COVID-19 Hype or Hazard

Hopefully you are concerned, but aren’t panicking about the new coronavirus that is all over the news right now.

Breaking News: we have seen community spread in the US, at least nine 41 deaths, and more cases in more states. (see below)

What do you think of the news of the 2019 novel coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)?

Experts say don't panic about the 2019 novel coronavirus.

Are you ready to put on a mask, never leave your home, or just wait and see what happens?

COVID-19 Hype or Hazard

Hopefully you are concerned, but aren’t panicking and want to wait and see what happens over the next few days, weeks, and months.

So what’s going on?

A new coronavirus, 2019-nCoV SARS-CoV-2 has been detected in Wuhan, China and it is spreading, killing some people.

Why is this a concern?

While there are coronaviruses that are very common, even causing many cases of the common cold, there are others that are much more serious.

Seasonal coronavirus are very common during cold and flu season.
Seasonal coronavirus are very common during cold and flu season.

These include the coronaviruses that cause SARS and MERS.

A worldwide outbreak of severe acute respiratory syndrome caused by SARS-CoV caused 8,098 cases and 774 deaths in 2002-03. It also started in China.

MERS-CoV, which causes Middle East Respiratory Syndrome, has been causing cases and deaths since 2012.

What’s Next With COVID-19?

Why are experts concerned about SARS-CoV-2?

Check for Travel Alerts and Warnings before your next trip.
Check for Travel Alerts and Warnings before your next trip.

Mostly because of past experiences with SARS and MERS.

There is also the fact that there is no treatment or vaccine for 2019-nCoV.

Coronavirus that shows up on those large respiratory panels that some health providers do is seasonal coronavirus = the common cold.
Coronavirus that shows up on those large respiratory panels that some health providers do is seasonal coronavirus = the common cold.

And no, your doctor won’t be able to routinely test you for SARS-CoV-2. Testing can be done for those who are high risk, but it still involves sending the specimens to a lab at your local or state health department or the CDC.

That shouldn’t put you into panic mode though…

“Two cases of 2019-nCoV have been reported in the United States. Both patients had recently returned from Wuhan, China. More cases are likely to be identified in the coming days, including more cases in the United States.”

COVID-19 Frequently Asked Questions

Unless you have recently traveled to Wuhan, China an area where there is a COVID-19 outbreak or have had close contract with someone who traveled to an area with a lot of cases while they were sick, then you likely aren’t at much risk to get sick with this virus.

“For the general American public, who are unlikely to be exposed to this virus at this time, the immediate health risk from COVID-19 is considered low.”

Coronavirus Disease 2019 (COVID-19) Situation Summary

It is certainly not something to ignore though.

Since first being detected in Wuhan, China on December 29, 2019, cases have spread to 28 41 46 64 72 134 other countries.

“More cases are likely to be identified in the coming days, including more cases in the United States. It’s also likely that person-to-person spread will continue to occur, including in the United States.”

Coronavirus Disease 2019 (COVID-19) Situation Summary

Most experts expect SARS-CoV-2 to become a pandemic, but that still shouldn’t put you into panic mode…

Experts are also working to learn more so that we know:

  • the original source of the virus – is it the animal markets in Wuhan, China?
  • the incubation period – it seems to be 1 to 14 days
  • how contagious the virus can be and how it spreads – close contact
  • how serious are the complications of infection or how deadly is this virus – so far, “reported illnesses have ranged from mild to severe, including illness resulting in death,” but the latest worldwide mortality rate of 1.4 to 3.4% is much higher than seasonal flu
  • can the virus be contained – this seems unlikely…

We got one answer recently, as it seems that people with the virus are contagious before they have symptoms.

What’s next?

Don’t panic. Plan ahead.

Stay up to date on SARS-CoV-2 information and call your health care provider if you have flu-like symptoms and recently traveled to Wuhan, China or had contact with someone who is under investigation for COVID-19.

“Limited reports of children with COVID-19 in China have described cold-like symptoms, such as fever, runny nose, and cough. Gastrointestinal symptoms (vomiting and diarrhea) have been reported in at least one child with COVID-19. These limited reports suggest that children with confirmed COVID-19 have generally presented with mild symptoms, and though severe complications (e.g., acute respiratory distress syndrome, septic shock) have been reported, they appear to be uncommon.”

CDC on Frequently Asked Questions and Answers: Coronavirus Disease-2019 (COVID-19) and Children

And even if you are starting to get nervous, at least you don’t have to worry too much about your kids. So far, there is no evidence that children are more susceptible to COVID-19 and there are reports that they actually get milder symptoms!

Lastly, if you haven’t yet, be sure to get a flu vaccine.

Affected geographic areas include China, Italy, South Korea, Iran, and Japan.
As we see community spread in more areas, the criteria to guide evaluation of PUI for COVID-19 continues to loosen up.

If you are going to develop a fever and symptoms of lower respiratory illness during cold and flu season in the United States, especially if you haven’t traveled to a high risk area, then it is probably the flu, not the new coronavirus…

More on COVID-19 Hype or Hazard

The Experts Defending Anthony Fauci

Anthony Fauci is receiving a lot of support from doctors, scientists, and public health experts.

Not surprisingly, more and more experts are speaking out to defend Dr. Anthony Fauci.

Anthony Fauci is receiving a lot of support from doctors, scientists, and public health experts.
Anthony Fauci is receiving a lot of support from doctors, scientists, and public health experts.

These experts understand that Dr. Fauci “deserves our deepest gratitude and support” and is “our best hope in these challenging times.”

The Experts Defending Anthony Fauci

Harold Bauchner certainly wasn’t alone in stating his public support for Dr. Fauci.

“As 12,000 medical doctors, research scientists and public health experts on the front lines of COVID-19, the infectious diseases community will not be silenced nor sidelined amidst a global pandemic. Reports of a campaign to discredit and diminish the role of Dr. Fauci at this perilous moment are disturbing.”

IDSA Statement in Support of Anthony Fauci, M.D.

