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Mosquitoes, Fleas & Outbreak: ID Update with Deena Sutter, M.D. · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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I'm Holly Wehmint, and this is Pediatrics Now, cases, updates,
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and discussions for the busy pediatric practitioner.
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Don't forget to click on the link in this podcast for free credit that may include
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CME, MOC, or ethics credit, depending on the topic or podcast.
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Pediatrics Now is brought to you by the Department of Pediatrics at UT Health
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San Antonio and University Health's new Women's and Children's Hospital.
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So I'm so thrilled today because here with me in the podcast studio is our new
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pediatric infectious disease doctor, Dina Sutter.
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Dina, thank you so much for being here today in the podcast studio.
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Thanks. I'm absolutely happy to be here. So you'll be seeing patients soon once
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your credentials come through.
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And I know you have close to 20 years of experience in infectious disease,
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being on the front lines, and you even were deployed to Afghanistan.
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I spent my career in the Air Force, and so I had a few overseas assignments
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that were short deployments,
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mostly humanitarian missions, and I did go to Afghanistan in 2008 and ran a
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pediatric ICU essentially at Bagram Air Base,
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and that was kind of one of the most significant experiences in my military career,
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and so I'm very grateful that I got to have that experience,
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but it was difficult.
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There were a lot of severe injuries, you know,
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blast injuries, children stepping on landmines, burns,
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and so I just feel like it was difficult, but I'm so grateful that I got to
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go and feel like I was making a difference at least as much as I possibly could
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in that setting, and I'm really looking forward to seeing patients and teaching.
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Well, we're so glad that you're here. And I know those tough experiences that
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we go through that helps with every day seeing patients here.
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I know you'll bring that experience.
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I mean, I had some great colleagues and I know so many people who were in more
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difficult situations where their physical well-being and their mental well-being
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were more severely affected, so I always try to, you know,
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take that into account when I think about it.
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But I had great colleagues, and we really worked hard together,
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so it's actually a good memory for me in many ways.
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I'd love to talk about some things that are in the news, items that are in the
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news involving infectious disease that pediatricians, pediatric practitioners
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may be getting asked about.
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A lot of people are worrying about it.
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First of all, the pronunciation is chikungunya, right? So it's like chicken gunya.
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And it's a virus that's spreading quickly, in particular in China.
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It's not in the United States yet.
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Yeah, so I just like to put everything in perspective.
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So chikungunya is a virus that when I was in training, in the fellowship training,
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which was in the mid-2000s, it wasn't like that big of a deal.
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We learned about it along with dengue virus and Zika virus. Then some outbreaks,
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you know, subsequently, which I'll talk about, some outbreaks made it more prevalent in the news.
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And so right now they're talking about 250,000 cases or so reported or confirmed,
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I think confirmed, worldwide so far this year as of July, August.
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And to put that in perspective, last year, depending on your source,
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there were probably greater than 600,000 cases and the year prior greater than 500,000.
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So some of the reporting is delayed, so we may exceed that this year.
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But the total number of cases is really, at this point, not particularly high.
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I think the attention that's being paid is because there are outbreaks in areas
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where the virus was not present.
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And in particular, the outbreak in Guangdong province in China has been a big
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deal in the news because this has not been reported in that area.
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And the authorities and the Chinese government are taking steps like massive
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amount of spraying and things like that that have kind of made it very big in the news.
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So chikungunya is a virus that is one of the arboviruses.
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And just to remind everybody, arbovirus stands for, we use arbovirus because
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it's arthropod-borne virus.
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So much like dengue and Zika, yellow fever, West Nile, and some of those others,
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it's spread by mosquitoes.
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And chikungunya often was mistaken in the past for dengue.
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So a lot of the areas, including now Zika, a lot of the areas where it's endemic,
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the same mosquitoes spread those viruses and the same populations will get infected.
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And so, you know, chikungunya was not even defined until the 1950s,
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although it probably existed for a couple of centuries prior to that in limited sporadic outbreaks.
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So what we know about chikungunya is that it presents similar to dengue with fever,
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and you can have rash, which is a little bit different than dengue,
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but chikungunya really is known because it causes severe joint pain,
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arthralgias, arthritis, that can actually persist for weeks,
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months, or years in a chronic phase.
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And so that's why it's become, it's so important for people to know about it,
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because it can be very debilitating to people.
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The mortality rate is very low. It's less than 1%, although it might be higher in some populations.
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But that debilitating disease, a chronic phase, is really why we worry about it.
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And it happens, it tends to happen in hot climates during the daytime.
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Right, right. So the 80s mosquitoes, which are the same mosquitoes that spread
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dengue and Zika, and people may not be as familiar with dengue,
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but they heard all about Zika a few years ago when there was outbreak,
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but dengue is actually a very, very prevalent and very significant worldwide problem.
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The same mosquitoes, which are the Aedes mosquitoes, so Aedes aegypti and Aedes albopictus are the.
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So in tropical climates, that's really where the disease is prevalent,
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but also the subtropics.
