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How an Infectious Disease Expert Actually Eats Right Now — Plus: Bexar County’s Rabies Hot Zone · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

0:03
I'm Holly Wehment, and this is Pediatrics Now, cases, updates,
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and discussions for the busy pediatric practitioner, brought to you by UT Health's
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Department of Pediatrics.
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I'm thrilled today because joining me here in the podcast studio back on the show is Dr. Dina Sutter.
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Dina is the new Division Chief for Allergy, Immunology, and Infectious Disease
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here at UTHealth San Antonio, and she has more than 20 years of experience in infectious disease.
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Dina, thank you so much for being back here on Pediatrics Now.
0:38
Thanks for having me, Holly.
0:40
This is being called one of the largest cyclospora outbreaks on record,
0:44
and it's gotten heavy social media attention.
0:47
How do you help families separate the scale of the national number from their actual local risk?
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And what is your advice for pediatricians who are getting these questions?
0:58
Ultimately, we know that Texas has cases.
1:02
Like all the other parts of the country, they're being underestimated for sure.
1:07
So I believe that we probably have, you know, there's been different reports,
1:12
probably over 200 cases, although they're a little bit lagging.
1:16
So I think there were about 140 that were reported a couple weeks ago.
1:20
We have had, and this is not patients that I have, these are actually adult
1:23
patients based on, you know, they just give the age.
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I don't know anything about the specific cases, but I know that we had one case
1:31
reported just generally on
1:33
our lab data last week, and then this week they're reporting nine cases.
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So without details on where the patient traveled, because potentially they went
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to another state, we do know that there was lettuce that was part of the recall
1:47
that was distributed in Texas.
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So I think overall for parents' questions, I think that looking at what the.
1:56
Department of Health is reporting,
1:59
up-to-date numbers, and then getting in the network of finding out what other people are seeing.
2:05
The reason that we actually can identify this pathogen in the vast majority
2:08
of cases is because it's part of a PCR panel for gastrointestinal pathogens.
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If we were just using the old school methods where they had to do special staining
2:18
on multiple stool samples, we probably wouldn't know about the vast majority of these.
2:22
But because these panels are so readily available, and because this is in the
2:27
news, potentially people are testing more.
2:30
So it's really, really hard to assess how many cases we have here locally versus nationally.
2:35
I mean, we know that there have been very, very numerous, large numbers of cases
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in Michigan, Ohio, and I think there's maybe another cluster in North Carolina
2:44
that's being discussed.
2:45
So Texas is relatively less affected, and hopefully we won't have a massive
2:51
number of cases as the product was recalled. But we also know...
2:55
That this organism takes a while to incubate in the human and actually cause disease.
3:02
It goes through a very complex life cycle, which is, you know,
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I don't, I can tell you exactly the states, but basically, you know,
3:08
invasion and then the organisms, you know, sporulates, you get these life forms
3:14
that go back into the intestine.
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So basically, you know, they say you could have symptoms within like three or
3:18
four days, but generally it's a couple of weeks.
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So the number of cases in Texas may rise, even with the product being recalled,
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because there's a delay in presentation of symptoms.
3:28
So it's really, really, really hard to say.
3:31
Overall, for families, one of the discussions is like, what should we avoid?
3:35
And I think we're going to talk about that.
3:37
The good news is that a lot of kids, I know families really try to get their
3:40
kids to eat vegetables, but
3:42
I feel like children, you know, especially young children who are infants and
3:46
And young children, especially children who are immunocompromised,
3:50
you know, transplant patients, those patients should not be eating,
3:53
any of these fresh fruits and vegetables anyway.
3:55
But young kids can get, you know,
3:56
diarrhea and get dehydrated faster than adults. It can be more severe.
4:00
But the good news is, I think, as we were discussing, a lot of times younger
4:03
kids don't want to eat lettuce, which is maybe a good thing right now.
4:08
Yeah, it's hard to get kids and teenagers, I know with my three kids,
4:12
to encourage lettuce. But my son and I were having lunch together yesterday
4:17
at a restaurant, and then he ordered lettuce wrap.
4:21
And then when I mentioned, you know, that that's on iceberg lettuce, but it's probably okay.
4:25
We've only had a handful of cases that we know of here in San Antonio.
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But then there was nothing I could say to get him to still, you know,
4:34
have the lettuce or have even get that. So I guess it's not hard to convince
4:38
people not to eat lettuce. But I mean, what is your advice?
4:41
Yesterday, it was funny because I went over to my neighbor had extra hamburger
4:45
patties and she was leaving town. She goes, would you like some?
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I said, sure, we'll eat hamburgers. And I went over and she had these two boxes
4:51
of lettuce from, you know, H-E-B, which is where we all get our groceries, you know.
4:55
And H-E-B has stated that none of their products were part of the recall.
4:58
I think that there was some distribution of these products to Walmart is what
5:02
I was told, you know, is what I read and possibly other stores.
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But it's hard to say, you know, you only have the information you have.
5:08
So my neighbor handed me these hamburger patties and these two boxes of lettuce that were...
5:14
Pre-washed, but it wasn't cut up in a salad. And she made a joke about,
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hey, you can have some diarrhea.
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And when I went home and I rinsed this lettuce, which my children do not eat
5:24
the lettuce, but my husband and I do, I actually was a little more careful than usual in rinsing it.
5:29
Now, I did not eat it. And it was, I don't know if it was iceberg.
5:33
I don't think it was iceberg anyway.
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So long story short, you only have the information you have that's being reported
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in the news. Sometimes the news will have information that's not coming up on
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the health department's websites.
