Mosquitoes, Fleas & Outbreak: ID Update with Deena Sutter, M.D.

I'm Holly Wehmint, and this is Pediatrics Now, cases, updates, and discussions for the busy pediatric practitioner.

Don't forget to click on the link in this podcast for free credit that may include CME, MOC, or ethics credit, depending on the topic or podcast. Pediatrics Now is brought to you by the Department of Pediatrics at UT Health San Antonio and University Health's new Women's and Children's Hospital. So I'm so thrilled today because here with me in the podcast studio is our new pediatric infectious disease doctor, Dina Sutter. Dina, thank you so much for being here today in the podcast studio.

Thanks. I'm absolutely happy to be here. So you'll be seeing patients soon once your credentials come through. And I know you have close to 20 years of experience in infectious disease, being on the front lines, and you even were deployed to Afghanistan.

I spent my career in the Air Force, and so I had a few overseas assignments that were short deployments, mostly humanitarian missions, and I did go to Afghanistan in 2008 and ran a pediatric ICU essentially at Bagram Air Base, and that was kind of one of the most significant experiences in my military career, and so I'm very grateful that I got to have that experience, but it was difficult.

There were a lot of severe injuries, you know, blast injuries, children stepping on landmines, burns, and so I just feel like it was difficult, but I'm so grateful that I got to go and feel like I was making a difference at least as much as I possibly could in that setting, and I'm really looking forward to seeing patients and teaching. Well, we're so glad that you're here. And I know those tough experiences that we go through that helps with every day seeing patients here.

I know you'll bring that experience. I mean, I had some great colleagues and I know so many people who were in more difficult situations where their physical well-being and their mental well-being were more severely affected, so I always try to, you know, take that into account when I think about it. But I had great colleagues, and we really worked hard together, so it's actually a good memory for me in many ways.

I'd love to talk about some things that are in the news, items that are in the news involving infectious disease that pediatricians, pediatric practitioners may be getting asked about. A lot of people are worrying about it. First of all, the pronunciation is chikungunya, right? So it's like chicken gunya. And it's a virus that's spreading quickly, in particular in China. It's not in the United States yet. Yeah, so I just like to put everything in perspective.

So chikungunya is a virus that when I was in training, in the fellowship training, which was in the mid-2000s, it wasn't like that big of a deal. We learned about it along with dengue virus and Zika virus. Then some outbreaks, you know, subsequently, which I'll talk about, some outbreaks made it more prevalent in the news. And so right now they're talking about 250,000 cases or so reported or confirmed, I think confirmed, worldwide so far this year as of July, August.

And to put that in perspective, last year, depending on your source, there were probably greater than 600,000 cases and the year prior greater than 500,000. So some of the reporting is delayed, so we may exceed that this year. But the total number of cases is really, at this point, not particularly high. I think the attention that's being paid is because there are outbreaks in areas where the virus was not present.

And in particular, the outbreak in Guangdong province in China has been a big deal in the news because this has not been reported in that area. And the authorities and the Chinese government are taking steps like massive amount of spraying and things like that that have kind of made it very big in the news. So chikungunya is a virus that is one of the arboviruses. And just to remind everybody, arbovirus stands for, we use arbovirus because it's arthropod-borne virus.

So much like dengue and Zika, yellow fever, West Nile, and some of those others, it's spread by mosquitoes. And chikungunya often was mistaken in the past for dengue. So a lot of the areas, including now Zika, a lot of the areas where it's endemic, the same mosquitoes spread those viruses and the same populations will get infected.

And so, you know, chikungunya was not even defined until the 1950s, although it probably existed for a couple of centuries prior to that in limited sporadic outbreaks. So what we know about chikungunya is that it presents similar to dengue with fever, and you can have rash, which is a little bit different than dengue, but chikungunya really is known because it causes severe joint pain, arthralgias, arthritis, that can actually persist for weeks, months, or years in a chronic phase.

And so that's why it's become, it's so important for people to know about it, because it can be very debilitating to people. The mortality rate is very low. It's less than 1%, although it might be higher in some populations. But that debilitating disease, a chronic phase, is really why we worry about it. And it happens, it tends to happen in hot climates during the daytime.

