COVID news & more 1/13/24

The northeastern U.S. is nearing the peak for the JN.1 COVID wave, but other regions will peak over the next few weeks. Over 4% of the American population is currently infected with COVID which equates to about 1.6 to 2.0 million new COVID infections each day. Currently, 1 in 21 people in the U.S. are infected and infectious. Over the several months of this wave, 1 in 3 people will become infected with COVID. Mitigation techniques like masking, improved air filtration, staying home when sick and getting the latest vaccine can slow the continued spread of COVID.

This is the second largest COVID wave of the entire pandemic. Hospitalizations and emergency room visits are just starting to peak and may be decreasing slightly, but there are still a lot of people, mostly older people, in the hospital now with COVID (and the flu). 

Chart from Lucky Tran, annotated by Eric Topol

Los Angeles county put out a public health warning yesterday stating that COVID and Flu infections and hospitalizations remain high as children go back to school and people go back to work after the holidays. They asked residents “to help limit exposures and take common sense precautions." Regarding vaccinations, only 21.4% of American adults have gotten the new COVID updated vaccine while 47% have gotten the flu vaccine. The flu vaccine matches the circulating virus well this year.

Chart from Michael Hoerger

There is a lot of misinformation about COVID and its treatments on the internet and especially on social media. But, there are a few helpful TikTok’rs like @mudflapbrokentire who made this 5 minute video explaining to her community why they should protect themselves against COVID and the social determinants that can make this hard. While I did not agree with everything she said, most of it was right on topic.

Pediatrics

School is back in session after the winter break. The Corsi-Rosenthal Foundation of the UK tweeted about conflicting messages on the NHS website regarding children and COVID. The NHS states that children can go to school if they have mild cold symptoms from probable COVID. But, if the child takes a COVID test and it is positive, they should stay at home for 3 days. It seems like a “Don’t ask. Don’t tell.” kind of policy, which is illogical and confusing. Since 70% of infections in households are spread by children, this recommendation may lead to many families getting COVID infections (again).

A new study looking at the Pfizer mRNA COVID vaccine in a large cohort of children and teens showed strong protection against COVID infection, severe disease, and ICU stays during the Delta wave for adolescents and in the Omicron wave for both children and adolescents. There was a lower risk of cardiac complications among the vaccinated group during Omicron periods. 

Last week, Scientific American reviewed data in adults showing that vaccination dramatically lowers Long COVID risk by 70% for 3 doses of vaccine. A new multinational cohort study from the UK, Spain and Estonia shows that one dose of any COVID vaccine reduced Long COVID by 40%. Protection against Long COVID was found to be about 15% higher for the Pfizer mRNA vaccine than the AstraZeneca vaccine.

This week in Nature magazine, another study shows that vaccination also reduces the risk of Long COVID in children. Unfortunately, as of mid-December 2023, only 8% of US children had received the updated fall COVID vaccine, as compared to 43% of kids who had received a flu shot. 

As each new SARS-CoV-2 variant outcompetes the last to infect us, it would be ideal to have a pan-coronavirus that could protect against many different variants. A new study in the Lancet shows that a universal pan-coronavirus vaccine would save billions of dollars. For every 1% increase in vaccine efficacy between 10% and 50%, a universal vaccine would save $1.0 billion in costs to society related to work productivity and direct medical costs.

Infectious disease physician, Dr. Judy Stone, wrote an article in Forbes about how Paxlovid is being underprescribed for COVID infections. Two-thirds of eligible people are not given the antiviral medication despite the fact that it can help reduce hospitalizations and deaths. Paxlovid also may reduce the risk of Long COVID by about 25%. “Disparities in treatment are likely to grow as the government stops covering the cost of treatment, and Pfizer plans to charge $1,390 per five-day course.”

Long COVID

An important new study from the Gladstone Institute and UCSF shows that there is a breakdown of normal communication between the humoral (B cell) and cellular (T cell) branches of the immune system in Long COVID which leads to immune dysregulation, persistent inflammation and disabling Long COVID symptoms.

B cells make antibodies that bind to invading viruses and bacteria so that they do not enter and infect human cells. T cells destroy human cells that have become infected by viruses or cells that have become cancerous. Usually, there is good communication via cytokine messaging between B cells (humoral immunity) and T cells (cellular immunity). This study showed that people who fully recovered after a COVID infection showed normal messaging between their B cells and T cells allowing them to have a coordinated immune response. But in Long COVID, B cells and T cells could not communicate correctly and their immune responses became uncoordinated.

