Judy Stone, MD

Every day we see stark images of the war in Ukraine – bombed-out buildings, explosions, and bodies lying in the streets. But there’s another, less visible war against the bacteria and viruses that are gathering their forces together. They, too, will infect parts of the population and may spread throughout Europe. Here’s what Ukrainians, and their neighbors, are facing on the infectious disease front.

Andrey Zinchuk, MD, MHS, a pulmonary/critical care physician at Yale and a native of Ukraine who immigrated to the U.S. at the age of 14 with his family, set the background for understanding this crisis. He said that TB and HIV rates in Ukraine have long been especially high, even before the current conflict: “Part of the challenge of the health care system in Ukraine is that it’s difficult to maintain a steady policy because of political instability,” he said. “We’ve had three revolutions in the last 20 years,” not counting the current Russian invasion.

The first was the breakup of the Soviet Union, which led to “an epidemic of people with HIV, hepatitis, and opioid use.” Next was the Orange Revolution in 2004 over fraud during a presidential election. In 2014 came the Maiden Revolution, after the government chose closer ties to Russia rather than Europe. Then-president Viktor Yanukovych fled to Russia.

“That’s when Russia annexed Crimea. There was essentially infiltration in Russian propaganda in the east of the country,” Dr. Zinchuk said. “This helped the Russians manufacture uprisings there to create a separatist state (the Luhansk and Donetsk People’s Republics) which were mostly Russian-speaking parts of the country,” an area known as the Donbas. This resulted in a war in eastern Ukraine that began 2014, with more than 10,000 deaths.

After the 2014 revolution, Dr. Zinchuk said, “There was a tremendous change in the way ... medical care was provided, and tremendous growth and stability in the medical supply for those chronic medical conditions.”

Nevertheless, health care expenditures in Ukraine have been quite low. Even before the current conflict, Dr. Zinchuk noted, annual health care expenditures in Ukraine were about $600 per capita. In comparison, it’s about $4,500 per person in Germany and $12,530 in the United States.

Despite those low per-capita expenditures in Ukraine, access to medicines – such as insulin for diabetes and antibiotics for tuberculosis – was stable before the war. But now, Dr. Zinchuk said, his aunt and uncle have had to flee Kyiv for the countryside and, while safe, they have “no plumbing and have to heat the house by burning firewood.” More significantly, their supply of medicine is unstable.

Asked what infections are of most immediate concern, Sten Vermund, MD, PhD, Dean of the Yale School of Public Health, told this news organization that it was “diarrheal diseases, especially in kids ... The water supply [of Mariupol] is no longer potable, but people are drinking it anyway. And sewage systems are destroyed, and raw sewage is just released into the rivers and streams. So the whole family of diarrheal diseases and war are bedfellows. So are respiratory diseases, whenever we have mass migrations and mixing of ... homeless people and transients.” 

There is one notable piece of good news that may reduce the spread of infectious diseases. Unlike the aftermath of World War II or the ongoing conflicts in the Middle East, Africa, and South Asia, refugees from the war in Ukraine are being taken into individual households throughout Poland, Germany, and other countries and are not being held in large displaced-persons camps. Dr. Vermund added, “The Syrian refugee camps in Lebanon are just tent camps with a million, 2 million people in them ... In theory, what the Poles are doing is a good thing from the point of view of preventing the spread of infection.”

One way of examining infections in war zones is by considering them based on how they are spread.
 

Respiratory infections

Although not as high on the list of concerns as TB or HIV, COVID-19 remains a big problem for infectious disease experts. Last fall, Ukraine ranked just behind the U.S. and Russia in deaths from COVID and in the top 10 in infections. Despite these dismal numbers, only 35% of people had completed the initial vaccination series.

The same conditions that fuel TB and COVID – crowding, especially in poorly ventilated settings – could lead to another measles outbreak. One occurred in Ukraine from 2017-2020, resulting in more than 115,000 cases. Even though the immunization rate for measles has now reached about 80%, the CDC considers Ukraine at high risk for another large outbreak since measles is so highly contagious.

According to the European Centre for Disease Prevention and Control (ECDC), Ukraine reported the second-highest number of TB cases in Europe (28,539). It is also one of the top 10 countries globally with the highest burden of multidrug-resistant tuberculosis (MDR-TB) – 27%. Equally disturbing is its ranking as having the second-highest rate of HIV/TB co-infection (26%) even before the war. Experts say war is a perfect breeding ground for TB, since starvation and overcrowding in poorly ventilated spaces encourages its spread.

Before the war, COVID had already caused severe disruptions in TB diagnosis and treatment access in Ukraine, and the World Health Organization suggested that the pandemic has set back efforts to end TB by more than a decade. 

Drug-resistant TB has been one of the biggest worries. In their report on TB in Ukraine, British tuberculosis experts Tom Wingfield, MBChB, PhD, from the Liverpool School of Tropical Medicine, and Jessica Potter MBBCh, PhD, from Queen Mary University of London, pointed out that “drug resistance thrives on fractured health systems and sporadic medicine supply.”

Frederick Altice, MD, a Yale epidemiologist and addiction specialist, noted, “[if] medication for tuberculosis is discontinued, that not only causes potential recurrence of disease but multidrug-resistant TB disease,” and patients could become infectious again.

Dr. Wingfield expressed concern that people will not seek care because they see it as unaffordable, although he told this news organization that he’s impressed at the Polish government’s efforts to ensure care. Especially with the triad of HIV, TB, and opioid use, Dr. Wingfield and Dr. Potter emphasized that these problems reflect the social determinants of health – “the experiences and conditions in which people live.” These medical conditions are all quite treatable with support, and once treated they pose no risk to others.
 

HIV and opioid use

Before the war, an estimated 260,000 people were living with HIV in Ukraine. Their rate of new HIV diagnoses in 2017 was second highest in the world – 37 out of every 100,000, exceeded only by Russia, with 71 out of 100,000.

Dr. Vermund told this news organization that “when Crimea was seized by the Russians in 2014, there was an immediate crisis among injection drug users who were in drug treatment programs, because it’s illegal in Russia to use buprenorphine or methadone ... So immediately, those programs were shut down, and all the drug users who were holding jobs, supporting their families, were withdrawing from their addictions and searching for a replacement, which was illegal heroin.”

Dr. Altice added that of 800 patients in the region who had to go cold turkey, “ten percent were dead within 6 months. Dependent on unreliable street drugs, some overdosed or committed suicide because they could not get treatment. They went through terrible withdrawal and stress.”

And as they relapsed, the HIV rate soared. “Fifty percent of the methadone patients have got HIV,” Dr. Altice said, “and if they stop taking the methadone, they’re going to stop taking their HIV medications as well. Their lives will become chaotic and very destabilized.”

This experience may soon repeat itself. There were two methadone factories in Ukraine – in Odessa and Kharkiv – that are now shut down by the war. Although there are efforts to import methadone and many other drugs, supply chain issues are “devastating,” Dr. Altice said. “If their medication for tuberculosis is discontinued, that not only causes potential recurrence of disease but multidrug-resistant TB disease,” and they could become infectious again. “[With a] lack of medication, lack of sterile syringes, people will be sharing syringes; they’ll be desperate. So as the desperation level goes up, the risk environment goes up, so that people have decreased opportunities to protect themselves,” and there will be an explosion in HIV.

Dr. Altice observed that with the immigration to Poland and the west, many Ukrainian refugees “are relying on the kindness of strangers.” They are likely to be “fearful to disclose either their HIV or their TB treatment status,” being afraid of being regarded as modern-day lepers, even though they are likely not infectious. Both Dr. Altice and Dr. Potter emphasized the need for the governments of Poland and other receiving countries to provide the refugees with “reassurance that their health information will not be shared with others.” Dr. Altice emphasized that “this is one of the things that I would say that these other countries have to get right.”

Dr. Potter echoed that, noting that extraordinary care needs to be taken so that shared information is not used for deportation.

When refugees are housed with rural hosts, transportation problems sometimes arise, creating major barriers to accessing care and treatment. In particular, refugees with TB, HIV, and addiction who are placed in small, remote locations may have difficulty securing transportation to sites where treatments for their complex illnesses are available, including specialists and medications.

Ukrainian-born microbiologist Olena Rzhepishevska, PhD, of Umeå University in Sweden, said in an interview that a network of European TB researchers have developed a database on TBNet where patients with TB can be specifically placed with understanding and helpful hosts outside of Ukraine. They can receive housing and medication through this network.

So far, 4 million Ukrainians have fled the country and millions more have been displaced internally. Dr. Altice noted that there is an “increased vulnerability beyond the vulnerability that they already [have] just by being a refugee” that we generally don’t recognize. Additionally, Poland and Hungary are not very progressive about methadone therapy nor are those nations well-equipped to provide it.

Dr. Altice explained that even within Ukraine, those who want to move to better their chance of getting their methadone are then at risk of being conscripted. He spoke of the grave calculations men must make, choosing to become internally displaced and risk conscription or losing life-saving methadone or medicines for HIV or TB.

One other unfortunate consequence of war might be a spike in rape, sexual abuse, prostitution, unwanted pregnancies, HIV, and sexually transmitted infections.

There were an estimated 80,100 female sex workers in Ukraine in 2016, with 5.2% HIV positive. In times of war, with no home or income, some women turn to prostitution to survive. Others are victims of sex trafficking, both within Ukraine and as refugees. The Russian invasion increased the risks of a surge in HIV infections, unwanted pregnancies, and abortions. Women who find themselves pregnant due to rape (a common tool of war) or sex trafficking may also struggle to access safe abortions. Poland, for example, has severe restrictions on abortion, and Ukrainian women may turn to unsafe, back-alley abortions, with their resulting high risk of infection.
 

Waterborne infections

Another concern involves waterborne infections. In addition to the common diarrheal diseases such as E coli, which can be expected from poor sanitation, polio is a significant concern. In the fall of 2021, Ukraine had an outbreak of vaccine-derived polio, with two cases of paralysis and 20 additional cases. As polio only paralyzes 1 person in 200 of those infected, many other cases were likely undetected. A vaccination campaign was just beginning when the war began.

Wound infections and antimicrobial resistance

The ECDC also reports high rates of antimicrobial resistance (AMR) in Ukraine, particularly involving common gram-negative bacteria, including Escherichia coli (53% resistance to third-generation cephalosporins), Klebsiella pneumoniae (54% resistance to carbapenems), and Acinetobacter spp. (77% resistance to carbapenems). Because of this, they recommend refugees requiring hospital admission be isolated on admission and screened for AMR. These AMR often complicate traumatic injuries of war.

Prevention

Many of these potential problems stemming from the war in Ukraine and the displacement of millions of its citizens can be avoided.

Attempts are being made to immunize refugees. WHO has made working with countries receiving refugees a priority, particularly by vaccinating children against measles, rubella, and COVID. The European Union has also purchased vaccines for polio and tuberculosis.

But Russia has waged an active anti-vaccine campaign against COVID in Ukraine, while at the same time advocating for vaccines in Russia. According to UNICEF, other countries with relatively low vaccination rates and high vaccine skepticism – Moldova, Romania, and Bulgaria – are at higher risk of polio and measles than those with high vaccination levels.

The continuing war in Ukraine has exacerbated the medical challenges the citizens of Ukraine face at home and as refugees fleeing to neighboring countries. Improving communication among agencies and governments and building trust with the refugees could go a long way toward limiting the spread of preventable infectious diseases as a result of the war.

Continuing to try to keep supply chains open within Ukraine and ensuring adequate supplies of medications and vaccines to refugees will also be essential. But, of course, the better solution is to end the war.

Dr. Altice, Dr. Potter, Dr. Wingfield, Dr. Vermund, and Dr. Zinchuk all report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Every day we see stark images of the war in Ukraine – bombed-out buildings, explosions, and bodies lying in the streets. But there’s another, less visible war against the bacteria and viruses that are gathering their forces together. They, too, will infect parts of the population and may spread throughout Europe. Here’s what Ukrainians, and their neighbors, are facing on the infectious disease front.

Andrey Zinchuk, MD, MHS, a pulmonary/critical care physician at Yale and a native of Ukraine who immigrated to the U.S. at the age of 14 with his family, set the background for understanding this crisis. He said that TB and HIV rates in Ukraine have long been especially high, even before the current conflict: “Part of the challenge of the health care system in Ukraine is that it’s difficult to maintain a steady policy because of political instability,” he said. “We’ve had three revolutions in the last 20 years,” not counting the current Russian invasion.

The first was the breakup of the Soviet Union, which led to “an epidemic of people with HIV, hepatitis, and opioid use.” Next was the Orange Revolution in 2004 over fraud during a presidential election. In 2014 came the Maiden Revolution, after the government chose closer ties to Russia rather than Europe. Then-president Viktor Yanukovych fled to Russia.

“That’s when Russia annexed Crimea. There was essentially infiltration in Russian propaganda in the east of the country,” Dr. Zinchuk said. “This helped the Russians manufacture uprisings there to create a separatist state (the Luhansk and Donetsk People’s Republics) which were mostly Russian-speaking parts of the country,” an area known as the Donbas. This resulted in a war in eastern Ukraine that began 2014, with more than 10,000 deaths.

After the 2014 revolution, Dr. Zinchuk said, “There was a tremendous change in the way ... medical care was provided, and tremendous growth and stability in the medical supply for those chronic medical conditions.”

Nevertheless, health care expenditures in Ukraine have been quite low. Even before the current conflict, Dr. Zinchuk noted, annual health care expenditures in Ukraine were about $600 per capita. In comparison, it’s about $4,500 per person in Germany and $12,530 in the United States.

Despite those low per-capita expenditures in Ukraine, access to medicines – such as insulin for diabetes and antibiotics for tuberculosis – was stable before the war. But now, Dr. Zinchuk said, his aunt and uncle have had to flee Kyiv for the countryside and, while safe, they have “no plumbing and have to heat the house by burning firewood.” More significantly, their supply of medicine is unstable.

Asked what infections are of most immediate concern, Sten Vermund, MD, PhD, Dean of the Yale School of Public Health, told this news organization that it was “diarrheal diseases, especially in kids ... The water supply [of Mariupol] is no longer potable, but people are drinking it anyway. And sewage systems are destroyed, and raw sewage is just released into the rivers and streams. So the whole family of diarrheal diseases and war are bedfellows. So are respiratory diseases, whenever we have mass migrations and mixing of ... homeless people and transients.” 

There is one notable piece of good news that may reduce the spread of infectious diseases. Unlike the aftermath of World War II or the ongoing conflicts in the Middle East, Africa, and South Asia, refugees from the war in Ukraine are being taken into individual households throughout Poland, Germany, and other countries and are not being held in large displaced-persons camps. Dr. Vermund added, “The Syrian refugee camps in Lebanon are just tent camps with a million, 2 million people in them ... In theory, what the Poles are doing is a good thing from the point of view of preventing the spread of infection.”

One way of examining infections in war zones is by considering them based on how they are spread.
 

Respiratory infections

Although not as high on the list of concerns as TB or HIV, COVID-19 remains a big problem for infectious disease experts. Last fall, Ukraine ranked just behind the U.S. and Russia in deaths from COVID and in the top 10 in infections. Despite these dismal numbers, only 35% of people had completed the initial vaccination series.

The same conditions that fuel TB and COVID – crowding, especially in poorly ventilated settings – could lead to another measles outbreak. One occurred in Ukraine from 2017-2020, resulting in more than 115,000 cases. Even though the immunization rate for measles has now reached about 80%, the CDC considers Ukraine at high risk for another large outbreak since measles is so highly contagious.

According to the European Centre for Disease Prevention and Control (ECDC), Ukraine reported the second-highest number of TB cases in Europe (28,539). It is also one of the top 10 countries globally with the highest burden of multidrug-resistant tuberculosis (MDR-TB) – 27%. Equally disturbing is its ranking as having the second-highest rate of HIV/TB co-infection (26%) even before the war. Experts say war is a perfect breeding ground for TB, since starvation and overcrowding in poorly ventilated spaces encourages its spread.

Before the war, COVID had already caused severe disruptions in TB diagnosis and treatment access in Ukraine, and the World Health Organization suggested that the pandemic has set back efforts to end TB by more than a decade. 

Drug-resistant TB has been one of the biggest worries. In their report on TB in Ukraine, British tuberculosis experts Tom Wingfield, MBChB, PhD, from the Liverpool School of Tropical Medicine, and Jessica Potter MBBCh, PhD, from Queen Mary University of London, pointed out that “drug resistance thrives on fractured health systems and sporadic medicine supply.”

Frederick Altice, MD, a Yale epidemiologist and addiction specialist, noted, “[if] medication for tuberculosis is discontinued, that not only causes potential recurrence of disease but multidrug-resistant TB disease,” and patients could become infectious again.

Dr. Wingfield expressed concern that people will not seek care because they see it as unaffordable, although he told this news organization that he’s impressed at the Polish government’s efforts to ensure care. Especially with the triad of HIV, TB, and opioid use, Dr. Wingfield and Dr. Potter emphasized that these problems reflect the social determinants of health – “the experiences and conditions in which people live.” These medical conditions are all quite treatable with support, and once treated they pose no risk to others.
 