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The CDC is supposed to have updated information. That has really lagged.
5:49
The reporting on a lot of these things has lagged, unfortunately.
5:52
And so if I was going into a situation where I was going to eat lettuce,
5:56
I tend to kind of like not follow all the rules exactly. But,
6:00
you know, again, if you can actually wash your products, not necessarily that
6:04
it's effective for high-burden cyclospora.
6:06
Cyclospora, you know, you probably might reduce the number of organisms,
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but you know that you can't necessarily get all the organism off of there.
6:13
But, you know, there's this guidance on how to manage your fruits and vegetables,
6:17
and I can talk more about that.
6:18
Yes. How much should we be washing our lettuce and produce? And it sounds so
6:22
scary that it can't be washed off. Is that because the way it's grown? Yeah.
6:26
I mean, ultimately, with any, some, you know, you should always rinse your produce.
6:31
So I get produce from the store and it says pre-washed, and I still rinse it.
6:34
Now, I also do things that I know I shouldn't do. I use a lot of parsley and cilantro.
6:39
Herbs are really highly implicated in these outbreaks, even more so than lettuce,
6:43
because if you think about the structure of an herb, when they're grown,
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there's so many different surfaces.
6:48
And then one thing that I have been reminding myself to do is you're supposed
6:51
to take them, you know, I shouldn't admit that I do this.
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They're in those little bunches that are tied like with a twist tie.
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And if I'm in a hurry, I'll usually like hold it and rinse it under the faucet
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and then chop it from the end. but really what you're supposed to do is take
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it apart, rinse it thoroughly in running water, and then you could like dry
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it on a paper towel or something.
7:12
Especially for herbs, it's a problem. So if you, you know, the guidance is like
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if you get lettuce, you should discard the outside leaves of the head of lettuce,
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cut any bad parts off, any part that looks like it might be a little brown.
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I mean, ideally you don't want that.
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And then rinse all the leaves thoroughly in running water. Now.
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So cyclospora is, you know, is an organism that tends to adhere.
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It also is not eradicated by using bleach or chlorine products.
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There are some chlorine products that along the way in production you could
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use to try to reduce the burden, but that works better for bacterial pathogens.
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And cyclospora, it's not as effective.
7:48
Overall, for food safety, because we have a lot of different outbreaks that
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are happening all the time, we can get E.
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Coli contamination, and cyclospora is classically associated with berries,
7:58
but things like E. coli and salmonella can also be implicated in produce.
8:03
Usually we think about salmonella with egg, chicken, and some milk products.
8:07
But overall, if you have something like an apple that you can rinse the surface
8:11
thoroughly, most organisms are not going to adhere to that.
8:14
If you have something like an orange or a banana where you can peel the surface,
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those are generally considered safe.
8:18
And this is the kind of things I tell people for when they're when they're traveling,
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you know, travel medicine advice, if they're going to a country where there's
8:25
a high risk of diarrheal illness from various pathogens, it's always like,
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you know, you're supposed to peel it or if you can't wash it,
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it's not smooth, you shouldn't be eating it.
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So lettuce salad in general is like one of those things where I'm like,
8:37
if you eat that, that you have a very high risk of getting diarrhea.
8:41
And we don't think about that being the issue in the United States.
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But clearly we're having a problem, you know, you have imported products and
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it's not impossible that a product grown here could have that, you know, to be honest.
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But a lot of times these products are coming from other countries where maybe
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there's a little bit less regulation of, you know, in terms of contamination.
9:00
They're supposed to, you know, there's all these FDA rules, you know,
9:03
they're supposed to food safety rules. But overall...
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You get these products, and then sometimes if you get like a mixed box,
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you know those boxes that you get from the grocery store where there's like
9:15
a pre-made salad, those are considered super risky even if there is an outbreak.
9:20
You know, in the U.S., I wouldn't say super risky, but riskier,
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because if there's products coming from multiple countries, multiple sources
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and farms, and they get mixed together in some plant.
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You can have a lot of additional contamination.
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And so right now, the recommendation is kind of potentially avoid some of those things.
9:40
The recall, if they don't report something, there's maybe other outbreaks going on.
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And if you don't know which product to avoid and then the product gets recalled,
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if you want to be careful, you know, getting your own head of lettuce,
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rinsing it thoroughly, rinsing your tomatoes thoroughly, rinsing all the products
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very thoroughly or peeling things.
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And if you have an immunocompromised person or someone who has a lot of health
10:00
problems, they probably should just, you know, that could, these are riskier.
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I'm not saying don't eat them, I'm just saying that they could be riskier foods
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in the absence of knowing that you shouldn't eat a certain product or a recall.
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Obviously the other safe thing to do is to be watching for recalls.
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Because there could be recalled products on a shelf somewhere that haven't been
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removed, and you definitely don't want those things either.
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And is it just the prepackaged salads or also, you know, where you can buy salad
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in a plastic box or bagged salads? Are those riskier than a head of lettuce?
10:32
Yeah, if there's contamination, they're considered riskier because there are more cut-up surfaces.
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And like I said, the aggregation of different vegetables that are coming from different sources.
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So if there's like, you know, one product is contaminated, it could actually
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be spread, you know, diffusely. And then they always say pre-washed and like, dude, don't do that.
10:55
Still wash it. I still wash it. Wash it in running water. Don't soak it.
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Don't soak it. Don't, yeah. Soaking it does not, you really need the running
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water. Again, that's not super effective for, you know, for cyclospora.
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If you put it in a colander and then let the water rinse through,
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is that ideal? Yeah, that's ideal. You just need to agitate it.