Right, right. So the 80s mosquitoes, which are the same mosquitoes that spread dengue and Zika, and people may not be as familiar with dengue, but they heard all about Zika a few years ago when there was outbreak, but dengue is actually a very, very prevalent and very significant worldwide problem. The same mosquitoes, which are the Aedes mosquitoes, so Aedes aegypti and Aedes albopictus are the. So in tropical climates, that's really where the disease is prevalent, but also the subtropics.

And some of those mosquitoes have moved into some more temperate climates, so a cooler climate. So if you looked at a map of the United States, you can see how far up. It's mostly the south part of the United States, but moving a little further up into the east coast and midwest, the 80s, especially the Alba Pictis, can be present. So the concern in the U.S. Here is, you know, could these things become endemic in the U.S. Or can we get spread from mosquitoes in the United States?

And that's why I think it's in the news in the U.S. And we can just, you know, we talk about the transmission again in a minute here. And I heard it's endemic in Mexico, too. It's Latin America, the Caribbean, and especially in Central and South America. Actually, the majority of the cases in the world are in South American countries. So basically, if you look at kind of what happened with the spread of chikungunya, it was initially identified in Tanzania.

And there were outbreaks there, although there probably had been some outbreaks in like the Indian subcontinent prior to that. And then in over the next few decades after it was identified in the 1950s, there were sporadic outbreaks that happened in Asia. It happened in like the Southeast Asian islands. And then there were some very large outbreaks that occurred.

In 2004, Kenya had a very large outbreak. It was a big deal. And subsequently, it spread into the islands in the Indian Ocean, which are near Africa, such as Madagascar and Mauritius. I've actually been to Mauritius. It's really beautiful. And some of the smaller islands, Reunion, which actually had a huge outbreak, and they had a huge outbreak 20 years ago. So those are places that it's been a real hotspot. But the other thing to know is that in the 20...

2013, it appeared in the Caribbean. And that's how it got widespread in the Western Hemisphere. And in the subsequent years, there were cases reported, not only in the Caribbean and South America, but there was actually, there were six cases, I believe, in Florida in 2014 and one case in Texas that were reported. And these were not in travelers. These were people who had never left. We do see cases for returning travelers. These were autochthonous cases.

Autochthonous means that it occurs locally and that you did not travel and you got it from a vector that was in your area. So that's some of the worry. According to this New York Times article that came out this week, a person who comes down with chikungunya could be fine one day and then very soon after that not be able to go to work, work, even pick up a pan to put on the stove to cook. Like, it's that, I mean, it sounds awful. It's very, it can be very debilitating.

And so, you know, although we haven't had as many cases until the last few years, it's that quality of life effect. And so most people who get exposed get infected, and most people who get infected are symptomatic, unlike some of these other arboviruses where, you know, the symptomatic patients are kind of the tip of the iceberg. Like Zika, you could not have symptoms. Zika, no symptoms. In many cases, dengue, no symptoms.

75% or more of patients have symptoms, and the vast majority of those patients have joint pain. And joint pain may be the only presenting sign. I mean, only about half have real fever, maybe a little bit more than half. Some GI symptoms, rash, which is nonspecific, could be on the hands, the feet, the extremities, can be in the trunk. It's not like pathognomonic rash.

And in these cases, the patients who have arthritis, a lot of them have resolution, but the a huge number of them do not have resolution and they have lingering symptoms. And there's estimates that, yeah, there's estimates that in some populations, only about 15 to 20% have lingering symptoms after 18 months. And other populations, 60 or more percent reported lingering joint pain after 18 months. And some of those patients have very, very severe disease, arthritis.

Synovitis, bursitis, you know, and axial skeleton can be involved as well as the small joints, which are most frequent, you know, hip, shoulder, knees, large joints can be affected. And these are patients who are often unable to work, unable to get out of bed, just very, very affected. And so this is the fear, is that if it becomes endemic here or if patients travel and they acquire it, that that outcome can be the case.

Pediatric patients, young children, are less likely to have the joint symptoms, which is good. They're just overall healthier. Adults with chronic diseases, elderly people, and those with underlying rheumatologic joint, pre-existing joint symptoms are more likely to be severely affected. And it could be severe in babies? It can be very severe in newborns, and there can be maternal to child transmission.

It's not commonly reported, but it's not probably studied enough that if a mother gets infected and has viremia at the time of, you know, around the time of delivery or right prior to delivery, the baby can be born with a congenital infection, but babies can also acquire it from mosquitoes shortly after birth.

