1/ #Marburg virus is a deadly relative of #Ebola. How certain people get infected and others don't despite similar exposures is a question we are investigating. I was reviewing an old case from a returned traveler in Colorado in 2008. This was the first ever imported case of a filovirus infection in the United States. So how did she get infected? cdc.gov/mmwr/preview/m… 2/ At first, the patient never received an accurate diagnosis and had ongoing symptoms for months. Apparently, she herself requested testing for Marburg 7 months later after reading about a fatal case in a European traveler who had visited the same caves that she had in Uganda.

The 'Python Caves' in Uganda have roosts of fruit bats which are known to shed the virus. She reported only being in the cave for about 15-20 minutes and her husband was with her as well (he didn't get sick)

1/ Masks reduce respiratory virus transmission

New paper @JAMA_current — one of the authors is @Stanford Professor Dr. Luby who led the Bangladesh RCT on community masking & *many* other RCTs in global health- a leading expert in this field

“Well-designed observational studies have demonstrated the association of mask use with reduced transmission of SARS-CoV-2 in community settings, and rigorous evaluations of mask mandates have found substantial protection”
2/ Well designed randomized controlled trials are often not possible for all types of interventions

“Disagreement about whether face masks reduce the spread of SARS-CoV-2 has been exacerbated by a focus on randomized trials, which are limited in number, scope, and statistical power. Many effective public health policies have never been assessed in randomized clinical trials; such trials are not the gold standard of evidence for the efficacy of all interventions.”

I often get asked why someone’s spouse got infected with #covid19 & they didn’t despite sleeping in the same room (or variations of this question). I think infectious disease epidemiology can be a very confusing field for the general public (this being a good example —> what might seem otherwise like a logical transmission pathway doesn’t give you the outcome you expected) & this inherently lends itself to risk of misinformation taking hold. In many outbreak investigations (a number of examples from outside the US), people often highlight how ‘cultural’ views of disease spread may make communities resistant to biomedical explanations (an oversimplification but there are many anthropological studies that elucidate this tension)

1/ Tpoxx (Tecovirimat) resistance in immunocompromised patients, many of whom received multiple courses of treatment. Reminder- tpoxx is our first-line antiviral against monkeypox/mpox.

Important pre-print from CDC Monkeypox/mpox response team
medrxiv.org/content/10.110… 2/ Having worked on surveillance for a number of cases for the past several months, I think key is that many are patients also w/ tough social challenges which have made adherence to antiretroviral medications difficult, setting them up for a double-hit with AIDS + mpox @g0ingmad

1/ Phenomenal lecture today from Dr. Stephen Luby on his team's work discovering the mechanisms of #NipahVirus transmission in Bangladesh over nearly the past two decades

The story starts with an outbreak of fatal encephalitis among 11 patients (Dec 2004)
pubmed.ncbi.nlm.nih.gov/17326940/ 2/ They asked the families of deceased cases about many exposures; & similarly asked the same to neighborhood controls

The evidence here pointed to consumption of raw date palm sap (odds ratio of 7.9)

Bats were suspected to drink from/near the clay pots of sap in the trees

If we were hit with another covid-like pandemic soon, are we ready? As USG & (likely soon) WHO end the "emergency" phase of #Covid19, we need to avoid panic-neglect cycles. I think this is the bigger emergency. @bmj_latest

bmj.com/content/380/bm… 2/ As much as this is a matter of public health, it is also (perhaps more) a matter of politics. What will a Republican-led House focus on/fund for pandemic preparedness? And, w/ elections next year, to what extent will prevention efforts get pushed further down priority list?

1/ It's difficult to see the pictures of severe #monkeypox infection in patients with uncontrolled HIV/AIDS in this Lancet case series. These patients are at high risk of death. These cases remind me of @NickKristof work on deaths of despair.

thelancet.com/action/showPdf… 2/ While these aren't the diseases that the term usually describes, the same social and economic despair underlies these infections as well. I have followed these cases in LA County as part of surveillance efforts for the past 6 months. Patients who were homeless, who had...

This. In these mask RCTs, what’s rarely accounted for & hard to determine is when transmission happened. If it happens mostly when masks are off & that is happening way more than you account for in your analysis, you likely have significant misclassification of exposure bias.

https://twitter.com/JenniferNuzzo/status/1621881125625815041

2/ This doesn’t mean masks don’t work. What it might mean is that masks aren’t worn at all times they need to be in order for them to work. So pragmatically an intervention may need to increase compliance at specific high risk times when they are being removed.

1/ "We identified high loads of #monkeypox virus DNA by qPCR in 35 (85%) of 41 saliva samples. Infectious monkeypox virus was recovered from 22 (67%) of 33 saliva samples positive for monkeypox virus DNA."

Interesting study but transmission more complex

thelancet.com/journals/lanmi… 2/ Detection of viral DNA in various samples is not equal to transmission. We often say that culturable virus is a proxy for transmission potential, but even this doesn't mean transmission routes from those specimens are inherently effective ones.

