IDSA News - September 2012
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Hospitals Required to Report HCW Influenza Vaccination Data in 2013
Starting Jan. 1, 2013, acute care hospitals participating in a Centers for Medicare and Medicaid Services (CMS) quality reporting program will be required to submit summary data on influenza vaccination of their health care workers (HWCs).
The reporting requirement was included in the CMS Inpatient Prospective Payment System (IPPS) final rule for the 2013 fiscal year (FY), issued by CMS in August, and applies to hospitals taking part in the Inpatient Quality Reporting Program. Although hospitals are required to submit data starting in January, CMS will not use the HCW influenza vaccination measure to determine payments until FY 2015. The HCW vaccination module, report form, and related reporting instructions are available online: www.cdc.gov/nhsn/hps_Vacc.html.
Vaccinating HCWs is a key measure in the prevention of health care-associated influenza; IDSA supports (PDF) the use of mandatory influenza vaccination policies to protect patients and HCWs.
C. difficile Updates, Related Sessions at IDWeek
Two recent developments related to Clostridium difficile treatment may be of interest to ID physicians, in addition to several relevant sessions at IDWeek 2012, Oct. 17-21, in San Diego, you won’t want to miss.
- The Centers for Medicare and Medicaid Services (CMS) recently approved a temporary add-on payment for hospitals for fidaxomicin, an oral drug used to treat C. difficile-associated diarrhea. The add-on payments are part of a CMS program designed to remove barriers to access for costly new technologies that are not yet fully reflected in current CMS hospital payment rates.
- The American Medical Association recently published a Current Procedural Terminology (CPT) code related to fecal transplantation. The new code is 44705, “Preparation of fecal microbiota for instillation, including assessment of donor specimen.” AMA’s CPT Changes: An Insider’s View 2013 may be helpful in understanding the application of this code.
Several sessions at IDWeek will focus on C. difficile prevention, diagnosis, treatment, and epidemiology, including:
Clostridium difficile and Host Defense
Symposium, Wednesday, Oct. 17, 1:30 - 3:30 p.m.
Room: SDCC 30 ABCDE
Update on Clostridium difficile Infection: Epidemiology, Diagnosis, and Treatment
Symposium, Thursday, Oct. 18, 2 - 3:30 p.m.
Room: SDCC Ballroom 6 DE
Clostridium difficile Infection
Meet-the-Professor Session, Saturday, Oct. 20, 7- 8:15 a.m.
Room: Marriott Hall 3
Related poster and oral abstract sessions are also scheduled:
C. difficile: Clinical and Outcomes
Poster Abstract Session, Thursday, Oct. 18, 12:30 - 2 p.m.
Room: SDCC Exhibit Hall D
C. difficile Diagnostics
Poster Abstract Session, Thursday, Oct. 18, 12:30 – 2 p.m.
Room: SDCC Exhibit Hall D
C. difficile Epidemiology
Poster Abstract Session, Thursday, Oct. 18, 12:30 – 2 p.m.
Room: SDCC Exhibit Hall D
C. difficile Prevention and Carriage
Poster Abstract Session, Thursday, Oct. 18, 12:30 – 2 p.m.
Room: SDCC Exhibit Hall D
C. difficile: Risk Factors and Outcomes
Oral Abstract Session, Friday, Oct. 19, 10:30 a.m. – noon
Room: SDCC 29 ABCD
Challenges in C. difficile Infection Surveillance
Oral Abstract Session, Saturday, Oct. 20, 10:30 a.m. – noon
Room: SDCC 29 ABCD
Drug Approvals, Recalls, Adverse Events Update
IDSA offers two email services to help members stay informed of updates from the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA). Content includes a range of topics, including new drug approvals and warnings. Recent alerts have included:
IDSA members can sign up for these services online. (To subscribe, check the appropriate boxes to receive CDC’s Health Alert Network (HAN) messages and/or alerts from FDA, and provide your email address and name where indicated.)
Is Your Facility Experiencing Antibiotic Shortages?
IDSA members are urged to report drug shortages directly to FDA and to copy IDSA staff at firstname.lastname@example.org.