And because they have an immature immune system and also the blood-brain barrier is not mature, as we know, those babies can have severe neurologic disease, more severe disease than older children for sure. Elderly people also are at high risk of being fatal? Elderly people are at high risk for being fatal. And interestingly, if you look at all the variants, because it's not just one lineage, there's multiple variants.

Some variants actually have a higher predilection for causing severe disease or for causing neurologic disease or for causing death. So they estimate one in a thousand for mortality, but there are some studies and some outbreaks where the rate was much higher. Wow. According to this New York Times article, this mosquito is the type that in China right now, people who are riding buses in their homes or apartments, the windows open or they're outside working in the heat.

Like it really likes the heat and it likes moisture. Are you worried about it coming to the United States? What are you? I think given the changes in climate, and this is really what's impacting this, when we have large storms, which of course we've been here in Texas have been hit very hard with some terrible storms, and across the U.S., when you have standing water and when you have higher temperatures, that is what really breeds these mosquitoes.

These mosquitoes can breed in tiny amounts of water, which is why in many of these countries, it is in impoverished areas and areas where people in these tropical areas, they do not have air conditioning. They often will save rainwater for their water use. So rainwater in barrels or even just like a puddle or water in a, you know, like a tire that's, you know, garbage, large amounts of garbage where water collects are very high risk factors.

So in the United States, I think the populations that would be more likely affected are the people who don't have air conditioning, who live in... You know, less advantageous conditions. And of course, along the southern border, because that's really Florida and Texas are where we've seen dengue pop up. You see these things pop up rarely, but Florida and Texas are kind of like that southern area where it's hot and where we do occasionally see that.

So if you start seeing in those areas and it becomes endemic here, we have an outbreak here, it's not just going to remain there. And so I am somewhat concerned about it. I think that's why those measures are being taken in China is because it's such an unusual case and they're really scared of it being maintained in that population. And when you have a naive population who is not immune, these are a whole population of people who have never seen this virus.

That's when you have huge, huge outbreaks because it gets spread from human to mosquito to human. There are animal reservoirs, but humans are the primary host. So when you get very high levels of viremia, very, very high viral loads. Mosquito bites you, bites somebody else. That's how you get infected. And that's why it can spread so quickly. But there's not human-to-human transmission.

No, the only human-to-human transmission is maternal to child. And then there's been a couple of cases of laboratory accidents where there was blood from a patient who was viremic. Somebody got stuck with a needle or something. So blood-borne pathogen type of risk. But this is really not ever transmitted directly, not respiratory, not touching. That's not how you get it. But there's a massive effort in China to prevent this.

They're trying to get people to follow the steps to not let mosquitoes come into their house and so that they won't get bitten by mosquitoes when they're outside and they're using pesticides. Do you think, from what you've seen, Does that seem like it's enough or? I mean, I think some of the pesticide use might be overblown there. I am not, this is not my area of expertise per se, but really getting rid of the standing water, using insect repellents if you have access to them.

And if you are able to use screens, bed nets are not something you normally use for the day biting mosquitoes. But if you have a situation where you have people who are sleeping outside, you know, or sleeping in a place with no air conditioning, that could help. If you do have air conditioning, go inside and use air conditioning if there's an outbreak. I mean, if that's what was happening here, that's what I would be doing with my family.

So I think really the main thing is trying to control the standing water and the breeding grounds for the mosquitoes. And so I would say where we live, you should be doing that anyway, because even if we don't have this virus, which you could set yourself up for a problem if there was an outbreak, we do have things like West Nile. And I have seen cases of severe cases, which are uncommon in children.

This particular case I'm thinking about, I saw in Washington, D.C., but it was associated with, you know, standing water in areas around the house, a lot of birds, that kind of thing.

And so, you know, any virus that can be spread by a mosquito that can survive in these particular 80s mosquitoes can survive in like, you know, like I said, puddles or, you know, just any kind of like, you know, I mean, I could go to my backyard right now and find things where I'm like, oh, this is where all the mosquitoes are coming from. We have a huge mosquito problem here. I mean, I go outside and just get bit.

So really getting rid of the water, avoiding being outside, and then just really using the other precautions, which is usually wearing, it's hot, but long sleeves, long pants, lightweight clothing, light-colored clothing is helpful to avoid mosquitoes. Not always ideal when it's very hot. And then using insect repellents such as DEET up to 30%. We don't use above 30% in children, and it's really not effective beyond 40% anyway. Or picaridin, which you go up to about 20%. Those are okay to use.