In addition, T cells specific to SARS-CoV-2 showed increased markers of exhaustion, but total CD8 T cells did not express exhaustion markers in Long COVID. Also, people with Long COVID had higher SARS-CoV-2 antibody levels possibly because of continued stimulation of B cells by SARS-CoV-2. Both of these findings support that there may be a reservoir of SARS-CoV-2 virus somewhere in the body of Long COVID patients that could lead to immune dysregulation and inflammation. 

A new study shows that COVID can significantly age the brain. One year after a moderate to severe COVID infection requiring hospitalization, patients were found to have evidence of ongoing brain injury, loss of gray matter and “cognitive deficits… equivalent in magnitude to 20 years of aging.” Giving corticosteroids (dexamethasone) during the acute phase of the infection was found to be protective, so brain injury in moderate to severe COVID infections may be immune mediated. 

Dr. Maria Van Kerkhove, head of the WHO’s emerging diseases and zoonoses unit spoke to Fortune magazine about COVID. “We are concerned—deeply concerned—that this virus is circulating unchecked around the world, and that we could have a variant at any time that would increase severity,” she said. “This is not meant to be a scare tactic. This is a scenario we plan for.” “Five years, 10 years, 20 years from now, what are we going to see in terms of cardiac impairment, pulmonary impairment, neurologic impairment? It’s year five in the pandemic, but there’s still a lot we don’t know about it.” We do know from Dr. Al-Aly’s studies at the V.A. in the United States and from Statistics Canada data, that each additional COVID infection increases the chances of long term consequences from COVID including Long COVID. 

This week, several different research groups reached out to Long COVID patients:

1. The FDA and CURE ID are asking people with Long COVID and healthcare providers who take care of people with Long COVID to answer a survey on which treatments help Long COVID and which do not help Long COVID symptoms. 

This is an important survey which will help with planning future clinical trials of treatments for Long COVID. See:  https://cure.ncats.io/home

2. Long COVID Physio and the University of Toronto invite people with Long COVID from the UK, Ireland, Canada and the US to fill out surveys on disability caused by LC.

3. The NYC Health Department is looking for 10,000 New Yorkers with Long COVID for a long term study. For information call 212-COVID19.

4. The U.S. Senate Committee on Health, Education, Labor & Pensions (HELP) have scheduled a meeting for this Thursday “Addressing Long COVID- Advancing Research and Improving Patient Care”

• You can watch the livestream Thursday, January 18th, 2024 at 10:00am ET https://buff.ly/4aQuOMn or you can go to the meeting in person if you live in the Washington DC area.

In non-COVID news, a small randomized controlled trial of intravenous immunoglobulin (IVIG) treatment in people with autoimmune POTS showed no difference in symptom relief compared to placebo (albumin infusion). Using autonomous A.I. increased diabetic eye exam completion rates in youth with diabetes and may be useful to decrease healthcare gaps for racial and ethnic minorities who disproportionately have higher rates of diabetic eye disease. This week, the FDA approved for the state of Florida to buy medications more cheaply from Canadian wholesale pharmacies. A new study shows again that Epstein Barr virus (EBV) may be implicated in Multiple Sclerosis as T cells in cerebrospinal fluid of MS patients were found to be specific for EBV. The CDC reported that there was another outbreak of Tuberculosis from infected bone allografts that had been transplanted into 36 patients.

Measles is making a comeback in Philadelphia and in Camden County, Pennsylvania, and also in Birmingham in the UK because some children have not received the MMR (measles, mumps, rubella) vaccine. Measles is one of the most contagious diseases and each person can infect 12 to 18 others. Flu-like symptoms appear two weeks after exposure. In the Birmingham outbreak, 40% of the infected children under age 5 had to be hospitalized.

On a lighter note, have you been wondering how you might learn to take great pictures of ground squirrels and other woodland critters? You are in luck. Award winning Austrian wildlife photographer Julian Rad is offering private ground squirrel photo lessons near Vienna.

Photos are from Julian Rad’s website

Have a great rest of your weekend,

Ruth Ann Crystal MD

P.S. I will be taking next week off for vacation.