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And like, again, if you have something that you can rub the surface,
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like, you know, you know, I'm using an apple as an example. There's other things.
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Then that's a lot more effective. But, you know, really vigorous rubbing the
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surface of iceberg lettuce is going to tear it up. And so you just kind of have
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to be realistic that that might not be effective.
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It. The other thing to think about is with fruits and vegetables,
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I'll give you another example of something that I should not do and I do.
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If you get like an onion, for example, or you get, you know,
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an avocado, you know, or something like that, I'll chop onion and I'm in a hurry
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and I don't cut it and then pre-peel it.
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And there is like, the onion was grown in soil.
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And so when you cut something and you drag the surface through,
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whether it's a pineapple or, you know, some watermelon or something like that,
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or even an avocado, it's safer to wash the surface of the thing and then cut it and then,
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remove the inside and not drag that surface, you know, like the surface of the.
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Onion skin or whatever, because that bacteria can be dragged through the food product.
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So peel the skin off and wash it. Ideally. Now, most of these are recommendations
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for like if you're in another country and you're preparing your own food there,
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you know, and we don't think about those things being an issue here.
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But every time we have an outbreak and a recall, then it's like,
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well, what could you have done in case you got exposed?
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You know, could you have mitigated some of the risk? Mm-hmm.
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At the restaurant, the waiter, he mentioned that he's had so much lettuce leftover,
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so he feeds it to his tortoise.
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But then I was thinking, like, wait, do you wash your hands before and after
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touching the tortoise? That could be another thing. The tortoise,
12:47
yeah. Like salmonella risk. Salmonella risk in a tortoise, yeah.
12:51
I mean, you know— It's interesting. The tortoise is being fed well because no one's— Yeah.
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And a lot of food preparation issue can be not contamination from a plant,
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but can be in a restaurant where, you know, people are shedding salmonella.
13:03
For example, and then that can contaminate the food.
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Things like E. coli, there's different types of E. coli and certain E. colis we have here.
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We call them shiga toxin-producing E. colis. People are probably familiar with the O157H7.
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We definitely have ongoing outbreaks or recent outbreaks with that and other
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shiga toxin-producing E. colis.
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And that often comes from animal products. If something happens where you have
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an animal product that's cut up and mixed into something else.
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You know, you can get contamination.
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It's not just meat and eggs, though, or meat and dairy.
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You can also get that into fruit and vegetables, too. And I always tell people,
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like, if you don't want to get even something like norovirus,
13:45
which can be easily spread from food workers, for example,
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the highest risk foods are, like, if you go somewhere and you go get,
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like, fresh salsa that's been sitting in a thing, then you have,
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like, multiple factors.
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You've got you've got vegetables from all over, you've got maybe whatever food
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handler issues there could possibly be, and then it's been sitting around.
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So I was told one time when I was in training that.
14:05
Going to eat salsa, like at a salsa bar, you know, which we have lots of here,
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eating like pico de gallo is like the highest risk thing you could possibly
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do. Really? I didn't know I needed to worry about salsa. Yeah.
14:15
I mean, especially if it's fresh. I mean, do I go and eat the pico de gallo? Yes, I do.
14:20
But, you know, if you have somebody who's immunocompromised,
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they should have been giving you, depending on the level of immunocompromised,
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for example, you know, you should be getting advice.
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Pediatricians should be giving, and especially if you have somebody who's like
14:33
on chemotherapy or has had a transplant, they're giving advice not to eat fresh
14:37
fruits and vegetables, you know, cook these things.
14:40
You know, cooking iceberg lettuce is not something I'm going to do,
14:42
but, you know, that's the way to destroy these pathogens is thorough cooking.
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Same with, obviously, meat.
14:48
And then milk products, we have outbreaks going on with milk and salmonella
14:53
in particular, but some of these other things can contaminate milk.
14:56
And I have, I run into a lot of patients who drink raw milk
14:59
and this is that's one thing that if they say that I kind of like that's a very
15:03
risky thing to do and people feel like there's health benefits but like really from the
15:07
the farm yeah it's got to be it's more natural so it must be better is that
15:11
the idea pasture you know pasteurizing it kills you know good things or whatever
15:15
but like I would never drink raw milk like that's I'm I'm kind of a little bit,
15:20
fault not following my own recommendations but I would you know if you have
15:22
patients who are drinking raw milk things like listeria salmonella E.
15:26
Coli, you can have contamination, and people do get sick from that.
15:29
And there's no health benefit to the raw milk versus pasteurized?
15:34
If there is, you know, it's questionable data.
15:38
I think the risk benefit is really not, you know, you really should probably
15:41
eat, you know, pasteurized cheeses, pasteurized milk, and even some that are
15:45
supposed to be pasteurized who have had outbreaks with soft cheeses that were
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produced in the U.S., you know, after they were produced in a U.S.
15:52
Plant, maybe have come, dairy has come from another country,
15:55
and there were listeria outbreaks in the last few months. So there's a lot of
15:59
different things, and this cyclospora thing has really hit the news because of the number of cases.
16:05
The, there are over, you know, the CDC is basically saying, based on,
16:09
you know, maybe not their site
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at the time, that there are at least 20,000 cases, not all lab confirmed.
16:15
But I also, you know, I'm sure there are a lot of cases out there that the reporting
16:20
is lagging and we really don't know about them.
16:22
We're doing this interview in early August. So, and that's where the numbers
16:26
are right now and nine in the San Antonio area. Yeah.
16:30
And I think the thing is, like I said, you have something in the news.