The Infectious Disease Society of America issued their own statement.

“If we have any hope of ending this crisis, all of America must support public health experts, including Dr. Fauci, and stand with science.”

IDSA Statement in Support of Anthony Fauci, M.D.

And so did the Association of American Medical Colleges, whose members comprise all 155 accredited U.S. and 17 accredited Canadian medical schools; nearly 400 major teaching hospitals and health systems, including 51 Department of Veterans Affairs medical centers; and more than 80 academic societies, with 173,000 faculty members, 89,000 medical students, 129,000 resident physicians, and more than 60,000 graduate students and postdoctoral researchers in the biomedical sciences.

“The AAMC is extremely concerned and alarmed by efforts to discredit Anthony Fauci, MD, our nation’s top infectious disease expert. Dr. Fauci has been an independent and outspoken voice for truth as the nation has struggled to fight the coronavirus pandemic….

Taking quotes from Dr. Fauci out of context to discredit his scientific knowledge and judgment will do tremendous harm to our nation’s efforts to get the virus under control, restore our economy, and return us to a more normal way of life.

America should be applauding Dr. Fauci for his service and following his advice, not undermining his credibility at this critical time.”

AAMC Statement in Support of Anthony Fauci, MD

Hopefully Dr. Fauci knows how much the majority of people value his work and trust his opinions.

“We have been very fortunate to have Dr. Anthony Fauci at the helm directing infectious diseases research at NIH for so many years. His leadership and support of a rigorous scientific process has been critical to transforming HIV from a death sentence to a chronic condition​, saving millions of lives worldwide. His voice and expertise need to be amplified not silenced if we are going to get control of the COVID-19 pandemic​, which has now taken the lives of more than 135,000 Americans and more than 570,000 people worldwide.”

HIV Medicine Association Stands with Science and Anthony Fauci, MD

And we know that the only way out of the COVID-19 pandemic is with our public health experts, like Anthony Fauci, leading the way.

“In his role as Director of the National Institute of Allergy and Infectious Diseases (NIAID), Dr. Fauci has fostered a longstanding and productive collaboration with the ATS. He has faithfully served the American people through six presidential administrations, always providing sound, science‐based guidance to threats large and small. As we move forward to combat COVID‐19, his scientific knowledge, expertise, and counsel will continue to be of critical importance.”

Statement by the ATS Executive Committee supporting Anthony S. Fauci, M.D., Director, National Institute of Allergy and Infectious Diseases

As cases of COVID-19 once again surge, one thing is becoming clear:

Science, not politics, must guide COVID-19 response

AIBS Supports Dr. Fauci

We can’t wish the SARS-CoV-2 virus away…

I am a pediatrician and #IStandWithFauci.

We need health experts like Anthony Fauci to help guide us through this. And we need people to listen to his advice.

More on Anthony Fauci

What Did the AAP Say About Sending Kids Back to School?

The AAP has offered guidance for a safe way to get our kids back in school during the COVID-19 pandemic. Will schools follow any of it when they open up?

The American Academy of Pediatrics recently issued some guidance about what to do about kids going to school this fall.

The AAP said a lot more than that parents should send their kids back to school. They offered guidance on how to safely send kids back to school...
The AAP said a lot more than that parents should send their kids back to school. They offered guidance on how to safely send kids back to school…

Not surprisingly, folks are a little confused about what they actually said…

What Did the AAP Say About Sending Kids Back to School?

It is true, the AAP guidance does favor opening up schools this fall.

“With the above principles in mind, the AAP strongly advocates that all policy considerations for the coming school year should start with a goal of having students physically present in school. The importance of in-person learning is well-documented, and there is already evidence of the negative impacts on children because of school closures in the spring of 2020. Lengthy time away from school and associated interruption of supportive services often results in social isolation, making it difficult for schools to identify and address important learning deficits as well as child and adolescent physical or sexual abuse, substance use, depression, and suicidal ideation. This, in turn, places children and adolescents at considerable risk of morbidity and, in some cases, mortality. Beyond the educational impact and social impact of school closures, there has been substantial impact on food security and physical activity for children and families.”

COVID-19 Planning Considerations: Guidance for School Re-entry

But, that isn’t all they said…

The goal is for kids to be in school this fall...

To get to that goal of opening schools, the AAP offered a list of key principles that schools should follow, including that:

  • school policies are going to have to be “flexible and nimble” so that they can quickly change as we get new information, especially “when specific policies are not working”
  • schools develop strategies that depend on the levels of COVID-19 cases in the school and community
  • schools make special considerations and accommodations for those who need them, “including those who are medically fragile, live in poverty, have developmental challenges, or have special health care needs or disabilities, with the goal of safe return to school”

So clearly, this is not a one-size-fits-all, lets open up schools no matter what kind of thing.

“Highest Risk: Full sized, in-person classes, activities, and events. Students are not spaced apart, share classroom materials or supplies, and mix between classes and activities.”

CDC on Considerations for Schools

The AAP didn’t say to simply open up schools without doing anything else…

“No single action or set of actions will completely eliminate the risk of SARS-CoV-2 transmission, but implementation of several coordinated interventions can greatly reduce that risk. For example, where physical distance cannot be maintained, students (over the age of 2 years) and staff can wear face coverings (when feasible). In the following sections, we review some general principles that policy makers should consider as they plan for the coming school year. For all of these, education for the entire school community regarding these measures should begin early, ideally at least several weeks before the start of the school year.”

COVID-19 Planning Considerations: Guidance for School Re-entry

They offered guidance on how to safely open schools.

Or at least how to open schools as safely as possible, as the alternative of keeping kids at home has risks too. And many people are skeptical that a strategy of closing schools is all that helpful in controlling the spread of SARS-CoV-2.