HIV and opioid use

Before the war, an estimated 260,000 people were living with HIV in Ukraine. Their rate of new HIV diagnoses in 2017 was second highest in the world – 37 out of every 100,000, exceeded only by Russia, with 71 out of 100,000.

Dr. Vermund told this news organization that “when Crimea was seized by the Russians in 2014, there was an immediate crisis among injection drug users who were in drug treatment programs, because it’s illegal in Russia to use buprenorphine or methadone ... So immediately, those programs were shut down, and all the drug users who were holding jobs, supporting their families, were withdrawing from their addictions and searching for a replacement, which was illegal heroin.”

Dr. Altice added that of 800 patients in the region who had to go cold turkey, “ten percent were dead within 6 months. Dependent on unreliable street drugs, some overdosed or committed suicide because they could not get treatment. They went through terrible withdrawal and stress.”

And as they relapsed, the HIV rate soared. “Fifty percent of the methadone patients have got HIV,” Dr. Altice said, “and if they stop taking the methadone, they’re going to stop taking their HIV medications as well. Their lives will become chaotic and very destabilized.”

This experience may soon repeat itself. There were two methadone factories in Ukraine – in Odessa and Kharkiv – that are now shut down by the war. Although there are efforts to import methadone and many other drugs, supply chain issues are “devastating,” Dr. Altice said. “If their medication for tuberculosis is discontinued, that not only causes potential recurrence of disease but multidrug-resistant TB disease,” and they could become infectious again. “[With a] lack of medication, lack of sterile syringes, people will be sharing syringes; they’ll be desperate. So as the desperation level goes up, the risk environment goes up, so that people have decreased opportunities to protect themselves,” and there will be an explosion in HIV.

Dr. Altice observed that with the immigration to Poland and the west, many Ukrainian refugees “are relying on the kindness of strangers.” They are likely to be “fearful to disclose either their HIV or their TB treatment status,” being afraid of being regarded as modern-day lepers, even though they are likely not infectious. Both Dr. Altice and Dr. Potter emphasized the need for the governments of Poland and other receiving countries to provide the refugees with “reassurance that their health information will not be shared with others.” Dr. Altice emphasized that “this is one of the things that I would say that these other countries have to get right.”

Dr. Potter echoed that, noting that extraordinary care needs to be taken so that shared information is not used for deportation.

When refugees are housed with rural hosts, transportation problems sometimes arise, creating major barriers to accessing care and treatment. In particular, refugees with TB, HIV, and addiction who are placed in small, remote locations may have difficulty securing transportation to sites where treatments for their complex illnesses are available, including specialists and medications.

Ukrainian-born microbiologist Olena Rzhepishevska, PhD, of Umeå University in Sweden, said in an interview that a network of European TB researchers have developed a database on TBNet where patients with TB can be specifically placed with understanding and helpful hosts outside of Ukraine. They can receive housing and medication through this network.

So far, 4 million Ukrainians have fled the country and millions more have been displaced internally. Dr. Altice noted that there is an “increased vulnerability beyond the vulnerability that they already [have] just by being a refugee” that we generally don’t recognize. Additionally, Poland and Hungary are not very progressive about methadone therapy nor are those nations well-equipped to provide it.

Dr. Altice explained that even within Ukraine, those who want to move to better their chance of getting their methadone are then at risk of being conscripted. He spoke of the grave calculations men must make, choosing to become internally displaced and risk conscription or losing life-saving methadone or medicines for HIV or TB.

One other unfortunate consequence of war might be a spike in rape, sexual abuse, prostitution, unwanted pregnancies, HIV, and sexually transmitted infections.

There were an estimated 80,100 female sex workers in Ukraine in 2016, with 5.2% HIV positive. In times of war, with no home or income, some women turn to prostitution to survive. Others are victims of sex trafficking, both within Ukraine and as refugees. The Russian invasion increased the risks of a surge in HIV infections, unwanted pregnancies, and abortions. Women who find themselves pregnant due to rape (a common tool of war) or sex trafficking may also struggle to access safe abortions. Poland, for example, has severe restrictions on abortion, and Ukrainian women may turn to unsafe, back-alley abortions, with their resulting high risk of infection.
 

Waterborne infections

Another concern involves waterborne infections. In addition to the common diarrheal diseases such as E coli, which can be expected from poor sanitation, polio is a significant concern. In the fall of 2021, Ukraine had an outbreak of vaccine-derived polio, with two cases of paralysis and 20 additional cases. As polio only paralyzes 1 person in 200 of those infected, many other cases were likely undetected. A vaccination campaign was just beginning when the war began.

Wound infections and antimicrobial resistance

The ECDC also reports high rates of antimicrobial resistance (AMR) in Ukraine, particularly involving common gram-negative bacteria, including Escherichia coli (53% resistance to third-generation cephalosporins), Klebsiella pneumoniae (54% resistance to carbapenems), and Acinetobacter spp. (77% resistance to carbapenems). Because of this, they recommend refugees requiring hospital admission be isolated on admission and screened for AMR. These AMR often complicate traumatic injuries of war.

Prevention

Many of these potential problems stemming from the war in Ukraine and the displacement of millions of its citizens can be avoided.

Attempts are being made to immunize refugees. WHO has made working with countries receiving refugees a priority, particularly by vaccinating children against measles, rubella, and COVID. The European Union has also purchased vaccines for polio and tuberculosis.

But Russia has waged an active anti-vaccine campaign against COVID in Ukraine, while at the same time advocating for vaccines in Russia. According to UNICEF, other countries with relatively low vaccination rates and high vaccine skepticism – Moldova, Romania, and Bulgaria – are at higher risk of polio and measles than those with high vaccination levels.

The continuing war in Ukraine has exacerbated the medical challenges the citizens of Ukraine face at home and as refugees fleeing to neighboring countries. Improving communication among agencies and governments and building trust with the refugees could go a long way toward limiting the spread of preventable infectious diseases as a result of the war.

Continuing to try to keep supply chains open within Ukraine and ensuring adequate supplies of medications and vaccines to refugees will also be essential. But, of course, the better solution is to end the war.

Dr. Altice, Dr. Potter, Dr. Wingfield, Dr. Vermund, and Dr. Zinchuk all report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Every day we see stark images of the war in Ukraine – bombed-out buildings, explosions, and bodies lying in the streets. But there’s another, less visible war against the bacteria and viruses that are gathering their forces together. They, too, will infect parts of the population and may spread throughout Europe. Here’s what Ukrainians, and their neighbors, are facing on the infectious disease front.

Andrey Zinchuk, MD, MHS, a pulmonary/critical care physician at Yale and a native of Ukraine who immigrated to the U.S. at the age of 14 with his family, set the background for understanding this crisis. He said that TB and HIV rates in Ukraine have long been especially high, even before the current conflict: “Part of the challenge of the health care system in Ukraine is that it’s difficult to maintain a steady policy because of political instability,” he said. “We’ve had three revolutions in the last 20 years,” not counting the current Russian invasion.

The first was the breakup of the Soviet Union, which led to “an epidemic of people with HIV, hepatitis, and opioid use.” Next was the Orange Revolution in 2004 over fraud during a presidential election. In 2014 came the Maiden Revolution, after the government chose closer ties to Russia rather than Europe. Then-president Viktor Yanukovych fled to Russia.

“That’s when Russia annexed Crimea. There was essentially infiltration in Russian propaganda in the east of the country,” Dr. Zinchuk said. “This helped the Russians manufacture uprisings there to create a separatist state (the Luhansk and Donetsk People’s Republics) which were mostly Russian-speaking parts of the country,” an area known as the Donbas. This resulted in a war in eastern Ukraine that began 2014, with more than 10,000 deaths.

After the 2014 revolution, Dr. Zinchuk said, “There was a tremendous change in the way ... medical care was provided, and tremendous growth and stability in the medical supply for those chronic medical conditions.”

Nevertheless, health care expenditures in Ukraine have been quite low. Even before the current conflict, Dr. Zinchuk noted, annual health care expenditures in Ukraine were about $600 per capita. In comparison, it’s about $4,500 per person in Germany and $12,530 in the United States.

Despite those low per-capita expenditures in Ukraine, access to medicines – such as insulin for diabetes and antibiotics for tuberculosis – was stable before the war. But now, Dr. Zinchuk said, his aunt and uncle have had to flee Kyiv for the countryside and, while safe, they have “no plumbing and have to heat the house by burning firewood.” More significantly, their supply of medicine is unstable.

Asked what infections are of most immediate concern, Sten Vermund, MD, PhD, Dean of the Yale School of Public Health, told this news organization that it was “diarrheal diseases, especially in kids ... The water supply [of Mariupol] is no longer potable, but people are drinking it anyway. And sewage systems are destroyed, and raw sewage is just released into the rivers and streams. So the whole family of diarrheal diseases and war are bedfellows. So are respiratory diseases, whenever we have mass migrations and mixing of ... homeless people and transients.” 

There is one notable piece of good news that may reduce the spread of infectious diseases. Unlike the aftermath of World War II or the ongoing conflicts in the Middle East, Africa, and South Asia, refugees from the war in Ukraine are being taken into individual households throughout Poland, Germany, and other countries and are not being held in large displaced-persons camps. Dr. Vermund added, “The Syrian refugee camps in Lebanon are just tent camps with a million, 2 million people in them ... In theory, what the Poles are doing is a good thing from the point of view of preventing the spread of infection.”

One way of examining infections in war zones is by considering them based on how they are spread.
 

Respiratory infections

Although not as high on the list of concerns as TB or HIV, COVID-19 remains a big problem for infectious disease experts. Last fall, Ukraine ranked just behind the U.S. and Russia in deaths from COVID and in the top 10 in infections. Despite these dismal numbers, only 35% of people had completed the initial vaccination series.

The same conditions that fuel TB and COVID – crowding, especially in poorly ventilated settings – could lead to another measles outbreak. One occurred in Ukraine from 2017-2020, resulting in more than 115,000 cases. Even though the immunization rate for measles has now reached about 80%, the CDC considers Ukraine at high risk for another large outbreak since measles is so highly contagious.

According to the European Centre for Disease Prevention and Control (ECDC), Ukraine reported the second-highest number of TB cases in Europe (28,539). It is also one of the top 10 countries globally with the highest burden of multidrug-resistant tuberculosis (MDR-TB) – 27%. Equally disturbing is its ranking as having the second-highest rate of HIV/TB co-infection (26%) even before the war. Experts say war is a perfect breeding ground for TB, since starvation and overcrowding in poorly ventilated spaces encourages its spread.

Before the war, COVID had already caused severe disruptions in TB diagnosis and treatment access in Ukraine, and the World Health Organization suggested that the pandemic has set back efforts to end TB by more than a decade. 

Drug-resistant TB has been one of the biggest worries. In their report on TB in Ukraine, British tuberculosis experts Tom Wingfield, MBChB, PhD, from the Liverpool School of Tropical Medicine, and Jessica Potter MBBCh, PhD, from Queen Mary University of London, pointed out that “drug resistance thrives on fractured health systems and sporadic medicine supply.”

Frederick Altice, MD, a Yale epidemiologist and addiction specialist, noted, “[if] medication for tuberculosis is discontinued, that not only causes potential recurrence of disease but multidrug-resistant TB disease,” and patients could become infectious again.

Dr. Wingfield expressed concern that people will not seek care because they see it as unaffordable, although he told this news organization that he’s impressed at the Polish government’s efforts to ensure care. Especially with the triad of HIV, TB, and opioid use, Dr. Wingfield and Dr. Potter emphasized that these problems reflect the social determinants of health – “the experiences and conditions in which people live.” These medical conditions are all quite treatable with support, and once treated they pose no risk to others.
 

HIV and opioid use

Before the war, an estimated 260,000 people were living with HIV in Ukraine. Their rate of new HIV diagnoses in 2017 was second highest in the world – 37 out of every 100,000, exceeded only by Russia, with 71 out of 100,000.

Dr. Vermund told this news organization that “when Crimea was seized by the Russians in 2014, there was an immediate crisis among injection drug users who were in drug treatment programs, because it’s illegal in Russia to use buprenorphine or methadone ... So immediately, those programs were shut down, and all the drug users who were holding jobs, supporting their families, were withdrawing from their addictions and searching for a replacement, which was illegal heroin.”

Dr. Altice added that of 800 patients in the region who had to go cold turkey, “ten percent were dead within 6 months. Dependent on unreliable street drugs, some overdosed or committed suicide because they could not get treatment. They went through terrible withdrawal and stress.”

And as they relapsed, the HIV rate soared. “Fifty percent of the methadone patients have got HIV,” Dr. Altice said, “and if they stop taking the methadone, they’re going to stop taking their HIV medications as well. Their lives will become chaotic and very destabilized.”

This experience may soon repeat itself. There were two methadone factories in Ukraine – in Odessa and Kharkiv – that are now shut down by the war. Although there are efforts to import methadone and many other drugs, supply chain issues are “devastating,” Dr. Altice said. “If their medication for tuberculosis is discontinued, that not only causes potential recurrence of disease but multidrug-resistant TB disease,” and they could become infectious again. “[With a] lack of medication, lack of sterile syringes, people will be sharing syringes; they’ll be desperate. So as the desperation level goes up, the risk environment goes up, so that people have decreased opportunities to protect themselves,” and there will be an explosion in HIV.

Dr. Altice observed that with the immigration to Poland and the west, many Ukrainian refugees “are relying on the kindness of strangers.” They are likely to be “fearful to disclose either their HIV or their TB treatment status,” being afraid of being regarded as modern-day lepers, even though they are likely not infectious. Both Dr. Altice and Dr. Potter emphasized the need for the governments of Poland and other receiving countries to provide the refugees with “reassurance that their health information will not be shared with others.” Dr. Altice emphasized that “this is one of the things that I would say that these other countries have to get right.”

Dr. Potter echoed that, noting that extraordinary care needs to be taken so that shared information is not used for deportation.

When refugees are housed with rural hosts, transportation problems sometimes arise, creating major barriers to accessing care and treatment. In particular, refugees with TB, HIV, and addiction who are placed in small, remote locations may have difficulty securing transportation to sites where treatments for their complex illnesses are available, including specialists and medications.

Ukrainian-born microbiologist Olena Rzhepishevska, PhD, of Umeå University in Sweden, said in an interview that a network of European TB researchers have developed a database on TBNet where patients with TB can be specifically placed with understanding and helpful hosts outside of Ukraine. They can receive housing and medication through this network.

So far, 4 million Ukrainians have fled the country and millions more have been displaced internally. Dr. Altice noted that there is an “increased vulnerability beyond the vulnerability that they already [have] just by being a refugee” that we generally don’t recognize. Additionally, Poland and Hungary are not very progressive about methadone therapy nor are those nations well-equipped to provide it.

Dr. Altice explained that even within Ukraine, those who want to move to better their chance of getting their methadone are then at risk of being conscripted. He spoke of the grave calculations men must make, choosing to become internally displaced and risk conscription or losing life-saving methadone or medicines for HIV or TB.

One other unfortunate consequence of war might be a spike in rape, sexual abuse, prostitution, unwanted pregnancies, HIV, and sexually transmitted infections.

There were an estimated 80,100 female sex workers in Ukraine in 2016, with 5.2% HIV positive. In times of war, with no home or income, some women turn to prostitution to survive. Others are victims of sex trafficking, both within Ukraine and as refugees. The Russian invasion increased the risks of a surge in HIV infections, unwanted pregnancies, and abortions. Women who find themselves pregnant due to rape (a common tool of war) or sex trafficking may also struggle to access safe abortions. Poland, for example, has severe restrictions on abortion, and Ukrainian women may turn to unsafe, back-alley abortions, with their resulting high risk of infection.
 

Waterborne infections

Another concern involves waterborne infections. In addition to the common diarrheal diseases such as E coli, which can be expected from poor sanitation, polio is a significant concern. In the fall of 2021, Ukraine had an outbreak of vaccine-derived polio, with two cases of paralysis and 20 additional cases. As polio only paralyzes 1 person in 200 of those infected, many other cases were likely undetected. A vaccination campaign was just beginning when the war began.

Wound infections and antimicrobial resistance

The ECDC also reports high rates of antimicrobial resistance (AMR) in Ukraine, particularly involving common gram-negative bacteria, including Escherichia coli (53% resistance to third-generation cephalosporins), Klebsiella pneumoniae (54% resistance to carbapenems), and Acinetobacter spp. (77% resistance to carbapenems). Because of this, they recommend refugees requiring hospital admission be isolated on admission and screened for AMR. These AMR often complicate traumatic injuries of war.

Prevention

Many of these potential problems stemming from the war in Ukraine and the displacement of millions of its citizens can be avoided.