CMS to Include Maintenance of Certification in Incentive Program
The Centers for Medicare and Medicaid Services (CMS) Physician Quality Reporting System (PQRS) is a voluntary reporting program that provides a 0.5 percent incentive payment to eligible individuals and practices who report data on quality measures. For eligible professionals who successfully participate in PQRS in 2012, CMS offers an additional incentive for those who also participate in Maintenance of Certification (MOC) programs—including those offered by IDSA and the HIV Medicine Association (HIVMA). By combining PQRS reporting with increased activities for MOC in 2012, physicians can also earn an additional incentive payment of 0.5 percent.
MOC modules, developed by panels of experts from IDSA and HIVMA on general ID, HIV, adult vaccines, and infections in the non-HIV immunocompromised host, are available online at idsa.knowledgedirectweb.com. Each module consists of 25 multiple-choice questions; each is worth 10 points toward the American Board of Internal Medicine’s (ABIM) MOC program and offers two AMA PRA Category 1 Credits™.
Two premeeting sessions at IDWeek, the first on Tuesday afternoon, Oct. 16, and the second on Wednesday morning, Oct. 17, will also feature the modules. (Act now to add the workshop to your IDWeek registration.) The MOC program will be discussed in detail at a Meet-the-Professor session on Thursday, Oct. 18, from 7 to 8:15 a.m.: Power Hour: American Board of Internal Medicine Maintenance of Certification: What ID Physicians Need to Know.
For more information about PQRS and how to earn the additional MOC incentive payment, visit CMS’s website and ABIM’s website. IDSA also has resources on CMS incentive programs, including PQRS.
Thai HIV Vaccine Trial Yields More News
A trial that showed a vaccine can prevent HIV infection also has shown that the vaccine changed the virus in people who did become infected, according to research revealed earlier this month at the AIDS Vaccine 2012 conference. Read more on Science Speaks, the blog of the Center for Global Health Policy.
More from Science Speaks:
The Role of HIV-Related Stigma in Maternal Care in Kenya
The word is out in rural Kenya: Pregnant women with HIV should deliver their babies in health facilities equipped to deal with the complications they might face. But researchers found that HIV-related stigma and discrimination is creating a disincentive that keeps women with and without HIV from getting medical care. Science Speaks, the blog of the Center for Global Health Policy, has more on the recent study.
More from Science Speaks:
HIV’s Impact on Men Who Have Sex with Men
Earlier this month, five noted experts discussed the policy implications of a series of recent Lancet articles examining the structural, biological, epidemiological, historical, and other reasons HIV epidemics among men who have sex with men are still increasing, and why programs are failing to meet their needs. See Science Speaks, the blog of the Center for Global Health Policy, for more on the discussion.
More from Science Speaks:
IDSA Issues Updated Influenza Principles for U.S. Action
IDSA published an updated set of principles earlier this month to educate federal policymakers about how to best prepare for and respond to pandemic and seasonal influenza. First issued in 2007, the updated document builds on experiences from the 2009 H1N1 influenza pandemic and is intended to assist the Department of Health and Human Services’ (HHS) Assistant Secretary for Preparedness and Response and other agency officials as they establish priorities and prepare to implement the reauthorized Pandemic and All-Hazards Preparedness Act, which awaits final passage by Congress. (In a recent letter (PDF), IDSA urged congressional leaders to quickly pass legislation reauthorizing the act.)
Developed by IDSA’s Pandemic Influenza Task Force, the 2012 principles (PDF) were released at a policy forum hosted by IDSA and the American Medical Association featuring government officials, policymakers, and influenza and public health experts. (An archived webcast is available online.) In the new document, IDSA calls for:
- coordination between HHS and other government departments, and better coordination within HHS, particularly concerning influenza vaccine efforts
- establishing processes to continually review critical components of influenza preparedness, such as the contents of the Strategic National Stockpile
- vigorously supporting the vaccination of health care workers against influenza, including through the adoption of a mandatory approach
- significant and sustainable multi-year funding that may be used for “all-hazards” preparedness
For more on IDSA’s “Pandemic and Seasonal Influenza Principles for United States Action,” visit the Society’s website.
IDSA, HIVMA Urge Congress to Protect Public Health Funding
Automatic, across-the-board budget cuts to all federal agencies would devastate the nation’s public health infrastructure and biomedical research, IDSA and the HIV Medicine Association (HIVMA) told congressional leaders in a recent letter. IDSA and HIVMA called on Congress to stop the cuts, including those to the National Institutes of Health and Centers for Disease Control and Prevention. Read IDSA’s full letter (PDF).
