Episode 119
119: Old Scourges, New Surges
Dr. Adam Ratner joins to discuss a case of facial swelling which leads to a conversation about vaccine hesitancy and current outbreaks.
Check out Booster Shots: The Urgent Lessons of Measles and the Uncertain Future of Children’s Health !
Episodes | Consult Notes | Subscribe | Twitter | Merch | febrilepodcast@gmail.com
Febrile is produced with support from the Infectious Diseases Society of America (IDSA)
Transcript
Hi everyone.
Speaker:Welcome to Febrile, a cultured podcast about all things infectious disease.
Speaker:We use consult questions to dive into ID clinical reasoning, diagnostics
Speaker:and antimicrobial management.
Speaker:I'm Sara Dong, your host and a Med-Peds ID doc.
Speaker:Today we are joined by Dr. Adam Ratner.
Speaker:He is a Professor of Pediatrics and Microbiology at NYU Grossman School
Speaker:of Medicine and the Director of the Division of Pediatric Infectious
Speaker:Diseases at Hassenfeld Children's Hospital and Bellevue Hospital Center.
Speaker:He also has recently written a book entitled Booster Shots, the
Speaker:Urgent Lessons of Measles and the Uncertain Future of Children's Health.
Speaker:We are excited to have Adam here.
Speaker:Today, he's sharing his opinions and not those of his institutions.
Speaker:As everyone's favorite cultured podcast, on Febrile, we like to ask our guests
Speaker:to share a little piece of culture.
Speaker:You know, just something that you enjoy or that brings you happiness.
Speaker:Sure.
Speaker:Um, so my happy place really is, uh, taking my dog for a walk in the park.
Speaker:Um, culture-wise, uh, you know, I, I love writing and I love reading and,
Speaker:and you know, the thing that I read most recently that I thought was fantastic
Speaker:is actually infectious disease related.
Speaker:It's, um, John Green's new book, which is, uh, Everything is Tuberculosis,
Speaker:which was just wonderfully written and, and beautiful and great.
Speaker:I, I even reached out to John Green's publicist.
Speaker:Just be like, I don't think you'd ever do anything small and ID oriented,
Speaker:but if you did, we would love to have you come talk on Febrile.
Speaker:I got to do an event with him, uh, around the time of his book launch, so
Speaker:I got to interview him about his book.
Speaker:We talked a little bit about my book.
Speaker:It was, it, it was like a dream come true.
Speaker:I mean, I, um, I've been a, a huge fan of his since my daughter
Speaker:and I read, um, uh, The Fault in Our Stars when she was younger.
Speaker:And so it's, it was great.
Speaker:That's awesome.
Speaker:Yeah, it's perfect.
Speaker:It's always nice when there's a little combo of the culture
Speaker:actually having an ID tie in.
Speaker:Well, I have brought a case to you today that we will talk
Speaker:through and get your thoughts on.
Speaker:So I'll give you a little bit of background.
Speaker:Uh, we have a nine-year-old boy who comes into the emergency room with his parents.
Speaker:He initially had said he had a little bit of ear ache on the right that
Speaker:started a couple days ago, and his family started to notice increased
Speaker:swelling of his face and jaw.
Speaker:And so the swelling was mostly on the right side.
Speaker:They feel like at this point though, that maybe his left jaw is a little
Speaker:bit more swollen as well, and so on exam you can see that he has swelling
Speaker:of his parotid gland bilaterally, but the right is certainly more
Speaker:pronounced than the left and kind of obscuring that angle of the mandible.
Speaker:He is otherwise healthy, has had no prior medical problems,
Speaker:has never been on medication.
Speaker:He received some initial vaccines through about the age of nine
Speaker:months, but he otherwise has not received any additional vaccinations.
Speaker:So, you get called by the emergency room.
Speaker:What's kind of going through your mind as you're thinking about this kid?
Speaker:Sure.
Speaker:So I'm assuming that, that he doesn't have fever or other systemic symptoms
Speaker:that are prominent as, as part of this, just based on the description.
Speaker:You know, the initial symptoms could be acute otitis media, although
Speaker:then the, the swelling and the parotids would be strange after that.
Speaker:Um, he could have, uh, a dental source for, for an infection.
Speaker:I mean, certainly that can give you ear pain to start with and
Speaker:then, and then pain, you know, in the area of, of the jaw.
Speaker:But again, you wouldn't necessarily expect swelling of the glands.
Speaker:You know, the most likely thing is, uh, parotitis.
Speaker:So, you know, some kind of inflammation of the parotids.
Speaker:And, you know, things that I'm thinking about are acute
Speaker:suppurative parotitis, which is usually but not always unilateral.
