1 00:00:05,002 --> 00:00:05,782 Hi everyone. 2 00:00:05,842 --> 00:00:10,072 Welcome to Febrile, a cultured podcast about all things infectious disease. 3 00:00:10,312 --> 00:00:13,912 We use consult questions to dive into ID clinical reasoning, diagnostics 4 00:00:13,912 --> 00:00:15,322 and antimicrobial management. 5 00:00:15,654 --> 00:00:18,564 I'm Sara Dong, your host and a Med-Peds ID doc. 6 00:00:19,554 --> 00:00:21,924 Today we are joined by Dr. Adam Ratner. 7 00:00:22,476 --> 00:00:26,976 He is a Professor of Pediatrics and Microbiology at NYU Grossman School 8 00:00:26,976 --> 00:00:30,486 of Medicine and the Director of the Division of Pediatric Infectious 9 00:00:30,486 --> 00:00:34,446 Diseases at Hassenfeld Children's Hospital and Bellevue Hospital Center. 10 00:00:35,106 --> 00:00:38,766 He also has recently written a book entitled Booster Shots, the 11 00:00:38,766 --> 00:00:42,186 Urgent Lessons of Measles and the Uncertain Future of Children's Health. 12 00:00:42,846 --> 00:00:44,556 We are excited to have Adam here. 13 00:00:44,856 --> 00:00:48,126 Today, he's sharing his opinions and not those of his institutions. 14 00:00:48,768 --> 00:00:52,878 As everyone's favorite cultured podcast, on Febrile, we like to ask our guests 15 00:00:52,878 --> 00:00:55,038 to share a little piece of culture. 16 00:00:55,308 --> 00:00:59,338 You know, just something that you enjoy or that brings you happiness. 17 00:01:00,688 --> 00:01:01,288 Sure. 18 00:01:01,348 --> 00:01:06,778 Um, so my happy place really is, uh, taking my dog for a walk in the park. 19 00:01:07,108 --> 00:01:12,808 Um, culture-wise, uh, you know, I, I love writing and I love reading and, 20 00:01:13,288 --> 00:01:17,758 and you know, the thing that I read most recently that I thought was fantastic 21 00:01:17,758 --> 00:01:19,978 is actually infectious disease related. 22 00:01:19,978 --> 00:01:24,478 It's, um, John Green's new book, which is, uh, Everything is Tuberculosis, 23 00:01:24,478 --> 00:01:29,848 which was just wonderfully written and, and beautiful and great. 24 00:01:30,868 --> 00:01:35,098 I, I even reached out to John Green's publicist. 25 00:01:35,098 --> 00:01:39,058 Just be like, I don't think you'd ever do anything small and ID oriented, 26 00:01:39,058 --> 00:01:42,568 but if you did, we would love to have you come talk on Febrile. 27 00:01:44,218 --> 00:01:48,508 I got to do an event with him, uh, around the time of his book launch, so 28 00:01:48,508 --> 00:01:51,028 I got to interview him about his book. 29 00:01:51,028 --> 00:01:52,828 We talked a little bit about my book. 30 00:01:52,828 --> 00:01:54,988 It was, it, it was like a dream come true. 31 00:01:54,988 --> 00:01:59,218 I mean, I, um, I've been a, a huge fan of his since my daughter 32 00:01:59,218 --> 00:02:03,118 and I read, um, uh, The Fault in Our Stars when she was younger. 33 00:02:03,118 --> 00:02:05,768 And so it's, it was great. 34 00:02:06,148 --> 00:02:06,768 That's awesome. 35 00:02:07,098 --> 00:02:07,738 Yeah, it's perfect. 36 00:02:07,738 --> 00:02:11,218 It's always nice when there's a little combo of the culture 37 00:02:11,218 --> 00:02:12,978 actually having an ID tie in. 38 00:02:13,368 --> 00:02:16,878 Well, I have brought a case to you today that we will talk 39 00:02:16,878 --> 00:02:18,948 through and get your thoughts on. 40 00:02:18,948 --> 00:02:20,928 So I'll give you a little bit of background. 41 00:02:21,468 --> 00:02:26,443 Uh, we have a nine-year-old boy who comes into the emergency room with his parents. 42 00:02:26,443 --> 00:02:30,335 He initially had said he had a little bit of ear ache on the right that 43 00:02:30,335 --> 00:02:33,605 started a couple days ago, and his family started to notice increased 44 00:02:33,605 --> 00:02:35,275 swelling of his face and jaw. 45 00:02:35,365 --> 00:02:38,125 And so the swelling was mostly on the right side. 46 00:02:38,165 --> 00:02:41,135 They feel like at this point though, that maybe his left jaw is a little 47 00:02:41,135 --> 00:02:45,725 bit more swollen as well, and so on exam you can see that he has swelling 48 00:02:45,725 --> 00:02:48,965 of his parotid gland bilaterally, but the right is certainly more 49 00:02:48,965 --> 00:02:53,075 pronounced than the left and kind of obscuring that angle of the mandible. 50 00:02:54,000 --> 00:02:57,863 He is otherwise healthy, has had no prior medical problems, 51 00:02:57,863 --> 00:02:59,813 has never been on medication. 52 00:03:00,213 --> 00:03:03,633 He received some initial vaccines through about the age of nine 53 00:03:03,633 --> 00:03:07,386 months, but he otherwise has not received any additional vaccinations. 54 00:03:07,836 --> 00:03:10,016 So, you get called by the emergency room. 55 00:03:10,016 --> 00:03:12,626 What's kind of going through your mind as you're thinking about this kid? 56 00:03:14,086 --> 00:03:14,596 Sure. 57 00:03:14,596 --> 00:03:19,336 So I'm assuming that, that he doesn't have fever or other systemic symptoms 58 00:03:19,336 --> 00:03:23,086 that are prominent as, as part of this, just based on the description. 59 00:03:23,416 --> 00:03:27,436 You know, the initial symptoms could be acute otitis media, although 60 00:03:27,436 --> 00:03:31,546 then the, the swelling and the parotids would be strange after that. 61 00:03:31,966 --> 00:03:37,701 Um, he could have, uh, a dental source for, for an infection. 62 00:03:37,701 --> 00:03:40,641 I mean, certainly that can give you ear pain to start with and 63 00:03:40,641 --> 00:03:44,661 then, and then pain, you know, in the area of, of the jaw. 64 00:03:44,661 --> 00:03:48,201 But again, you wouldn't necessarily expect swelling of the glands. 65 00:03:48,201 --> 00:03:51,991 You know, the most likely thing is, uh, parotitis. 66 00:03:52,011 --> 00:03:55,401 So, you know, some kind of inflammation of the parotids. 67 00:03:55,431 --> 00:03:58,941 And, you know, things that I'm thinking about are acute 68 00:03:58,941 --> 00:04:04,866 suppurative parotitis, which is usually but not always unilateral. 69 00:04:04,916 --> 00:04:06,506 It's often polymicrobial. 70 00:04:06,596 --> 00:04:10,676 Uh, Staph aureus is most common, but you can have group A strep, Strep 71 00:04:10,676 --> 00:04:15,596 pneumo, Haemophilus, like, and, and lots of oral organisms can do it. 72 00:04:15,656 --> 00:04:19,671 Um, you can get granulomatous infiltration. 73 00:04:19,701 --> 00:04:24,231 Um, if you have, MAI or MTB, which would be rare in this 74 00:04:24,321 --> 00:04:25,971 circumstance or Bartonella. 75 00:04:26,271 --> 00:04:31,501 Um, so those all kind of go under the heading of acute suppurative parotitis. 76 00:04:31,831 --> 00:04:36,311 And then under non-suppurative parotitis, I would think about, um, 77 00:04:36,371 --> 00:04:41,121 still some infectious causes, so mostly viral causes of, of parotitis. 