Attempts are being made to immunize refugees. WHO has made working with countries receiving refugees a priority, particularly by vaccinating children against measles, rubella, and COVID. The European Union has also purchased vaccines for polio and tuberculosis.

But Russia has waged an active anti-vaccine campaign against COVID in Ukraine, while at the same time advocating for vaccines in Russia. According to UNICEF, other countries with relatively low vaccination rates and high vaccine skepticism – Moldova, Romania, and Bulgaria – are at higher risk of polio and measles than those with high vaccination levels.

The continuing war in Ukraine has exacerbated the medical challenges the citizens of Ukraine face at home and as refugees fleeing to neighboring countries. Improving communication among agencies and governments and building trust with the refugees could go a long way toward limiting the spread of preventable infectious diseases as a result of the war.

Continuing to try to keep supply chains open within Ukraine and ensuring adequate supplies of medications and vaccines to refugees will also be essential. But, of course, the better solution is to end the war.

Dr. Altice, Dr. Potter, Dr. Wingfield, Dr. Vermund, and Dr. Zinchuk all report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Aerosolized hydrogen peroxide (aHP) can significantly reduce Clostridioides difficile infection (CDI) and is an effective disinfection system, suggests a study published in the American Journal of Infection Control.

C. difficile is the most common cause of health care–associated infection and increasingly occurs outside acute care hospitals. CDI symptoms can range from mild diarrhea to life-threatening colitis and sepsis, sometimes requiring urgent colon removal.

The Centers for Disease Control and Prevention has reported that, in the United States, 223,900 people required hospitalization for CDI and at least 12,800 died in 2017. Because of its large toll, CDI is grouped with antimicrobial-resistant “threat” organisms that often accompany it. People older than age 65 are at particular risk for disease, and at least 20% of patients experience recurrence.

In health care facilities, C. difficile is transmitted by bacterial spores that readily contaminate surfaces in patients’ rooms, from handrails to bedside tables to light switches and knobs. The spores are resistant to disinfectants, and rooms are often cleaned with bleach solutions. But those bleach fumes are irritating and may cause bronchospasm for patients with asthma or chronic obstructive pulmonary disease, and so alternative cleaning agents are needed.

In a retrospective study of an acute-care facility in Philadelphia, researchers compared the incidence of health care–associated CDI (HA-CDI) at the facility before and after adding aHP to other infection control practices. The aHP process produces an aerosolized dry-mist fog that contains a specified percentage of hydrogen peroxide. The fog is used after the room has been physically cleaned, settling on exposed surfaces and killing any remaining C. difficile spores.

The aHP mixture also contains 0.01% ionic silver. The study lead was Christopher L. Truitt, PhD, of Wayland Baptist University. Dr. Truitt told this news organization that hydrogen peroxide affects the endospore layer of the C. difficile organism and allows the “ionic silver to get into the cell and is shown to bind to enzymes and inactivate those inside the cell and actually improve the efficacy.”

Asked whether it’s the silver or the peroxide that disinfects, Dr. Truitt replied: “I can’t answer that. We don’t know if it’s the silver or the hydrogen peroxide. The commercially available chemical that’s used in that machine is a proprietary set-up ... with EPA approval as a sporicidal.”

In the baseline 27-month period, the hospital tallied 120 HA-CDI cases. After aHP was introduced, they counted just 72 cases over 33 months, a 41% decrease in the facility’s HA-CDI rate, from 4.6 per 10,000 patient-days to 2.7 per 10,000 patient-days (P < .001).

There was also a progressive decrease in hospital-onset CDI even after aHP was introduced, from 5.4 per 10,000 patient-days in 2015 to 1.4 per 10,000 patient-days in 2019.

Yoav Golan, MD, of Tufts University, Boston, told this news organization there were two major study limitations. “One is the fact that they did not control for other interventions that may have an effect on C. difficile: antibiotic stewardship and infection control,” he explained. This limitation was noted by the study authors and may explain the continued decline in infections after the introduction of aHP. The other limitation was not using a crossover study design.

“I would argue that they should have provided a little more information about their own practices in their own hospital when it comes to intensification of infection control [and] when it comes to a stewardship and changes that they’ve made to antibiotic usage,” Dr. Golan continued. “The description of changes over time and those practices would have allowed us to better understand the impact of the hydrogen peroxide intervention.”

Despite his criticisms, Dr. Golan concluded: “I think that the study is important. I think their intervention is unique in a way that they’ve been using an aerosolizing system that’s using a relatively high concentration of hydrogen peroxide. I think that there’s enough in this paper to suggest that using such a system may have an impact on the environment, and through that, on dissemination.”

Dr. Truitt added that a next step would be to compare aHP with ultraviolet light, which is commonly used to disinfect hospital rooms.

Dr. Truitt is chief science officer at Infection Controls, dba Germblast, a proprietary service that uses cold-mist hydrogen peroxide and other modalities to disinfect surfaces. Dr. Golan has reported being a consultant for Merck, Seres Therapeutics, Vedanta Biosciences, and Ferring Pharmaceuticals.

A version of this article first appeared on Medscape.com.

Aerosolized hydrogen peroxide (aHP) can significantly reduce Clostridioides difficile infection (CDI) and is an effective disinfection system, suggests a study published in the American Journal of Infection Control.

C. difficile is the most common cause of health care–associated infection and increasingly occurs outside acute care hospitals. CDI symptoms can range from mild diarrhea to life-threatening colitis and sepsis, sometimes requiring urgent colon removal.

The Centers for Disease Control and Prevention has reported that, in the United States, 223,900 people required hospitalization for CDI and at least 12,800 died in 2017. Because of its large toll, CDI is grouped with antimicrobial-resistant “threat” organisms that often accompany it. People older than age 65 are at particular risk for disease, and at least 20% of patients experience recurrence.

In health care facilities, C. difficile is transmitted by bacterial spores that readily contaminate surfaces in patients’ rooms, from handrails to bedside tables to light switches and knobs. The spores are resistant to disinfectants, and rooms are often cleaned with bleach solutions. But those bleach fumes are irritating and may cause bronchospasm for patients with asthma or chronic obstructive pulmonary disease, and so alternative cleaning agents are needed.

In a retrospective study of an acute-care facility in Philadelphia, researchers compared the incidence of health care–associated CDI (HA-CDI) at the facility before and after adding aHP to other infection control practices. The aHP process produces an aerosolized dry-mist fog that contains a specified percentage of hydrogen peroxide. The fog is used after the room has been physically cleaned, settling on exposed surfaces and killing any remaining C. difficile spores.

The aHP mixture also contains 0.01% ionic silver. The study lead was Christopher L. Truitt, PhD, of Wayland Baptist University. Dr. Truitt told this news organization that hydrogen peroxide affects the endospore layer of the C. difficile organism and allows the “ionic silver to get into the cell and is shown to bind to enzymes and inactivate those inside the cell and actually improve the efficacy.”

Asked whether it’s the silver or the peroxide that disinfects, Dr. Truitt replied: “I can’t answer that. We don’t know if it’s the silver or the hydrogen peroxide. The commercially available chemical that’s used in that machine is a proprietary set-up ... with EPA approval as a sporicidal.”

In the baseline 27-month period, the hospital tallied 120 HA-CDI cases. After aHP was introduced, they counted just 72 cases over 33 months, a 41% decrease in the facility’s HA-CDI rate, from 4.6 per 10,000 patient-days to 2.7 per 10,000 patient-days (P < .001).

There was also a progressive decrease in hospital-onset CDI even after aHP was introduced, from 5.4 per 10,000 patient-days in 2015 to 1.4 per 10,000 patient-days in 2019.

Yoav Golan, MD, of Tufts University, Boston, told this news organization there were two major study limitations. “One is the fact that they did not control for other interventions that may have an effect on C. difficile: antibiotic stewardship and infection control,” he explained. This limitation was noted by the study authors and may explain the continued decline in infections after the introduction of aHP. The other limitation was not using a crossover study design.

“I would argue that they should have provided a little more information about their own practices in their own hospital when it comes to intensification of infection control [and] when it comes to a stewardship and changes that they’ve made to antibiotic usage,” Dr. Golan continued. “The description of changes over time and those practices would have allowed us to better understand the impact of the hydrogen peroxide intervention.”

Despite his criticisms, Dr. Golan concluded: “I think that the study is important. I think their intervention is unique in a way that they’ve been using an aerosolizing system that’s using a relatively high concentration of hydrogen peroxide. I think that there’s enough in this paper to suggest that using such a system may have an impact on the environment, and through that, on dissemination.”

Dr. Truitt added that a next step would be to compare aHP with ultraviolet light, which is commonly used to disinfect hospital rooms.

Dr. Truitt is chief science officer at Infection Controls, dba Germblast, a proprietary service that uses cold-mist hydrogen peroxide and other modalities to disinfect surfaces. Dr. Golan has reported being a consultant for Merck, Seres Therapeutics, Vedanta Biosciences, and Ferring Pharmaceuticals.

A version of this article first appeared on Medscape.com.

Aerosolized hydrogen peroxide (aHP) can significantly reduce Clostridioides difficile infection (CDI) and is an effective disinfection system, suggests a study published in the American Journal of Infection Control.

C. difficile is the most common cause of health care–associated infection and increasingly occurs outside acute care hospitals. CDI symptoms can range from mild diarrhea to life-threatening colitis and sepsis, sometimes requiring urgent colon removal.

The Centers for Disease Control and Prevention has reported that, in the United States, 223,900 people required hospitalization for CDI and at least 12,800 died in 2017. Because of its large toll, CDI is grouped with antimicrobial-resistant “threat” organisms that often accompany it. People older than age 65 are at particular risk for disease, and at least 20% of patients experience recurrence.

In health care facilities, C. difficile is transmitted by bacterial spores that readily contaminate surfaces in patients’ rooms, from handrails to bedside tables to light switches and knobs. The spores are resistant to disinfectants, and rooms are often cleaned with bleach solutions. But those bleach fumes are irritating and may cause bronchospasm for patients with asthma or chronic obstructive pulmonary disease, and so alternative cleaning agents are needed.

In a retrospective study of an acute-care facility in Philadelphia, researchers compared the incidence of health care–associated CDI (HA-CDI) at the facility before and after adding aHP to other infection control practices. The aHP process produces an aerosolized dry-mist fog that contains a specified percentage of hydrogen peroxide. The fog is used after the room has been physically cleaned, settling on exposed surfaces and killing any remaining C. difficile spores.

The aHP mixture also contains 0.01% ionic silver. The study lead was Christopher L. Truitt, PhD, of Wayland Baptist University. Dr. Truitt told this news organization that hydrogen peroxide affects the endospore layer of the C. difficile organism and allows the “ionic silver to get into the cell and is shown to bind to enzymes and inactivate those inside the cell and actually improve the efficacy.”

Asked whether it’s the silver or the peroxide that disinfects, Dr. Truitt replied: “I can’t answer that. We don’t know if it’s the silver or the hydrogen peroxide. The commercially available chemical that’s used in that machine is a proprietary set-up ... with EPA approval as a sporicidal.”

In the baseline 27-month period, the hospital tallied 120 HA-CDI cases. After aHP was introduced, they counted just 72 cases over 33 months, a 41% decrease in the facility’s HA-CDI rate, from 4.6 per 10,000 patient-days to 2.7 per 10,000 patient-days (P < .001).

There was also a progressive decrease in hospital-onset CDI even after aHP was introduced, from 5.4 per 10,000 patient-days in 2015 to 1.4 per 10,000 patient-days in 2019.

Yoav Golan, MD, of Tufts University, Boston, told this news organization there were two major study limitations. “One is the fact that they did not control for other interventions that may have an effect on C. difficile: antibiotic stewardship and infection control,” he explained. This limitation was noted by the study authors and may explain the continued decline in infections after the introduction of aHP. The other limitation was not using a crossover study design.

“I would argue that they should have provided a little more information about their own practices in their own hospital when it comes to intensification of infection control [and] when it comes to a stewardship and changes that they’ve made to antibiotic usage,” Dr. Golan continued. “The description of changes over time and those practices would have allowed us to better understand the impact of the hydrogen peroxide intervention.”

Despite his criticisms, Dr. Golan concluded: “I think that the study is important. I think their intervention is unique in a way that they’ve been using an aerosolizing system that’s using a relatively high concentration of hydrogen peroxide. I think that there’s enough in this paper to suggest that using such a system may have an impact on the environment, and through that, on dissemination.”

Dr. Truitt added that a next step would be to compare aHP with ultraviolet light, which is commonly used to disinfect hospital rooms.

Dr. Truitt is chief science officer at Infection Controls, dba Germblast, a proprietary service that uses cold-mist hydrogen peroxide and other modalities to disinfect surfaces. Dr. Golan has reported being a consultant for Merck, Seres Therapeutics, Vedanta Biosciences, and Ferring Pharmaceuticals.

A version of this article first appeared on Medscape.com.

There’s mixed news from Pfizer on results from their CLOVER trial (CLOstridium difficile Vaccine Efficacy TRial), a phase 3 study involving 17,500 adults aged 50 and older that evaluated their candidate vaccine (PF-06425090) against Clostridioides difficile (C. diff) for the prevention of C. diff. infection (CDI).

The bad news is that the trial didn’t meet its efficacy endpoint – the prevention of primary CDI. According to a Pfizer press release, “Vaccine efficacy under the primary endpoint was 31% (96.4%, confidence interval -38.7, 66.6) following the third dose and 28.6% (96.4%, CI -28.4, 61.0) following the second dose. For all CDI cases recorded at 14 days post dose 3, vaccine efficacy was 49%, 47%, and 31% up to 12 months, 24 months, and at final analysis, respectively.”

clostridium_diff3_web.jpg

A version of this article first appeared on Medscape.com.

There’s mixed news from Pfizer on results from their CLOVER trial (CLOstridium difficile Vaccine Efficacy TRial), a phase 3 study involving 17,500 adults aged 50 and older that evaluated their candidate vaccine (PF-06425090) against Clostridioides difficile (C. diff) for the prevention of C. diff. infection (CDI).

The bad news is that the trial didn’t meet its efficacy endpoint – the prevention of primary CDI. According to a Pfizer press release, “Vaccine efficacy under the primary endpoint was 31% (96.4%, confidence interval -38.7, 66.6) following the third dose and 28.6% (96.4%, CI -28.4, 61.0) following the second dose. For all CDI cases recorded at 14 days post dose 3, vaccine efficacy was 49%, 47%, and 31% up to 12 months, 24 months, and at final analysis, respectively.”

clostridium_diff3_web.jpg

A version of this article first appeared on Medscape.com.

There’s mixed news from Pfizer on results from their CLOVER trial (CLOstridium difficile Vaccine Efficacy TRial), a phase 3 study involving 17,500 adults aged 50 and older that evaluated their candidate vaccine (PF-06425090) against Clostridioides difficile (C. diff) for the prevention of C. diff. infection (CDI).

The bad news is that the trial didn’t meet its efficacy endpoint – the prevention of primary CDI. According to a Pfizer press release, “Vaccine efficacy under the primary endpoint was 31% (96.4%, confidence interval -38.7, 66.6) following the third dose and 28.6% (96.4%, CI -28.4, 61.0) following the second dose. For all CDI cases recorded at 14 days post dose 3, vaccine efficacy was 49%, 47%, and 31% up to 12 months, 24 months, and at final analysis, respectively.”

clostridium_diff3_web.jpg

A version of this article first appeared on Medscape.com.

It seems obvious that increased use of mosquito bed nets in sub-Saharan Africa would decrease the incidence of malaria, but a lingering question remained: Would controlling malaria in children under 5 years of age shift deaths to older children by delaying functional immunity?  A new report in the New England Journal of Medicine seems to have laid that concern to rest.

Malaria from Plasmodium falciparum infection exacts a significant toll in sub-Saharan Africa. According to the World Health Organization, there were about 228 million cases and 602,000 deaths from malaria in 2020 alone. About 80% of those deaths were in children less than 5 years old. In some areas, as many as 5% of children die from malaria by age 5.

Efforts to reduce the burden of malaria have been ongoing for decades. In the 1990s, insecticide-treated nets were shown to reduce illness and deaths from malaria in children.

As a result, the use of bed nets has grown significantly. In 2000, only 5% of households in sub-Saharan Africa had a net in the house. By 2020, that number had risen to 65%. From 2004 to 2019 about 1.9 billion nets were distributed in this region. The nets are estimated to have prevented more than 663 million malaria cases between 2000 and 2015.

As described in the NEJM report, public health researchers conducted a 22-year prospective longitudinal cohort study in rural southern Tanzania following 6,706 children born between 1998 and 2000. Initially, home visits were made every 4 months from May 1998 to April 2003. Remarkably, in 2019, they were able to verify the status of fully 89% of those people by reaching out to families and community/village leaders.

