Confirmed case of polio in the US signals need to increase vaccination rates

 - Jennifer Middleton, MD, MPH

In the Midwest United States (US) in the early 1950s, two of my uncles contracted poliomyelitis ("polio"). One recovered uneventfully; the other required months of respiratory support with an iron lung. Thanks to vaccination against poliovirus, those of us born in the US since 1955 mostly have known only of polio through family stories like these. News of a confirmed polio case in New York (NY) state earlier this summer, however, has brought polio back into our awareness. 

According to the US Centers for Disease Control and Prevention (CDC), most cases of poliovirus infection are asymptomatic. Approximately 25% of infected persons will experience flu-like symptoms, 1-5% will have meningitis, and between between 1 out of 200 persons to 1 out of 2000 persons will experience paralysis of limbs and, potentially, the muscles that control breathing. The CDC notes that only persons with paralytic disease, by definition, have poliomyelitis (or "polio"). Poliovirus "lives in an infected person's throat and intestines," and infected persons can shed the virus for weeks. The New York State Department of Health launched a poliovirus wastewater surveillance program after this individual's diagnosis was confirmed, which has since detected poliovirus in 4 counties in and around where the diagnosed individual lives. 

In the US, only inactivated polio vaccine (IPV) is administered, but many other countries rely on oral polio vaccine (OPV). OPV is attentuated but live, and unvaccinated persons can contract this attenuated virus:

VDPVs [vaccine-derived poliovirus] can emerge when live, attenuated OPV is administered in a community with low vaccination coverage. Replication of OPV in a person who was recently vaccinated can result in viral reversion to neurovirulence, which can cause paralytic poliomyelitis in unvaccinated persons who are exposed to the vaccine-derived virus.

The individual in NY state with polio had "[v]accine-derived poliovirus type 2 (VDPV2) ...detected in stool specimens obtained on days 11 and 12 after initial symptom onset." Since OPVs haven't been administered in the US since 2000, this individual would presumably have caught poliovirus from an individual vaccinated outside of the US; "[e]pidemiologic investigation [has] revealed that the patient attended a large gathering 8 days before symptom onset and had not traveled internationally during the presumed exposure period." 

The wastewater reports indicate that VDVP2 has spread through this four-county area in the southeast corner of the state. Vaccination levels in the diagnosed individual's county are relatively low, with "3-dose polio vaccination coverage among infants and children aged <24 months living in Rockland County [at] 67.0% in July 2020 [which] declined to 60.3% by August 2022, with zip code–specific coverage as low as 37.3%." The NY State Department of Health has been working with local physicians and health care systems to increase IPV vaccination.

The COVID-19 pandemic has resulted in delayed and missed preventive care for countless persons, including a marked decrease in routine vaccination administrations. The reemergence of polio in NY state should prompt all of us to reassess our patients' vaccination status and engage in targeted, deliberate efforts to increase vaccinations. Office reminder and recall interventions can increase vaccination rates, as can physician face-to-face counseling with parents. This 2016 AFP article on "Strategies for Addressing and Overcoming Vaccine Hesitancy" has many useful tips, and a new online guide developed by Canadian researchers to address COVID-19 vaccine hesitancy, which was recently described in the Annals of Family Medicine, also contains useful strategies.

The evidence is in: WIC improves maternal and child health

 - Kenny Lin, MD, MPH

Food insecurity is increasingly recognized as a modifiable social determinant of health. The American Academy of Family Physicians has endorsed "sustained funding for evidence-based policies and programs to eliminate disparities in healthy food access, including ... the Special Supplemental Nutritional Program for Women, Infants, and Children (WIC)." In a 2019 editorial about interventions to reduce maternal mortality, Drs. Katy Kozhimannil and Andrea Westby recommended postpartum screening for food insecurity. But how strong is the evidence that WIC improves maternal and child health?

