom said. “Parents need the facts.”

The facts are these: Through Dec. 2, 2022, more than 3 million cases of COVID-19 have been reported in children aged younger than 5 years. While COVID is generally less severe in young children than older adults, it is difficult to predict which children will become seriously ill. When children are hospitalized, one in four requires intensive care. COVID-19 is now a vaccine-preventable disease, but too many children remain unprotected.

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She is a member of the AAP’s Committee on Infectious Diseases and one of the lead authors of the AAP’s Recommendations for Prevention and Control of Influenza in Children, 2022-2023. The opinions expressed in this article are her own. Dr. Bryant discloses that she has served as an investigator on clinical trials funded by Pfizer, Enanta, and Gilead. Email her at [email protected]. Ms. Ezell is a recent graduate from Indiana University Southeast with a Bachelor of Arts in English. They have no conflicts of interest.

References

1. Fleming-Dutra KE et al. Morb Mortal Wkly Rep. 2023;72:177-182.

2. Murthy BP et al. Morb Mortal Wkly Rep. 2023;72:183-9.

3. Lopes L et al. KFF COVID-19 vaccine monitor: July 2022. San Francisco: Kaiser Family Foundation, 2022.

4. Cadet K et al. J Child Neurol. 2022 Apr;37(5):410-5.

5. Antoon JW et al. Pediatrics. 2022 Nov 1;150(5):e2022058167.

Case: A 3-year-old girl presented to the emergency department after a brief seizure at home. She looked well on physical exam except for a fever of 103° F and thick rhinorrhea.

The intern on duty methodically worked through the standard list of questions. “Immunizations up to date?” she asked.

“Absolutely,” the child’s mom responded. “She’s had everything that’s recommended.”

“Including COVID-19 vaccine?” the intern prompted.

“No.” The mom responded with a shake of her head. “We don’t do that vaccine.”

That mom is not alone. 

COVID-19 vaccines for children as young as 6 months were given emergency-use authorization by the Food and Drug Administration in June 2022 and in February 2023, the Advisory Committee on Immunization Practices included COVID-19 vaccine on the routine childhood immunization schedule.

COVID-19 vaccines are safe in young children, and they prevent the most severe outcomes associated with infection, including hospitalization. Newly released data confirm that the COVID-19 vaccines produced by Moderna and Pfizer also provide protection against symptomatic infection for at least 4 months after completion of the monovalent primary series. 

In a Morbidity and Mortality Weekly Report released on Feb. 17, 2023, the Centers for Disease Control and Prevention reported the results of a test-negative design case-control study that enrolled symptomatic children tested for SARS-CoV-2 infection through Feb. 5, 2023, as part of the Increasing Community Access to Testing (ICATT) program.¹ ICATT provides SARS-CoV-2 testing to persons aged at least 3 years at pharmacy and community-based testing sites nationwide.

Two doses of monovalent Moderna vaccine (complete primary series) was 60% effective against symptomatic infection (95% confidence interval, 49%-68%) 2 weeks to 2 months after receipt of the second dose. Vaccine effectiveness dropped to 36% (95% CI, 15%-52%) 3-4 months after the second dose. Three doses of monovalent Pfizer-BioNTech vaccine (complete primary series) was 31% effective (95% CI, 7%-49%) at preventing symptomatic infection 2 weeks to 4 months after receipt of the third dose. A bivalent vaccine dose for eligible children is expected to provide more protection against currently circulating SARS-CoV-2 variants. 

Despite evidence of vaccine efficacy, very few parents are opting to protect their young children with the COVID-19 vaccine. The CDC reports that, as of March 1, 2023, only 8% of children under 2 years and 10.5% of children aged 2-4 years have initiated a COVID vaccine series. The American Academy of Pediatrics has emphasized that 15.0 million children between the ages of 6 months and 4 years have not yet received their first COVID-19 vaccine dose.

