IDSA Media Briefing: Summer Bug-In’: Lyme and Other Infectious Diseases

Dr. Jeanne Marrazzo: [00:00:00] Hello, everybody. Thank you so much for joining us this morning. I am Doctor Jeanne Marrazzo. I'm the chief executive officer of the Infectious Diseases Society of America. And I represent more than 13,000 physicians, scientists and public health experts whose focus is the prevention, treatment and cure of infectious diseases. So it is the season of the creepy crawlies. Uh, the morning's briefing that we're going to talk about today covers the latest on several vector borne and summer season infectious disease outbreaks. Several of these have been very prominent in the news lately. So hopefully we'll have a lot of great questions. And we have two fantastic experts who are going to talk to us today to take us through some of these, um, very interesting and hot topics. First is Doctor Thomas Moore. Doctor Moore is a clinical professor of medicine at the University of Kansas School of Medicine in Wichita. He is a fellow of the Infectious Diseases Society of America. After Doctor Moore, we'll hear from Dr. Paul Auwaerter. Dr. Paul Auwaerter is the Sherrilyn and Ken Fisher professor of medicine and the director of the Sherrilyn and Ken Fisher Center for Environmental Infectious Diseases at Johns Hopkins School of Medicine. He's also a past president of the IDSA. After we hear from our two speakers, we'll open the floor to questions. To ask a question, please click the Raise My Hand button. Or for those on the phone, select star nine and you will be added to the queue. I am going to now turn it over to Doctor Moore.

Dr. Thomas Moore: [00:01:42] Thanks, Doctor Marrazzo. Um good morning everyone. Uh, so summer is the usual season to see, uh, diarrheal diseases. And this summer is certainly no exception. Uh, many of you have been following the multistate outbreak of cyclosporiasis, which has afflicted at least a few thousand people. Since its discovery in the latter part of the 20th century, cyclosporiasis has occurred sporadically every year. It is routinely foodborne, usually fresh fruits and vegetables. Although the source of the current outbreak remains obscure. It's expected that it will likely be linked to fresh produce of some kind, as it has with prior outbreaks. For example, the last multistate outbreak occurred in 2018 and was traced back to lettuce. The incubation period is two days to two weeks, with an average of one week, and the disease is usually self-limited, lasting less than two weeks. But it can last several weeks in some patients with impaired immunity. Because the disease is usually self-limited and the severity is usually mild or moderate, most infections go unrecognized. Indeed, reported cases are believed to be just the tip of the iceberg lettuce. Thank you. Anyway. However, with increased public awareness, both providers and patients have a lower threshold for testing. Uh, and this is where it's important. Uh, the press actions are quite important. By helping us publicize this outbreak, individuals are more likely to be tested, and those with the infection are more likely to be identified. The more cases that are identified, the more quickly epidemiological epidemiologists or epidemiologists can identify a smoking garbanzo, if you will.

Dr. Thomas Moore: [00:03:13] I get a lot of questions regarding prevention. It has been said that a physician recommended the avoidance of all fruits and vegetables until the source is identified or the outbreak is over. That's certainly the safest way to avoid the disease, but in my opinion, it's not necessary, particularly if you have normal immunity. You can reduce your risk of this and other diarrheal diseases by thoroughly washing fresh produce under clean running water before eating, and by following safe food handling practices. People should be aware that chemically disinfecting or sanitizing produce may not fully eliminate Cyclospora. It's important to thoroughly wash produce even if it is labeled as pre-washed. Keep in mind that this disease is very rarely transmitted from person to person, so only standard isolation precautions are recommended for hospitalized patients. As I mentioned, diarrheal diseases are more common in the summer, but other diseases also favor these months, particularly diseases associated with outdoor activity. So please note, I'm not recommending people stay inside, only that people be educated about the risks of certain diseases so they can protect themselves. Over the course of the summer, the mosquito population steadily increases and West Nile virus infections follow suit. Since its introduction into the United States in 1999, the virus has spread rapidly across America, and cases have been reported from several states with um with most of the states reporting cases in southern states. I'm sorry, most of the eastern coast.

Dr. Thomas Moore: [00:04:40] Now let me back up. Most of the East Coast states started reporting the cases. But this year, excuse me, this year, most of the cases reported so far have been in Arizona and Texas. Uh, it is still relatively early in the season, though in most cases are reported in late summer and early fall as the mosquito population reaches its peak before the first hard freeze. Since 1999, cases of West Nile virus disease have been reported in all 50 states and Puerto Rico. Dengue, another disease transmitted by mosquitoes, is becoming a more significant problem over time. Between 2010 and 2023, annual cases of dengue averaged 828 cases per year. But in 2024, the most recent year for which national data are available, the number of cases had increased to 3798, which is an increase of 359%. Most cases of dengue. That's about 97%, are imported from countries where the disease is endemic, making the major vector for this disease in the United States, the airplanes that bring the travelers back to the United States. Um, there are some autochthonous cases that is locally transmitted cases, uh, in Texas and in Florida. Thankfully, those are quite rare. Um, because there's no current vaccine against either of these viruses, that's West Nile or dengue in the United States, the only way to prevent infections from these agents is the prevention of mosquito bites through the use of personal protective measures. So first, I would recommend applying skin repellents use only repellents approved by the EPA.