78 00:04:41,141 --> 00:04:45,881 Um, first on the list would be mumps, especially because you said that this 79 00:04:45,881 --> 00:04:50,501 is a kid who got vaccinated up until nine months and then not since then. 80 00:04:50,681 --> 00:04:55,431 So in a child who hasn't received the measles, mumps, rubella vaccine, which 81 00:04:55,491 --> 00:05:01,021 we usually give at, at 12 to 15 months, I'm thinking about mumps in this child. 82 00:05:01,306 --> 00:05:04,996 There's a long list of other viruses that can give you parotid inflammation. 83 00:05:04,996 --> 00:05:10,126 You know, the CMV, EBV, influenza, parainfluenza, some of the 84 00:05:10,126 --> 00:05:13,126 enteroviruses including coxsackievirus. 85 00:05:13,636 --> 00:05:19,156 Um, there are some herpes viruses that can do it like HSV1 or 2, like HHV six. 86 00:05:19,486 --> 00:05:23,016 Uh, there are reports of COVID associated parotitis. 87 00:05:23,446 --> 00:05:24,016 Um. 88 00:05:24,441 --> 00:05:27,281 Rarely LCMV. 89 00:05:27,281 --> 00:05:31,201 HIV uh, untreated HIV can, can be a cause of, of parotitis. 90 00:05:31,221 --> 00:05:34,461 Again, I think the many of these are, are much lower on the list. 91 00:05:34,671 --> 00:05:37,591 And then there are non-infectious causes, some of which can 92 00:05:37,591 --> 00:05:40,151 cause bilateral parotitis. 93 00:05:40,171 --> 00:05:42,931 Um, often they're, uh, unilateral. 94 00:05:42,961 --> 00:05:43,291 Um. 95 00:05:43,871 --> 00:05:49,661 You know, a sialolithiasis just blockage of a, of a, um, duct can, 96 00:05:49,691 --> 00:05:52,331 um, can give you parotid swelling. 97 00:05:52,411 --> 00:05:56,331 Chronic recurrent parotitis, which can be due to problems in 98 00:05:56,331 --> 00:05:58,431 salivary production or drainage. 99 00:05:59,001 --> 00:06:03,651 There's this entity called juvenile recurrent parotitis, which I don't 100 00:06:03,801 --> 00:06:07,941 understand well, and I think nobody really understands that well. 101 00:06:08,141 --> 00:06:09,341 But that can happen. 102 00:06:09,701 --> 00:06:12,671 Um, and then there are, there are autoimmune things. 103 00:06:12,721 --> 00:06:14,931 Sjogren's syndrome, sarcoid. 104 00:06:15,501 --> 00:06:18,901 I suppose Kawasaki can be a cause of parotitis. 105 00:06:18,921 --> 00:06:23,871 Um, I'm running out of things, but, but I, I think that, you know, based 106 00:06:23,871 --> 00:06:29,641 on how he looks at least per the description, I think less likely 107 00:06:29,641 --> 00:06:33,211 acute suppurative parotitis, I think more likely a viral cause. 108 00:06:33,211 --> 00:06:35,581 Although you, you know, it's hard to rule out one of the 109 00:06:35,581 --> 00:06:37,501 autoimmune things at the beginning. 110 00:06:38,296 --> 00:06:38,716 Yeah. 111 00:06:38,746 --> 00:06:41,566 And you know, that's, we have this big list. 112 00:06:41,566 --> 00:06:45,436 How would you approach at least sort of your first batch of testing? 113 00:06:45,436 --> 00:06:48,346 Like, what would you prioritize for this, uh, this child? 114 00:06:49,126 --> 00:06:53,176 Yeah, so I mean, I'd wanna take a look in his mouth. 115 00:06:53,176 --> 00:06:58,516 I'd, I'd wanna look at the, at, at stenson's duct I could and, and, you 116 00:06:58,516 --> 00:07:01,756 know, maybe see if you can either see or feel a stone, because if 117 00:07:01,756 --> 00:07:06,666 this is, is truly a mechanical thing than your approach is different. 118 00:07:06,666 --> 00:07:10,766 You're, you're calling someone to take a look and, and see if that can be removed. 119 00:07:11,016 --> 00:07:12,426 There are sort of basic labs. 120 00:07:12,426 --> 00:07:17,286 I, I would look at, you know, a CBC, a set of electrolytes, you 121 00:07:17,286 --> 00:07:21,666 know, with, with mumps you would expect a, uh, a, some leukopenia, 122 00:07:21,666 --> 00:07:23,826 but maybe a relative lymphocytosis. 123 00:07:24,216 --> 00:07:28,796 Some viral testing and I think we can be a bit judicious at the 124 00:07:28,826 --> 00:07:30,926 beginning in terms of, of that. 125 00:07:30,926 --> 00:07:34,916 Depending on the season, you might send, you know, influenza testing because 126 00:07:34,916 --> 00:07:37,286 that would be actionable if positive. 127 00:07:37,616 --> 00:07:39,446 Um, COVID testing. 128 00:07:40,351 --> 00:07:45,871 Maybe EBV and CMV and, and certainly a mumps PCR and maybe 129 00:07:45,871 --> 00:07:48,541 a, maybe a mumps IGM as well. 130 00:07:48,621 --> 00:07:54,031 The mumps PCR, you, you would try to get some parotid gland 131 00:07:54,111 --> 00:07:55,851 secretions for, for that. 132 00:07:56,211 --> 00:07:59,541 It's my understanding, I haven't done this in a while, but I think that you have to 133 00:07:59,541 --> 00:08:04,401 massage the parotid gland for, uh, for 30 seconds or something before you collect 134 00:08:04,401 --> 00:08:06,741 the, the sample to get maximum yield. 135 00:08:07,191 --> 00:08:12,986 And I would call my local public health department at this point, not 136 00:08:12,986 --> 00:08:16,796 so much because I wanna report a case of mumps, but if I'm sending mumps 137 00:08:16,796 --> 00:08:21,206 testing, I'm calling them because often, and this is true with measles 138 00:08:21,206 --> 00:08:25,526 testing, at, at least for us in New York City, they can turn these things 139 00:08:25,526 --> 00:08:30,717 around much faster than either our lab or a, uh, a commercial lab can. 140 00:08:30,776 --> 00:08:33,836 So they may be helpful in terms of, of diagnostics. 141 00:08:33,866 --> 00:08:37,536 And then the, you know, the other thing that you could think about, depending on 142 00:08:37,536 --> 00:08:42,336 how the kid looks, is either a sonogram of the area or I suppose if you want 143 00:08:42,396 --> 00:08:48,066 detailed imaging, you could do a CT, but I would probably start with a sono unless 144 00:08:48,721 --> 00:08:49,011 Yeah. 145 00:08:49,446 --> 00:08:51,066 exam gave you something obvious. 146 00:08:51,836 --> 00:08:52,116 Yeah. 147 00:08:52,716 --> 00:08:56,136 And you know, we'll say we at least have a CBC back. 148 00:08:56,136 --> 00:08:58,866 We just have some mild leukocytosis at the moment. 149 00:08:59,320 --> 00:09:01,870 Um, We're working on sending off some of this additional testing, you 150 00:09:01,870 --> 00:09:07,030 mentioned kind of just an intro of like, flu, EBV, CMV, and then we've 151 00:09:07,030 --> 00:09:10,900 touched base with, um, our health department and, and infection control. 152 00:09:10,900 --> 00:09:15,130 Just to ask the questions about sending off mumps PCR 'cause um. 153 00:09:15,655 --> 00:09:18,925 I didn't say it, but that's what the emergency room has called you for. 154 00:09:19,285 --> 00:09:22,525 So, you know, while we're waiting for the results, they 155 00:09:22,525 --> 00:09:23,805 ask what should we think about? 