While the reasons underlying low COVID-19 vaccination rates in young children are complex, themes emerge. Socioeconomic disparities contributing to low vaccination rates in young children were highlighted in another recent MMWR article.² Through Dec. 1, 2022, vaccination coverage was lower in rural counties (3.4%) than in urban counties (10.5%). Rates were lower in Black and Hispanic children than in White and Asian children. 

According to the CDC, high rates of poverty in Black and Hispanic communities may affect vaccination coverage by affecting caregivers’ access to vaccination sites or ability to leave work to take their child to be vaccinated. Pediatric care providers have repeatedly been identified by parents as a source of trusted vaccine information and a strong provider recommendation is associated with vaccination, but not all families are receiving vaccine advice. In a 2022 Kaiser Family Foundation survey, parents of young children with annual household incomes above $90,000 were more likely to talk to their pediatrician about a COVID-19 vaccine than families with lower incomes.³Vaccine hesitancy, fueled by general confusion and skepticism, is another factor contributing to low vaccination rates. Admittedly, the recommendations are complex and on March 14, 2023, the FDA again revised the emergency-use authorization for young children. Some caregivers continue to express concerns about vaccine side effects as well as the belief that the vaccine won’t prevent their child from getting sick. 

Kendall Purcell, MD, a pediatrician with Norton Children’s Medical Group in Louisville, Ky., recommends COVID-19 vaccination for her patients because it reduces the risk of severe disease. That factored into her own decision to vaccinate her 4-year-old son and 1-year-old daughter, but she hasn’t been able to convince the parents of all her patients. “Some feel that COVID-19 is not as severe for children, so the risks don’t outweigh the benefits when it comes to vaccinating their children.” Back to our case: In the ED the intern reviewed the laboratory testing she had ordered. She then sat down with the mother of the 3-year-old girl to discuss the diagnosis: febrile seizure associated with COVID-19 infection. Febrile seizures are a well-recognized but uncommon complication of COVID-19 in children. In a retrospective cohort study using electronic health record data, febrile seizures occurred in 0.5% of 8,854 children aged 0-5 years with COVID-19 infection.⁴ About 9% of these children required critical care services. In another cohort of hospitalized children, neurologic complications occurred in 7% of children hospitalized with COVID-19.⁵ Febrile and nonfebrile seizures were most commonly observed.

“I really thought COVID-19 was no big deal in young kids,” the mom said. “Parents need the facts.”

The facts are these: Through Dec. 2, 2022, more than 3 million cases of COVID-19 have been reported in children aged younger than 5 years. While COVID is generally less severe in young children than older adults, it is difficult to predict which children will become seriously ill. When children are hospitalized, one in four requires intensive care. COVID-19 is now a vaccine-preventable disease, but too many children remain unprotected.

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She is a member of the AAP’s Committee on Infectious Diseases and one of the lead authors of the AAP’s Recommendations for Prevention and Control of Influenza in Children, 2022-2023. The opinions expressed in this article are her own. Dr. Bryant discloses that she has served as an investigator on clinical trials funded by Pfizer, Enanta, and Gilead. Email her at [email protected]. Ms. Ezell is a recent graduate from Indiana University Southeast with a Bachelor of Arts in English. They have no conflicts of interest.

References

1. Fleming-Dutra KE et al. Morb Mortal Wkly Rep. 2023;72:177-182.

2. Murthy BP et al. Morb Mortal Wkly Rep. 2023;72:183-9.

3. Lopes L et al. KFF COVID-19 vaccine monitor: July 2022. San Francisco: Kaiser Family Foundation, 2022.

4. Cadet K et al. J Child Neurol. 2022 Apr;37(5):410-5.

5. Antoon JW et al. Pediatrics. 2022 Nov 1;150(5):e2022058167.

About half a million children between the ages of 1 and 3 years old have ear tube surgery in the United States every year at an annual cost exceeding $2 billion. It is the most common childhood surgery performed with anesthesia. It is a surgery commonly performed on children in most other high- and middle-income countries.