Visit IDSA’s “Take Action” webpage now to urge your representatives in Congress to protect federal funding for public health, prevention, and medical research.
IDSA Offers Recommendations for Antibiotic Clinical Trial Designs
In a new policy paper, IDSA provides recommendations for clinical trial designs to determine if investigational antibiotics are superior in efficacy to approved agents for the treatment of infections caused by highly drug-resistant bacteria. Published in the Oct. 15 issue of Clinical Infectious Diseases, the recommendations come as the Food and Drug Administration prepares guidance for industry on this topic. IDSA will continue to make sure the perspective of ID specialists is heard during this process.
Action Needed to Address Resistance, Spur R&D, Expand Immunizations
In a recent letter (PDF), the Society urged the Department of Health and Human Services to take several actions aimed at combating antimicrobial resistance, spurring the development of new antibiotics and diagnostics, and expanding immunizations. The recommendations build on language, requested by IDSA, contained in a funding bill passed by the Senate Appropriations Committee earlier this year.
Check Out “My IDSA” for Latest Member News
Find the latest membership news on “My IDSA” on the IDSA website, including the 2012 Joint Research Award winners; updates on Judith A. Aberg, MD, FIDSA, and Lynne M. Mofenson, MD, FIDSA; and new IDSA members.
Are you a member on the move? Do you know someone who is? Contact Stephanie Cox at email@example.com so that we can announce it to our membership.
From the President: Volunteers Are Critical to IDSA’s Work
Member volunteers play a crucial role in the Society’s work, in a variety of ways. IDSA’s accomplishments would not be possible without the hard work of these volunteers.
It has been a tremendous honor to serve as your president this past year. Throughout these past months, I have come to appreciate the wide range of activities that IDSA undertakes on behalf of members, whether they work in academia, public health, clinical care, research, teaching, or administration. I’ve also seen the crucial role that member volunteers play in the Society’s work, in a variety of ways.
Important steps, such as the passage of federal legislation this summer that includes incentives for much-needed antibiotic research and development, the release of IDSA’s updated Pandemic and Seasonal Influenza Principles for U.S. Action earlier this month, and the continuing effort to document the value ID specialists provide to patients and the health care system, would not be possible without the hard work of volunteers serving on IDSA committees, work groups, and task forces.
Society volunteers contribute in other critical ways. Sharing the perspectives of ID and HIV specialists with Congress, federal, state, and local agencies, and other policymakers on key issues is a prime example. Given the challenging economic and fiscal realities, this advocacy will be more important than ever. (Visit IDSA’s “Take Action” webpage to communicate with your representatives in Congress on the need for adequate federal funding for public health, prevention, and medical research.)
IDSA released three new or updated practice guidelines during the past year—on acute bacterial rhinosinusitis, diabetic foot infections, and group A Streptococcal pharyngitis—thanks to the work of volunteers serving on guideline panels. Volunteers also help develop questions for Maintenance of Certification modules created by IDSA and the HIV Medicine Association (HIVMA) to help physicians with American Board of Internal Medicine recertification. Two new modules, one on adult vaccines and one on infections in the non-HIV immunocompromised host, launched this month.
Peer reviewers volunteer their time to review manuscripts submitted to the Society’s popular journals, Clinical Infectious Diseases and The Journal of Infectious Diseases. Member volunteers also serve as media spokespeople on behalf of IDSA, helping to get accurate information on ID-related topics and Society priorities to the public and other target audiences through news coverage.
IDWeek 2012, Oct. 17-21, in San Diego, reflects the important contributions of IDSA and HIVMA volunteers as well, in addition to those from our partner organizations for the joint meeting, the Society for Healthcare Epidemiology of America and the Pediatric Infectious Diseases Society. From program committee members who created a comprehensive, cutting-edge scientific program to volunteers who reviewed submitted abstracts, volunteers have helped make IDWeek a must-attend event in our field.
On that note, I hope you can join me during IDWeek at the IDSA Presidential Forum, 6 to 7 p.m. on Friday, Oct. 19, in Ballroom 20 ABCD in the San Diego Convention Center, to hear more about the Society, recent developments, and a brief reflection on the past as IDSA marks its 50th meeting this year. John G. Bartlett, MD, FIDSA, a past IDSA president, will also share his thoughts on the opportunities and challenges facing our field moving forward. It will be an engaging session, and I look forward to seeing you there.
