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Experts provide community physicians treating HIV with practical advice for screening, diagnosing, and managing patients with HIV.

HIV Treatment Advice for Community Physicians

Along with a 1 reported case in Massachusetts, the

New Hampshire Department of Health and Human Services (DHHS) has confirmed a person infected with eastern equine encephalitis (EEE) has died. The public health agency said the person was hospitalized due to severe central nervous system disease. The last reported human EEEV infection in New Hampshire was in 2014, when DHHS identified 3 human infections, including 2 fatalities. In the same statement, DHHS mentions there has been 1 confirmed case in Vermont this summer.

On August 16, the Massachusetts Department of Public Health (MDPH) released a statement discussing the confirmation of the first human case of EEE in the state this year. The confirmed case was discovered in an 80 year old man who was exposed to the vector borne disease in Worcester County. As a result, the risk level in the local communities of Douglas, Oxford, Sutton, and Webster has been raised to critical, and in Dudley, Northbridge, and Uxbridge the risk is increased to high.

Additionally, the neighboring communities of Auburn, Charlton, Grafton, Leicester, Mendon, Millbury, Millville, Southbridge, and Upton are now considered at moderate risk according to MDPH.

“This is the first time we have seen a person infected with EEE in Massachusetts since 2020,” Public Health Commissioner Robbie Goldstein, MD, PhD, said in a statement. “EEE is a rare but serious disease and a public health concern. We want to remind residents of the need to protect themselves from mosquito bites, especially in areas of the state where we are seeing EEE activity.

Though very rare, EEE is serious and a potentially fatal disease that can affect people of all ages. EEE is generally spread to humans through the bite of an infected mosquito. There were 12 human cases of EEE in Massachusetts in 2019 with 6 deaths, and 5 human cases with 1 death in 2020. There were no human cases of EEE in Massachusetts in 2021, 2022, or 2023.

EEE has a fatality rate of 33% to 70%, with most deaths occurring 2–10 days after the onset of symptoms.

In addition to a high mortality rate, long-term physical and mental complications, including permanent neurological deficits have been identified in many people who survive EEE.

Plymouth is approximately 40 miles south of Boston along the coast, and Worcester County is in the middle of the state, so the 2 areas are not in close proximity, but due to the elevated risk locally, the town of Plymouth decided to take action in response to outdoor parks. As of last Friday, all town public parks and fields are close daily from dusk until dawn.

“As Mass DPH has now elevated Plymouth’s EEE risk status to high, it is important to take extra precautions when outdoors and follow state and local health guidelines to avoid unnecessary risk to exposure to EEE. The health and safety of our community, residents, and visitors remain our priority,” Plymouth’s Commissioner of Health and Human Services, Michelle Bratti, said in a statement.

According to the Centers for Disease Control and Prevention (CDC) most people who are infected with the virus do not develop symptoms; however, for those that do, the date from the bite to the onset of the illness is 4 to 10 days. EEE can also result in fever or neurologic disease. The type of illness will depend on the age of the person and other factors. Those who are infected can develop meningitis.

There are no FDA-approved treatments for EEE and for patients who develop severe cases, they can be hospitalized to receive supportive treatment.

Over the weekend, MDPH detailed plans of spraying for mosquitos including aerially in areas of Plymouth County, and truck-mounted spraying in parts of Worcester County. As of Saturday, 10 communities in Massachusetts were raised to high or critical risk for EEE virus.

“The risk from EEE is high in parts of Plymouth County and critical in parts of Worcester County,” State Epidemiologist Catherine M. Brown, DVM, said in a statement. “In addition to recommending that people use mosquito repellent with an EPA-registered active ingredient and clothing to reduce exposed skin, we also recommend that evening outdoor events be rescheduled to avoid the hours between dusk and dawn. The mosquitoes most likely to spread EEE are most active during the dusk to dawn hours.”

There are preventative strategies to avoid EEE, and the MDPH has listed such measures 

For those who live in Massachusetts and want more information on EEE, it can be found 

 or by calling the DPH Division of Epidemiology at 617-983-6800.

