EA Serman, B Witrick, L Rennett. NEJM 2026; DOI: 10.1056/NEJMc2604004. Clusters of Concern — Spatial Link between Childhood Undervaccination and Measles Outbreaks in South Carolina
An excerpt:
As of April 8, 2026, South Carolina had 997 confirmed cases of measles, of which 95.3% were reported to be among unvaccinated residents.2 Of these cases, 90.8% occurred in children (<18 years of age).2 Thus, school-based vaccination patterns provide a reasonable indicator of local pediatric susceptibility in the communities where transmission has occurred…
Spartanburg County (population, 380,000) was identified as the dominant cluster, containing 27 of 109 hot-spot tracts (24.8%). Of the 997 reported measles cases in the state, 940 (94.3%) occurred in Spartanburg County…
The mean vaccination coverage was lower in the schools with reported measles cases (coverage, 83.9%) than in those with no reported cases (coverage, 92.9%)…The locations of the 30 schools with measles exposure were not uniformly distributed: 26 (87%) were located within or adjacent to undervaccinated hot-spot tracts
In other health news, there is a reason why milk is pasteurized:
For those of you who like online games, there are two that I recently discovered that are quick and fun. Currently, both games are free.
MapTap.gg Daily geography game. Each day, the game asks you to identify 5 locations on a realistic unmarked 3D globe. The closer your guess, the higher your score. Each day there are short vignettes and facts.
Anno-Game Daily history game. Each day, the game asks you to determine the year of 5 important historical events. The closer your guess, the higher your score.
K Schulman, AL Kellermann. NEJM 2026;394:1669-1672. Substandard Generic Drugs — Threats to Patient Safety and National Security
An excerpt:
Generic drugs account for more than 90% of prescriptions filled in the United States. The first paragraph on the home page of the Office of Generic Drugs at the Food and Drug Administration (FDA) asserts that “FDA-approved generic drugs have the same high quality, strength, purity and stability as brand-name drugs.” On the strength of this assurance, America’s doctors, pharmacists, and patients assume that every version of a generic drug is equally safe. But this proposition is now being seriously challenged...
Between 2009 and 2019, the availability of generic medicines saved U.S. patients $2.2 trillion, according to the FDA.
Over time, intense price competition drove most production of generic drugs and ingredients offshore to countries with low labor costs and lax regulatory controls. Once that shift occurred, relentless pressure to minimize costs led some manufacturers to compromise on quality. Rapid globalization also outstripped the FDA’s capacity to monitor manufacturers. In 2022, the Government Accountability Office reported that 61% of foreign plants had not been inspected by the FDA in the preceding 5 years.1
When FDA inspectors finally reach these plants, some find glaring problems…More than 60% of generic-drug shortages are attributable to quality concerns, according to the FDA…
A private-sector laboratory detected high levels of nitrosamines (known carcinogens) in drugs made by several FDA-approved manufacturers, prompting recalls of metformin, angiotensin-receptor blockers, angiotensin-converting–enzyme inhibitors, prazosin, and ranitidine. More recently, independent tests of generic methylphenidate found nitrosamine levels above the FDA’s safety threshold in 7 of 15 immediate-release products…2
Recently, a team of U.S. and South Korean researchers with access to FDA data determined that significantly more serious adverse event reports were linked to generic drugs manufactured in India than to equivalent drugs manufactured in the United States…4
In 2008, a total of 238 deaths in the United States were linked to adulterated Chinese heparin. When the FDA toughened its approach to quality assessment of foreign manufacturers, shortages of more than 200 medications followed. This crisis prompted the FDA to prioritize minimizing drug shortages over ensuring safety…
There is a better way to assure the safety of generic drugs. In 1994, the European Medicines Agency (EMA), for example, established a proactive approach involving risk-based surveillance in addition to systematic planned and ad hoc testing of generic drugs both on the market and during routine inspections of manufacturers (in contrast, the FDA does not routinely test generic-drug products themselves, either on the market or during quality inspections of manufacturing plants). EMA testing relies on a network of official medicines control laboratories (OMCLs) that operate in accordance with International Organization for Standardization (ISO) accreditation standards for testing and calibration laboratories. At any point in a drug’s life cycle, an OMCL can pull samples for product testing...
The U.S. government should oversee an effort to rebuild America’s capacity to manufacture generic drugs, combining investment in private manufacturing with incentives for purchasing U.S.-made products under the Medicare and Medicaid programs. Currently, the United States is vulnerable to an embargo of essential drugs or the materials required to make them. A recent evaluation for the Department of Health and Human Services found that 87% of sites that make active pharmaceutical ingredients (APIs) and 63% of sites that produce finished dosage forms were located overseas…
My take (borrowed from the authors): Most generic drugs are safe, but a troubling minority are not…The United States already tests a wide range of consumer products. We should also test our generic drugs.
Methods: This accelerometer-based prospective cohort study using the UK Biobank analyzed 17,088 participants. There were 1233 incident cardiovascular disease events which occurred over a median follow-up of 7.85 years.