COVID news:

US Variant tracker: https://covid.cdc.gov/covid-data-tracker/#variant-proportions

Variants in locations around the globe: https://outbreak.info/

CDC COVID data tracker: https://covid.cdc.gov/covid-data-tracker/index.html#datatracker-home

CDC COVID Hospitalizations (blue) and Emergency Room (orange) visits tracker: https://covid.cdc.gov/covid-data-tracker/index.html#trends_weeklyhospitaladmissions_7dayeddiagnosed_00

Weekly ED visits for respiratory illnesses, by age and disease: https://www.cdc.gov/ncird/surveillance/respiratory-illnesses/index.html

US Wastewater Monitoring: CDC Wastewater Monitor 

CDC wastewater reporting: https://www.cdc.gov/nwss/rv/COVID19-nationaltrend.html

CDC wastewater map: https://www.cdc.gov/nwss/rv/COVID19-currentlevels.html

Biobot: https://biobot.io/data/

National SARS-CoV-2 data from Sarah Anne Willette: https://iowacovid19tracker.org/

Wastewater SCAN: https://data.wastewaterscan.org/

Sewer Coronavirus Alert Network (SCAN) project by Stanford University: https://soe-wbe-pilot.wl.r.appspot.com/charts

Santa Clara County wastewater: https://covid19.sccgov.org/dashboard-wastewater

1/11/24 County of Los Angeles: COVID-19 and Flu Transmission, Hospitalizations Remain Elevated as Residents Return to School, Work https://buff.ly/48rK9RO

"With respiratory virus transmission and hospitalizations remaining elevated in Los Angeles County, the Los Angeles County Department of Public Health (Public Health) is asking residents to help limit exposures and take common sense precautions." 

CDC Respiratory vaccination trends: https://www.cdc.gov/respiratory-viruses/data-research/dashboard/vaccination-trends-adults.html

COVID vaccine 21.4%

Flu vaccine 46.8%

RSV (age 60+) 20.1%

JP Weiland: https://twitter.com/JPWeiland

1/9/24 https://twitter.com/JPWeiland/status/1744862849279643895

Lucky Tran https://twitter.com/i/lists/1425000060979269635

Annotated by Eric Topol MD:

Michael Hoerger modeling:  http://pmc19.com/data/

https://twitter.com/michael_hoerger/status/1744832190309900306

1/9/24:

Variants 

1/8/24 Fortune Well: New, highly mutated COVID variants ‘Pirola’ BA.2.86 and JN.1 may cause more severe disease, new studies suggest https://buff.ly/3RXcmcj

• The author says that 2 studies show that JN.1 may infect deeper in the lung like earlier variants did before Omicron. That potentially could cause more severe disease. But, I did not find that from reading the studies because BA.2.86 and JN.1 can be neutralized by the new XBB.1.5 vaccine.

1/12/24 Fortune Well: COVID levels are 2 to 19 times higher than reported, WHO says as it warns of the potential dangers of repeat reinfection: ‘We don’t know everything about this virus’ https://buff.ly/3ShoKnN

• “We are concerned—deeply concerned—that this virus is circulating unchecked around the world, and that we could have a variant at any time that would increase severity,” she said. “This is not meant to be a scare tactic. This is a scenario we plan for.” said Dr. Maria Van Kerkhove, head of the WHO’s emerging diseases and zoonoses unit.

• “Five years, 10 years, 20 years from now, what are we going to see in terms of cardiac impairment, pulmonary impairment, neurologic impairment? It’s year five in the pandemic, but there’s still a lot we don’t know about it.”

• The concerns regarding COVID infection are multipronged, she said, and include potential acute implications like hospitalization and death, the development of long COVID, and “even longer term effects” like those she referenced.

• It’s estimated that 6% to 10% of those infected with COVID will go on to develop Long COVID, she added. 

Social

TikTok’r @mudflapbrokentire made a 5 minute video telling her community why they should protect themselves against COVID and the social determinants that can make this hard. (I disagree with her saying that COVID is like HIV, however. Although, studies do show that Long COVID can affect your immune system coordination.)

https://twitter.com/drseanmullen/status/1745635997558153369

Pediatrics

1/9/24 Annals of Internal Medicine: Real-World Effectiveness of BNT162b2 (Pfizer mRNA vaccine) Against Infection and Severe Diseases in Children and Adolescents https://buff.ly/48Myi0i

• The Pfizer mRNA vaccine studied in a large cohort of children and teens showed strong protection against COVID infection, severe disease, and ICU during the Delta wave for adolescents and the Omicron wave for children and adolescents, with lower risk of cardiac complications among the vaccinated group during Omicron periods. 

