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How do you get typhus? Can you die from typhus? What age do you get the measles vaccine? Are people still getting COVID? When does flu season end 2025?
AMA's Vice President of Science, Medicine and Public Health, Andrea Garcia, JD, MPH, discusses murine typhus and measles outbreaks in the U.S., the latest measles vaccination rates, as well as current COVID-19 and seasonal flu going around. AMA Chief Experience Officer Todd Unger hosts.
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Speaker
- Andrea Garcia, JD, MPH, vice president, science, medicine & public health, American Medical Association
Transcript
Garcia: The case count we're at right now is the second highest annual total the country has seen in a decade. In the only year with more cases, which was 2019, the U.S. nearly lost its measles elimination status.
Unger: Hello and welcome to the AMA Update video and podcast. Today is our weekly look at the public health issues facing physicians and patients across the country, with the AMA's Vice President of Science, Medicine and Public Health, Andrea Garcia. I'm Todd Unger, AMA's chief experience officer. Welcome back, Andrea.
Garcia: Thanks, Todd. It's great to be here.
Unger: We've talked about a lot of things over the past few weeks, but one thing we haven't talked about much is making headlines, and that is a certain type of typhus that's making a comeback. It sounds like something out of a Dickens novel. Andrea, what is that all about?
Garcia: Well, Todd, the disease we're talking about here is known as murine typhus. And it sounds like something out of a novel because with large-scale sanitation and pest management, this really hasn't been a problem in the U.S. for quite some time. Murine typhus is a flea-borne bacterial disease that was once nearly eradicated in the U.S., but as you said, according to the CDC, may be making a comeback.
So far, we've seen cases rise in two states—Texas and California. The data from Texas shows an uptick beginning back in 2004, with even higher levels since 2018. Texas now sees between 500 and 700 cases per year. California has had about 150 to 200 cases a year in that same time period.
Just for context, those levels are still well below the levels from the 1930s and '40s when we saw 42,000 cases from 1931 to 1946, with more than 5,000 cases in 1944 alone. Although we are nowhere near those levels, the numbers may be higher than we think because some of these cases may be going undiagnosed.
Unger: Andrea, obviously, people may not be familiar with the disease or its symptoms or even how it spreads. So why don't we talk a little bit about that?
Garcia: Yeah, Todd. Murine typhus mainly infects rat and cat fleas, which, despite their names, feed on a number of other animals. In fact, some of the theories about this recent rise suggest that cat fleas may have found a new host in possums. Infection usually occurs through contact with the feces of fleas, typically after being scratched into the skin, but can spread other ways as well. People who have close contact with feral cats and rodents are thought to be at greatest risk.
Although murine typhus is generally considered mild when compared to other illnesses in the same family, it can be fatal. The symptoms typically start about 11 days after contact with infected fleas, and most patients will develop a severe headache, fever, chills and myalgia. And then nearly half of patients get a rash, and some may experience GI symptoms. As the disease progresses, about a quarter of patients will also develop a cough.
Unger: Feral cats and rodents, definitely stay away from both of those things. Andrea, how is typhus diagnosed and are there treatments available for this?
Garcia: It's diagnosed through bloodwork and can be easily treated with doxycycline. However, with good reason, most physicians don't initially think of typhus when they see a patient with these symptoms. And if left untreated, that's when problems can occur. Untreated patients can be sick with a fever for up to three weeks, and some may even require hospitalization, experience hypotension, organ dysfunction and even death. This is something that the CDC is now asking physicians to be on the lookout for.
Unger: We will certainly keep an eye on that. Something else we're watching, obviously, in Texas and other states, is the measles outbreak. Andrea, what's the latest there?
Garcia: Well, Todd, those numbers continue to rise. Last time we talked, Texas had reported 309 cases. According to the Texas Department of State Health Service, that number has now risen to more than 400. On Sunday, we also learned that Fort Bend County, Texas now has its first confirmed case. According to a press release, that case involves a 50- to 60-year-old woman who was potentially exposed after recently traveling internationally.
In New Mexico, there are 44 cases, which is up from 42 the week prior. In Oklahoma, as of March 28, the number of cases had more than doubled there from four to nine, with seven confirmed cases and two probable.
Unger: Now, we've talked about those states before in earlier reports. We're hearing things about Kansas and Ohio. Are we seeing the outbreak extend there as well?