156 00:09:23,805 --> 00:09:26,325 Like say this was mumps, what are complications? 157 00:09:26,325 --> 00:09:29,535 'cause we haven't seen it and we don't really know what to think about. 158 00:09:30,345 --> 00:09:35,625 Yeah, we, we, we still do not see it a lot, uh, whi which is good 159 00:09:35,625 --> 00:09:37,605 because most people are vaccinated. 160 00:09:38,005 --> 00:09:43,225 The, the things that you worry about with mumps infection, so, so kids 161 00:09:43,225 --> 00:09:47,380 present like this child usually though, so fever, maybe some headaches 162 00:09:47,380 --> 00:09:49,720 and myalgias, parotid swelling. 163 00:09:50,010 --> 00:09:56,010 It's often unilateral followed by then swelling of the contralateral gland. 164 00:09:56,010 --> 00:09:59,580 But, but sometimes it can only be, you know, it can just be unilateral. 165 00:09:59,636 --> 00:10:04,531 The reason that we worry about mumps is you can get orchitis in about 166 00:10:04,531 --> 00:10:08,281 30% of cases that are unvaccinated. 167 00:10:08,281 --> 00:10:13,561 It, it's much lower, but not zero in, in cases that happen in vaccinated people. 168 00:10:13,711 --> 00:10:18,781 The orchitis is usually unilateral, but can be bilateral, and so I 169 00:10:18,781 --> 00:10:22,981 think it's 90% unilateral and, and in 10% of cases can be bilateral. 170 00:10:22,981 --> 00:10:27,431 That's relevant because you can get testicular atrophy after mumps 171 00:10:27,561 --> 00:10:31,386 orchitis, and so there can, if you have bilateral orchitis, there 172 00:10:31,386 --> 00:10:34,906 can be effects on fertility later. 173 00:10:34,966 --> 00:10:37,546 Uh, oophoritis also happens. 174 00:10:37,606 --> 00:10:40,106 Um, it's less frequent than orchitis. 175 00:10:40,126 --> 00:10:43,546 Um, but, and it can be harder to, to diagnose, but that, 176 00:10:43,576 --> 00:10:45,756 that is also a concern. 177 00:10:46,321 --> 00:10:51,271 You get aseptic meningitis in about 1% of kids with mumps. 178 00:10:51,331 --> 00:10:57,991 Although my understanding is that if you, if you do taps on a larger number of kids, 179 00:10:57,991 --> 00:11:02,981 you find that most of them have a mild lymphocytic pleocytosis, even if they 180 00:11:02,981 --> 00:11:06,361 don't have symptoms of aseptic meningitis. 181 00:11:06,361 --> 00:11:10,501 I'm not advocating tapping this well appearing child, but I, but 182 00:11:10,501 --> 00:11:13,291 just to throw that out there, um. 183 00:11:14,081 --> 00:11:18,291 You know, and then more rarely you can have some important, 184 00:11:18,321 --> 00:11:20,181 uh, downstream complications. 185 00:11:20,181 --> 00:11:23,331 So hearing loss happens in a small percentage of, of 186 00:11:23,331 --> 00:11:24,771 kids, but can be permanent. 187 00:11:25,041 --> 00:11:29,091 Some kids get pancreatitis or, um, myocarditis. 188 00:11:29,600 --> 00:11:34,130 Older kids and adults really are more likely to have most of these 189 00:11:34,130 --> 00:11:38,960 complications, like they happen at higher rates in, in unvaccinated adults. 190 00:11:39,380 --> 00:11:43,340 Um, so I, I think that's where I would start in terms of, of why I, 191 00:11:43,370 --> 00:11:45,270 why I worry about kids with mumps. 192 00:11:45,845 --> 00:11:46,115 Yeah. 193 00:11:46,265 --> 00:11:46,865 Perfect. 194 00:11:47,355 --> 00:11:49,335 So I'll kind of speed us along. 195 00:11:49,335 --> 00:11:53,425 We did do an ultrasound of the area, didn't really identify an abscess 196 00:11:53,425 --> 00:11:55,795 fortunately, or an obvious stone. 197 00:11:56,505 --> 00:11:59,055 Wasn't identified on exam or that ultrasound. 198 00:11:59,475 --> 00:12:03,465 Um, there was discussion and attempt to look and see if drainage could be sent 199 00:12:03,465 --> 00:12:07,215 off of the Stenson duct, but really they weren't expressing anything. 200 00:12:07,575 --> 00:12:12,495 Um, so that wasn't sent off and we ended up getting back an EBV test that 201 00:12:12,495 --> 00:12:14,700 was suggestive of acute infection. 202 00:12:15,250 --> 00:12:17,955 Um, and fortunately our, our mumps testing, which was 203 00:12:17,955 --> 00:12:19,790 sent off is, is negative. 204 00:12:20,120 --> 00:12:22,070 So fortunately this is great, right? 205 00:12:22,070 --> 00:12:23,310 Our kid doesn't have mumps. 206 00:12:23,330 --> 00:12:26,540 They have EBV, which would be a very common explanation for this. 207 00:12:26,960 --> 00:12:31,490 Um, but you know, now that you're here with the family, we have this opportunity, 208 00:12:31,850 --> 00:12:33,920 uh, to talk a little bit about vaccines. 209 00:12:33,920 --> 00:12:37,550 'cause, you know, lots of people have been going in the room and asking them, Hey, do 210 00:12:37,580 --> 00:12:40,370 you remember if he got this MMR vaccine? 211 00:12:40,850 --> 00:12:44,720 Um, and we of course that mumps is preventable with immunization. 212 00:12:44,780 --> 00:12:48,835 Everyone who listens to Febrile I'm sure knows that, but, at least my 213 00:12:48,835 --> 00:12:52,945 approach, at least to start, is when I encounter patients or families that 214 00:12:52,945 --> 00:12:57,355 have not received certain vaccines or have expressed vaccine hesitancy, 215 00:12:57,685 --> 00:13:02,045 I ask, you know, what their concerns are, exploring that with, can you tell 216 00:13:02,045 --> 00:13:06,665 me a little bit about what worried you about the MMR vaccine, or can you share 217 00:13:06,665 --> 00:13:11,985 what you've experienced and so I'll let you know that we started that and the 218 00:13:11,985 --> 00:13:15,705 parents share that they just felt like their son had gotten too many vaccines. 219 00:13:16,025 --> 00:13:18,275 All these antigens that they've read about online. 220 00:13:18,275 --> 00:13:22,115 They're really worried and they also share that they kind of just felt like, 221 00:13:22,265 --> 00:13:27,245 you know, if he got natural infection, that immunity might be better and 222 00:13:27,245 --> 00:13:31,655 that everyone that they knew who had chickenpox and mumps when in the past. 223 00:13:32,325 --> 00:13:35,565 Everything was fine and that they can be vigilant and try to deal 224 00:13:35,565 --> 00:13:37,335 with natural infection if it comes. 225 00:13:37,395 --> 00:13:41,285 And so I will open it up to you on like how, how do you 226 00:13:41,555 --> 00:13:43,115 move this conversation forward? 227 00:13:43,115 --> 00:13:44,340 What would sort of be your approach? 228 00:13:45,145 --> 00:13:45,535 Sure. 229 00:13:45,535 --> 00:13:49,345 And, and you've done a lot of the, the heavy lifting at the beginning already. 230 00:13:49,345 --> 00:13:53,545 I mean, the, that, and that's, that's how I would open this conversation also. 231 00:13:53,545 --> 00:13:58,615 I mean, I'll, I'll start by saying that I'm a, a hospital based ID doctor. 