Inside Medicine: Five on Friday (May 3, 2024).

This week in medicine, what I'm thinking about, etc. You know, an actual newsletter.

We are back with “Five on Friday", the feature where Inside Medicine behaves like an actual medical/health/science newsletter. Below are the top-of-mind things that I’m thinking about right now, although this week I gave over a lot of space to the first item, because I didn’t want to get behind on H5N1.

Also, please vote in the poll at the end!

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If you value this feature—and Inside Medicine in general…

Here we go…

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Item 1. H5N1. How is it spreading and what does it mean for us?

I would not want to be a cow right now. Or ever. But especially now. A new study, preprinted prior to peer review on biorxiv contains key information about the genetics of the various H5N1 avian flu strains that have made their way into a number of animal species, starting with cows, but also affecting cats, raccoons, and, yes, “neurologic goat kids.” The investigations started early in 2024 when veterinarians noticed “unexplained reductions in milk production, decreased feed intake, and changes in milk quality.” (Hand it to the vets for situational awareness.)

A few comments about this new paper. First, it’s great that these scientists (including US government employees) preprinted this information prior to publication in a fancy journal. In a potentially dangerous time like this, hoarding information could be harmful and these scientists risked that a top tier journal won’t be interested in publishing it. But this was the ethical thing to do, and I applaud it.

Some quotations that highlight key findings (note: if nothing else, the Discussion of the paper is really clearly written)…

On virus transmission: “Based upon current information, it appears 20 that once infected, a cow may shed virus for 2-3 weeks.”

On where the virus came from: “These data support a single introduction event from wild bird origin virus into cattle, likely followed by limited local circulation for approximately 4 months prior to confirmation by USDA.”

How long has this been going on? “We detected some amino acid mutations at sites associated with mammalian adaptation that had already become fixed in the virus population that likely reflect the ~4 months of evolution and limited local circulation in dairy cattle.”

On whether a novel threat could emerge that would threaten humans: “[influena A virus] co-infection with [avian flu] could result in reassortment and the emergence of new strains,” which would create a virus that both causes severe disease and is highly contagious in humans. Basically, this happens when a virus that has been circulating in humans infects a person at the same time they are infected with an avian flu, and they exchange genetic material, leading to one nasty bug.

On whether possible vaccines we have will work: “The existing prepandemic candidate vaccine viruses (CVV)…retain cross-reactivity with currently circulating clades. However, recent viruses collected in the US had reduced reactivity with [another] candidate vaccine virus.” In response to this and other analyses, a new CVV is being considered.

On whether our antivirals will work: This is actually not discussed in the paper. There have already been descriptions of avian flu strains that have mutations that likely render our main influenza antiviral (oseltamavir, or “Tamiflu”) less effective. The problem is that this drug already barely does anything, despite what most physicians, guidelines, and expert bodies seem to think.

How much testing is being done? Not enough. My friend Dr. Carter Mecher thinks we ought to be testing milk trucks, rather than farms. (As usual, his “redneck epidemiology” math is pretty compelling. Look, the more tests that are done, the more we can learn. For example, epidemiologists have now found asymptomatic avian flu cases among cows. While this seems to have surprised many people, it should not. It’s likely that many pathogens cause far more asymptomatic disease and spread than we’ve appreciated in the past. Covid-19 should have woken most of us up to that. Remember, Covid is not “special,” in any way that makes it immune to the rules of biology. It’s just worse in a variety of ways because it’s new to us.

Watching this story closely. There has still been only one human case in the US this year, and it was mild.

Item 2: Hospitals no longer required to report Covid and capacity data.

When Covid-19 began, the US government required hospitals to report lots of data to the CDC and to HHS. This was exceedingly useful information. It helped us track and measure the extent of the Covid-19 burden and it helped us know when hospitals were reaching unsafe levels. In fact, those data are what allowed Inside Medicine data guru Benjy Renton and I (with help from Dr. Kristen Panthagani and Alexander Chen) to build our“circuit breaker” model and dashboard) which predicted (quite well) which US hospitals were in danger of getting overwhelmed in the following week or two. (That work eventually made its way into a national Covid plan aimed at getting us to the “next normal” safely.)

As of May 1, the CDC has ended the requirement. This will make it harder for observers (and even insiders) to track hospital safety. Given the fact that we could be facing another pandemic (H5N1 or some other pathogen), it seems unwise to me to take this away. Fortunately, HHS agrees. There is a new proposal that would reinstate the reporting requirements. I hope it goes through. We need data so we know when to act.

Item 3. Semaglutide (Ozempic, Wegovy, Mounjaro) helps patients with arthritis of the knee.

A quick installment for the semaglutide files. Add knee arthritis to the list of conditions that drugs like Ozempic, Wegovy, and Mounjaro treat. New data show an impressive effect. And there was another indirect effect: patients who took semaglutide for knee osteoarthritis went on to use less opioids. So, you could say that these drugs could help decrease rates of arthritis and, by extension, help decrease the opioid epidemic.

Item 4: National Mental Health Awareness Month.

May is National Mental Health Awareness Month. Here is a proclamation on this from President Biden. Also, a reminder that the 988 suicide and crisis hotline is live and always available, by phone or text.

Item 5. Poll of the Week results.

Last week, there was a technical problem with the weekly poll. Sorry! Let’s try it again.

Item 5a. Poll of the Week for this week! Since April was Alcohol Awareness Month, I’m asking you about your own use. Now, this is purely a question about frequency, not amount. There are some people who drink weekly and have a serious problem because of how much they consume, and some who drink daily who do not have a serious problem because of how little they consume. So, this purely a question of “how often.” Lastly, I can’t see your individual responses (nor can anyone), so please be honest :)

Whatever your answer, please do not drive while intoxicated.

That said….

Thanks for chiming in.

That’s it. Your “Friday Five!”

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