AMA Update covers a range of health care topics affecting the lives of physicians, residents, medical students and patients. From private practice and health system leaders to scientists and public health officials, hear from the experts in medicine on COVID-19, medical education, advocacy issues, burnout, vaccines and more.
In today’s AMA Update, AMA Vice President of Science, Medicine and Public Health Andrea Garcia, JD, MPH, shares the latest from the CDC on drug-resistant ringworm infections in New York City and monkeypox cases in Chicago. Also FDA considers recommendations on over-the-counter birth control pills. AMA Chief Experience Officer Todd Unger hosts.
- Andrea Garcia, JD, MPH, vice president, science, medicine & public health, American Medical Association
Unger: Hello and welcome to the AMA Update video and podcast series. Today we have our weekly look at the headlines with the AMA's Vice President of Science, Medicine and Public Health, Andrea Garcia in Chicago. I'm Todd Unger, AMA's chief experience officer, also in Chicago. Welcome, Andrea.
Garcia: Thanks, Todd. It's good to be here.
Unger: Now, this is a headline I didn't expect to see this weekend, but it is what we're talking about, which is ringworm. What's going on with that?
Garcia: Yeah, so last Thursday, the CDC released a new report revealing that two cases of highly-contagious, drug resistant ringworm infections had been detected in New York City. And while two doesn't sound like a big number, these are the first such cases reported in the U.S. And according to multiple sources, one infection was identified at a 47-year-old woman who developed a bad case of ringworm, which is also known as tinea, and she was traveling in Bangladesh.
Reportedly, that rash appeared across most of her body and the typical antifungal creams did nothing to alleviate it. That prompted the diagnosing physician to ask colleagues if they'd seen anything similar, which revealed a second case in a 28-year-old New York woman. Reportedly, that second woman had developed ringworm back in the summer of 2021. In that case, there was no travel outside of the U.S. Both of these infections turned out to be caused by a relatively new species of ringworm-causing fungus called T. indotineae.
Unger: Do we have any sense of what's driving this?
Garcia: Well, over the past decade, infections from this drug resistant fungus have spread rapidly in South Asia. According to the CDC, it's likely being driven by overuse of medications to treat them, including topical antifungals, corticosteroids. But outside of Asia, cases have also been identified in Europe and Canada. What makes these cases unique is that those typical antifungals and oral terbinafine, which are normally those first line treatments, are frequently ineffective against these infections.
We know that ringworm spreads pretty easily through skin-to-skin contact, and while it can occur at any age, it is more common in children. So it's definitely something to keep an eye on.
Unger: Is that—in terms of level of concern, where are we on this one?
Garcia: Well, I think it's the overall trend that we need to be watching here. We're often very focused on drug resistant bacteria, but drug resistant fungi are also a serious public health concern. And you'll probably recall, a few months ago, we talked about cases of C. auris, which is another type of drug resistant fungal infection. That's been spreading in health care facilities in the U.S. That infection is extremely difficult to treat and can be deadly.
And some physicians are reporting that they are seeing an increase in patients with fungal infections whose conditions either take longer to respond to the usual treatments or require additional medications. And I think the worry comes when you are used to treating something and use a treatment and expect to work, and then it doesn't.
Unger: I'm starting to think of that opening scene of The Last of Us when they talked about fungus being the real problem is turning out to be kind of prescient here. Andrea, what do physicians need to know about this?
Garcia: The CDC has said that physicians should be on the lookout for antimicrobial resistant tinea, particularly when lesions do not improve with those first line treatments. Also, diagnosing this type of infection requires specialized testing, so physicians who suspect it should be reaching out to their state and local health departments for assistance. They should also be aware of treatment options and that some patients may require prolonged therapy, so sometimes up to 12 weeks.
It's important to take standard precautions when caring for patients with possible tinea and also educating patients on ways to prevent it. Physicians can also help prevent the spread by just being good stewards of antifungal medications and corticosteroids.
Unger: Thank you so much for that update. We're going to add ringworm to the list of things we're paying attention to while we take, hopefully, something off. Let's talk a little bit about monkey pox or mpox, as it's known. Tell us about the latest there.