So the AAP guidance says that we open schools and also plan for:

  • Physical distancing – cohort classes, block schedules, rotating teachers instead of students, etc.
  • Cleaning and disinfecting
  • Testing and screening – schools will need a rapid response plan for when a child or staff member develops a fever at school.
  • Face Coverings and PPE – although it won’t be possible in all situations and for all children, “school staff and older students (middle or high school) may be able to wear cloth face coverings safely and consistently and should be encouraged to do so.”
  • Organized Activities – although this isn’t something most folks want to hear, they should understand that opening schools doesn’t mean that everything will be back to normal… “It is likely that sporting events, practices, and conditioning sessions will be limited in many locations.”

If we do all of that, will it really be safe to go to school with these guidelines?

Unfortunately, the most important part of the guidelines, the section on Testing and Screening, was a bit light on details…

“Parents should be instructed to keep their child at home if they are ill.”

COVID-19 Planning Considerations: Guidance for School Re-entry

The guidelines acknowledge that it will be too hard to do temperature checks and symptom screening each day and that schools should have a rapid response plan if anyone has a fever had school, but then what?

“Here in Colorado, I’ve been following our state health department website very closely. They update data every day and include the outbreaks in the state they are investigating. As you can imagine, there are lots and lots in long-term care facilities and skilled nursing homes, some in restaurants and grocery stores. There have been a total of four in child care centers, and we do have a lot of child care centers open. In almost every one of those cases, transmission was between two adults. The kids in the centers are not spreading Covid-19. I’m hearing the same thing from other states, as well.”

Why a Pediatric Group Is Pushing to Reopen Schools This Fall

So what’s going to happen if kids in school start to get sick and test positive for COVID-19?

Among the 950 COVID-19 in Texas daycare centers are 307 children.
Among the 950 COVID-19 in Texas daycare centers are 307 children. (Dallas Morning News)

The 60,000 members of the AAP who didn’t participate in writing the guideline know what’s going to happen…

A ton of parents from the school are going to call their pediatricians looking to get their kids tested!

What likely should happen?

That classroom or cohort and their close contacts should move to self-quarantine and home/online education until they pass the incubation period from their last contact.

“Put in place the infrastructure and resources to test, trace and isolate new cases.”

Safely Reopening America’s Schools and Communities

(I’m guessing we will get more details about this from the AAP soon and well before school starts. )

Most importantly though, our communities should do everything they can to keep their case counts down – wash hands, practice social distancing, wear a face cover.

And if we are going to send our kids back to school, we should make sure that we are protecting all of the folks making that possible.

Can we do all of that?

Sure!

Will we???

Sending Your Kids Back to School

Are you still unsure about whether or not you should send your own kids back to school?

I don’t blame you…

Some things to consider when making the decision:

  • is your child or any of their contacts at risk for a more severe case of COVID-19, including having an underlying, chronic medical condition, keeping in mind that the risk increases with age, especially once you reach age 65 years? If possible, online schooling might be a better option for students in high risk categories.
  • was staying home from school hard for your child? If your child had problems learning at home or the social isolation was an issue, than that would make going back to school even more important.
  • will your school or school district be “flexible and nimble” and respond to new information, rising case counts, and evolve their policies if necessary?

Most importantly, if you send your kids back to school, are you going to be constantly worried that they are going to get COVID-19 or bring home the SARS-CoV-2 virus? If so, then keep them home this fall.

On the other hand, if they are healthy, have no high risk contacts at home, and are eager to go back to school, then you should probably feel comfortable sending them if the school follows the guidance offered by the AAP.

More on COVID-19

Why Are Social Distancing Kids Still Getting Sick?

Why are some kids still getting sick if they are have been our of school and stuck in the house for weeks because of COVID-19?

COVID-19 has kept most kids out of school for some time now. Many are also out of daycare. And few are out playing with friends.

So why are some still getting sick? What else is going on with kids stuck at home while we are all social distancing to flatten the curve.

Why Are Social Distancing Kids Still Getting Sick?

The first thought of some parents and pediatric providers upon reading this might be, wait, what, kids are still getting sick?

Flu activity is low in most of the United States.
Flu activity is low in most of the United States.

And that’s because it does seem that in addition to flattening the COVID-19 curve, staying home from school and daycare, washing hands, and general social distancing techniques has worked to keeps from getting sick with the flu and most other contagious diseases!

So while pediatric providers are available to do telemedicine appointments, it certainly isn’t business as usual, even as their days have gotten quite unusual.

Some kids are still getting sick though, and while we know what you are thinking, most probably don’t have COVID-19.

Why?

It might be because:

  1. they aren’t social distancing as well as they think they are, keeping in mind that with many diseases, people can be contagious for a few days before they show symptoms and you can sometimes catch germs from touching fomites, or objects that a sick person has recently touched. That still doesn’t mean that they have COVID-19 though. If they have contact with others, they could catch almost anything.
  2. they caught something from someone who had a disease a few weeks or months ago and is still shedding. For example, some infants can shed RSV for as long as 4 weeks after they get better. And they can shed the virus that causes hand, foot and mouth disease (HFMD) for almost two months! Human parainfluenza viruses (HPIV), a common cause of colds and croup (seal bark cough), can also shed for many months.
  3. they caught something from someone who had a viral disease that causes a lifelong latent infection with periodic reactivation and shedding. Wait, what? While herpes (cold sores) is the main disease you might think of as causing a lifelong latent infection, there are others. You may not realize this, but after getting roseola (causes a high fever for a few days, followed by a rash after the fever breaks), HHV-6 (human herpes virus-6) kind of does the same thing. The big difference is that while you shed HHV-6 in your saliva from time to time, you don’t have any symptoms. You can get other folks sick though, especially older infants, once they lose the passive immunity they got from maternal antibodies.
  4. they have a sore throat caused by a virus, allergies, or reflux, but have tonsil stones and a positive strep test because they are a strep carrier. Nearly 20% of kids are thought to be carriers of strep, which means that every time they get tested, they will be positive, whether or not they actually have strep throat. That means that you don’t have to worry about testing the dog to see if they are carrying strep…
  5. they were exposed to a disease with a long incubation period. While the incubation period (the time between getting exposed to something to when you get sick) is just a few days for many diseases, it can be several weeks or months for others. In fact, your child might not get sick until 30 to 50 days after being exposed to someone with mono!
  6. they had a virus a few weeks ago and now have Gianotti Crosti syndrome (GCS), a post-viral rash on a child’s legs, arms, and buttocks. Although GCS might linger for weeks or months, it eventually goes away on its own. Another rash, this one likely caused by reactivation of the virus that causes roseola, might have you thinking your child is covered in ringworm (how would they get that if they haven’t left the house??). Instead, they likely have pityriasis rosea.
  7. their symptoms are caused by a non-contagious infectious disease that is spread from an animal or insect and not from another person – think Lyme disease (ticks), Cat scratch disease (cats), and West Nile virus (mosquitoes), etc.
  8. they got sick (bacteria, virus, or parasite) from contaminated lake or well water, which can cause diarrhea – giardiasis, Crypto, shigellosis, norovirus,
  9. they got sick (bacteria, virus, or parasite) from eating raw or contaminated food – giardiasis, shigellosis, norovirus, E. coli, salmonellosis
  10. their symptoms are caused by a non-infectious disease, which could be anything from allergies and asthma to poison ivy or herpes zoster (shingles).