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And some of those mosquitoes have moved into some more temperate climates, so a cooler climate.
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So if you looked at a map of the United States, you can see how far up.
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It's mostly the south part of the United States, but moving a little further
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up into the east coast and midwest, the 80s, especially the Alba Pictis,
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can be present. So the concern in the U.S.
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Here is, you know, could these things become endemic in the U.S.
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Or can we get spread from mosquitoes in the United States?
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And that's why I think it's in the news in the U.S.
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And we can just, you know, we talk about the transmission again in a minute
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here. And I heard it's endemic in Mexico, too.
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It's Latin America, the Caribbean, and especially in Central and South America.
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Actually, the majority of the cases in the world are in South American countries.
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So basically, if you look at kind of what happened with the spread of chikungunya,
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it was initially identified in Tanzania.
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And there were outbreaks there, although there probably had been some outbreaks
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in like the Indian subcontinent prior to that.
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And then in over the next few decades after it was identified in the 1950s,
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there were sporadic outbreaks that happened in Asia.
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It happened in like the Southeast Asian islands.
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And then there were some very large outbreaks that occurred.
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In 2004, Kenya had a very large outbreak. It was a big deal.
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And subsequently, it spread into the islands in the Indian Ocean,
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which are near Africa, such as Madagascar and Mauritius.
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I've actually been to Mauritius. It's really beautiful.
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And some of the smaller islands, Reunion, which actually had a huge outbreak,
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and they had a huge outbreak 20 years ago.
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So those are places that it's been a real hotspot.
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But the other thing to know is that in the 20...
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2013, it appeared in the Caribbean. And that's how it got widespread in the Western Hemisphere.
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And in the subsequent years, there were cases reported, not only in the Caribbean
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and South America, but there was actually, there were six cases,
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I believe, in Florida in 2014 and one case in Texas that were reported.
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And these were not in travelers. These were people who had never left.
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We do see cases for returning travelers. These were autochthonous cases.
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Autochthonous means that it occurs locally and that you did not travel and you
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got it from a vector that was in your area. So that's some of the worry.
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According to this New York Times article that came out this week,
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a person who comes down with chikungunya could be fine one day and then very
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soon after that not be able to go to work,
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work, even pick up a pan to put on the stove to cook.
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Like, it's that, I mean, it sounds awful.
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It's very, it can be very debilitating.
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And so, you know, although we haven't had as many cases until the last few years,
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it's that quality of life effect.
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And so most people who get exposed get infected, and most people who get infected
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are symptomatic, unlike some of these other arboviruses where,
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you know, the symptomatic patients are kind of the tip of the iceberg.
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Like Zika, you could not have symptoms. Zika, no symptoms. In many cases, dengue, no symptoms.
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75% or more of patients have symptoms, and the vast majority of those patients have joint pain.
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And joint pain may be the only presenting sign. I mean, only about half have
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real fever, maybe a little bit more than half.
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Some GI symptoms, rash, which is nonspecific, could be on the hands,
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the feet, the extremities, can be in the trunk. It's not like pathognomonic rash.
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And in these cases, the patients who have arthritis, a lot of them have resolution, but the
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a huge number of them do not have resolution and they have lingering symptoms.
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And there's estimates that, yeah, there's estimates that in some populations,
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only about 15 to 20% have lingering symptoms after 18 months.
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And other populations, 60 or more percent reported lingering joint pain after 18 months.
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And some of those patients have very, very severe disease, arthritis.
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Synovitis, bursitis, you know, and axial skeleton can be involved as well as
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the small joints, which are most frequent, you know, hip, shoulder,
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knees, large joints can be affected.
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And these are patients who are often unable to work, unable to get out of bed,
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just very, very affected.
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And so this is the fear, is that if it becomes endemic here or if patients travel
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and they acquire it, that that outcome can be the case.
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Pediatric patients, young children, are less likely to have the joint symptoms,
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which is good. They're just overall healthier.
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Adults with chronic diseases, elderly people, and those with underlying rheumatologic
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joint, pre-existing joint symptoms are more likely to be severely affected.
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And it could be severe in babies?
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It can be very severe in newborns, and there can be maternal to child transmission.
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It's not commonly reported, but it's not probably studied enough that if a mother
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gets infected and has viremia at the time of,
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you know, around the time of delivery or right prior to delivery,
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the baby can be born with a congenital infection, but babies can also acquire
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it from mosquitoes shortly after birth.
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And because they have an immature immune system and also the blood-brain barrier
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is not mature, as we know, those babies can have severe neurologic disease,
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more severe disease than older children for sure.
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Elderly people also are at high risk of being fatal?
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Elderly people are at high risk for being fatal. And interestingly,
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if you look at all the variants, because it's not just one lineage,
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there's multiple variants.
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Some variants actually have a higher predilection for causing severe disease
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or for causing neurologic disease or for causing death.
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So they estimate one in a thousand for mortality, but there are some studies
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and some outbreaks where the rate was much higher.
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Wow. According to this New York Times article, this mosquito is the type that
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in China right now, people who are riding buses in their homes or apartments,
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the windows open or they're outside working in the heat.