Since 2012, American Family Physician's Implementing AHRQ Effective Health Care Reviews feature has summarized dozens of primary care-relevant systematic reviews from the Agency for Healthcare Research and Quality's Effective Health Care Program with accompanying clinical commentaries. A team of investigators in this program recently reviewed maternal and child outcomes associated with WIC and published a synopsis of their report in Annals of Internal Medicine. Investigators identified 82 studies that examined associations between WIC participation and maternal, birth, infant, and child health outcomes.

Based on direct evidence from 49 studies, they concluded that WIC participation likely reduces the incidence of preterm birth, low birth weight, and infant mortality. Lower strength of evidence suggested WIC is associated with less inadequate gestational weight gain and alcohol use and better diet quality during pregnancy, and it may increase child preventive care visits and immunizations. WIC was not associated with differences in breastfeeding rates or premature (before 4 months) introduction of solid foods. Children of families receiving WIC had better diet quality, increased household purchasing of healthy foods compared to less healthy foods and beverages, and higher cognitive development than WIC-eligible children not receiving benefits. There was insufficient evidence that WIC reduced childhood obesity or affected health status or risk of hospitalization.

The U.S. Department of Agriculture (USDA) found that food insecurity in households with children declined to its lowest rate in two decades in 2021, despite the negative impact of the COVID-19 pandemic on the economy. The nonpartisan Center on Budget and Policy Priorities observed:

About 10.2 percent of U.S. households were food insecure in 2021, meaning they struggled to afford enough food for an active, healthy life year-round. That the rate held steady during the pandemic — when accounting for statistical noise it’s not significantly different from the 10.5 percent rate for 2019 and 2020 — is a testament to robust relief measures policymakers enacted. These include Economic Impact Payments, an expanded Child Tax Credit, improved unemployment insurance, and expanded food assistance, along with [the Supplemental Nutrition Assistance Program]'s built-in ability to respond to increased need.

On the negative side, food insecurity increased from 2020 to 2021 in households without children and for women and older people living alone. Households headed by Black, Hispanic, and American Indian / Alaska Native persons were more likely to experience food insecurity than other households. Finally, the expiration of temporary pandemic emergency relief measures, such as free meals for all children attending public schools, may worsen food insecurity in families ineligible for WIC.

COVID bivalent booster vaccines ("updated boosters") roll out across the US

 - Jennifer Middleton, MD, MPH

On August 31, the United States (US) Food and Drug Administration (FDA) authorized Pfizer and Moderna's new bivalent COVID booster vaccines, also described as "updated boosters." The FDA amended  Emergency Use Authorizations to authorize the Pfizer and Moderna bivalent vaccines for persons aged 12 years and older and 18 years and older, respectively. The bivalent vaccines "add Omicron BA.4 and BA.5 spike protein components to the current vaccine composition, helping to restore protection that has waned since previous vaccination by targeting variants that are more transmissible and immune-evading." Bivalent/ updated booster vaccines are anticipated to be available later this fall for younger ages. 

Although Pfizer and Moderna ran trials in humans earlier this year with a bivalent vaccine designed to protect against both the original SARS-CoV-2 strain and the B.1 subvariant, the FDA asked both companies to switch their strategy to targeting the B.A.4/5 subvariants this spring. To fast track their vaccines and hopefully get them approved before the virus can mutate again, the FDA approved the use of data from mouse models only instead of waiting for further human trials:

Regulators [relied] on those results, along with the human neutralizing antibody data from the BA.1 bivalent booster studies, to decide whether to authorize the boosters....The companies will continue to gather more data from human studies; those results probably won't be available until late October or early November.

The FDA emphasized that this strategy has been used successfully for many years to update annual influenza vaccination components and emphasized that they "'have worked closely with the vaccine manufacturers to ensure the development of these updated boosters was done safely and efficiently.'"