16:33
So people with diarrhea, because you can get explosive diarrhea from norovirus,
16:37
you know, may present a little different.
16:39
But if you see a severe diarrheal illness in the, you know, in the past,
16:43
we didn't have these tests where you could look and sometimes you'll see a kid who's got E.
16:46
Coli, salmonella, campylobacter, you know, norovirus, and they might have multiple
16:52
different organisms depending on where they came from and what they ate,
16:55
especially international travelers.
16:57
So we wouldn't have known about a lot of these things if these tests weren't
17:00
readily available. And a lot of places, smaller hospitals, clinics,
17:04
like they aren't readily available, or they might be able to order them but send them out.
17:09
So if you're in a large place like this that actually does the testing on site,
17:13
you're going to get that data a lot faster.
17:15
But there may be, you know, for every patient who they've identified,
17:18
there may be patients who have very mild cases, who are asymptomatic,
17:23
or people who are sick and just never got tested.
17:26
The good thing about this is Is this not spread directly from human to human?
17:29
Like salmonella can be? Yeah, salmonella can be. And also it doesn't have an animal reservoir.
17:34
So this is just this particular species of cyclospora is only in humans.
17:40
And you can shed it in your stool. I mean, presumably these things did come
17:45
from a human because only humans get them.
17:47
But you have to have like fecal contamination of water. This is probably what
17:50
happened in this plant, this place in Mexico, right?
17:55
The argument is not that people are actually defecating in the field.
17:58
They probably have something equivalent to a latrine. They may have porta-potties,
18:04
maybe the management of that contaminated water products that went on the lettuce.
18:14
So you have to have these organisms have to be in the environment for some period
18:18
of time, several days to a couple weeks, before they become infected.
18:22
So if somebody is shedding in their home with diarrhea, you're not going to
18:27
transmit it to another person like norovirus, which is very,
18:29
very, very likely to be transmitted.
18:32
It's really the food product is a problem here. Dina, how does pediatric cyclosporiasis
18:38
typically present and what should prompt a clinician to specifically test for
18:42
it since routine stool panels miss it?
18:45
It depends on what kind of assay you have. Most people will do an assay that
18:50
includes parasites, including Giardia, Cryptosporidium, and Cyclospora.
18:55
If you're going to send that test... Now, if people are using different assays,
18:58
like the pediatricians in the East community, and these are,
19:00
you know, obviously you're not going to have on-site testing.
19:03
You're going to order it and send it out.
19:04
So if people are using different assays that only can include bacteria and viruses,
19:09
then you're going to miss it in those cases. But the panel that's most commonly used is,
19:14
today, and they've modified that panel over time, will detect it.
19:18
Send it out. And your clinic is in University Hospital. Yeah.
19:21
So, I mean, I haven't been sending this test, but if I have a child,
19:24
like if we have a patient admitted to the hospital, or if I had a patient who
19:28
I had a concern about, I'll order the test and it'll get done locally.
19:31
But the symptoms really are, if you have a kid who's got profuse, watery diarrhea.
19:37
Or if you have a kid who has other kinds of presentation, like fever and diarrhea,
19:41
you know, bloody diarrhea, which does not really occur with this,
19:43
you're probably going to send that panel if it's significant enough for all
19:47
the patients who come in with diarrhea.
19:48
Now, if the pediatricians in the community are not doing this because it's a
19:51
send out, or honestly, because it's much easier to obtain a stool sample from
19:57
a child who's admitted to the hospital.
19:59
So if you tell a parent, like, unless this kid is stooling right there and you
20:02
can collect it in a diaper or something, or the kid can do it on command because
20:05
there's so much diarrhea, you send them home and they may not,
20:08
you know, frequently people don't, come back with the stool sample.
20:12
So I think that your patient would really have to have significant symptoms.
20:16
It's not recommended that we do it like to survey and for surveillance type
20:21
of testing, but, you know, it's worth sending the panel if your patient has,
20:26
significant diarrhea because you need to know whether you should give antibiotics or not.
20:29
And in this case, there is an antibiotic that can be used as opposed to something
20:33
like the shiga toxin producing E. coli where you should not give antibiotics.
20:37
Or in general, salmonella, depending on the patient's age, we generally don't
20:40
give antibiotics if it's just diarrhea.
20:42
So do you want to mention which antibiotic that is?
20:45
Oh, yeah. So for this, you would get Bactrim, trimethoprim sulfamethoxazole,
20:50
which is generally not used for other things, other kinds of diarrhea.
20:54
Like in the old days, we might use it for Shigella, which also can be treated
20:58
with antibiotics. But there's more resistance among Shigella.
21:01
This is really the most effective.
21:03
Other medications, quinolones and nitazoxinide, can be used.
21:07
They're just not as effective as the trimethoprim sulfa.
21:10
And the exception with salmonella is if it's a baby, four months or less.
21:15
It could be a medical emergency.
21:16
It depends on the age. Yeah, we've kind of bumped that age up.
21:19
So, you know, we historically would say under three months you should treat them.
21:23
Typically, if they have bacteria in the bloodstream, they're bacteremic.
21:26
They have invasive disease, intra-abdominal stuff.
21:28
We always treat everybody no matter what their age. Because it could be quickly
21:32
life or death situation. Yeah, and then if the kid's sick, sometimes we'll treat
21:37
kids even older than the three to four month range. It depends on how they present.
21:40
And there's been a couple of serious cases recently involving babies.
21:45
Yeah, we've had a lot of salmonella cases.
21:47
It comes in waves, and sometimes you really try to pin down where the patient
21:51
was or what the exposure was.
21:53
In town, not at my hospital, but recently we've had a baby.