Key findings:
“Meeting the 150 min/week guideline yielded a modest ~8%–9% risk reduction across fitness levels, whereas achieving a >30% risk reduction required threefold to fourfold higher volumes (~560–610 min/week)”
“Approximately 11.6% of participants, 1980 of 17,088, achieved at least 560 min per week, indicating that although such volumes are attainable, they represent a high behavioural threshold for most individuals”
Limitations: the cohort is likely healthier and fitter than the general population, reflecting a healthy volunteer bias
My take: More moderate-to-vigorous physical activity (MVPA) is associated with better outcomes. Current recommendations of 150 min/week offer benefits but more time is associated with optimal cardiovascular protection.
I am reposting this from last year with slight modifications.
An ICU colleague indicated that she really does not like to work on summer holiday weekends. While she is a hard worker, what she doesn’t like is seeing kids with drowning and firework injuries. All of a sudden a happy time becomes tragic. With that in mind, here are a few tips to prevent drowning.
Also, firearm deaths are the leading cause of death in children in the U.S. and motor vehicle accidents are second. So, firearms need to be secured and drive safely on the way to the pool, lake, river or beach.
S Gerke et al. NEJM 2026; 394: 1561-1563. Utah’s Prescription-Renewal Pilot Program — Autonomous AI Managing Patient Care
An excerpt:
In January 2026, Utah rolled out a 12-month pilot program involving an AI system developed by health tech startup Doctronic that autonomously renews certain prescriptions for people with chronic conditions…1,2
Although the program is limited to prescription renewals for 192 commonly prescribed drugs (see box),1,2 it could pave the way for expanded initiatives that include additional products, autonomous initial prescribing, and broader geographic areas…
One question is whether it targets a clinically meaningful problem. The stated purpose is to address medication nonadherence…Automated medication-refill programs for various classes of drugs, including antihypertensives, lipid-lowering agents, and antidiabetic agents, have meaningfully increased adherence…4
Autonomous renewal would be inappropriate for medications requiring frequent dose adjustments or in patients whose clinical status could change rapidly…physician oversight to detect early signs of toxic effects, disease progression, or changing organ function that would necessitate dose modification…AI-based refill generation without a defined end point may preclude opportunities for physician–patient discussions that could curb polypharmacy or medication overuse.
The Utah program could also present legal problems. Doctronic’s AI system, which reportedly hasn’t been reviewed by the Food and Drug Administration (FDA),1 should probably be considered a device under the Federal Food, Drug, and Cosmetic Act (FDCA)…
Another FDCA provision specifies that dispensing a prescription drug constitutes misbranding — a violation carrying potential civil or criminal penalties — unless it occurs “upon a written prescription of a practitioner licensed by law to administer such drug” or upon an oral order that is promptly turned into a written order by the pharmacist…
It is unclear whether Utah’s AI system complies with these requirements. Even if Utah allows AI-based prescribing in the absence of supervision by a licensed physician or other prescriber, federal law would preempt state law…
The FDA may decide to look the other way and allow this experiment to continue, leaving clinicians and patients without safety assurances amid an extraordinary expansion of autonomy for AI.
My take: There may be many situations in which agentic AI would be helpful with pharmacy management. However, until this technology is proven to be safe, like all other devices, it should be limited to situations in which the prescribing physician is in agreement with this process.
“One death is a tragedy; a million is a statistic.” This quote is often misattributed to Joseph Stalin but is likely derived from the German journalist and satirist Kurt Tucholsky. So much of the arguments for vaccines focus on the millions of lives that have been saved. Yet, it is the individual sad stories that are often much more powerful. I was thinking of this quote as I read a NY Times Commentary by Rebecca Archer (4/21/26): Measles Took My Daughter. This Is What I Want Everyone to Know.
An excerpt:
When my daughter Renae, my firstborn, was 5 months old she spiked a fever…At the hospital the doctors noted the red spots on her body and diagnosed her with measles.
This was 2013, and Manchester, England, where we lived, was experiencing a measles outbreak that resulted in more than 1,000 suspected cases. A 1998 study by a British doctor, Andrew Wakefield, linking the measles, mumps and rubella vaccine to autism had caused vaccination rates to plummet. The study was later retracted and Mr. Wakefield stripped of his medical license, but the damage had been done. In 2013, most of the cases were among school-age children whose parents had refused to give them the vaccine, which is not compulsory in Britain, or among babies too young to be vaccinated, like my daughter…
Within a week she seemed back to normal. What I didn’t know was that measles can cause long-term complications. A child can seem fine while the virus slowly replicates in her brain, poised to exact a terrible toll years later…
Toward the end of the summer [2023], … she had also started moving very slowly, almost robotically, and often seemed confused. We took her back to the hospital, where another M.R.I. showed the swelling in her brain had become much worse… Renae had subacute sclerosing panencephalitis, a rare complication of measles. The doctors told me it was fatal, and there was nothing else they could do…
Last year, the United States saw its highest rate of measles cases in more than three decades and the country may soon lose its measles elimination status as well. Despite this, Health Secretary Robert F. Kennedy Jr. said he doesn’t think the government should be mandating vaccines, and that they should be a matter of personal choice.
