Dr. Ruth Report, 3/22/26

COVID is decreasing, RSV is unusually high for this time of year, and Flu B is high in some places in the U.S.

Regional wastewater levels for COVID, RSV, Flu A, Flu B:

From: https://data.wastewaterscan.org/

Flu

Overall, outpatient visits for Influenza-like Illness (ILI) have finally decreased significantly, but influenza B is still high in the midwest and northeast.

CDC Outpatient Respiratory Illness Activity Map (Flu) through 3/14/26

Other viruses in wastewater

Regional wastewater levels of HMPV, EVD68, Norovirus, Rotavirus from WastewaterSCAN:

Human Metapneumovirus (HMPV)

This week, a reader asked about HMPV. Most people get HMPV as young children under age 5 and partial immunity helps to protect them from severe symptoms later in life. HMPV causes cold symptoms in most people, but it can make young babies, the elderly and immunocompromised people more sick. It is HIGH in wastewater now across many parts of the United States, but appears to be plateauing. There is no vaccine for HMPV.

Norovirus

Norovirus, sometimes referred to as the “stomach flu”, causes nausea, vomiting, and diarrhea. It is the top cause of foodborne illness in the United States. Norovirus has caused outbreaks on cruise ships and is very contagious. Wastewater levels of Norovirus are HIGH right now, but have plateaued.

Rotavirus

Rotavirus causes diarrheal illness mostly in babies and young children under age 5. Adults are rarely affected due to immunity to the virus. We are seeing HIGH levels of Rotavirus especially in the northeast.

COVID

COVID levels are very low in the West and are at medium levels in most of the rest of the country where there are pockets of higher levels of COVID especially in the Midwest and Northeast. On March 10, JP Weiland estimated that there were about 325,000 new COVID infections per day with about every 1 in 200 people infected, but levels vary depending on location. Michael Hoerger took this week off from calculations, but will update the pmc19.org website in the next few days.

From: Wastewater SCAN today (omits 12 states): https://data.wastewaterscan.org/

In Europe and in the UK, COVID levels in wastewater are low according to Bob Hawkins.

Acute COVID infections, General COVID info

Using machine learning models to inspect US death certificates, a new study shows that there were actually 19% more COVID deaths (155,536 more people died of COVID) through 2021 than previously reported. The unrecognized deaths occurred disproportionately in the South and among individuals with lower educational attainment or belonging to racial minority groups.

Pfizer researchers conducted a multinational trial involving 150 immunocompromised adults to evaluate the efficacy of different nirmatrelvir and ritonavir (Paxlovid) treatment durations (5, 10, or 15 days of Paxlovid treatment) for acute COVID infection. “No significant treatment-arm differences were observed, except people with severe immune problems had better physical health scores at Day 10 of the study if they had been assigned to take 10 days instead of 5 days of [Paxlovid] treatment.” People with severe immunosuppression may benefit from extended treatment with Paxlovid.

A group from Ottawa used freshly cultured umbilical cord derived mesenchymal stromal cells (MSCs) to treat 37 patients with severe COVID acute respiratory distress syndrome (ARDS) in a Phase 1 and a Phase 2b study. The umbilical cord derived MSCs were safe in these critical patients and showed qualitative improvement in all measured clinical outcomes. “MSCs resulted in resolution of lymphopenia, consistent with an important immunomodulatory effect, with significant improvement in patient reported quality-of-life measures (SF-36) at 6 months pointing to possible durable clinical effects,” however the trial was limited by its small size.

From: https://www.cell.com/stem-cell-reports/fulltext/S2213-6711(26)00065-2

Spanish researchers followed immune responses in people who were hospitalized for COVID-19. “Individuals who subsequently developed Long COVID exhibited early abnormalities at infection in innate immunity, particularly involving dendritic cells and γδ T cells. Moreover, three months post-discharge, persistent alterations were observed in several adaptive immune cell subsets in patients who next developed Long COVID over time.” Early innate immune dysregulation and lasting T cell shifts after severe COVID infection appears to predispose patients to Long COVID.