Speaker:It's often polymicrobial.
Speaker:Uh, Staph aureus is most common, but you can have group A strep, Strep
Speaker:pneumo, Haemophilus, like, and, and lots of oral organisms can do it.
Speaker:Um, you can get granulomatous infiltration.
Speaker:Um, if you have, MAI or MTB, which would be rare in this
Speaker:circumstance or Bartonella.
Speaker:Um, so those all kind of go under the heading of acute suppurative parotitis.
Speaker:And then under non-suppurative parotitis, I would think about, um,
Speaker:still some infectious causes, so mostly viral causes of, of parotitis.
Speaker:Um, first on the list would be mumps, especially because you said that this
Speaker:is a kid who got vaccinated up until nine months and then not since then.
Speaker:So in a child who hasn't received the measles, mumps, rubella vaccine, which
Speaker:we usually give at, at 12 to 15 months, I'm thinking about mumps in this child.
Speaker:There's a long list of other viruses that can give you parotid inflammation.
Speaker:You know, the CMV, EBV, influenza, parainfluenza, some of the
Speaker:enteroviruses including coxsackievirus.
Speaker:Um, there are some herpes viruses that can do it like HSV1 or 2, like HHV six.
Speaker:Uh, there are reports of COVID associated parotitis.
Speaker:Um.
Speaker:Rarely LCMV.
Speaker:HIV uh, untreated HIV can, can be a cause of, of parotitis.
Speaker:Again, I think the many of these are, are much lower on the list.
Speaker:And then there are non-infectious causes, some of which can
Speaker:cause bilateral parotitis.
Speaker:Um, often they're, uh, unilateral.
Speaker:Um.
Speaker:You know, a sialolithiasis just blockage of a, of a, um, duct can,
Speaker:um, can give you parotid swelling.
Speaker:Chronic recurrent parotitis, which can be due to problems in
Speaker:salivary production or drainage.
Speaker:There's this entity called juvenile recurrent parotitis, which I don't
Speaker:understand well, and I think nobody really understands that well.
Speaker:But that can happen.
Speaker:Um, and then there are, there are autoimmune things.
Speaker:Sjogren's syndrome, sarcoid.
Speaker:I suppose Kawasaki can be a cause of parotitis.
Speaker:Um, I'm running out of things, but, but I, I think that, you know, based
Speaker:on how he looks at least per the description, I think less likely
Speaker:acute suppurative parotitis, I think more likely a viral cause.
Speaker:Although you, you know, it's hard to rule out one of the
Speaker:autoimmune things at the beginning.
Speaker:Yeah.
Speaker:And you know, that's, we have this big list.
Speaker:How would you approach at least sort of your first batch of testing?
Speaker:Like, what would you prioritize for this, uh, this child?
Speaker:Yeah, so I mean, I'd wanna take a look in his mouth.
Speaker:I'd, I'd wanna look at the, at, at stenson's duct I could and, and, you
Speaker:know, maybe see if you can either see or feel a stone, because if
Speaker:this is, is truly a mechanical thing than your approach is different.
Speaker:You're, you're calling someone to take a look and, and see if that can be removed.
Speaker:There are sort of basic labs.
Speaker:I, I would look at, you know, a CBC, a set of electrolytes, you
Speaker:know, with, with mumps you would expect a, uh, a, some leukopenia,
Speaker:but maybe a relative lymphocytosis.
Speaker:Some viral testing and I think we can be a bit judicious at the
Speaker:beginning in terms of, of that.
Speaker:Depending on the season, you might send, you know, influenza testing because
Speaker:that would be actionable if positive.
Speaker:Um, COVID testing.
Speaker:Maybe EBV and CMV and, and certainly a mumps PCR and maybe
Speaker:a, maybe a mumps IGM as well.
Speaker:The mumps PCR, you, you would try to get some parotid gland
Speaker:secretions for, for that.
Speaker:It's my understanding, I haven't done this in a while, but I think that you have to
Speaker:massage the parotid gland for, uh, for 30 seconds or something before you collect
Speaker:the, the sample to get maximum yield.
Speaker:And I would call my local public health department at this point, not
Speaker:so much because I wanna report a case of mumps, but if I'm sending mumps
Speaker:testing, I'm calling them because often, and this is true with measles
Speaker:testing, at, at least for us in New York City, they can turn these things
Speaker:around much faster than either our lab or a, uh, a commercial lab can.
Speaker:So they may be helpful in terms of, of diagnostics.