1.NH DHHS Identifies Person Infected with Eastern Equine Encephalitis Virus in New Hampshire.The New Hampshire Department of Health and Human Services. August 27, 2024. Accessed August 28, 2024.
https://www.dhhs.nh.gov/news-and-media/nh-dhhs-identifies-person-infected-eastern-equine-encephalitis-virus-new-hampshire
2. State health officials announce season’s first human case of Eastern Equine Encephalitis in Massachusetts. MDPH. August 16, 2024. Accessed August 27, 2024.
https://www.mass.gov/news/state-health-officials-announce-seasons-first-human-case-of-eastern-equine-encephalitis-in-massachusetts
3.Plymouth to Close all Public Parks and Fields from Dusk to Dawn. Town of Plymouth. August 23, 2024. Accessed August 27, 2024. PDF.
4. Eastern Equine Encephalitis: Symptoms, Diagnosis, and Treatment. CDC. May 15, 2024. Accessed August 27, 2024.
https://www.cdc.gov/eastern-equine-encephalitis/symptoms-diagnosis-treatment/index.html
5. State officials announce plans to spray for mosquitoes in sections of Worcester and Plymouth counties due to EEE. MDPH. August 24, 2024. Accessed August 27, 2024. 
https://www.mass.gov/news/state-officials-announce-plans-to-spray-for-mosquitoes-in-sections-of-worcester-and-plymouth-counties-due-to-eee



The town of Plymouth decided to prohibit people from using the parks from dusk to dawn due to concerns over eastern equine encephalitis after a man contracted the rare disease in the state.

Concerns Over Mosquito-Borne Illness Causes Massachusetts Town to Create Curfew for Parks, Spraying in Counties

Diane Shader Smith discusses her daughter and AMR advocacy.

Honoring Her Daughter’s Legacy After a Long-Standing Battle With Antimicrobial Resistance

Mallory Smith was diagnosed with cystic fibrosis (CF) when she was 3 years old, explained her mother, Diane Shader Smith, but it did not become problematic until the pathogen 

 was found in her lungs when she was 12 years old.

When people with CF become colonized with a bacteria such as 

, they are often put in a situation where it becomes a revolving door of medical encounters including hospitalizations, lung treatments, and antibiotic therapy. Unfortunately, antibiotic treatment can see diminishing returns as previously effective therapies are no longer working against the bacteria and a greater antimicrobial resistance is seen against a pathogen that never leaves the lungs.

“Over time, they told us that the antibiotics would stop working. And they started with single ones, and then they did synergistic connections to try to put different drugs together, and the cocktails eventually stopped working,” Smith said.

Through the years, Mallory had been hospitalized to treat infections and, eventually, she became a candidate for a double-lung transplant. She had a successful surgery, but even with new lungs, the pathogen was back and sadly, Mallory succumbed to AMR at the age of 25. 

Diane is a publicist by profession, and wanted to give the general public more information about AMR. Although her family lived through it for years, she didn’t realize the magnitude of AMR until after Mallory’s death.

“The most important thing that I try to communicate is that we have global health leaders all over the world working on this problem, but lay people and the mainstream public don't understand it,” Diane said. “I consider myself a bridge between those who are working in the silos, the inner sanctums, really seriously addressing the problem and getting the information out to people.”

Since getting involved in advocacy, she has given hundreds of presentations to different walks of life to everyone—from high school kids to grandparents—to let them know the scope and severity of the problem. Along with her talks, she has been involved in getting Mallory’s memoir, 

, published after her death, and a documentary with the same name about her daughter’s experience.

, which allows people to tell their individual medical stories about AMR.

Despite a growing spotlight around AMR, she says it is hard for everyone to see this as one major issue. “We're trying to push the global AMR diary as a way to get people to engage with the stories—to connect. But, it's challenging because it's an amorphous problem that people don't really understand,” Smith said.

In the first part of this interview, Smith discusses her mission for building AMR awareness, her daughter’s battle with cystic fibrosis, and her advocacy initiatives. 

 will be running the second part of this interview in the coming days.

After Diane Shader Smith lost her daughter, Mallory, to a multidrug resistant infection, she turned her personal tragedy into a mission designed to inform people about antimicrobial resistance (AMR), and have the public coalesce around this expanding medical issue.  

Conferences

The Infectious Diseases Society of America (IDSA)’s Amanda Jezek offers some insights on the prospective bill in Congress as well as other AMR initiatives the organization is involved in.

A Pasteur Act Update

The Pasteur Act has been in Congress for a few years now, seemingly in a holding pattern. This bill authorizes the Department of Health and Human Services (HHS) to enter into subscription contracts for critical-need antimicrobial drugs, provides $6 billion in appropriations for activities under the bill, and contains other related provisions.