21:57
We've had several babies with salmonella who do not eat food.
21:59
They just take formula. And then there's always a concern is,
22:02
you know, their salmonella contamination of formula is possible.
22:06
And then it's really tough because you think, well, it could be in the environment,
22:11
you know, if a parent or a sibling is shedding or they cross-contaminate formula
22:16
preparation when they're cooking chicken or something, that could be the source.
22:19
But these things sometimes need to be investigated and we try to hand it over
22:23
to the health department.
22:24
And in our Pediatrics Now news feed, we have an episode with Dr.
22:28
J.B. Canty on salmonella and medical emergency in babies with more information on that.
22:35
So, Dina, is there a rational clinical basis for elevated caution with iceberg
22:39
lettuce specifically, or is it more about supply chain traceability than the vegetable itself?
22:46
Yeah, because the prior outbreaks have been things like basil and cilantro.
22:51
So it's not something specific to iceberg lettuce. It just happened to be the
22:54
thing. You know, leafy greens are the highest risk, as I've discussed.
22:58
You know, those are the things that are higher risk than other things,
23:01
even things that you can't peel.
23:03
If it's like, and the leafy greens and berries, specifically raspberries,
23:08
I guess blackberries could be implicated.
23:09
Anything that's like a bumpy surface where there's a higher risk of bacteria
23:13
getting there or parasites in this case, it's not iceberg lettuce intrinsically.
23:19
It's just what happened with the supply chain.
23:22
Now they're doing investigations of different outbreaks and there may be other
23:26
outbreaks that are being caused by other, because every summer we do have cases,
23:30
you know, there are usually like, you know, three or 4,000 cases in the U.S.,
23:33
and they may be coming from other sources, so they have to do these,
23:37
you know, exhaustive epidemiologic,
23:39
evaluations, you know, investigations to try to figure out if there's maybe
23:43
another supplier, another food product that's being implicated,
23:47
and if you have cases all over the country,
23:49
you know, they can trace the one supplier, but there's concern that there might
23:52
be, you know, other sources, and it's a lot of work.
23:57
There are also, as we know, there have been a lot of cuts to personnel at the CDC.
24:03
I was reading that instead of the cyclosporiasis unit, I guess,
24:07
I don't know what they call them, they got cut down from 13 people or 12 people down to three.
24:12
These are truly affecting the you know messaging whether there's timely messaging
24:17
the number of people with expertise the number of people who have hands-on ability
24:21
to do these investigations all this stuff does affect the numbers that we're getting,
24:26
in this case and maybe the ability to you know identify them and then you know
24:30
when you identify them then recalls can be,
24:33
you know issued and then of course you have to have the people who are selling
24:36
the product you know follow through.
24:38
I think a combination of that, the distribution of this product,
24:41
maybe the amount of, you know, parasite on there, and also,
24:45
the fact that we have more readily available tests, more public health awareness
24:50
will amplify the number of identified cases as opposed to what we would have
24:54
had as maybe unidentified cases.
24:56
Since washing doesn't reliably remove it, what should families actually do?
25:00
Are you saying cooking produce right now is the only truly safe option?
25:05
And is it realistic to expect restaurants to cook lettuce rather than serve it raw?
25:10
I don't think restaurants are going to cook lettuce. And I think as long as
25:12
the product isn't recalled, they're going to continue to serve lettuce.
25:15
I think it's like an individual's decision of what they're going to eat.
25:19
You know, when I got that lettuce at home and I rinsed it, I felt totally comfortable with that.
25:24
You know, you have your own role in food safety, food preparation at home if you're cooking.
25:30
And, you know, if there's a recall, you know, you could be, you could be,
25:34
my cilantro could have maybe been contaminated. I just didn't know about it.
25:36
So I just have to mitigate that risk by properly, you know, preparing and managing it.
25:41
I will admit that I actually love Taco Bell, which is kind of embarrassing maybe.
25:46
And I'm not, this is not a plug for them or against them. But,
25:50
you know, I didn't go and get my, you know, occasionally I will go.
25:52
I don't go all the time to get, you know, Taco Supreme, which,
25:55
you know, might have lettuce on it. I was like, well, maybe I shouldn't eat that.
25:58
You know, so like that's how much I'm changing my eating patterns,
26:01
which is pretty minor. So you're not getting lettuce at Taco Bell.
26:04
Well, I didn't go to Taco Bell at all since this happened.
26:07
But, you know, this actually, I love the fact that I can't remember what year
26:10
it was. I should have looked this up.
26:12
There was an outbreak of E. coli that was associated with Taco Bell years and years ago.
26:17
And they did this investigation and they took all green onions off of their
26:22
products. And I was like, mad because I like the green onions.
26:25
And then ultimately it turned out it was actually iceberg lettuce that caused that outbreak.
26:29
So, you know, it's not necessarily Taco Bell or a fast food restaurant per se.
26:34
It's just this mass distribution of a product that they don't know is contaminated,
26:39
and is going to affect people until after maybe thousands of people have eaten
26:43
it, you know. And so there's always going to be that lag. I mean, as y'all know. So...
26:49
Bottom line, I appreciate how you tell us, like, but I'm not doing this.
26:53
This is the advice because you're more relaxed.
26:56
You know that there's a risk to a lot of things. Is that what goes into that?
27:00
I mean, I'm not going to stop eating produce. I mean, if there's a recall, I wouldn't eat it.
27:04
We all know how healthy it is for us. Yeah, if you have a young kid,
27:07
and iceberg lettuce is actually not that healthy for you.