Pediatrics

A group from Munich studied 83 children and teens and found “measurable vascular alterations in pediatric Long COVID, including microvessel reduction and increased arterial stiffness.” Children with shortness of breath (dyspnea) had “a distinct vascular phenotype characterized by marked capillary loss.”

Researchers analyzed a cohort of 1,180 children under the age of two hospitalized at multiple U.S. pediatric medical centers to compare the severity of respiratory failure caused by RSV versus SARS-CoV-2. The study found that while RSV was more prevalent, the children infected with COVID experienced higher rates of intensive care admission and a more rapid progression to severe disease states.

Long COVID

A Swiss prospective multicenter cohort study followed 1,027 healthcare workers (HCWs), 456 who were infected with ancestral COVID and 571 who were uninfected, for four years. At 18.5 months follow up, 41% of infected HCWs still had at least one Long COVID symptom with fatigue, loss of smell or taste and brain fog being the most common. By 4 years after COVID infection, 59% of HCW who were still in the study reported at least one Long COVID symptom, although the number of participants in the study declined over time.

Intravenous immunoglobulin (IVIG) is a therapy made from pooled plasma from >4,000 people and contains a wide range of antibodies. A new study from China studied how antibodies to COVID changed over time by evaluating different samples of IVIG and found that SARS-CoV-2 neutralizing antibodies increased sharply from 2020 to 2023 in IVIG samples, reflecting increasing population immunity to COVID. They also found that “IVIG exerts anti-COVID-19 effects via synergism between antibody blockade and Ab-dependent cellular cytotoxicity (ADCC).” Some people with Long COVID feel better after getting IVIG and this could possibly be due to antibodies in IVIG helping to neutralize persistent SARS-CoV-2 virus.

Peroxisomes are small, membrane-bound organelles found in the cytoplasm of cells that play a critical role in metabolism, detoxification, and lipid biosynthesis in cells. Scientists from China studied the SARS-CoV-2 virus in mice, hamsters, drosophila flies and in 1,032 people with Long COVID. They found that the SARS-CoV-2 virus impairs intestinal stem cell function and inhibits epithelial repair of the gut lining by disrupting peroxisomes. GI symptoms were alleviated with peroxisome activator medications sodium phenylbutyrate and fenofibrate.

A new review from Korea looks at the evidence for viral persistence of SARS-CoV-2 in various human tissues and how the resultant immune dysregulation and chronic inflammation may lead to Long COVID symptoms. It also reviews possible treatments for Long COVID.

Figure 4: Mediator and pathway framework linking SARS-CoV-2 persistence to long COVID (PASC).

Figure 5: Therapeutic strategies for addressing viral persistence in long COVID.

From: https://www.mdpi.com/2673-8112/6/3/54

A study from the University of Alberta analyzing 20 participants found that Long COVID with ME/CFS is associated with major immune system changes, including T cell exhaustion, impaired NK cell function, and depletion of MAIT and gamma delta T cells. These changes were linked to elevated Galectin-9 and TIM-3 signaling, suggesting ongoing immune dysregulation. The findings support the idea that persistent immune exhaustion may contribute to chronic symptoms in Long COVID, ME/CFS type.

A study from Rio de Janeiro evaluated 75 patients with Long COVID and found early kidney tubular injury in Long COVID using urinary biomarkers, even when standard kidney function tests appeared normal. Tubular damage was more common at 6 months, while glomerular dysfunction appeared later at 24 months. These findings suggest kidney injury in Long COVID may be underrecognized and detectable earlier with more sensitive tests.

A review from BRAC University and Qassim University analyzing 202 studies found that neurological complications of COVID are primarily driven by immune activation and vascular injury rather than widespread direct viral infection of the brain. Receptors such as ACE2 and NRP1 may allow viral entry, while toll-like receptors amplify inflammation.

A mouse study from Seoul National University found that the SARS-CoV-2 spike protein S1 subunit activates microglia through Kv1.3 channels, triggering neuroinflammation and anxiety-like behavior. The antipsychotic medication chlorpromazine reduced both microglial activation and behavioral effects.