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Like it really likes the heat and it likes moisture.
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Are you worried about it coming to the United States? What are you?
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I think given the changes in climate,
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and this is really what's impacting this, when we have large storms,
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which of course we've been here in Texas have been hit very hard with some terrible
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storms, and across the U.S., when you have standing water and when you have
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higher temperatures, that is what really breeds these mosquitoes.
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These mosquitoes can breed in tiny amounts of water, which is why in many of
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these countries, it is in impoverished areas and areas where people in these
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tropical areas, they do not have air conditioning.
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They often will save rainwater for their water use.
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So rainwater in barrels or even just like a puddle or water in a,
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you know, like a tire that's, you know, garbage, large amounts of garbage where
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water collects are very high risk factors.
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So in the United States, I think the populations that would be more likely affected
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are the people who don't have air conditioning, who live in...
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You know, less advantageous conditions. And of course, along the southern border,
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because that's really Florida and Texas are where we've seen dengue pop up.
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You see these things pop up rarely, but Florida and Texas are kind of like that
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southern area where it's hot and where we do occasionally see that.
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So if you start seeing in those areas and it becomes endemic here,
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we have an outbreak here, it's not just going to remain there.
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And so I am somewhat concerned about it.
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I think that's why those measures are being taken in China is because it's such
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an unusual case and they're really scared of it being maintained in that population.
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And when you have a naive population who is not immune, these are a whole population
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of people who have never seen this virus.
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That's when you have huge, huge outbreaks because it gets spread from human to mosquito to human.
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There are animal reservoirs, but humans are the primary host.
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So when you get very high levels of viremia, very, very high viral loads.
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Mosquito bites you, bites somebody else. That's how you get infected.
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And that's why it can spread so quickly. But there's not human-to-human transmission.
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No, the only human-to-human transmission is maternal to child.
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And then there's been a couple of cases of laboratory accidents where there
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was blood from a patient who was viremic.
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Somebody got stuck with a needle or something.
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So blood-borne pathogen type of risk.
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But this is really not ever transmitted directly, not respiratory,
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not touching. That's not how you get it.
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But there's a massive effort in China to prevent this.
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They're trying to get people to follow the steps to not let mosquitoes come
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into their house and so that they won't get bitten by mosquitoes when they're
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outside and they're using pesticides.
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Do you think, from what you've seen, Does that seem like it's enough or?
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I mean, I think some of the pesticide use might be overblown there.
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I am not, this is not my area of expertise per se, but really getting rid of
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the standing water, using insect repellents if you have access to them.
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And if you are able to use screens, bed nets are not something you normally
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use for the day biting mosquitoes.
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But if you have a situation where you have people who are sleeping outside,
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you know, or sleeping in a place with no air conditioning, that could help.
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If you do have air conditioning, go inside and use air conditioning if there's an outbreak.
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I mean, if that's what was happening here, that's what I would be doing with my family.
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So I think really the main thing is trying to control the standing water and
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the breeding grounds for the mosquitoes.
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And so I would say where we live, you should be doing that anyway,
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because even if we don't have this virus, which you could set yourself up for
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a problem if there was an outbreak, we do have things like West Nile.
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And I have seen cases of severe cases, which are uncommon in children.
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This particular case I'm thinking about, I saw in Washington,
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D.C., but it was associated with, you know, standing water in areas around the
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house, a lot of birds, that kind of thing.
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And so, you know, any virus that can be spread by a mosquito that can survive
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in these particular 80s mosquitoes can survive in like, you know,
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like I said, puddles or, you know, just any kind of like, you know,
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I mean, I could go to my backyard right now and find things where I'm like,
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oh, this is where all the mosquitoes are coming from.
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We have a huge mosquito problem here. I mean, I go outside and just get bit.
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So really getting rid of the water, avoiding being outside,
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and then just really using the other precautions, which is usually wearing,
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it's hot, but long sleeves, long pants, lightweight clothing,
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light-colored clothing is helpful to avoid mosquitoes.
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Not always ideal when it's very hot. And then using insect repellents such as
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DEET up to 30%. We don't use above 30% in children, and it's really not effective beyond 40% anyway.
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Or picaridin, which you go up to about 20%. Those are okay to use.
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And I do recommend using them because even if we don't have this virus,
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we do have things like West Nile and we do have the potential to have mosquito-borne
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viral illnesses in the U.S.
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And Dina, even though it's hot, as much as you can cover up,
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wear the long sleeves and pants, it's hard for the mosquitoes to fly underneath
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the clothing, right? Yeah.
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I mean, I think the main thing is that you cover up.
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If they can't fly, these are not usually mosquitoes that get underneath your
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clothing, but then you spray the exposed skin.
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You don't spray the skin that's covered typically, especially because if you're
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trying to limit the amount of spray you're putting on a young child, for example.
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But you're still going to get bit. I mean, we have so many mosquitoes right now after all the rains.
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And I can only imagine in these places where there's rampant cases of chikungunya
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and dengue and other viruses. Malaria.