 Last year, Senators Michael Bennet (D-CO) and Todd Young (R-IN) and Representatives Drew Ferguson (R-GA) and Scott Peters (D-CA), 

reintroduced the Pasteur Act in Congress.

 The bill was initially introduced in Congress by Bennet and Young in September 2020; the pair, along with Representatives Mike Doyle (D-PA) and Ferguson, then reintroduced the bill in June 2021.

After the bill’s reintroduction last year, 5 national organizations—the Biotechnology Innovation Organization, the Cystic Fibrosis Foundation, the Infectious Diseases Society of America (IDSA), the Partnership to Fight Infectious Disease, and The Pew Charitable Trusts—issued a statement on the topic. “Antimicrobial resistance is not a partisan issue. It is an increasingly challenging public health emergency that reverberates far beyond just health care settings. Every 15 minutes, a person in the United States dies from an infection resistant to treatment with existing antimicrobial drugs. This means that since PASTEUR’s last introduction on June 16, 2021, more than 64,000 Americans have died because they did not have adequate medications to treat their infections,” part of the statement read.

, held in Philadelphia, Pennsylvania, Amanda Jezek, the senior vice president for Public Policy and Government Relations at IDSA, is participating in sessions, serving as chairperson of Impact, Policy, and Awareness, as well as participating on a panel around antimicrobial resistance (AMR).

In between activities at the meeting, Jezek sat down with 

 to offer some Washington insider updates on the prospective bill, as well as provide feedback about ongoing AMR initiatives that IDSA is working on.

Jezek does believe the Pasteur Act will pass and says it is better to do so now than deal with the consequences of increased mortality rates and the inability to perform procedures due to concerns over AMR. “I think it has to; the stakes are too high,” Jezek said. “Right now we are trying to convince Congress to do the right thing, and pass this while we have a little bit of lead time to protect modern medicine.” 

Jezek says that along with being a major supporter of the Congressional bill, IDSA is involved in other AMR-related activities including the US national plan to address AMR, and the United Nation’s meeting at the end of this month looking at AMR and a One Health approach. “IDSA has been really excited to have multiple opportunities to be able to brief UN leaders and other experts who are involved in this process.” 

Reference
1. Summary: S.1355 — 118th Congress (2023-2024). Congress.gov. Accessed September 5, 2024. https://www.congress.gov/bill/118th-congress/senate-bill/1355

Amanda Jezek, of the Infectious Diseases Society of America (IDSA), offers some insight on the prospective bill in Congress, as well as other AMR initiatives the organization is involved in.

An Update on the Pasteur Act 

At this week’s World AMR Congress, Benjamin Park, MD, senior advisor for Global Programs, Division of Healthcare Quality Promotion, CDC’s National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), participated on a panel, titled, The Role of ID Surveillance to Reduce AMR. During the conference, Park spoke to 

 and he provided information on the agency’s involvement in AMR, including some of its initiatives and educational resources.

 In terms of the scope of the problem, can you talk about the importance of AMR as a public health issue?


 Antimicrobial resistance is an urgent global public health threat. It has the potential to affect people at any stage of life, regardless of health status, and threatens our progress in health care, food production, and life expectancy. Antimicrobial resistance already affects all regions of the world. It is estimated to kill at least 1.27 million people worldwide each year, more than HIV/AIDS or malaria. Most of these deaths are occurring in low- and middle-income countries, especially sub-Saharan Africa.

Antimicrobial resistance happens when germs like bacteria or fungi develop the ability to defeat one or more of the drugs designed to kill them. Infections caused by antimicrobial-resistant germs can be difficult, even impossible, to treat. It can complicate nearly every health problem—from chronic conditions to infectious diseases. Modern medicine depends on antibiotics, including for joint replacements, organ transplants, cancer therapy, and the treatment of chronic diseases like diabetes, asthma, and rheumatoid arthritis.

When antibiotics and antifungals lose their effectiveness, we lose the ability to treat infections and control these public health threats. Everyone should have antibiotics and antifungals that work when they are needed.

 You are on a panel at the World AMR Congress discussing the role of infectious disease clinicians and AMR. Can you talk about the strategies providers can employ to prevent resistance?


