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In this narrative review of studies evaluating antiretroviral stewardship programs (ARVSPs), we propose core elements for ARVSPs that are based on published evidence, clinical experience, and adapted from antimicrobial stewardship programs.

Antiretroviral Stewardship: The Time is Now

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

the panel weighs in on treatments not specifically indicated for COVID-19 treatment, including metformin, and concerns around using medications in this way.

COVID-19 Roundtable: Considering Off Label COVID Therapies

During the earliest stages of the pandemic, and before the development of antivirals and other therapies, clinicians were struggling to find ways to treat their patients. As providers began to use off-label treatments, small studies began to surface around various therapies including hydroxychloroquine, the antimalarial therapy, and the antibiotic, azithromycin. One published paper found these 2 therapies used in combination could help reduce viral loads.

And while clinicians quickly realized these therapies were not reducing symptoms or mortality, both disinformation and misinformation was prevalent enough and making the therapies out to be wonder drugs. These therapies’ efficacy for COVID-19 treatment were debated on social media for way too long.

Just this week, that aforementioned paper about hydroxychloroquine and azithromycin was finally retracted.The paper had been published in the 

International Journal of Antimicrobial Agents

 back in 2020, and the lead author was Philippe Gautret of the Hospital Institute of Marseille Mediterranean Infection. In the paper, it was claimed that hydroxychloroquine was able to reduce virus loads in COVID-19 patients, and that used in combination with azithromycin, was even more effective.

This year, there has been some studies looking at metformin as an off-label treatment for COVID-19. However, with limited data showing efficacy and potential adverse effects, our roundtable panel believes it is better to prescribe FDA approved therapies.

“I don't think there's an overwhelming amount of data that would support it. With metformin, there were two studies together that pretty much showed it wasn't effective,” said Michael Curulewski, PharmD, BCPS, BCIDP, BCGP infectious diseases and antimicrobial stewardship pharmacist, Endeavor health, Northwest Community Hospital. “One thing to keep in mind is anytime that we use an off-label therapy or a therapy that's not supported by a large amount of data, [or even] the safety profile is a major one for me—because a lot of the medications are not benign. Metformin, for example, we have to watch out for patients who have renal dysfunction, IV contrast exposure, and drug-drug interactions. So, without that data to support it, I would say I don't routinely endorse or recommend off-label therapies.”



This is episode 3 of our 4-part series. Check back for the last episode next week.

Reference
1. O’ Grady C. Infamous paper that popularized unproven COVID-19 treatment finally retracted. 

December 17, 2024. Accessed December 17, 2024. https://www.science.org/content/article/infamous-paper-popularized-unproven-covid-19-treatment-finally-retracted

In this week's episode, the panel weighs in on treatments not specifically indicated for COVID-19 treatment, including metformin, and concerns around using medications in this way.



Canonical

COVID-19 Roundtable: Should Clinicians Consider Off Label COVID Therapies?

 has increased significantly in rural areas across the US. One study pointed out that the number of cases had more than double in rural areas vs urban areas.

 This increase has also been linked to injection drug use with 75% of the individuals followed in the study having reported engaged in this activity. Much of these developments stem from the prescription opioid crisis with people possibly starting with opioids and progressing to illicit drug use.

Additionally, getting people in rural areas with hepatitis C into the continuum of care can be difficult, especially with limited, nearby medical institutions and programs or having a network of peers who might also be affected with the same affliction.

With these inherent challenges, a new study published recently in the journal,  

 demonstrated the success of getting people who use drugs into the continuum of care for HCV through a community-based peer support telemedicine approach. The study evaluated enlisting people with a lived experience of substance abuse and having them meet others who use drugs, try to get them tested for the blood borne disease and into treatment via telehealth or referral to a physical clinic.

“Rural people who use drugs may be more likely to trust their peers, even when they don’t trust health care providers,” lead author Andrew Seaman, MD, an associate professor of medicine (general internal medicine and geriatrics) in the OHSU School of Medicine, said. 

Peers with a shared drug use experience recruited other people who use drugs (PWUD) in 7 rural counties in Oregon where there were higher incidence rates of hepatitis C and opioid overdoses. 