And I do recommend using them because even if we don't have this virus, we do have things like West Nile and we do have the potential to have mosquito-borne viral illnesses in the U.S. And Dina, even though it's hot, as much as you can cover up, wear the long sleeves and pants, it's hard for the mosquitoes to fly underneath the clothing, right? Yeah. I mean, I think the main thing is that you cover up.

If they can't fly, these are not usually mosquitoes that get underneath your clothing, but then you spray the exposed skin. You don't spray the skin that's covered typically, especially because if you're trying to limit the amount of spray you're putting on a young child, for example. But you're still going to get bit. I mean, we have so many mosquitoes right now after all the rains. And I can only imagine in these places where there's rampant cases of chikungunya

and dengue and other viruses. Malaria. Malaria, which is a totally different type of mosquito and the protection is a little different, but these are all, you know, so you get co-infections and these are all co-occurring in a lot of these tropical climates. So I see, you know, nobody wants to have this in their population. I can see why the Chinese are taking this very seriously, but this is a minority of the number of cases that are happening worldwide.

You know, we have many thousands of cases happening in these other endemic areas, which, you know, is not getting the attention in the news as much because we're talking about an area in China, which I think always just kind of hits the news more. People get excited about something in China just because it's China and what are they doing now?

I've seen some news clips where they were trying to spin it into, oh, the Chinese government is doing this. So maybe some of the attention is on that. But when you look at the real scientific kind of literature, they're looking at it in terms of the ecology and a new area where it has not been seen before. But if you look at the numbers in Brazil or you look at the numbers in these Indian Ocean islands, it's like they're far eclipsing the numbers in China.

Dr. Tess Barton, who has been on the show many times with infectious disease, and she said something that really stood out to me that I think a lot of people don't realize. She said that the mosquito is the most dangerous animal in the world. And here in San Antonio, it's more fleas that are the problem because of typhus. Yeah, from an infectious disease standpoint in San Antonio, fleas definitely cause more problems than mosquitoes.

Mosquitoes are the most dangerous animal in the world. And it's, you know, I often have conversations with people like my sister, like, you know, if I could just destroy one thing on earth, it's mosquitoes. So it's more because they were, you know, biting us and annoying us, not from an infectious standpoint. They're just awful, you know, and they do cause so much disease. But fleas are really a problem here in San Antonio and South Texas.

And you don't even have to have a pet. You know, I know people who have bought a house and moved in and there were fleas hopping all over the yard from prior pets. And we have, typhus is a disease that, you know, it's not as easy to get as what we were talking about, chikungunya. But it does live in animals, especially young animals, feral animals. And children will get that from their pets, but they'll also get it from exposure

to flea-infested areas. And I've had kids who don't even have pets getting typhus at times. From a park or something. But most of the time, it's because they have a household pet. They're sleeping with the pet. The pet is not on flea and tick prevention, is the problem. It's so important. It's so crucial. It's very important. I always tell my patients this because I see a lot of typhus. Like chikungunya, it's often summertime outbreaks.

You know, a lot of these pest-associated things, you know, vector-borne illnesses are summertime things because when it freezes, it gets cold, and these things kind of hibernate, and they're not surviving or thriving. But I saw a typhus even in the winter during the COVID outbreak because children were at home and they were like, all these kids I felt, my own child was doing this too, were fostering all these kittens and puppies because they were bored.

I mean, it was just like, hey, mom, can I have kittens? Okay. And the kittens and the puppies are often too young to have flea and tick prevention, but they came out of a litter where there were fleas and ticks sometimes, or people just, you know, find some animal in the street and they don't go get animal, you know, they don't get flea and tick prevention. And the effective flea and tick prevention can be pretty expensive too. So that sometimes is a...

Is an obstacle for people as well. But people don't realize that fleas are such a problem here. And typhus can be a very severe illness. I've seen many, many children hospitalized with it. And so I do, you know, I do emphasize that to families who have pets that make sure that you have them on their flea and tick prevention. Tick's not so much of a big problem here in Texas, spreading disease, but fleas, definitely.