Dr. Thomas Moore: [00:06:13] That's, uh, Deet, picaridin, excuse me, or oil of lemon eucalyptus. Uh, it's recommended that you spray onto your hands first before gently wiping it onto your face. And you do not use the oil of lemon eucalyptus on children under the age of three. You can also treat your gear and clothes. Mosquitoes can bite through tight, thin clothes. So if you wear loose long sleeved clothing to keep the bugs from reaching your skin, that's helpful. You can also spray your gear and your clothes with permethrin, um, to kill or repel bugs. This also works against ticks. Um, the other thing you can do is, and this is very important really for, for just in general is to clear breeding grounds. Mosquitoes lay eggs in standing water. So dump any standing water that you see that's empty. Birdbaths pet bowls and flowerpot saucers once a week. Um, uh, you can also turn over small boats, tires, kids toys so they don't collect rain and lead to breeding grounds. Uh, also create physical barriers to keep mosquitoes from getting inside. If you have window screens, uh, and leave your windows open, make sure your screens have unbroken, uh, or unbroken. Um, also, mosquitoes are actually quite weak fliers. So if you have a ceiling fan, uh, you can a strong outdoor ceiling fan you can on your porch, you can use that to, to blow them away. It doesn't have to be ceiling. It could just be a regular fan, a box fan.

Dr. Thomas Moore: [00:07:41] So I would also be remiss, uh, for the summer if I didn't remind everybody to use sunscreen with both UVA and UVB protection, and be sure to apply it at least 15 minutes before going out, and then reapply liberally when out. Um, I come from a very pale people. So this is a very important topic to me. Um, one other, uh, sorry, another disease that I'll talk about, uh, associated with summertime outdoor activity is primary amoebic meningoencephalitis, which is a devastating infection of the brain caused by the thermophilic free-living amoeba, naegleria fowleri. Infection occurs when water containing the amoeba enters the body through the nose, usually during recreational water activities, such as swimming or diving. When acquired from these activities, the infection is most often seen late in the summer, as evaporation of water from lakes exceeds rainfall during the dog days of summer, leading to lower water levels and an increased chance that boating activity stirs up the lakebed, where the amoeba like to like to live. Uh, historically, in the United States, cases were most reported from southern states with warmer climates, however, since 2011, there's been a northward expansion of infections with this with this free-living amoeba into Minnesota and other, uh, and other states. Uh, there's also been an association, an association with other types of water exposures. Uh, for example, the use of neti pots to irrigate the sinuses.

Dr. Thomas Moore: [00:09:05] Um, there have also been some recent reports of survivors of this devastating disease, which is almost always fatal. Um, and those reports of survivors actually provide hope for improved outcomes with early, excuse me, excuse me, early diagnosis and aggressive treatment. Sorry. You take some water for a second to Marco Rubio here. Okay. Sorry about that. Uh, clinicians treating patients with meningitis and warm freshwater exposure are encouraged to consider meningoencephalitis in their differential diagnosis. Uh, again, because early detection and treatment as early detection, early diagnosis leads to earlier treatment and improved outcomes. Um, the one case of meningoencephalitis primary amebic meningoencephalitis that I saw years ago, uh, that we published with the CDC, was a patient that had used tap water at a neti pot for sinus irrigation. Now, the case was not suspected initially, but our, uh, our lab director at the time, Doctor Linscott, uh, who had worked in a pediatric hospital. And she reported, uh, that the unwritten rule for spinal fluid that looked like patients, that it came from a patient with bacterial meningitis and had a negative gram stain was to do a wet mount. And there is some evidence to suggest that, uh, doing a wet mount on those, uh, on spinal fluid with that characteristic, uh, may, may lead to earlier diagnosis.

Dr. Thomas Moore: [00:10:27] One last, uh, disease I'll mention that will require a little more time than I have today is the one that we see every year here in Kansas, which is, which is common nationwide, and that's tularemia. Uh, tularemia, also known as rabbit fever, is a highly infectious disease caused by the bacterium Francisella Tularensis, which the CDC has designated as a tier one select agent that is the highest risk category based on its potential for use as a bioweapon. Humans can become infected through tick or deer fly bites. Improper handling of infected animals such as rabbits, muskrats, prairie dogs around here, and other rodents, as well as inhaling contaminated dust or drinking contaminated water. So the reason I mention that this disease today is for the last ten years, cases have steadily increased. And the manifestation that we typically see in the summertime is pulmonary or pneumonic tularemia, sometimes known as lawn mower tularemia, where, uh, patients are on riding lawn mowers, typically mowing the median strips between the highways, uh, and inadvertently or unintentionally running over a dead or dying rabbit that, uh, that has succumbed to tularemia aerosolizing the particles and inhaling it and then coming in with severe, pneumonia in the largest study of community acquired pneumonia in the Post-antibiotic era. Uh, out of Toledo, uh, Barbara Marsden published a study that showed that, uh, cases of severe pneumonia in the summertime are less likely to be due to diseases like strep pneumo, uh, the typical infections with Streptococcus pneumoniae or Haemophilus influenza, and more likely to be due to things like tularemia or Legionnaires disease. That's all I have, Doctor Marrazzo.