Speaker:And then the, you know, the other thing that you could think about, depending on
Speaker:how the kid looks, is either a sonogram of the area or I suppose if you want
Speaker:detailed imaging, you could do a CT, but I would probably start with a sono unless
Speaker:Yeah.
Speaker:exam gave you something obvious.
Speaker:Yeah.
Speaker:And you know, we'll say we at least have a CBC back.
Speaker:We just have some mild leukocytosis at the moment.
Speaker:Um, We're working on sending off some of this additional testing, you
Speaker:mentioned kind of just an intro of like, flu, EBV, CMV, and then we've
Speaker:touched base with, um, our health department and, and infection control.
Speaker:Just to ask the questions about sending off mumps PCR 'cause um.
Speaker:I didn't say it, but that's what the emergency room has called you for.
Speaker:So, you know, while we're waiting for the results, they
Speaker:ask what should we think about?
Speaker:Like say this was mumps, what are complications?
Speaker:'cause we haven't seen it and we don't really know what to think about.
Speaker:Yeah, we, we, we still do not see it a lot, uh, whi which is good
Speaker:because most people are vaccinated.
Speaker:The, the things that you worry about with mumps infection, so, so kids
Speaker:present like this child usually though, so fever, maybe some headaches
Speaker:and myalgias, parotid swelling.
Speaker:It's often unilateral followed by then swelling of the contralateral gland.
Speaker:But, but sometimes it can only be, you know, it can just be unilateral.
Speaker:The reason that we worry about mumps is you can get orchitis in about
Speaker:30% of cases that are unvaccinated.
Speaker:It, it's much lower, but not zero in, in cases that happen in vaccinated people.
Speaker:The orchitis is usually unilateral, but can be bilateral, and so I
Speaker:think it's 90% unilateral and, and in 10% of cases can be bilateral.
Speaker:That's relevant because you can get testicular atrophy after mumps
Speaker:orchitis, and so there can, if you have bilateral orchitis, there
Speaker:can be effects on fertility later.
Speaker:Uh, oophoritis also happens.
Speaker:Um, it's less frequent than orchitis.
Speaker:Um, but, and it can be harder to, to diagnose, but that,
Speaker:that is also a concern.
Speaker:You get aseptic meningitis in about 1% of kids with mumps.
Speaker:Although my understanding is that if you, if you do taps on a larger number of kids,
Speaker:you find that most of them have a mild lymphocytic pleocytosis, even if they
Speaker:don't have symptoms of aseptic meningitis.
Speaker:I'm not advocating tapping this well appearing child, but I, but
Speaker:just to throw that out there, um.
Speaker:You know, and then more rarely you can have some important,
Speaker:uh, downstream complications.
Speaker:So hearing loss happens in a small percentage of, of
Speaker:kids, but can be permanent.
Speaker:Some kids get pancreatitis or, um, myocarditis.
Speaker:Older kids and adults really are more likely to have most of these
Speaker:complications, like they happen at higher rates in, in unvaccinated adults.
Speaker:Um, so I, I think that's where I would start in terms of, of why I,
Speaker:why I worry about kids with mumps.
Speaker:Yeah.
Speaker:Perfect.
Speaker:So I'll kind of speed us along.
Speaker:We did do an ultrasound of the area, didn't really identify an abscess
Speaker:fortunately, or an obvious stone.
Speaker:Wasn't identified on exam or that ultrasound.
Speaker:Um, there was discussion and attempt to look and see if drainage could be sent
Speaker:off of the Stenson duct, but really they weren't expressing anything.
Speaker:Um, so that wasn't sent off and we ended up getting back an EBV test that
Speaker:was suggestive of acute infection.
Speaker:Um, and fortunately our, our mumps testing, which was
Speaker:sent off is, is negative.
Speaker:So fortunately this is great, right?
Speaker:Our kid doesn't have mumps.
Speaker:They have EBV, which would be a very common explanation for this.
Speaker:Um, but you know, now that you're here with the family, we have this opportunity,
Speaker:uh, to talk a little bit about vaccines.
Speaker:'cause, you know, lots of people have been going in the room and asking them, Hey, do
Speaker:you remember if he got this MMR vaccine?
Speaker:Um, and we of course that mumps is preventable with immunization.
Speaker:Everyone who listens to Febrile I'm sure knows that, but, at least my
Speaker:approach, at least to start, is when I encounter patients or families that
Speaker:have not received certain vaccines or have expressed vaccine hesitancy,
Speaker:I ask, you know, what their concerns are, exploring that with, can you tell
Speaker:me a little bit about what worried you about the MMR vaccine, or can you share
Speaker:what you've experienced and so I'll let you know that we started that and the
Speaker:parents share that they just felt like their son had gotten too many vaccines.