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Malaria, which is a totally different type of mosquito and the protection is
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a little different, but these are all, you know, so you get co-infections and
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these are all co-occurring in a lot of these tropical climates.
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So I see, you know, nobody wants to have this in their population.
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I can see why the Chinese are taking this very seriously, but this is a minority
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of the number of cases that are happening worldwide.
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You know, we have many thousands of cases happening in these other endemic areas,
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which, you know, is not getting the attention in the news as much because we're
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talking about an area in China, which I think always just kind of hits the news more.
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People get excited about something in China just because it's China and what are they doing now?
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I've seen some news clips where they were trying to spin it into,
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oh, the Chinese government is doing this.
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So maybe some of the attention is on that. But when you look at the real scientific
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kind of literature, they're looking at it in terms of the ecology and a new
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area where it has not been seen before.
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But if you look at the numbers in Brazil or you look at the numbers in these
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Indian Ocean islands, it's like they're far eclipsing the numbers in China.
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Dr. Tess Barton, who has been on the show many times with infectious disease,
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and she said something that really stood out to me that I think a lot of people don't realize.
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She said that the mosquito is the most dangerous animal in the world.
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And here in San Antonio, it's more fleas that are the problem because of typhus.
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Yeah, from an infectious disease standpoint in San Antonio, fleas definitely
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cause more problems than mosquitoes.
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Mosquitoes are the most dangerous animal in the world. And it's,
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you know, I often have conversations with people like my sister,
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like, you know, if I could just destroy one thing on earth, it's mosquitoes.
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So it's more because they were, you know, biting us and annoying us,
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not from an infectious standpoint.
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They're just awful, you know, and they do cause so much disease.
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But fleas are really a problem here in San Antonio and South Texas.
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And you don't even have to have a pet. You know, I know people who have bought
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a house and moved in and there were fleas hopping all over the yard from prior pets.
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And we have, typhus is a disease that, you know, it's not as easy to get as
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what we were talking about, chikungunya.
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But it does live in animals, especially young animals, feral animals.
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And children will get that from their pets, but they'll also get it from exposure
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to flea-infested areas. And I've had kids who don't even have pets getting typhus at times.
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From a park or something. But most of the time, it's because they have a household pet.
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They're sleeping with the pet. The pet is not on flea and tick prevention, is the problem.
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It's so important. It's so crucial. It's very important. I always tell my patients
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this because I see a lot of typhus.
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Like chikungunya, it's often summertime outbreaks.
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You know, a lot of these pest-associated things, you know, vector-borne illnesses
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are summertime things because when it freezes, it gets cold,
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and these things kind of hibernate, and they're not surviving or thriving.
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But I saw a typhus even in the winter during the COVID outbreak because children
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were at home and they were like, all these kids I felt, my own child was doing
21:11
this too, were fostering all these kittens and puppies because they were bored.
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I mean, it was just like, hey, mom, can I have kittens? Okay.
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And the kittens and the puppies are often too young to have flea and tick prevention,
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but they came out of a litter where there were fleas and ticks sometimes,
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or people just, you know, find some animal in the street and they don't go get
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animal, you know, they don't get flea and tick prevention.
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And the effective flea and tick prevention can be pretty expensive too.
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So that sometimes is a...
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Is an obstacle for people as well. But people don't realize that fleas are such
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a problem here. And typhus can be a very severe illness.
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I've seen many, many children hospitalized with it. And so I do,
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you know, I do emphasize that to families who have pets that make sure that
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you have them on their flea and tick prevention.
21:55
Tick's not so much of a big problem here in Texas, spreading disease, but fleas, definitely.
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And can you talk about some of the early warning signs of typhus.
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Like a lot of other... Yes.
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Nobody knows what typhus is until after you figure it out. So,
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you know, usually it's very sudden onset.
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Kids will have some malaise, some headache, high fevers, and you can't differentiate
22:19
it from other things until you start seeing a characteristic rash.
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And honestly, not all the kids have this characteristic rash,
22:27
and it also overlaps with other rickettsial infections, so you can't really
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prove it. And even the testing, there's a lot of overlap with other rickettsial infections.
22:35
Rocky Mountain spotted fever is our kind of prototypic rickettsial infection in the United States.
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And it's well known because it has a high mortality rate.
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Typhus is less likely to cause mortality or severe, severe ICU kind of illness.
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But they look very similar.
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The geography is a little bit different. And really what we have here in South
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Texas is primarily typhus, which is good, but you know, they can present with
23:01
high fever, bad headaches, retroorbital pain.
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And then typically you'll start seeing after a few days, a rash.
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If you do see the rash, it's often a petechial maculopapular on the hands and feet.
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And often if you don't look, you might miss the early signs of it.
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And so the kids, you know, They can be in, they can look shocky,
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or they can be just high fevers and very ill-appearing with a lot of pain.
23:27
Differentiating that from other severe viral illnesses or severe manifestations
23:31
of common viral illnesses is really hard.
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Because rickettsial infections are bacterial, and you can actually treat them.