232 00:13:58,615 --> 00:14:02,905 I'm not a primary pediatrician, and the primary pediatricians are the 233 00:14:02,905 --> 00:14:05,155 superheroes of having these conversations. 234 00:14:05,155 --> 00:14:10,485 And I think that when we have these conversations, ID folks in 235 00:14:10,485 --> 00:14:13,335 a, in a hospital setting, it's a different kind of conversation. 236 00:14:13,335 --> 00:14:16,785 Like either it's something like this where it's a child where we were 237 00:14:16,785 --> 00:14:20,205 worried about a vaccine preventable disease and then it didn't end up 238 00:14:20,205 --> 00:14:24,915 being this, or I've had a lot of these conversations with kids who, you know, are 239 00:14:24,915 --> 00:14:30,550 hospitalized for measles or hospitalized for flu, and so, they're, they're in 240 00:14:30,550 --> 00:14:32,260 a situation where the child is sick. 241 00:14:32,260 --> 00:14:36,190 It, it can be an emotionally fraught situation. 242 00:14:36,220 --> 00:14:40,840 I still think it's important to at least begin the, the conversation, 243 00:14:40,840 --> 00:14:42,790 but it can be, it can be hard. 244 00:14:42,790 --> 00:14:46,960 You have to be careful that the conversation doesn't go off the rails. 245 00:14:46,960 --> 00:14:50,440 That, that they don't think that you're blaming them for anything. 246 00:14:50,680 --> 00:14:55,650 I mean, thi this is, I, I think probably a more comfortable situation where 247 00:14:55,650 --> 00:14:59,010 you say, okay, we were worried about this because of the vaccine status. 248 00:14:59,010 --> 00:15:02,400 Now let, let's have a conversation. 249 00:15:02,490 --> 00:15:02,550 Um. 250 00:15:03,840 --> 00:15:09,420 And I think figuring out what the concern is is really important because it's 251 00:15:09,420 --> 00:15:14,400 a different conversation if there's one vaccine that the parents are, 252 00:15:14,400 --> 00:15:17,670 are frightened about and it's because of one thing that they heard online, 253 00:15:17,670 --> 00:15:20,430 and you can really zoom in on that. 254 00:15:20,460 --> 00:15:24,310 Um, I've gotten a lot of that with, with flu vaccine discussions where 255 00:15:24,310 --> 00:15:26,980 parents are like, well, every year there's a, you know, there's an 256 00:15:26,980 --> 00:15:31,000 article that says that the flu vaccine is only 20 or 30% effective, so I 257 00:15:31,000 --> 00:15:32,320 just feel like it's not worth it. 258 00:15:32,650 --> 00:15:35,500 And they, you know, they've gotten their kid vaccinated against everything else. 259 00:15:35,530 --> 00:15:41,170 Totally different conversation than, you know, we, we think that, you know, 260 00:15:41,170 --> 00:15:45,190 vaccines are gonna harm our child, or, you know, we think it's too many too soon. 261 00:15:45,190 --> 00:15:48,190 There, there are all of these other things. 262 00:15:48,190 --> 00:15:49,300 So, I mean. 263 00:15:49,665 --> 00:15:53,745 For, for this family, I might sit and talk to them specifically about mumps a 264 00:15:53,745 --> 00:15:59,175 little bit, and because that's, that'll be sort of front of mind for them and what I 265 00:15:59,175 --> 00:16:01,455 would worry about and the fertility thing. 266 00:16:01,515 --> 00:16:04,755 And then I would talk about, you know, measles and how 267 00:16:04,755 --> 00:16:06,975 that can be dangerous as well. 268 00:16:07,515 --> 00:16:12,510 And then, you know, you may not be able to move the needle in terms 269 00:16:12,510 --> 00:16:17,670 of, of convincing them that vaccine immunity is, is worth getting and 270 00:16:17,670 --> 00:16:22,710 is better than natural immunity if you know, in to use their words. 271 00:16:23,130 --> 00:16:24,945 Um, you know, I, I think. 272 00:16:25,785 --> 00:16:31,365 We can also bring up, I, I think this resonates with some families, the idea of, 273 00:16:31,425 --> 00:16:35,505 you know, vaccines as a way of protecting not just your child and obviously you 274 00:16:35,505 --> 00:16:40,335 want to protect your child, but also pitching in to protect the community. 275 00:16:40,395 --> 00:16:44,235 And I'll, you know, I'll talk about kids who can't get vaccinated, you know. 276 00:16:44,820 --> 00:16:47,850 Older people who may have been vaccinated and, and had waning 277 00:16:47,850 --> 00:16:51,420 immunity and that we try to stop these things from circulating to protect 278 00:16:51,780 --> 00:16:55,710 young kids and kids who are getting chemotherapy and, and folks like that. 279 00:16:55,750 --> 00:17:00,070 A lot of it depends on kind of the particulars of how the conversation 280 00:17:00,520 --> 00:17:03,550 goes and what they seem to respond to. 281 00:17:03,550 --> 00:17:10,120 And often the best you can hope for is to start them thinking about it, you know? 282 00:17:10,630 --> 00:17:13,780 Encourage them to have another conversation with their pediatrician 283 00:17:13,780 --> 00:17:17,655 when they go back there and maybe, maybe you make some headway. 284 00:17:18,640 --> 00:17:19,060 Yeah. 285 00:17:19,210 --> 00:17:23,920 And uh, I think the point you made about how so many of these conversations 286 00:17:23,920 --> 00:17:28,690 are not happening when we see them as consultants in the hospital is so vital. 287 00:17:28,690 --> 00:17:32,770 And, you know, you made me think about, I had a, I was having a conversation 288 00:17:32,770 --> 00:17:38,065 with some other peds peds folks recently about how challenging it is to talk about 289 00:17:38,065 --> 00:17:42,805 it in the inpatient setting, especially if perhaps that child has a pretty 290 00:17:43,165 --> 00:17:48,370 devastating infection from something that they could have been vaccinated against. 291 00:17:48,370 --> 00:17:51,550 And I think everyone who's a pediatrician sees a really bad 292 00:17:51,550 --> 00:17:53,350 case of flu, at least a year. 293 00:17:53,440 --> 00:17:57,250 And I was wondering if, you know, with your experience, for example, 294 00:17:57,250 --> 00:18:01,390 with the measles outbreak that you talk about in New York, uh. 295 00:18:01,665 --> 00:18:07,035 Are there any other sort of tools or, or, or advice that you give to people 296 00:18:07,035 --> 00:18:10,755 who are potentially navigating these types of challenging discussions, which 297 00:18:10,755 --> 00:18:17,185 at baseline are hard, but even harder when a child already is experiencing 298 00:18:17,185 --> 00:18:22,105 some symptoms, some something impacting their, their health already. 