Günther Fink, PhD, associate professor of epidemiology and household economics, University of Basel (Switzerland), explained the approach and primary findings to this news organization. The analysis looked at three main groups – children whose parents said they always slept under treated nets, those who slept protected most of the time, and those who spent less than half the time under bed nets. The hazard ratio for death was 0.57 (95% confidence interval, 0.45-0.72) for the first two groups, compared with the least protected. The corresponding hazard ratio between age 5 and adulthood was 0.93 (95% CI, 0.58-1.49).

The findings confirmed what they had suspected. Dr. Fink summarized simply, “If you always slept under a net, you did much better than if you never slept under the net. If you slept [under a net] more than half of the time, it was much better than if you slept [under a net] less than half the time.” So the more time children slept under bed nets, the less likely they were to acquire malaria. Dr. Fink stressed that the findings showing protective efficacy persisted into adulthood. “It seems just having a healthier early life actually makes you more resilient against other future infections.”

One of the theoretical concerns was that using nets would delay developing functional immunity and that there might be an increase in mortality seen later. This study showed that did not happen.

An accompanying commentary noted that there was some potential that families receiving nets were better off than those that didn’t but concluded that such confounding had been accounted for in other analyses.

Mark Wilson, ScD, professor emeritus of epidemiology, University of Michigan, Ann Arbor, concurred. He told this news organization that the study was “very well designed,” and the researchers “did a fantastic job” in tracking patients 20 years later.

“This is astounding!” he added. “It’s very rare to find this amount of follow-up.”

Dr. Fink’s conclusion? “Bed nets protect you in the short run, and being protected in the short run is also beneficial in the long run. There is no evidence that protecting kids in early childhood is weakening them in any way. So we should keep doing this.”

Dr. Fink and Dr. Wilson report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

It seems obvious that increased use of mosquito bed nets in sub-Saharan Africa would decrease the incidence of malaria, but a lingering question remained: Would controlling malaria in children under 5 years of age shift deaths to older children by delaying functional immunity?  A new report in the New England Journal of Medicine seems to have laid that concern to rest.

Malaria from Plasmodium falciparum infection exacts a significant toll in sub-Saharan Africa. According to the World Health Organization, there were about 228 million cases and 602,000 deaths from malaria in 2020 alone. About 80% of those deaths were in children less than 5 years old. In some areas, as many as 5% of children die from malaria by age 5.

Efforts to reduce the burden of malaria have been ongoing for decades. In the 1990s, insecticide-treated nets were shown to reduce illness and deaths from malaria in children.

As a result, the use of bed nets has grown significantly. In 2000, only 5% of households in sub-Saharan Africa had a net in the house. By 2020, that number had risen to 65%. From 2004 to 2019 about 1.9 billion nets were distributed in this region. The nets are estimated to have prevented more than 663 million malaria cases between 2000 and 2015.

As described in the NEJM report, public health researchers conducted a 22-year prospective longitudinal cohort study in rural southern Tanzania following 6,706 children born between 1998 and 2000. Initially, home visits were made every 4 months from May 1998 to April 2003. Remarkably, in 2019, they were able to verify the status of fully 89% of those people by reaching out to families and community/village leaders.

Günther Fink, PhD, associate professor of epidemiology and household economics, University of Basel (Switzerland), explained the approach and primary findings to this news organization. The analysis looked at three main groups – children whose parents said they always slept under treated nets, those who slept protected most of the time, and those who spent less than half the time under bed nets. The hazard ratio for death was 0.57 (95% confidence interval, 0.45-0.72) for the first two groups, compared with the least protected. The corresponding hazard ratio between age 5 and adulthood was 0.93 (95% CI, 0.58-1.49).

The findings confirmed what they had suspected. Dr. Fink summarized simply, “If you always slept under a net, you did much better than if you never slept under the net. If you slept [under a net] more than half of the time, it was much better than if you slept [under a net] less than half the time.” So the more time children slept under bed nets, the less likely they were to acquire malaria. Dr. Fink stressed that the findings showing protective efficacy persisted into adulthood. “It seems just having a healthier early life actually makes you more resilient against other future infections.”

One of the theoretical concerns was that using nets would delay developing functional immunity and that there might be an increase in mortality seen later. This study showed that did not happen.

An accompanying commentary noted that there was some potential that families receiving nets were better off than those that didn’t but concluded that such confounding had been accounted for in other analyses.

Mark Wilson, ScD, professor emeritus of epidemiology, University of Michigan, Ann Arbor, concurred. He told this news organization that the study was “very well designed,” and the researchers “did a fantastic job” in tracking patients 20 years later.

“This is astounding!” he added. “It’s very rare to find this amount of follow-up.”

Dr. Fink’s conclusion? “Bed nets protect you in the short run, and being protected in the short run is also beneficial in the long run. There is no evidence that protecting kids in early childhood is weakening them in any way. So we should keep doing this.”

Dr. Fink and Dr. Wilson report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

It seems obvious that increased use of mosquito bed nets in sub-Saharan Africa would decrease the incidence of malaria, but a lingering question remained: Would controlling malaria in children under 5 years of age shift deaths to older children by delaying functional immunity?  A new report in the New England Journal of Medicine seems to have laid that concern to rest.

Malaria from Plasmodium falciparum infection exacts a significant toll in sub-Saharan Africa. According to the World Health Organization, there were about 228 million cases and 602,000 deaths from malaria in 2020 alone. About 80% of those deaths were in children less than 5 years old. In some areas, as many as 5% of children die from malaria by age 5.

Efforts to reduce the burden of malaria have been ongoing for decades. In the 1990s, insecticide-treated nets were shown to reduce illness and deaths from malaria in children.

As a result, the use of bed nets has grown significantly. In 2000, only 5% of households in sub-Saharan Africa had a net in the house. By 2020, that number had risen to 65%. From 2004 to 2019 about 1.9 billion nets were distributed in this region. The nets are estimated to have prevented more than 663 million malaria cases between 2000 and 2015.

As described in the NEJM report, public health researchers conducted a 22-year prospective longitudinal cohort study in rural southern Tanzania following 6,706 children born between 1998 and 2000. Initially, home visits were made every 4 months from May 1998 to April 2003. Remarkably, in 2019, they were able to verify the status of fully 89% of those people by reaching out to families and community/village leaders.

Günther Fink, PhD, associate professor of epidemiology and household economics, University of Basel (Switzerland), explained the approach and primary findings to this news organization. The analysis looked at three main groups – children whose parents said they always slept under treated nets, those who slept protected most of the time, and those who spent less than half the time under bed nets. The hazard ratio for death was 0.57 (95% confidence interval, 0.45-0.72) for the first two groups, compared with the least protected. The corresponding hazard ratio between age 5 and adulthood was 0.93 (95% CI, 0.58-1.49).

The findings confirmed what they had suspected. Dr. Fink summarized simply, “If you always slept under a net, you did much better than if you never slept under the net. If you slept [under a net] more than half of the time, it was much better than if you slept [under a net] less than half the time.” So the more time children slept under bed nets, the less likely they were to acquire malaria. Dr. Fink stressed that the findings showing protective efficacy persisted into adulthood. “It seems just having a healthier early life actually makes you more resilient against other future infections.”

One of the theoretical concerns was that using nets would delay developing functional immunity and that there might be an increase in mortality seen later. This study showed that did not happen.

An accompanying commentary noted that there was some potential that families receiving nets were better off than those that didn’t but concluded that such confounding had been accounted for in other analyses.

Mark Wilson, ScD, professor emeritus of epidemiology, University of Michigan, Ann Arbor, concurred. He told this news organization that the study was “very well designed,” and the researchers “did a fantastic job” in tracking patients 20 years later.

“This is astounding!” he added. “It’s very rare to find this amount of follow-up.”

Dr. Fink’s conclusion? “Bed nets protect you in the short run, and being protected in the short run is also beneficial in the long run. There is no evidence that protecting kids in early childhood is weakening them in any way. So we should keep doing this.”

Dr. Fink and Dr. Wilson report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The recently published “Clinical Practice Guidelines for the Prevention and Management of Tick-Borne Illness,” from the Wilderness Medical Society, are a good compilation of treatment suggestions but are not, in fact, new recommendations, lead author Benjamin Ho, MD, of Southern Wisconsin Emergency Associates in Janesville, acknowledged in an interview.

Dr. Ho emphasized that the focus of the report was on “practitioners who practice in resource-limited settings” and are “the group’s way of solidifying a ... standard of practice” for such physicians. Dr. Ho also said that, while “a lot of the recommendations aren’t well supported, the risk-benefit ratio, we believe, supports the recommendations.”

The article first reviewed the different types of ticks and their distribution in the United States, the specific pathogen associated with each, the disease it causes, and comments about seasonal variations in biting behavior. Another table outlines the most common clinical syndromes, typical lab findings, recommended diagnostic testing, and antibiotic treatments. A third section contains images of different types of ticks and photos of ticks in various life-cycle stages and different levels of engorgement.

The authors were careful to note: “Several tick species are able to carry multiple pathogens. In one study, nearly 25% of Ixodes were coinfected with some combination of the bacteria or parasites causing Lyme disease, anaplasmosis, or babesiosis. Although TBI [tick-borne illness] diagnosis is not the focus of this [clinical practice guideline], providers should be aware of high rates of coinfection; the presence of one TBI should in many instances prompt testing for others.”

In terms of recommendations for preventing TBIs, the authors challenge the suggestion of wearing light-colored clothing. For repellents, they recommend DEET, picaridin, and permethrin. And they also give instructions for laundering clothing and removing ticks.

[embed:render:related:node:233159]

One recommendation is controversial: that of providing single-dose doxycycline as prophylaxis against Lyme disease. Dr. Ho stresses that this was only for “high-risk” tick bites, defined as a tick bite from an identified Ixodes vector species in which the tick was attached for at least 36 hours and that occurred in an endemic area.

The recommendation for prophylactic doxycycline originated with an article by Robert Nadelman and colleagues in the New England Journal of Medicine and has been strongly challenged by ILADS (International Lyme and Associated Diseases Society) physicians, including Daniel Cameron, MD, and others.

Sam Donta, MD, a recent member of the Department of Health & Human Services Tick-borne Working Group and a member of the Infectious Disease Society of America, said in an interview: “The problem with the one-dose doxycycline is you may not begin to develop symptoms until 2 months later.” It might mask the early symptoms of Lyme. “My impression is that the doxycycline – even the single dose – might have abrogated the ability to see an immune response. The idea, though, if you’ve had a tick bite, is to do nothing and to wait for symptoms to develop. That becomes a little bit more complex. But even then, you could choose to follow the patient and see the patient in 2 weeks and then get blood testing.”

Dr. Donta added: “I think the screening test is inadequate. So you have to go directly to the Western blot. And you have to do both the IgM and IgG” and look for specific bands.

Dr. Donta emphasized that patients should be encouraged to save any ticks that were attached and that, if at all possible, ticks should be sent to a reference lab for testing before committing a patient to a course of antibiotics. There is no harm in that brief delay, he said, and most labs can identify an array of pathogens.

The Wilderness Society guidelines on TBIs provide a good overview for clinicians practicing in limited resource settings and mirror those from the IDSA.

Dr. Ho and Dr. Donta reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The recently published “Clinical Practice Guidelines for the Prevention and Management of Tick-Borne Illness,” from the Wilderness Medical Society, are a good compilation of treatment suggestions but are not, in fact, new recommendations, lead author Benjamin Ho, MD, of Southern Wisconsin Emergency Associates in Janesville, acknowledged in an interview.

Dr. Ho emphasized that the focus of the report was on “practitioners who practice in resource-limited settings” and are “the group’s way of solidifying a ... standard of practice” for such physicians. Dr. Ho also said that, while “a lot of the recommendations aren’t well supported, the risk-benefit ratio, we believe, supports the recommendations.”

The article first reviewed the different types of ticks and their distribution in the United States, the specific pathogen associated with each, the disease it causes, and comments about seasonal variations in biting behavior. Another table outlines the most common clinical syndromes, typical lab findings, recommended diagnostic testing, and antibiotic treatments. A third section contains images of different types of ticks and photos of ticks in various life-cycle stages and different levels of engorgement.

The authors were careful to note: “Several tick species are able to carry multiple pathogens. In one study, nearly 25% of Ixodes were coinfected with some combination of the bacteria or parasites causing Lyme disease, anaplasmosis, or babesiosis. Although TBI [tick-borne illness] diagnosis is not the focus of this [clinical practice guideline], providers should be aware of high rates of coinfection; the presence of one TBI should in many instances prompt testing for others.”

In terms of recommendations for preventing TBIs, the authors challenge the suggestion of wearing light-colored clothing. For repellents, they recommend DEET, picaridin, and permethrin. And they also give instructions for laundering clothing and removing ticks.

[embed:render:related:node:233159]

One recommendation is controversial: that of providing single-dose doxycycline as prophylaxis against Lyme disease. Dr. Ho stresses that this was only for “high-risk” tick bites, defined as a tick bite from an identified Ixodes vector species in which the tick was attached for at least 36 hours and that occurred in an endemic area.

The recommendation for prophylactic doxycycline originated with an article by Robert Nadelman and colleagues in the New England Journal of Medicine and has been strongly challenged by ILADS (International Lyme and Associated Diseases Society) physicians, including Daniel Cameron, MD, and others.

Sam Donta, MD, a recent member of the Department of Health & Human Services Tick-borne Working Group and a member of the Infectious Disease Society of America, said in an interview: “The problem with the one-dose doxycycline is you may not begin to develop symptoms until 2 months later.” It might mask the early symptoms of Lyme. “My impression is that the doxycycline – even the single dose – might have abrogated the ability to see an immune response. The idea, though, if you’ve had a tick bite, is to do nothing and to wait for symptoms to develop. That becomes a little bit more complex. But even then, you could choose to follow the patient and see the patient in 2 weeks and then get blood testing.”

Dr. Donta added: “I think the screening test is inadequate. So you have to go directly to the Western blot. And you have to do both the IgM and IgG” and look for specific bands.

Dr. Donta emphasized that patients should be encouraged to save any ticks that were attached and that, if at all possible, ticks should be sent to a reference lab for testing before committing a patient to a course of antibiotics. There is no harm in that brief delay, he said, and most labs can identify an array of pathogens.

The Wilderness Society guidelines on TBIs provide a good overview for clinicians practicing in limited resource settings and mirror those from the IDSA.

Dr. Ho and Dr. Donta reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The recently published “Clinical Practice Guidelines for the Prevention and Management of Tick-Borne Illness,” from the Wilderness Medical Society, are a good compilation of treatment suggestions but are not, in fact, new recommendations, lead author Benjamin Ho, MD, of Southern Wisconsin Emergency Associates in Janesville, acknowledged in an interview.

Dr. Ho emphasized that the focus of the report was on “practitioners who practice in resource-limited settings” and are “the group’s way of solidifying a ... standard of practice” for such physicians. Dr. Ho also said that, while “a lot of the recommendations aren’t well supported, the risk-benefit ratio, we believe, supports the recommendations.”

The article first reviewed the different types of ticks and their distribution in the United States, the specific pathogen associated with each, the disease it causes, and comments about seasonal variations in biting behavior. Another table outlines the most common clinical syndromes, typical lab findings, recommended diagnostic testing, and antibiotic treatments. A third section contains images of different types of ticks and photos of ticks in various life-cycle stages and different levels of engorgement.

The authors were careful to note: “Several tick species are able to carry multiple pathogens. In one study, nearly 25% of Ixodes were coinfected with some combination of the bacteria or parasites causing Lyme disease, anaplasmosis, or babesiosis. Although TBI [tick-borne illness] diagnosis is not the focus of this [clinical practice guideline], providers should be aware of high rates of coinfection; the presence of one TBI should in many instances prompt testing for others.”

In terms of recommendations for preventing TBIs, the authors challenge the suggestion of wearing light-colored clothing. For repellents, they recommend DEET, picaridin, and permethrin. And they also give instructions for laundering clothing and removing ticks.

[embed:render:related:node:233159]

One recommendation is controversial: that of providing single-dose doxycycline as prophylaxis against Lyme disease. Dr. Ho stresses that this was only for “high-risk” tick bites, defined as a tick bite from an identified Ixodes vector species in which the tick was attached for at least 36 hours and that occurred in an endemic area.

The recommendation for prophylactic doxycycline originated with an article by Robert Nadelman and colleagues in the New England Journal of Medicine and has been strongly challenged by ILADS (International Lyme and Associated Diseases Society) physicians, including Daniel Cameron, MD, and others.

Sam Donta, MD, a recent member of the Department of Health & Human Services Tick-borne Working Group and a member of the Infectious Disease Society of America, said in an interview: “The problem with the one-dose doxycycline is you may not begin to develop symptoms until 2 months later.” It might mask the early symptoms of Lyme. “My impression is that the doxycycline – even the single dose – might have abrogated the ability to see an immune response. The idea, though, if you’ve had a tick bite, is to do nothing and to wait for symptoms to develop. That becomes a little bit more complex. But even then, you could choose to follow the patient and see the patient in 2 weeks and then get blood testing.”

Dr. Donta added: “I think the screening test is inadequate. So you have to go directly to the Western blot. And you have to do both the IgM and IgG” and look for specific bands.