Speaker:All these antigens that they've read about online.
Speaker:They're really worried and they also share that they kind of just felt like,
Speaker:you know, if he got natural infection, that immunity might be better and
Speaker:that everyone that they knew who had chickenpox and mumps when in the past.
Speaker:Everything was fine and that they can be vigilant and try to deal
Speaker:with natural infection if it comes.
Speaker:And so I will open it up to you on like how, how do you
Speaker:move this conversation forward?
Speaker:What would sort of be your approach?
Speaker:Sure.
Speaker:And, and you've done a lot of the, the heavy lifting at the beginning already.
Speaker:I mean, the, that, and that's, that's how I would open this conversation also.
Speaker:I mean, I'll, I'll start by saying that I'm a, a hospital based ID doctor.
Speaker:I'm not a primary pediatrician, and the primary pediatricians are the
Speaker:superheroes of having these conversations.
Speaker:And I think that when we have these conversations, ID folks in
Speaker:a, in a hospital setting, it's a different kind of conversation.
Speaker:Like either it's something like this where it's a child where we were
Speaker:worried about a vaccine preventable disease and then it didn't end up
Speaker:being this, or I've had a lot of these conversations with kids who, you know, are
Speaker:hospitalized for measles or hospitalized for flu, and so, they're, they're in
Speaker:a situation where the child is sick.
Speaker:It, it can be an emotionally fraught situation.
Speaker:I still think it's important to at least begin the, the conversation,
Speaker:but it can be, it can be hard.
Speaker:You have to be careful that the conversation doesn't go off the rails.
Speaker:That, that they don't think that you're blaming them for anything.
Speaker:I mean, thi this is, I, I think probably a more comfortable situation where
Speaker:you say, okay, we were worried about this because of the vaccine status.
Speaker:Now let, let's have a conversation.
Speaker:Um.
Speaker:And I think figuring out what the concern is is really important because it's
Speaker:a different conversation if there's one vaccine that the parents are,
Speaker:are frightened about and it's because of one thing that they heard online,
Speaker:and you can really zoom in on that.
Speaker:Um, I've gotten a lot of that with, with flu vaccine discussions where
Speaker:parents are like, well, every year there's a, you know, there's an
Speaker:article that says that the flu vaccine is only 20 or 30% effective, so I
Speaker:just feel like it's not worth it.
Speaker:And they, you know, they've gotten their kid vaccinated against everything else.
Speaker:Totally different conversation than, you know, we, we think that, you know,
Speaker:vaccines are gonna harm our child, or, you know, we think it's too many too soon.
Speaker:There, there are all of these other things.
Speaker:So, I mean.
Speaker:For, for this family, I might sit and talk to them specifically about mumps a
Speaker:little bit, and because that's, that'll be sort of front of mind for them and what I
Speaker:would worry about and the fertility thing.
Speaker:And then I would talk about, you know, measles and how
Speaker:that can be dangerous as well.
Speaker:And then, you know, you may not be able to move the needle in terms
Speaker:of, of convincing them that vaccine immunity is, is worth getting and
Speaker:is better than natural immunity if you know, in to use their words.
Speaker:Um, you know, I, I think.
Speaker:We can also bring up, I, I think this resonates with some families, the idea of,
Speaker:you know, vaccines as a way of protecting not just your child and obviously you
Speaker:want to protect your child, but also pitching in to protect the community.
Speaker:And I'll, you know, I'll talk about kids who can't get vaccinated, you know.
Speaker:Older people who may have been vaccinated and, and had waning
Speaker:immunity and that we try to stop these things from circulating to protect
Speaker:young kids and kids who are getting chemotherapy and, and folks like that.
Speaker:A lot of it depends on kind of the particulars of how the conversation
Speaker:goes and what they seem to respond to.
Speaker:And often the best you can hope for is to start them thinking about it, you know?
Speaker:Encourage them to have another conversation with their pediatrician
Speaker:when they go back there and maybe, maybe you make some headway.
Speaker:Yeah.
Speaker:And uh, I think the point you made about how so many of these conversations
Speaker:are not happening when we see them as consultants in the hospital is so vital.
Speaker:And, you know, you made me think about, I had a, I was having a conversation
Speaker:with some other peds peds folks recently about how challenging it is to talk about
Speaker:it in the inpatient setting, especially if perhaps that child has a pretty
Speaker:devastating infection from something that they could have been vaccinated against.
Speaker:And I think everyone who's a pediatrician sees a really bad
Speaker:case of flu, at least a year.