27:10
It's like zero nutrients, but, you know, darker greens and berries,
27:13
people really want to do that.
27:15
I mean, I'm not telling people to change their eating patterns, but just to be aware.
27:19
And I'm just telling them maybe to watch their food preparation.
27:23
And then whether you go to a restaurant and eat a salad, like,
27:26
would I go to a restaurant and eat a salad? Yes.
27:28
If I have young kids that, you know, happen to eat vegetables and they may be,
27:33
a toddler, you know, I don't know, I used to try to make my kids do that.
27:38
Maybe you want to skip that. Maybe you want to give them some alternate vegetable
27:41
that's cooked, you know, if they'll eat that.
27:43
But if we start having more investigations into more sources and,
27:48
you know, you start implicating more foods, why would we change the way we're
27:52
behaving if the recalled product has been removed? Well, because maybe we don't
27:55
have as much trust in, you know.
28:00
In the food chain or the product chain and the testing and the reporting and
28:06
the transparency. You know, I feel like maybe this could be a bigger problem,
28:10
in the future. And I'm just going to say, you know, if you cut public health...
28:15
You know, funding in employees. And this funding actually affects local health departments too.
28:19
You know, grant money, if you don't have grant money, these people cannot do
28:22
these investigations. They can't do the testing.
28:25
So it's a reality. And maybe things are going to be like this or get worse. And I don't know.
28:31
So, and as we all know, it's such a struggle.
28:35
My last question about this outbreak, to get kids, and even for all of us,
28:40
to really, are you getting enough fruits and vegetables.
28:43
And I know pediatricians try to counsel patients about less fast food and eating
28:48
more fruits and vegetables.
28:50
But is this kind of setting us back where it's become such a worry nationally?
28:56
I mean, I guess everybody can make that decision for themselves in terms of
28:59
the risk assessments. But this is kind of how things are in a lot of other countries.
29:05
Like I said, you counsel people when they're traveling not to do things like
29:08
eating. In a lot of countries, people will actually wash their produce in various
29:14
products that may have chlorine in them. Now, again, I said that's not going
29:17
to work for this particular organism, but.
29:20
Cooking all vegetables, peeling all vegetables is the safest thing to do if
29:26
you're in a country where there may be less regulation, there may be more high
29:30
risk of diarrheal pathogens at baseline.
29:33
So I think that we're not there. I mean, I think we actually had a response
29:38
and a recall, and recall the products, but as I said, you know,
29:42
the recall happens after people have eaten it, so I think...
29:46
You know, just do your part, you know, in terms of the things I said about the
29:50
rinsing. I mean, those are just, you know, they're common sense things,
29:52
but people don't always do it. They don't always follow through on that.
29:55
And rinsing can reduce your risk.
29:57
Yeah, it's going to reduce your risk of everything. There is no recommendation
30:00
in this country to start using any kind of like dilute chlorine type of washing,
30:05
you know, as people do other places. In general, that's not currently recommended.
30:10
My sister-in-law's from another country, and she only eats cooked vegetables
30:13
and is very careful about that and even cooks lettuce.
30:18
Yeah, I mean, I think that that's because they grew up knowing that you'll get diarrhea.
30:23
The other thing about this is, you know, their cyclospora is much more endemic
30:28
in a lot of other countries, but then we import the food.
30:31
Could there be contamination in farms here? Yeah, that's possible.
30:35
Or in plants? That's certainly possible. But if somebody has never had an infection
30:41
before, you're a naive host, people are going to get worse with something like cyclospora.
30:47
The cases are more severe than if you go somewhere where it's endemic and people
30:51
have already had it. Okay.
30:54
And Dina, shifting to rabies, with Bexar County confirmed as a state hot zone,
31:00
what should pediatricians tell families about wildlife exposure risk,
31:04
and when does a scratch or a bite warrant post-exposure prophylaxis?
31:09
So we've had some interesting rabies issues here.
31:12
Typically, bats have been the vast majority of the number of cases of rabies.
31:18
You know, animals that have been confirmed to have rabies.
31:20
Testing often occurs when someone finds a sick or dead animal or someone gets
31:24
scratched or bitten they actually have been reporting that the equal number,
31:28
of skunk and bat cases right now and there have been Fox cases that have been
31:33
in the news in general if a kid is scratched without breaking the skin like
31:39
for example let's say you have like,
31:41
the most common thing is cats you know kids like to go play with you know an alley cat or a feral cat.
31:47
If it's something very surface and it scratches the skin minimally,
31:51
generally we don't recommend doing anything other than washing the site.
31:54
If there's a puncture wound, you know, then that's different.
31:57
If you get bitten by a feral cat and then you don't have, you know,
32:01
you don't know the cat's vaccination status, there's consideration of,
32:05
and dogs as well. You know, we have had rabies cases in dogs that were not vaccinated.
32:09
Then they need to be assessed. They need to wash the site. They need to go in
32:12
and see if that the health department recommends giving rig and vaccine.
32:16
And they don't always recommend it depending on the situation.
32:19
But we do know this gunk strain that's endemic to South Central Texas can cross
32:23
over to cats. It sounds like it's been crossing over into foxes.
32:27
So, yeah, according to the Express News in May, a young boy was bitten by a
32:33
rabid fox in Hollywood Park. And that sounds terrifying. So close to home,
32:38
yeah. Very close to home. Yeah.
32:41
I mean, I don't know the exact details of how the kid encountered,
32:45
but, you know, in general, a rabid animal is either going to shy away and,
32:50
you know, they call it dumb rabies, avoid people, or it can be aggressive.