Dr. Donta emphasized that patients should be encouraged to save any ticks that were attached and that, if at all possible, ticks should be sent to a reference lab for testing before committing a patient to a course of antibiotics. There is no harm in that brief delay, he said, and most labs can identify an array of pathogens.

The Wilderness Society guidelines on TBIs provide a good overview for clinicians practicing in limited resource settings and mirror those from the IDSA.

Dr. Ho and Dr. Donta reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The Center for Disease Control and Prevention’s Advisory Committee on Immunization Practices has now recommended using Sanofi’s dengue vaccine, Dengvaxia, in the United States, with specific restrictions. The vaccine is only to be used for children aged 9-16 who live in endemic areas and who have evidence with a specific diagnostic test of prior dengue infection.

Dengue is a mosquito-borne virus found throughout the world, primarily in tropical or subtropical climates. Cases had steadily been increasing to 5.2 million in 2019, and the geographic distribution of cases is broadening with climate change and urbanization. About half of the world’s population is now at risk.

The dengue virus has four serotypes. The first infection may be mild or asymptomatic, but the second one can be life-threatening because of a phenomenon called antibody-dependent enhancement.

The lead author of the new recommendations is Gabriela Paz-Bailey, MD, PhD, division of vector-borne diseases, dengue branch, CDC. She told this news organization that, during the second infection, when there are “low levels of antibodies from that first infection, the antibodies help the virus get inside the cells. There the virus is not killed, and that results in increased viral load, and then that can result in more severe disease and the plasma leakage” syndrome, which can lead to shock, severe bleeding, and organ failure. The death rate for severe dengue is up to 13%.

Previous infection with Zika virus, common in the same areas where dengue is endemic, can also increase the risk for symptomatic and severe dengue for subsequent infections.

In the United States, Puerto Rico is the main focus of control efforts because 95% of domestic dengue cases originate there – almost 30,000 cases between 2010 and 2020, with 11,000 cases and 4,000 hospitalizations occurring in children between the ages of 10 and 19.

Because Aedes aegypti, the primary mosquito vector transmitting dengue, is resistant to all commonly used insecticides in Puerto Rico, preventive efforts have shifted from insecticides to vaccination.
 

Antibody tests prevaccination

The main concern with the Sanofi’s dengue vaccine is that it could act as an asymptomatic primary dengue infection, in effect priming the body for a severe reaction from antibody-dependent enhancement with a subsequent infection. That is why it’s critical that the vaccine only be given to children with evidence of prior disease.

Dr. Paz-Bailey said: “The CDC came up with recommendations of what the performance of the test used for prevaccination screening should be. And it was 98% specificity and 75% sensitivity. ... But no test by itself was found to have a specificity of 98%, and this is why we’re recommending the two-test algorithm,” in which two different assays are run off the same blood sample, drawn at a prevaccination visit.

If the child has evidence of prior dengue, they can proceed with vaccination to protect against recurrent infection. Dengvaxia is given as a series of three shots over 6 months. Vaccine efficacy is 82% – so not everyone is protected, and additionally, that protection declines over time.

There is concern that it will be difficult to achieve compliance with such a complex regimen. Dr. Paz-Bailey said, “But I think that the trust in vaccines that is highly prevalent for [Puerto] Rico and trusting the health care system, and sort of the importance that is assigned to dengue by providers and by parents because of previous outbreaks and previous experiences is going to help us.” She added, “I think that the COVID experience has been very revealing. And what we have learned is that Puerto Rico has a very strong health care system, a very strong network of vaccine providers. ... Coverage for COVID vaccine is higher than in other parts of the U.S.”

One of the interesting things about dengue is that the first infection can range from asymptomatic to life-threatening. The second infection is generally worse because of this antibody-dependent enhancement phenomenon. Eng Eong Ooi, MD, PhD, professor of microbiology and immunology, National University of Singapore, told this news organization, “After you have two infections, you seem to be protected quite well against the remaining two [serotypes]. The vaccine serves as another episode of infection in those who had prior dengue, so then any natural infections after the vaccination in the seropositive become like the outcome of a third or fourth infection.”

Vaccination alone will not solve dengue. Dr. Ooi said, “There’s not one method that would fully control dengue. You need both vaccines as well as control measures, whether it’s Wolbachia or something else. At the same time, I think we need antiviral drugs, because hitting this virus in just one part of its life cycle wouldn’t make a huge, lasting impact.” Dr. Ooi added that as “the spread of the virus and the population immunity drops, you’re actually now more vulnerable to dengue outbreaks when they do get introduced. So, suppressing transmission alone isn’t the answer. You also have to keep herd immunity levels high. So if we can reduce the virus transmission by controlling either mosquito population or transmission and at the same time vaccinate to keep the immunity levels high, then I think we have a chance of controlling dengue.”

Dr. Paz-Bailey concluded: “I do want to emphasize that we are excited about having these tools, because for years and years, we have had really limited options to prevent and control dengue. It’s an important addition to have the vaccine be approved to be used within the U.S., and it’s going to pave the road for future vaccines.”

Dr. Paz-Bailey and Dr. Ooi reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The Center for Disease Control and Prevention’s Advisory Committee on Immunization Practices has now recommended using Sanofi’s dengue vaccine, Dengvaxia, in the United States, with specific restrictions. The vaccine is only to be used for children aged 9-16 who live in endemic areas and who have evidence with a specific diagnostic test of prior dengue infection.

Dengue is a mosquito-borne virus found throughout the world, primarily in tropical or subtropical climates. Cases had steadily been increasing to 5.2 million in 2019, and the geographic distribution of cases is broadening with climate change and urbanization. About half of the world’s population is now at risk.

The dengue virus has four serotypes. The first infection may be mild or asymptomatic, but the second one can be life-threatening because of a phenomenon called antibody-dependent enhancement.

The lead author of the new recommendations is Gabriela Paz-Bailey, MD, PhD, division of vector-borne diseases, dengue branch, CDC. She told this news organization that, during the second infection, when there are “low levels of antibodies from that first infection, the antibodies help the virus get inside the cells. There the virus is not killed, and that results in increased viral load, and then that can result in more severe disease and the plasma leakage” syndrome, which can lead to shock, severe bleeding, and organ failure. The death rate for severe dengue is up to 13%.

Previous infection with Zika virus, common in the same areas where dengue is endemic, can also increase the risk for symptomatic and severe dengue for subsequent infections.

In the United States, Puerto Rico is the main focus of control efforts because 95% of domestic dengue cases originate there – almost 30,000 cases between 2010 and 2020, with 11,000 cases and 4,000 hospitalizations occurring in children between the ages of 10 and 19.

Because Aedes aegypti, the primary mosquito vector transmitting dengue, is resistant to all commonly used insecticides in Puerto Rico, preventive efforts have shifted from insecticides to vaccination.
 

Antibody tests prevaccination

The main concern with the Sanofi’s dengue vaccine is that it could act as an asymptomatic primary dengue infection, in effect priming the body for a severe reaction from antibody-dependent enhancement with a subsequent infection. That is why it’s critical that the vaccine only be given to children with evidence of prior disease.

Dr. Paz-Bailey said: “The CDC came up with recommendations of what the performance of the test used for prevaccination screening should be. And it was 98% specificity and 75% sensitivity. ... But no test by itself was found to have a specificity of 98%, and this is why we’re recommending the two-test algorithm,” in which two different assays are run off the same blood sample, drawn at a prevaccination visit.

If the child has evidence of prior dengue, they can proceed with vaccination to protect against recurrent infection. Dengvaxia is given as a series of three shots over 6 months. Vaccine efficacy is 82% – so not everyone is protected, and additionally, that protection declines over time.

There is concern that it will be difficult to achieve compliance with such a complex regimen. Dr. Paz-Bailey said, “But I think that the trust in vaccines that is highly prevalent for [Puerto] Rico and trusting the health care system, and sort of the importance that is assigned to dengue by providers and by parents because of previous outbreaks and previous experiences is going to help us.” She added, “I think that the COVID experience has been very revealing. And what we have learned is that Puerto Rico has a very strong health care system, a very strong network of vaccine providers. ... Coverage for COVID vaccine is higher than in other parts of the U.S.”

One of the interesting things about dengue is that the first infection can range from asymptomatic to life-threatening. The second infection is generally worse because of this antibody-dependent enhancement phenomenon. Eng Eong Ooi, MD, PhD, professor of microbiology and immunology, National University of Singapore, told this news organization, “After you have two infections, you seem to be protected quite well against the remaining two [serotypes]. The vaccine serves as another episode of infection in those who had prior dengue, so then any natural infections after the vaccination in the seropositive become like the outcome of a third or fourth infection.”

Vaccination alone will not solve dengue. Dr. Ooi said, “There’s not one method that would fully control dengue. You need both vaccines as well as control measures, whether it’s Wolbachia or something else. At the same time, I think we need antiviral drugs, because hitting this virus in just one part of its life cycle wouldn’t make a huge, lasting impact.” Dr. Ooi added that as “the spread of the virus and the population immunity drops, you’re actually now more vulnerable to dengue outbreaks when they do get introduced. So, suppressing transmission alone isn’t the answer. You also have to keep herd immunity levels high. So if we can reduce the virus transmission by controlling either mosquito population or transmission and at the same time vaccinate to keep the immunity levels high, then I think we have a chance of controlling dengue.”

Dr. Paz-Bailey concluded: “I do want to emphasize that we are excited about having these tools, because for years and years, we have had really limited options to prevent and control dengue. It’s an important addition to have the vaccine be approved to be used within the U.S., and it’s going to pave the road for future vaccines.”

Dr. Paz-Bailey and Dr. Ooi reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The Center for Disease Control and Prevention’s Advisory Committee on Immunization Practices has now recommended using Sanofi’s dengue vaccine, Dengvaxia, in the United States, with specific restrictions. The vaccine is only to be used for children aged 9-16 who live in endemic areas and who have evidence with a specific diagnostic test of prior dengue infection.

Dengue is a mosquito-borne virus found throughout the world, primarily in tropical or subtropical climates. Cases had steadily been increasing to 5.2 million in 2019, and the geographic distribution of cases is broadening with climate change and urbanization. About half of the world’s population is now at risk.

The dengue virus has four serotypes. The first infection may be mild or asymptomatic, but the second one can be life-threatening because of a phenomenon called antibody-dependent enhancement.

The lead author of the new recommendations is Gabriela Paz-Bailey, MD, PhD, division of vector-borne diseases, dengue branch, CDC. She told this news organization that, during the second infection, when there are “low levels of antibodies from that first infection, the antibodies help the virus get inside the cells. There the virus is not killed, and that results in increased viral load, and then that can result in more severe disease and the plasma leakage” syndrome, which can lead to shock, severe bleeding, and organ failure. The death rate for severe dengue is up to 13%.

Previous infection with Zika virus, common in the same areas where dengue is endemic, can also increase the risk for symptomatic and severe dengue for subsequent infections.

In the United States, Puerto Rico is the main focus of control efforts because 95% of domestic dengue cases originate there – almost 30,000 cases between 2010 and 2020, with 11,000 cases and 4,000 hospitalizations occurring in children between the ages of 10 and 19.

Because Aedes aegypti, the primary mosquito vector transmitting dengue, is resistant to all commonly used insecticides in Puerto Rico, preventive efforts have shifted from insecticides to vaccination.
 

Antibody tests prevaccination

The main concern with the Sanofi’s dengue vaccine is that it could act as an asymptomatic primary dengue infection, in effect priming the body for a severe reaction from antibody-dependent enhancement with a subsequent infection. That is why it’s critical that the vaccine only be given to children with evidence of prior disease.

Dr. Paz-Bailey said: “The CDC came up with recommendations of what the performance of the test used for prevaccination screening should be. And it was 98% specificity and 75% sensitivity. ... But no test by itself was found to have a specificity of 98%, and this is why we’re recommending the two-test algorithm,” in which two different assays are run off the same blood sample, drawn at a prevaccination visit.

If the child has evidence of prior dengue, they can proceed with vaccination to protect against recurrent infection. Dengvaxia is given as a series of three shots over 6 months. Vaccine efficacy is 82% – so not everyone is protected, and additionally, that protection declines over time.

There is concern that it will be difficult to achieve compliance with such a complex regimen. Dr. Paz-Bailey said, “But I think that the trust in vaccines that is highly prevalent for [Puerto] Rico and trusting the health care system, and sort of the importance that is assigned to dengue by providers and by parents because of previous outbreaks and previous experiences is going to help us.” She added, “I think that the COVID experience has been very revealing. And what we have learned is that Puerto Rico has a very strong health care system, a very strong network of vaccine providers. ... Coverage for COVID vaccine is higher than in other parts of the U.S.”

One of the interesting things about dengue is that the first infection can range from asymptomatic to life-threatening. The second infection is generally worse because of this antibody-dependent enhancement phenomenon. Eng Eong Ooi, MD, PhD, professor of microbiology and immunology, National University of Singapore, told this news organization, “After you have two infections, you seem to be protected quite well against the remaining two [serotypes]. The vaccine serves as another episode of infection in those who had prior dengue, so then any natural infections after the vaccination in the seropositive become like the outcome of a third or fourth infection.”

Vaccination alone will not solve dengue. Dr. Ooi said, “There’s not one method that would fully control dengue. You need both vaccines as well as control measures, whether it’s Wolbachia or something else. At the same time, I think we need antiviral drugs, because hitting this virus in just one part of its life cycle wouldn’t make a huge, lasting impact.” Dr. Ooi added that as “the spread of the virus and the population immunity drops, you’re actually now more vulnerable to dengue outbreaks when they do get introduced. So, suppressing transmission alone isn’t the answer. You also have to keep herd immunity levels high. So if we can reduce the virus transmission by controlling either mosquito population or transmission and at the same time vaccinate to keep the immunity levels high, then I think we have a chance of controlling dengue.”

Dr. Paz-Bailey concluded: “I do want to emphasize that we are excited about having these tools, because for years and years, we have had really limited options to prevent and control dengue. It’s an important addition to have the vaccine be approved to be used within the U.S., and it’s going to pave the road for future vaccines.”

Dr. Paz-Bailey and Dr. Ooi reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A Maryland woman came down with a severe tropical infection called melioidosis from her freshwater home aquarium, says a report in Emerging Infectious Diseases describing a new route of transmission. Melioidosis is caused by the bacteria Burkholderia pseudomallei in soil or water.

Until last year, almost all U.S. cases of melioidosis were from people who lived or traveled to disease-endemic areas. It has been a rare infection in the United States.

But this is not the first case of melioidosis from an unusual source. Earlier in 2021, CDC and state epidemiologists traced an outbreak of melioidosis in Georgia, Kansas, Minnesota, and Texas to B pseudomallei in a bottle of “Better Homes & Gardens Lavender & Chamomile Essential Oil Infused Aromatherapy Room Spray with Gemstones.”

In the aquarium case, the patient was a 56-year-old woman with diabetes and rheumatologic disease. She had been on immunosuppressives (methotrexate, azathioprine, and prednisone) until 1 month before she became symptomatic. She was hospitalized for fever and pneumonia.

Multiple blood cultures obtained on days 1-4 grew B. pseudomallei, but she had no evidence of endocarditis or intravascular seeding. Despite weeks of meropenem (Merrem), she developed evidence of a lung abscess, and trimethoprim/sulfamethoxazole (Bactrim) was added. Ultimately, the patient required a 12-week course of antibiotics.

CDC epidemiologist Patrick Dawson, PhD, first author of the report, told this news organization that although outbreak investigators always ask about pet ownership, they have not explicitly asked about fish. In this case, the patient did not volunteer exposure to the fish.

When state epidemiologists visited the patient’s home, “one of the first things they saw was a few aquariums,” Dr. Dawson said. Seeing the water and knowing “that most freshwater tropical fish in the U.S. are imported from Southeast Asia” led them to culture specifically for B. pseudomallei, which can be difficult for the microbiology lab to identify.

From there, Dr. Dawson explained, “The Maryland Department of Health sent a team to the local pet store” but did not find any of the bacteria there. (The patient had bought her fish 6 months earlier.) The investigators then worked with the national brand “to identify where they had actually sourced the fish from.”

Two retailers supply almost all of U.S. guppies and plants. While investigators could not find an exact matching isolate after so many months had elapsed, they found a positive PCR for B. pseudomallei in a water sample from imported fish in Los Angeles.

Dr. Dawson said tropical fish are imported from southeast Asia and typically come from small family fish farms. The fish import industry has “certain products that they add to the water to hopefully kill any bacteria.” He was unaware whether this included antibiotics but suggested, “we would have seen many more cases [of antibiotic resistance] by now” if it did.

In general advice for the public, Dr. Dawson said, “I would recommend washing hands before and after contact with the aquarium. If you have cuts or wounds on your hands, it’s really important to wear gloves if you have to go clean or maintain the aquarium and you’re putting your hands in the water, just for that extra layer of protection. It’s probably a strong idea to just avoid that altogether if someone’s immunocompromised. And not letting young children under 5 years old clean aquariums.” These are the “simplest things to do to protect yourself.”