Study criteria included individuals who were at least 18 years of age or older, lived within the study area, had injected drugs or used non-prescribed opioids within 90 days of screening, and had a detectable HCV. For nearly 2 ½ years, from July 17, 2020 to December 12, 2022, 774 people were screened, with 227 having detectable HCV RNA, and 203 participants were randomized with 100 of the participants assigned to peer-assisted telemedicine hepatitis C treatment (TeleHCV) and 103 participants were placed into the peer-assisted referral to local providers enhanced usual care (EUC).

“Eighty-five percent (85/100) of participants randomized to the TeleHCV arm initiated treatment compared to 13% (13/103) of EUC (RR = 6.70, 95% CI 4.00, 11.30, 

In addition, viral clearance or functional cure, was achieved in 63% of people in the TeleHCV group vs just 16%in the EUC group.

“This study shows the importance of empowering trusted peers to support the health of people who use drugs, and the crucial role telemedicine can play to expand hepatitis C treatment to rural communities...Hepatitis C causes liver cancer, loss of productivity, diabetes and all kinds of complications that cost lives and money. And it’s transmissible, so every time a patient is cured, we also prevent multiple transmissions to other people, Seaman said.”


References
1. Suryaprasad AG, White JZ, Xu F, et al. 

Emerging epidemic of hepatitis C virus infections among young nonurban persons who inject drugs in the United States, 2006-2012

. 2014;59(10):1411-1419. doi:10.1093/cid/ciu643
2. Robinson E. Telehealth plus local peer support boosts treatment success for hepatitis C in rural patients. Oregon Health & Science University News. November 27, 2024. Accessed December 17, 2024. 

https://news.ohsu.edu/2024/11/27/telehealth-significantly-boosts-treatment-success-for-hepatitis-c-in-rural-patients


3. Seaman A, Cook R, Leichtling G, et al. Peer-assisted telemedicine for hepatitis C in people who use drugs: A randomized controlled trial. 

. Published online November 27, 2024. doi:10.1093/cid/ciae520

A study found deploying peers with lived experience in illicit drug use increased the rate of people diagnosed, treated, and cured of the disease.

Peer-Assisted Telemedicine Enables More People With Hepatitis C to Get into the Continuum of Care  

The buzz around AI in the medical industry is impossible to ignore. As service providers and biotech partners race to claim they can harness AI and real-world data (RWD) to tackle challenges like streamlining clinical trial enrollment, a pressing question emerges: How can we separate the genuine game-changers from the empty promises, all while prioritizing patient safety?

Navigating the Line Between Hype and Reality

In this transformative era, discerning the real potential of AI from mere hype is more critical than ever. It’s essential to delve into the ethical implications and the necessity for comprehensive, secure, and representative data to ensure real progress.

Protecting Patient Privacy: The Non-Negotiable Priority

As groundbreaking as AI can be, current laws governing patient data are struggling to keep pace with rapid advancements in technology. Consider the unsettling news of retail algorithms predicting pregnancies before individuals even realize they are expecting. The specter of a similar invasion of privacy looms in the healthcare insurance industry where companies could potentially exploit data to predict genetic predispositions and make coverage decisions.



Ensuring that AI models can be interpreted and understood by healthcare professionals, patients, and regulators is essential for building trust and accountability. So, while regulatory bodies work to catch up, life science brands have a unique opportunity to carve a path of integrity.

The safeguarding of patient data is foundational to AI offerings. For example, by embedding HIPAA-certified de-identification processes from the data ingestion stage, protected health information (PHI) can remain more secure and free from exposure risk. It’s also important to clearly spell out data sourcing, cleansing, and utilization processes to create transparency in your proprietary AI algorithms.

Garbage In, Implicit Bias Out: The Data Dilemma

The integrity of AI outputs directly correlates to the quality of input data. Biased or incomplete datasets can distort analyses and amplify existing disparities in healthcare. For example, clinical trials often favor recruitment from sites that create a narrow data pool which overlooks minority and underserved communities. This lack of representation can lead to solutions that don’t meet the needs of the broader population.