Updated Guideline on Group A Streptococcal Pharyngitis Now Online
IDSA’s updated guideline for the diagnosis and management of group A streptococcal pharyngitis is now available, along with an audio podcast featuring Stanford T. Shulman, MD, the lead guideline author.
An updated IDSA guideline for the diagnosis and management of group A streptococcal (GAS) pharyngitis is now available online and will appear in the Nov. 15 issue of Clinical Infectious Diseases.
The objective of the guideline, which replaces a guideline issued in 2002, is to provide recommendations for appropriate treatment and management of this common clinical condition. It addresses concerns clinicians face related to the diagnosis of streptococcal pharyngitis and its treatment in patients, including those allergic to penicillin. Specific treatment recommendations are provided, such as penicillin or amoxicillin, and include recommendations for the penicillin-allergic patient.
“The guideline promotes accurate diagnosis and treatment, particularly in avoiding the inappropriate use of antibiotics, which contributes to drug-resistant bacteria,” said lead author Stanford T. Shulman, MD, chief of the division of infectious diseases at Ann & Robert H. Lurie Children’s Hospital of Chicago and professor of pediatrics at Northwestern University Fineberg School of Medicine. “We recommend penicillin or amoxicillin for treating strep because they are very effective and safe in those who are not allergic, and there is increasing resistance of strep to the broader-spectrum—and more expensive—macrolides, including azithromycin.”
The guideline provides key recommendations such as identifying the preferred method of diagnosis for patients with streptococcus pharyngitis. For instance, clinicians should swab the throat and test for GAS pharyngitis by rapid antigen detection test, since clinical features cannot discriminate between GAS and viral pharyngitis. In addition, several recommendations are provided regarding the preferred treatment regimen (e.g., antibiotic dosage and duration) for patients diagnosed with GAS
The guideline explains that improved methods of diagnosis are under study. Therefore, future research should focus on issues such as distinguishing acute infection from chronic pharyngeal carriage and developing simpler therapeutic regimens for acute GAS pharyngitis.
A podcast with Dr. Shulman is available on IDSA’s website, and the guideline will be available in a smartphone format and a pocket-sized quick-reference edition. Visit the practice guidelines section of the IDSA website for additional guidelines and related resources.
EIN Update: West Nile Cases Underscore Lack of Treatment Data
A recent discussion highlighted the recent increase in West Nile virus encephalitis cases and the lack of data on treatment.
The Emerging Infections Network (EIN) is a forum for infectious diseases consultants and public health officials to report information on clinical phenomena and epidemiological issues with public health significance. Any diagnostic or therapeutic recommendations and all opinions presented are those of the individual contributor. They do not necessarily represent the views of EIN, IDSA (EIN’s sponsor), or the Centers for Disease Control and Prevention (CDC), which funds EIN. The reader assumes all risks in using this information.
A recent EIN discussion highlighted the increase in West Nile virus (WNV) encephalitis cases and the lack of data on treatment.
“We have recently had several cases of WNV meningoencephalitis in the hospital,” an EIN member in Ohio wrote, including a patient who arrived completely lucid with pure meningitis and by day two had signs of encephalitis. “I’m worried that he is going to get worse,” the member continued. “Previously there was discussion of ribavirin for WNV. I can’t find anything else. Has anyone used any other agents? I am aware there is no approved treatment.”
A respondent in Nebraska shared a March 2005 brief report in Clinical Infectious Diseases on the use of interferon in two cases of West Nile encephalitis.
“We in North Texas are in the midst of an epidemic outbreak of WNV disease, including many neuroinvasive cases, and about 10 deaths so far,” another respondent wrote. “Some of our local individuals are currently involved in trying to set up an IRB-approved protocol to evaluate the efficacy of interferon-alpha2.”
Another EIN member in Texas reported a large concentration of WNV cases locally, “ranging from asymptomatic to post-viral transverse myelitis. Not many have continued to have clinical encephalitis for more than a couple of days, which makes use of interferon of doubtful clinical utility.”