Dr. Jeanne Marrazzo: [00:12:20] Tom. Thank you. That was an amazing overview of, of, uh, some really important conditions, especially a great discussion of what's going on with the Cyclospora outbreak. I'm going to turn it over to Doctor Auwaerter who's going to get into ticks Lyme disease and alpha gal syndrome.

Dr. Paul Auwaerter: [00:12:37] Yeah thank you Doctor Marrazzo. And also Doctor Moore. You know, I did my training in the 1980s, and as a medical student, probably what I only heard about was Rocky Mountain spotted fever and Lyme disease, which was just emerging at that time. But we now have a bevy of tick borne illnesses. And indeed, I think ticks are no longer just viewed as a seasonal nuisance. Um, you may have seen reports from the Centers of Disease Control, which has been tracking tick bites since 2017, that this spring has been the worst ever since reporting began, with an estimated 31 million tick bites. And this has been reported in most states of the country. And I think the other figure, which many of you may be familiar with, is that the most common vector borne disease, which is tick borne in our country in North America, is Lyme disease, with perhaps over 476,000 cases annually, and has become quite a public health issue. So much, as Doctor Moore mentioned about mosquito prevention, I think tick awareness and tick prevention and some of the EPA products that Doctor Moore mentioned, is should be part of our routine activities so that we can enjoy the outdoors in safe fashion, much like we use sunscreen or seat belts. Now, a frequent question I get is why are we seeing more ticks and tick bites? And a lot has to do with increased populations and geographic expansion. For example, the Lone Star tick, which transmits, Ehrlichia, or also called human monocytic ehrlichiosis, used to be in the South central states, but has spread northward to Maine and, uh, to other parts of the country from its usual locations.

Dr. Paul Auwaerter: [00:14:31] And we've seen quite an expansion with Lyme disease, which is another tick borne illness, uh, towards the Midwest and in states which previously hadn't been, uh, with frequent disease such as Michigan, northern Indiana, Ohio, eastern Iowa, and so on down the Shenandoah Mountains to northwestern North Carolina. Why this is happening? Many people will say, well, it's milder and warmer winters that allow for suitable humidity, and therefore ticks are more active and more abundant. There's also been reforestation, more abundant deer and rodent host reservoirs. Also, of course, we, uh, are moving into suburbs and enjoy gardening and outdoor activities and recreation, which are probably all contributing. So it's probably just not a single factor. Now, turning to Lyme disease, it is clearly the most common in New England, Mid-Atlantic, and the Upper Midwest in states such as Minnesota and Wisconsin. But the tick that carries it, I would just mention carries six other tick borne illnesses. It's really quite remarkable and promiscuous as a tick because it can transmit an infection called anaplasmosis babesiosis, as well as certain rarer forms of Erlichia some spotted fever, rickettsia, Borrelia miyamotoi and even Powassan virus, a viral agent that can cause neuroinvasive disease. But the blacklegged, or often called the deer tick, is what is responsible for Lyme disease, and it is the female that tends to transmit this, and often the nymphs, which I call the teenagers, that are more frequent and biting. In the spring and early summer months now Lyme disease.

Dr. Paul Auwaerter: [00:16:26] Many of you are familiar with the classic bull's eye rash. One of my main points that I emphasize to patients and clinicians are that's not the most common rash. That's the classic rash. The most common rash is really an ovoid expansile pink homogeneous rash without the central clearing. And not everyone has symptoms of illness. About a third of people only have a rash. Others might have headache and flu like symptoms or fever. Uh, and of course, if there's untreated Lyme disease that progresses, it can affect the heart. It can affect the nervous system and also Lyme arthritis. Now it is, uh, if recognized and diagnosed, uh, readily treatable with antibiotics. Um, although about 10% of people seem to suffer a post infectious complication, which we call post-treatment Lyme disease syndrome. Uh, very much akin to long Covid. One of the chinks in our abilities to diagnose Lyme disease, though, is a lack of having good diagnostic tests, especially early in infection, since we rely on antibodies. Uh, and of course, the body doesn't make them for up to 2 to 4 weeks after infection, which hampers, uh, diagnosis, especially in people that are presenting without classic symptoms of Lyme disease. Now prevention, uh, despite using tick awareness and removing ticks promptly. In fact, Lyme disease can't be transmitted unless a tick is attached for over 36 hours. We've seen, uh, increasing cases, uh, over the years. And therefore there's been a re, uh, examination trying to go to a prevention aspect with an immunization strategy.