Speaker:And I was wondering if, you know, with your experience, for example,
Speaker:with the measles outbreak that you talk about in New York, uh.
Speaker:Are there any other sort of tools or, or, or advice that you give to people
Speaker:who are potentially navigating these types of challenging discussions, which
Speaker:at baseline are hard, but even harder when a child already is experiencing
Speaker:some symptoms, some something impacting their, their health already.
Speaker:Yeah, it's, uh, it's not easy.
Speaker:Um, and, and I think that you need to make sure that everyone is on the same
Speaker:page in terms of the family should understand that I know that they love
Speaker:the, their kid and that they are trying to protect their child and that they
Speaker:want the same thing that I'm trying to do, which is for their kid to grow
Speaker:up and be happy and, and healthy.
Speaker:And if you can start from that point of alignment where they know, that
Speaker:I'm willing to sit and talk to them and that I'm not judging them and
Speaker:that I really, really do want their kid to get better and, and want their
Speaker:kid to be as, as healthy as they can.
Speaker:And they know that I know that about them.
Speaker:I think that really helps.
Speaker:You know, am I ever frustrated by the of, of course, like it's, it is enormously
Speaker:frustrating to be in a situation where you're, you're taking care of a sick child
Speaker:and, and it was a preventable disease.
Speaker:I've seen a number of kids over the last couple of years with HiB
Speaker:meningitis, um, which I had never seen for like the prior 30 years, and it's.
Speaker:It's a horrible disease and it was totally preventable and it's,
Speaker:it's unbelievably frustrating.
Speaker:But that just, even just from a, a totally practical point of view, going in with
Speaker:that message doesn't help.. Like, it's not gonna bring anyone closer to vaccinating.
Speaker:It's, you know, it's gonna make the parents feel attacked.
Speaker:It's going, they're gonna lash out and say, why don't you just focus
Speaker:on, on getting my child better now?
Speaker:And then, you know, you've sort of lost that opportunity to talk.
Speaker:So I, I think spending time on that alignment at the beginning.
Speaker:And, you know, and then you can take your own feelings later and, and
Speaker:talk about them with someone else.
Speaker:But, uh, but that's, that's really important.
Speaker:Yeah, yeah.
Speaker:And like you were saying.
Speaker:Opening it up so that they have more conversations with
Speaker:perhaps their pediatrician that they trust in the future.
Speaker:Um, and you know, I of course wanna point to your recent book.
Speaker:I know I have, uh, several colleagues of mine that have really enjoyed Booster
Speaker:Shots and you talk about measles as being this quintessential human pathogen and
Speaker:kind of case example and your experiences, but also historical perspectives.
Speaker:And, we are obviously in a very abnormal year for measles cases in the
Speaker:US and you know, I think naturally many healthcare professionals are struggling
Speaker:and feel like messaging is challenging.
Speaker:And I was wondering for you, as someone, you know, you've written this book,
Speaker:but also as a leader in your division and and with your experience, are there
Speaker:examples of ways that you encourage people to advocate beyond, you know,
Speaker:we all do daily one-on-one or family conversations in clinical practice, but
Speaker:like as a trainee or an early career physician, how, how should we think about
Speaker:advocating for vaccines on a larger scale and or sort of how can we improve the
Speaker:way we communicate as ID specialists?
Speaker:Yeah, I, I think, you know, if ever there was a time that we needed people
Speaker:to be out there, this is that time.
Speaker:And that can be, you know, finding specific causes that you're, you
Speaker:know, passionate about in contacting your representatives and doing that.
Speaker:Just like any citizen can.
Speaker:Often I have, I have, you know.
Speaker:People who are not in medicine ask me this question.
Speaker:And I, I say that one thing that that is I think very powerful that doesn't happen
Speaker:a lot is, when you're a parent and you're at the playground or in the store or
Speaker:whatever, like the messages that people hear tend to be anti-vaccine messages.
Speaker:They are much louder than we are.
Speaker:And not that we have to be loud, but I think that conversations
Speaker:where we normalize vaccination because most families still, the
Speaker:vast majority of families get their kids vaccinated on schedule.
Speaker:And so saying at the playground, Hey, I took my daughter to,
Speaker:you know, to get her MMR today.
Speaker:Not saying anything else, not saying, you know, you should do this or
Speaker:whatever, but like, making that part of the conversation, I think helps a lot.
Speaker:Um.
Speaker:In terms of what physicians can do, have that conversation within your
Speaker:family, even if it's uncomfortable.
Speaker:I mean, I, I do not recommend burning bridges.
Speaker:Uh, I try hard not to burn bridges in my own family.
