January 28, 1945 — Audie Murphy and Stephen Ambrose write about the hell of Colmar
January 28, 2025
January 30-31, 1945 — Finally, light at the end of the Colmar Pocket tunnel
January 30, 2025
I’ve been honored to write a quarterly column, “Vaccine News You Can Use” for the Colorado Family Physician (CSP) journal for a number of years. Below is the second part of the Winter 2025 edition of the CFP .
FIND THE PREVIOUS PUBLISHED PART 1 ARTICLES HERE
FIND THE PART 2 ARTICLES BELOW
My Winter 2025 column in the CAFP journal was just published; however, it turned out that there was so much news about vaccines in the last quarter of 2024, that the second half of my column was posted online as PART 1, here, earlier this month. I’ve also posted it as a blog titled, “Vaccine News You Can Use” for Family Physicians — Winter 2025 — Part 1,” that you can find here.
The second part, which was the part actually published in the journal, can be found online here, on pages 26-28. I’ve also posted it below.
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PRACTICE ALERT: More flu, COVID, RSV cases expected due to low vaccination rates
The CDC expects sharp increases in flu, COVID and RSV cases and hospitalizations during the winter holiday season as vaccination rates are alarmingly low. Only about 18% of adults have received the most up-to-date COVID vaccine, about 35% of adults have had the flu vaccine, and less than 40% of people 75 or older have taken the RSV vaccine. As for the 2024-2025 COVID vaccine, a Pew Research Center survey reported that 60% of US adults said they are probably not going to get it, about 25% said they probably will, while 15% said they had received it. We FPs can definitely make a dent in these numbers in our practices.
PRACTICE ALERT: AAFP Call to Action for vaccines during pregnancy
A new resource from the Maternal Immunization Task Force (a collaboration of the AAFP and five other medical organization) summarizes clinical recommendations for four vaccines during pregnancy: COVID, flu, and pertussis (as Tdap) vaccines at any point in pregnancy, and the Abrysvo RSV vaccine at 32-36 weeks’ gestation. Unfortunately, vaccine uptake is low among pregnant women – about 60% for Tdap, 32-33% for flu and RSV, and 28% for COVID. The task urges FPs to strongly recommend these vaccines to our pregnant patients. Read more here.
PRACTICE ALERT: RSV vaccines
(adapted from Medscape)
RSV vaccine has both age- and risk-based recommendations
Now, everyone aged 75 or older needs a dose of RSV vaccine. Adults aged 60-75 with risk factors for severe RSV are also recommended to receive a dose of RSV vaccine, but NOT adults without any of these risk factors. The conditions associated with increased risk for severe RSV disease include lung disease, heart disease, immune compromise, diabetes, morbid obesity (BMI of > 40), neurologic or neuromuscular conditions, chronic kidney disease, liver disorders, and hematologic disorders. Frailty, as well as living in a nursing home or other long-term care facility, are also risk factors for severe RSV disease. Those aged 60-75 without these risk factors are no longer recommended to receive it – although admittedly, that will only be a minority of these patients.
Three RSV vaccines for adults
We now have three RSV vaccines to choose from. Two are protein subunit vaccines: one is by Pfizer (Abrysvo that does not contain an adjuvant) and the other is by GSK (Arexvy which does contain an adjuvant). The third, by Moderna (mRESVIA), uses an mRNA platform. Although the durability of protection from RSV vaccines is still unclear, recent studies now suggest that the RSV protein subunit vaccines confer 36 months of protection rather than only 24 months. All three RSV vaccines are licensed for those aged 60 or older. The age indication for Arexvy has been lowered by the FDA to age 50 and for Abrysvo to age 18 for those at high risk. However, ACIP has not yet expanded its age recommendations for getting these vaccines. One of the main hesitations is vaccine safety concerns. FDA’s safety update presented to ACIP still suggests an increased risk for Guillain-Barré syndrome with both protein-based RSV vaccines among those age 65 or older. Fortunately, the risk is rare: less than 10 cases per million vaccinations.
RSV immunization for infant protection
Nearly all infants get infected with RSV at least once by the time they are 2 years old. RSV is potentially dangerous being the most common cause of hospitalization in infants under 1 year of age. RSV season typically runs from October through March and there are two new ways to protect infants. One is a maternal RSV vaccine, given at 32-36 weeks of pregnancy, to moms who will deliver their babies during RSV season; however, only Pfizer’s RSV vaccine (Abrysvo) can be given during pregnancy. The second option is nirsevimab (Beyfortus) immunization during the RSV season for infants under 8 months of age and for children age 8 through 19 months who are at increased risk for severe RSV disease and entering their second RSV season. The antibodies in the RSV immunization work right away to protect babies against RSV and last for at least 5 months. Either of these choices (maternal or infant immunization) is very effective at preventing babies from being hospitalized.
CME Question:
PRACTICE ALERT: Pertussis (whooping cough)
Cases of whooping cough are on the rise across the US and in Colorado. In Colorado, the year-to-date cases of pertussis, as of November 21, 2024, were more than 600 compared to 203 cases in 2023 and an average of 126 from 2020-2022. There has been a noted increase in clusters of outbreaks, particularly in school settings, with the highest rates observed among 15-18-year-olds and infants.
The CDPHE advises that we FPs should consider a diagnosis of pertussis with testing and treatment for patients
- presenting with a prolonged coughing illness AND paroxysms of coughing, post-tussive vomiting, an inspiratory whoop, OR
- an unexplained cough lasting two weeks or more in duration.
