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Measles Outbreak Update: “It’s Heartbreaking” · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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I'm Holly Wehment, and this is Pediatrics Now, cases, updates,
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and discussions for the busy pediatric practitioner.
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Click on the link in this podcast for free credit that may include CME,
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MOC, or ethics credit, depending on our topic or podcast.
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Today, we're talking about something that is on a lot of pediatricians' minds, measles.
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Joining me here today, it's such an honor, Dr.
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Jason Bolling, Professor and Interim Chief, Division of Infectious Diseases,
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UT Health San Antonio and University Hospital.
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And he's also the Director of Hospital Epidemiology at University Health.
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Dr. Bolling, thank you so much for being here today on Pediatrics Now. Thank you for having me.
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What is the state? The big question, if we look at our community and in Texas,
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What's the state of measles right now?
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We are still experiencing the largest outbreak in the United States,
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in Texas, up in the panhandle region of Texas, with Gaines County being the
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epicenter of that, just south of Lubbock.
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The most recent numbers for that area are up to 717 confirmed cases,
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which, for context, there were 285 cases in the entire United States for all of 2024.
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So a large number of measles cases in Texas, that's our current state.
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And two children, as we know, have passed away from complications due to measles. That's right.
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Tragic deaths of two children, unfortunately, related to this outbreak,
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which again, largely centered up there.
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There have been other cases in Texas imported from travel to other areas,
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which also shows kind of this dynamic state of measles in Texas,
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but also globally, because these other people have traveled internationally
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and brought back cases that just haven't led to the large outbreak that we're
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seeing right now in the Gaines County area.
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In Bexar County, here in the San Antonio area, there have not been any reported cases as of yet?
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That's correct. Fortunately, we have not yet to date seen any confirmed cases
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in the Bexar County area.
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We're obviously keeping close track of that. Early on with the outbreak,
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there was somebody that was within their transmissible infectious window that
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traveled through the Bexar County region.
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And so there were some potential exposures. But fortunately,
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we didn't see any conversions, no confirmed cases. The closest county with a
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confirmed case to us is one in Atascosa County, which is a neighboring county to the south of us.
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But that is not related to the outbreak. It is thought to be related to travel.
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So that was one of the questions we had when we saw that case pop up.
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And we'll talk about the United States and the world where we have listeners
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around the world and throughout the United States.
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But here in Bexar County, the vaccination rate, it's my understanding,
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it's still high enough to have that firewall. Or is that what it's called to
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protect against an outbreak?
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Yes, we often call it the firewall. It's really the amount of people that you
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need in a community to have herd immunity, right?
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So there are definitely a few people in the community that can't receive the
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vaccine because of health conditions or wouldn't be expected to respond to the vaccine.
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Their immune system is suppressed. You can't give the vaccine to people that
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are on high-dose immunosuppressants.
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And so what you need is enough people in the community that have protection
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with antibodies so that if the disease is introduced, it doesn't spread from person to person.
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The ideal number for measles is really 95% or higher.
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So we are just under that, but we're above the national average,
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which is around 92.7%. And that's drifted down over the last few years,
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which is one of the reasons why we're seeing more measles cases today.
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Well, as we know, pediatricians, they often see 40 patients a day.
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And as we all know, kids get a lot of rashes for various reasons.
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Any insight you want to give regarding the measles, rash, measles symptoms?
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Yes. So rashes and fever can go together, particularly in the pediatric population.
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And so it can be tricky because there are other viral illnesses in particular that commonly cause it.
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So roseola is a really common one that could cause fever and a rash in very small children.
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That's caused by human herpes virus 6.
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You could see a rash with erythema, infectiousism, parovirus B19.
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And those can be more commonly seen.
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We have not seen a lot of measles since it's been declared eliminated in 2000,
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but obviously with this increased number of cases this year,
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people are understandably and appropriately on alert to look for measles. And so part of.
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Way to ferret that out or to tease that out when you're talking with a patient
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and the parents is to really ask them about recent travel, if they've been around,
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and particularly currently, if they've been in that outbreak area,
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that would be good to ask about from travel.
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And right now, saying here, Bexar County, it's my understanding the Department
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of Health is the place to send a patient to get tested, but it can be tough
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because they can only accept, there has to be a certain criteria in order to
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be tested. Is that correct?
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So generally, the tests that we send are a throat swab or an asopharyngeal swab,
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and then that is held. You also send blood tests for antibodies.