Persons who have not yet received their primary COVID vaccinations need to complete that series prior to receiving the bivalent/updated booster; the bivalent/updated boosters "come in booster-sized doses" and "contain less vaccine than the primary series." For persons eligible for a COVID vaccine booster, the EUA recommends only the use of the bivalent/updated booster vaccines going forward. They also recommend a minimum of 2 months' time between the final dose of the primary series and/or last monovalent booster prior to receiving the bivalent/updated booster. Persons recovering from recent COVID-19 infection may "consider waiting a minimum of 3 months."  Some infectious disease experts, though, are recommending longer intervals:

An advisory panel to the C.D.C. voted to recommend the same interval between doses, although several members voiced concerns that two months was too short. Doctors and immunologists said that in general, people should wait around four to six months after immunization or infection. "That’s because your body will probably not generate much of an immune response so soon after a previous encounter with the virus," Aubree Gordon, an epidemiologist at the University of Michigan, said. “Your immunity level is so high that you’ll just neutralize immediately the antigen that’s being produced — you kind of reach a ceiling."

The CDC has given the green light to co-administering the bivalent/updated booster with influenza and/or any other indicated vaccinations; injection sites should be separated by a minimum of 1 inch. 

The CDC encourages all eligible persons for the bivalent/updated booster to receive it to protect against severe illness, long COVID, and the risk of transmitting the disease to those more vulnerable. If your office or care site won't be stocking it, the vaccines.gov website provides a tool to search for COVID-19 vaccine providers by zip code. The AFP By Topic on COVID-19 will continue to be regularly updated, and this recent AFP Curbside Consultation on "Vaccine Disagreement Between Parents" provides guidance regarding vaccine hesitancy. 

Neurosyphilis, ocular syphilis, and otosyphilis are don't-miss diagnoses

 - Kenny Lin, MD, MPH

When a patient with a history of migraine headaches presents with a "severe frontal headache and left-eye blurred vision and pain," neurosyphilis is unlikely to be foremost in the differential. Even after she mentions a two-month history of a diffuse maculopapular rash, clinicians may feel reassured because it doesn't involve the palms and soles. But syphilis, the great imitator, was in fact the eventual diagnosis in this patient, the subject of a case report published in Cureus.

In the August issue of AFP, Dr. Jennifer Jones-Vanderleest reviewed detection and treatment of neurosyphilis, ocular syphilis, and otosyphilis, which can occur at any stage of syphilis regardless of immune status. Early neurosyphilis (within the first few years of infection) can present with "headache, dizziness, altered mental status, cranial neuropathies, motor and sensory deficits, meningitis, or stroke." Neurosyphilis is diagnosed with the combination of neurologic signs and symptoms and reactive syphilis serology and cerebrospinal fluid (CSF) tests. The 2021 Centers for Disease Control and Prevention (CDC) Sexually Transmitted Infections Treatment Guidelines recommend that patients with neurosyphilis be treated with 18 to 24 million units of aqueous crystalline penicillin G per day for 10 to 14 days, administered as a continuous infusion or 3 to 4 million units intravenously every 4 hours. These patients should be tested for HIV and be offered HIV preexposure prophylaxis if HIV negative. After treatment, normalization of the serum RPR titer predicts normalization of CSF parameters; thus, repeated CSF sampling is not needed unless the patient is HIV positive and not receiving antiretroviral therapy.

As I discussed in a previous AFP Community Blog post, the incidence of syphilis in the U.S. has been rising for the past two decades due to stagnant health department funding for contact tracers and the recent impact of the COVID-19 pandemic. Far from being ancient history, "in 2020, 133,945 cases of all stages of syphilis were reported, including 41,655 cases of primary and secondary syphilis," according to the CDC. Although a disproportionate number of cases occur in men who have sex with men, rates in women have increased sharply since 2016.

A draft recommendation statement from the U.S. Preventive Services Task Force (USPSTF) reaffirmed screening nonpregnant adolescents and adults at increased risk for syphilis infection. The USPSTF recommends that all pregnant patients be screened for syphilis as early as possible in pregnancy. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists recommend rescreening women at high risk for syphilis at 28 weeks of gestation and again at delivery to prevent congenital syphilis.