And can you talk about some of the early warning signs of typhus. Like a lot of other... Yes. Nobody knows what typhus is until after you figure it out. So, you know, usually it's very sudden onset. Kids will have some malaise, some headache, high fevers, and you can't differentiate it from other things until you start seeing a characteristic rash. And honestly, not all the kids have this characteristic rash, and it also overlaps with other rickettsial infections, so you can't really

prove it. And even the testing, there's a lot of overlap with other rickettsial infections. Rocky Mountain spotted fever is our kind of prototypic rickettsial infection in the United States. And it's well known because it has a high mortality rate. Typhus is less likely to cause mortality or severe, severe ICU kind of illness. But they look very similar.

The geography is a little bit different. And really what we have here in South Texas is primarily typhus, which is good, but you know, they can present with high fever, bad headaches, retroorbital pain. And then typically you'll start seeing after a few days, a rash. If you do see the rash, it's often a petechial maculopapular on the hands and feet. And often if you don't look, you might miss the early signs of it.

And so the kids, you know, They can be in, they can look shocky, or they can be just high fevers and very ill-appearing with a lot of pain. Differentiating that from other severe viral illnesses or severe manifestations of common viral illnesses is really hard. Because rickettsial infections are bacterial, and you can actually treat them. And the other viruses, of course, you cannot. So it's really important to try to figure that out.

So if you suspect typhus, what is your advice for the pediatric practitioner? Well, you don't necessarily have to admit a patient who has typhus. They need to get on doxycycline right away. You can send serologic testing to try to confirm, and sometimes the serology takes quite a while for them to develop antibodies. So I think that we really need better diagnostics. I'm not aware of a molecular test for typhus right now that is marketed, but there might and I just don't know about it yet.

But mainly the goal is to get doxycycline into the kid right away. And this doesn't matter how old the kid is. So this whole concern of you can't use doxycycline under the age of eight or nine is not true. For rickettsial illnesses, you give doxycycline to children. The problem is usually the kid in the clinic, it takes a while for the clinician to actually suspect typhus. They may be languishing with persistent fever for several days.

And unless they see that rash, they may not really think about it. The other things are you can get labs on them and you can see cytopenias, you can see elevated liver enzymes, you can see elevated inflammatory markers. Some of these are really a lot of overlap with some of the other viruses, including like EBV and other things. So it's kind of hard to differentiate.

Thrombocytopenia is a real big hallmark of this, but it's also a hallmark of some of these other diseases as well, including chikungunya, which is, you know, obviously not, we're not trying to differentiate those. But so, you know, they need to really be thinking about the exposure of the pets or, you know, in the rare cases, you know, outdoor exposure to non-pet infested areas, which is kind of hard to tease out.

And the fact that it's summertime and that the kid is, you know, usually summertime and the kid is being exposed to, like I said, fleas and asking the So asking the parents about fleas, have you seen fleas? Is there flea and tick prevention? And a lot of times the parents will be like, oh yeah, there's fleas everywhere. And you're like, yeah, get that kid on doxycycline.

And I think it can be hard for pediatricians. I know one pediatrician was saying to me, like, a family comes in and they say, like, what is this bite that happened to my child? And it's so hard to know, looking at a bite, what it is. Do you, you know, as we're talking about chikungunya, we're talking about typhus and fleas. Any advice before we move on to our next topic for pediatricians that we haven't covered? The bite thing is, you know, we get such weird questions.

I mean, general pediatricians, ID docs, you know, if your kid has a reaction to mosquito bite, it doesn't indicate that the child is going to have an infection as a secondary result. And I wouldn't be able to differentiate, you know, one mosquito bite from another. And in terms of, like, you know, spider bites, you know, the historical thing is, could it be a spider bite, you know? Brown recluse, or MRSA, which was in the days of, you know, kids coming in with MRSA infections. Yes.

And in the very early days of community-acquired MRSA, that was a big thing. The spider bite was the purported thing. You know, I don't differentiate bites. The one thing that you can see is when you get tick bites in an endemic area, which is not here, the exodes ticks that spread Lyme disease. In the northeast.

Northeast, a little tiny little patch in the Northwest, but upper Midwest or the Great Lakes area and the Northeast kind of, I always say like Virginia all the way up to the mid part of Maine along the coast. And then there's some around the Great Lakes as well. That's really where we see Lyme disease and that can give you the classic bullseye at the site of the tick bite, the prior tick bite.

And so those are the cases where if the tick is still attached to the child or you live in an area where Lyme disease is prevalent, you need to check your kids for ticks, and the tick needs to be removed if it was on the child. And then in some cases, depending on if you can figure out the timing of how long it was on, empirically giving a dose of doxycycline to prevent Lyme disease in those cases.