Stephen A. Smith, DVM, PhD, a professor in the Aquatic Medicine Program at Virginia-Maryland College of Veterinary Medicine, Blacksburg, also stressed the importance of careful hand hygiene when caring for aquariums. He said that the filter, filter floss, biofilm, charcoal, and gravel might have exceptionally high concentrations of bacteria. Dr. Smith also recommended gloves when cleaning aquariums and not doing this task if immunocompromised.

Dr. Smith, who was not involved in the CDC study, shared a broader perspective, noting that “the reason why it’s important to federal regulators is that [B. pseudomallei] is a tier 1 select agent. And so, when that was isolated, it sent up all the red flags.” The far more common Mycobacterium marinum, or fish handler’s disease, is not reportable.

Mycobacterium marinum is another pathogen of concern that can be acquired from aquariums. These infections typically occur as nodular lesions on the arms and require months of therapy.

Dr. Smith stressed the importance of physicians eliciting a careful exposure history as the key to diagnosing zoonoses. For most exotic aquarium animals, he noted, “They’re caught in the wild wherever they are. They’re transported to a major hub to transport to the U.S., and a lot of times, we don’t have quarantine for those animals.”

Aquatic zoonoses (infections from water) are important because an estimated 11.5 million U.S. households have pet fish, totaling about 139 million freshwater fish, Dr. Smith said.

Many infections also occur in the course of water sports – or even hiking and getting a cut or abrasion wet from a stream or lake. Aeromonas hydrophila can cause life-threatening infections. Vibrio vulnificus infections from salt-water injuries can cause sepsis and characteristic hemorrhagic bullae – large, discolored blisters filled with body fluid – during the summer. And eating contaminated shellfish has a 50%-60% death rate.

Other exposures to water-loving bacteria happen during fishing or cleaning/preparing fish. For example, Streptococcus iniae has caused cellulitis, arthritis, endocarditis, and meningitis following superficial or puncture injuries, notably from cleaning tilapia.

Other infections from contact with fish include Erysipelothrix rhusiopathiae (primarily skin infections) and gastroenteritis from Plesiomonas shigelloides, Campylobacter spp, and Salmonella spp.

Each of these zoonoses illustrates the importance of a careful exposure history when there’s an atypical presentation or an infection that is not responding promptly to empiric treatment. The aquarium case broadens the differential to include melioidosis, a serious disease from southeast Asia.

Dr. Dawson and Dr. Smith have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A Maryland woman came down with a severe tropical infection called melioidosis from her freshwater home aquarium, says a report in Emerging Infectious Diseases describing a new route of transmission. Melioidosis is caused by the bacteria Burkholderia pseudomallei in soil or water.

Until last year, almost all U.S. cases of melioidosis were from people who lived or traveled to disease-endemic areas. It has been a rare infection in the United States.

But this is not the first case of melioidosis from an unusual source. Earlier in 2021, CDC and state epidemiologists traced an outbreak of melioidosis in Georgia, Kansas, Minnesota, and Texas to B pseudomallei in a bottle of “Better Homes & Gardens Lavender & Chamomile Essential Oil Infused Aromatherapy Room Spray with Gemstones.”

In the aquarium case, the patient was a 56-year-old woman with diabetes and rheumatologic disease. She had been on immunosuppressives (methotrexate, azathioprine, and prednisone) until 1 month before she became symptomatic. She was hospitalized for fever and pneumonia.

Multiple blood cultures obtained on days 1-4 grew B. pseudomallei, but she had no evidence of endocarditis or intravascular seeding. Despite weeks of meropenem (Merrem), she developed evidence of a lung abscess, and trimethoprim/sulfamethoxazole (Bactrim) was added. Ultimately, the patient required a 12-week course of antibiotics.

CDC epidemiologist Patrick Dawson, PhD, first author of the report, told this news organization that although outbreak investigators always ask about pet ownership, they have not explicitly asked about fish. In this case, the patient did not volunteer exposure to the fish.

When state epidemiologists visited the patient’s home, “one of the first things they saw was a few aquariums,” Dr. Dawson said. Seeing the water and knowing “that most freshwater tropical fish in the U.S. are imported from Southeast Asia” led them to culture specifically for B. pseudomallei, which can be difficult for the microbiology lab to identify.

From there, Dr. Dawson explained, “The Maryland Department of Health sent a team to the local pet store” but did not find any of the bacteria there. (The patient had bought her fish 6 months earlier.) The investigators then worked with the national brand “to identify where they had actually sourced the fish from.”

Two retailers supply almost all of U.S. guppies and plants. While investigators could not find an exact matching isolate after so many months had elapsed, they found a positive PCR for B. pseudomallei in a water sample from imported fish in Los Angeles.

Dr. Dawson said tropical fish are imported from southeast Asia and typically come from small family fish farms. The fish import industry has “certain products that they add to the water to hopefully kill any bacteria.” He was unaware whether this included antibiotics but suggested, “we would have seen many more cases [of antibiotic resistance] by now” if it did.

In general advice for the public, Dr. Dawson said, “I would recommend washing hands before and after contact with the aquarium. If you have cuts or wounds on your hands, it’s really important to wear gloves if you have to go clean or maintain the aquarium and you’re putting your hands in the water, just for that extra layer of protection. It’s probably a strong idea to just avoid that altogether if someone’s immunocompromised. And not letting young children under 5 years old clean aquariums.” These are the “simplest things to do to protect yourself.”

Stephen A. Smith, DVM, PhD, a professor in the Aquatic Medicine Program at Virginia-Maryland College of Veterinary Medicine, Blacksburg, also stressed the importance of careful hand hygiene when caring for aquariums. He said that the filter, filter floss, biofilm, charcoal, and gravel might have exceptionally high concentrations of bacteria. Dr. Smith also recommended gloves when cleaning aquariums and not doing this task if immunocompromised.

Dr. Smith, who was not involved in the CDC study, shared a broader perspective, noting that “the reason why it’s important to federal regulators is that [B. pseudomallei] is a tier 1 select agent. And so, when that was isolated, it sent up all the red flags.” The far more common Mycobacterium marinum, or fish handler’s disease, is not reportable.

Mycobacterium marinum is another pathogen of concern that can be acquired from aquariums. These infections typically occur as nodular lesions on the arms and require months of therapy.

Dr. Smith stressed the importance of physicians eliciting a careful exposure history as the key to diagnosing zoonoses. For most exotic aquarium animals, he noted, “They’re caught in the wild wherever they are. They’re transported to a major hub to transport to the U.S., and a lot of times, we don’t have quarantine for those animals.”

Aquatic zoonoses (infections from water) are important because an estimated 11.5 million U.S. households have pet fish, totaling about 139 million freshwater fish, Dr. Smith said.

Many infections also occur in the course of water sports – or even hiking and getting a cut or abrasion wet from a stream or lake. Aeromonas hydrophila can cause life-threatening infections. Vibrio vulnificus infections from salt-water injuries can cause sepsis and characteristic hemorrhagic bullae – large, discolored blisters filled with body fluid – during the summer. And eating contaminated shellfish has a 50%-60% death rate.

Other exposures to water-loving bacteria happen during fishing or cleaning/preparing fish. For example, Streptococcus iniae has caused cellulitis, arthritis, endocarditis, and meningitis following superficial or puncture injuries, notably from cleaning tilapia.

Other infections from contact with fish include Erysipelothrix rhusiopathiae (primarily skin infections) and gastroenteritis from Plesiomonas shigelloides, Campylobacter spp, and Salmonella spp.

Each of these zoonoses illustrates the importance of a careful exposure history when there’s an atypical presentation or an infection that is not responding promptly to empiric treatment. The aquarium case broadens the differential to include melioidosis, a serious disease from southeast Asia.

Dr. Dawson and Dr. Smith have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A Maryland woman came down with a severe tropical infection called melioidosis from her freshwater home aquarium, says a report in Emerging Infectious Diseases describing a new route of transmission. Melioidosis is caused by the bacteria Burkholderia pseudomallei in soil or water.

Until last year, almost all U.S. cases of melioidosis were from people who lived or traveled to disease-endemic areas. It has been a rare infection in the United States.

But this is not the first case of melioidosis from an unusual source. Earlier in 2021, CDC and state epidemiologists traced an outbreak of melioidosis in Georgia, Kansas, Minnesota, and Texas to B pseudomallei in a bottle of “Better Homes & Gardens Lavender & Chamomile Essential Oil Infused Aromatherapy Room Spray with Gemstones.”

In the aquarium case, the patient was a 56-year-old woman with diabetes and rheumatologic disease. She had been on immunosuppressives (methotrexate, azathioprine, and prednisone) until 1 month before she became symptomatic. She was hospitalized for fever and pneumonia.

Multiple blood cultures obtained on days 1-4 grew B. pseudomallei, but she had no evidence of endocarditis or intravascular seeding. Despite weeks of meropenem (Merrem), she developed evidence of a lung abscess, and trimethoprim/sulfamethoxazole (Bactrim) was added. Ultimately, the patient required a 12-week course of antibiotics.

CDC epidemiologist Patrick Dawson, PhD, first author of the report, told this news organization that although outbreak investigators always ask about pet ownership, they have not explicitly asked about fish. In this case, the patient did not volunteer exposure to the fish.

When state epidemiologists visited the patient’s home, “one of the first things they saw was a few aquariums,” Dr. Dawson said. Seeing the water and knowing “that most freshwater tropical fish in the U.S. are imported from Southeast Asia” led them to culture specifically for B. pseudomallei, which can be difficult for the microbiology lab to identify.

From there, Dr. Dawson explained, “The Maryland Department of Health sent a team to the local pet store” but did not find any of the bacteria there. (The patient had bought her fish 6 months earlier.) The investigators then worked with the national brand “to identify where they had actually sourced the fish from.”

Two retailers supply almost all of U.S. guppies and plants. While investigators could not find an exact matching isolate after so many months had elapsed, they found a positive PCR for B. pseudomallei in a water sample from imported fish in Los Angeles.

Dr. Dawson said tropical fish are imported from southeast Asia and typically come from small family fish farms. The fish import industry has “certain products that they add to the water to hopefully kill any bacteria.” He was unaware whether this included antibiotics but suggested, “we would have seen many more cases [of antibiotic resistance] by now” if it did.

In general advice for the public, Dr. Dawson said, “I would recommend washing hands before and after contact with the aquarium. If you have cuts or wounds on your hands, it’s really important to wear gloves if you have to go clean or maintain the aquarium and you’re putting your hands in the water, just for that extra layer of protection. It’s probably a strong idea to just avoid that altogether if someone’s immunocompromised. And not letting young children under 5 years old clean aquariums.” These are the “simplest things to do to protect yourself.”

Stephen A. Smith, DVM, PhD, a professor in the Aquatic Medicine Program at Virginia-Maryland College of Veterinary Medicine, Blacksburg, also stressed the importance of careful hand hygiene when caring for aquariums. He said that the filter, filter floss, biofilm, charcoal, and gravel might have exceptionally high concentrations of bacteria. Dr. Smith also recommended gloves when cleaning aquariums and not doing this task if immunocompromised.

Dr. Smith, who was not involved in the CDC study, shared a broader perspective, noting that “the reason why it’s important to federal regulators is that [B. pseudomallei] is a tier 1 select agent. And so, when that was isolated, it sent up all the red flags.” The far more common Mycobacterium marinum, or fish handler’s disease, is not reportable.

Mycobacterium marinum is another pathogen of concern that can be acquired from aquariums. These infections typically occur as nodular lesions on the arms and require months of therapy.

Dr. Smith stressed the importance of physicians eliciting a careful exposure history as the key to diagnosing zoonoses. For most exotic aquarium animals, he noted, “They’re caught in the wild wherever they are. They’re transported to a major hub to transport to the U.S., and a lot of times, we don’t have quarantine for those animals.”

Aquatic zoonoses (infections from water) are important because an estimated 11.5 million U.S. households have pet fish, totaling about 139 million freshwater fish, Dr. Smith said.

Many infections also occur in the course of water sports – or even hiking and getting a cut or abrasion wet from a stream or lake. Aeromonas hydrophila can cause life-threatening infections. Vibrio vulnificus infections from salt-water injuries can cause sepsis and characteristic hemorrhagic bullae – large, discolored blisters filled with body fluid – during the summer. And eating contaminated shellfish has a 50%-60% death rate.

Other exposures to water-loving bacteria happen during fishing or cleaning/preparing fish. For example, Streptococcus iniae has caused cellulitis, arthritis, endocarditis, and meningitis following superficial or puncture injuries, notably from cleaning tilapia.

Other infections from contact with fish include Erysipelothrix rhusiopathiae (primarily skin infections) and gastroenteritis from Plesiomonas shigelloides, Campylobacter spp, and Salmonella spp.

Each of these zoonoses illustrates the importance of a careful exposure history when there’s an atypical presentation or an infection that is not responding promptly to empiric treatment. The aquarium case broadens the differential to include melioidosis, a serious disease from southeast Asia.

Dr. Dawson and Dr. Smith have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The number of reported circulating vaccine-derived poliovirus (cVDPV) outbreaks more than tripled to 29 since Jan. 2017. Most (86%) of these outbreaks were caused by cVDPV2 (circulating VDPV type 2 poliovirus, which originated with the vaccine), and most occurred in Africa, according to a new study of vaccine-derived poliovirus outbreaks between Jan. 2020 and June 2021 published in the CDC’s Morbidity and Mortality Weekly Report.

The Global Polio Eradication Initiative (GPEI) was launched in 1988 and used live attenuated oral poliovirus vaccine (OPV). Since then, cases of wild poliovirus have declined more than 99.99%.

The cVDPV2 likely originated among children born in areas with poor vaccine coverage. Jay Wenger, MD, director, Polio, at the Bill and Melinda Gates Foundation, told this news organization that “the inactivated vaccines that we give in most developed countries now are good in that they provide humoral immunity, the antibodies in the bloodstream. They don’t necessarily provide mucosal immunity. They don’t make the kid’s gut immune to getting reinfected or actually immune to reproducing the virus if they get it in their gut. So we could still have a situation where everybody was vaccinated with IPV [inactivated poliovirus], but the virus could still be transmitting around because kids’ guts would still be producing the virus and there will still be transmission in your population, probably without much or any paralysis because of the IPV. As soon as that virus hit a population that was not vaccinated, they would get paralyzed.”

Dr. Wenger added, “The ideal vaccine would be an oral vaccine that didn’t mutate back and couldn’t cause these VDPVs.” Scientists developed such a vaccine, approved by the World Health Organization last year under an Emergency Use Authorization. This nOPV2 (novel oral poliovirus type 2) vaccine has been given since March 2021 in areas with the VDPD2 outbreaks. The nOPV2 should allow them to “basically stamp out the outbreaks.”

The world had almost eradicated the disease, with the last cases of polio from wild virus occurring in Nigeria, Afghanistan, and Pakistan as of 2014. Africa was declared free of wild polio in 2020 after it had been eradicated from Nigeria, which accounted for more than half of the world’s cases only a decade earlier. Now cVDPV outbreaks affect 28 African countries, plus Iran, Yemen, Afghanistan, Pakistan, Tajikistan, Malaysia, the Philippines, and Indonesia. And there was also one case in China. Globally, there were 1,335 cases of cVDPV causing paralysis during the reporting period.

The COVID-19 pandemic has had a significant impact on polio, accounting for much of this year’s increase in cases. Dr. Wenger said, “We couldn’t do any campaigns. We pretty much stopped doing outbreak response campaigns in the middle of the year because of COVID.”

The CDC report notes that many of the supplementary immunizations in response to cVDPV2 outbreaks were of “poor quality,” and prolonged delays enabled geographically expanding cVDPV2 transmission.

Steve Wassilak, MD, chief coauthor of the CDC study, told this news organization that, because of COVID, “what we’ve been lacking is a rapid response for the most part. Some of that is due to laboratory delays and shipment because of COVID’s effect on international travel.” He noted, however, that there has been good recovery in surveillance and immunization activities despite COVID. And, he added, eradication “can be done, and many outbreaks have closed even during the [COVID] outbreak.”

Dr. Wassilak said that in Nigeria, “the face of the campaign became national.” In Pakistan, much of the work is done by national and international partners.

Dr. Wenger said that in Nigeria and other challenging areas, “the approach was essentially to make direct contact with the traditional leaders and the religious leaders and the local actors in each of these populations. So, it’s really getting down to the grassroots level.” Infectious disease officials send teams to speak with individuals in the “local, traditional leader system.”

“Just talking to them actually got us a long way and giving them the information that they need. In most cases, I mean, people want to do things to help their kids,” said Dr. Wenger.

For now, the initial plan, per the CDC, is to “initiate prompt and high coverage outbreak responses with available type 2 OPV to interrupt transmission” until a better supply of nOPV2 is available, then switch to IPVs.