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And the other viruses, of course, you cannot. So it's really important to try to figure that out.
23:41
So if you suspect typhus, what is your advice for the pediatric practitioner?
23:47
Well, you don't necessarily have to admit a patient who has typhus.
23:50
They need to get on doxycycline right away.
23:52
You can send serologic testing to try to confirm, and sometimes the serology
23:57
takes quite a while for them to develop antibodies.
24:01
So I think that we really need better diagnostics.
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I'm not aware of a molecular test for typhus right now that is marketed,
24:10
but there might and I just don't know about it yet.
24:13
But mainly the goal is to get doxycycline into the kid right away.
24:16
And this doesn't matter how old the kid is. So this whole concern of you can't
24:20
use doxycycline under the age of eight or nine is not true.
24:25
For rickettsial illnesses, you give doxycycline to children.
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The problem is usually the kid in the clinic, it takes a while for the clinician
24:33
to actually suspect typhus.
24:34
They may be languishing with persistent fever for several days.
24:39
And unless they see that rash, they may not really think about it.
24:42
The other things are you can get labs on them and you can see cytopenias,
24:47
you can see elevated liver enzymes, you can see elevated inflammatory markers.
24:53
Some of these are really a lot of overlap with some of the other viruses,
24:57
including like EBV and other things.
24:58
So it's kind of hard to differentiate.
25:02
Thrombocytopenia is a real big hallmark of this, but it's also a hallmark of
25:06
some of these other diseases as well, including chikungunya,
25:09
which is, you know, obviously not, we're not trying to differentiate those.
25:12
But so, you know, they need to really be thinking about the exposure of the
25:16
pets or, you know, in the rare cases, you know, outdoor exposure to non-pet
25:20
infested areas, which is kind of hard to tease out.
25:23
And the fact that it's summertime and that the kid is, you know,
25:27
usually summertime and the kid is being exposed to, like I said,
25:30
fleas and asking the So asking the parents about fleas, have you seen fleas?
25:35
Is there flea and tick prevention?
25:36
And a lot of times the parents will be like, oh yeah, there's fleas everywhere.
25:39
And you're like, yeah, get that kid on doxycycline.
25:42
And I think it can be hard for pediatricians. I know one pediatrician was saying
25:47
to me, like, a family comes in and they say, like, what is this bite that happened
25:51
to my child? And it's so hard to know, looking at a bite, what it is.
25:56
Do you, you know, as we're talking about chikungunya, we're talking about typhus and fleas.
26:02
Any advice before we move on to our next topic for pediatricians that we haven't covered?
26:07
The bite thing is, you know, we get such weird questions.
26:12
I mean, general pediatricians, ID docs, you know, if your kid has a reaction
26:17
to mosquito bite, it doesn't indicate
26:19
that the child is going to have an infection as a secondary result.
26:24
And I wouldn't be able to differentiate, you know, one mosquito bite from another.
26:29
And in terms of, like, you know, spider bites, you know, the historical thing
26:33
is, could it be a spider bite, you know?
26:37
Brown recluse, or MRSA, which was in the days of, you know, kids coming in with MRSA infections. Yes.
26:44
And in the very early days of community-acquired MRSA, that was a big thing.
26:48
The spider bite was the purported thing.
26:51
You know, I don't differentiate bites. The one thing that you can see is when
26:55
you get tick bites in an endemic area, which is not here, the exodes ticks that
27:00
spread Lyme disease. In the northeast.
27:02
Northeast, a little tiny little patch in the Northwest, but upper Midwest or
27:08
the Great Lakes area and the Northeast kind of, I always say like Virginia all
27:11
the way up to the mid part of Maine along the coast.
27:15
And then there's some around the Great Lakes as well.
27:17
That's really where we see Lyme disease and that can give you the classic bullseye
27:22
at the site of the tick bite, the prior tick bite.
27:25
And so those are the cases where if the tick is still attached to the child
27:28
or you live in an area where Lyme disease is prevalent, you need to check your
27:32
kids for ticks, and the tick needs to be removed if it was on the child.
27:35
And then in some cases, depending on if you can figure out the timing of how
27:40
long it was on, empirically giving a dose of doxycycline to prevent Lyme disease in those cases.
27:45
However, you know, we're talking in Texas, we have listeners other places,
27:49
we don't have endemic Lyme disease here in Texas, and there are reasons that
27:54
we know this because they do these field surveys, they look at the ticks.
27:57
Could that change as the global climate changes?
28:02
Yes, it's possible, but it's really a regional thing. So you've got to be aware
28:07
of where the disease actually is.
28:09
And you recently were on a trip to Cape Cod, and you saw that a tick was on
28:15
you, and you did something that probably most people wouldn't do,
28:18
but maybe a lot of our listeners would.
28:20
Well, infectious disease doctors are really weird. We're just like kind of strange
28:25
people, and we're giant nerds, as I said.
28:27
So, yeah, I was sitting at my friend's beautiful house, and she said, We don't have ticks.
28:32
And I came and I'm like, here, I had this tick on me. And I wanted to make sure it wasn't an Ixodes.