Parents must realize that refusing vaccinations doesn’t just put your own child at risk. It puts other children at risk.
Related articles:
LA Bacheschi, et al. NEJM 2026; 394: 1662. Measles 2025. Subacute sclerosing panencephalitis “was not rare before vaccination, as shown by an account of 82 cases… in Brazil from 1961 to 1983.”
DN Durrheim, JK Andrus. NEJM 2026; 394: 1662-1663.Measles 2025. The “measles still kills more than 100,000 children worldwide each year.”
Background: “Vaccination status cannot be verified through standard blood supply channels, patients seeking “unvaccinated” blood have increasingly resorted to directed donation from known donors…directed donations demonstrate higher rates of infectious disease marker reactivity compared with repeat community donors, particularly among first-time parental donors.25, 26“
Methods: This was retrospective review of directed donations (n=15 including 9 pediatric patients) received at Vanderbilt University Medical Center between January1, 2024 and December 31, 2025
Key findings:
Two patients clinically deteriorated in the setting of refusal of standard components
Two additional patients had surgical delay/cancellation with rescheduling associated with directed component availability
Conclusion by authors: “Directed donation pursued for “unvaccinated” blood concerns occurred across pediatric and adult settings in both elective and urgent clinical scenarios. These requests were associated with clinical deterioration, care delays, and resource inefficiencies when standard inventory products were refused.”
My take: Many families do not understand that directed donation is less safe than using the blood bank.
“The daily pill, called Foundayo [orforglipron], follows the approval of Novo Nordisk’s Wegovy pill in recent months. The lowest dose is expected to cost $149 a month for people paying out of pocket…Foundayo will be offered in six doses, with patients typically starting on the lowest dose and working their way up to reduce side effects. It can be taken at any time of day without meal restrictions — unlike the Wegovy pill, which must be taken on an empty stomach each morning…Phase 3 clinical trial data found that Foundayo helped people lose 12.4% of their weight, on average, at its highest dose after 72 weeks — similar to the Wegovy pill but less than injectable versions of Wegovy and Zepbound.”
This was a retrospective study comparing the high dose influenza vaccine (H-IIV) compared to the standard dose (S-IIV) in 65+ patients. The H-IIV group included 120,775 unique participants (185,183 person-trials; mean age 74.4 years, SD 5.5; 57.3% female), and the S-IIV group included 44,022 participants (53,918 person-trials; mean age 73.0, SD 6.1; 56.4% female).
Key findings:
H-IIV was associated with significantly lower AD risk during months 1–25 postvaccination (minimum NNT = 185.2 at 25 months), with a stronger effect among women.
“Routine childhood immunizations in the United States from 1994 through 2023 are estimated to have prevented roughly 508 million illnesses, 32 million hospitalizations, and more than 1 million deaths. Those gains translated into approximately $540 billion in direct medical cost savings and nearly $2.7 trillion in total societal savings. Put simply, every $1 spent on childhood immunizations generated about $11 in savings…Adult vaccination also produces meaningful economic gains, particularly through reduced absenteeism, less presenteeism, and better labor-market continuity. Evidence suggests that adult immunization programs can return up to 19 times their initial investment.”
“In South Carolina, a 2025–2026 outbreak with 993 cases generated an estimated $35.5 million in costs, compared with $66,193 to vaccinate the same number of children through VFC. Those costs are only growing – the outbreak in South Carolina has not yet abated.”
Over-the-top supplement regimens have become bragging rights for the health-conscious and wellness-obsessed. From beauty lovers to masculinity influencers, everyone is boasting about their “stacks”—the numerous capsules, powders and injections they take regularly in the hopes of achieving a cumulative, self-optimizing effect. They’re spending over $1,000 a month in some cases on products that purport to improve their sleep, mental health, fertility, appearance and longevity, but often aren’t approved for those purposes. Some are making money from their endorsements….
Supplements went from a means of treating diseases caused by nutritional deficiencies in the 1900s to lifestyle products that are now the backbone of a $70 billion industry. Because they do not undergo approval by the FDA, they aren’t reviewed for safety or efficacy before coming to market. Some have lots of scientific research backing their use, while others have very limited support. Manufacturers are prohibited from making claims about treating or preventing disease, but influencers have sold the idea that buying the right products can fend off or cure almost any ailment…
Nutritionists generally recommend filling nutrient gaps through food rather than supplements when possible. Some supplements can actually introduce or exacerbate health issues.
“It’s a new addiction that people have,” said Mona Sharma, a celebrity nutritionist in Los Angeles. She said many of her clients take upward of 15 supplements a day. One female client, she said, was taking 70 of them, following guidance she’d seen online, without feeling any positive effect on her well-being.
My take: Supplements are a $70 billion/year industry, with no proven benefit in healthy individuals; yet, these products are promoted heavily by thousands of paid influencers. Many of the same people who are taking and/or promoting supplements oppose vaccines, when only the later has extensive evidence of benefits.
gutsandgrowth 