Dr. Wenger and Dr. Wassilak report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The number of reported circulating vaccine-derived poliovirus (cVDPV) outbreaks more than tripled to 29 since Jan. 2017. Most (86%) of these outbreaks were caused by cVDPV2 (circulating VDPV type 2 poliovirus, which originated with the vaccine), and most occurred in Africa, according to a new study of vaccine-derived poliovirus outbreaks between Jan. 2020 and June 2021 published in the CDC’s Morbidity and Mortality Weekly Report.

The Global Polio Eradication Initiative (GPEI) was launched in 1988 and used live attenuated oral poliovirus vaccine (OPV). Since then, cases of wild poliovirus have declined more than 99.99%.

The cVDPV2 likely originated among children born in areas with poor vaccine coverage. Jay Wenger, MD, director, Polio, at the Bill and Melinda Gates Foundation, told this news organization that “the inactivated vaccines that we give in most developed countries now are good in that they provide humoral immunity, the antibodies in the bloodstream. They don’t necessarily provide mucosal immunity. They don’t make the kid’s gut immune to getting reinfected or actually immune to reproducing the virus if they get it in their gut. So we could still have a situation where everybody was vaccinated with IPV [inactivated poliovirus], but the virus could still be transmitting around because kids’ guts would still be producing the virus and there will still be transmission in your population, probably without much or any paralysis because of the IPV. As soon as that virus hit a population that was not vaccinated, they would get paralyzed.”

Dr. Wenger added, “The ideal vaccine would be an oral vaccine that didn’t mutate back and couldn’t cause these VDPVs.” Scientists developed such a vaccine, approved by the World Health Organization last year under an Emergency Use Authorization. This nOPV2 (novel oral poliovirus type 2) vaccine has been given since March 2021 in areas with the VDPD2 outbreaks. The nOPV2 should allow them to “basically stamp out the outbreaks.”

The world had almost eradicated the disease, with the last cases of polio from wild virus occurring in Nigeria, Afghanistan, and Pakistan as of 2014. Africa was declared free of wild polio in 2020 after it had been eradicated from Nigeria, which accounted for more than half of the world’s cases only a decade earlier. Now cVDPV outbreaks affect 28 African countries, plus Iran, Yemen, Afghanistan, Pakistan, Tajikistan, Malaysia, the Philippines, and Indonesia. And there was also one case in China. Globally, there were 1,335 cases of cVDPV causing paralysis during the reporting period.

The COVID-19 pandemic has had a significant impact on polio, accounting for much of this year’s increase in cases. Dr. Wenger said, “We couldn’t do any campaigns. We pretty much stopped doing outbreak response campaigns in the middle of the year because of COVID.”

The CDC report notes that many of the supplementary immunizations in response to cVDPV2 outbreaks were of “poor quality,” and prolonged delays enabled geographically expanding cVDPV2 transmission.

Steve Wassilak, MD, chief coauthor of the CDC study, told this news organization that, because of COVID, “what we’ve been lacking is a rapid response for the most part. Some of that is due to laboratory delays and shipment because of COVID’s effect on international travel.” He noted, however, that there has been good recovery in surveillance and immunization activities despite COVID. And, he added, eradication “can be done, and many outbreaks have closed even during the [COVID] outbreak.”

Dr. Wassilak said that in Nigeria, “the face of the campaign became national.” In Pakistan, much of the work is done by national and international partners.

Dr. Wenger said that in Nigeria and other challenging areas, “the approach was essentially to make direct contact with the traditional leaders and the religious leaders and the local actors in each of these populations. So, it’s really getting down to the grassroots level.” Infectious disease officials send teams to speak with individuals in the “local, traditional leader system.”

“Just talking to them actually got us a long way and giving them the information that they need. In most cases, I mean, people want to do things to help their kids,” said Dr. Wenger.

For now, the initial plan, per the CDC, is to “initiate prompt and high coverage outbreak responses with available type 2 OPV to interrupt transmission” until a better supply of nOPV2 is available, then switch to IPVs.

Dr. Wenger and Dr. Wassilak report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The number of reported circulating vaccine-derived poliovirus (cVDPV) outbreaks more than tripled to 29 since Jan. 2017. Most (86%) of these outbreaks were caused by cVDPV2 (circulating VDPV type 2 poliovirus, which originated with the vaccine), and most occurred in Africa, according to a new study of vaccine-derived poliovirus outbreaks between Jan. 2020 and June 2021 published in the CDC’s Morbidity and Mortality Weekly Report.

The Global Polio Eradication Initiative (GPEI) was launched in 1988 and used live attenuated oral poliovirus vaccine (OPV). Since then, cases of wild poliovirus have declined more than 99.99%.

The cVDPV2 likely originated among children born in areas with poor vaccine coverage. Jay Wenger, MD, director, Polio, at the Bill and Melinda Gates Foundation, told this news organization that “the inactivated vaccines that we give in most developed countries now are good in that they provide humoral immunity, the antibodies in the bloodstream. They don’t necessarily provide mucosal immunity. They don’t make the kid’s gut immune to getting reinfected or actually immune to reproducing the virus if they get it in their gut. So we could still have a situation where everybody was vaccinated with IPV [inactivated poliovirus], but the virus could still be transmitting around because kids’ guts would still be producing the virus and there will still be transmission in your population, probably without much or any paralysis because of the IPV. As soon as that virus hit a population that was not vaccinated, they would get paralyzed.”

Dr. Wenger added, “The ideal vaccine would be an oral vaccine that didn’t mutate back and couldn’t cause these VDPVs.” Scientists developed such a vaccine, approved by the World Health Organization last year under an Emergency Use Authorization. This nOPV2 (novel oral poliovirus type 2) vaccine has been given since March 2021 in areas with the VDPD2 outbreaks. The nOPV2 should allow them to “basically stamp out the outbreaks.”

The world had almost eradicated the disease, with the last cases of polio from wild virus occurring in Nigeria, Afghanistan, and Pakistan as of 2014. Africa was declared free of wild polio in 2020 after it had been eradicated from Nigeria, which accounted for more than half of the world’s cases only a decade earlier. Now cVDPV outbreaks affect 28 African countries, plus Iran, Yemen, Afghanistan, Pakistan, Tajikistan, Malaysia, the Philippines, and Indonesia. And there was also one case in China. Globally, there were 1,335 cases of cVDPV causing paralysis during the reporting period.

The COVID-19 pandemic has had a significant impact on polio, accounting for much of this year’s increase in cases. Dr. Wenger said, “We couldn’t do any campaigns. We pretty much stopped doing outbreak response campaigns in the middle of the year because of COVID.”

The CDC report notes that many of the supplementary immunizations in response to cVDPV2 outbreaks were of “poor quality,” and prolonged delays enabled geographically expanding cVDPV2 transmission.

Steve Wassilak, MD, chief coauthor of the CDC study, told this news organization that, because of COVID, “what we’ve been lacking is a rapid response for the most part. Some of that is due to laboratory delays and shipment because of COVID’s effect on international travel.” He noted, however, that there has been good recovery in surveillance and immunization activities despite COVID. And, he added, eradication “can be done, and many outbreaks have closed even during the [COVID] outbreak.”

Dr. Wassilak said that in Nigeria, “the face of the campaign became national.” In Pakistan, much of the work is done by national and international partners.

Dr. Wenger said that in Nigeria and other challenging areas, “the approach was essentially to make direct contact with the traditional leaders and the religious leaders and the local actors in each of these populations. So, it’s really getting down to the grassroots level.” Infectious disease officials send teams to speak with individuals in the “local, traditional leader system.”

“Just talking to them actually got us a long way and giving them the information that they need. In most cases, I mean, people want to do things to help their kids,” said Dr. Wenger.

For now, the initial plan, per the CDC, is to “initiate prompt and high coverage outbreak responses with available type 2 OPV to interrupt transmission” until a better supply of nOPV2 is available, then switch to IPVs.

Dr. Wenger and Dr. Wassilak report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A new survey from the National Foundation for Infectious Diseases shows that, despite the recommendation that patients who have chronic illnesses receive annual flu vaccines, only 45% of these patients do get them. People with chronic diseases are at increased risk for serious flu-related complications, including hospitalization and death.

Vaccine_syringe_web.jpg

The survey looked at physicians’ practices toward flu vaccination and communication between health care providers (HCP) and their adult patients with chronic health conditions.

Overall, less than a third of HCPs (31%) said they recommend annual flu vaccination to all of their patients with chronic health conditions. There were some surprising differences between subspecialists. For example, 72% of patients with a heart problem who saw a cardiologist said that physician recommended the flu vaccine. The recommendation rate dropped to 32% of lung patients seeing a pulmonary physician and only 10% of people with diabetes who saw an endocrinologist.

There is quite a large gap between what physicians and patients say about their interactions. Fully 77% of HCPs who recommend annual flu vaccination say they tell patients when they are at higher risk of complications from influenza. Yet only 48% of patients say they have been given such information.

Although it is critically important information for patients to learn, their risk of influenza is often missing from the discussion. For example, patients with heart disease are six times more likely to have a heart attack within 7 days of flu infection. People with diabetes are six times more likely to be hospitalized from flu and three times more likely to die. Similarly, those with asthma or chronic obstructive pulmonary disorder are at a much higher risk of complications.

One problem is that more than half of specialist physicians who do not offer flu vaccinations report that it is because they believe that immunizations are the responsibility of the primary care physician. Yet only 65% of patients with one of these chronic illnesses report seeing their primary care physician at least annually.

Much of the disparity between the patient’s perception of what they were told and the physician’s is “how the ‘recommendation’ is actually made,” William Schaffner, MD, NFID’s medical director and professor of medicine at Vanderbilt University, Nashville, Tenn., told this news organization. Dr. Schaffner offered the following example: At the end of the visit, the doctor might say: “It’s that time of the year again – you want to think about getting your flu shot.”

“The doctor thinks they’ve recommended that, but the doctor really has opened the door for you to think about it and leave [yourself] unvaccinated.”

Dr. Schaffner’s alternative? Tell the patient: “‘You’ll get your flu vaccine on the way out. Tom or Sally will give it to you.’ That’s a very different kind of recommendation. And it’s a much greater assurance of providing the vaccine.”

Another major problem, Dr. Schaffner said, is that many specialists “don’t think of vaccination as something that’s included with their routine care” even though they do direct much of the patient’s care. He said that physicians should be more “directive” in their care and that immunizations should be better integrated into routine practice.

Jody Lanard, MD, a retired risk communication consultant who spent many years working with the World Health Organization on disease outbreak communications, said in an interview that this disconnect between physician and patient reports “was really jarring. And it’s actionable!”

She offered several practical suggestions. For one, she said, “the messaging to the specialists has to be very, very empathic. We know you’re already overburdened. And here we’re asking you to do something that you think of as somebody else’s job.” But if your patient gets flu, then your job as the cardiologist or endocrinologist will become more complicated and time-consuming. So getting the patients vaccinated will be a good investment and will make your job easier.

Because of the disparity in patient and physician reports, Dr. Lanard suggested implementing a “feedback mechanism where they [the health care providers] give out the prescription, and then the office calls [the patient] to see if they’ve gotten the shot or not. Because that way it will help correct the mismatch between them thinking that they told the patient and the patient not hearing it.”

Asked about why there might be a big gap between what physicians report they said and what patients heard, Dr. Lanard explained that “physicians often communicate in [a manner] sort of like a checklist. And the patients are focused on one or two things that are high in their minds. And the physician was mentioning some things that are on a separate topic that are not on a patient’s list and it goes right past them.”

Dr. Lanard recommended brief storytelling instead of checklists. For example: “I’ve been treating your diabetes for 10 years. During this last flu season, several of my diabetic patients had a really hard time when they caught the flu. So now I’m trying harder to remember to remind you to get your flu shots.”

She urged HCPs to “make it more personal ... but it can still be scripted in advance as part of something that [you’re] remembering to do during the check.” She added that their professional associations may be able to send them suggested language they can adapt.

Finally, Dr. Lanard cautioned about vaccine myths. “The word myth is so insulting. It’s basically a word that sends the signal that you’re an idiot.”

She advised specialists to avoid the word “myth,” which will make the person defensive. Instead, say something like, “A lot of people, even some of my own family members, think the flu vaccine gives you the flu. ... But it doesn’t. And then you go into the reality.”

Dr. Lanard suggested that specialists implement the follow-up calls and close the feedback loop, saying: “If they did the survey a few years later, I bet that gap would narrow.”

Dr. Schaffner and Dr. Lanard disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A new survey from the National Foundation for Infectious Diseases shows that, despite the recommendation that patients who have chronic illnesses receive annual flu vaccines, only 45% of these patients do get them. People with chronic diseases are at increased risk for serious flu-related complications, including hospitalization and death.

Vaccine_syringe_web.jpg

The survey looked at physicians’ practices toward flu vaccination and communication between health care providers (HCP) and their adult patients with chronic health conditions.

Overall, less than a third of HCPs (31%) said they recommend annual flu vaccination to all of their patients with chronic health conditions. There were some surprising differences between subspecialists. For example, 72% of patients with a heart problem who saw a cardiologist said that physician recommended the flu vaccine. The recommendation rate dropped to 32% of lung patients seeing a pulmonary physician and only 10% of people with diabetes who saw an endocrinologist.

There is quite a large gap between what physicians and patients say about their interactions. Fully 77% of HCPs who recommend annual flu vaccination say they tell patients when they are at higher risk of complications from influenza. Yet only 48% of patients say they have been given such information.

Although it is critically important information for patients to learn, their risk of influenza is often missing from the discussion. For example, patients with heart disease are six times more likely to have a heart attack within 7 days of flu infection. People with diabetes are six times more likely to be hospitalized from flu and three times more likely to die. Similarly, those with asthma or chronic obstructive pulmonary disorder are at a much higher risk of complications.

One problem is that more than half of specialist physicians who do not offer flu vaccinations report that it is because they believe that immunizations are the responsibility of the primary care physician. Yet only 65% of patients with one of these chronic illnesses report seeing their primary care physician at least annually.

Much of the disparity between the patient’s perception of what they were told and the physician’s is “how the ‘recommendation’ is actually made,” William Schaffner, MD, NFID’s medical director and professor of medicine at Vanderbilt University, Nashville, Tenn., told this news organization. Dr. Schaffner offered the following example: At the end of the visit, the doctor might say: “It’s that time of the year again – you want to think about getting your flu shot.”

“The doctor thinks they’ve recommended that, but the doctor really has opened the door for you to think about it and leave [yourself] unvaccinated.”

Dr. Schaffner’s alternative? Tell the patient: “‘You’ll get your flu vaccine on the way out. Tom or Sally will give it to you.’ That’s a very different kind of recommendation. And it’s a much greater assurance of providing the vaccine.”

Another major problem, Dr. Schaffner said, is that many specialists “don’t think of vaccination as something that’s included with their routine care” even though they do direct much of the patient’s care. He said that physicians should be more “directive” in their care and that immunizations should be better integrated into routine practice.

Jody Lanard, MD, a retired risk communication consultant who spent many years working with the World Health Organization on disease outbreak communications, said in an interview that this disconnect between physician and patient reports “was really jarring. And it’s actionable!”

She offered several practical suggestions. For one, she said, “the messaging to the specialists has to be very, very empathic. We know you’re already overburdened. And here we’re asking you to do something that you think of as somebody else’s job.” But if your patient gets flu, then your job as the cardiologist or endocrinologist will become more complicated and time-consuming. So getting the patients vaccinated will be a good investment and will make your job easier.

Because of the disparity in patient and physician reports, Dr. Lanard suggested implementing a “feedback mechanism where they [the health care providers] give out the prescription, and then the office calls [the patient] to see if they’ve gotten the shot or not. Because that way it will help correct the mismatch between them thinking that they told the patient and the patient not hearing it.”

Asked about why there might be a big gap between what physicians report they said and what patients heard, Dr. Lanard explained that “physicians often communicate in [a manner] sort of like a checklist. And the patients are focused on one or two things that are high in their minds. And the physician was mentioning some things that are on a separate topic that are not on a patient’s list and it goes right past them.”

Dr. Lanard recommended brief storytelling instead of checklists. For example: “I’ve been treating your diabetes for 10 years. During this last flu season, several of my diabetic patients had a really hard time when they caught the flu. So now I’m trying harder to remember to remind you to get your flu shots.”

She urged HCPs to “make it more personal ... but it can still be scripted in advance as part of something that [you’re] remembering to do during the check.” She added that their professional associations may be able to send them suggested language they can adapt.

Finally, Dr. Lanard cautioned about vaccine myths. “The word myth is so insulting. It’s basically a word that sends the signal that you’re an idiot.”

She advised specialists to avoid the word “myth,” which will make the person defensive. Instead, say something like, “A lot of people, even some of my own family members, think the flu vaccine gives you the flu. ... But it doesn’t. And then you go into the reality.”