Speaker:Um, we all have challenging family members, but like, it's easier to
Speaker:shy away from the conversations.
Speaker:You try not to let them devolve into yelling, but you put good
Speaker:information out there as best you can.
Speaker:It's, uh, it is not easy.
Speaker:Um, I've been lucky in that, you know, this book has come out at a time when
Speaker:we have a large measles outbreak.
Speaker:There's a lot of interest.
Speaker:I've gotten to do a lot of press and, and have had a, a bigger voice than I've,
Speaker:I've had before and I've been lucky to be able to talk about vaccines and talk
Speaker:about things that are important out there.
Speaker:But, but I think we can all do that.
Speaker:And, and of course like if you want to like write op-eds, write, you
Speaker:know, like, like to the extent that you're comfortable, like get out there
Speaker:and do that kind of thing as well.
Speaker:Yeah, so , I actually wanted this episode to serve as a really a kickoff for a few
Speaker:episodes related to vaccine preventable illnesses, which are of course on the
Speaker:top of everyone's mind, and, today we've chatted a little bit about mumps.
Speaker:We have two additional episodes that are gonna follow this discussing, um,
Speaker:two other vaccine preventable illnesses.
Speaker:I won't spoil the topics quite yet.
Speaker:Um, for those who haven't listened to it already.
Speaker:I encourage you to check out our prior episode number 102: Rubeola Response.
Speaker:This shared a measles outbreak response from a team of ID docs,
Speaker:really from the perspective of the hospital epidemiology team.
Speaker:And maybe I'll, um, ask you, Adam, to give a few thoughts on measles,
Speaker:particularly given your new book.
Speaker:Um, and then I can update with the latest case numbers right before
Speaker:we post the episode as well.
Speaker:Yeah, I mean, we are having quite a year for vaccine preventable diseases.
Speaker:As I'm sure the whole audience knows, there is a large measles
Speaker:outbreak now in Texas and New Mexico and Oklahoma and Kansas.
Speaker:That appears to be one large outbreak.
Speaker:Um, and that, that is now well over 500 cases, it may be over 600 at this point.
Speaker:Um, there are also now outbreaks in Indiana and Ohio.
Speaker:Um, I saw a, an alert just in the past couple of days that there
Speaker:are more cases in Philadelphia.
Speaker:It's not just one place in the US and I think that there are a couple
Speaker:of things going on with that.
Speaker:I mean, we had nationwide a reasonable kindergarten MMR vaccination
Speaker:coverage rate, prior to the COVID-19 pandemic, it was about 95%, but that
Speaker:nationwide rate masks state to state variability, and then community to
Speaker:community variability within states.
Speaker:The overall rate has dropped.
Speaker:We're below 93% for kindergarten MMR, and and falling for As, as a nationwide rate.
Speaker:And then even in states where you have good coverage across the states.
Speaker:So the Texas overall rate is about 94%, but the Gaines County rate where
Speaker:the, where the outbreak started and is, is, uh, is concentrated, is about 80%.
Speaker:And we saw a very similar thing in 20 18, 20 19 in New York City where the
Speaker:citywide rate, um, for MMR vaccination in kindergarten was about 98%, so I
Speaker:wouldn't have thought that we would be at risk, but if you look on a, a zip
Speaker:code level or a neighborhood level, it was more like 80% in, you know, in
Speaker:the specific communities that, that were really involved in the outbreak.
Speaker:And so I, I'm worried about measles in particular because it's so
Speaker:contagious and so dangerous for kids.
Speaker:We've, you know, at the time we're recording this, there've been
Speaker:two pediatric deaths, one adult death in the measles outbreak.
Speaker:But I'm also worried because measles is the canary in the coal mine.
Speaker:It's the bellwether because it's so contagious and it, it means
Speaker:that there's likely to be much more than just measles going on soon.
Speaker:And we're, we're seeing that already.
Speaker:Like there have been a ton of pertussis cases.
Speaker:Um, there were two deaths of, of infants in Louisiana from pertussis
Speaker:just in the, in recent weeks or months, and, that I, I fear will
Speaker:also become a, a nationwide trend.
Speaker:So there's, you know, there, there's the worry that we're not gonna get
Speaker:this measles outbreak under control.
Speaker:But even if we get this specific one out under control, I'm worried with
Speaker:falling vaccination rates that more frequent and larger outbreaks of measles
Speaker:are gonna be common, and that more frequent and larger outbreaks of other
Speaker:vaccine preventable diseases are coming.
Speaker:And so just to give a quick update, as of May 11th, 2025, the United States has a
Speaker:total of over a thousand confirmed measles cases reported from 31 jurisdictions.