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If the antibodies are positive, then that swab gets sent through the health
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department to the state, and they send that for PCR to confirm that it's a true case of measles.
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So the blood tests generally get run with our labs here, and the health department
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requires that those be run and that they have a positive before they send the swab for the PCR test.
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So here locally, but is it still for that initial blood test?
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Is that done in the pediatrician's office and then sent to you at University Hospital?
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Or what's the process just to make sure?
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So it depends on the clinic. I think many clinics will send those tests out.
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The measles test gets sent out. And University Health is able to do an IgG test,
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but you send both an IgM and IgG antibody test.
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So at least one of those is a send out. And depending on your clinic setting,
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both of those may be sent out. And so there's a few days of waiting to see those results.
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And then that would trigger sending the swab for the PCR through the health
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department to the state lab.
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And so do the test in the clinic and then send it to University Hospital?
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Is that right? I, I, I, it will depend on the lab setup for,
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for the clinic that you're using.
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I'm so I, I guess I would, this is definitely something to look at now.
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It's unfortunately somewhat of a hassle that it's not something that we have,
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you know, available where you can get quick turnaround time.
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Cause every, obviously everybody would want to know the answer right away.
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I think there's some research ahead about where you would send serology testing
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and the swab would be held, would be good to check with your clinics that you
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would know in advance if you don't know already.
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Okay. And for the doctor listeners for clinics...
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They probably have a process in place, but if there's any specifics for here
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in Bexar County, you want to send me, you know, how to get, what's the best way to get a test?
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Or if there's anything you want to say here, let me know about that.
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Yeah, so I guess, yeah, I guess each clinic is a little bit different what labs
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they use. A lot of them you send out labs.
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So I don't know, like university health clinics would use the university health lab.
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And so they have a process, but other clinics are going to have different processes.
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It's kind of a hassle too, because it's two different tests,
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right? It's the blood test for the two different antibodies in the swab.
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But if people had questions, they could always call the MetroHealth to ask.
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Okay. So call, yeah, call MetroHealth.
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Anything else you want to say about, so is something that for you,
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you know, with your 15 years of experience in infectious disease,
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that you would really raise a red flag about, well, this really could be measles.
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Or could it look like something else until you get that test result?
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Yeah, and did you want to talk about complications from measles or why do we
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worry about measles or the numbers nationally?
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Yes, I would love to talk about that. I was just wondering for the pediatric
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practitioner, is there anything else you want to say about identifying measles?
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They don't want to have the family go through the alarm or having to go through
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the testing unnecessarily. necessarily.
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And then, of course, at the same time, of course, you don't want to miss it.
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You know, so is there anything else you want to say there regarding identifying who needs to be tested?
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Or is your advice like, better to be safe and sorry, go ahead and test if you suspect it?
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Yeah, sure. So I think it's important to kind of review the clinical course
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of measles because, again, it's not something that we've seen a lot of cases
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of until this big outbreak.
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Since it was declared eliminated in 2000, we've been fortunate to not have to
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worry a lot about what the clinical course looks like.
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And it's important because it can help to distinguish measles from other viral
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rash syndromes. Most people tend to have their symptoms initially start about
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10 to 12 days after their exposure.
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So really within the one to two weeks after their exposure can be as far out
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as three weeks from exposure.
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But the point is there's a delay from the potential exposure to when someone
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will start to first have symptoms.
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And the first symptoms are really nonspecific, which can make it really challenging.
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People start off with a fever, a cough, runny nose, and then itchy, watery eyes.
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And just that description alone is really nonspecific, right?
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That's what we see with a lot of people with viral upper respiratory infections,
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which are still circulating, right? We're moving out of respiratory virus season.
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You don't see the rash, the characteristic rash, develop until about three to
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four days after those nonspecific symptoms.
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And that is a little bit tricky. The rash is pretty characteristic.
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It usually starts with the face near the hairline as these flat brown or red spots.
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It then kind of moves down the face to the trunk of the arms and legs.
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So it moves from top to bottom.
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And then that characteristic rash can make it a little bit easier to identify
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that someone has measles.
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And that rash lasts for about a week before it goes. And it's usually accompanied with very high fever.
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And usually with our upper respiratory illnesses, we may see some fever.
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But fever with measles can be as high as 104 degrees.
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So it can be pretty high. People are considered infectious from four days before
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the rash, which is tricky, right?
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Because that's when they're having those nonspecific symptoms to four days after the rash.