32:53
And so most of the time it's attacking or there's a fight between a domestic
32:58
dog, a pet, and one of those animals.
33:00
I have, you like stories that are personal. So two mornings ago,
33:06
or on Friday morning, actually, I needed to get up and get here early.
33:09
I let my dogs outside and they both ran at a raccoon that was sitting next to
33:13
my pool drinking out of it.
33:14
And I'm yelling, my dogs are vaccinated, but I'm yelling at them and chasing
33:19
them, but they're not going to listen to me and go back outside.
33:21
So the raccoon got in the pool and swam back and forth about 20 times. The raccoon?
33:25
Yeah, to get away from my dogs. And finally, the dogs kind of like got a little
33:29
bit less interested so he was able to get out without being but I was like,
33:33
okay I don't want my dogs to get in a fight with a raccoon they are up to date
33:36
on rabies vaccines but you know then do I need to reassess you know how long
33:40
it's been and that you know obviously don't want them to get hurt,
33:43
and you know that's all I could think about was rabies you know and also you
33:46
know just the injury and it took a long time to get that raccoon it was that
33:50
abnormal behavior for the raccoon no I mean they probably goes there and drinks
33:54
well you know I just happened to get up a little earlier.
33:56
But if an animal is coming up to you I had a fox walk right up to me Right outside
34:01
the dental building You know, a couple months ago Like walk right up to me The dental building?
34:06
Yeah, the dental school Oh, wow And I was like,
34:09
Okay, it's the middle of the day. What are you doing? So those are considered not normal behaviors.
34:14
I'm not a little kid. I didn't try to pet it, you know, but I know lots of adults
34:17
who do things like that, too.
34:19
They try to, you know, wildlife is cute and they try to mess with it and little
34:23
children are at higher risk.
34:25
So a dog and a fox is not like a dog, even though they're related,
34:30
but they're so cute. But don't think of them that way.
34:33
They're so cute. But they are, you know, coyotes, foxes, skunks, especially bats.
34:39
Those are the highest risk animals we have here. Any mammal can get rabies.
34:44
But, you know, my backyard, squirrels were being really weird today,
34:47
walking right up to me. But generally things like squirrels and mice and rats,
34:51
are considered to not be at risk. and possums are not considered high risk.
34:56
They're not good hosts for it. And they also usually die when they get attacked
34:58
by rabid animals. So a lot of weird daytime wildlife stuff, and most of them probably are not rabid.
35:05
But, you know, really telling the parents that we have cases.
35:09
Bats are the biggest problem. I've dealt with so many kids over my career here
35:13
in Bexar County with kids who are playing with bats. There's a dead bat. They picked it up.
35:18
The bat was in the room. The classic story a bat was in the room and like somebody's
35:22
camping it's in the cabin they wake up and you know could the kid have gotten
35:25
bitten could you have you're supposed to actually give vaccine and
35:29
rabies immunoglobulin to all those people even because even if they were licked
35:33
by the bat while they were sleeping yeah theory you know like you could have salivary transmission,
35:39
into the respiratory tract without a bite which is really.
35:42
Not well established but you know usually it's a bite maybe that is so small that it's not noticed.
35:48
And this is something I get calls about on a regular basis. It's usually bats.
35:53
But also we get a lot of dog bites.
35:55
And one thing, a comment I was going to make, I'm sure the pediatricians may
35:59
not be dealing with this, but.
36:01
You know, occasionally, if you get a bite on your, people know you get a bite
36:04
on your face or your head, the rabies, if you do get exposed,
36:08
you get the animals rabid,
36:10
you're going to develop symptoms near your brain, and it's going to travel there
36:14
much faster than it's on your, like, your foot or your hand.
36:17
So I recently had a case where a kid, we have a lot of dog bites here in our
36:21
trauma ICU, and I had a kid who was bitten on the head, and the animal was,
36:25
you know, somebody else's animal, probably wasn't vaccinated, was being observed.
36:30
And I said, I recommend it to the team, you know, then they don't routinely
36:33
do this. You need to go ahead and just start the rabies series because even
36:36
if you observe this animal for 10 days and they don't show symptoms,
36:40
it is possible, you know, usually it's a few weeks to develop rabies.
36:44
You have a few weeks like window, but you're really supposed to vaccinate people
36:47
right away. And if it's on the head or the face, I would really be sort of aggressive
36:52
about trying to get the health department to get vaccine and immunoglobulin.
36:56
So a lot of times, you know, you'll send them to the emergency room.
36:59
I've had people who did not go to the emergency room. It's like,
37:02
where can I get it? You know, the MetroHealth is supposed to be coordinating
37:05
this, but we do have these products in the ER.
37:07
And then they'd have to get follow-up rabies shots after they get the initial
37:10
dose. And that can be a little challenging.
37:12
And at University Hospital, it's the only level one trauma center other than BAMC.
37:18
And so you see a lot of these cases, as you mentioned.
37:22
Is it too late to start treatment once someone shows signs of rabies? Oh, yeah.
37:27
I mean, there's all kinds of concoctions and protocols people have used,
37:32
but no, you need to develop immunity fast.
37:36
You know, you need to get them vaccinated and rig into them like right away.
37:40
And then also your advice is if an animal's acting strangely,
37:44
stay away and don't try to pet an animal that's walking on the street that's
37:49
in the woods. Yeah, don't try to put any animal you don't know.
37:51
I mean, that's really, you think that adults would know that and have common
37:56
sense. I've dealt with so many adults who just, you know, touched every animal
38:00
they could find. What about a stray dog?