Speaker:These cases have been in about 30% with children under five years of
Speaker:age, 38% of those who are five to 19 years old, and the remaining
Speaker:in adults 20 and older or unknown.
Speaker:96% were unvaccinated.
Speaker:13% of measles cases have been hospitalized , and there have
Speaker:been three confirmed deaths.
Speaker:Back to the episode.
Speaker:Yeah, and this que question isn't probably totally fair, but if
Speaker:you had the opportunity to make a couple decisions, that, like, let's
Speaker:say it's, it's totally up to you.
Speaker:What would be the things that you would be most focused on for us to support
Speaker:the kids that we take care of, um, and sort of getting through these outbreaks?
Speaker:I mean, there, there is so much that I would change about what's going on now.
Speaker:I mean, and it, it goes way beyond vaccines as you might imagine.
Speaker:Like I am from a, a, a children's health overall point of view, I am
Speaker:really, really worried about Medicaid.
Speaker:I mean, so many of our patients are dependent on Medicaid for their
Speaker:coverage, for their ability to get care.
Speaker:Um, I'm, I'm worried about the vaccines for children program.
Speaker:I'm worried about state and local health departments being able
Speaker:to provide even basic functions.
Speaker:And just in the last couple of days, um, CDC, it appears, has been unable to
Speaker:respond to a request for help from I think it was Wisconsin that was asking for help
Speaker:with an issue with lead contamination.
Speaker:And CDC did not have the manpower to do it.
Speaker:There is so much that we need to fix.
Speaker:So much that has gone wrong just in the last couple of months.
Speaker:Um, and I mean, like I, I'm an ID person, I'm a vaccine per, like,
Speaker:that's the stuff I think about most.
Speaker:But it, it's, in terms of child health, it just goes way beyond that.
Speaker:Yeah.
Speaker:Yeah.
Speaker:And I feel like we're feeling it in our, our patients too.
Speaker:I had, I spent a really long time talking to someone about measles vaccination
Speaker:yesterday because she has young kids.
Speaker:And, she had perceived from the news like, well, how would I know
Speaker:if there's measles in my community?
Speaker:What if there aren't people who are surveilling and, and
Speaker:communicating that there's a case and that I should be worried?
Speaker:And, um, it, it really is causing everyone across the board so much anxiety.
Speaker:Yeah.
Speaker:And I, I think there's worry about that even in Texas now, with the cuts to
Speaker:local health departments, they've had to scale back on vaccination clinics.
Speaker:I don't know the state of surveillance there.
Speaker:I mean, we're still getting updates from them, but I, I hope that
Speaker:robust testing is still available.
Speaker:I, I think we all think that the case numbers that are being reported
Speaker:are, are a vast underestimate.
Speaker:That's my understanding.
Speaker:Um, and so I, I worry about our ability to get good data.
Speaker:Yeah.
Speaker:And so usually at the end I open it up to see if there are additional points, but
Speaker:maybe today we can pivot and, and focus a little bit on just asking if you wanted
Speaker:to share something that you love about ID.
Speaker:You know, we focused a little bit on, on things that have felt like
Speaker:setbacks and things that we wanna improve, but I thought it would
Speaker:be nice to sort of reorient as we close out on a, on a positive note.
Speaker:Yeah, I mean, I, I still, there are challenges, but I still
Speaker:love taking care of patients.
Speaker:I love being on service.
Speaker:I love the puzzles of ID, I love getting to work with trainees.
Speaker:Um, I feel very, very lucky to still have a career where I get to combine
Speaker:research and teaching and seeing patients and, uh, you know, I write on the side.
Speaker:And so it's been, you know, it, it's all around the theme of, of infectious
Speaker:diseases, but I've just, I feel very lucky to have been able to be part of that
Speaker:and to still be able to be part of that.
Speaker:Yeah, I guess I should ask, any tips for folks to be more active writers,
Speaker:you know, you wrote this, this book, and we often talk about struggling to,
Speaker:to fit writing into our academic life, but you know, it tips that you've used.
Speaker:Yeah, if I, I, not easy.
Speaker:Um, it, it's, you know, I started writing this book in 2019.
Speaker:Um, you know, at the, at sort of the tail end of the, the New York City outbreak
Speaker:before anyone had ever heard of, of Covid, I decided I wanted to write a book about
Speaker:measles because I'd learned so much in the outbreak, and it, you know, it, it
Speaker:changed the way I thought about measles.
Speaker:It changed the way I thought about vaccines and the anti-vaccine lobby.
Speaker:And I, I thought it was this great metaphor for, you know, many things
Speaker:that were going on in children's health.