PCR tests from a NP swab or nasal wash taken at 0 to 3 weeks following cough onset is the preferred test for diagnosing pertussis but may be accurate up to four weeks. Testing and empiric treatment are particularly important in high-risk patients, including pregnant women, infants, and unvaccinated individuals. Fully immunized individuals can still develop pertussis and should be tested and treated with antibiotics if they meet clinical criteria.
An empiric antibiotic treatment with azithromycin or an appropriate alternative antibiotic (clarithromycin, azithromycin, or as an alternative to macrolides is trimethoprim-sulfamethoxazole) should be administered prior to receiving test results for patients suspected of having pertussis and who have coughed for 21 days or less (as the benefit of treating pertussis infection for illnesses lasting more than 21 days is unclear). Also, pertussis is contagious from illness onset through 21 days after onset of cough; however, patients are no longer infectious after completion of a full five days of antibiotic treatment.
In addition, CDPHE advises that all household and other close contacts of a confirmed or suspected pertussis case should receive antibiotic chemoprophylaxis promptly without waiting for results of pertussis testing, regardless of age or immunization history. The CDHPE asks us to “Please assist in providing a prescription when requested from public health.”
Finally, “Instruct patients suspected of having pertussis to remain out of school or in-person work while awaiting test results, and/or until completion of a five-day course of antibiotic treatment” (tinyurl.com/2ayfvvrn).
PRACTICE ALERT: Measles
Adapted from AFP and Immunize Colorado.
Measles, eliminated from the US in 2000, is among the most dangerous of vaccine-preventable diseases, and it’s making a comeback. From the 2019–2020 to the 2022–2023 school year, MMR vaccine coverage among children in kindergarten in Colorado declined almost 2%, down to 87%, which was the 6th worse decline in the US. This is important as groups of children with vaccination rates below 95% are significantly more vulnerable to measles outbreaks. In the US, the number of measles cases by September 2024 was up 271% over 2023. Earlier in 2024 a confirmed case of measles was identified in a teen who flew to Denver International Airport from overseas. While symptom monitoring of known contacts to this individual indicated it was contained and not further spread in our state, we can’t continue to rely on luck or chance. We’re only one plane ride away from a full-on outbreak.
Measles is not a benign illness. It is easily spread when an infected person coughs or sneezes. The virus can live in the air for up to two hours. You don’t even have to be in the same room as an infected person to get measles. Simply touching an infected surface or breathing contaminated air is all it takes. It is so contagious that an infected person can spread it to up to 90% of unvaccinated individuals they contact. Common complications include otitis media, bronchopneumonia, laryngotracheo-bronchitis, and diarrhea. Encephalitis occurs in 1 out of 1,000 people, and 1 out of 500 people with measles will die. Those at highest risk of serious complications include young children and patients who are immunocompromised or pregnant. The incubation period for measles is typically 10 to 12 days but can be as long as 21 days.
Measles typically starts with a high fever and the 3 Cs: cough, coryza, and conjunctivitis. After about 4 days, an erythematous, maculopapular rash appears on the face and spreads downward to cover the body. This rash lasts about 6 days. Koplik spots (tiny white spots inside the mouth) may also appear 2 or 3 days after the first symptoms. A person with measles is infectious 4 days before through 4 days after the appearance of the rash. Most FPs have never seen a case, which can lead to missing the diagnosis or confusing it with other illnesses that cause fever and a rash, such as rubella, RMSF, fifth disease, and scarlet fever. The clinical characteristics of measles are shown on the CDC’s website (tinyurl.com/3z4hz4wr).
Since medical settings are a common source of measles exposures during an outbreak if you, a colleague, or your staff suspect a patient has measles, the following steps should be taken immediately:
- Place a mask on the patient and keep them isolated in an examination room. No patient with a rash and fever should ever remain in a common waiting area.
- Contact your local health department to report the suspected case and to obtain information on how to collect and process samples for confirmation, including blood for measles-specific immunoglobulin M and a NP swab for reverse transcriptase–PCR testing.
- Inform patients with suspected measles that they need to self-isolate while awaiting confirmation. They will likely be contacted by the local health department for investigating potential contacts.
Besides these steps, to avoid spreading measles in the clinical setting:
- All personnel with whom you work should be fully vaccinated, and
- Infection control policies and practices should be established and followed.
- Protocols should be in place to separate patients with a rash illness from others, physically and temporally.
- We FPs should encourage all children older than 12 months and unvaccinated adolescents and adults to receive two doses of the MMR vaccine, as recommended by the CDC.
Abbreviations used:
- AAFP – American Academy of Family Physicians
- ACIP – Advisory Committee for Immunization Practices
- CDC – Centers for Disease Control and Prevention
- CDPHE – Colorado Department of Public Health and Environment
- CME – Continuing Medical Education
- COVID – COVID-19, SARS-CoV-2
- CPR – Colorado Public Radio
- CV – cardiovascular
- FPM – a magazine formerly know as Family Practice Management
- FPs – family physicians
- H5N1 – HPAI A(H5N1) virus, avian flu, bird flu
- HIV – human immunodeficiency virus
- HPV – human papillomavirus
- JAMA – Journal of the American Medical Association
- flu – influenza
- MMR – measles, mumps, and rubella
- NNT – number needed to treat
- NYC – New York City
- RCT – randomized controlled trial
- RSV – respiratory syncytial virus
- SARS-CoV-2 – severe acute respiratory syndrome coronavirus 2
- UN – United Nations
- UNAIDS – Joint United Nations Programme on HIV/AIDS
- US – United States
© Copyright WLL, INC. 2025. This blog provides healthcare tips and advice you can trust about a wide variety of general health information only and is not intended to substitute for professional medical advice, diagnosis, or treatment from your regular physician. If you are concerned about your health, take what you learn from this blog and meet with your personal doctor to discuss your concerns.