It is also possible that their symptoms are being caused by anxiety, fear, and stress, which is not unexpected as they see schools closed, people getting sick and wearing masks, and are likely unsure about what’s coming next.

Has your child been sick recently?

Do you have a pet turtle or chickens in your backyard? They could be a source for Salmonella…

Do you understand why now?

Now call your pediatric provider if you have questions and need help getting them well, especially if they seem anxious or have extra stress from being home all of the time and away from school and their friends.

You especially want to call if you think that they might actually have COVID-19. While most kids have mild symptoms or are asymptomatic, if your child has a fever, cough, and difficulty breathing, you should call your pediatric provider or seek medical attention.

More on Covid-19 Kids Getting Sick

Telemedicine for Parents and Pediatric Providers

Ideally, we would continue to see kids in our office when they are sick, but until the COVID-19 pandemic is over, telemedicine is a great alternative to help us keep all of our kids healthy and recognize when they are truly sick, perhaps even needing immediate medical attention.

Many parents and pediatric providers are getting a crash course in telemedicine because of the COVID-19 pandemic.

Although using virtual visits when kids are sick certainly isn’t a new idea, many things have gotten in the way of making online visits to pediatric offices more popular. Chief among them is the simple fact that most people prefer an in-person, in-office visit.

Telemedicine for Parents and Pediatric Providers

Unfortunately, with the risk of spreading the SARS-CoV-2 virus, even when kids don’t have symptoms, in-office visits aren’t always possible and certainly aren’t always safe anymore.

That doesn’t mean that your pediatric provider is going to close, as other non-essential businesses are doing.

Newborns, infants, children, and teens still need to be seen for essential preventative care and when they are sick.

Be flexible. Consider modifying your clinical schedule and physical space to minimize risk. Increase capacity to deliver telehealth when possible.”

Sally Goza, MD, FAAP President, American Academy of Pediatrics

Still, we are going to have to change how we provide that care until the COVID-19 pandemic is over.

Remember, while it is true that kids aren’t thought to be at risk for severe COVID-19 symptoms, they likely can still get and spread the spreading SARS-CoV-2 virus.

That’s why most pediatric providers are encouraging patients with fever and respiratory symptoms (URI, cough, runny nose, difficulty breathing) to stay home and are instead moving to phone/virtual consultations.

And with community spread in more and more areas, many are switching to telemedicine visits for any non-essential visit. Is your child due for an ADHD recheck? Do you need to discuss test results or need your pediatrician to look at a rash? Is your child constipated? With the risk of COVID-19, these are all ideal reasons to ask for a telemedicine appointment instead of visiting the office.

“Aetna announced it will offer zero co-pay telemedicine visits nationally for any reason for the next 90 days for all commercial plans. Humana, Blue Cross Blue Shield of Massachusetts, Horizon Blue Cross Blue Shield of New Jersey, and others have announced similar expansions of telehealth coverage.”

Opportunities To Expand Telehealth Use Amid The Coronavirus Pandemic

Before COVID-19, the simple fact that most insurance companies didn’t pay for telemedicine visits got in the way of there becoming more popular. That’s changed now, as have some laws and regulations (especially HIPAA restrictions) that had previously made it harder to do telemedicine.

Making the Most of Your Telemedicine Visit With Your Pediatric Provider

While some parents likely are excited about doing telemedicine visits, since they can be more convenient than visiting the office, many others probably still have doubts.

However you feel about it, since it is likely that your child might need a telemedicine visit before this is all over, let’s look at how we can all make the most of it.

To start, if possible, make the telemedicine visit with your usual pediatric provider or someone else in their office. Sign their telehealth consent form and review other polices and procedures before your online appointment.

It can also help if, just before the visit, you:

  • weigh your child
  • check your child’s temperature
  • check your child’s heart rate or pulse
  • check your child’s respiratory rate (count the breaths per minute)
  • write down all of the medicines your child has been taking
  • write down all of your child’s symptoms, including how long they have had them and if they are getting better or worse
  • write down how your child’s symptoms are affecting their eating, sleeping, and other activities, for example, are they drinking fluids, playful, consolable, or are they just crying all of the time?
  • write down any questions you have, as you might forget them during the telemedicine visit!
  • make sure you have a flashlight handy in case your provider wants to take a look at your child’s throat. Maybe even practice having them open wide before the visit.

And most importantly, understand how you are going to connect to your pediatric provider for the online visit! Are you using Facetime, Skype, or a website like doxy.me, etc?

Telemedicine Do’s and Don’ts

Are you and your child (yes, you want your child to be with you during the telemedicine visit!) ready for your first telemedicine visit with your pediatric provider?

Do have everything ready at home and be prepared for when your pediatric provider “shows up” to the visit.