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So if someone develops that rash, if one of your patients develops that rash,
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you'd want them to be seen, but you'd want them to contact the clinic first if possible.
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So you can make arrangements to move them into a private room,
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put a mask on them, and then make sure whichever people on the health care team
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are seeing this patient, even if they're fully immunized, should still wear
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a respirator, an N95 respirator, to make sure that they're protected.
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Because could they be contagious with the virus if they're vaccinated, kind of like with COVID?
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The patient or the healthcare provider? The patient who's vaccinated against,
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or were you saying even if the healthcare provider is vaccinated,
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he or she should wear a mask?
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Correct. So if the healthcare provider, even if the healthcare provider is fully
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immunized, and most healthcare providers are fully immunized,
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which is great, it's still recommended to wear an N95 respirator,
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even though the measles vaccine is very, very protective,
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97% protective if you've had two doses.
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There's obviously a 3% chance, right? And so you don't want to take any risks.
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And so wearing an N95 respirator for the healthcare provider,
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in addition to being vaccinated, is the way to protect yourself while you're
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examining the patient, testing the patient, interacting with the patient, the family members.
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And as we know, the measles, it can float in the air for some time, right?
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That's absolutely right. So one of the challenges with measles,
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it's one of the most transmissible pathogens we know.
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It's one we use as an example when we're looking at outbreak models.
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Up to 90% of people that are susceptible to measles, meaning they haven't been
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immunized or had measles, if they're exposed, will develop disease.
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That's a really high infection rate.
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And it lingers in the air in these tiny little droplets.
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And they can linger in the air up to two hours, as you mentioned.
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It's been tested up to two hours after someone that's infected with measles leaves a room.
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They leave this plume of infectious particles that sits there for up to two hours.
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And the other challenging part is, again, you're considered infectious for up
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to four days before that rash starts, where you're having those nonspecific
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symptoms that sound a lot like an upper respiratory infection.
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So it has some elements to it that make it very easy to transmit to others,
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transmitting before you would suspect that it's measles. And then it has this
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really high attack rate.
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It just sounds scary. It's a very, very concerning disease, which is why it's
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so heartbreaking to see us lose some of the ground that we've made from being
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declared eliminated to 2000 to where we're sitting at here in 2025.
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That's a great way to put it, Jason. Would you recommend, so say if there was
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a patient, you don't know yet if he or she actually has the measles.
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Whoever's been helping that patient in the exam room has an N95 on.
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After that, not have anyone in that room for the rest of the day?
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Or what would you recommend there in the pediatric practitioner setting where
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they're seeing a high volume of patients?
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Sure. Yeah, that's a tricky issue, right?
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Because you don't want to mess with the workflow too much. You don't want to
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expose patients either.
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Uh, so they need to be, that room needs to be left empty for at least two hours
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after this suspected measles patients with suspected measles has left the room.
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So there's enough time for ventilation to change that out.
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Some people will let it sit for a bit longer and be conservative.
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And can it go through the vents to other rooms? Well, in a hospital setting, so the answer is yes.
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So ideally, in the hospital setting, we have prolonged stays of these patients.
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We place them in an airborne infection isolation room, and that has dedicated
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exhaust that goes directly outside.
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It doesn't connect to the air conditioning for all of the other vents.
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In the outpatient setting, most outpatient settings don't have that type of
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room, but they're also not seeing the patient for such a prolonged time period.
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And so really the recommendation in the outpatient setting or where you don't
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have an airborne infection isolation room is to put them in a private room and
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then again let that room air out, as we talked about, ventilate after that patient has left the room.
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There's less risk for transmission through the ventilation system if they're
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there for a shorter period of time.
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In the inpatient setting where they're sitting for days potentially, you have a higher risk.
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Like we saw with COVID, a lot of clinics were testing patients outside.
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I mean, it's really hot right now in San Antonio, but is that something,
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if a clinic is set up to do that, is that something that you would recommend?
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If we started seeing confirmed cases, we may have to start looking at something
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similar, yes, to try and help reduce the risk of other patients in the clinic being exposed.
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If we were to start to see an outbreak here, we would need to look at what would
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be the most effective way to do screening and testing of people that we're presenting with symptoms.
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And this is even more infectious than COVID, right?
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Yes, much more infectious than COVID. So we talked about that 90% infection rate.
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So 9 out of 10 people that are susceptible that are exposed will get infected.
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With COVID, that number is much lower. It kind of depends depending on immune
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status. If you've been vaccinated or had COVID, which most people at this point
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have, most people are protected. But the attack rate for COVID is closer to
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like 40% to 60%. So much, much lower than measles.