28:37
It doesn't matter because it could have been an Ixodes. And I'm sure they have
28:40
them there because they're in a
28:40
very high-risk area for Lyme and also for Babesia, which is very regional.
28:46
It's very limited to this particular area.
28:48
What is that? It's another tick-borne illness that is most often asymptomatic,
28:54
but it can cause severe disease, especially in people who don't have a spleen.
28:58
It's very, very isolated to like this area of Rhode Island, typically Block
29:03
Island of Rhode Island, Martha's Vineyard, which is right across the way from
29:07
where we were, and then some parts of Cape Cod.
29:09
So I brought the tick inside, and then I put it into one of her lovely glass.
29:14
You know, she doesn't use the plastic tupperware. She uses the glass ones, of course.
29:17
And I put that in there. And then I got two more on me and I put them in there.
29:20
She was so uncomfortable walking by looking at it like, can we put that tick somewhere else?
29:24
And I brought it home in a Ziploc. And then my husband and I were both looking at the tick.
29:29
Turns out I don't think that one was an exodes. But the point is that if I couldn't
29:33
tell after looking under a magnifying glass, you may not be able to tell either.
29:37
But do take the tick with you if you can, if you're in one of those areas and
29:41
see if you can get it tested at the health department.
29:43
I am not talking about here in Texas. I'm talking about in those areas where
29:46
you know there's a lot of Lyme disease because it can be important.
29:48
Did you get it off of you with tweezers or?
29:51
I was just crawling on my leg. It hadn't bitten me that I knew of.
29:55
And then the other ones just rode in on my jacket or something.
29:59
So they just took a ride and came inside the house.
30:02
So they are pests. And if you're a wooded area, they are everywhere in those regions.
30:08
Here we have dog ticks primarily.
30:10
And they don't spread a lot of diseases. So I guess we're lucky there.
30:13
But in those other regions, it's a real concern.
30:17
So moving on to not a vector-borne illness, we're talking about something else
30:23
that's in the news right now.
30:25
There's been an increase in hand, foot, and mouth disease.
30:29
It's not required to be reported to the CDC, so we don't know exact numbers.
30:35
But I know when in talking to pediatricians this summer, several pediatricians
30:39
told me they're seeing a lot of cases.
30:41
And it's also been in The New York Times about that, that more cases of hand,
30:45
foot and mouth disease. What do you want to say about that?
30:49
It happens. Hand, foot, and mouth outbreaks do happen. They're not on a specific
30:54
cycle, but every few years we have a lot more cases.
30:57
Certain enteroviruses, so a hand, foot, and mouth is caused by an enterovirus,
31:01
and the enteroviruses are broken into the numbered enteroviruses,
31:04
the Coxsackieviruses, the echoviruses, and the polioviruses.
31:08
And the polioviruses, because they're related, some of these enteroviruses can
31:12
cause severe disease that are polio-like syndromes.
31:15
But in general, when the child has hand, foot, and mouth disease,
31:18
They're really not at risk for those things.
31:20
They typically have lesions on their lips, around their lips,
31:24
in their mouth, and then they get these little blisters all over their hands and feet.
31:27
They can get them elsewhere, including buttocks or other parts of the body.
31:30
But they really are, this is really a common childhood illness.
31:34
And whether it's one enterovirus, which is a Coxsackie, Coxsackie A16 is the
31:39
most common cause, or an enterovirus, which is, enterovirus 71 is implicated
31:44
most commonly among the numbered ones.
31:46
And actually, that can be more severe.
31:47
And a higher risk of neurologic complications, but it's very uncommon.
31:51
So otherwise, this is just a thing that happens to kids.
31:55
And they're not immune to it until they become immune to that type of venerovirus.
31:59
And so perhaps what we get is a certain amount of population who hasn't been
32:03
exposed because it's usually the youngest children.
32:06
Older people are less likely to get it because they're probably at least partially
32:09
immune or they're immune from getting it as a child.
32:12
But older children and adults can get it. They usually don't have the classic
32:15
manifestations of the blisters that are so severe in the mouth,
32:20
around the mouth. And so...
32:22
The fact that it's in the news is like, yeah, we're having a bad enteroviral year.
32:25
When I get more concerned is the years where we start seeing things like acute
32:29
flaccid myelitis, which we have seen with certain enteroviruses in the last
32:33
few years, a polio-like illness.
32:36
And so that's what, in the news,
32:38
that's what really makes me get concerned because I have seen these cases.
32:43
So right now we're not hearing that. We're just hearing about these cases,
32:45
which are kind of more nuisance cases.
32:47
You know, children are in daycare. This is how it gets spread.
32:50
It gets spread through secretions. It's very hard to prevent children from getting
32:54
an infection in a daycare.
32:55
They're just kind of like, you know what daycare is like. I mean,
32:58
kids are touching each other. They're touching things.
33:01
And so I think that these outbreaks, kids need to be out of daycare for a few
33:05
days, which is very inconvenient for the parents.
33:08
Kids are sometimes very miserable. If they have lesions in their mouth, they can be painful.