It is also a good idea that you:

  • don’t use medical terminology, like lethargic (is your child really hard to wake up?), dehydrated (just mention the last time your child urinated, etc.), or say that your child is having trouble breathing (is your child breathing fast and hard or having trouble catching their breath?) – instead, just describe what your child is doing and how they are acting, which, since it is a telemedicine visit, your provider will actually get to see for themselves!
  • don’t say that you can’t control your child’s fever, if what you really mean is that it goes back up after their fever reducer wears off, and remember that fever is typically just a symptom, like a cough or runny nose, and not a sign of how sick your child is
  • don’t ask for or expect a prescription, especially for an antibiotic, just because you had an online visit with your provider. Studies have found high rates of antibiotic prescribing during telemedicine visits, especially for kids with respiratory infections, and that hopefully won’t continue as telehealth becomes more popular.
  • avoid sitting in a dark or noisy room, as that will make it harder for your provider to see and hear you

And at the end of the visit, make sure you understand your child’s diagnosis, recommendations for treatment, and most importantly, don’t forget to ask when you should expect that your child should begin to get better and the signs to look for that might indicate that they are getting worse.

“We recognize we are all practicing pediatrics in circumstances we have never encountered before in our careers.”

Sally Goza, MD, FAAP President, American Academy of Pediatrics

Are there limits to telemedicine?

Sure.

We can’t sew up a cut that needs stitches, for example, but you know what? If your child falls and cuts themselves, we can do a telemedicine visit to let you know if they do need stitches, maybe saving you a visit to the office or the ER.

Ideally, we would continue to see kids in our office when they are sick, but until the COVID-19 pandemic is over, telemedicine is a great alternative to help us keep all of our kids healthy and recognize when they are truly sick, perhaps even needing immediate medical attention.

More on Telemedicine for Parents and Pediatricians

Does Zantac Cause Cancer?

While you might be worried over the hype about NDMA in Zantac, just remember that this is the same stuff that adds tiny extra risk of cancer from eating bacon.

Breaking News – Zantac syrup, made by Lannett, has been recalled too.

Have you heard the news that taking ranitidine (Zantac) could cause cancer?

I’d be surprised if you haven’t…

Does Zantac Cause Cancer?

So does Zantac really cause cancer or is this just media hype?

“The U.S. Food and Drug Administration has learned that some ranitidine medicines, including some products commonly known as the brand-name drug Zantac, contain a nitrosamine impurity called N-nitrosodimethylamine (NDMA) at low levels. NDMA is classified as a probable human carcinogen (a substance that could cause cancer) based on results from laboratory tests. NDMA is a known environmental contaminant and found in water and foods, including meats, dairy products, and vegetables.”

FDA Statement alerting patients and health care professionals of NDMA found in samples of ranitidine

Ok, so Zantac might contain NDMA and NDMA could cause cancer.

But NDMA is found in many things, so how concerned should we be about it being in Zantac?

“Although NDMA may cause harm in large amounts, the levels the FDA is finding in ranitidine from preliminary tests barely exceed amounts you might expect to find in common foods.”

FDA Statement alerting patients and health care professionals of NDMA found in samples of ranitidine

Although the FDA is still “evaluating whether the low levels of NDMA in ranitidine pose a risk to patients,” so far, it doesn’t sound like a very big concern.

While Novartis AG’s Sandoz division, which makes ranitidine, has stopped distributing their generic version of Zantac, Sanofi will continue to distribute brand name Zantac. And many other companies make ranitidine, so it will likely continue to be available.

Most companies are voluntarily recalling their prescription and over-the-counter versions of ranitidine tablets, capsules, and syrup.

How do medications become contaminated with NDMA?

In the case of blood pressure medications (sartans), regulators began looking for NDMA last year.

“It is now known that these impurities can form during the production of sartans that contain a specific ring structure known as a tetrazole ring under certain conditions and when certain solvents, reagents, and other raw materials are used. In addition, it is possible that impurities were present in some sartans because manufacturers had inadvertently used contaminated equipment or reagents in the manufacturing process.”

Sartan medicines: companies to review manufacturing processes to avoid presence of nitrosamine impurities

Ranitidine doesn’t contain a tetrazole ring, but as with the sartans, it is possible that the NDMA formed during production or that contaminated equipment or reagents were used in the manufacturing process.

“Valisure’s research, along with that of Stanford University and others, found that NDMA was the result of the “inherent instability” of the ranitidine molecule.”

Valisure Detects NDMA in Ranitidine

And food?

“The typical diet in most countries contains nitrates, nitrites, and nitrosamines. Nitrates and nitrites occur naturally in fruit and vegetables, which are regarded as an important part of a healthy diet due to the powerful evidence of beneficial health effects against cancer. In the same time, nitrates and nitrites are often used as food additives in processed meats such as ham, bacon, sausages, and hot dogs, to retard microbial spoilage, and preserve meat products recognizable appearance and flavor as well. A high consumption of processed meats is linked to an increased gastric cancer risk, and many people consider nitrates/nitrites as the main reason for that. Nitrosamines are produced by chemical reactions of nitrates, nitrites and other proteins.”

Song et al on Dietary Nitrates, Nitrites, and Nitrosamines Intake and the Risk of Gastric Cancer: A Meta-Analysis

NDMA is not in food because of contamination.

“…excess lifetime cancer risk was calculated separately for each of the five nitrosamines and then summed to arrive at a total excess lifetime cancer risk of 1.46 × 10-6 (or about 1 in 683,000) due to average population exposure to nitrosamines through pork bacon.”

Cancer Risk from Nitrosamines in Pork Bacon

And the cancer risk from NDMA in food is considered to be small.

“Nitrosamines are ubiquitous in the human environment and have been detected in food items, including cured meat, bacon, fish, and beer, in cosmetics, drugs, and in the front passenger areas of new cars.”

Exposure to high concentrations of nitrosamines and cancer mortality among a cohort of rubber workers

The bigger risk is likely from nitrosamines in cigarette smoke and occupational exposures.

What should you do if your child takes ranitidine?

Still, do you want to give your kids a medicine that might contain a substance that could cause cancer?

