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Assistant Professor of Molecular Virology and Microbiology at Baylor.

Sasirekha Ramani, PhD, discusses the potential of 2′FL as a treatment for norovirus and what more research could reveal.

Human Milk Sugar Blocks Norovirus in Lab Models

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

Robert H. Hopkins, Jr, MD, medical director, National Foundation for Infectious Diseases (NFID) provides an update on incidence rates and virus patterns across different regions of the US.

Seasonal Respiratory Virus Season: How Are We Doing Right Now?

The seasonal respiratory virus season in the northern hemisphere runs from October through April. As we are at about the halfway point of the season, we wanted to identify incidence rates and get some guidance from Robert H. Hopkins, Jr, MD, medical director, NFID, on the current state of the virus season focusing on COVID-19, influenza, and RSV.

The latest surveillance report from the Centers for Disease Control and Prevention (CDC) states the infection positivity rate of the 3 viruses remains stable or increased. “Nationally, influenza test positivity is stable at 18.6%. COVID-19 test positivity has remained stable at 6.9%. RSV test positivity increased to 11.6%,” CDC reported on its site.

And the federal agency said the amount of respiratory illness causing people to seek healthcare was characterized as high in the US.

“Nationally, emergency department visits are high for diagnosed influenza and very high for diagnosed RSV. Emergency department visits for COVID-19 are elevated,” CDC reported.

CDC sees the possibility of decline in COVID-19 and influenza based on emergency department visits. 

“As we think about trends, influenza seems to be, maybe peaking out, and starting to decline a little bit. Although, we have to remember this is data that's coming out for the holiday season, so it may be under reporting, but hopefully we see a decline in influenza across most of the US,” Hopkins said.

He also points out that not all the seasonal viruses run in concert.

“You'll often see an increase in influenza and or COVID, kind of in parallel,” Hopkins said. “RSV tends to have a bit of its own pattern. RSV really typically starts in the southeast and spreads rapidly across the country. We're kind of right in the middle of the mix right now, and hopefully we're going to see a decline over the next few weeks. But we don't want to predict that yet. We need to see a little more data.”

This is the first part of a 3-part interview with Hopkins. Next week he will offer his insights on avian influenza and our preparedness around the virus.

Reference
1. Respiratory Virus Activity Levels. CDC. January 13, 2025. Accessed January 17, 2025. https://www.cdc.gov/respiratory-viruses/data/activity-levels.html

George Thompson, MD, offers some insights on 2 studies looking at these antifungals in patients with Candidemia and invasive candidiasis

Rezafungin is Noninferior to Caspofungin For All-Cause Mortality For Candida Infections

deeply into the body and develop into fungal infections, including candidemia and invasive candidiasis. These fungal infections can affect the bloodstream and internal organs. Candidemia, in particular, is a common infection found in hospitalized patients. In addition, there are some specific clinical challenges associated with them.

“There's really 2 major problems with candidemia and invasive candidiasis right now. One of them relies on diagnostics. We often don't make the diagnosis of 

 until several days after the infection has manifested. Blood cultures take a little bit to grow; at a minimum, probably 2 days—and that's improved by PCR availability. So, we do get the diagnosis earlier now, but we have to order the correct test, and that's not always done in clinical care,” said George Thompson, MD, professor of Medicine at the University of California, Davis, School of Medicine. “And the other aspect is, even when we do know the diagnosis, the associated mortality rate of candidemia is still high.”

One antifungal looking to address these infections is rezafungin (Rezzayo), which was 

 in 2023. It is a long-acting, next-generation echinocandin indicated for the treatment of candidemia and invasive candidiasis. Rezafungin was developed by Cidara Therapeutics, and it’s marketed by Melinta Therapeutics and Mundipharma. Melinta acquired the exclusive rights to commercialize the antifungal in the US. Cidara retains the rights to rezafungin in Japan and has licensed the commercial rights to Melinta Therapeutics in the US and Mundipharma in all other geographies.