My group recently published a paper on the timing and necessity of tympanostomy tubes for recurrent otitis media in young children. The primary objective was to quantitatively examine recurrent acute otitis media (AOM) incidence with respect to age of occurrence, the influence of daycare attendance, and other risk factors in individual children. We introduced the concept of a “window of susceptibility” to AOM as new terminology referring to a child who has two or more closely spaced AOM occurrences during a window of time. We sought to know what to expect and how to advise the parent when a child presents with closely spaced AOMs.

A secondary objective was to develop models to predict the risk and timing of AOM recurrences based on the natural history of disease in young children who do not get tympanostomy tubes. Prediction models were developed to assist clinicians in understanding and explaining to parents the benefit of tympanostomy tubes based on the child’s age and number of AOMs.

The children were all from a primary care pediatric practice in Rochester, N.Y., which comprised a typical mixed demographic of largely middle-class, health care–insured families that was broadly representative of the racial/ethnic diversity in the community. The sample included both wealthy families and those living below the poverty line. The diagnosis of AOM was made based on the American Academy of Pediatrics guidance in which a presumed middle ear effusion and a full or bulging tympanic membrane were required. Almost all episodes (> 85%) of clinically diagnosed AOM cases were confirmed by culture of middle ear fluid collected by tympanocentesis to ensure diagnostic accuracy.

286 children who had ear infections were studied. We found that 80% of ear infections occurred during a very narrow window of susceptibility – age 6-21 months. About 72% of children had a window of susceptibility to ear infections that lasted 5 months or less; 97% of children had a window of susceptibility that lasted 10 months or less.

From this result, we observed that about 90% of children have a window of time lasting about 10 months when they get repeated ear infections. By the time a child gets three ear infections in 6 months (a period of time recommended by the AAP and American Academy of Otolaryngology–Head and Neck Surgery when ear tubes might be considered) and then a referral for ear tubes is made and the child gets an appointment with the ear, nose, and throat doctor, and surgery is scheduled, the ear infections were going to stop anyway.

In other words, millions of children worldwide have been getting ear tubes and physicians and parents saw that the ear infections stopped. So they concluded the ear tubes stopped the infections. We found the infections were going to stop anyway even if the child did not receive ear tubes because their susceptibility to ear infections is over by the time the surgery is performed. The child outgrew ear infections.

An exception was children in daycare at an early age. Our study found that children in daycare who are around 6 months old and start getting ear infections at that age are likely destined to have three or more ear infections in the first year of life. If children are going to be in daycare, perhaps those who need them should receive ear tubes early. Analysis of other demographic and risk factor covariates – sex, race/ethnicity, breastfeeding, siblings in the home, smoking in the home, atopy, and family history of otitis media – were not significantly associated with the number of AOMs in the child population we studied.

We developed a prediction model for doctors, so they could input a child’s age, number of ear infections, and daycare attendance and receive back an estimate of the number of likely future ear infections for that child. With that knowledge, physicians and parents can make more informed decisions.

Our message to clinicians and parents is to reconsider the necessity and timing of ear tube surgery for children with recurrent ear infections because the future is not predicted by the past. Children having several ear infections in a short time does not predict that they will have a similar number of ear infections in the future.

The study was supported by the National Institutes of Health awarded to Rochester Regional Health. Dr. Pichichero was principal investigator for the award.

Dr. Pichichero is a specialist in pediatric infectious diseases, Center for Infectious Diseases and Immunology, and director of the Research Institute, at Rochester (N.Y.) General Hospital. He has no conflicts of interest to declare.

About half a million children between the ages of 1 and 3 years old have ear tube surgery in the United States every year at an annual cost exceeding $2 billion. It is the most common childhood surgery performed with anesthesia. It is a surgery commonly performed on children in most other high- and middle-income countries.