Dr. Paul Auwaerter: [00:18:10] Uh, I will just tell you that I was an investigator in a, uh, Pfizer Valneva phase three study, which is looking at a transmission blocking vaccine, vla15, which, uh, has had some high level, uh, results reported by the companies this past March where it appeared to prevent Lyme disease by about 73%, which was very much in line with an older vaccine called Lymerix, which is no longer marketed. There were no identified safety concerns, and the companies are planning to present this to the Food and Drug Administration for approval, although it didn't meet its pre-specified primary endpoint. A secondary analysis was very much in keeping with this 7,374% figure and did meet statistical significance. So I think this is something that hopefully can be available for patients down the road. And then I'll close with Alpha gal syndrome. Excuse me. I'll do my own Marco Rubio. So Alpha gal syndrome is not an infection, but it is increasingly on the mind of many people. And it appears to be an allergy triggered by a tick bite, probably mostly the Lone Star tick. And what it appears to do is sensitize people to a certain carbohydrate, the alpha gal. And unlike most allergies, where you get an immediate response itching or shortness of breath, this is a delayed response after eating red meat products, which could even include dairy, gelatin, and even mammalian derived medical products. And, uh, because the Lone Star tick has been spreading, we're seeing more and more cases in areas that we wouldn't normally entertain.

Dr. Paul Auwaerter: [00:20:06] Uh, a recent MMWR study looked at seroprevalence of these antibodies against alpha gal. And, uh, where the Lone star tick is most common is in the South central states. And there, for example, the range, uh, was people with an estimated seroprevalence of containing these antibodies. Tennessee was reported at 21.5%, Arkansas 31.2%. Of course, there was a bit of a split between urban and rural, with more people living in the rural areas having the higher rates. But I importantly emphasize that just having the antibodies does not mean you have alpha gal syndrome. In fact, you should not be checked for routine features unless you have the characteristic clinical presentations, which is usually a delayed abdominal pain, diarrhea, swelling, perhaps hives, or even anaphylaxis. But this usually will only occur hours after ingesting these meats, which makes it very different amongst allergy syndromes. Uh, so, um, we talked a little bit about alpha gal and just removing ticks promptly is, is incredibly important along with considering repellents. So three quick take home points or ticks are active for longer periods across wider geographic areas. A Lyme is highly treatable when recognized early, and that clinical recognition is important, and perhaps a vaccine can help on a prevention standpoint. And lastly, a tick bite can cause more than just an infection with Alpha-gal syndrome. And this delayed and potentially life threatening allergy to mammalian meat is something which is maybe now affecting estimated up to 3% of patients in some US states that we mentioned with higher seroprevalence, and it is probably underdiagnosed. So thank you.

Dr. Jeanne Marrazzo: [00:22:05] Thank you so much, Doctor Auwaerter. That was that was terrific. Way, way too much to cover. I know briefly but but really nice job. And so as both of our experts noted, um, there are several infectious diseases that ramp up during the summer. We talked about cyclosporiasis in particular. It's not a new infection, but we are seeing pretty much a record number of cases relative to this time any previous year. And then our other vector borne diseases like West Nile, dengue and Lyme disease continue to be to be major threats. One thing I'll just say about this is that these domestic outbreaks point to the need for robust federal public health funding and infection investment in the infectious disease workforce. These diseases are not just going to go away. And Doctor Dr. Auwaerter in particular, mentioned several things that look fairly promising on the research side. So really, really critical to continue to invest in in measures to control these harmful and sometimes fatal infections. So we're going to go ahead now and move on to some of the questions that we're getting from our reporters. As a reminder, if you want to ask a question which we strongly encourage, please click the Raise My Hand button. Or for those on the phone, select star nine and you'll be added to the queue. So let's start with some questions from our colleagues at Medscape. And Tom, I'm going to turn this over to you. There's two questions about the Cyclospora outbreak. The first one is why has it been so hard? And why is it traditionally so hard to identify the source of outbreaks with Cyclospora? And the second is, what do you think might be contributing to the five fold increase in cases compared to last year at this time?

Dr. Thomas Moore: [00:23:58] Those are excellent questions. Well, as I alluded to early on, the you know, most cases go unreported because the disease is typically self-limited. And short lived. Um, so we really do see just the, the, the, a very small minority of actual cases. And when that is the case you don't have the wealth of demographic data or epidemiologic data that you really would like to have in order to say, you know, out of 1000 people, these people ate at a specific restaurant that, you know, ships in lettuce from a specific provider. Um, most significant portion of the food that we consume is imported depending on the season. And, um, you know, it's that the main thing is just the absence of data to be able to track down a specific product. Eventually it comes around, but, you know, um, like I say, the more cases, the more people come forward and want to be tested, the better off, uh, the faster that this will be over because you can get the information and, and pursue it. The other the other unspoken, um, gorilla in the room is, uh, or unrecognized elephant in the room is the, is the fact that there's been, there have been some, uh, cutbacks in, um, CDC, uh, budget, uh, for, uh, um, you know, now this basically there's something called food net, by the way, it's a food surveillance program, uh, that is run through the CDC.