299 00:18:23,075 --> 00:18:25,145 Yeah, it's, uh, it's not easy. 300 00:18:25,295 --> 00:18:32,425 Um, and, and I think that you need to make sure that everyone is on the same 301 00:18:32,425 --> 00:18:39,865 page in terms of the family should understand that I know that they love 302 00:18:39,865 --> 00:18:44,365 the, their kid and that they are trying to protect their child and that they 303 00:18:44,365 --> 00:18:49,085 want the same thing that I'm trying to do, which is for their kid to grow 304 00:18:49,085 --> 00:18:51,005 up and be happy and, and healthy. 305 00:18:51,395 --> 00:18:57,170 And if you can start from that point of alignment where they know, that 306 00:18:57,170 --> 00:19:01,040 I'm willing to sit and talk to them and that I'm not judging them and 307 00:19:01,040 --> 00:19:04,640 that I really, really do want their kid to get better and, and want their 308 00:19:04,640 --> 00:19:07,400 kid to be as, as healthy as they can. 309 00:19:07,700 --> 00:19:10,310 And they know that I know that about them. 310 00:19:10,670 --> 00:19:12,020 I think that really helps. 311 00:19:12,120 --> 00:19:17,640 You know, am I ever frustrated by the of, of course, like it's, it is enormously 312 00:19:17,640 --> 00:19:22,500 frustrating to be in a situation where you're, you're taking care of a sick child 313 00:19:22,530 --> 00:19:24,720 and, and it was a preventable disease. 314 00:19:24,720 --> 00:19:28,780 I've seen a number of kids over the last couple of years with HiB 315 00:19:28,800 --> 00:19:35,220 meningitis, um, which I had never seen for like the prior 30 years, and it's. 316 00:19:35,485 --> 00:19:39,985 It's a horrible disease and it was totally preventable and it's, 317 00:19:40,045 --> 00:19:41,965 it's unbelievably frustrating. 318 00:19:41,995 --> 00:19:49,225 But that just, even just from a, a totally practical point of view, going in with 319 00:19:49,225 --> 00:19:54,300 that message doesn't help.. Like, it's not gonna bring anyone closer to vaccinating. 320 00:19:54,330 --> 00:19:57,120 It's, you know, it's gonna make the parents feel attacked. 321 00:19:57,150 --> 00:20:02,220 It's going, they're gonna lash out and say, why don't you just focus 322 00:20:02,220 --> 00:20:04,830 on, on getting my child better now? 323 00:20:04,890 --> 00:20:09,000 And then, you know, you've sort of lost that opportunity to talk. 324 00:20:09,000 --> 00:20:13,050 So I, I think spending time on that alignment at the beginning. 325 00:20:13,545 --> 00:20:17,055 And, you know, and then you can take your own feelings later and, and 326 00:20:17,055 --> 00:20:18,585 talk about them with someone else. 327 00:20:18,645 --> 00:20:21,675 But, uh, but that's, that's really important. 328 00:20:22,170 --> 00:20:23,010 Yeah, yeah. 329 00:20:23,010 --> 00:20:24,060 And like you were saying. 330 00:20:25,410 --> 00:20:28,350 Opening it up so that they have more conversations with 331 00:20:28,410 --> 00:20:30,990 perhaps their pediatrician that they trust in the future. 332 00:20:31,590 --> 00:20:35,010 Um, and you know, I of course wanna point to your recent book. 333 00:20:35,010 --> 00:20:39,270 I know I have, uh, several colleagues of mine that have really enjoyed Booster 334 00:20:39,270 --> 00:20:45,020 Shots and you talk about measles as being this quintessential human pathogen and 335 00:20:45,020 --> 00:20:50,480 kind of case example and your experiences, but also historical perspectives. 336 00:20:50,480 --> 00:20:57,995 And, we are obviously in a very abnormal year for measles cases in the 337 00:20:57,995 --> 00:21:05,405 US and you know, I think naturally many healthcare professionals are struggling 338 00:21:05,435 --> 00:21:08,585 and feel like messaging is challenging. 339 00:21:08,585 --> 00:21:12,215 And I was wondering for you, as someone, you know, you've written this book, 340 00:21:12,215 --> 00:21:17,105 but also as a leader in your division and and with your experience, are there 341 00:21:17,765 --> 00:21:23,095 examples of ways that you encourage people to advocate beyond, you know, 342 00:21:23,095 --> 00:21:27,835 we all do daily one-on-one or family conversations in clinical practice, but 343 00:21:28,105 --> 00:21:32,845 like as a trainee or an early career physician, how, how should we think about 344 00:21:32,845 --> 00:21:38,455 advocating for vaccines on a larger scale and or sort of how can we improve the 345 00:21:38,455 --> 00:21:40,825 way we communicate as ID specialists? 346 00:21:41,350 --> 00:21:45,850 Yeah, I, I think, you know, if ever there was a time that we needed people 347 00:21:45,850 --> 00:21:48,190 to be out there, this is that time. 348 00:21:48,640 --> 00:21:54,205 And that can be, you know, finding specific causes that you're, you 349 00:21:54,205 --> 00:21:57,295 know, passionate about in contacting your representatives and doing that. 350 00:21:57,295 --> 00:21:59,755 Just like any citizen can. 351 00:22:00,035 --> 00:22:01,475 Often I have, I have, you know. 352 00:22:02,705 --> 00:22:05,435 People who are not in medicine ask me this question. 353 00:22:05,705 --> 00:22:11,585 And I, I say that one thing that that is I think very powerful that doesn't happen 354 00:22:11,585 --> 00:22:16,955 a lot is, when you're a parent and you're at the playground or in the store or 355 00:22:16,955 --> 00:22:22,235 whatever, like the messages that people hear tend to be anti-vaccine messages. 356 00:22:22,235 --> 00:22:24,455 They are much louder than we are. 357 00:22:24,605 --> 00:22:28,745 And not that we have to be loud, but I think that conversations 358 00:22:28,745 --> 00:22:33,265 where we normalize vaccination because most families still, the 359 00:22:33,265 --> 00:22:37,825 vast majority of families get their kids vaccinated on schedule. 360 00:22:38,245 --> 00:22:42,325 And so saying at the playground, Hey, I took my daughter to, 361 00:22:42,445 --> 00:22:43,915 you know, to get her MMR today. 362 00:22:44,905 --> 00:22:48,715 Not saying anything else, not saying, you know, you should do this or 363 00:22:48,715 --> 00:22:53,455 whatever, but like, making that part of the conversation, I think helps a lot. 364 00:22:54,025 --> 00:22:54,565 Um. 365 00:22:55,400 --> 00:23:00,170 In terms of what physicians can do, have that conversation within your 366 00:23:00,170 --> 00:23:02,810 family, even if it's uncomfortable. 367 00:23:02,810 --> 00:23:05,570 I mean, I, I do not recommend burning bridges. 368 00:23:05,630 --> 00:23:10,190 Uh, I try hard not to burn bridges in my own family. 369 00:23:10,250 --> 00:23:15,710 Um, we all have challenging family members, but like, it's easier to 370 00:23:16,010 --> 00:23:17,870 shy away from the conversations. 371 00:23:18,080 --> 00:23:22,370 You try not to let them devolve into yelling, but you put good 372 00:23:22,370 --> 00:23:25,400 information out there as best you can. 373 00:23:25,430 --> 00:23:29,030 It's, uh, it is not easy. 374 00:23:29,400 --> 00:23:36,410 Um, I've been lucky in that, you know, this book has come out at a time when 375 00:23:36,750 --> 00:23:38,640 we have a large measles outbreak. 