Speaker:And I, you know, I, I told my wife, who's also a physician that I, I, I think
Speaker:I'm gonna write a book about measles.
Speaker:And she was like, that's great.
Speaker:Why would anyone read a book about measles?
Speaker:And I was like, okay, fair enough.
Speaker:Um, and like I started working on it and, and then we had covid and
Speaker:it's that, once again changed how I thought about ID and, you know,
Speaker:everything really, you know, it, it changed the way that we worked.
Speaker:It changed the way that I thought about public health and I, you know,
Speaker:it also changed how I was thinking about this book and about measles, and
Speaker:I tried to incorporate what I thought that measles could have taught us
Speaker:that would've been useful in in the setting of the Covid pandemic and.
Speaker:You know how to fit writing it.
Speaker:It took me years to write this, but it took four years, give
Speaker:or take to to write the book.
Speaker:I am so lucky that I had this project though during Covid because I feel like
Speaker:everyone needed something that wasn't just taking care of patients and going to work
Speaker:and coming home from work and worrying about my family and, and you know, all
Speaker:the other things that we were all doing.
Speaker:And this was my project.
Speaker:Um, and it's a little weird that my project to take me away from a pandemic
Speaker:was reading about old pandemics.
Speaker:But, but it was, but it worked.
Speaker:Um, and I, it took me longer than I thought to write, in part
Speaker:because I kept getting pulled into more and more covid things.
Speaker:Um, but it also helped me get through the challenges of Covid to have that project.
Speaker:There were points along the way.
Speaker:It, it was a small number.
Speaker:It was probably two or three points along the way where I really needed to push
Speaker:to get, you know, a final draft done or to get final edits done or something.
Speaker:And my dog and I left and we went somewhere together
Speaker:and it was the two of us.
Speaker:And we worked on the book for a few days, and then we came home.
Speaker:Um, and
Speaker:Nice.
Speaker:because my, my, you know, my child is an adult now, and I could do the,
Speaker:you know, I had the privilege of being able to, to do that, but that.
Speaker:You know, that helped me a lot.
Speaker:What I learned about myself as, as a writer, was that I could fit
Speaker:doing background research and, and drafting some things into my
Speaker:schedule, because those were things that I could do with 15 minutes
Speaker:here or half hour there if I had it.
Speaker:Um, but that there were times when I really needed to, to sit and focus, and
Speaker:I, I was lucky that I was able to do that.
Speaker:Yeah.
Speaker:And it's true.
Speaker:I feel like it's, some people are really good at scheduling, you know,
Speaker:times that fit into other things, but sometimes I'm the same way.
Speaker:I often need kind of a dedicated chunk, um, to, I think mostly for
Speaker:me to sort through my own thoughts.
Speaker:Yeah, it's, it's very hard because there, there will never be a time when
Speaker:my to-do list gets to zero, as I imagine is true for everyone listening to this.
Speaker:You know, like, I'm never gonna clear the decks and, and be like, okay,
Speaker:now I can finally sit down and write.
Speaker:Like, it has to be something that makes it onto that list where, you know, yes.
Speaker:I mean, some people say, you know.
Speaker:Make sure you have 15 minutes, 30 minutes every single day.
Speaker:That didn't happen for me.
Speaker:Um, but, you know, if I'm on service, I'm not sitting and
Speaker:doing 30 minutes of writing a day.
Speaker:I'm, I'm on service all the time.
Speaker:But I, you know, during times when I wasn't, during times when I could
Speaker:carve out little pieces, I, I did.
Speaker:Well thank you so much for coming today and, uh, talking to the Febrile audience.
Speaker:No, I'm just really grateful to have the chance to to be here.
Speaker:Thank you for inviting me and this was super
Speaker:So a big thanks to Adam for joining Febrile Today.
Speaker:Be sure to check out his book, booster Shots, the Urgent Lessons
Speaker:of Measles and the Uncertain Future of Children's Health, available now.
Speaker:As we mentioned earlier, you can check out our prior episode on
Speaker:measles called Rubeola Response, episode number 1 0 2 of Febrile.
Speaker:And then stay tuned for two more episodes related to Vaccine preventable diseases.
Speaker:Please check out the website febrile podcast.com, where you'll find the consult
Speaker:notes, which are written supplements to the episodes with links to references,
Speaker:our library of ID infographics, and a link to our merch store.
Speaker:PEP is produced with support from the Infectious Diseases Society of America.
Speaker:Please reach out if you have any suggestions for future shows or
Speaker:wanna be more involved with febrile.
Speaker:Thanks for listening.
Speaker:Stay safe and I'll see you next time.