CDC leads US public health efforts to combat antimicrobial resistance in support of the 

The US National Action Plan for Combating Antibiotic-resistant Bacteria, 2020-2025

 supports domestic and global programs to track infections, respond to outbreaks, and prevent infections, while building strong local relationships between public health and healthcare facilities that facilitate the implementation of actionable prevention strategies locally. Our goal is to protect people, animals, and our shared environment by preventing the spread of existing and emerging antimicrobial-resistant threats in, and into, the United States.

Prevention must be our first defense against antimicrobial resistant germs. Healthcare providers play an essential role in preventing infections and stopping the spread of germs. They can help protect patients and communities with 

Follow infection prevention and control guidelines and access training resources, including screening at-risk patients when indicated.

Ensure your patients receive recommended vaccines. Talk to them and their families about:

Seeking medical care when an infection is not getting better.

Understanding when antibiotics and antifungals are needed.

Educate patients on ways to prevent spread of germs and infections, for example share 

ways to be a safe patient while in the hospital

Ask patients if they have recently traveled or received care in another facility. Germs can spread easily when people move.

Alert the receiving facility when transferring patients who are colonized or infected with antimicrobial-resistant pathogens.

CDC leads the US public health efforts to combat antimicrobial resistance with a global, One Health approach. The agency’s prevention efforts span healthcare settings, communities, the food supply, and the environment such as water and soil. Through CDC’s 

Antimicrobial Resistance Solutions Initiative

, the agency invests in national infrastructure to detect, respond, control, and prevent antimicrobial-resistant infections. CDC supports efforts to slow the spread of resistance in all 50 state health departments, several local health departments, Puerto Rico, Guam, and the US Virgin Islands.

CDC is also supporting innovative antimicrobial resistance projects and programs in more than 50 countries throughout the world to improve antibiotic and antifungal use, track resistance, and slow the spread of untreatable infections through infection prevention and control activities. Many of these investments, including CDC’s Global AR Laboratory and Response Network, and CDC’s Global Action in Healthcare Network, are highlighted in the 

Benjamin Park, MD, offers insights on the federal agency’s role in AMR.

CDC’s Role in Antimicrobial Resistance

Jennifer Ronholm discusses agriculture and antibitoics

Agriculture and Antibiotics: Trying to Protect the Former and Preserve the Latter

One of the ongoing, major issues associated with antimicrobial resistance is that massive amounts of antibiotics are used in agriculture. In 2020, approximately 160,000 tons of antibiotics were fed to farm animals in the United States alone.

Along with the sheer numbers that the agricultural industry is utilizing, the other aspect is the potential misuse, which can lead to resistance. A majority of the time, antibiotics are administered indiscriminately through animals’ feed and water supplies.

According to the FDA’s 2019 summary report on Antimicrobials Sold or Distributed for Use in Food-Producing Animals, the domestic sales and distribution of medically important antimicrobials approved for use in food-producing animals for 2019 included:

“An estimated 41% was intended for use in cattle, an estimated 42% intended for use in swine, an estimated 10% intended for use in turkeys, an estimated 3% intended for use in chickens, and an estimated 4% intended for use in other species/unknown.

Tetracyclines accounted for 67%, penicillins for 12%, macrolides for 8%, sulfas for 5%,aminoglycosides for 5%, lincosamides for 2%, cephalosporins for less than 1%, and fluoroquinolones for less than 1%.

An estimated 81% of cephalosporins, 65% of sulfas, 45% of aminoglycocides, and 42%of tetracyclines were intended for use in cattle.

An estimated 85% of lincosamides and40% of macrolides were intended for use in swine. An estimated 66% of penicillins were intended for use in turkeys.”

“We can't just stop farming without antibiotics tomorrow, because we still have to eat every day and without antibiotics, food prices would go up, and productivity would go down,” said Jen Ronholm, PhD, associate professor, McGill University and Canada research chair in agricultural microbiology. “We'd have shortages of a lot of things that we need. So, it's really bridging that gap to come up with the novel technologies that don't currently exist to be able to farm effectively and not affect human health through over consumption of antibiotics.”

Looking for novel ways to reduce antibiotics in the agricultural industry has been an area of focus for Ronholm. She has been studying the microbiome and how it can help reduce the need for antibiotics in animals.