My group recently published a paper on the timing and necessity of tympanostomy tubes for recurrent otitis media in young children. The primary objective was to quantitatively examine recurrent acute otitis media (AOM) incidence with respect to age of occurrence, the influence of daycare attendance, and other risk factors in individual children. We introduced the concept of a “window of susceptibility” to AOM as new terminology referring to a child who has two or more closely spaced AOM occurrences during a window of time. We sought to know what to expect and how to advise the parent when a child presents with closely spaced AOMs.

A secondary objective was to develop models to predict the risk and timing of AOM recurrences based on the natural history of disease in young children who do not get tympanostomy tubes. Prediction models were developed to assist clinicians in understanding and explaining to parents the benefit of tympanostomy tubes based on the child’s age and number of AOMs.

The children were all from a primary care pediatric practice in Rochester, N.Y., which comprised a typical mixed demographic of largely middle-class, health care–insured families that was broadly representative of the racial/ethnic diversity in the community. The sample included both wealthy families and those living below the poverty line. The diagnosis of AOM was made based on the American Academy of Pediatrics guidance in which a presumed middle ear effusion and a full or bulging tympanic membrane were required. Almost all episodes (> 85%) of clinically diagnosed AOM cases were confirmed by culture of middle ear fluid collected by tympanocentesis to ensure diagnostic accuracy.

286 children who had ear infections were studied. We found that 80% of ear infections occurred during a very narrow window of susceptibility – age 6-21 months. About 72% of children had a window of susceptibility to ear infections that lasted 5 months or less; 97% of children had a window of susceptibility that lasted 10 months or less.

From this result, we observed that about 90% of children have a window of time lasting about 10 months when they get repeated ear infections. By the time a child gets three ear infections in 6 months (a period of time recommended by the AAP and American Academy of Otolaryngology–Head and Neck Surgery when ear tubes might be considered) and then a referral for ear tubes is made and the child gets an appointment with the ear, nose, and throat doctor, and surgery is scheduled, the ear infections were going to stop anyway.

In other words, millions of children worldwide have been getting ear tubes and physicians and parents saw that the ear infections stopped. So they concluded the ear tubes stopped the infections. We found the infections were going to stop anyway even if the child did not receive ear tubes because their susceptibility to ear infections is over by the time the surgery is performed. The child outgrew ear infections.

An exception was children in daycare at an early age. Our study found that children in daycare who are around 6 months old and start getting ear infections at that age are likely destined to have three or more ear infections in the first year of life. If children are going to be in daycare, perhaps those who need them should receive ear tubes early. Analysis of other demographic and risk factor covariates – sex, race/ethnicity, breastfeeding, siblings in the home, smoking in the home, atopy, and family history of otitis media – were not significantly associated with the number of AOMs in the child population we studied.

We developed a prediction model for doctors, so they could input a child’s age, number of ear infections, and daycare attendance and receive back an estimate of the number of likely future ear infections for that child. With that knowledge, physicians and parents can make more informed decisions.

Our message to clinicians and parents is to reconsider the necessity and timing of ear tube surgery for children with recurrent ear infections because the future is not predicted by the past. Children having several ear infections in a short time does not predict that they will have a similar number of ear infections in the future.

The study was supported by the National Institutes of Health awarded to Rochester Regional Health. Dr. Pichichero was principal investigator for the award.

Dr. Pichichero is a specialist in pediatric infectious diseases, Center for Infectious Diseases and Immunology, and director of the Research Institute, at Rochester (N.Y.) General Hospital. He has no conflicts of interest to declare.

About half a million children between the ages of 1 and 3 years old have ear tube surgery in the United States every year at an annual cost exceeding $2 billion. It is the most common childhood surgery performed with anesthesia. It is a surgery commonly performed on children in most other high- and middle-income countries.

My group recently published a paper on the timing and necessity of tympanostomy tubes for recurrent otitis media in young children. The primary objective was to quantitatively examine recurrent acute otitis media (AOM) incidence with respect to age of occurrence, the influence of daycare attendance, and other risk factors in individual children. We introduced the concept of a “window of susceptibility” to AOM as new terminology referring to a child who has two or more closely spaced AOM occurrences during a window of time. We sought to know what to expect and how to advise the parent when a child presents with closely spaced AOMs.