“Our biggest issue has been getting any serologic diagnosis in time to be clinically useful,” the member continued. “The commercial lab we were using gave us turnarounds of two-four weeks in July. The state lab has been better, but still not within the period useful to discontinue other treatment, and as a big county hospital we cannot discount herpetic and bacterial processes, which we continue to see, of course."
An EIN member from Louisiana urged caution in “interpreting the results of any case reports using interferon in WNV infection—as Marvin Turck used to say, the plural of ‘anecdote’ is ‘anecdotes,’ and not ‘data.’ ” Citing involvement with an open-label interferon trial for the treatment of WNV encephalitis and a double-blind placebo trial, the member continued, “We simply don’t know yet whether interferon helps or hurts these patients, anecdotal reports notwithstanding.”
A table of WNV human infections, by state, reported to the Centers for Disease Control and Prevention (CDC) and updated weekly, is available online. As of Sept. 25, a total of 3,545 cases of WNV disease in people, including 147 deaths, had been reported to CDC. Of these, 1,816 (51 percent) were classified as neuroinvasive disease (such as meningitis or encephalitis) and 1,729 (49 percent) were classified as non-neuroinvasive disease.
E-mail the Emerging Infections Network.
The Emerging Infections Network (EIN) is a provider-based sentinel network designed to help the public health community detect trends in emerging infectious diseases.
A joint project of IDSA and the Pediatric Infectious Diseases Society (PIDS) with funding from the Centers for Disease Control and Prevention (CDC), EIN tracks emerging infectious diseases and keeps the public health community up to date with new disease trends, difficult cases, and other issues affecting members’ clinical practices. The Network provides a great opportunity for members to share knowledge quickly across large geographical distances. Both IDSA and PIDS members are eligible to join. Click here for more information or to join EIN.
IDSA Journal Club
This month, studies investigating: doxycycline’s effect on Clostridium difficile in patients with community-acquired pneumonia; sinus irrigation with tap water via neti pots and fatal Naegleria meningoencephalitis; and human papillomavirus vaccination and herd immunity.
In this feature, a panel of IDSA members identifies and critiques important new studies in the current literature that have a significant impact on the practice of infectious diseases medicine.
Click here for the previous edition of Journal Club. For a review of other recent research in the infectious diseases literature, see “In the Literature,” by Stanley Deresinski, MD, in each issue of Clinical Infectious Diseases.
Doxycycline’s Effect on Clostridium difficile in Patients with Community-Acquired Pneumonia
Reviewed by Ed Dominguez, MD
Hospital-acquired Clostridium difficile infection (CDI) occurs at a rate of 6.5–8.5 per 10,000 patient-days with an attributable mortality of 5.7 to 6.9 percent. Currently, up to 7 percent of people receiving antibiotics develop CDI within 30 days. While there is renewed interest in developing new compounds (e.g., fidaxomicin) for CDI, there is also interest in prescribing available antibiotics that promote less selective pressure. In vitro studies and anecdotal reports have identified tetracyclines and glycylcyclines as such drugs. A historical cohort study reported in the Sept. 1 Clinical Infectious Diseases evaluated doxycycline’s effect on CDI in patients with community-acquired pneumonia (CAP) admitted to a single center.
Investigators evaluated 2,734 CAP hospitalizations for five and half years through December 2010. The primary outcome was development of CDI within 30 days of the first dose of ceftriaxone. CDI was defined as a positive stool enzyme immunoassay for toxins A and B. All patients received at least one dose of ceftriaxone and 39 percent received doxycycline. Forty-three patients developed CDI, an overall incidence 5.60 per 10,000 patient-days. Five of 1,066 doxycycline recipients developed CDI, an incidence of 1.67 per 10,000 patient-days. The incidence for the 38 patients with CDI not receiving doxycycline was 8.11 per 10,000 patient-days.
There was a 27 percent lower rate of CDI for each additional day of doxycycline when adjusted for multiple variables. Comparing hazard ratios for five-day courses of ceftriaxone plus doxycyline to ceftriaxone plus either a macrolide or a flouroquinolone antibiotic, doxycycline proved protective with a hazard ratio of 0.15 or less. However, the strongest predictor of CDI was remaining in the hospital with a hazard 15.1-fold that of outpatients. Unfortunately, investigators did not rule out a clonal outbreak. Regardless, the study findings suggest centers with a high CDI incidence might substitute doxycycline for macrolides or fluoroquinolones for use with ceftriaxone in patients with CAP.