376 00:23:38,670 --> 00:23:39,690 There's a lot of interest. 377 00:23:39,690 --> 00:23:46,050 I've gotten to do a lot of press and, and have had a, a bigger voice than I've, 378 00:23:46,110 --> 00:23:51,870 I've had before and I've been lucky to be able to talk about vaccines and talk 379 00:23:51,870 --> 00:23:54,120 about things that are important out there. 380 00:23:54,120 --> 00:23:56,760 But, but I think we can all do that. 381 00:23:57,180 --> 00:24:00,766 And, and of course like if you want to like write op-eds, write, you 382 00:24:00,766 --> 00:24:04,786 know, like, like to the extent that you're comfortable, like get out there 383 00:24:04,786 --> 00:24:06,196 and do that kind of thing as well. 384 00:24:06,526 --> 00:24:12,176 Yeah, so , I actually wanted this episode to serve as a really a kickoff for a few 385 00:24:12,176 --> 00:24:17,423 episodes related to vaccine preventable illnesses, which are of course on the 386 00:24:17,423 --> 00:24:22,253 top of everyone's mind, and, today we've chatted a little bit about mumps. 387 00:24:22,523 --> 00:24:27,173 We have two additional episodes that are gonna follow this discussing, um, 388 00:24:27,203 --> 00:24:29,382 two other vaccine preventable illnesses. 389 00:24:29,386 --> 00:24:31,396 I won't spoil the topics quite yet. 390 00:24:31,906 --> 00:24:34,366 Um, for those who haven't listened to it already. 391 00:24:34,366 --> 00:24:40,246 I encourage you to check out our prior episode number 102: Rubeola Response. 392 00:24:40,493 --> 00:24:44,423 This shared a measles outbreak response from a team of ID docs, 393 00:24:44,423 --> 00:24:49,103 really from the perspective of the hospital epidemiology team. 394 00:24:49,793 --> 00:24:54,133 And maybe I'll, um, ask you, Adam, to give a few thoughts on measles, 395 00:24:54,373 --> 00:24:57,083 particularly given your new book. 396 00:24:57,173 --> 00:25:00,763 Um, and then I can update with the latest case numbers right before 397 00:25:00,763 --> 00:25:02,143 we post the episode as well. 398 00:25:02,439 --> 00:25:07,389 Yeah, I mean, we are having quite a year for vaccine preventable diseases. 399 00:25:07,469 --> 00:25:11,699 As I'm sure the whole audience knows, there is a large measles 400 00:25:11,699 --> 00:25:16,679 outbreak now in Texas and New Mexico and Oklahoma and Kansas. 401 00:25:16,679 --> 00:25:20,429 That appears to be one large outbreak. 402 00:25:20,489 --> 00:25:27,184 Um, and that, that is now well over 500 cases, it may be over 600 at this point. 403 00:25:27,574 --> 00:25:32,884 Um, there are also now outbreaks in Indiana and Ohio. 404 00:25:32,944 --> 00:25:36,874 Um, I saw a, an alert just in the past couple of days that there 405 00:25:36,874 --> 00:25:39,424 are more cases in Philadelphia. 406 00:25:39,474 --> 00:25:43,464 It's not just one place in the US and I think that there are a couple 407 00:25:43,464 --> 00:25:44,874 of things going on with that. 408 00:25:44,874 --> 00:25:50,559 I mean, we had nationwide a reasonable kindergarten MMR vaccination 409 00:25:50,559 --> 00:25:56,019 coverage rate, prior to the COVID-19 pandemic, it was about 95%, but that 410 00:25:56,319 --> 00:26:01,779 nationwide rate masks state to state variability, and then community to 411 00:26:01,779 --> 00:26:03,789 community variability within states. 412 00:26:04,119 --> 00:26:05,739 The overall rate has dropped. 413 00:26:05,739 --> 00:26:13,419 We're below 93% for kindergarten MMR, and and falling for As, as a nationwide rate. 414 00:26:13,779 --> 00:26:18,999 And then even in states where you have good coverage across the states. 415 00:26:18,999 --> 00:26:24,804 So the Texas overall rate is about 94%, but the Gaines County rate where 416 00:26:24,804 --> 00:26:30,414 the, where the outbreak started and is, is, uh, is concentrated, is about 80%. 417 00:26:30,534 --> 00:26:35,454 And we saw a very similar thing in 20 18, 20 19 in New York City where the 418 00:26:35,454 --> 00:26:41,454 citywide rate, um, for MMR vaccination in kindergarten was about 98%, so I 419 00:26:41,454 --> 00:26:45,864 wouldn't have thought that we would be at risk, but if you look on a, a zip 420 00:26:45,864 --> 00:26:50,814 code level or a neighborhood level, it was more like 80% in, you know, in 421 00:26:50,814 --> 00:26:55,374 the specific communities that, that were really involved in the outbreak. 422 00:26:55,524 --> 00:27:01,864 And so I, I'm worried about measles in particular because it's so 423 00:27:01,864 --> 00:27:03,994 contagious and so dangerous for kids. 424 00:27:03,994 --> 00:27:06,334 We've, you know, at the time we're recording this, there've been 425 00:27:06,634 --> 00:27:09,924 two pediatric deaths, one adult death in the measles outbreak. 426 00:27:10,194 --> 00:27:14,304 But I'm also worried because measles is the canary in the coal mine. 427 00:27:14,304 --> 00:27:19,669 It's the bellwether because it's so contagious and it, it means 428 00:27:19,669 --> 00:27:23,959 that there's likely to be much more than just measles going on soon. 429 00:27:23,959 --> 00:27:25,489 And we're, we're seeing that already. 430 00:27:25,489 --> 00:27:28,939 Like there have been a ton of pertussis cases. 431 00:27:28,999 --> 00:27:33,979 Um, there were two deaths of, of infants in Louisiana from pertussis 432 00:27:33,979 --> 00:27:40,069 just in the, in recent weeks or months, and, that I, I fear will 433 00:27:40,069 --> 00:27:43,249 also become a, a nationwide trend. 434 00:27:43,249 --> 00:27:45,889 So there's, you know, there, there's the worry that we're not gonna get 435 00:27:45,889 --> 00:27:48,369 this measles outbreak under control. 436 00:27:48,579 --> 00:27:52,959 But even if we get this specific one out under control, I'm worried with 437 00:27:52,959 --> 00:27:57,729 falling vaccination rates that more frequent and larger outbreaks of measles 438 00:27:57,729 --> 00:28:01,179 are gonna be common, and that more frequent and larger outbreaks of other 439 00:28:01,179 --> 00:28:03,909 vaccine preventable diseases are coming. 440 00:28:05,005 --> 00:28:10,645 And so just to give a quick update, as of May 11th, 2025, the United States has a 441 00:28:10,645 --> 00:28:16,255 total of over a thousand confirmed measles cases reported from 31 jurisdictions. 442 00:28:17,035 --> 00:28:21,745 These cases have been in about 30% with children under five years of 443 00:28:21,745 --> 00:28:26,815 age, 38% of those who are five to 19 years old, and the remaining 444 00:28:26,815 --> 00:28:29,185 in adults 20 and older or unknown. 445 00:28:29,845 --> 00:28:32,065 96% were unvaccinated. 446 00:28:32,350 --> 00:28:35,660 13% of measles cases have been hospitalized , and there have 447 00:28:35,660 --> 00:28:36,920 been three confirmed deaths. 