Dr. Thomas Moore: [00:25:35] What's happened with current administration has been to, uh, last year, the CDC reduced its surveillance for Cyclospora and several other pathogens in a program that tracks longer term disease trends. So the program is known as Foodnet. Um, and it was scaled back because funding for food safety has not been maintained over the last several years, and not just with this administration, but even even preceding them. But it's become more acute recently, um, uh, with, uh, layoffs through, through Doge. The program is really not designed for real time outbreak detection and response. It's really designed to, um, uh, so, you know, uh, what it's really designed to do is to covers long range issues. Um, and there's no, no substitute for, uh, good, substantial funding of public health infrastructure to, uh, you know, when these outbreaks do occur and they do, they do occur intermittently, um, uh, you know, with better funding, you have better personnel to go track these cases down and try to stop it before it gets, you know, before it enlarges.

Dr. Jeanne Marrazzo: [00:26:46] Thanks, Tom. That's great. Um, I'm going to shift back to Doctor Auwaerter and, um, ask you also from Medscape some questions related to Lyme disease and two questions. Uh, what new strategies are being put in place to help reduce tick borne infections? I know you touched on a couple of things, but maybe you could just review those one more time. And what ongoing challenges remain in identifying and treating Lyme disease and how might those be addressed?

Dr. Paul Auwaerter: [00:27:16] Right. Uh, I'll let's start with the, the diagnostic aspects where I think Lyme remains a clinical diagnosis. It's a fastidious bacteria. It's not something we grow routinely in commercial labs. We're dependent on measuring antibodies. Unlike other infections where we'll use a PCR direct molecular detection. So we're really hampered. We're waiting for the body's immune response to generate antibodies. So there are a number of strategies to try to help assist clinicians in an effort for detection. Several companies are looking at combining antibody based tests, along with what are called T cell based tests, such as gamma interferon antibodies, similar to what's used in tuberculosis. Now as a standard screening test, along with perhaps other abilities that might enhance direct detection through molecular, uh, so-called DNA A based techniques, but nothing has yet been FDA approved or validated. But the hopes are that we can do a better job also of diagnosing patients that just present with fever and headache during the summer and have a summertime infection in terms of prevention. Vaccines have been a traditional strategy for prevention of Lyme disease, and a number of companies have also been examining aspects, for example, using a monoclonal antibody to help prevent transmission of the bacteria from the tick gut to the person. Uh, so, uh. And another is using a molecule which is in Nexguard for dogs, but might be safe enough in humans, lotilaner, uh, which, um, if it's safe in humans, uh, is very long lasting, offers near immediate relief. And when ticks bite people that are taking this drug, they fall off so effectively, not being attached long enough for the 36 hours to transmit Lyme disease. So those are a few of the strategies that I know people are examining.

Dr. Jeanne Marrazzo: [00:29:32] Thank you. Thank you very much. I've often wondered, as I give my dogs that monthly pill, why we don't have something that causes the ticks to just fall off us like that. I assume it's the medications are not particularly friendly to us, but it would be really great to have something you could take as a chemoprophylactic, sort of a chemical shield to get rid of those, to get rid of those ticks. So thanks for that. Um, let's go to a live question from Sarah at USA Today. And I just want to remind both of you, we do have a number of questions lining up. So if you could keep your answers a little bit brief, that would be fantastic. Thank you.

Speaker 4: [00:30:08] Hi there, Sarah with USA Today. Thank you so much for taking my question. Um, on Cyclosporiasis, Doctor Moore, I know you said for those with normal immunity, there's not that much concern, as long as you're taking proper precautions with the food you're eating. I'm curious about children, you know. How concerned should parents be, for example, with what they may be eating at summer camp?

Dr. Thomas Moore: [00:30:29] Well, it's hard to know, primarily because we don't know where this is coming from. Um, and that's really the biggest issue. Uh, so, uh, as I mentioned, I think the safest thing to do really is to just practice good food hygiene. You know, wash the fruits and vegetables before consuming them. I'm not going to tell people not to eat them because again, we just don't know where this is coming from. And you know, that's part of a healthy diet. Um, I would, you know, uh, as a parent, I would, you know, I would just tell my kids, just make sure you, you know, you wash the fruits and vegetables before you eat them. Hopefully they're washed in the kitchen before they're given to the kids.