However, you know, we're talking in Texas, we have listeners other places, we don't have endemic Lyme disease here in Texas, and there are reasons that we know this because they do these field surveys, they look at the ticks. Could that change as the global climate changes? Yes, it's possible, but it's really a regional thing. So you've got to be aware of where the disease actually is.

And you recently were on a trip to Cape Cod, and you saw that a tick was on you, and you did something that probably most people wouldn't do, but maybe a lot of our listeners would. Well, infectious disease doctors are really weird. We're just like kind of strange people, and we're giant nerds, as I said. So, yeah, I was sitting at my friend's beautiful house, and she said, We don't have ticks. And I came and I'm like, here, I had this tick on me. And I wanted to make sure it wasn't an Ixodes.

It doesn't matter because it could have been an Ixodes. And I'm sure they have them there because they're in a very high-risk area for Lyme and also for Babesia, which is very regional. It's very limited to this particular area. What is that? It's another tick-borne illness that is most often asymptomatic, but it can cause severe disease, especially in people who don't have a spleen.

It's very, very isolated to like this area of Rhode Island, typically Block Island of Rhode Island, Martha's Vineyard, which is right across the way from where we were, and then some parts of Cape Cod. So I brought the tick inside, and then I put it into one of her lovely glass. You know, she doesn't use the plastic tupperware. She uses the glass ones, of course. And I put that in there. And then I got two more on me and I put them in there.

She was so uncomfortable walking by looking at it like, can we put that tick somewhere else? And I brought it home in a Ziploc. And then my husband and I were both looking at the tick. Turns out I don't think that one was an exodes. But the point is that if I couldn't tell after looking under a magnifying glass, you may not be able to tell either. But do take the tick with you if you can, if you're in one of those areas and see if you can get it tested at the health department.

I am not talking about here in Texas. I'm talking about in those areas where you know there's a lot of Lyme disease because it can be important. Did you get it off of you with tweezers or? I was just crawling on my leg. It hadn't bitten me that I knew of. And then the other ones just rode in on my jacket or something. So they just took a ride and came inside the house. So they are pests. And if you're a wooded area, they are everywhere in those regions. Here we have dog ticks primarily.

And they don't spread a lot of diseases. So I guess we're lucky there. But in those other regions, it's a real concern.

So moving on to not a vector-borne illness, we're talking about something else that's in the news right now. There's been an increase in hand, foot, and mouth disease. It's not required to be reported to the CDC, so we don't know exact numbers. But I know when in talking to pediatricians this summer, several pediatricians told me they're seeing a lot of cases. And it's also been in The New York Times about that, that more cases of hand, foot and mouth disease. What do you want to say about that?

It happens. Hand, foot, and mouth outbreaks do happen. They're not on a specific cycle, but every few years we have a lot more cases. Certain enteroviruses, so a hand, foot, and mouth is caused by an enterovirus, and the enteroviruses are broken into the numbered enteroviruses, the Coxsackieviruses, the echoviruses, and the polioviruses. And the polioviruses, because they're related, some of these enteroviruses can cause severe disease that are polio-like syndromes.

But in general, when the child has hand, foot, and mouth disease, They're really not at risk for those things. They typically have lesions on their lips, around their lips, in their mouth, and then they get these little blisters all over their hands and feet. They can get them elsewhere, including buttocks or other parts of the body. But they really are, this is really a common childhood illness.

And whether it's one enterovirus, which is a Coxsackie, Coxsackie A16 is the most common cause, or an enterovirus, which is, enterovirus 71 is implicated most commonly among the numbered ones. And actually, that can be more severe. And a higher risk of neurologic complications, but it's very uncommon. So otherwise, this is just a thing that happens to kids. And they're not immune to it until they become immune to that type of venerovirus.

And so perhaps what we get is a certain amount of population who hasn't been exposed because it's usually the youngest children. Older people are less likely to get it because they're probably at least partially immune or they're immune from getting it as a child. But older children and adults can get it. They usually don't have the classic manifestations of the blisters that are so severe in the mouth, around the mouth. And so...

The fact that it's in the news is like, yeah, we're having a bad enteroviral year. When I get more concerned is the years where we start seeing things like acute flaccid myelitis, which we have seen with certain enteroviruses in the last few years, a polio-like illness. And so that's what, in the news, that's what really makes me get concerned because I have seen these cases. So right now we're not hearing that. We're just hearing about these cases, which are kind of more nuisance cases.