A secondary objective was to develop models to predict the risk and timing of AOM recurrences based on the natural history of disease in young children who do not get tympanostomy tubes. Prediction models were developed to assist clinicians in understanding and explaining to parents the benefit of tympanostomy tubes based on the child’s age and number of AOMs.

The children were all from a primary care pediatric practice in Rochester, N.Y., which comprised a typical mixed demographic of largely middle-class, health care–insured families that was broadly representative of the racial/ethnic diversity in the community. The sample included both wealthy families and those living below the poverty line. The diagnosis of AOM was made based on the American Academy of Pediatrics guidance in which a presumed middle ear effusion and a full or bulging tympanic membrane were required. Almost all episodes (> 85%) of clinically diagnosed AOM cases were confirmed by culture of middle ear fluid collected by tympanocentesis to ensure diagnostic accuracy.

286 children who had ear infections were studied. We found that 80% of ear infections occurred during a very narrow window of susceptibility – age 6-21 months. About 72% of children had a window of susceptibility to ear infections that lasted 5 months or less; 97% of children had a window of susceptibility that lasted 10 months or less.

From this result, we observed that about 90% of children have a window of time lasting about 10 months when they get repeated ear infections. By the time a child gets three ear infections in 6 months (a period of time recommended by the AAP and American Academy of Otolaryngology–Head and Neck Surgery when ear tubes might be considered) and then a referral for ear tubes is made and the child gets an appointment with the ear, nose, and throat doctor, and surgery is scheduled, the ear infections were going to stop anyway.

In other words, millions of children worldwide have been getting ear tubes and physicians and parents saw that the ear infections stopped. So they concluded the ear tubes stopped the infections. We found the infections were going to stop anyway even if the child did not receive ear tubes because their susceptibility to ear infections is over by the time the surgery is performed. The child outgrew ear infections.

An exception was children in daycare at an early age. Our study found that children in daycare who are around 6 months old and start getting ear infections at that age are likely destined to have three or more ear infections in the first year of life. If children are going to be in daycare, perhaps those who need them should receive ear tubes early. Analysis of other demographic and risk factor covariates – sex, race/ethnicity, breastfeeding, siblings in the home, smoking in the home, atopy, and family history of otitis media – were not significantly associated with the number of AOMs in the child population we studied.

We developed a prediction model for doctors, so they could input a child’s age, number of ear infections, and daycare attendance and receive back an estimate of the number of likely future ear infections for that child. With that knowledge, physicians and parents can make more informed decisions.

Our message to clinicians and parents is to reconsider the necessity and timing of ear tube surgery for children with recurrent ear infections because the future is not predicted by the past. Children having several ear infections in a short time does not predict that they will have a similar number of ear infections in the future.

The study was supported by the National Institutes of Health awarded to Rochester Regional Health. Dr. Pichichero was principal investigator for the award.

Dr. Pichichero is a specialist in pediatric infectious diseases, Center for Infectious Diseases and Immunology, and director of the Research Institute, at Rochester (N.Y.) General Hospital. He has no conflicts of interest to declare.

I received a call late one night from a colleague in the emergency department of the children’s hospital. “This 2-year-old has a fever, cough, red eyes, and an impressive rash. I’ve personally never seen a case of measles, but I’m worried given that this child has never received the MMR vaccine.”

By the end of the call, I was worried too. Measles is a febrile respiratory illness classically accompanied by cough, coryza, conjunctivitis, and a characteristic maculopapular rash that begins on the face and spreads to the trunk and limbs. It is also highly contagious: 90% percent of susceptible, exposed individuals become infected.