448 00:28:37,709 --> 00:28:38,354 Back to the episode. 449 00:28:39,242 --> 00:28:43,012 Yeah, and this que question isn't probably totally fair, but if 450 00:28:43,012 --> 00:28:50,802 you had the opportunity to make a couple decisions, that, like, let's 451 00:28:50,802 --> 00:28:52,332 say it's, it's totally up to you. 452 00:28:52,332 --> 00:28:58,695 What would be the things that you would be most focused on for us to support 453 00:28:58,755 --> 00:29:03,105 the kids that we take care of, um, and sort of getting through these outbreaks? 454 00:29:03,135 --> 00:29:07,635 I mean, there, there is so much that I would change about what's going on now. 455 00:29:07,635 --> 00:29:11,085 I mean, and it, it goes way beyond vaccines as you might imagine. 456 00:29:11,085 --> 00:29:16,545 Like I am from a, a, a children's health overall point of view, I am 457 00:29:16,605 --> 00:29:18,795 really, really worried about Medicaid. 458 00:29:18,825 --> 00:29:24,115 I mean, so many of our patients are dependent on Medicaid for their 459 00:29:24,475 --> 00:29:27,325 coverage, for their ability to get care. 460 00:29:27,415 --> 00:29:31,295 Um, I'm, I'm worried about the vaccines for children program. 461 00:29:31,715 --> 00:29:36,215 I'm worried about state and local health departments being able 462 00:29:36,215 --> 00:29:38,675 to provide even basic functions. 463 00:29:38,675 --> 00:29:44,555 And just in the last couple of days, um, CDC, it appears, has been unable to 464 00:29:44,795 --> 00:29:49,625 respond to a request for help from I think it was Wisconsin that was asking for help 465 00:29:49,625 --> 00:29:52,615 with an issue with lead contamination. 466 00:29:52,675 --> 00:29:55,385 And CDC did not have the manpower to do it. 467 00:29:55,385 --> 00:29:58,655 There is so much that we need to fix. 468 00:29:58,655 --> 00:30:02,615 So much that has gone wrong just in the last couple of months. 469 00:30:02,705 --> 00:30:07,775 Um, and I mean, like I, I'm an ID person, I'm a vaccine per, like, 470 00:30:07,775 --> 00:30:09,455 that's the stuff I think about most. 471 00:30:09,455 --> 00:30:12,995 But it, it's, in terms of child health, it just goes way beyond that. 472 00:30:13,595 --> 00:30:13,895 Yeah. 473 00:30:14,765 --> 00:30:15,095 Yeah. 474 00:30:15,095 --> 00:30:18,635 And I feel like we're feeling it in our, our patients too. 475 00:30:18,635 --> 00:30:22,752 I had, I spent a really long time talking to someone about measles vaccination 476 00:30:22,752 --> 00:30:25,272 yesterday because she has young kids. 477 00:30:25,272 --> 00:30:29,377 And, she had perceived from the news like, well, how would I know 478 00:30:29,377 --> 00:30:30,817 if there's measles in my community? 479 00:30:30,817 --> 00:30:34,327 What if there aren't people who are surveilling and, and 480 00:30:34,327 --> 00:30:37,957 communicating that there's a case and that I should be worried? 481 00:30:37,957 --> 00:30:42,997 And, um, it, it really is causing everyone across the board so much anxiety. 482 00:30:43,427 --> 00:30:43,727 Yeah. 483 00:30:43,727 --> 00:30:48,317 And I, I think there's worry about that even in Texas now, with the cuts to 484 00:30:48,317 --> 00:30:52,817 local health departments, they've had to scale back on vaccination clinics. 485 00:30:52,847 --> 00:30:54,587 I don't know the state of surveillance there. 486 00:30:54,587 --> 00:30:58,592 I mean, we're still getting updates from them, but I, I hope that 487 00:30:58,952 --> 00:31:00,752 robust testing is still available. 488 00:31:00,837 --> 00:31:04,922 I, I think we all think that the case numbers that are being reported 489 00:31:04,922 --> 00:31:07,562 are, are a vast underestimate. 490 00:31:07,562 --> 00:31:08,792 That's my understanding. 491 00:31:08,912 --> 00:31:12,502 Um, and so I, I worry about our ability to get good data. 492 00:31:12,681 --> 00:31:13,071 Yeah. 493 00:31:13,071 --> 00:31:17,721 And so usually at the end I open it up to see if there are additional points, but 494 00:31:18,111 --> 00:31:22,791 maybe today we can pivot and, and focus a little bit on just asking if you wanted 495 00:31:22,791 --> 00:31:25,281 to share something that you love about ID. 496 00:31:25,281 --> 00:31:29,061 You know, we focused a little bit on, on things that have felt like 497 00:31:29,061 --> 00:31:32,301 setbacks and things that we wanna improve, but I thought it would 498 00:31:32,301 --> 00:31:36,891 be nice to sort of reorient as we close out on a, on a positive note. 499 00:31:37,351 --> 00:31:41,011 Yeah, I mean, I, I still, there are challenges, but I still 500 00:31:41,371 --> 00:31:43,201 love taking care of patients. 501 00:31:43,201 --> 00:31:44,371 I love being on service. 502 00:31:44,371 --> 00:31:50,011 I love the puzzles of ID, I love getting to work with trainees. 503 00:31:50,041 --> 00:31:56,361 Um, I feel very, very lucky to still have a career where I get to combine 504 00:31:56,886 --> 00:32:03,546 research and teaching and seeing patients and, uh, you know, I write on the side. 505 00:32:03,546 --> 00:32:08,196 And so it's been, you know, it, it's all around the theme of, of infectious 506 00:32:08,196 --> 00:32:13,266 diseases, but I've just, I feel very lucky to have been able to be part of that 507 00:32:13,266 --> 00:32:15,186 and to still be able to be part of that. 508 00:32:15,996 --> 00:32:22,721 Yeah, I guess I should ask, any tips for folks to be more active writers, 509 00:32:22,771 --> 00:32:26,581 you know, you wrote this, this book, and we often talk about struggling to, 510 00:32:26,581 --> 00:32:32,851 to fit writing into our academic life, but you know, it tips that you've used. 511 00:32:33,254 --> 00:32:36,914 Yeah, if I, I, not easy. 512 00:32:37,124 --> 00:32:41,039 Um, it, it's, you know, I started writing this book in 2019. 513 00:32:41,279 --> 00:32:45,599 Um, you know, at the, at sort of the tail end of the, the New York City outbreak 514 00:32:45,599 --> 00:32:51,359 before anyone had ever heard of, of Covid, I decided I wanted to write a book about 515 00:32:51,359 --> 00:32:57,269 measles because I'd learned so much in the outbreak, and it, you know, it, it 516 00:32:57,269 --> 00:32:58,559 changed the way I thought about measles. 517 00:32:58,559 --> 00:33:03,344 It changed the way I thought about vaccines and the anti-vaccine lobby. 518 00:33:03,344 --> 00:33:07,694 And I, I thought it was this great metaphor for, you know, many things 519 00:33:07,694 --> 00:33:09,344 that were going on in children's health. 520 00:33:09,734 --> 00:33:14,264 And I, you know, I, I told my wife, who's also a physician that I, I, I think 521 00:33:14,264 --> 00:33:15,854 I'm gonna write a book about measles. 522 00:33:15,914 --> 00:33:17,834 And she was like, that's great. 523 00:33:17,864 --> 00:33:20,024 Why would anyone read a book about measles? 