1/10/24 Nature: Vaccines reduce the risk of Long COVID in children https://buff.ly/4879S1L

• Vaccination reduced the likelihood of developing at least one long COVID symptom by 34% and of developing two or more symptoms by 48%. This is likely an underestimate.

• As of mid-December 2023, 7.8% of US children had received their autumn COVID-19 vaccine, well below the rate of influenza vaccination, at 43.3%. 

• A recent US household survey found that the rate of long COVID in children was only 1.3% in 2022, but that still translates to thousands of kids whose health is affected, meaning they might not be able to run around, play or go to school. “If you read the individual stories, the impact of long COVID on a child’s life can be very severe,” Yousaf says. 

1/3/24 Scientific American: Vaccination Dramatically Lowers Long Covid Risk in adults https://buff.ly/3RMFiDx or without the paywall https://archive.is/uhwDB

• Receiving multiple doses of COVID vaccine before your first COVID infection greatly reduces the risk of Long COVID.(70% reduction of LC with 3 doses of vaccine.)

NHS: Is my child too ill for school? https://buff.ly/48sLfwI

Vaccines

1/11/24 Lancet: The effectiveness of COVID-19 vaccines to prevent Long COVID symptoms: staggered cohort study of data from the UK, Spain, and Estonia https://buff.ly/3TS4hYY

• Compared to unvaccinated people, there was a significant (about 40%) lower risk of Long COVID symptoms in people vaccinated with a first dose of any COVID-19 vaccine in 4 multinational cohorts. 

• Protection against Long COVID was about 15% higher for the Pfizer mRNA vaccine than the AstraZeneca vaccine.

1/11/24 Lancet: The potential epidemiologic, clinical, and economic value of a universal coronavirus vaccine: a modelling study https://buff.ly/3TXmV1z

• A universal pan-coronavirus vaccine would be cost effective, saving billions.

• Every 1% increase in efficacy between 10% and 50% could avert an additional 395,000 infections and save $1.0 billion in total societal costs ($45.3 million in productivity losses, $1.1 billion in direct medical costs).

1/10/24 Los Angeles Times: Dr. Joseph A. Ladapo, public health menace https://buff.ly/3TT33g9

• Florida Surgeon General Dr. Ladapo recommends against anyone receiving the mRNA COVID-19 vaccines, even as cases surge nationwide. “Ladapo has moved from promoting useless treatments for COVID-19, such as the drugs hydroxychloroquine and ivermectin, to waging an ever-expanding fact-free campaign against the leading COVID vaccines.” 

Antiviral treatments

1/9/24 

1/9/24 Dr Judy Stone in Forbes: Doctors Aren’t Prescribing Paxlovid Often Enough. Here’s Why https://buff.ly/4aNedZN

• A study showed that providers did not give Paxlovid to ⅔ of eligible patients.

• Paxlovid reduces hospitalizations and it may also decrease the risk of Long COVID by 26%, at least in unvaccinated individuals.

• A a multicentre, randomized, quadruple-blind, parallel-group, phase 3 trial showed that 14 days of Metformin reduced Long COVID by 42% in overweight patients. Most providers do not prescribe metformin for COVID infections however.

• Healthcare providers most often refused to prescribe an antiviral against COVID infection because the patient “wasn’t sick enough.”. But, this shows the provider does not understand how the medications work.

• “Disparities in treatment are likely to grow as the government stops covering the cost of treatment, and Pfizer plans to charge $1,390 per five-day course.” 

Long COVID

1/11/23 Tweet

https://twitter.com/Dakota_150/status/1745481658600464785

The U.S. Senate Committee on Health, Education, Labor & Pensions (HELP): Addressing Long COVID- Advancing Research and Improving Patient Care

• Watch the livestream Thursday, January 18th, 2024 at 10:00am https://buff.ly/4aQuOMn

1/11/24 Nature Immunology (Gladstone UCSF): Long COVID manifests with T cell dysregulation, inflammation and an uncoordinated adaptive immune response to SARS-CoV-2 https://buff.ly/3tZAmDs

Improper communication between the cellular (T cell) and humoral (B cells) adaptive immunity in Long COVID (LC), which can lead to immune dysregulation, inflammation and clinical symptoms associated with this debilitating condition.