Expanding our horizons to include diverse healthcare data sources, such as physician notes and patient-reported outcomes, paints a comprehensive picture of patient experiences and needs. This holistic view is vital for mitigating biases in AI algorithms and yielding insights that drive equitable healthcare solutions.

Imagine an AI system trained on rich, representative datasets, catalyzing substantial changes in the industry. Picture a world where AI accelerates clinical trials by enhancing enrollment speeds and ensuring diverse participant representation. Envision it analyzing unstructured symptom data to pinpoint physicians specializing in rare diseases, facilitating faster and more accurate diagnoses for struggling patients earlier in their journeys.

Moreover, when it comes to understanding both patient experience and physician sentiment, this type of proprietary insights-rich data coupled with AI, shines where traditional methods falter. Instead of relying solely on time-consuming and often biased focus groups, AI can analyze vast volumes of anonymized data to rapidly unearth real patient challenges, like significant treatment barriers, and unveil “why” physicians make or don’t make certain prescribing choices.

Cutting Through the Noise: Assessing AI's Value

To ensure AI's role transcends mere buzz, all stakeholders who utilize this tool must engage in critical self-reflection and dialogue with their partners. Here are pivotal questions they should consider:

Is the data feeding your AI applications diverse enough to meet FDA guidelines (

Do your AI tools and platforms have mechanisms to detect and rectify errors or biases?

Can you articulate your AI model in straightforward terms?

Are you able to objectively quantify key performance indicators (KPIs) linked to your AI initiatives?

What security and compliance measures do you and your vendors use today and what plans are in place to mitigate future risks of discriminatory uses?

Do you and your partners proactively engage in forums to discuss rapid advancements and potential misuses of AI-generated insights?

Building Trust Through Ethical AI Practices

Trust is the cornerstone upon which the medical industry is built. With robust privacy measures, a commitment to diverse data sourcing, and transparent business objectives, AI has the potential to uplift patients and communities alike. By collaborating through the complexities and nuances, we can unlock a future where AI-driven technologies propel innovative therapies to those who need them most.

Ultimately, it's not just about technology; it's about transforming lives—ensuring that the powerful capabilities of AI create not just economic value, but real, lasting solutions that prioritize the well-being of all patients.



Patient-centered innovation amidst evolving regulations and policies is a key strategy. 

Ethical and Innovative Use of AI in Infectious Disease 

the panel discusses therapies and care around inpatients including mechanical ventilation, extracorporeal membrane oxygenation (ECMO), and remdesivir.

COVID-19 THERAPY Roundtable: Addressing Inpatient Clinical Care

According to the Centers for Disease Control and Prevention, the week ending November 30, 2024, there has been a rate of 0.8 hospitalizations per 100,000 people, and this shows a good downward trend over the last few weeks.

Although the number of hospitalizations have decreased significantly since the beginning of the pandemic, there are waves where incidence rates increase and a number of people who are contracting severe cases of COVID-19 need to be hospitalized.

During the height of the pandemic and before the development of vaccines and therapies, there were therapeutic limitations and patients could be put on mechanical ventilation or extracorporeal membrane oxygenation (ECMO).

ECMO was utilized more frequently in a time when there was not other treatments. And in some select cases, James Wilson, DO, FACP, FAWM, CTropMed, says ECMO did show some benefit, and there might be some select situations where it might be warranted but overall he says treatment protocols have changed considerably since 2020.

“If they're breathing at 40 times a minute for more than an hour, you're going to have to do it [ECMO],” Wilson. “But now we have modalities to treat those patients.”

One of the treatments that emerged was remdesivir for inpatients with severe COVID-19.

“I triage COVID between requiring oxygen and not requiring oxygen,” said Scott Roberts, MD, associate medical director of Infection Prevention, Yale School of Medicine. “And then once you become severe enough to require it, we really start remdesivir as soon as we can in the inpatient setting. And we know from many studies at this point there are reductions in mortality in those who do receive remdesivir. We use it for all really severe patients.”

This is episode 2 of our 4-part series. Check back for future episodes.