Measles

As of March 19, 2026, 1,487 confirmed measles cases were reported in the United States in 2026. We are only a quarter of the way through this year and we are expected to surpass the 2,285 U.S. measles cases reported for the entire year of 2025 by this summer. Last year was a 35 year high for measles cases. The U.S. has not lost its measles elimination status yet, but it probably will in November when officials will evaluate the numbers.

It appears that the South Carolina measles outbreak may be slowing down. As of March 20, 2026, the South Carolina Department of Public Health reports 997 cases of measles centered around Spartanburg County.

As of March 17, 2026, 443 Utahns have been infected with measles, 98 of which were reported in the last 3 weeks.

Government Health News

This week, a federal judge blocked RFK Jr.’s vaccine policy changes on childhood vaccines, invalidated his appointed Advisory Committee for Immunization Practices (ACIP) panel, and voided all decisions made by ACIP advisers over the past year. As a result, ACIP cannot meet this week at their previously scheduled meeting. While this appears to be a victory for evidence-based science, Kennedy’s previous vaccine misinformation has unfortunately already increased uncertainty among some parents about routine childhood vaccinations.

Border czar Tom Homan confirmed that hundreds of ICE officers will be deployed to U.S. airports starting Monday to assist with security lines during a 6 week partial government shutdown that has caused over 400 TSA agents to resign and thousands more to miss work due to unpaid wages. Critics worry about the lack of specific airport security training for the ICE agents.

Other news

A deadly outbreak of meningitis in the UK has led to two deaths and more than two dozen confirmed or suspected cases, primarily affecting teens and young adults. The NHS started giving the meningitis vaccine to babies in 2015, so most young people born before 2015 are unprotected against meningitis. Vaccine centers have opened to give the meningitis vaccine to students.

“Athletes who play collision and combat sports with exposure to repetitive head trauma are at increased risk for cognitive decline.” MRI scans show that persistent blood-brain barrier (BBB) disruption and systemic inflammation remain in these athletes for years after they have retired.

Fig. 1. BBB disruption is associated with cognitive decline in retired athletes.

3D BBB permeability maps from one control participant and two retired players, revealing contrast-agent leakage in players with nonextensive and extensive BBB disruption.

From: https://www.science.org/doi/10.1126/scitranslmed.adu6037

In a real-world study of 888 patients with solid cancers, tumor whole-genome sequencing (WGS) led to clinically actionable findings in over 40% of cases. These results influenced treatment decisions, including targeted therapies and clinical trial enrollment. Biomarker-informed cancer treatment also yielded significantly longer overall survival.

“The thymus is an organ in the chest that produces T cells, essential components of the immune system. However, after peaking in size in adolescence, the thymus progressively shrinks as people age, leaving its relevance to adult health unclear.” Using AI-based imaging in studies of over 5,000 individuals, researchers found that thymus health in adults predicts overall health, disease risk, and response to cancer immunotherapy.

From: https://www.nature.com/articles/d41586-026-00633-6

There is a growing primary care shortage in America and patients are often having to wait 1 to 2 years to be seen by a new primary care doctor or physician’s assistant. In response, some healthcare systems including Mass General Brigham (MGB) are using AI-powered virtual care models where patients may interact primarily with digital tools. These systems aim to improve access, triage, and efficiency, but questions remain about quality, trust, and the role of human clinicians.

“Many factors contribute to the shortage of primary care providers. Many primary care doctors, such as pediatricians, internists, and family medicine physicians, are dissatisfied with their pay; they earn about 30-50% less, on average, than specialists such as surgeons, cardiologists or anesthesiologists. At the same time, their workload has been increasing for at least 20 years” with more complex patient visits in shorter time slots, more paperwork like prior authorizations required by health insurance companies, medical records documentation and responding to patient messages.