1/ Also, the move recently has been away from screening asymptomatic patients who are being admitted to the hospital. This will reduce burden on hospital/labs to process tons of samples, many which will be negative. It will miss some cases who are incubating + infectious

https://twitter.com/AbraarKaran/status/1616492787138199553

2/ I appreciate costs/benefits of this. On one hand, missed cases could transmit to staff who may be wearing surgical masks (still some protection but less than N95). For shared rooms, more concerning (see our paper) so would definitely screen prior

academic.oup.com/cid/article/74…

1/ I was asked yesterday by @mehdirhasan about the ‘with v for’ argument on #covid19 hospitalizations/deaths which has been used by some to argue that hospitals are over-counting @MSNBC 2/ One of the arguments is that we have 'over-screened' because many infections aren't leading to 2020-21 pneumonia syndromes. Or, that screening can/does sometimes pick up persistent positive on rtPCR representing old infections

Spoke to @mehdirhasan today alongside @jeremyfaust ⬇️

CDC has public facing data on excess deaths during the pandemic— they specifically highlight that it’s still likely an undercount given covid-related complications aren’t always accounted for in the reporting.

https://twitter.com/mehdirhasan/status/1616247212308332544

2/ Many of us who have worked on primary teams in the hospital during the pandemic have filled out death certificates. We put thought into this when referring to the primary cause of death as well as contributing causes.

https://twitter.com/mehdihasanshow/status/1616247495192887296?s=46&t=_150yiRq3JHyJ4701do6Sw

Many postmortems of the first years of the pandemic clearly point to social inequities as the biggest driver of rapid pathogen transmission. What have we done to change this for the next time we are dealing w a highly transmissible pandemic-prone pathogen? 2/ We were able to stop covid19 transmission in 2020…with enough money and resources, the NBA did this, creating a literal bubble to allow their business to continue as frontline workers couldn’t even get proper PPE to protect themselves and families from dying. Think about it

Anecdotes and/or personal experiences play an outsized role in how people see or understand diseases. This is a problem in epidemics. The fallacy that covid wasn’t a significant problem & mitigation efforts are overblown because you personally had mild disease is case in point. 2/ This is especially a problem in highly contagious diseases spread person-person, in which people may have ways of reducing spread but may lack motivation to do so because they don’t personally feel threatened. This exploits vulnerabilities in our lack of social cohesion.

1/ Another important paper on bivalent covid19 vaccines & newer #SARSCoV2 variants including XBB in @NatureMedicine

Even if not perfectly targeted, bivalent vaxx + history of prior infection & other aspects of immunity hopefully = better clinical outcomes
nature.com/articles/s4159… 2/ “The results showed that a BA.5-bivalent-booster elicited a high neutralizing titer against BA.4/5 measured at 14- to 32-day post-boost; however, the BA.5-bivalent-booster did not produce robust neutralization against the newly emerged BA.2.75.2, BQ.1.1, or XBB.1.”

Also important is clinical data — on hospitalizations, deaths etc as well as morbidity concerns. This paper is of course important but immunity is also more than humoral response. Not trying to minimize nor panic — neither will be helpful.

https://twitter.com/abraarkaran/status/1609067496484794370

2/ I think all pieces of data are important to look at. Significance of these findings must be contextualized with real-world outcomes.

Same mitigation measures will work for infection prevention. For treatment of severe disease, situation may be more complex.

1/ New CDC MMWR: "The VISION Network evaluated the effectiveness of a bivalent booster dose among immunocompetent adults during September 13–November 18, 2022" cdc.gov/mmwr/volumes/7… 2/ "VE was estimated using a test-negative case-control design, comparing the odds of having received versus having not received a bivalent booster dose among case-patients...and control patients (those who received a negative SARS-CoV-2 test result)."

"Together, our findings indicate that BQ and XBB subvariants present serious threats to current COVID-19 vaccines, render inactive all authorized antibodies, and may have gained dominance in the population because of their advantage in evading antibodies."
cell.com/cell/fulltext/… 2/ "The rapid rise of these subvariants and their extensive array of spike mutations are reminiscent of the appearance of the first Omicron variant last year"

1/ It may be a huge failure but people’s perceptions of individual risk likely influence behavior more than their concern for population benefit. Will public messaging shifts from current leadership be x-factor that will change this? If not, then best focus efforts in a diff way

https://twitter.com/wsbgnl/status/1607979485017821185

2/ ultimately I agree w your diagnosis- there has been a deliberate frame shift; efforts to normalize current harms, or at least rely on vertical interventions not easily accessible to all (Paxlovid) or perhaps w/o addressing concerns to implement effectively (booster shots)

1/ Yet again family member sick w/ #covid19 few months after initial infection

Was able to quickly get them Paxlovid (through colleagues who work in that system— wait for a clinic callback otherwise up to 2 days)

Able to use GVS N99 I had in supply to protect self while helping 2/ take care of family member. Very clear though that if I were not here, this process would not have been as easy

Had to leave middle of the day, 1.5 hour wait at pharmacy (Kaiser); able to do it but many jobs would preclude this flexibility

How attributable is the shift in people’s views on covid to
-public health messaging
-public health policies
-overall fatigue
-people’s own experience now having been infected/recovered multiple times

How does it differ by demographic & SE factors? Any recent polls?

https://twitter.com/AbraarKaran/status/1607620448224964610

2/ if the messaging of our leaders is so effective & influential, why is the booster rate still so low?
-bad messaging?
-lack of mandates?
-lack of access?
-people’s own experiences influencing their decisions more than the former three?
-something else?
Any polls?