LC individuals exhibited systemic inflammation and immune dysregulation with:

• global differences in T cell distribution implying ongoing immune responses,

• sex-specific perturbations in cytolytic subsets

• increased CD4+ T cells with homing receptors to inflamed tissues

• exhausted SARS-CoV-2-specific CD8+ T cells (PD1 and CTLA4 expressed)

• A higher levels of SARS-CoV-2 antibodies and

• a lack of coordination between their SARS-CoV-2-specific T and B cell responses.

1/11/24 Gladstone Institute: In Patients with Long COVID, Immune Cells Don’t Follow the Rules https://buff.ly/3vzTBnN

• People with long COVID have dysfunctional immune cells that show signs of chronic inflammation and faulty movement into organs, among other unusual activity.

• CD4 T cells, which coordinate immune responses, were inflammatory in some people with long COVID.

• CD8 T cells normally kill cells that are infected by viruses or bacteria. In Long COVID, SARS-CoV-2 specific CD8 T cells showed exhaustion, but the broader population of CD8 T cells did not.

  • “Such exhaustion is typically seen in chronic viral infections such as HIV, and means the T cell branch of the immune system stops responding to a virus and no longer kills infected cells,” says Peluso, assistant professor in the UCSF Department of Medicine and co-first author. “This finding fits with some hypotheses that long COVID, or at least some cases of it, are caused by persistent infections by the SARS-CoV-2 virus.”

• “In this current study, we don’t look at specific tissues, but our results indirectly suggest that in long COVID, something is happening within tissues, recruiting tissue homing T cells to migrate there.”

• In people with long COVID, levels of antibodies against SARS-CoV-2 are unusually high, and they don’t synchronize as they usually do with levels of T cells that fight the virus.

  • “This finding points to the notion that during long COVID, you have a breakdown in coordination between different arms of the immune system,” said Dr. Henrich.

“The study provides evidence that ‘LC is a tissue-based disease’ meaning.. dysfunction is happening in different organ systems, said Dr. Michael Peluso.”

3 studies need Long COVID patients’ responses:

1. The FDA and CURE ID’s survey of Long COVID which treatments help and which do not. Important study which will drive future clinical trials of different LC treatments.

2. Long COVID Physio and the University of Toronto invite people with Long COVID from the UK, Ireland, Canada and the US to fill out surveys on disability caused by LC.

3. The NYC Health Department is looking for 10,000 New Yorkers with Long COVID for a long term study. 

1/11/24 What treatments have helped your Long COVID? What treatments have hurt?

The FDA and CURE ID ask that Long COVID patients and clinicians fill out the survey:

Long COVID Treatment Survey for patients and clinicians: https://cure.ncats.io/home

1. Sign In with your Facebook, Twitter or “create one”

—----

Long COVID Physio study (University of Toronto)

https://utorontopt.az1.qualtrics.com/jfe/form/SV_b33Jr3264cjsqFM

Chris Cuomo and Dr. Birx on News Nat8/24 Putrino Lab tweet thread:

https://twitter.com/PutrinoLab/status/1744499645013696707

• If someone has PEM, exercise is contraindicated. Not only do you not prescribe/suggest exercise, you recommend avoiding exercise. That's it. Simple. No gray area.

• Why? 

• Folks with PEM have experienced changes to their physiology. Changes that result in damage when they exert themselves. @RobWust's excellent new paper digs into some of these changes in detail, but the bottom line is: if you have PEM, exertion causes damage. No gray area. 2/ 

• It would be OUTRAGEOUS malpractice to force someone with two freshly broken arms and legs to run on a treadmill and expect an improvement in their health status. If you wouldn't force someone with two freshly broken arms and legs to run on a treadmill, then don't force someone with PEM to exercise. It's that simple. No gray area. /

1/4/24 The Guardian: Long Covid causes changes in body that make exercise debilitating – study https://buff.ly/47vlYR9

• Lay summary of this study from 1/4/24 Nature (Wust lab): Muscle abnormalities worsen after post-exertional malaise in Long COVID https://buff.ly/3vp9GN0

• Biopsies taken before exercise show that in Long COVID, there are more white muscle fibers with fewer mitochondria and fewer capillaries.

• Also, the mitochondria that power the cells did not work well in Long COVID and mitochondrial function worsened after exercise in Long COVID.