Researchers have identified a brain-skin-immune pathway in mouse models showing that psychological stress activates certain sympathetic neurons that recruit and activate eosinophils which worsen skin inflammation. This pathway, involving CCL11-CCR3 signaling and beta-adrenergic activation, may help explain stress-related flares in conditions like eczema. Targeting this neuroimmune circuit may offer new treatment approaches.

Figure: Pdyn+ sympathetic neurons mediate psychological stress–evoked eosinophilia and dermatitis

From: https://www.science.org/doi/10.1126/science.adv5974

The FDA has expanded approval of the RSV vaccine Arexvy to adults aged 18–49 who are at increased risk of severe disease.

“The human digestive tract is much more than a place where food is processed; it is the largest immune organ in the body.” In HIV disease, a constant, chronic inflammation from a “leaky gut” may cause increased risks of heart disease, metabolic disorders, and accelerated aging. A group from Spain tested antiviral treatment with amivudine/abacavir plus either dolutegravir or ritonavir-boosted darunavir for 2 years. “Both groups had similar HIV-1 suppression rates and recovery of CD4+ T cells. However, treatment with dolutegravir led to increased gut microbial richness…associated with reduced inflammation and lower immune activation, outcomes that did not occur with darunavir/ritonavir.”

From: https://communities.springernature.com/posts/beyond-viral-suppression-how-the-right-hiv-drug-helps-the-gut-heal-itself

As heart attacks are being seen at younger ages, the ACC and AHA recommend in new guidelines that everyone get a lipoprotein(a) test once, and that people with high triglycerides or diabetes should also get ApoB tests. In addition, children should have cholesterol and lipids checked once as a screen between ages 9 to 11. Starting at age 19, cholesterol levels and lipids should be checked at least every 5 years. At age 30, people should be screened with the online AHA calculator called Prevent.

A gift shop at Hobart Airport in Tasmania got an unexpected visitor when a brushtail possum tried to blend in the stuffed animal display. A customer noticed the possum’s eyes moving and airport staff were called to catch and release the little fellow back outside.

From: https://www.cnn.com/2026/03/19/travel/possum-toys-australia-airport-shop-intl-scli

Have a good week,

Ruth Ann Crystal MD

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References & Notes

CDC Respiratory Illnesses https://www.cdc.gov/respiratory-viruses/data/index.html

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

Regional wastewater levels for COVID, RSV, Flu A, Flu B.

RSV

RSV in California

From: https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/RespiratoryVirusReport.aspx

Flu

CDC Flu View: https://www.cdc.gov/fluview/index.html

Outpatient Visits for Influenza-like Illness (Flu):

Outpatient Respiratory Illness Activity Map (Flu) through 3/14/26

California Influenza: https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/RespiratoryVirusReport.aspx

Other viruses in wastewater

Regional ww levels of HMPV, EVD68, Norovirus, Rotavirus.

COVID

Wastewater SCAN (omits 12 states): https://data.wastewaterscan.org/

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

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

https://www.cdc.gov/respiratory-viruses/data/activity-levels.html

JP Weiland: https://twitter.com/JPWeiland https://bsky.app/profile/jpweiland.bsky.social

3/10/26

Michael Hoerger modeling: http://pmc19.com/data/, https://twitter.com/michael_hoerger

• Find the complete PMC dashboard at http://pmc19.com/data

• US by State: https://pmc19.com/data/index.php#states

• Worldwide data: https://pmc19.com/data/index.php#internationa

“There is no update for the week of March 16. Updates will resume soon (Mar 20-23). Transmission is following the forecasted decline.”

CDPH California SARS-CoV-2 in Wastewater: https://skylab.cdph.ca.gov/calwws/

https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/RespiratoryVirusReport.aspx

COVID in California is VERY LOW

Santa Clara County wastewater: https://publichealth.santaclaracounty.gov/health-information/health-data/disease-data/covid-19/covid-19-wastewater

International Surveillance

Mike Hoerger https://pmc19.com/data/index.php#international

• Austria: Federal Government of Austria |

• Canada: C19 Resources Canada * | World Health Network (WHN) Canada **

• Finland: WHN Finland **

• France: Airborne Risk Reduction Association (ARRA) France

• Germany: WHN Germany **

• Netherlands: WHN Netherlands **

• U.K: Buckinghamshire Disability Service (BuDS) U.K.