The FDA’s approval was largely based on positive data from phase 3 clinical trials. Dosed once a week, rezafungin was determined to be statistically noninferior compared to once-daily caspofungin, the current standard of care.

A Long-Acting Injectable for the Treatment of 



Thompson was part of a team of investigators who conducted a pooled analysis of 2 trials—the phase 2 STRIVE and phase 3 ReSTORE studies— and they examined the all-cause mortality at day 30 of patients with these infections.

“In STRIVE, rezafungin was found to be efficacious with a similar safety and tolerability profile to that of caspofungin. In ReSTORE, once-weekly rezafungin (using a dosing regimen of 400 mg and 200 mg) was non-inferior for 30-day all-cause mortality to once-daily caspofungin (70 mg and 50 mg), with a similar safety profile,” the investigators wrote.

One of the important findings that was realized related to the rezafungin dosing regimen as patients treated with this antifungal saw an early benefit.

“It's once a week, so it gets this very high front-loaded exposure more rapidly, clears blood cultures, and probably tissue sites as well,” said Thompson. “In the analysis we saw, the ICU patients actually improved faster in the rezafungin group compared to caspofungin. So all of that makes some sense, I think, just from the PK/PD standpoint, from what we've seen on animal models. And so that was really pretty neat to see it carried forward into the clinical trials and the pooled analysis as well. I think it represents an incremental advance to have rezafungin available for the treatment of those patients.”

Stay tuned for the second installment of the interview this week, as Thompson will discuss patient profiles for rezafungin and prescribing considerations.



References
1. Cidara Therapeutics and Melinta Therapeutics Announce FDA Approval of REZZAYO™ (rezafungin for injection) for the Treatment of Candidemia and Invasive Candidiasis. Cidara Therapeutics press release. March 22, 2023. Accessed January 21, 2025.
https://www.cidara.com/news/cidara-therapeutics-and-melinta-therapeutics-announce-fda-approval-of-rezzayo-rezafungin-for-injection-for-the-treatment-of-candidemia-and-invasive-candidiasis/
2.Thompson GR 3rd, Soriano A, Honore PM, et al. Efficacy and safety of rezafungin and caspofungin in candidaemia and invasive candidiasis: pooled data from two prospective randomised controlled trials. 

. 2024;24(3):319-328. doi:10.1016/S1473-3099(23)00551-0
 

George Thompson, MD, offers some insights on 2 studies looking at these antifungals in patients with candidemia and invasive candidiasis.

Rezafungin is Noninferior to Caspofungin For All-Cause Mortality in Treating Candida Infections

The federal government is working on measures to mitigate the potential impact including looking at vaccines, therapies, and other strategies

How PRepared are we for Avian Influenza

When it comes to public health, and the idea of being prepared for a potential outbreak or pandemic, there are some objective measures that can be put into place including stockpiling vaccines and therapies, having emergency plans, and carrying out surveillance measures to name a few.

The federal government, for example, is working to make sure there are vaccines and therapies available to the general public if they are needed. The Centers for Disease Control and Prevention (CDC) is looking to prepare by developing candidate vaccine viruses (CVV) for avian influenza (H5). “CVVs are used to produce influenza vaccines. Having a CVV that protects against H5 bird flu in humans is an important step for being prepared for an H5 vaccination program, if one is needed,” the federal agency writes on its site.

The Biomedical Advanced Research and Development Authority (BARDA) overees the National Pre-pandemic Influenza Vaccine Stockpile (NPIVS). And the stockpile has enough raw materials to develop vaccine doses to immunize critical care workers and at-risk populations in the early phases of a needed response. And they also have enough materials to make millions of additional doses within weeks.

And separately there are a handful of vaccine candidates in development. The US Department of Health and Human Services (HHS) announced last week it was going to provide approximately $590 million to Moderna to accelerate the development of mRNA-based pandemic influenza vaccines and enhance mRNA platform capabilities so that the US is better prepared to respond to other emerging infectious diseases.

And in terms of therapies, the Strategic National Stockpile has millions of treatment courses of antivirals including, oseltamivir (Tamiflu), which is expected to work against avian influenza.