• People with Long COVID had much more skeletal muscle tissue damage after exercise and signs of the body attempting repairs. This could explain muscle pain after exercise in Long COVID.

• In addition, there were more amyloid deposits in the skeletal muscles of people with Long COVID. 

Brain injury, loss of grey matter, and cognitive dysfunction at 1-year in people initially hospitalized compared with controls.

"cognitive deficits...equivalent in magnitude to 20 years of aging"

1/5/24 Nature Preprint: Post-COVID cognitive deficits at one year are global and associated with elevated brain injury markers and grey matter volume reduction: national prospective study https://buff.ly/48FlNnC

• 1 year after hospitalization for moderate to severe COVID (n = 351), vs. 2,927 controls.

• 1 year after infection, cognitive defects were global in patients hospitalized for COVID acute infection were equivalent to 20 years of aging. 

• “Cognitive deficits were associated with elevated brain injury biomarkers and reduced grey matter volume. The half-lives of the brain injury markers mean that this is objective evidence of *ongoing* brain injury one year after COVID-19.”

• Global cognitive deficits, elevated brain injury markers with evidence of ongoing brain injury and reduced anterior cingulate cortex volume one year after COVID infection.

• Giving corticosteroids (dexamethasone) during the acute phase was protective which means that brain injury in moderate to severe COVID-19 may be immune-mediated.

• Tweet thread by Greta Wood

https://twitter.com/gkwood3/status/1744650529467228475

11/2023 Preprint: Randomized Controlled Trial of Intravenous Immunoglobulin for Autoimmune Postural Tachycardia Syndrome (iSTAND) https://buff.ly/48OIpBP

• n = 16 got IVIG, 14 got albumin

• Randomized controlled trial of IVIG in POTS found no difference in symptom response compared to albumin infusion. 

Other news:

1/11/2024 Nature: Autonomous artificial intelligence increases screening and follow-up for diabetic retinopathy in youth: the ACCESS randomized control trial https://buff.ly/3vEahdA

• "The [RCT] results ... confirmed our hypothesis that autonomous AI increases diabetic eye exam completion rates, and closes this care gap in a racially and ethnically diverse population of youth with diabetes, compared to standard of care." 

1/5/24 CDC: Second outbreak of Tuberculosis (last was in 2021) from infected bone allografts transplanted into 36 patients https://buff.ly/3NQDgRO

• 2 patients who had spinal surgeries with the bone grafts died.

• At least 15 of 36 recipient patients had sx/sx of TB.

1/5/23 CNN: The FDA has authorized the state of Florida to purchase medications directly from Canadian wholesalers for much less. Pharmaceutical companies oppose the plan. https://buff.ly/3S8vN2X

1/8/24 PNAS: Expanded T lymphocytes in the cerebrospinal fluid of multiple sclerosis patients are specific for Epstein-Barr-virus-infected B cells https://buff.ly/3HbWsFX

• Epstein-Barr virus (EBV) specific lymphocytes are increased in the cerebrospinal fluid (CSF) of people with the first symptoms of Multiple Sclerosis. Thus, EBV may be related to the pathophysiology of MS.

1/12/24 BBC: Birmingham Children’s Hospital inundated with measles cases https://buff.ly/3TZ9yOg

• The hospital has more children with measles than in past decades because of low vaccination rate. Forty percent (40%) of the kids under age 5 with measles had to be hospitalized.

• Each person with measles infects 12 to 18 other people, unless the other people have been vaccinated with the MMR (measles, mumps, rubella) vaccine.

1/13/24 Philadelphia Inquirer: Camden County child tests positive for measles; no known connection to Philly’s outbreak https://buff.ly/3S0r1Dq

• Measles is highly infectious and spreads through breathing in an airborne virus or touching contaminated surfaces, according to the U.S. Centers for Disease Control and Prevention. By some measures, measles is seven times more contagious than COVID-19.

• Measles symptoms appear up to two weeks after an exposure, according to the CDC. Initially, measles presents like a regular flu like illness: Patients may have a high fever, runny nose, and red, watery eyes. Three to five days after symptoms begin, the rash commonly associated with measles breaks out.

• People with known exposure who are not vaccinated or otherwise immune should quarantine for 21 days. 

Do you feel the need to get great pictures of ground squirrels? Austrian wildlife photographer Julian Rad offers a ground squirrel photo workshop near Vienna. How fun! https://radwildlife.com/en/groundsquirrels-photoworkshop/