Dr. Jeanne Marrazzo: [00:31:05] Or perhaps they are cooked within an inch of their life, which I guess is which I didn't realize, apparently you do need to cook it. Like just not a, not a flash sort of heat kind of thing doesn't kill it. There's a substantial temperature that you need to get these things to, which I did not realize either. Um, so I guess, you know, cooking lettuce is not unless you're doing a stir fry, maybe that would be good. But yeah, that's a real challenge. Um thank you. Thank you for that, Doctor Moore. We have um, several more questions from our, our Medscape participants on cyclosporiasis. Um, I'm going to do these one at a time and either of you can jump in. I know, Tom, I think you can answer these in your sleep, but let's just go ahead and start with you. First is how might improved wastewater surveillance be helpful in earlier detection?

Dr. Thomas Moore: [00:31:59] Uh, that's a good question. I mean, in theory, you could do it and, uh, you know, get an idea of the burden in the community, but, um, uh, I think the jury's still out on that. I, you know, there really aren't that many cases. Um, uh, yeah, I, I'm not really I have, I don't know, I hadn't thought about that.

Dr. Jeanne Marrazzo: [00:32:20] Well, I don't think we've heard about it. Uh.

Dr. Thomas Moore: [00:32:22] I mean.

Dr. Jeanne Marrazzo: [00:32:23] And, remember, wastewater monitoring costs money and significant money. And, uh, and again, it's the kind of thing that investing in the infrastructure and interpretation of what you're seeing in the wastewater, um, is a fantastic tool. You might remember just recently, there was a paper in the New England Journal pointing out that wastewater surveillance in the upper Midwest, I can't remember if it was Michigan or Wisconsin, sort of signaled the future detection of a single case of measles. Um, and it was, it was pretty astonishing how sensitive could be. So you, you might think it could be, uh, could be a good approach. But I agree with you. I don't, I'm not aware of any data to show that we could use that. Paul, do you have any.

Dr. Paul Auwaerter: [00:33:06] Yeah. No, I, I think, you know, lots of folks have been doing this more for, uh, issues of outbreaks and pandemics. You know, looking at airline, uh, carriage of their wastewater, for example, uh, polio with New York City. Uh, another example, uh, that was from a few years ago. Of course, Covid was a frequent, uh, use as well. Uh, but, uh, I agree, you need to, you would alert the community of the potential, uh, so you'd still have to think through what it would do, right? What different than our current public health warning, right at this point.

Dr. Jeanne Marrazzo: [00:33:43] So, and given the scale of the outbreak right now, I would guess you would detect it pretty much everywhere. And what it wouldn't really help you. I think this is my interpretation.

Dr. Paul Auwaerter: [00:33:53] Well, and then of course, people put, uh, lettuce in their um, disposal units. Right.

Dr. Jeanne Marrazzo: [00:34:00] Exactly. Yeah. Now, all good questions. Um, let's go back to you, Doctor Moore really, really a question. I've been getting a lot, um, have improvements in gastrointestinal testing panels on stool specifically contributed to more effective identification of cases in the current outbreak. And do you think that might be helping us have higher numbers or contributing to the higher number of cases?

Dr. Thomas Moore: [00:34:24] It's hard to know, but I think it's reasonable to assume that that is the case. I mean, uh, so, so the, uh, the traditional approach of identifying parasites in the stool, you know, traditionally was, uh, gathering a stool sample every other day for a total of three samples. That is over a period, over a period of five days. Um, pretty laborious, um, difficult to execute. Uh, and, you know, by the time you gather the third sample, a lot of these cases are actually better. So, um, there's no question that the, that the molecular testing of the stool has greatly improved our ability to, to detect both disease from and colonization with or carriage of a variety of Organisms. Um, is it responsible for the increased number of cases? Difficult to know, I would say probably in some respects, but by no means would this explain everything. Uh, this is this would be it might be a small contributor, but, um, uh, it certainly makes it a lot more, a lot easier and more convenient to, um, to make a diagnosis in patients who are symptomatic.

Dr. Jeanne Marrazzo: [00:35:29] Yeah. Thank you. Oh, go ahead Paul.

Dr. Paul Auwaerter: [00:35:31] Just a quick add there. There are these commercial multiplex GI panels, but I'll just point out they're quite expensive. Um, and, uh, there may be some directed Cyclospora ones rather than ordering the big panel. Um, and it's just something that I think is an important issue to note that they're not inexpensive tests.

Dr. Thomas Moore: [00:35:51] Good point. Yeah.

Dr. Jeanne Marrazzo: [00:35:52] The other point I'd make too, is that not all the molecular panels have Cyclospora. So you may go in to your doctor and I'm going to get to another question, the last question, Tom, I would like for both of you to comment on, should clinicians maintain a high level of suspicion for testing patients with cyclosporiasis symptoms? So when do you decide to get this test? And remember, you might request a test for sight for your diarrhea symptoms that might not include Cyclospora. So you might get a reassuringly negative answer, but it's not really giving you the specific know that you might need. So, Tom, do you just want to comment on what's your approach to when you go ahead and order a test for Cyclospora?