“What we're trying to do is come up with ways that we can still farm effectively without using those antibiotics,” Ronholm said. “And we're trying to do this through manipulating the microbiome of animals so making it really resist to infections so we don't need those antibiotics in agriculture, and that would have the effect of lowering usage and saving the antibiotics for human use.” 

Ronholm says she and her coinvestigators are looking to identify what a “healthy” microbiome is, and what a microbiome that might be susceptible to bacterial infections looks like. They are exploring down to the species level, which means they are looking to identify members of the microbiome that are protective against different types of infection so that these bacteria can be investigated as potential probiotics to prevent these types of infections.

In humans, studies have been ongoing looking at the gut and how the microbiome can affect overall health. One area of study has been around the microbiome and treatment for 

 using this concept have been FDA approved to help patients with recurrent bouts of the infection.

, Ronholm made a presentation titled, Precision Microbiome Engineering as an Alternative to Antibiotics to Prevent Bacterial infections in Agriculture. She sat down with 

 to discuss her ongoing work in this area.

She believes there is a lot of potential to understanding the microbiome in agriculture with better benefits.

“It has a lot of potential in agriculture, specifically because you control everything about the animals: you control their environment, you control their food. So, it might actually be more effective in agriculture than in humans.”

Jennifer Ronholm, PhD, discusses the novel concept of microbiome protection to create healthier animals and reduce antimicrobial usage. 

Kate Broderick, PhD, molecular geneticist,  discusses  the mRNA capping technology.

mRNA Capping: A Component That Protects the COVID-19 Vaccine and Lends to its Effectiveness

mRNA capping is a specific technology that is little known or discussed, outside of vaccine development. Capping is utilized in 100% of approved COVID-19 mRNA vaccines, and 75% of them are using CleanCap mRNA capping technology.

mRNA capping is a specialized structure placed in the beginning of the mRNA molecule, acting like a protective shield, and enabling it to generate the desired therapeutic effect.

It helps in the delivery and efficacy of vaccines.

“One of the downsides to mRNA is the fact that it's really not the most stable molecule, but there are things that you can do in the design of that molecule to really enhance its stability, to really make it a more effective molecule, just through the design of the molecule itself. And that's really where mRNA capping comes into. So if you can envision the mRNA molecule a little bit like a car, then you can think of the mRNA cap as the front bumper on the front of the car. And that's really there to protect the car or the molecule itself; in this case, from being broken down or being degraded,” said Kate Broderick, PhD, chief innovation officer, Maravai LifeSciences in an interview with 

. She says another role the capping provides is to serve as a GPS. “The cap also helps position the molecule when it needs to be in the cell.”

TriLink Biotechnologies is a subsidiary of Maravai and is looking to improve the mRNA capping platform. One of its signature products is titled the CleanCap, and the technology offers a 5-inch cap structure that is integral to the stability, expression, and immunogenicity of an mRNA product. According to the company, the technology offers: 1-pot co-transcriptional capping strategy; mRNA with an optimal Cap 1 structure; and over 95% capping efficiency. Additionally, co-transcriptional capping with this technology overcomes the limitations of legacy capping methods.

Broderick was part of teams that helped to create successful vaccines for Ebola, Zika, Lassa fever, and MERS before tackling COVID-19. In early 2020, she was invited to take part in the first emergency meeting of the World Health Organization (WHO) about what was then called the novel coronavirus. Broderick was part of a small group of scientists from around the world to go to Geneva, Switzerland for a 2-day meeting. “At that point in time, it was February 2020, so it was all still very much China-focused at that time, but it was really to better understand the virus as we knew it at that time, and really take that back to our respective countries, and how we might apply that to coming up with new vaccine designs, and how we could apply that to better preparing our countries for the potential of the pandemic,” Broderick said.

This year, Broderick was named one of the Top 25 Biotech Executives of 2024 for the Healthcare Technology Report. 

about the exciting aspects of the capping platform, mRNA technologies, and what the field is working on to deliver targeted vaccines and therapies.

1. 5 Things to Know About mRNA Capping for Next-Generation Vaccines and Therapies. NIH. May 23, 2024. Accessed August 10, 2024.


https://crex.nih.gov/blog/2024/05/23/5-things-to-know-about-mrna-capping-for-next-generation-vaccines-and-therapies

Kate Broderick, PhD, molecular geneticist, discusses the mRNA capping technology and how it helps create stability to mRNA molecules within vaccines and guides them to cells.

Eric S. Daar, MD

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