Canada

Tara Moriarty Canadian COVID data: https://bsky.app/profile/moriartylab.bsky.social

Canada wastewater https://health-infobase.canada.ca/wastewater/

UK

UKHSA Dashboard: https://ukhsa-dashboard.data.gov.uk/

UK BuDS: https://buds.org.uk/category/our-work/iag-covid-19/risk-assessments/

UK COVID PCR Test Positivity Map: https://jamestindall.info/skeuomorphology/ladb_covid/index.html

Wastewater monitoring in Scotland

Bob Hawkins UK and Europe https://substack.com/@bhawkins3

UK Summary.

Once again, the key Covid indicators in England, Scotland, Wales, and Northern Ireland stayed low, suggesting a low level of risk.

Flu activity has dropped to baseline levels across all home nations, returning to typical out-of-season patterns and confirming that this year’s flu season is over.

Europe through 3/12/26

Europe

https://arcgis.jrc.ec.europa.eu/portal/apps/dashboards/e296cdf0c0d042e6b60b07a351f2dc5c

Australia https://bsky.app/profile/mikehoney.bsky.social

Variants

US Variant tracker, Last updated 8/28/25

https://x.com/RajlabN

Weekly variant roundup by Mike Honey: https://bsky.app/profile/mikehoney.bsky.social

Acute COVID infections, General COVID info

3/18/26 Science: Applying machine learning to identify unrecognized COVID-19 deaths recorded as other causes of death in the United States https://buff.ly/5knqHnt

3/19/26 Health and Quality of Life Outcomes: Health-related quality of life in immunocompromised adults with mild–moderate COVID-19 treated with nirmatrelvir-ritonavir: results from the randomized, double-blinded EPIC-IC trial https://buff.ly/rSXUnYk

3/12/26 Cellular immunotherapy for COVID-19-induced acute respiratory distress syndrome: Results of the CIRCA-19 phase 1 safety and phase 2 randomized controlled trials https://buff.ly/vTWS5QO

3/17/26 J of Infection: Persistent T cell phenotypic alterations and early innate immune dysregulation as potential biomarkers of Long COVID https://buff.ly/UpeDVgL

Pediatrics

3/16/26 European Journal of Pediatrics: Microcirculatory impairment and increased arterial stiffness in pediatric Long COVID patients https://buff.ly/V8llSNn

3/6/26 CIDRAP: Babies with COVID-19 develop more serious disease than those with RSV, US data reveal https://buff.ly/7Cbj6NP

3/2026 Open Forum Infectious Diseases: Characteristics of Young Children Hospitalized With Acute Respiratory Failure From Infection With Respiratory Syncytial Virus, SARS-CoV-2, or Both, November 2023–March 2024 https://buff.ly/93SlOP7

https://academic.oup.com/ofid/article/13/3/ofag088/8505676

Long COVID

3/17/26 Infection: Persistence of Post-Acute COVID-19 Sequelae (PASC) symptoms in healthcare workers four years after ancestral SARS-CoV-2 infection: a prospective multicentre cohort https://buff.ly/XZfxIKQ

3/2026 European Respiratory Journal: Clinical practice guideline for long COVID prevention and treatment https://buff.ly/xmNpjc5

3/13/26 iScience: Increased anti-SARS-CoV-2 antibody titers in plasma-derived intravenous immunoglobulin collected in Southern China https://buff.ly/E4dAgbW

3/11/26 Developmental Cell: Impaired VLCFA-peroxisome-mediated intestinal epithelial repair causes gastrointestinal sequelae of long COVID https://buff.ly/7EDg4IA