“The FDA is not calling for individuals to stop taking ranitidine at this time; however, patients taking prescription ranitidine who wish to discontinue use should talk to their health care professional about other treatment options. People taking OTC ranitidine could consider using other OTC medicines approved for their condition. There are multiple drugs on the market that are approved for the same or similar uses as ranitidine.”

FDA Statement alerting patients and health care professionals of NDMA found in samples of ranitidine

Since the risk seems so small, whether or not you continue giving your child Zantac or you switch to something else might depend on how easy it would be to switch.

Over the counter Zantac is approved for adults and children 12 years and over. There are many options to treat reflux for these folks, including Pepcid, Prevacid, Nexium, and Prilosec, etc.

On the other hand, prescription ranitidine syrup is approved for infants as young as one-month-old. Not many medicines are approved at this age.

There is one though.

Although not an H2-receptor antagonists like ranitidine, Nexium is another reflux medicine that is approved for infants. It is a proton pump inhibitor (also decreases the production of acid in the stomach) that is available in delayed release oral suspension packets.

Should you stop taking Zantac?

So what should you do?

Although doing nothing or switching seem like your two options, if your child’s reflux has been well controlled on Zantac for awhile, this might be a good idea to ask your pediatrician if a trial off medications might be appropriate.

Most infants and children eventually outgrow having reflux and are able to wean off their reflux medicine. Is your child ready?

Of course, you shouldn’t stop your child’s medicine without talking to your doctor first. And instead of stopping their Zantac, it might be better to switch to another reflux medicine.

“Carcinogens do not cause cancer at all times, under all circumstances.”

American Cancer Society on Known and Probable Human Carcinogens

Could you keep taking Zantac? That’s also an option for now, especially if you only expect that your child will be on it for a short time, but as more manufactures declare that they will recall and stop shipping ranitidine, you might have to switch anyway.

Whatever you do, don’t panic over this news. Your kids are almost certainly not at any real increased risk to develop cancer just because they have been taking Zantac.

More on NDMA in Zantac

Updated: October 30, 2019

The New Vaccine Surveillance Network Report on Enterovirus D68 Infections

Anyone who has been following the outbreaks of Acute Flaccid Myelitis the last few years will likely think the following report is long overdue.

The report, Enterovirus D68–Associated Acute Respiratory Illness — New Vaccine Surveillance Network, United States, July–October,2017 and 2018, is especially welcome by those folks who are already convinced that AFM is associated with EV D68.

The New Vaccine Surveillance Network Report on Enterovirus D68 Infections

But wait, why was surveillance done through the New Vaccine Surveillance Network?

And for that matter, what is the New Vaccine Surveillance Network?

“The New Vaccine Surveillance Network (NVSN) includes study sites that focus on population-based surveillance and data collection on the use and impact of vaccines and the impact of vaccine policies. Since 2006, NVSN sites have conducted active, population-based surveillance for hospitalizations and outpatient visits associated with acute gastroenteritis (AGE) in children (2006-present). NVSN sites have conducted surveillance for acute respiratory illness (ARI) from 2000 to 2009, and again beginning in 2015.”

New Vaccine Surveillance Network (NVSN)

Before you start thinking that this means a new Enterovirus D68 vaccine is coming out soon, many NVSN studies have nothing to do with vaccines…

“NVSN supports broad-based surveillance and research projects for acute gastroenteritis and acute respiratory infections in areas with a population base of at least 500,000.”

New Vaccine Surveillance Network (NVSN) Overview

In addition to studies on the flu and pneumococcal disease, they have done studies on norovirus, coronavirus, human metapneumovirus, HPIV, RSV, and rhinovirus infections.

So what did they find out about Enterovirus D68 infections?

“Based on preliminary data, test results were positive for EV-D68 for two (0.08%) of 2,433 patients with ARI who were tested during 2017 and 358 (13.9%) of 2,579 tested during 2018. “

Enterovirus D68–Associated Acute Respiratory Illness — New Vaccine Surveillance Network, United States, July–October, 2017 and 2018

There were a lot more EV D68 infecions in 2018 than there were in 2017

And what does that mean?

Considering that we had “only” 33 confirmed cases of AFM in 16 states in 2017 and at least 223 confirmed cases of AFM in 41 states in 2018, the rise in EV-D68 cases seems to correlate with the rise in AFM.

“Although AFM is rare in the United States, these AFM surveillance data, along with the EV-D68 activity documented through NVSN, provide additional supporting evidence for a temporal association between EV-D68 respiratory illness and AFM. “

Enterovirus D68–Associated Acute Respiratory Illness — New Vaccine Surveillance Network, United States, July–October, 2017 and 2018

Again, few people are going to be surprised by this news…

So, what’s next?

You mean besides the 2019 AFM season?

More on Acute Flaccid Myelitis News


Acute Flaccid Myelitis Update

The latest update on acute flaccid myelitis, including case counts.

Breaking News – The CDC has updated the Acute Flaccid Myelitis (AFM) case counts. (see below).

These 223 confirmed cases are among the total of 374 reports that CDC received of patients under investigation.

We continue to get regular updates from the CDC about AFM.

CDC Telebriefing: Update on Acute Flaccid Myelitis (AFM) in the U.S.

Unfortunately, we aren’t getting the real answer we were looking for – how to stop the outbreak.

Acute Flaccid Myelitis Update

Since the last update, we have learned that:

  • the case count is up to 223 confirmed cases among 374 reports, with most cases being confirmed at this point (2018)
  • cases have been reported in 41 states (2018)
  • there have been 2 confirmed cases (NC and UT) among 15 reported cases so far this year (2019)

That means that we have clearly exceeded the last record of 149 cases in 2016.

There are also 49 confirmed cases and 28 cases under investigation in Canada since January 2018.