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How worried are you about the current state of things?
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I'm very concerned that we could potentially move to where we have to worry
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about measles on a regular basis.
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Part of that is because of this large outbreak, but more concerned by the fact
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that we have now 31 jurisdictions in the United States.
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So that's 30 states, and then New York City is listed as its own jurisdiction
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that have reported cases.
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And so it's over half of the states in the U.S. now have confirmed cases.
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And most of those started off with an imported case because globally,
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measles is really high right now.
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We have had some decrease in our firewalls we talked about before,
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the number of people that are fully immunized.
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We were about 95% in 2019, so right before the pandemic.
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But we have drifted down to the national average being around 93%.
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So that decrease is worrisome because that increases the chances that one of
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these imported cases could lead to another outbreak.
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And if you look at the map, the CDC has a nice map where they show percentage
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vaccine rate in different states.
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There are some states like Idaho, which is all the way down at 79%.
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And so they're at much higher risk for an outbreak occurring there if they get an imported case.
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So those things are what concern me that we're going to see ongoing activity
17:05
for a while, not just this huge outbreak, obviously, that's worrisome in the
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Panhandle region, but the number of cases throughout the U.S. right now.
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For our listeners in Idaho and in the Texas Panhandle, those are the two real
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hotspots right now, it sounds like.
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They don't have any ongoing cases in Idaho, but just looking at areas of vulnerability
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based on where that vaccine uptake rate is.
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And they basically use the data from kids that are entering kindergarten,
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school-age children, and they have a lower percentage uptake compared to some of the other states.
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It almost sounds like it's like the tsunami or hurricane warning.
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That's right. There are different risks depending on where you're at and then,
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you know, how much influx of travelers you have and where your vaccine firewall
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immunization rate is at.
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Is there one thing with, you know, pediatric practitioners are so busy as are
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family practitioners and seeing 40 patients a day.
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Given the state of things, is there one line you would hope that could be said in between,
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I mean, asking are you vaccinated or any thoughts there if we could have a crystal
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ball and everybody say something to help the situation?
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I know a lot of doctors feel pretty helpless right now regarding this.
18:24
Sure. Yeah, I understand that too.
18:27
It's discouraging. There is an overall increase in some vaccine hesitancy.
18:34
But what I would say I look at, it's optimistic,
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and it is the silver lining, is that when patients are polled and surveyed,
18:43
they do look to their pediatrician as a source of truth, a credible source of information.
18:49
And so I think starting that conversation about vaccines is really important.
18:55
Understandable that people might
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have questions. But I think starting a conversation is the best thing.
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And pediatricians are great about this, about talking with families.
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I would encourage everyone to continue having those conversations with their
19:07
patients and families so that they can get those questions answered because they do listen.
19:12
Even if it doesn't seem like they may be listening, they do listen.
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There's good published data showing that doctors are still considered an excellent,
19:21
consistent source of truth.
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That's great reassurance, Jason. And we do have in this Pediatrics Now newsfeed
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our previous, two previous episodes on motivational interviewing.
19:32
And our expert in the Department of Psychiatry addresses specifically how to
19:38
utilize motivational interviewing to talk about vaccines.
19:42
So hopefully that's helpful. And is your hope for it to be mentioned in each
19:48
visit if you haven't seen a patient in a couple of months or anything you want to say there?
19:52
Yeah, I think motivational interviewing and finding out ways,
19:56
some scripting that you can use when you're busy to engage in these conversations
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is really helpful, and it's good to know that there's resources for that available.
20:06
It is something that needs to be talked about. There's strategies such as when
20:09
a patient is there saying,
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well, today we have your vaccine scheduled, as opposed to asking if you want
20:14
a vaccine, because that kind of highlights that you're endorsing it as an important
20:19
part of their care, and they can, of course, decline it if they don't want it,
20:22
but knowing that you're recommending it, I think is also something that helps.
20:26
It's a positive nudge towards what we would want them to do,
20:29
which is take the vaccine.
20:31
Jason, do you have anything you want to say to our pediatric practitioner listeners
20:37
worldwide? We have listeners in Ukraine.
20:40
We have listeners in Israel, in Africa. Anything you want to say there?
20:45
I would encourage everybody to keep up the good work.
20:50
It's really important for people to continue the physician-patient relationship and dialogue.