Of course, learning from history so as not to repeat it is an age-old adage. And certainly, fresh off the COVID-19 pandemic, there are many things we can glean when considering a potential avian influenza outbreak.

“I think we've learned a lot of important lessons about what we've done well and what we've done not so well in responding to a pandemic,” Hopkins said. “There were tremendous investments from the federal government, from states, from others, to help us respond, to grow our public health workforce, to reach out to communities to get vaccine into arms, without regard for insurance. So we learned an awful lot. Unfortunately, a lot of that spending, that money that was invested is gone. So in a lot of ways, we've learned, but we don't have the resources to respond as effectively now.”

He also mentions the need for the federal government’s continued vigilance to monitor the ongoing situation. “We know that this can be a serious infection and can cause death…This needs to be on our radar,” Hopkins said. “Ongoing public health surveillance, ongoing biosecurity around cattle farms, and around our poultry operations is really critical.”

This is the first in a short series on preparedness, check back in tomorrow and Thursday as different authors tackle biocontainment and how immunomics may help in preparing for future pandemics.

References
1. CDC Activities and Accomplishments to Date in 2024—2025 H5 Bird Flu Response. CDC. January 17, 2025. Accessed January 21, 2025.


https://www.cdc.gov/bird-flu/spotlights/h5n1-response-01172025.html


2.ASPR’s Response to H5N1 Bird Flu. Administration for Strategic Preparedness & Response. Accessed January 21, 2025.
https://aspr.hhs.gov/H5N1/Pages/default.aspx



The federal government is working on measures to mitigate the potential impact including looking at vaccines, therapies, and other strategies. Robert Hopkins, Jr, MD, medical director, National Foundation for Infectious Diseases (NFID), provides some insights on our preparation now and lessons learned from the pandemic. 

How Prepared Are We For Avian Influenza? 

Clinical Decision Support (CDS) tools play a crucial role in healthcare, particularly in optimizing antibiotic prescribing and reducing infections. These tools are essential to Antimicrobial Stewardship (ASP) and Infection Prevention (IP) programs. A recent study highlights the application of established CDS evaluation frameworks, such as the "Five Rights" and "Ten Commandments," to real-world tools like the Vancomycin Best Practice Advisory and 

) order panel. The findings emphasize the importance of user engagement and efficiency in designing and implementing these tools to improve antibiotic use and diagnostic stewardship. The results suggest that with a structured approach, these tools can significantly enhance quality improvement initiatives in ASP and IP programs. CDS tools contribute to better patient outcomes and more efficient healthcare delivery by focusing on effective implementation and user-centered design.

In an exclusive email interview, Mary Rochelle Smith, MD, MPH, Julie J Lee, MD, MPH, and Amy Chang, MD, PharmD, from Stanford University School of Medicine, shared valuable insights on the development and implementation of CDS tools in ASP and IP programs. They discussed the challenges of maintaining tool adaptability as clinical guidelines evolve, strategies for engaging clinicians in high-pressure environments, and how to evaluate the impact of CDS interventions on patient outcomes.

Contagion: How do you ensure CDS tools remain adaptable as clinical guidelines evolve, especially for conditions like antimicrobial resistance?

: "Routine maintenance by CDS tool creators/owners of any CDS intervention/tool is vital to ensuring that it remains up to date and in line with recent national and institutional guidelines and local resistance patterns. This includes scheduled structured evaluation of the tool using a framework such as the ‘5 Rights’ of CDS or ’10 Commandments” that we outlined in our article to optimize the functionality of the intervention."

Agreed with the above. It’s critical to 1) maintain a comprehensive database of active AMR CDS tools, supported by a multidisciplinary team, including a physician who stays up-to-date with infectious disease guidelines and local/regional trends, 2) establish clear standards for updating tools, such as clinical content, intervention formats, or order options, and retiring those that are no longer necessary or aligned with current guidelines, with all changes documented in a detailed changelog, and 3) implement a methodical process to update all stakeholders when tools are updated or retired, ensuring consistent use and adherence to evolving guidelines."