Reference
1.COVID Tracker. CDC. Accessed December 10, 2024.
https://covid.cdc.gov/covid-data-tracker/#covidnet-hospitalization-network

In this week's episode, the panel discusses therapies and care involving inpatients, including mechanical ventilation, extracorporeal membrane oxygenation (ECMO), and remdesivir.

COVID-19 Therapy Roundtable: Addressing Inpatient Clinical Care 

Joseph Zackular, PhD, shares insights on his team’s mRNA vaccine research for C. difficile, highlighting progress in animal models and future plans for human trials.

mRNA Vaccine Shows Potential for C difficile Infections

Joseph Zackular, PhD, an assistant professor at the Children's Hospital of Philadelphia and the University of Pennsylvania, is leading research on 

) and the development of an mRNA vaccine. His recent work has shown promise in reducing mortality and improving outcomes for infections caused by this bacterium.

In our recent interview, Zackular discussed how his team used animal models, including mice and non-human primates, to test the vaccine's safety, immunogenicity, and efficacy. 

 has long posed a major public health threat due to its ability to form spores that survive harsh environments, making treatment difficult. Zackular believes the mRNA vaccine could help address this persistent infection, especially for patients with recurrent cases.

The current study builds on promising results from animal models, including mice, where the vaccine showed encouraging efficacy. When asked about the transition from animal to human trials, Zackular emphasized the importance of animal models in understanding immune response, vaccine efficacy, and safety.

“To start with, animal models that recapitulate what we see in humans, so that we can study the immune response, the efficacy of, you know, treatments like vaccines, you know. So ultimately, thinking about safety, thinking about immunogenicity, thinking about the effectiveness of these strategies for taking on a challenging infection like 

," Zackular explained. He further noted that while animal models are valuable, the ultimate goal is to bring these therapies, particularly vaccines, to human trials.

"Our work in animal models was by design using physiologically relevant concentrations of these mRNA vaccines that would be safe for humans, validated by the work done with the COVID-19 vaccines. What we’re working towards now is using other animal models, like hamsters and non-human primates, to assess immunogenicity and safety, and ultimately bring this to phase one clinical trials to evaluate efficacy and safety in humans,” he said.

Zackular is hopeful that results from animal models will be replicated in humans, providing an important tool for addressing 

 is known for its ability to oscillate between a vegetative cell state and a dormant spore form, making it extremely difficult to eliminate. The pathogen's lifecycle, which includes toxin production and spore formation, complicates treatment and prevention efforts.

 is a really challenging and uniquely challenging pathogen for us to take on. It lives a really complex life cycle, and so, 

 is a vegetative cell, so a bacterium that produces two really potent toxins that cause disease, but 

 also makes a spore, and this spore is really, really hard to kill and survive outside of the body, but even when it’s inside the body, it can be really challenging for antibiotics to kill, can be challenging for our own immune systems to kill," Zackular explained.

Despite these challenges, the vaccine developed in his lab has shown the potential to reduce the severity of disease. While it has not yet prevented the initial colonization of 

 in animal models, the vaccine significantly reduced mortality and improved outcomes.

 from being able to colonize and cause infection, but that’s challenging. It's an organism that lives in this relatively hard-to-get-to part of our body, the lumen of the gut, and it doesn’t invade. And so being able to prevent it from colonizing, of course, can be challenging,” Zackular said.

In studies with a highly virulent strain of 

, the vaccine prevented 100% of mortality in mice, which is a remarkable outcome. “What we found is that we aren’t able to prevent the initial colonization and outgrowth of this pathogen. However, we are able to find that we can dramatically stunt the pathogenicity and the disease that's caused by this really problematic infection,” he added.

This vaccine uses the mRNA platform, which has already proven successful in COVID-19 vaccines. Zackular's team has developed a tetravalent vaccine targeting both toxins responsible for 

’s harmful effects and the bacterial cell and spores.

“This mRNA vaccine platform allows us to create multivalent vaccines very readily. And so what we’re able to do in this paper was make a tetravalent vaccine that targets both of the really important toxins that cause disease with 

Joseph Zackular, PhD, shares insights on his team’s mRNA vaccine research for C difficile, highlighting progress in animal models and future plans for human trials.

Sarah M. Michienzi, PharmD

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