Making measles great again, part 2

Six months ago, I wrote about why measles outbreaks matter to everyone. At that time, Lancaster County had recently diagnosed 5 people with measles, the first cases in Pennsylvania this year. As of today, the state Department of Health has recorded 296 cases of measles in 2026. Of those, 61 cases were confirmed in the past 7 days, most of these in Lancaster County. 52 patients became sick enough to be hospitalized; fortunately, no one has died. I am now practicing at the center of an outbreak that is threatening to become a full-blown epidemic, the likes of which we haven't seen since Covid.

It's not all Robert F. Kennedy, Jr.'s fault - but he certainly fanned the flames of anti-vaccine sentiment that brought us to this point.

The costs of a measles outbreak are not limited to patients' direct medical expenses, or even the indirect costs of missed school or work. Public health workers (Lancaster County, inexplicably, has no public health department, so we are relying on assistance from the state) are mobilized to track down contacts of ill persons and contain the spread. Vaccination clinics are organized and deployed throughout affected communities, requiring additional staff and medical resources. From February to August 2025, the New Mexico Department of Health responded to a 9-county measles outbreak that totaled 99 cases - fewer than the number we've already seen in Lancaster County this year. The estimated cost of the public health response was a staggering $5.4 million, or about $53,500 per case. Those dollars weren't just sitting in a government account waiting to be used - they had to be diverted from education, policing, highway maintenance, and other essential services.

In an incisive commentary on the "hidden costs" of a measles outbreak, Dr. Katherine Wells, the public health director of Lubbock, Texas, wrote: "When people hear that Lubbock had 50 measles cases in 2025, they often picture something manageable: a handful of sick children, some telephone calls, a few weeks of extra work. That is not what 50 measles cases look like." Instead, she explained, it looked like this:

1. An outbreak is not an event but a cascade - "a case is the start of a cascade of exposures, responses, and system disruptions that unfold over time. ... What emerges is not a series of isolated incidents but a pattern: each exposure generates conditions for the rest. Each setting does not simply experience the outbreak. It amplifies its complexity."

2. When systems bend, people improvise - "Clinics expanded capacity, added hours, and brought in additional staff where possible. But these resources did not materialize from nowhere. They were pulled from other services, such as routine immunizations, chronic disease management, [and] sexual health care - that now had to function with less."

3. The hidden erosion of emergency capacity - "An ambulance transports a patient with suspected measles. After the transfer, it must be taken offline, decontaminated, and cleared. Then it happens again. And again. Each time, the delay is measured in hours, but the impact is cumulative."

4. Survival is not the end of the story - For the sickest children, "survival ... entails extended hospital stays, ongoing clinical needs, and the quiet displacement of other patients who depend on the same finite resources."

5. The costs we do not count - "The most consequential impact [of an outbreak] lies elsewhere: in the work that did not happen."

As vaccination coverage declines in young children across the U.S., outbreaks of measles and other preventable diseases will inevitably become more common and widespread. I'll give the last word to Dr. Noel Brewer, a public health professor at the University of North Carolina, who chairs a committee that is evaluating whether the U.S. should lose its hard-won measles elimination status dating back to the year 2000:

Measles is a brutal disease that has no medical cure. Parents of children made sickest must wait it out in the hospital, despairingly wondering whether their child will die. That level of risk is indefensible in 2026 — more than 25 years after the United States achieved measles elimination. Kids are suffering and dying from a disease we already know how to prevent, and that failure is entirely ours.

The long arc of recommendations to prevent peanut and egg allergies

Our approach to preventing egg and peanut allergies has changed over the past 2 decades. At the turn of the century, the American Academy of Pediatrics (AAP) made an expert consensus recommendation that high-risk infants avoid eggs until age 2 years and peanuts until age 3 years. Unfortunately, the ensuing decade saw a substantial increase in self-reported peanut allergy prevalence, rising from 0.4% of US children in 1997 to 1.4% in 2008. Subsequent randomized trials found that introducing peanuts by age 6 months reduces the risk of developing a peanut allergy by age 5 years, leading to a reversal of the earlier recommendation.