Garcia: Well, the WHO announced last week that it is no longer classifying mpox as a public health emergency of international concern. And that comes nearly a year after it was first deemed one back in July of 2022. The WHO director lifted that designation based on the recommendation of their advisory committee. And that advisory committee cited a sustained decline in recent infections with about 90% fewer cases globally over the last three months.
The director did urge countries to maintain their testing capacity so they could quickly respond to outbreaks. And I think that advice hits close to home here in the U.S. as the CDC just issued a health alert for mpox earlier this week.
Unger: Yes, indeed close to home because I believe that does involve the city of Chicago. Tell us more about that, Andrea.
Garcia: While we've seen cases decline here since they peaked in August of 2022, that health alert stressed that the outbreak is not over. The CDC continues to receive reports of cases that reflect ongoing community transmission. CDC and local partners are investigating a cluster of mpox cases here in Chicago where a total of 12 confirmed and one probable case of mpox have been reported in less than a month. All of those cases were among symptomatic men. None have been hospitalized.
I think it's worth noting that nine of the 13 cases were among men who had received two doses of the Jynneos vaccine. And although we know that vaccine induced immunity is not complete, vaccination continues to be one of the most important prevention measures and it can help reduce the severity of symptoms.
The primary purpose of that HAN from the CDC was to inform clinicians and public health agencies about the potential for new clusters or outbreaks, especially as we head into spring and summer when people tend to gather for festivals and other events and to provide resources to clinicians on evaluation, treatment, vaccination and testing.
Unger: All right, that's good to know and we'll keep our eye on that as well. Andrea, moving into—back to the world of COVID, seems like a good time to take stock of the pandemic with the COVID public health emergency officially ending here last Thursday. Been a lot of headlines over the past few years, but it did seem to end pretty quietly. What's your take?
Garcia: I think that's true, and it certainly went out quieter than it came in. It's not really being seen as a celebratory moment but more a phasing out of pandemic-era policies. I think that's understandable given where we are. According to The Washington Post COVID tracker, we're at about 1.1 million Americans who died of COVID since late February of 2020, and we're still seeing about 1,000 people die every week. And even though we did see a significant drop in COVID deaths between 2021 and 2022, it's still the fourth leading cause of death in the last year or so.
And then if we look globally, it's claimed nearly 7 million lives, and those are the ones that we know about. While we've seen those mandates fall away, this is a complicated moment for a lot of people, especially for those who lost people close to them, who are still suffering from long COVID, and of course, those who remain at high risk of severe outcomes.
Unger: And indeed, those are still significant numbers, and as we'll find out from the AMA Update that's upcoming with Dr. Akiko Iwasaki, long COVID still represents the quote, "pandemic after the pandemic." More on that soon. Andrea, we'll continue to follow that as we navigate what is a new phase, but another headline this week could have broad implications. And that is that FDA advisors have cleared the way for an over-the-counter birth control pill. Why don't you tell us where that stands now and what it'll mean if it goes through?
Garcia: So it was a unanimous vote last week by an FDA advisory committee of outside experts that backed allowing Opill, which is a daily progesterone-only birth control pill to be available without a prescription. And if the FDA follows this recommendation, this medication would be the first birth control pill available over the counter in the United States. As a reminder, the agency doesn't have to follow the recommendations of its advisors, and a decision is expected on this in the summer or early fall.
Unger: And what is the AMA's stance on this?
Garcia: The AMA applauded the advisory committee's decision, saying it strongly supports removing prescription access barrier to contraceptive, given that access is one of the most cited reasons why patients do not use oral contraceptives. We believe the benefits of widespread availability far outweigh the limited risk associated with their use.
That statement read, "At this tumultuous time for reproductive health in the United States, allowing access to OTC oral contraceptives is a safe and necessary step that must be taken to ensure that all individuals are able to effectively limit unintended pregnancies. And we urge the FDA to act swiftly to approve OTC access to oral contraceptives without an age restriction."
Unger: We'll keep an eye on that as well. That's big news. Andrea, thanks so much for being here today. That wraps up today's AMA Update. We'll be back soon with another episode. In the meantime, you can find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us. Please, take care.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.