Dr. Lanard suggested that specialists implement the follow-up calls and close the feedback loop, saying: “If they did the survey a few years later, I bet that gap would narrow.”

Dr. Schaffner and Dr. Lanard disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A new survey from the National Foundation for Infectious Diseases shows that, despite the recommendation that patients who have chronic illnesses receive annual flu vaccines, only 45% of these patients do get them. People with chronic diseases are at increased risk for serious flu-related complications, including hospitalization and death.

Vaccine_syringe_web.jpg

The survey looked at physicians’ practices toward flu vaccination and communication between health care providers (HCP) and their adult patients with chronic health conditions.

Overall, less than a third of HCPs (31%) said they recommend annual flu vaccination to all of their patients with chronic health conditions. There were some surprising differences between subspecialists. For example, 72% of patients with a heart problem who saw a cardiologist said that physician recommended the flu vaccine. The recommendation rate dropped to 32% of lung patients seeing a pulmonary physician and only 10% of people with diabetes who saw an endocrinologist.

There is quite a large gap between what physicians and patients say about their interactions. Fully 77% of HCPs who recommend annual flu vaccination say they tell patients when they are at higher risk of complications from influenza. Yet only 48% of patients say they have been given such information.

Although it is critically important information for patients to learn, their risk of influenza is often missing from the discussion. For example, patients with heart disease are six times more likely to have a heart attack within 7 days of flu infection. People with diabetes are six times more likely to be hospitalized from flu and three times more likely to die. Similarly, those with asthma or chronic obstructive pulmonary disorder are at a much higher risk of complications.

One problem is that more than half of specialist physicians who do not offer flu vaccinations report that it is because they believe that immunizations are the responsibility of the primary care physician. Yet only 65% of patients with one of these chronic illnesses report seeing their primary care physician at least annually.

Much of the disparity between the patient’s perception of what they were told and the physician’s is “how the ‘recommendation’ is actually made,” William Schaffner, MD, NFID’s medical director and professor of medicine at Vanderbilt University, Nashville, Tenn., told this news organization. Dr. Schaffner offered the following example: At the end of the visit, the doctor might say: “It’s that time of the year again – you want to think about getting your flu shot.”

“The doctor thinks they’ve recommended that, but the doctor really has opened the door for you to think about it and leave [yourself] unvaccinated.”

Dr. Schaffner’s alternative? Tell the patient: “‘You’ll get your flu vaccine on the way out. Tom or Sally will give it to you.’ That’s a very different kind of recommendation. And it’s a much greater assurance of providing the vaccine.”

Another major problem, Dr. Schaffner said, is that many specialists “don’t think of vaccination as something that’s included with their routine care” even though they do direct much of the patient’s care. He said that physicians should be more “directive” in their care and that immunizations should be better integrated into routine practice.

Jody Lanard, MD, a retired risk communication consultant who spent many years working with the World Health Organization on disease outbreak communications, said in an interview that this disconnect between physician and patient reports “was really jarring. And it’s actionable!”

She offered several practical suggestions. For one, she said, “the messaging to the specialists has to be very, very empathic. We know you’re already overburdened. And here we’re asking you to do something that you think of as somebody else’s job.” But if your patient gets flu, then your job as the cardiologist or endocrinologist will become more complicated and time-consuming. So getting the patients vaccinated will be a good investment and will make your job easier.

Because of the disparity in patient and physician reports, Dr. Lanard suggested implementing a “feedback mechanism where they [the health care providers] give out the prescription, and then the office calls [the patient] to see if they’ve gotten the shot or not. Because that way it will help correct the mismatch between them thinking that they told the patient and the patient not hearing it.”

Asked about why there might be a big gap between what physicians report they said and what patients heard, Dr. Lanard explained that “physicians often communicate in [a manner] sort of like a checklist. And the patients are focused on one or two things that are high in their minds. And the physician was mentioning some things that are on a separate topic that are not on a patient’s list and it goes right past them.”

Dr. Lanard recommended brief storytelling instead of checklists. For example: “I’ve been treating your diabetes for 10 years. During this last flu season, several of my diabetic patients had a really hard time when they caught the flu. So now I’m trying harder to remember to remind you to get your flu shots.”

She urged HCPs to “make it more personal ... but it can still be scripted in advance as part of something that [you’re] remembering to do during the check.” She added that their professional associations may be able to send them suggested language they can adapt.

Finally, Dr. Lanard cautioned about vaccine myths. “The word myth is so insulting. It’s basically a word that sends the signal that you’re an idiot.”

She advised specialists to avoid the word “myth,” which will make the person defensive. Instead, say something like, “A lot of people, even some of my own family members, think the flu vaccine gives you the flu. ... But it doesn’t. And then you go into the reality.”

Dr. Lanard suggested that specialists implement the follow-up calls and close the feedback loop, saying: “If they did the survey a few years later, I bet that gap would narrow.”

Dr. Schaffner and Dr. Lanard disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Although the estimated annual number of measles deaths decreased 94% from 2000 to 2020, the COVID-19 pandemic took a toll on both measles vaccination and surveillance, according to a recent report in Morbidity and Mortality Weekly Report.

The number of World Health Organization member states that achieved more than 90% coverage with the first dose of the measles vaccine (MCV1) declined 37% from 2019 to 2020. In 2020, 23 million infants did not receive MCV1 through routine immunization services, and another 93 million were affected by the postponement of mass immunizations or supplementary immunization activities because of the pandemic. Also, endemic transmission was reestablished in nine countries that had previously eliminated measles.

But perhaps the most overlooked aspect of COVID-19 is its effect on surveillance.

“The entire COVID pandemic really put a lot of strain on the surveillance systems, not only for measles but for all vaccine-preventable disease, because there’s a lot of overlap in the staff who work for surveillance,” said Katrina Kretsinger, MD, a medical epidemiologist at the Centers for Disease Control and Prevention, who contributed to the MMWR report.

Because of the stress on the systems, a lot fewer specimens were tested, she said in an interview. And it’s not just measles that is at risk. This has had an impact on the Global Polio Eradication Initiative, which lost staff.

In addition, many vaccination campaigns “were postponed and curtailed throughout 2020,” Dr. Kretsinger said. The strengthening of surveillance systems – and immunization systems, more broadly – needs to be a priority.

“It’s not clear that the children who were missed during that year were subsequently caught up,” she explained. Having a “cohort of children who have missed measles vaccine creates the reservoir of susceptibility that will provide the nidus for the next big outbreak.”

Measles is the indicator disease. That could mean a resurgence of other vaccine-preventable diseases as well.

This report “was written by some of the world’s experts in measles, and it raises concerns about potential resurgence of measles,” said Walter Orenstein, MD, professor of medicine, epidemiology, global health, and pediatrics at Emory University, Atlanta. “Measles is sort of a canary in the coal mine. If you look at vaccine-preventable diseases, measles is probably the most contagious, so the herd-immunity threshold is highest. Usually on the order of 92%-94% immunity is needed to stop transmission.”

“Measles is the indicator disease,” he said in an interview. “That could mean a resurgence of other vaccine-preventable diseases as well.” Outbreaks don’t just affect the countries where infections are occurring, they “also affect our own domestic health security.”

“Some sort of periodic intensified routine immunization” would be helpful, said Dr. Kretsinger, who recommends “going through and selectively doing some sort of intensified efforts to catch children up early for the entire range of vaccines that they may have missed.”

“Some of these capture campaigns in areas that are thought to have the major problem would be very, very important,” agreed Dr. Orenstein. “A school entry check is one way of trying to look at kids, let’s say at 4-6 years of age, in schools around the world,” offering doses if they’re unvaccinated or inadequately vaccinated. “Another is to try to improve surveillance and try to understand if the cases are vaccine failure or failure to vaccinate.”

“Where the health systems are the most fragile is where those gaps will be the last to be filled, if they are at all, and where we have the basic concerns,” Dr. Kretsinger explained.

“Years ago, WHO recognized that vaccine hesitancy is a top global health threat,” said Dr. Orenstein. “People may not see these diseases so they don’t mean much to them. Since vaccines, we’re victims of our own success.” There’s also a lot of incorrect information circulating.

“We need to realize – and it’s been shown with COVID – that a decision not to vaccinate is not just a decision for your own child. It’s a community decision,” he pointed out. “It’s not my freedom to drive drunk, because not only do I put myself at risk, but others can’t control the car. We have speed limits and other examples where we restrict personal choice because it can adversely affect individuals.”

“My favorite line is vaccines don’t save lives, vaccinations save lives,” Dr. Orenstein said. “The vaccine dose that remains in the vial is 0% effective, no matter what the clinical trials show. And the issue, I think, is that we need to determine how to convince the hesitant to get confident enough to accept vaccination. For that, there is behavioral research; there’s a whole bunch of things that need to be supported. Just purchasing the vaccine doesn’t get it into the bodies.”

Dr. Kretsinger and Dr. Orenstein disclosed no relevant financial relationships .

A version of this article first appeared on Medscape.com.

Although the estimated annual number of measles deaths decreased 94% from 2000 to 2020, the COVID-19 pandemic took a toll on both measles vaccination and surveillance, according to a recent report in Morbidity and Mortality Weekly Report.

The number of World Health Organization member states that achieved more than 90% coverage with the first dose of the measles vaccine (MCV1) declined 37% from 2019 to 2020. In 2020, 23 million infants did not receive MCV1 through routine immunization services, and another 93 million were affected by the postponement of mass immunizations or supplementary immunization activities because of the pandemic. Also, endemic transmission was reestablished in nine countries that had previously eliminated measles.

But perhaps the most overlooked aspect of COVID-19 is its effect on surveillance.

“The entire COVID pandemic really put a lot of strain on the surveillance systems, not only for measles but for all vaccine-preventable disease, because there’s a lot of overlap in the staff who work for surveillance,” said Katrina Kretsinger, MD, a medical epidemiologist at the Centers for Disease Control and Prevention, who contributed to the MMWR report.

Because of the stress on the systems, a lot fewer specimens were tested, she said in an interview. And it’s not just measles that is at risk. This has had an impact on the Global Polio Eradication Initiative, which lost staff.

In addition, many vaccination campaigns “were postponed and curtailed throughout 2020,” Dr. Kretsinger said. The strengthening of surveillance systems – and immunization systems, more broadly – needs to be a priority.

“It’s not clear that the children who were missed during that year were subsequently caught up,” she explained. Having a “cohort of children who have missed measles vaccine creates the reservoir of susceptibility that will provide the nidus for the next big outbreak.”

Measles is the indicator disease. That could mean a resurgence of other vaccine-preventable diseases as well.

This report “was written by some of the world’s experts in measles, and it raises concerns about potential resurgence of measles,” said Walter Orenstein, MD, professor of medicine, epidemiology, global health, and pediatrics at Emory University, Atlanta. “Measles is sort of a canary in the coal mine. If you look at vaccine-preventable diseases, measles is probably the most contagious, so the herd-immunity threshold is highest. Usually on the order of 92%-94% immunity is needed to stop transmission.”

“Measles is the indicator disease,” he said in an interview. “That could mean a resurgence of other vaccine-preventable diseases as well.” Outbreaks don’t just affect the countries where infections are occurring, they “also affect our own domestic health security.”

“Some sort of periodic intensified routine immunization” would be helpful, said Dr. Kretsinger, who recommends “going through and selectively doing some sort of intensified efforts to catch children up early for the entire range of vaccines that they may have missed.”

“Some of these capture campaigns in areas that are thought to have the major problem would be very, very important,” agreed Dr. Orenstein. “A school entry check is one way of trying to look at kids, let’s say at 4-6 years of age, in schools around the world,” offering doses if they’re unvaccinated or inadequately vaccinated. “Another is to try to improve surveillance and try to understand if the cases are vaccine failure or failure to vaccinate.”

“Where the health systems are the most fragile is where those gaps will be the last to be filled, if they are at all, and where we have the basic concerns,” Dr. Kretsinger explained.

“Years ago, WHO recognized that vaccine hesitancy is a top global health threat,” said Dr. Orenstein. “People may not see these diseases so they don’t mean much to them. Since vaccines, we’re victims of our own success.” There’s also a lot of incorrect information circulating.

“We need to realize – and it’s been shown with COVID – that a decision not to vaccinate is not just a decision for your own child. It’s a community decision,” he pointed out. “It’s not my freedom to drive drunk, because not only do I put myself at risk, but others can’t control the car. We have speed limits and other examples where we restrict personal choice because it can adversely affect individuals.”

“My favorite line is vaccines don’t save lives, vaccinations save lives,” Dr. Orenstein said. “The vaccine dose that remains in the vial is 0% effective, no matter what the clinical trials show. And the issue, I think, is that we need to determine how to convince the hesitant to get confident enough to accept vaccination. For that, there is behavioral research; there’s a whole bunch of things that need to be supported. Just purchasing the vaccine doesn’t get it into the bodies.”

Dr. Kretsinger and Dr. Orenstein disclosed no relevant financial relationships .

A version of this article first appeared on Medscape.com.

Although the estimated annual number of measles deaths decreased 94% from 2000 to 2020, the COVID-19 pandemic took a toll on both measles vaccination and surveillance, according to a recent report in Morbidity and Mortality Weekly Report.

The number of World Health Organization member states that achieved more than 90% coverage with the first dose of the measles vaccine (MCV1) declined 37% from 2019 to 2020. In 2020, 23 million infants did not receive MCV1 through routine immunization services, and another 93 million were affected by the postponement of mass immunizations or supplementary immunization activities because of the pandemic. Also, endemic transmission was reestablished in nine countries that had previously eliminated measles.

But perhaps the most overlooked aspect of COVID-19 is its effect on surveillance.

“The entire COVID pandemic really put a lot of strain on the surveillance systems, not only for measles but for all vaccine-preventable disease, because there’s a lot of overlap in the staff who work for surveillance,” said Katrina Kretsinger, MD, a medical epidemiologist at the Centers for Disease Control and Prevention, who contributed to the MMWR report.

Because of the stress on the systems, a lot fewer specimens were tested, she said in an interview. And it’s not just measles that is at risk. This has had an impact on the Global Polio Eradication Initiative, which lost staff.

In addition, many vaccination campaigns “were postponed and curtailed throughout 2020,” Dr. Kretsinger said. The strengthening of surveillance systems – and immunization systems, more broadly – needs to be a priority.

“It’s not clear that the children who were missed during that year were subsequently caught up,” she explained. Having a “cohort of children who have missed measles vaccine creates the reservoir of susceptibility that will provide the nidus for the next big outbreak.”

Measles is the indicator disease. That could mean a resurgence of other vaccine-preventable diseases as well.

This report “was written by some of the world’s experts in measles, and it raises concerns about potential resurgence of measles,” said Walter Orenstein, MD, professor of medicine, epidemiology, global health, and pediatrics at Emory University, Atlanta. “Measles is sort of a canary in the coal mine. If you look at vaccine-preventable diseases, measles is probably the most contagious, so the herd-immunity threshold is highest. Usually on the order of 92%-94% immunity is needed to stop transmission.”

“Measles is the indicator disease,” he said in an interview. “That could mean a resurgence of other vaccine-preventable diseases as well.” Outbreaks don’t just affect the countries where infections are occurring, they “also affect our own domestic health security.”

“Some sort of periodic intensified routine immunization” would be helpful, said Dr. Kretsinger, who recommends “going through and selectively doing some sort of intensified efforts to catch children up early for the entire range of vaccines that they may have missed.”

“Some of these capture campaigns in areas that are thought to have the major problem would be very, very important,” agreed Dr. Orenstein. “A school entry check is one way of trying to look at kids, let’s say at 4-6 years of age, in schools around the world,” offering doses if they’re unvaccinated or inadequately vaccinated. “Another is to try to improve surveillance and try to understand if the cases are vaccine failure or failure to vaccinate.”

“Where the health systems are the most fragile is where those gaps will be the last to be filled, if they are at all, and where we have the basic concerns,” Dr. Kretsinger explained.

“Years ago, WHO recognized that vaccine hesitancy is a top global health threat,” said Dr. Orenstein. “People may not see these diseases so they don’t mean much to them. Since vaccines, we’re victims of our own success.” There’s also a lot of incorrect information circulating.

“We need to realize – and it’s been shown with COVID – that a decision not to vaccinate is not just a decision for your own child. It’s a community decision,” he pointed out. “It’s not my freedom to drive drunk, because not only do I put myself at risk, but others can’t control the car. We have speed limits and other examples where we restrict personal choice because it can adversely affect individuals.”

“My favorite line is vaccines don’t save lives, vaccinations save lives,” Dr. Orenstein said. “The vaccine dose that remains in the vial is 0% effective, no matter what the clinical trials show. And the issue, I think, is that we need to determine how to convince the hesitant to get confident enough to accept vaccination. For that, there is behavioral research; there’s a whole bunch of things that need to be supported. Just purchasing the vaccine doesn’t get it into the bodies.”

Dr. Kretsinger and Dr. Orenstein disclosed no relevant financial relationships .

A version of this article first appeared on Medscape.com.