33:12
And they actually can get dehydrated enough to have to go to the hospital. But that's uncommon.
33:17
So really, it's more of a nuisance overall. And so I don't think we should be
33:21
panicking about having it in the news because every few years we have a lot of cases.
33:25
But if the cases start manifesting with more severe manifestations in terms
33:30
of non-cutaneous things, more things that are severe like the neurologic cases
33:37
or the severe respiratory cases,
33:39
then I get more worried about the outcomes in the kids.
33:43
And can anyone get hand, foot, and mouth disease, though, even though it's not
33:46
as common to occur in adults?
33:49
Anyone can get it, but they usually, like I said, they usually don't show up
33:52
looking like the kids with the hand, foot, and mouth lesions classically.
33:55
They can, but usually what happens is, you know, the toddlers are the ones,
34:00
or they say less than five-year-olds, get the classic manifestations.
34:05
Adults can get enteroviruses just like children if they are not immune,
34:09
but they may present with just sort of nonspecific, you know,
34:11
So maybe they have a fever, maybe they have, you know, headache,
34:15
GI symptoms, maybe they have a nonspecific rash, but they can certainly get this illness.
34:21
Back to chikungunya, is there a vaccine?
34:26
There are many, many vaccines that have been studied.
34:29
There are currently two in the United States that have been licensed for use,
34:33
very recently licensed for use, coincidentally.
34:36
One is called Ixchik, and it is not recommended for children.
34:42
It is recommended for adults.
34:43
And there have been some safety concerns in older adults where the FDA and some
34:50
other regulatory agencies in other countries did pause the use in older adults.
34:54
And then the pause has been lifted.
34:56
But you don't want to give it to immunocompromised individuals.
34:59
You don't want to give it to pregnant women.
35:01
You don't want to give it to anybody who should not receive a live virus.
35:06
These vaccines, they're only recommended for travelers?
35:10
For travelers going to an area with a current outbreak, actually, which is, you know...
35:17
That's a time-limited thing. But if people are moving, geographically locating,
35:22
and so they say greater than six months of residence is the recommendation on the travel sites.
35:29
When I've given other vaccines against viruses like Japanese encephalitis virus,
35:35
I would typically give it if someone was going to live there more than one or two months.
35:38
But the point is that we're not giving it in the U.S. routinely at all.
35:42
And this would be part of a comprehensive review of travel risks,
35:47
because if you're at risk for chikungunya during an outbreak,
35:51
you may be at risk for other things, including malaria,
35:54
including other infections that you can get vaccinated against.
35:59
And so you may need to see a travel medicine doctor, get some travel medicine
36:03
advice, and then the whole family needs to be evaluated.
36:07
Or you can go to the CDC Traveler's Health site and look at where you're traveling
36:11
to, to determine other things that you might need, because the chikungunya vaccine
36:16
is, like I said, a new one. And there's a lot of other things out there you might need to be doing.
36:19
But we are not giving this routinely in the United States to anybody who's here.
36:24
That is not a recommendation.
36:25
At this time, they don't need to be vaccinated. No, not unless they're traveling specifically.
36:31
You know, travel vaccines. You know, I've given rabies series to kids who are
36:35
going to high risk for rabies. That series is well over $1,000.
36:39
I mean, it might be more now. I mean, all of these yellow fever vaccine,
36:42
all of these things are pretty expensive.
36:44
My neighbor, actually, so she said her grandbaby had to be vaccinated for rabies
36:50
because there was a bat just flying in their house for a little while.
36:54
So the parents had to be vaccinated and the baby.
36:56
I didn't know that just because the bat was present.
36:59
Yeah, that's a classic board question. Like, you know, a child is in a crib
37:04
and there's no evidence of bat bites on the child, but the bat was found in the room with the child.
37:09
You know, it doesn't have to be a baby in a crib. It can be anybody, an adult, anybody else.
37:13
When bats bite, their bites are almost undetectable and you may not have felt them.
37:19
Now, there is the possibility of salivary, you know, like the bat has saliva
37:24
and it gets into you that you can have transmission that way.
37:27
But biting is by far the most effective way of transmitting.
37:30
And so the concern is that the bat had exposure to you when you were asleep and you weren't aware.
37:35
Whereas if you were awake and you were an adult, right? So a baby who's awake
37:38
in the crib also is a problem because the baby can't tell you what happened.
37:41
An adult who knows that they did not have direct contact with the bat,
37:45
that has to be teased out by people like the health department or,
37:49
you know, your physician.
37:51
And in that case, you may not need to be vaccinated, but if you're sleeping and you don't know...
37:55
Then you would need the shots because especially in this area,
37:58
we have a lot of bat rabies here, a ton. Really?
38:02
And rabies in other animals and mammals as well. But bat rabies is very prevalent in South Texas.
38:08
I mean, this area is bad. Well, my neighbors, and she was worried about her
38:12
grandbaby mostly because, and I was shocked to hear it, but we know this happens.
38:16
She was worried about the vaccine.