Dr. Thomas Moore: [00:36:34] Well, um, the main thing to keep in mind is that diarrheal diseases are more common in the summer, and that's diarrheal diseases of all kinds. So, um, somebody has, uh, one day worth of, uh, loose stools, you know, maybe it's Cyclospora, but it could be almost anything else as well. So, um, I certainly would, uh, your suspicion should be raised. That is, the clinician's suspicion should be raised. If the diarrhea persists over several days, at least, I would say three days. Um, uh, you know, in this current outbreak, any other time of year, if we weren't having an outbreak, I would say probably a little longer before testing. Um, so that's I guess probably the way I'd say it.

Dr. Jeanne Marrazzo: [00:37:17] Perfect. Okay.

Dr. Paul Auwaerter: [00:37:18] I'll just add some color to that, which I think is true, that, you know, many are just self-limiting, as Doctor Moore mentioned. And, and unless if someone's getting worse, um, I usually will just tell them to try to eat simple foods and hydrate. Uh, but people that are at higher risk. So if they have immunosuppression, uh, the frail older patients, for example, um, are, uh, groups, you know, people that have had cancer or just multiple health problems or people that will have a lower threshold for ordering testing to see if they would benefit from antimicrobial therapy.

Dr. Jeanne Marrazzo: [00:37:57] Yeah. Thank you. Um, one thing I would add is The other thing that we tell people is things that are not okay are getting a high fever with diarrhea or bloody diarrhea. So either of those things could signal a more invasive process that almost always would require consideration of antibiotic treatment. So, so just a reminder about that. Thanks. Great questions on the Cyclosporiasis practical management, which is frankly not very clear. I mean, it's really a lot of judgment there. Um, and a lot of options for, for what you should do.

Dr. Thomas Moore: [00:38:36] Um, I'll just pipe in and just, I'm sorry to interrupt. Around here, the biggest issue we have is whether it's covered by insurance.

Dr. Jeanne Marrazzo: [00:38:43] Yeah, the testing.

Dr. Thomas Moore: [00:38:44] Because as Paul said, you know, this is definitely an, it's an expensive test. And, you know, for people who have limited resources, you know, if they have to go the traditional approach or make an educated guess.

Dr. Jeanne Marrazzo: [00:38:57] Yeah. And one possibility when that's the case too, that I would love to get your thoughts on. And when we say expensive tests, we don't mean like $50. We mean like $200 to $400 to $500. So these are and these are really expensive tests. Are there situations in the current outbreak where say, somebody comes in and they can't afford that? Would you do presumptive antibiotic therapy? Because one of the interesting things about Cyclosporiasis is that it does get better very quickly with treatment with trimethoprim sulfamethoxazole, commonly known as Bactrim, a pretty short course. So one thing people have been asking me is when would you just give a prescription for Bactrim? It's not something we like to do without a diagnosis, but this outbreak is so big and some of these symptoms are so severe, it might be worth considering. And Tom, I don't know what your approach would be to that.

Dr. Thomas Moore: [00:39:47] Well, as Paul pointed out as well, I think it really depends on the host. Um, that's really the main issue. I mean, you know, are they getting better or they're not? Uh, you know, are they at risk for severe disease or not? That's when I would weigh that.

Dr. Jeanne Marrazzo: [00:40:01] Yeah. Excellent, excellent. Okay. Thank you. Um, let's go to a live question from Margaret at Notice. Margaret, please unmute your line.

Speaker 5: [00:40:09] Hi. Thank you so much for doing this. Um, I have two questions. One is, as clinicians, have you been getting the normal amount of information from the CDC and other federal agencies about this outbreak that you would expect at this point? And second, um, is it normal for the source of this to go undetected for this period of time? Thanks.

Dr. Jeanne Marrazzo: [00:40:34] Maybe I can comment on the first part of that question, and then I'm going to punt that back to you, Tom, in terms of the source, because I think you eloquently started to address that. Um, I would say what was somewhat surprising many of you, I'm sure, are familiar with health alert network, um, issuances from the CDC, what we call HANs. These are typically issued, pretty early in outbreaks because you want to give people guidance and you want to sort of alert them to what's going on. The first CDC HAN about Cyclosporiasis came out two days ago, which, as you know, is well into what's going on. So that is an unusual delay. Um, and I think, um, we don't know why. Uh, honestly, honestly, there's, we can only conjecture, um, I think about, about why, um, why the CDC was so late in getting that out. Uh, no doubt they're working very hard with state health departments to figure this out. Um, I will say that the Michigan Health Department has some fantastic resources online. They have a clinicians guide to how to approach this. They've got great tracking of what's going on. Um, so this is an example of where strong health state health departments can make a huge difference, both in educating people and also leading the investigation of what's going on. Uh, Tom, what do you want to say about the, why this outbreak has been so tough to detect a source for.