3/11/26 Developmental Cell: Gut check: Peroxisomes as a missing link in long COVID intestinal repair https://buff.ly/JNgdcrg

https://www.cell.com/developmental-cell/abstract/S1534-5807(26)00076-6

3/18/26 COVID (S. Korea): Persistent Viral Reservoirs in Post-COVID Patients: Current Evidence and Clinical Implications https://buff.ly/wsW2gwP

2/24/26 Frontiers in Immunology: Single-cell analysis reveals immune remodeling of monocytes, NK cells, T cell exhaustion, and Galectin-9–associated depletion of gamma delta and mucosal-associated invariant T cells in Long COVID with ME/CFS https://buff.ly/E5HbYgw

3/5/26 Int J of Molecular Sciences: Tubular Damage Biomarkers Are a Useful Tool for Identifying Early Renal Injury in Long COVID | MDPI https://buff.ly/Qgj1XyG

3/9/26 3 Biotech: Receptor-mediated mechanisms underlying neurological complications in COVID-19: from viral entry to neuroinflammation https://buff.ly/eHnMr9e

3/4/26 Biological Psychiatry Global Open Science (Preprint): SARS-CoV-2 spike protein S1 subunit induces neuroinflammation via microglial Kv1.3 channel [in mice] https://buff.ly/0qs98LI

Measles

CDC Measles updates (on Wed.): https://www.cdc.gov/measles/data-research/index.html

South Carolina Department of Public Health (Measles):

https://dph.sc.gov/diseases-conditions/infectious-diseases/measles-rubeola/2025-measles-outbreak

Utah Department of Public Health (Measles): https://epi.utah.gov/measles-response/

John Hopkins US Measles Tracker: https://publichealth.jhu.edu/ivac/resources/us-measles-tracker

3/20/26 CIDRAP: US measles outbreak approaches 1,500 cases https://buff.ly/dVtD2Rw

Vaccine Preventable Disease Tracker

10/29/25 Vaccine-Preventable Disease: A Global Tracker from Think Global Health https://buff.ly/6qBMq0w

Government Health News

3/16/26 PBS: Judge blocks RFK Jr. from scaling back childhood vaccine recommendations https://buff.ly/jyTWaNe

3/16/26 NY Times: Judge Strikes Down Kennedy’s Vaccine Policies https://buff.ly/OhxPQbc

3/22/26 NPR: ICE officers set to deploy to airports as delays mount, border czar Homan confirms https://buff.ly/3NBE8qx

Other news

3/20/26 Sky News: UK Meningitis outbreak: More vaccine centres to open after 100 students turned away https://buff.ly/zZUu2tK

3/18/26 Science Translational Medicine: Blood-brain barrier disruption, traumatic encephalopathy, and cognitive decline in retired athletes https://buff.ly/77F8dty

3/20/26 Nature Medicine: Real-world clinical utility of tumor whole-genome sequencing in solid cancers https://buff.ly/QaihFWx

3/18/26 Nature: Thymus health is a predictor of lifelong well-being and immunotherapy effectiveness https://buff.ly/KSH5lHu

3/19/26 Science: A sympathetic-eosinophil axis orchestrates psychological stress to exacerbate skin inflammation https://buff.ly/EF65OGc

3/4/26 Nature: Dolutegravir restores gut microbiota in late-stage HIV-1 unlike darunavir: an open-label, randomized clinical trial https://buff.ly/w8FdV4i

3/9/26 Nature: Beyond Viral Suppression: How the Right HIV Drug Helps the Gut Heal Itself https://buff.ly/KjhcWk0

3/13/26 CIDRAP: FDA approves use of RSV vaccine Arexvy in at-risk younger adults

https://www.cidrap.umn.edu/respiratory-syncytial-virus-rsv/fda-approves-use-rsv-vaccine-risk-younger-adults

3/16/26 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Dyslipidemia: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines https://buff.ly/eH8E6TE

1/9/26 NPR: Your next primary care doctor could be online only, accessed through an AI tool https://buff.ly/HpYQ3i1

3/19/26 CNN: Real possum found among plush toy animals in Australian airport gift shop https://buff.ly/p62leLQ