Admittedly, measles is rare. Just 118 cases were reported in the United States in 2022, but 83 of those were in Columbus just 3 hours from where my colleague and I live and work. According to City of Columbus officials, the outbreak occurred almost exclusively in unimmunized children, the majority of whom were 5 years and younger. An unexpectedly high number of children were hospitalized. Typically, one in five people with measles will require hospitalization. In this outbreak, 33 children have been hospitalized as of Jan. 10.

Public health experts warn that 2023 could be much worse unless we increase measles immunization rates in the United States and globally. Immunization of around 95% of eligible people with two doses of measles-containing vaccine is associated with herd immunity. Globally, we’re falling short. Only 81% of the world’s children have received their first measle vaccine dose and only 71% have received the second dose. These are the lowest coverage rates for measles vaccine since 2008.

A 2022 joint press release from the Centers for Disease Control and Prevention and the World Health Organization noted that “measles anywhere is a threat everywhere, as the virus can quickly spread to multiple communities and across international borders.” Some prior measles outbreaks in the United States have started with a case in an international traveler or a U.S. resident who contracted measles during travel abroad.

In the United States, the number of children immunized with multiple routine vaccines has fallen in the last couple of years, in part because of pandemic-related disruptions in health care delivery. Increasing vaccine hesitancy, fueled by debates over the COVID-19 vaccine, may be slowing catch-up immunization in kids who fell behind.

Investigators from Emory University, Atlanta, and Marshfield Clinic Research Institute recently estimated that 9,145,026 U.S. children are susceptible to measles. If pandemic-level immunization rates continue without effective catch-up immunization, that number could rise to more than 15 million.

School vaccination requirements support efforts to ensure that kids are protected against vaccine-preventable diseases, but some data suggest that opposition to requiring MMR vaccine to attend public school is growing. According to a 2022 Kaiser Family Foundation Vaccine Monitor survey, 28% of U.S. adults – and 35% of parents of children under 18 – now say that parents should be able to decide to not vaccinate their children for measles, mumps, and rubella. That’s up from 16% of adults and 23% of parents in a 2019 Pew Research Center poll.

Public confidence in the benefits of MMR has also dropped modestly. About 85% of adults surveyed said that the benefits of MMR vaccine outweigh the risk, down from 88% in 2019. Among adults not vaccinated against COVID-19, only 70% said that benefits of these vaccines outweigh the risks.

While the WHO ramps up efforts to improve measles vaccination globally, pediatric clinicians can take steps now to mitigate the risk of measles outbreaks in their own communities. Query health records to understand how many eligible children in your practice have not yet received MMR vaccine. Notify families that vaccination is strongly recommended and make scheduling an appointment to receive vaccine easy. Some practices may have the bandwidth to offer evening and weekend hours for vaccine catch-up visits.

Curious about immunization rates in your state? The American Academy of Pediatrics has an interactive map that reports immunization coverage levels by state and provides comparisons to national rates and goals.

Prompt recognition and isolation of individuals with measles, along with prophylaxis of susceptible contacts, can limit community transmission. Measles can resemble other illnesses associated with fever and rash. Washington state has developed a screening tool to assist with recognition of measles. The CDC also has a measles outbreak toolkit that includes resources that outline clinical features and diagnoses, as well as strategies for talking to parents about vaccines.
 

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She is a member of the AAP’s Committee on Infectious Diseases and one of the lead authors of the AAP’s Recommendations for Prevention and Control of Influenza in Children, 2022-2023. The opinions expressed in this article are her own. Dr. Bryant disclosed that she has served as an investigator on clinical trials funded by Pfizer, Enanta, and Gilead. Email her at [email protected].

I received a call late one night from a colleague in the emergency department of the children’s hospital. “This 2-year-old has a fever, cough, red eyes, and an impressive rash. I’ve personally never seen a case of measles, but I’m worried given that this child has never received the MMR vaccine.”

By the end of the call, I was worried too. Measles is a febrile respiratory illness classically accompanied by cough, coryza, conjunctivitis, and a characteristic maculopapular rash that begins on the face and spreads to the trunk and limbs. It is also highly contagious: 90% percent of susceptible, exposed individuals become infected.