You know, children are in daycare. This is how it gets spread. It gets spread through secretions. It's very hard to prevent children from getting an infection in a daycare. They're just kind of like, you know what daycare is like. I mean, kids are touching each other. They're touching things. And so I think that these outbreaks, kids need to be out of daycare for a few days, which is very inconvenient for the parents.

Kids are sometimes very miserable. If they have lesions in their mouth, they can be painful. And they actually can get dehydrated enough to have to go to the hospital. But that's uncommon. So really, it's more of a nuisance overall. And so I don't think we should be panicking about having it in the news because every few years we have a lot of cases.

But if the cases start manifesting with more severe manifestations in terms of non-cutaneous things, more things that are severe like the neurologic cases or the severe respiratory cases, then I get more worried about the outcomes in the kids. And can anyone get hand, foot, and mouth disease, though, even though it's not as common to occur in adults?

Anyone can get it, but they usually, like I said, they usually don't show up looking like the kids with the hand, foot, and mouth lesions classically. They can, but usually what happens is, you know, the toddlers are the ones, or they say less than five-year-olds, get the classic manifestations.

Adults can get enteroviruses just like children if they are not immune, but they may present with just sort of nonspecific, you know, So maybe they have a fever, maybe they have, you know, headache, GI symptoms, maybe they have a nonspecific rash, but they can certainly get this illness.

Back to chikungunya, is there a vaccine? There are many, many vaccines that have been studied. There are currently two in the United States that have been licensed for use, very recently licensed for use, coincidentally. One is called Ixchik, and it is not recommended for children. It is recommended for adults. And there have been some safety concerns in older adults where the FDA and some other regulatory agencies in other countries did pause the use in older adults.

And then the pause has been lifted. But you don't want to give it to immunocompromised individuals. You don't want to give it to pregnant women. You don't want to give it to anybody who should not receive a live virus. These vaccines, they're only recommended for travelers? For travelers going to an area with a current outbreak, actually, which is, you know...

That's a time-limited thing. But if people are moving, geographically locating, and so they say greater than six months of residence is the recommendation on the travel sites. When I've given other vaccines against viruses like Japanese encephalitis virus, I would typically give it if someone was going to live there more than one or two months. But the point is that we're not giving it in the U.S. routinely at all.

And this would be part of a comprehensive review of travel risks, because if you're at risk for chikungunya during an outbreak, you may be at risk for other things, including malaria, including other infections that you can get vaccinated against. And so you may need to see a travel medicine doctor, get some travel medicine advice, and then the whole family needs to be evaluated.

Or you can go to the CDC Traveler's Health site and look at where you're traveling to, to determine other things that you might need, because the chikungunya vaccine is, like I said, a new one. And there's a lot of other things out there you might need to be doing. But we are not giving this routinely in the United States to anybody who's here. That is not a recommendation. At this time, they don't need to be vaccinated. No, not unless they're traveling specifically.

You know, travel vaccines. You know, I've given rabies series to kids who are going to high risk for rabies. That series is well over $1,000. I mean, it might be more now. I mean, all of these yellow fever vaccine, all of these things are pretty expensive. My neighbor, actually, so she said her grandbaby had to be vaccinated for rabies because there was a bat just flying in their house for a little while. So the parents had to be vaccinated and the baby.

I didn't know that just because the bat was present. Yeah, that's a classic board question. Like, you know, a child is in a crib and there's no evidence of bat bites on the child, but the bat was found in the room with the child. You know, it doesn't have to be a baby in a crib. It can be anybody, an adult, anybody else. When bats bite, their bites are almost undetectable and you may not have felt them.

Now, there is the possibility of salivary, you know, like the bat has saliva and it gets into you that you can have transmission that way. But biting is by far the most effective way of transmitting. And so the concern is that the bat had exposure to you when you were asleep and you weren't aware. Whereas if you were awake and you were an adult, right? So a baby who's awake in the crib also is a problem because the baby can't tell you what happened.

An adult who knows that they did not have direct contact with the bat, that has to be teased out by people like the health department or, you know, your physician. And in that case, you may not need to be vaccinated, but if you're sleeping and you don't know... Then you would need the shots because especially in this area, we have a lot of bat rabies here, a ton. Really? And rabies in other animals and mammals as well. But bat rabies is very prevalent in South Texas.