: "Yes, agreed with the above. One additional note to add: Our CDS committee at Stanford frequently encounters alerts that are out of date. Because there are hundreds of different alerts operating at any given time, you cannot rely on a governing body like a CDS committee to point out where guidelines need to be updated; nor would this necessarily be their area of expertise. As such, we really rely on the requesting operational team, in this case the ASP or IPC team, to keep their own inventory of alerts they own and periodically re-examine alerts when local/national guidance changes."

Contagion: In your experience, what factors help maintain clinician engagement with CDS tools, particularly in high-pressure environments like ICUs or emergency departments?

: "Clinician engagement is maintained through a longitudinal collaborative process with most successful interventions. Some factors that can help are: Designing the CDS tool in a way that it is no longer an obstacle added to their workflow, but rather a tool to ultimately optimize their workflow."

: "User-centered design, or in other words, involving the end users at every stage of development, is a valuable approach that can help to improve not only the user interface, but also the overall perception of an alert and engagement with the process you are trying to improve."

: "Facilitating easy access and feedback to CDS tools is also important as this approach allows clinicians to feel supported and ensures the tools are refined based on their input. I would strongly recommend assigning a dedicated team to the feedback process and respond to feedback."

: "Building relationships with clinicians and finding a champion within those targeted units to support the CDS tool. Also building trust and goodwill by being receptive to removing other CDS interventions in their units that are ineffective or cumbersome for providers."

: "Adapting CDS intervention formats to the needs and realities of high-pressure environments will be critical for seamless workflow and adoption."

: "Incentivizing the use of the CDS tool by tracking metrics that can be tied to quality improvement measures can also maintain clinician engagement."

: "Sharing these improvements in metrics and quality outcomes with end users is important to highlight how these tools are truly driving better decisions and outcomes, as it fosters trust and aligns clinicians with the greater purpose of using CDS tools effectively."

Contagion: How do you incorporate patient outcomes into evaluating the effectiveness of CDS interventions in antimicrobial stewardship?

This would likely vary significantly and be specific for each stewardship CDS intervention and the goal outcome of the intervention. For example, if there is a CDS intervention such as an alert for IV to PO conversion, then an outcome measure such as Length of Stay (LOS) could be a helpful outcome metric to track. If your intervention is revising a 

 order panel to appropriate ordering on high-risk patients and discouraging inappropriate ordering on low-risk patients, then an outcome metric such as hospital acquired 

: "That is the question of the day. With all the complexities involved in patient care, it can be difficult to incorporate patient outcomes and pinpoint the effectiveness of CDS interventions for antimicrobial stewardship in isolation. For instance, comparing hospital-acquired 

 rates before and after an intervention might help, but it’s essential to acknowledge confounding variables, such as temporal factors, that can influence outcomes."

: "The key lies in approaching this like a well-thought-out study design. First, identify the key patient outcomes you want to measure, such as reductions in CLABSIs, along with the composite metrics or process measures that contribute to those outcomes. Then, design the CDS tool to address these specific goals and ensure you have the means to track the necessary data. Finally, it’s crucial to define and confirm your success metrics before launching the intervention; otherwise, you may risk chasing data that may not even exist or is difficult to capture."

: "‘Success’ is overall a difficult to define concept within CDS in general. Similar to any QI intervention, you will have some outcome measures that will establish your final ‘goal’, like the metrics mentioned above. However, on the way to that goal, there will likely be several process metrics that help you iterate upon your CDS tool and improve engagement over time. As an example, we have the vancomycin interruptive alert mentioned in our article. How would you define success of this pop-up alert? Should it be every time vancomycin is discontinued? Probably not, given that it may be perfectly reasonable for front-line providers to see the alert, and upon reviewing criteria, realize the patient still requires vancomycin. Instead, perhaps an initial process measure would be to attempt to measure each time the provider ‘appropriately’ interacted with the OPA by either discontinuing the order or identifying criteria that suggests vancomycin should continue. Meanwhile, you would also want to measure your outcome metric – in this case vancomycin DOT - which you would expect to decrease overall, but may take longer time to show meaningful effect. Lastly, but often forgotten -- in order to iterate upon the process, teams should obtain end-user feedback through surveys, focus groups, or feedback tools provided by the electronic medical record system. This process may reveal some design issues that may lead to decreased engagement and/or errors in design. It is important to recognize the unintended consequences of interruptive pop-up alerts leading to alert fatigue and increased medical errors. Unfortunately, because there is no gold standard metric to evaluate for this, we really rely on optimized design that takes into account the end-users workflow and has maximal engagement (eg high ‘acceptance’ rates)."