Dr. Thomas Moore: [00:42:00] Well, I think you hit the nail on the head. I mean, I alluded to the administration cuts in CDC personnel and CDC budget, um, before. But, you know, it's not just the federal budget. Uh, there are many states that have cut back on their public health infrastructure. Um, I'm in one of them now. There's others as well. And, you know, when you're trying to fight an outbreak with one hand tied behind your back, it makes it very difficult. So, um, you know, uh, uh, you know, the thing about public health, it's not, uh, it doesn't grab a lot of, uh, headlines. It's not a very sexy topic, uh, so to speak, but boy howdy, when you need it, you really need it. And, and we, we really need it now.

Dr. Jeanne Marrazzo: [00:42:43] Yeah, I think I, I like to tell people public health is really pretty boring until it isn't. And then, you know, it all goes to hell in a handbasket and people are like, what, what, how did this happen? What, what? So the things you don't you never see are the things that public health does really well, because we don't get outbreaks because public health works. Um, so, or we manage to contain them quickly because public health works. So appreciate your, your question. Um, let's go to Anthony from Helio. Anthony, please unmute your line to ask your question.

Speaker 6: [00:43:13] Hi. Thank you so much for doing this. Uh, call here. My question is for Doctor Paul Auwaerter. Um, doctor, why is it deemed safe for a puppy or a dog to take an anti tick oral compound or the tick falls off and dies but considered highly dangerous for humans. And are there any trials or underway currently that are examining this?

Dr. Paul Auwaerter: [00:43:40] Yes, yes. So, um, and I'll just say I've helped, uh, design some clinical trials for pharmaceutical companies, just so you're aware, uh, one of which is Tarsus, which is examining the same product that's used in canines, for example. There is a concern about neurotoxicity. So there is a phase two trial underway, uh, examining, uh, this particular medication. Uh, and, you know, one of the secondary endpoints will be Lyme disease. So it's not really an efficacy trial. It's still predominantly more for safety. Um, but yeah, you know, if it's promising, uh, and has low toxicity, uh, then I think this would be another effective tool.

Dr. Jeanne Marrazzo: [00:44:29] Thank you. Thank you very much, Anthony, for that question. Um, I think we are coming towards the end. One, one quick thing I wanted to ask your opinion about both of you. Um, you know, it relates to mosquito control. And Tom, I really appreciated your comments about controlling standing water. I don't think people realize how small these, you know what a small ecosystem would will suffice for a pretty healthy micro population of mosquitoes in your backyard. Um, a lot of people are very concerned about using pesticides, particularly people who are interested in pollinators, native gardens, gardens, recognizing that bees and all these butterflies are greatly affected. Um, and I've come across this, um, natural, uh, control called the bucket of doom. I'm curious if you, you have heard about this. It's actually, um, very cool because it's a, it's a bio, uh, biocide and what it is, it's a mosquito trap. You just put this, um, puck into a bucket and it is, um, it contains naturally occurring bacillus thuringiensis is, is really bacteria. And that actually neutralizes the mosquito larva. So, um, it's something, you know, if people want to explore garden friendly, pet friendly, kid friendly options for their backyards. It's quite interesting. And I think we're going to see more of these sort of, um, environmentally friendly, um, interventions in the future. Wasn't sure if you had thought about that or knew about that, but I think it's pretty-

Dr. Thomas Moore: [00:46:06] Well I, I knew about the, uh, the bacillus thuringiensis. Um, but I love the name bucket of doom. I mean, come on.

Dr. Jeanne Marrazzo: [00:46:14] Right? Yeah.

Dr. Thomas Moore: [00:46:14] Um, it was actually really interesting. I mean, the thing I, I enjoy so much about infectious diseases is this is this is yet another example. It's the observation that leads to these discoveries, right? So the story goes that there was an Israeli scientist who noticed that mosquitoes bred in one puddle, but not in another. That was actually just quite nearby. He figured there had to be something in it. And so he took a sample of the water. Long story short, you know, yielded this organism, this bacillus, thuringiensis that makes a toxin. That's cidal to mosquito larvae. And you can buy it in in blocks. You know, we use them all the time, all the time around here. Uh, it's yeah. It's fantastic.

Dr. Jeanne Marrazzo: [00:46:59] Yeah, it's pretty interesting. Thank you so much for this wide-ranging conversation that really not only covered a ton of really complicated and complex infectious diseases, but also some of the environmental factors that are putting us at risk and, and that we can hopefully control, um, as, as we move on. So, um, I want to thank everybody who, um, who, um, asked questions and, and dialed in. I really want to thank both Doctor Auwaerter and Doctor Moore for just their really deep expertise and enthusiasm and willingness to, to do this today. Um, for more information on IDSA, please visit us at idsociety.org. And with that, um, I'll say goodbye and tell everybody to stay safe this summer. Thanks.