Admittedly, measles is rare. Just 118 cases were reported in the United States in 2022, but 83 of those were in Columbus just 3 hours from where my colleague and I live and work. According to City of Columbus officials, the outbreak occurred almost exclusively in unimmunized children, the majority of whom were 5 years and younger. An unexpectedly high number of children were hospitalized. Typically, one in five people with measles will require hospitalization. In this outbreak, 33 children have been hospitalized as of Jan. 10.

Public health experts warn that 2023 could be much worse unless we increase measles immunization rates in the United States and globally. Immunization of around 95% of eligible people with two doses of measles-containing vaccine is associated with herd immunity. Globally, we’re falling short. Only 81% of the world’s children have received their first measle vaccine dose and only 71% have received the second dose. These are the lowest coverage rates for measles vaccine since 2008.

A 2022 joint press release from the Centers for Disease Control and Prevention and the World Health Organization noted that “measles anywhere is a threat everywhere, as the virus can quickly spread to multiple communities and across international borders.” Some prior measles outbreaks in the United States have started with a case in an international traveler or a U.S. resident who contracted measles during travel abroad.

In the United States, the number of children immunized with multiple routine vaccines has fallen in the last couple of years, in part because of pandemic-related disruptions in health care delivery. Increasing vaccine hesitancy, fueled by debates over the COVID-19 vaccine, may be slowing catch-up immunization in kids who fell behind.

Investigators from Emory University, Atlanta, and Marshfield Clinic Research Institute recently estimated that 9,145,026 U.S. children are susceptible to measles. If pandemic-level immunization rates continue without effective catch-up immunization, that number could rise to more than 15 million.

School vaccination requirements support efforts to ensure that kids are protected against vaccine-preventable diseases, but some data suggest that opposition to requiring MMR vaccine to attend public school is growing. According to a 2022 Kaiser Family Foundation Vaccine Monitor survey, 28% of U.S. adults – and 35% of parents of children under 18 – now say that parents should be able to decide to not vaccinate their children for measles, mumps, and rubella. That’s up from 16% of adults and 23% of parents in a 2019 Pew Research Center poll.

Public confidence in the benefits of MMR has also dropped modestly. About 85% of adults surveyed said that the benefits of MMR vaccine outweigh the risk, down from 88% in 2019. Among adults not vaccinated against COVID-19, only 70% said that benefits of these vaccines outweigh the risks.

While the WHO ramps up efforts to improve measles vaccination globally, pediatric clinicians can take steps now to mitigate the risk of measles outbreaks in their own communities. Query health records to understand how many eligible children in your practice have not yet received MMR vaccine. Notify families that vaccination is strongly recommended and make scheduling an appointment to receive vaccine easy. Some practices may have the bandwidth to offer evening and weekend hours for vaccine catch-up visits.

Curious about immunization rates in your state? The American Academy of Pediatrics has an interactive map that reports immunization coverage levels by state and provides comparisons to national rates and goals.

Prompt recognition and isolation of individuals with measles, along with prophylaxis of susceptible contacts, can limit community transmission. Measles can resemble other illnesses associated with fever and rash. Washington state has developed a screening tool to assist with recognition of measles. The CDC also has a measles outbreak toolkit that includes resources that outline clinical features and diagnoses, as well as strategies for talking to parents about vaccines.
 

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She is a member of the AAP’s Committee on Infectious Diseases and one of the lead authors of the AAP’s Recommendations for Prevention and Control of Influenza in Children, 2022-2023. The opinions expressed in this article are her own. Dr. Bryant disclosed that she has served as an investigator on clinical trials funded by Pfizer, Enanta, and Gilead. Email her at [email protected].

I received a call late one night from a colleague in the emergency department of the children’s hospital. “This 2-year-old has a fever, cough, red eyes, and an impressive rash. I’ve personally never seen a case of measles, but I’m worried given that this child has never received the MMR vaccine.”