20:55
Everybody is really busy, but it's really important that we continue this conversation
21:01
and endorsement of vaccines.
21:03
They're the most effective public health strategy we have for reducing infections.
21:08
So we deal with infections when they come up, but the more that we can prevent,
21:12
the better off that we are and we can avoid unnecessary morbidity and try to
21:18
take deaths from vaccine-preventable illness.
21:20
And maybe it's more important now than ever for the doctor listeners to take
21:25
care of themselves, do something fun on their time off work,
21:28
like you were mentioning, and it just, it can be so frustrating because it just
21:32
feels like an uphill battle.
21:34
Yes, I think it is important for people to reach out to colleagues,
21:38
talk to each other, Look for other sources of reassurance and then,
21:43
you know, keeping tabs on what's going on as well is important.
21:47
One pediatric practitioner, she was wondering about incidents,
21:53
clinic presentation, and infectivity of measles from vaccination.
21:57
She says, I know it's super rare for them to have a reaction,
22:00
but she had a nine-month-old patient have a reaction.
22:06
There can be some reactions from measles vaccines. So overall,
22:09
it's very well tolerated, right? The measles vaccine has been out since 1963.
22:12
So we have decades of experience with it, which is great.
22:15
Some patients have very little side effects or no side effects at all.
22:19
The most common side effect we see is soreness and redness at the injection
22:22
site in the arm, right, which is similar to other vaccines.
22:26
And then some children will develop some stiffness in their joints and they can have some fever.
22:31
It is also possible, it's much less common, but it's possible a few days after
22:35
the vaccine to develop a rash, similar to the measles rash, but children that
22:40
develop that are not contagious to others.
22:42
It's not true measles, but it looks very much like measles and it can be associated with a fever.
22:46
Serious side effects from the vaccine are very rare. They should be reported
22:50
if they occur, but overall the vaccine is very well tolerated.
22:53
That's great to know and that's reassuring. Have you heard of there's some parents
22:58
requesting and some parents are getting their baby vaccinated sooner?
23:04
Yes, it is recommended. So a lot of people are asking about getting extra doses
23:08
of measles vaccine, and that's not recommended.
23:10
But what is recommended is if you're planning to travel and you have a child
23:14
that is less than 12 months of age, so the routine vaccine schedule is you get
23:19
the first dose at 12 months of age or one year, and then the second dose of
23:22
age is four to six years of age.
23:24
But if you have a child that's between six to 12 months, so six to 11 months,
23:29
and you're going to be traveling internationally, it is recommended that you
23:31
give a dose of the MMR to that child so that they'll be protected when you're
23:36
traveling internationally, since we are seeing increased cases of measles globally.
23:40
Now, they'll still need to get their two doses when they return,
23:44
you know, one year of age and between four to six years of age.
23:47
It doesn't count as early credit for that, but it's a way that you can protect
23:51
a child between six and 11 months of age from that risk of measles if they're
23:56
traveling internationally.
23:57
So really, they would get some kids, babies are getting an extra dose,
24:02
and that's okay, but they still would need to stay on the, in addition to that,
24:06
stay on the regular schedule.
24:08
That's right. Yes, that's the nice way to summarize it.
24:11
Okay, because then I think pediatricians are getting asked a lot about getting an early dose.
24:17
Yes. Anything else, anything else, Jason, you want to say to pediatric practitioners
24:23
or family practice doctors in general?
24:26
Yeah, it's also important for any adults that are unclear, if they're up to
24:31
speed on their vaccine, to talk with their provider as well.
24:33
So they're around the children, they could get sick themselves,
24:36
and so they should make sure that they're also up to speed and they've received
24:39
the two doses of vaccine.
24:42
The way that you're analyzing things, do you see this summer places where there's
24:48
not any sort of, there's not been a reported case,
24:51
things really amping up this summer or anything you want to say there?
24:58
It's always tricky to predict, right? But, you know, at this rate,
25:03
we are still seeing a number of cases.
25:05
And we're seeing with the widespread nature of these, the concern is always
25:09
that you're going to see an active case in an area with much lower rates of
25:14
infection. So a little pocket of infection.
25:16
This outbreak in Gaines County is largely associated with an area of under-vaccinated
25:23
community, a Mennonite community that had a much lower vaccine rate.
25:27
And so if you were to see an active case in another area with a lower vaccine
25:33
uptake rate, you could see another outbreak.
25:34
And so each time we see more cases in more states, you always worry you're going
25:38
to see that intersection of a transmissible person with a susceptible population.