In other news:

  • the CSTE will be issuing issued a new statement on AFM reporting reaffirming that they “are confident state and local health departments are working closely with doctors to ensure suspected cases are reported.”
  • the CDC has posted updated treatment guidelines
  • an MMWR early release, Increase in Acute Flaccid Myelitis — United States, 2018,  will provide details on the first 80 cases of 2018 – but sound similar to what we have learned from outbreaks in 2014 and 2016…
  • the CDC is working with local and state health departments on better long term tracking of cases – something parents have been pushing for!
  • an AFM Task Force has been established to “bring together experts from a variety of scientific, medical, and public health disciplines to help solve this critical public health issue.”

Most importantly though, we again learned that the CDC still doesn’t feel that they have enough evidence to say that any one thing is causing AFM.

AFM Cases in the United States

In addition to this year’s cases, there were:

  • 33 confirmed cases in 16 states in 2017
  • 149 confirmed cases in 39 states in 2016
  • 22 confirmed cases in 17 states in 2015
  • 120 confirmed cases in 34 states in 2014 – with most of the cases being reported in California (24), Colorado (10), Utah (6), Massachusetts (9), Virginia (5), Indiana (5), and Illinois (4)

What’s next?

More on Acute Flaccid Myelitis News

Updated on March 27, 2019

What to Know About the Acute Flaccid Myelitis Investigations

Although you may just now be hearing about acute flaccid myelitis, it is important to understand that it isn’t new.

The rise in AFM cases began in 2014 and seem to occur every other year.
The rise in AFM cases began in 2014 and seem to occur every other year.

It wasn’t even new when we started to see an increased number of cases a few years ago.

What is new, is that we are seeing an increased number of cases.

Acute Flaccid Myelitis Timeline

AFM refers to acute (sudden onset) flaccid (droopy or loose muscles) myelitis (inflammation of the spinal cord) and it is a subtype of acute flaccid paralysis.

If that explanation doesn’t really help you, it might help to understand that paralytic polio, like AFM, is another subtype of acute flaccid paralysis.

“In August 2012, the California Department of Public Health (CDPH) was contacted by a San Francisco Bay area clinician who requested poliovirus testing for an unvaccinated man aged 29 years with acute flaccid paralysis (AFP) associated with anterior myelitis (i.e., evidence of inflammation of the spinal cord involving the grey matter including anterior horn cell bodies) and no history of international travel during the month before symptom onset. Within 2 weeks, CDPH had received reports of two additional cases of AFP with anterior myelitis of unknown etiology.”

Acute Flaccid Paralysis with Anterior Myelitis — California, June 2012–June 2014

That seems to be about when this started, in 2012.

Unfortunately, they didn’t figure out what was causing the paralysis in these three patients, despite extensive testing and more cases followed.

“To identify other cases of AFP with anterior myelitis and elucidate possible common etiologies, CDPH posted alerts in official communications for California local health departments during December 2012, July 2013, and February 2014.”

Among 23 cases, California health officials found that the median age of the patients was 10 years old, only two tested positive for EV-D68, although most did have a recent “an upper respiratory or gastrointestinal prodrome.”

“Acute flaccid paralysis (AFP) with anterior myelitis is not a reportable condition, and baseline rates of disease are unknown but are likely quite low. Data from 1992–1998 on children aged <15 years in California indicated an incidence of 1.4 AFP cases per 100,000 children per year and did not identify a single case of AFP with anterior myelitis.”

California wasn’t the only state with cases.

In 2014, there were at least 12 cases in Colorado and 11 in Utah.

“In response to the CDPH and CHCO reports, the CDC established a case definition for enhanced nationwide surveillance of AFM, which included individuals less than 21 years of age with acute flaccid limb weakness and MRI involvement of predominantly the gray matter of the spinal cord without identified etiology presenting after August 1, 2014.”

Messacar et al on Acute Flaccid Myelitis: A Clinical Review of US Cases 2012–2015

All together though, in 2014, once  the CDC began actively investigating cases, at least 120 cases were discovered in 34 states. The cases were associated with a large outbreak of EV-D68-associated respiratory illness, although they weren’t able to conclusively link those respiratory illnesses to the AFM cases.

Is there any evidence that there were a lot of cases before 2012?

Or that the CDC has dropped the ball and hasn’t been doing enough to investigate cases?

Not if you look at the timeline.

The CDC was involved very early, called for all cases to be reported, and is actively investigating those cases.

CDC activities include… using multiple research methods to further explore the potential association of AFM with possible causes as well as risk factors for AFM. This includes collaborating with experts to review MRI scans of people from the past 10 years to determine how many AFM cases occurred before 2014, updating treatment and management protocols, and engaging with several academic centers to conduct active surveillance simultaneously for both AFM and respiratory viruses.

CDC on the AFM Investigation

And if the first cases in California and Colorado triggered so much attention, isn’t it likely that any cases anywhere else would have done the same thing?

That makes it very unlikely that many cases were missed in earlier years.

  • EV-D68 first identified as a cause of respiratory tract infections – 1962
  • the first reports that EV-D68 could cause severe, even fatal respiratory disease – 2008
  • first AFM cases are discovered in California – August 2012
  • the Colorado Department of Public Health and Environment notifies the CDC about a cluster of AFM cases at Children’s Hospital Colorado and a joint investigation begins between the CDPH, CDC, and the physicians caring for the patients  – September 2014
  • the CDC issues a health advisory on Acute Neurologic Illness with Focal Limb Weakness of Unknown Etiology in Children and calls on local and state health departments to report patients to the CDC – September 2014
  • the CDC conducts a conference call on Neurologic Illness with Limb Weakness in Children, so that clinicians could learn about the latest situation, surveillance, and CDC clinical guidance for AFM testing, patient evaluation and case reporting – October 2014
  • the CDC posts Interim Considerations for Clinical Management – November 2014
  • 120 AFM cases in 34 states – 2014
  • Council of State and Territorial Epidemiologists AFM case definition adopted – June 2015
  • 22 AFM cases in 17 states – 2015
  • 149 AFM cases in 39 states – 2016
  • Council of State and Territorial Epidemiologists AFM case definition updated, which once again, recommends against adding AFM to the Nationally Notifiable Disease List – June 2017
  • 33 AFM cases in 16 states, including one death – 2017
  • CDC Telebriefing on Acute Flaccid Myelitis in the US with Dr. Nancy Messonnier, director of CDC’s National Center for Immunization and Respiratory Diseases – August 2018
  • 158 AFM cases confirmed in 36 states among 311 reported cases that are being investigated – 2018

The other issue that concerns many parents is why a definitive cause hasn’t yet been identified. And why don’t we have treatments or a cure yet?