38:03
You know, you really shouldn't touch them. I mean, I, you know,
38:06
would I, you know, would I, would I touch a stray dog who came up and looked,
38:09
you know, sick and, you know, I mean, that's a risk, right?
38:14
I've already been vaccinated for rabies in the past when I was traveling.
38:16
So, I mean, maybe I'm, I'm safer, but I definitely don't recommend talking to
38:22
your kids, make sure they understand, like, you know, if you see a cat or a
38:25
dog, just don't touch it.
38:26
You know, I mean, if it's not somebody's pet that's been vaccinated,
38:29
especially if it's acting weird And then the pediatrician's issue is that they
38:34
just have to deal with it after the bite happens or the questionable bite or
38:37
the questionable exposure. And that's when I usually get called.
38:41
Yeah, there was a guy in my neighborhood and I was walking and his dog was off
38:46
the leash. It kept getting unhooked from the collar, actually.
38:50
And then so he needed help. So I ran over to help him. But I asked,
38:52
I said, is your dog up to date on rabies?
38:56
Oh, look at you. I know, look at me. Being careful. But he just looked at me
38:59
like, you know, kind of offended or whatever. And he's like, yeah, I think so.
39:03
I was just like, okay, well, I guess I'll go with that.
39:06
Yeah, yeah. I mean, I definitely wouldn't let my, you know, wouldn't want my kids doing that.
39:10
But yeah, they do quarantine animals when there's bites. Even if they're vaccinated,
39:15
animal control has to make you fill out a form and you have to document the
39:20
vaccine. But you also have to fill out a form if you want to keep your animal
39:22
at home under quarantine.
39:24
I'm kind of strict about that. Wow. The concern is like when you don't actually
39:28
recognize a bite like from a bat or,
39:30
you know, people don't go seek help right away.
39:34
We have very, very few rabies cases in the United States, but you can get it.
39:40
There's more cases here if you don't get your kid into the clinic,
39:44
to the hospital, and get timely treatment, you know.
39:48
And you have a special certification, a fellowship you did on tropical medicine?
39:52
Yeah, it's not a fellowship. It's a certification for TropMed with AST Mitch.
39:56
So basically, it's just additional training, and you know, you have to go to
40:00
spend time overseas. You have to, you know, there's certain criteria,
40:03
but it was really fascinating topic.
40:06
It is so fascinating. Is there anything, Dina, you want to mention that we didn't
40:10
cover these very different topics, but both so important right now?
40:17
I just really, I just really have a lot of sympathy, you know,
40:21
for the pediatrician who's got parents asking these questions all the time,
40:24
and then they have to be up to date.
40:27
But, you know, Follow what's going on and develop answers to these questions or research.
40:34
But again, if you're limited on being able to test, the decision on whether
40:38
to test somebody, it's similar to the decision whether you should send a kid to the ED for admission.
40:43
You've got to assess the risks and then figure out if you can do anything about it.
40:48
If the patient's like E. coli 0157, those are kids that may need closer monitoring,
40:54
even if they don't need antibiotics.
40:55
So, you know, if anybody has any feedback for me, they can always email me and
41:00
say, hey, what are you talking about? We don't we don't do that. Or this is impossible.
41:04
I'm always interested to hear.
41:06
And so we'll include your email address in the text for the podcast.
41:10
So we'd like to promote having a life outside of medicine.
41:14
What do you like to do to unplug? I know you've talked about travel before,
41:17
and you recently got back from Italy. Yeah, I got to go to Italy.
41:21
I attended a conference in Bologna and then did a lot of traveling to different cities in Italy.
41:28
We drove up into the Dolomites. We went to Venice. We went to Florence.
41:34
It was pretty cool. Wow. And the food was generally very good.
41:38
There was some food that was like, I'm disappointed I'm eating this in Italy, but I ate a lot of pizza.
41:42
It was fantastic. It was very good. And do you want to mention,
41:46
I also, on Pediatrics Now, I love quotes. Is there a favorite quote?
41:50
I would like to share a quote or two about public health, since that's what we're talking about.
41:58
And not worrying or worrying?
42:01
It's not a worry one. It's more like an ethical one. Okay. So one is C.
42:05
Everett Koop, who was the Surgeon General back in the 80s to 90s,
42:10
I think. I can't remember the dates.
42:12
It's healthcare is vital to all of us some of the time, but public health is
42:15
vital to all of us all of the time.
42:18
The other one I wanted to share was by Dr. Martin Luther King Jr.
42:23
Of all forms of inequality, injustice in health is the most shocking and inhumane.
42:29
Will you say it again for us? I like that one. That was too fast.
42:35
Of all the forms of inequality, injustice in health is the most shocking and inhumane.
42:41
So that's not specifically public health, but it's a great quote for us to think
42:47
about. As pediatricians, we really believe everybody should have access to health.
42:52
I'm sorry. Pediatricians are the best people. They're good people. Amazing.
42:56
Dedicating their lives. I love them. Making the world a better place.
43:00
They are. That's wonderful.
43:03
Dr. Dina Sutter with UT Health San Antonio Infectious Disease and University
43:08
Health, thank you so much for being here again on Pediatrics Now. Thanks, Molly.
43:14
We need to do these regular segments. There's always so much going on.
43:17
Click on the link in this podcast for a free credit that may include CME,
43:21
MOC, or ethics credit, depending on our topic or podcast.
43:25
Coming up next week, I'll take you to the surgical unit at University Hospital,
43:31
and you'll see behind the scenes a baby whose life was changed for the better.
43:36
An update on plastic surgery coming up next week on Pediatrics Now.
43:41
I'm Holly Wayment. I'll see you soon.