524 00:33:21,554 --> 00:33:23,054 And I was like, okay, fair enough. 525 00:33:23,504 --> 00:33:31,004 Um, and like I started working on it and, and then we had covid and 526 00:33:31,034 --> 00:33:37,244 it's that, once again changed how I thought about ID and, you know, 527 00:33:39,374 --> 00:33:42,974 everything really, you know, it, it changed the way that we worked. 528 00:33:42,974 --> 00:33:48,284 It changed the way that I thought about public health and I, you know, 529 00:33:48,284 --> 00:33:52,454 it also changed how I was thinking about this book and about measles, and 530 00:33:52,454 --> 00:33:58,244 I tried to incorporate what I thought that measles could have taught us 531 00:33:58,829 --> 00:34:04,739 that would've been useful in in the setting of the Covid pandemic and. 532 00:34:06,404 --> 00:34:08,834 You know how to fit writing it. 533 00:34:08,834 --> 00:34:13,154 It took me years to write this, but it took four years, give 534 00:34:13,154 --> 00:34:15,224 or take to to write the book. 535 00:34:15,284 --> 00:34:20,474 I am so lucky that I had this project though during Covid because I feel like 536 00:34:20,504 --> 00:34:26,414 everyone needed something that wasn't just taking care of patients and going to work 537 00:34:26,414 --> 00:34:32,069 and coming home from work and worrying about my family and, and you know, all 538 00:34:32,069 --> 00:34:34,499 the other things that we were all doing. 539 00:34:34,499 --> 00:34:36,569 And this was my project. 540 00:34:36,629 --> 00:34:41,819 Um, and it's a little weird that my project to take me away from a pandemic 541 00:34:41,819 --> 00:34:43,589 was reading about old pandemics. 542 00:34:43,679 --> 00:34:45,959 But, but it was, but it worked. 543 00:34:46,919 --> 00:34:52,049 Um, and I, it took me longer than I thought to write, in part 544 00:34:52,049 --> 00:34:56,069 because I kept getting pulled into more and more covid things. 545 00:34:56,459 --> 00:35:03,829 Um, but it also helped me get through the challenges of Covid to have that project. 546 00:35:04,129 --> 00:35:06,259 There were points along the way. 547 00:35:06,259 --> 00:35:07,459 It, it was a small number. 548 00:35:07,459 --> 00:35:12,319 It was probably two or three points along the way where I really needed to push 549 00:35:12,379 --> 00:35:16,579 to get, you know, a final draft done or to get final edits done or something. 550 00:35:16,849 --> 00:35:22,054 And my dog and I left and we went somewhere together 551 00:35:22,114 --> 00:35:23,854 and it was the two of us. 552 00:35:23,854 --> 00:35:27,154 And we worked on the book for a few days, and then we came home. 553 00:35:27,694 --> 00:35:28,174 Um, and 554 00:35:28,204 --> 00:35:28,624 Nice. 555 00:35:28,804 --> 00:35:32,854 because my, my, you know, my child is an adult now, and I could do the, 556 00:35:32,854 --> 00:35:36,814 you know, I had the privilege of being able to, to do that, but that. 557 00:35:37,729 --> 00:35:38,989 You know, that helped me a lot. 558 00:35:38,989 --> 00:35:42,739 What I learned about myself as, as a writer, was that I could fit 559 00:35:43,069 --> 00:35:47,779 doing background research and, and drafting some things into my 560 00:35:47,779 --> 00:35:51,589 schedule, because those were things that I could do with 15 minutes 561 00:35:51,589 --> 00:35:53,539 here or half hour there if I had it. 562 00:35:53,959 --> 00:35:58,789 Um, but that there were times when I really needed to, to sit and focus, and 563 00:35:58,789 --> 00:36:01,159 I, I was lucky that I was able to do that. 564 00:36:02,254 --> 00:36:02,644 Yeah. 565 00:36:02,824 --> 00:36:03,424 And it's true. 566 00:36:03,424 --> 00:36:07,144 I feel like it's, some people are really good at scheduling, you know, 567 00:36:07,144 --> 00:36:10,954 times that fit into other things, but sometimes I'm the same way. 568 00:36:10,954 --> 00:36:15,784 I often need kind of a dedicated chunk, um, to, I think mostly for 569 00:36:15,784 --> 00:36:17,464 me to sort through my own thoughts. 570 00:36:18,969 --> 00:36:24,999 Yeah, it's, it's very hard because there, there will never be a time when 571 00:36:25,179 --> 00:36:30,099 my to-do list gets to zero, as I imagine is true for everyone listening to this. 572 00:36:30,579 --> 00:36:34,599 You know, like, I'm never gonna clear the decks and, and be like, okay, 573 00:36:34,599 --> 00:36:36,549 now I can finally sit down and write. 574 00:36:36,609 --> 00:36:42,219 Like, it has to be something that makes it onto that list where, you know, yes. 575 00:36:42,219 --> 00:36:43,959 I mean, some people say, you know. 576 00:36:44,249 --> 00:36:48,209 Make sure you have 15 minutes, 30 minutes every single day. 577 00:36:48,899 --> 00:36:50,279 That didn't happen for me. 578 00:36:50,579 --> 00:36:54,239 Um, but, you know, if I'm on service, I'm not sitting and 579 00:36:54,239 --> 00:36:56,399 doing 30 minutes of writing a day. 580 00:36:56,399 --> 00:36:58,079 I'm, I'm on service all the time. 581 00:36:58,079 --> 00:37:02,214 But I, you know, during times when I wasn't, during times when I could 582 00:37:03,209 --> 00:37:04,574 carve out little pieces, I, I did. 583 00:37:04,854 --> 00:37:10,404 Well thank you so much for coming today and, uh, talking to the Febrile audience. 584 00:37:10,692 --> 00:37:14,142 No, I'm just really grateful to have the chance to to be here. 585 00:37:14,142 --> 00:37:16,841 Thank you for inviting me and this was super 586 00:37:17,198 --> 00:37:20,108 So a big thanks to Adam for joining Febrile Today. 587 00:37:20,407 --> 00:37:23,767 Be sure to check out his book, booster Shots, the Urgent Lessons 588 00:37:23,767 --> 00:37:27,997 of Measles and the Uncertain Future of Children's Health, available now. 589 00:37:28,777 --> 00:37:32,347 As we mentioned earlier, you can check out our prior episode on 590 00:37:32,557 --> 00:37:37,487 measles called Rubeola Response, episode number 1 0 2 of Febrile. 591 00:37:37,607 --> 00:37:42,377 And then stay tuned for two more episodes related to Vaccine preventable diseases. 592 00:37:42,829 --> 00:37:46,369 Please check out the website febrile podcast.com, where you'll find the consult 593 00:37:46,369 --> 00:37:50,029 notes, which are written supplements to the episodes with links to references, 594 00:37:50,449 --> 00:37:53,449 our library of ID infographics, and a link to our merch store. 595 00:37:54,199 --> 00:37:57,919 PEP is produced with support from the Infectious Diseases Society of America. 596 00:37:58,474 --> 00:38:01,204 Please reach out if you have any suggestions for future shows or 597 00:38:01,204 --> 00:38:02,854 wanna be more involved with febrile. 598 00:38:03,244 --> 00:38:04,084 Thanks for listening. 599 00:38:04,144 --> 00:38:05,619 Stay safe and I'll see you next time.