38:18
Like, will my grandbaby be able to grow normally now? So I assured her it's
38:23
been well-studied. Yeah.
38:24
I mean, I've had people take their newborns to a place where I was like,
38:30
we don't routinely give rabies vaccine to little kids who can't toddle around and get near an animal.
38:34
But if you had a possible exposure, there is no lower limit of age for giving
38:42
post-exposure rabies vaccine.
38:44
For travel, it's called pre-exposure vaccine because you're giving it so that
38:47
they don't actually need the antibody, the immunoglobulin or rig,
38:51
after they get exposed if you're pre-vaccinated.
38:56
But there's not huge, huge studies on young babies getting rabies vaccine,
39:00
but it has been used many, many times. And it's felt to be whatever is going
39:05
on much, much safer than getting rabies, which is universally fatal,
39:08
of course. Yes, that's what I said as well.
39:11
Well, Dina, this is such an honor to be able to talk to you,
39:15
and I really appreciate you giving us all this information and updating it.
39:21
It's hard to stay current on everything, and pediatric practitioners who are
39:24
seeing 30 to 40 patients a day, now we know what to say when someone asks about chikungunya.
39:32
And if you have a question for Dr. Sutter, our website is pediatricsnowpodcast.com. com.
39:39
My email address is on there. Please email me the question and I will pass it on to you.
39:44
And if you want to email me a voice recorded question, we may put that on the air as well.
39:50
So I really appreciate you being here. And here on Pediatrics Now,
39:54
we love quotes. I love quotes.
39:56
You have a favorite quote or two you want to share with us?
40:01
Yes, I did my assignment and found some quotes. So I found a quote from one
40:06
of my favorite books, which is Cutting for Stone by Abraham Verghese.
40:10
And I thought it was a little poignant at my age, just looking back.
40:14
And it's, the quote is, I grew up and found my purpose and it was to become a physician.
40:18
My intent wasn't to save the world as much as to heal myself.
40:22
Few doctors will admit this, certainly not young ones, but subconsciously in
40:25
entering the profession, we must believe that ministering to others will heal our woundedness.
40:31
That's beautiful. And then my other quote is by Ellie Weissel,
40:35
who is a Holocaust survivor.
40:36
And the quote is, when adults wage war, children perish. And I actually have that tattooed on my arm.
40:42
Really? Wow. This is my post-Afghanistan belief.
40:49
When you hear about the children being killed in the wars, it's something that affects me profoundly.
40:56
Gut-wrenching. It's gut-wrenching. And so that's not a medical quote,
41:00
but probably the, you know, the quote that I would pick over everything else
41:04
to share with the world. Well, when did you get it tattooed, Anya?
41:08
That part, it was added on. It was last year sometime. So, yeah,
41:12
I was on spring chicken, but I still did it. Wow.
41:17
Maybe next time you can show us the tattoo. Let's hold off on that. It's my first time.
41:25
And Dina, you'll be seeing patients at University Hospital, and you're a mom
41:30
of three like me, and you also have stepchildren.
41:34
And you love children. I love children.
41:36
I love children a lot more than adults.
41:40
I've always been the person where if you go to a party and there are children,
41:44
I end up in the corner on the floor playing a game with them or,
41:47
you know, running around the backyard.
41:48
And I just love them. I think they're the most important thing.
41:53
The future of the world. The future of the world. And I truly wish that we valued
41:58
their health care more than we do as a society, that we valued their education more than we do,
42:04
that we valued their well-being, mental and physical, more than we do as a society.
42:09
And this is something I think about every day when I take care of my patients
42:13
and when I encounter children in any situation.
42:16
I just I wish for more for them. Well, I know you're making a difference,
42:21
and I want to get that book. That sounds like a great book. Oh, yeah.
42:25
So will you tell us the title again? Oh, Cutting for Stone. It's very famous.
42:29
I think it won the Pulitzer. It won the Man Booker or one of those.
42:33
I'm forgetting. But it was very famous.
42:37
The main character becomes a physician, and there's several physicians in it.
42:41
It's a great book. You should read it.
42:44
I'm going to. And I really appreciate that recommendation.
42:48
And you're headed back to Cape Cod, even though you had that experience.
42:57
It's not keeping you away. Yeah. No, my friend had this like slash and burn
43:01
experience after that, where she had them cut down all these bushes. She did.
43:06
It was overgrowth. And it was some kind of a wake up call for her.
43:10
But that was fine. And yes, It's very beautiful there.
43:14
And so I just, you know, I relearns lessons and she learned that she should
43:18
be checking her kids for ticks and she's very aware and telling all her friends.
43:22
And so public health, you know, sharing it neighbor to neighbor is always important.
43:28
Dr. Dina Sutter with Pediatric Infectious Disease at UT Health San Antonio and University Hospital.
43:35
Thank you for being here today on Pediatrics Now. Thank you.
43:39
Don't forget to click on the link in this podcast for free credit.
43:42
That may include CME, MOC, or Ethics Credit, depending on your topic or podcast.
43:48
I'm Holly Wayment. I'll see you next week.