“To date, no pathogen (germ) has been consistently detected in the patients’ spinal fluid; a pathogen detected in the spinal fluid would be good evidence to indicate the cause of AFM since this condition affects the spinal cord.”

CDC on AFM Investigation

Although enteroviruses can be difficult to detect in spinal fluid, it is important to keep in mind that isn’t the only thing that is keeping experts from declaring the investigation over and naming a cause, such as EV-D68.

“Among 41 patients whose upper respiratory tract samples were available for enterovirus/rhinovirus testing at CDC, 17 (41%) tested positive: eight (20%) for EV-D68 and nine (22%) for eight other enterovirus/rhinovirus types.”

Eyal Leshem on Notes from the Field: Acute Flaccid Myelitis Among Persons Aged ≤21 Years — United States, August 1–November 13, 2014

Another big issue is that EV-D68 has not been detected in every, or even most AMF patients, and many others have been found to have other enteroviral infections, including EV-A71.

Could it be a coincidence that investigators are finding these enteroviruses simply because it is the season for them to appear? That would mean something else is causing these kids to have AFM.

“During September–November 2016, 10 confirmed cases of AFM were reported in Washington. No common etiology or source of exposure was identified. Enterovirus-A71 was detected in one patient and EV-D68 in two patients, one of whom also tested positive for adenovirus.”

Acute Flaccid Myelitis Among Children — Washington, September–November 2016

While the focus is on EV-D68 as a cause and everyone wants an answer, no one wants the CDC or other investigators to be wrong.

That doesn’t mean that they should be overly cautious and waste time or resources once an answer is evident, but just that they should follow sound epidemiological principles, get the right answer, and help stop kids from getting AFM.

What’s Next for AFM?

There are still a lot of unknowns about AFM, but this is likely what we can expect in the coming months:

  • the CDC will continue to investigate all unconfirmed cases that have occurred this year, which can take about four weeks after a case is reported and all necessary information is sent in. Keep in mind that since we don’t know if the CDC has already received all of the information on the cases they are investigating, we don’t know when they will finish investigating any pending cases.
  • local or state health departments will likely reach out to treating physicians to get followup about AFM patients about two months after they developed limb weakness and then report this short-term follow-up data to the CDC. In general, the CDC does not seem to contact patients directly.

From the current investigation, information from outbreaks and cases over the previous years, and cases in other countries, we will hopefully get the answers we need soon to prevent and treat AFM.

During the COCA Call, the AFM Surveillance Team will discuss the activities CDC is conducting as part of its AFM investigation.
The AFM Surveillance Team will participate in a COCA Call in mid-November.

Maybe some of those answers will come during a Clinician Outreach and Communication Activity (COCA) Call on November 13, when members from the CDC Acute Flaccid Myelitis Surveillance Team discuss the “activities the CDC is conducting as part of its investigation into AFM.”

The fact that the CDC has an Acute Flaccid Myelitis Surveillance Team will be news and is hopefully reassuring to some folks…

This is also probably a good time to remind folks that funding for public health has been declining in recent years, even as we expect our public health officials to respond to more things and react more quickly to keep us all safe and healthy. Let’s make sure we fund our public health programs, including the CDC and NIH, so that they have all of the resources they need to address all of today’s public health challenges.

More on the Acute Flaccid Myelitis Timeline

Updated on December 10, 2018

Infants’ Ibuprofen Concentrated Oral Suspension Recall

Three lots of Infants’ Ibuprofen Concentrated Oral Suspension that were made by Tris Pharma, Inc. and sold under the Equate, CVS Health, and Family Wellness brands and sold at Wal-Mart, CVS, and Family Dollar stores have been recalled.

Three lots of  Infants' Ibuprofen Concentrated Oral Suspension that were made by Tris Pharma, Inc. and sold under the Equate, CVS Health, and Family Wellness brands and sold at Wal-Mart, CVS, and Family Dollar stores have been recalled.

If you have little kids who sometimes take pain or fever medications, you will want to check your medicine cabinet for this recall.

Three lots of Infants’ Ibuprofen Concentrated Oral Suspension have been recalled because the concentration in the bottle might be higher than they it is supposed to be.

What does that mean?

Although they are supposed to be at a 50mg per 1.25ml concentration, if it is indeed higher, then if you gave your child 1.25ml, they might get more than just 50mg.

“To date, Tris Pharma, Inc. has not received any reports of adverse events related to the lots of product that are the subject of this recall.”

How much more? We don’t know, since we don’t know what the “potentially” higher concentration might be.

Infants’ Ibuprofen Concentrated Oral Suspension Recall

Fortunately, the recall is limited to just 3 lots of  Infants’ Ibuprofen Concentrated Oral Suspension that were made by Tris Pharma, Inc. and sold under the Equate, CVS Health, and Family Wellness brands and sold at Wal-Mart, CVS, and Family Dollar stores.

Do you have any recalled Ibuprofen?
Do you have any recalled Ibuprofen? Check your lot numbers!

If you have the recalled Ibuprofen, don’t use it. Contact Tris Pharma for a refund.

And seek medical attention if you think your child got too much Ibuprofen and is having any symptoms, especially nausea, vomiting, epigastric pain, or more rarely, diarrhea.

Fortunately, getting extra Ibuprofen is not usually as dangerous as getting extra Acetaminophen.

Although, of course, neither is good! Be careful when dosing your kids and be sure they need it first.

Oh, and yes, at least in this case, store brand Ibuprofen at Family Dollar and Wal-Mart is the same as store brand Ibuprofen at CVS…

More on Infants’ Ibuprofen Concentrated Oral Suspension Recall