By the end of the call, I was worried too. Measles is a febrile respiratory illness classically accompanied by cough, coryza, conjunctivitis, and a characteristic maculopapular rash that begins on the face and spreads to the trunk and limbs. It is also highly contagious: 90% percent of susceptible, exposed individuals become infected.

Admittedly, measles is rare. Just 118 cases were reported in the United States in 2022, but 83 of those were in Columbus just 3 hours from where my colleague and I live and work. According to City of Columbus officials, the outbreak occurred almost exclusively in unimmunized children, the majority of whom were 5 years and younger. An unexpectedly high number of children were hospitalized. Typically, one in five people with measles will require hospitalization. In this outbreak, 33 children have been hospitalized as of Jan. 10.

Public health experts warn that 2023 could be much worse unless we increase measles immunization rates in the United States and globally. Immunization of around 95% of eligible people with two doses of measles-containing vaccine is associated with herd immunity. Globally, we’re falling short. Only 81% of the world’s children have received their first measle vaccine dose and only 71% have received the second dose. These are the lowest coverage rates for measles vaccine since 2008.

A 2022 joint press release from the Centers for Disease Control and Prevention and the World Health Organization noted that “measles anywhere is a threat everywhere, as the virus can quickly spread to multiple communities and across international borders.” Some prior measles outbreaks in the United States have started with a case in an international traveler or a U.S. resident who contracted measles during travel abroad.

In the United States, the number of children immunized with multiple routine vaccines has fallen in the last couple of years, in part because of pandemic-related disruptions in health care delivery. Increasing vaccine hesitancy, fueled by debates over the COVID-19 vaccine, may be slowing catch-up immunization in kids who fell behind.

Investigators from Emory University, Atlanta, and Marshfield Clinic Research Institute recently estimated that 9,145,026 U.S. children are susceptible to measles. If pandemic-level immunization rates continue without effective catch-up immunization, that number could rise to more than 15 million.

School vaccination requirements support efforts to ensure that kids are protected against vaccine-preventable diseases, but some data suggest that opposition to requiring MMR vaccine to attend public school is growing. According to a 2022 Kaiser Family Foundation Vaccine Monitor survey, 28% of U.S. adults – and 35% of parents of children under 18 – now say that parents should be able to decide to not vaccinate their children for measles, mumps, and rubella. That’s up from 16% of adults and 23% of parents in a 2019 Pew Research Center poll.

Public confidence in the benefits of MMR has also dropped modestly. About 85% of adults surveyed said that the benefits of MMR vaccine outweigh the risk, down from 88% in 2019. Among adults not vaccinated against COVID-19, only 70% said that benefits of these vaccines outweigh the risks.

While the WHO ramps up efforts to improve measles vaccination globally, pediatric clinicians can take steps now to mitigate the risk of measles outbreaks in their own communities. Query health records to understand how many eligible children in your practice have not yet received MMR vaccine. Notify families that vaccination is strongly recommended and make scheduling an appointment to receive vaccine easy. Some practices may have the bandwidth to offer evening and weekend hours for vaccine catch-up visits.

Curious about immunization rates in your state? The American Academy of Pediatrics has an interactive map that reports immunization coverage levels by state and provides comparisons to national rates and goals.

Prompt recognition and isolation of individuals with measles, along with prophylaxis of susceptible contacts, can limit community transmission. Measles can resemble other illnesses associated with fever and rash. Washington state has developed a screening tool to assist with recognition of measles. The CDC also has a measles outbreak toolkit that includes resources that outline clinical features and diagnoses, as well as strategies for talking to parents about vaccines.
 

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She is a member of the AAP’s Committee on Infectious Diseases and one of the lead authors of the AAP’s Recommendations for Prevention and Control of Influenza in Children, 2022-2023. The opinions expressed in this article are her own. Dr. Bryant disclosed that she has served as an investigator on clinical trials funded by Pfizer, Enanta, and Gilead. Email her at [email protected].