25:43
So I think we're going to have to keep a close eye on it.
25:47
And it doesn't sound like the summer travel season is going to help.
25:51
That's right. The more travel we have, the more mixing we have,
25:54
and the more chances we have for that intersection of a transmissible person to a susceptible host.
26:00
Would you be surprised if we don't get a case in Bexar County where we are?
26:06
I wouldn't be surprised if we had a case, I guess is the way I would say it.
26:10
I'm hopeful that we don't, but with cases that we've seen in Travis County,
26:15
Harris County, and then the one in Atascosa, I would not at all be surprised if we have a case.
26:22
This is so helpful, Dr. Bolling. Before we wrap up for the practitioners,
26:27
anything else you want to mention about measles that we did not cover?
26:30
We covered a lot of the important points. I think it's really important to,
26:36
again, stress the importance of vaccine.
26:39
We don't have antivirals for treatment after someone gets sick.
26:43
Children bear the brunt of the real problems of severe illness,
26:46
hospitalizations, pneumonia, which can lead to death, the most common cause of death with measles.
26:52
Kids can also have bacterial infections afterwards, too, when children have a case of measles.
26:58
It suppresses their immune system temporarily, and so they're at higher risk
27:02
of bacterial infections following that, which is another problem that parents
27:06
of children should know about.
27:08
There's multiple risks if you do develop measles.
27:10
It's not something that just happens and goes away.
27:13
The more people that we have that have measles, unfortunately,
27:15
the more chances we have of having another severe case and potentially even another tragic death.
27:20
Yeah. So we know that measles causes fever, causes itchy, watery eyes,
27:25
cough, runny nose, and a rash.
27:27
Other complications, I think, are sometimes not as well known,
27:30
especially to parents of kids that are considering vaccines.
27:34
About 1 in 10 people with measles will develop diarrhea. That's probably the
27:38
most common complication.
27:39
Children, about 1 in 10 will get otitis media, which is obviously problematic for them.
27:45
Ear infections, exactly. 1 in 20 will develop pneumonia.
27:49
And that viral pneumonia can be very serious. 1 in 5 kids gets hospitalized
27:53
with measles, a lot of them with respiratory complications.
27:57
1 out of 20 can get a viral pneumonia. We don't have a treatment for that.
28:01
It's the most common cause of death with measles. The death rate for measles
28:06
is about 1 to 3 out of 1,000.
28:08
And then about 1 in 1,000 kids can get encephalitis or swelling in the brain. They can have seizures.
28:13
And they can have long-term complications like deafness or delays in cognitive
28:18
challenges from inflammation from the encephalitis.
28:22
So there's some serious consequences that can happen from measles.
28:25
It's more than just a viral rash that goes away that people used to get in the past.
28:29
So long-term brain damage can occur. Long-term brain damage can occur.
28:33
There's even a condition called, the letters are SSPE or subacute sclerosing panencephalitis.
28:38
It's pretty rare, so we don't have a lot of data on it.
28:41
Back when we used to have more measles, about 7 to 11 kids out of 100,000 could develop this.
28:47
This is a neurologic condition that happens about 7 to 10 years after the measles.
28:53
So the kids have recovered from measles, they're doing better,
28:56
and then they develop this debilitating, progressive, and universally fatal
29:01
neurologic condition called SSPE. PE.
29:04
But so that's something we saw when we had more cases of measles.
29:07
It doesn't happen very often.
29:09
It starts to be either delayed immunologic response or a variant of the virus,
29:14
but it happened so infrequently. We don't have a lot of data on it,
29:17
but it's obviously extremely concerning, severe consequence that can occur rarely
29:22
with measles infection. Awful.
29:24
Kids who get pneumonia from measles, is it otherwise healthy kids or is it mostly
29:29
kids who have an underlying lung condition?
29:32
Great question. It can happen in healthy kids that don't have underlying lung conditions.
29:37
So underlying lung conditions can increase the chances of infections,
29:41
but a measles viral pneumonia can occur in children with no health problems.
29:45
They can also develop bacterial supra-infections, again, from that temporary
29:50
suppression of the immune system, and that can cause, you can get a bacterial pneumonia,
29:54
bacterial otitis on top of the viral otitis, but you can see a viral pneumonia
29:59
at a completely healthy child.
30:02
Dr. Bolling, thank you so much for doing this interview. It's really been insightful.
30:07
And thank you so much for being here on Pediatrics Now. Thank you so much.