Garcia: Yeah, so cases are rising there, too. As of March 26, cases in Kansas had more than doubled, bringing the total to 23. And then as of March 28, Ohio had reported 11 cases. In Kansas, that outbreak has mainly affected unvaccinated children, appears to be linked to the Texas and New Mexico outbreaks, whereas in Ohio, 10 of the 11 cases have been linked to international travel. And in addition to these clusters, there are at least 14 other states and DC that now have reported isolated cases, most of which have been linked to international travel as well.
Just stepping back and looking at the totality of spread, as of March 28, the country has now seen about 500 reported cases in all, and that's in less than three months. According to the CDC, we saw 277 cases total through all of last year. The case count we're at right now is the second highest annual total the country has seen in a decade. The only year with more cases was 2019, and that's the year that we nearly lost our measles elimination status.
Unger: And speaking of losing measles elimination status, the pace that we're seeing this spread, is that going to risk losing that status?
Garcia: Well, Todd, NBC News dove into that question last week and concluded that we may be closer to losing it than we initially thought, citing that measles vaccination rates for young children may be far lower than publicly reported. According to the CDC, measles has been eliminated in the U.S. since 2000.
And that means that we haven't had a chain of transmission extend for more than 52 weeks or 12 consecutive months. But as we just talked about last week, this current outbreak could take more than a year to get through, especially if younger children aren't getting vaccinated at the rate we need to maintain herd immunity.
Unger: All right. And what are those numbers looking like?
Garcia: Well, remember, the CDC recommends two doses of the MMR vaccine. The first one given between the ages of 12 to 15 months, and the second at ages four to six years before entering school. The CDC estimates that just under 93% of kindergartners have had two doses of the vaccine. That's below the recommended rate of 95% needed to produce herd immunity.
It's important to remember, though, that MMR surveillance is drawn from older children who are already in kindergarten. So children under the age of five are not fully captured in that surveillance data because they haven't reached kindergarten age. So that true percentage of MMR vaccine coverage could actually be much lower.
As we've talked about before, we've also seen a rising rate of vaccine exemptions among school-aged children, which certainly doesn't help. So between those declining vaccination rates and increasing pockets of unvaccinated individuals and greater ease in travel, our elimination status is definitely in danger. One expert put the likelihood of re-establishment of measles in this country at over 50%.
Unger: Well, that is certainly a disturbing trend, but there has also been some good news. Andrea, tell us more about that.
Garcia: Well, Todd, over the weekend, we saw NPR report on a positive trend that some pediatricians are seeing among parents. And that's vaccine enthusiasm. One pediatrician said her Florida-based office has been flooded with calls about the MMR vaccine, with parents asking if their child is up to date on their vaccinations, if they should get another dose, or even if their child can get it ahead of schedule.
Last year, Florida's kindergarten vaccination rate for the measles dropped to 88.1%, so far below that 95% we discussed that's needed for herd immunity. So this is a positive sign.
Pediatricians in other states have seen similar trends, with many reporting an increase in requests by parents to have their children vaccinated earlier, especially ahead of that spring break travel season. The CDC does say that infants as young as six months old can receive the MMR vaccine if they are traveling abroad or are in an outbreak area. As that NPR article points out, however, it's really too soon to tell if these anecdotal reports of vaccine enthusiasm will help counter the growing vaccine hesitancy.
Unger: Well, I certainly like hearing about the topic of vaccine enthusiasm. That's good news. Andrea, for our final topic today, let's take a quick look at COVID and seasonal flu. What are the numbers looking like?
Garcia: Well, it's really a mixed bag right now, particularly with seasonal flu. In its most recent weekly update, the CDC said that while flu indicators declined for the sixth straight week, levels still remain elevated nationally, and that activity is expected to continue for the next several weeks.
Nationally, the percentage of outpatient visits for flu-like illness remains above the national baseline for the 17th consecutive week. However, only seven jurisdictions are still reporting high or very high flu activity. And that's a sharp drop from the 20—the previous week. So it's good news. Hospitalizations and deaths are also trending downward.
But overall, the season hasn't been an easy one. The CDC has defined it as high severity. And according to the latest estimates, there have been at least 44 million infections, 580,000 hospitalizations and 25,000 deaths so far.
Unger: All right, that's a great update on the flu. Andrea, what about COVID?
Garcia: Well, there's better news there. According to the CDC's latest data updates, COVID levels continue to decline from already low levels. Wastewater detections last week declined from medium to the low level, with detections being highest in the South. And then the proportion of overall deaths that were from COVID last week was 0.9%, lower than the 1.5% for flu.
Unger: Well, Andrea, that's certainly a more positive note to end today's discussion on. And as always, thank you for being here and keeping us up to date.
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As always, you can find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. Please take care.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
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