I mean, this area is bad. Well, my neighbors, and she was worried about her grandbaby mostly because, and I was shocked to hear it, but we know this happens. She was worried about the vaccine. Like, will my grandbaby be able to grow normally now? So I assured her it's been well-studied. Yeah. I mean, I've had people take their newborns to a place where I was like, we don't routinely give rabies vaccine to little kids who can't toddle around and get near an animal.

But if you had a possible exposure, there is no lower limit of age for giving post-exposure rabies vaccine. For travel, it's called pre-exposure vaccine because you're giving it so that they don't actually need the antibody, the immunoglobulin or rig, after they get exposed if you're pre-vaccinated. But there's not huge, huge studies on young babies getting rabies vaccine,

but it has been used many, many times. And it's felt to be whatever is going on much, much safer than getting rabies, which is universally fatal, of course. Yes, that's what I said as well. Well, Dina, this is such an honor to be able to talk to you, and I really appreciate you giving us all this information and updating it.

It's hard to stay current on everything, and pediatric practitioners who are seeing 30 to 40 patients a day, now we know what to say when someone asks about chikungunya. And if you have a question for Dr. Sutter, our website is pediatricsnowpodcast.com. com. My email address is on there. Please email me the question and I will pass it on to you. And if you want to email me a voice recorded question, we may put that on the air as well.

So I really appreciate you being here. And here on Pediatrics Now, we love quotes. I love quotes. You have a favorite quote or two you want to share with us? Yes, I did my assignment and found some quotes. So I found a quote from one of my favorite books, which is Cutting for Stone by Abraham Verghese. And I thought it was a little poignant at my age, just looking back. And it's, the quote is, I grew up and found my purpose and it was to become a physician.

My intent wasn't to save the world as much as to heal myself. Few doctors will admit this, certainly not young ones, but subconsciously in entering the profession, we must believe that ministering to others will heal our woundedness. That's beautiful. And then my other quote is by Ellie Weissel, who is a Holocaust survivor. And the quote is, when adults wage war, children perish. And I actually have that tattooed on my arm. Really? Wow. This is my post-Afghanistan belief.

When you hear about the children being killed in the wars, it's something that affects me profoundly. Gut-wrenching. It's gut-wrenching. And so that's not a medical quote, but probably the, you know, the quote that I would pick over everything else to share with the world. Well, when did you get it tattooed, Anya? That part, it was added on. It was last year sometime. So, yeah, I was on spring chicken, but I still did it. Wow.

Maybe next time you can show us the tattoo. Let's hold off on that. It's my first time. And Dina, you'll be seeing patients at University Hospital, and you're a mom of three like me, and you also have stepchildren. And you love children. I love children. I love children a lot more than adults. I've always been the person where if you go to a party and there are children, I end up in the corner on the floor playing a game with them or, you know, running around the backyard.

And I just love them. I think they're the most important thing. The future of the world. The future of the world. And I truly wish that we valued their health care more than we do as a society, that we valued their education more than we do, that we valued their well-being, mental and physical, more than we do as a society. And this is something I think about every day when I take care of my patients and when I encounter children in any situation.

I just I wish for more for them. Well, I know you're making a difference, and I want to get that book. That sounds like a great book. Oh, yeah. So will you tell us the title again? Oh, Cutting for Stone. It's very famous. I think it won the Pulitzer. It won the Man Booker or one of those. I'm forgetting. But it was very famous. The main character becomes a physician, and there's several physicians in it. It's a great book. You should read it.

I'm going to. And I really appreciate that recommendation. And you're headed back to Cape Cod, even though you had that experience. It's not keeping you away. Yeah. No, my friend had this like slash and burn experience after that, where she had them cut down all these bushes. She did. It was overgrowth. And it was some kind of a wake up call for her. But that was fine. And yes, It's very beautiful there.

And so I just, you know, I relearns lessons and she learned that she should be checking her kids for ticks and she's very aware and telling all her friends. And so public health, you know, sharing it neighbor to neighbor is always important. Dr. Dina Sutter with Pediatric Infectious Disease at UT Health San Antonio and University Hospital. Thank you for being here today on Pediatrics Now. Thank you. Don't forget to click on the link in this podcast for free credit.

That may include CME, MOC, or Ethics Credit, depending on your topic or podcast. I'm Holly Wayment. I'll see you next week.