(Doernberg et al. Clin Infect Dis. 2012;55(5): 615-620.)
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Sinus Irrigation with Tap Water via Neti Pots and Fatal Naegleria Meningoencephalitis
Reviewed by Christopher J. Graber, MD, MPH
A recent article published in Clinical Infectious Diseases describes two cases of fatal amebic meningoencephalitis in Louisiana from 2011 that resulted from sinus irrigation with tap water contaminated with Naegleria fowleri. Both patients, a 28-year-old male and a 51-year-old female, presented with altered mental status and fever and died within 4 days of admission; N. fowleri was isolated from the cerebrospinal fluid of the first patient and from brain tissue of the second patient.
Neither patient had a history of recreational freshwater exposure, but they both regularly used neti pots for the treatment of sinus congestion. An investigation of the patients’ homes resulted in the isolation of N. fowleri (either by culture or PCR) from the tankless water heater of one patient and the kitchen faucet, shower, bathtub faucet, and bathroom sink faucet of the other patient.
Neti pots, when used properly, can provide effective relief for chronic sinus congestion, but water used in these devices should be distilled, sterile, previously boiled then cooled, or filtered using a filter with an absolute pore size of 1 μm or smaller. After use, the device should be rinsed with the same treated water as above. Premanufactured salt packets are also available, but the investigators in this study tested them and found no decrease in N. fowleri load or degradation after four hours. Further guidance for patients can be found in a recent Food and Drug Administration alert. While these cases represent uncommon presentations of a rare illness, the press that this report has received presents an opportunity for educating our patients in prevention of waterborne illness.
(Yoder et al. Clin Infect Dis 2012; published online Aug. 22, advance access)
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When a Good Vaccine Gets Better: Evidence of Herd Immunity Against HPV
Reviewed by Christian B. Ramers, MD, MPH
Human papillomavirus (HPV) causes common warts as well as cervical, anal, and oropharyngeal carcinoma. Two vaccines have been shown to be safe and effective in preventing HPV infection and cervical intraepithelial neoplasia. The first vaccine, Gardasil, which protects against HPV types 6, 11, 16, and 18, was approved in June 2006 and recommended by the U.S. Advisory Committee on Immunization Practices shortly thereafter. While the individual benefit of these vaccines was demonstrated in the clinical trials that led to their approval, the effect of vaccine introduction on rates of HPV infection in real-world, community settings has been uncertain.
A study in the August 2012 issue of Pediatrics aimed to describe the effect of vaccine introduction on HPV rates in both immunized and unimmunized young women. In 2006-2007, the authors recruited 368 sexually active young women aged 13-26 for a pre-vaccination surveillance study. A separate sample of 409 women was recruited in 2009-2010 for post-vaccination surveillance. Fifty-nine percent of these women had received the quadrivalent HPV vaccine. Subjects completed behavioral questionnaires and had cervicovaginal samples submitted for HPV DNA PCR and type identification using a blot detection system.
Although overall HPV infection rates actually increased during the study period, there was a decrease of 60-70 percent in vaccine-type HPV infection. Prior to the introduction of HPV vaccine, the overall prevalence of vaccine-type HPV was 31.7 percent and this decreased to 13.4 percent (p<0.0001). This effect was seen both in vaccinated (31.8 percent à 9.9 percent, p < 0.0001), and unvaccinated young women (30.2 percent à 15.4 percent, p < 0.0001). The proportion of non-vaccine HPV types did increase in vaccinated individuals (60.7 percent à 75.9 percent, p < 0.0001).
This simple study demonstrates yet another triumph of public health prevention through immunization. The pre-vaccination prevalence was extremely high, indicating early and significant impact of widespread vaccination. The observation of ‘type replacement’ by non-vaccine strains warrants further study.
(Kahn et al. Pediatrics. 2012;130(2): e249-256.)
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For a review of other recent research in the infectious diseases literature, see “In the Literature,” by Stanley Deresinski, MD, in each issue of Clinical Infectious Diseases:
- Intravenously Administered Voriconazole in Patients With Renal Insufficiency
- Human T-Lymphotrophic Virus Type 1 and Organ Transplantation
- Two Novel Treatable Immunodeficiency Diseases With Presentation in Adulthood: MonoMAC and WHIM
- Eczema Herpeticum