Overall, CDS tools play a key role in ASP and IP programs by improving antibiotic use, reducing infections, and supporting diagnostic decisions. A structured approach to the development and evaluation of CDS tools ensures alignment with clinical guidelines and enhances tool effectiveness. Regular updates, clinician engagement, and feedback are essential for maintaining the utility of these tools. As CDS tools evolve, they can improve patient outcomes, support decision-making, and contribute to more efficient healthcare delivery.

Smith MR, Lee JJ, Holubar M, et al. Clinical decision support in the electronic health record: a primer for antimicrobial stewards and infection preventionists: work smarter so end users don't work harder. Antimicrob Steward Healthc Epidemiol. 2024;4(1):e204. Published 2024 Nov 14. Accessed January 16, 2024. doi:10.1017/ash.2024.448

Mary Rochelle Smith, MD, Julie J Lee, MD, and Amy Chang, MD, PharmD, share expert strategies for implementing effective clinical decision support tools in practice.

Advice for Clinicians from Clinicians: Improving Antibiotic Stewardship and Infection Control

Last night, the US Food and Drug Administration (FDA) approved the injectable antifungal 

 to treat candidemia and invasive candidiasis in adults with few to no alternative treatment options.

The decision came late on rezafungin’s Presecription Drug User Fee Act (PDUFA) date of March 22, 2023, just days after the US Centers for Disease Control and Prevention 

 across the country. With this approval, rezafungin become the first new drug approved to treat candidemia and invasive candidiasis in more than 10 years. Rezafungin was developed by Cidara Therapeutics, and it will be marketed by Melinta Therapeutics and Mundipharma under the name Rezzayo.

“We are extremely pleased that the FDA’s advisory committee has recommended that the FDA approve rezafungin for difficult-to-treat and often deadly candidemia and invasive candidiasis,” said Jeffrey Stein, PhD, president and CEO of Cidara. “This positive recommendation is a significant step towards our goal of providing a once-weekly treatment option for patients with invasive Candida infections, for which no new drugs have been approved in over a decade. We believe rezafungin, if approved, could provide an effective new alternative for patients battling these potentially deadly diseases.”

causes fungal infections if it grows unmitigated or enter deep into the body. Left untreated, 

 can cause infections in the bloodstream or the kidney, heart, brain, and other internal organs.

Candidemia and invasive candidiasis are infections that can affect multiple parts of the body after 

spreads. Candidemia in particular is a common infection in hospitalized patients.

Rezafungin is a once-weekly, next-generation echinocandin. The FDA’s affirmative decision was largely based on positive data from phase 3 clinical trials. Dosed once a week, rezafungin was determined to be statistically noninferior compared to once-daily caspofungin, the current standard of care. Rexafungin met the primary trial endpoints for the FDA and the European Medicines Agency (EMA).

Melinta Therapeutics announced injectable rezafungin (Rezzayo) will be available summer 2023.

“The Committee’s robust discussion was an important step in the FDA’s review of rezafungin,” said Christine Ann Miller, president and CEO of Melinta Therapeutics. “We are pleased that the committee recognized the unmet need that rezafungin will address in the treatment of candidemia and invasive candidiasis. We remain committed to working closely with our partner Cidara in securing FDA approval of rezafungin.”

With yesterday’s FDA decision, Cidara’s injectable antifungal rezafungin become the first new drug approved to treat candidemia and invasive candidiasis in over a decade. 

Sasirekha Ramani, PhD

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