In Australia, infant feeding guidelines were revised on a similar timetable as in the United States, with a 2016 guideline recommending that all infants be introduced to peanuts and eggs in the first year of life, regardless of allergy risk factors. A cross-sectional study found that the percentage of Australian infants who consumed eggs by age 6 months increased from 25% in 2007-2011 to 58% in 2018-2019, with 89% consuming eggs by age 12 months. A recent study by the same research team found that adjusted egg allergy prevalence decreased from 9.2% in 2007-2011 to 7.6% in 2018-2019. The prevalence of egg allergy in infants with eczema in the first 6 months of life also decreased from 34.6% to 21.9%.

In an accompanying editorial, Drs. Aaron Carroll and Ron Keren frankly assessed the harms of the AAP’s and other consensus guidelines that had incorrectly advised parents and guardians against early introduction of eggs in a misguided attempt to prevent allergies:

For years, pediatric guidelines in multiple countries told parents to do something that may have increased the risk of the very outcome they feared most. The deeper problem was not that strong evidence had been misinterpreted; it was that strong evidence did not yet exist. Committees faced a plausible theory, rising anxiety, and pressure to give families an answer. Unfortunately, they gave one with more confidence than the data could support.

The lesson that clinicians and expert panels should learn from this humbling experience, Carroll and Keren argued, is to avoid making strong recommendations based on weak or no evidence:

The field issued recommendations that outran the evidence, and families lived with the consequences. We owe families an honest accounting of that. And we owe it to the next generation of patients to hold ourselves to a higher standard—one that includes evidence grading so families understand the degree of certainty behind a recommendation, mandatory reassessment at regular intervals, and a commitment to funding the trials that can fill evidentiary gaps before guidance is issued rather than decades after.

In a 2023 American Family Physician article on food allergies, a key practice recommendation with an A evidence rating (consistent, good-quality patient-oriented evidence) stated that “early introduction of peanuts, cow’s milk, wheat, and cooked eggs between four and six months of age decreases the risk of developing food allergies.” According to a 2018 Cochrane review, children with egg allergies can be desensitized with oral immunotherapy (“daily, steadily increasing doses of egg protein over an extended period of time”), but 75% will experience allergy-related adverse effects, 8.4% of them serious enough to require medication.

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This post first appeared on the AFP Community Blog.

Reducing unnecessary phototherapy for jaundice in newborns

Up to 4 in 5 newborns will develop jaundice from the accumulation of unconjugated bilirubin during the first week of life. Most of the time, neonatal hyperbilirubinemia is benign and does not require intervention. To prevent the rare outcomes of acute bilirubin encephalopathy (1 in 10,000 infants) and kernicterus (1 in 100,000 infants), the American Academy of Pediatrics (AAP) recommends universal screening of newborns 35 weeks' gestational age or greater using total serum bilirubin and transcutaneous bilirubin at 24 to 48 hours of life or before hospital discharge if occurring sooner.

Online tools such as the BiliTool allow clinicians to quickly compare measured bilirubin levels with the AAP’s hour- and gestational age-specific thresholds for phototherapy (these are slightly lower in infants with neurotoxicity risk factors). Phototherapy converts unconjugated bilirubin to lumirubin, a structural isomer that is directly excreted via urine or stool. In its 2022 guideline, the AAP increased previous phototherapy thresholds based on updated evidence regarding the risk of neurotoxicity. An FPIN (Family Physicians Inquiries Network) Clinical Inquiry found that rebound elevation of bilirubin levels after phototherapy discontinuation is uncommon (less than 2% of infants with levels less than 14 mg per dL at initial discontinuation). In infants without known hemolytic disease or other significant risk factors, repeating a bilirubin level after phototherapy discontinuation is not recommended.

Reducing unnecessary treatment of jaundiced neonates with safe bilirubin levels, or subthreshold phototherapy, was previously identified by pediatric hospitalists as a Choosing Wisely campaign goal. Subthreshold phototherapy is common and may have increased after the 2022 AAP guideline.

A recent report in Pediatrics described the Learning and Implementing Guidelines for Hyperbilirubinemia Treatment (LIGHT) Collaborative, a national quality improvement collaborative involving 146 hospitals that aimed to reduce subthreshold phototherapy use to 10% of all phototherapy encounters over a 12-month period. Baseline data was collected from February 2022 to January 2023. Hospitals implemented a combination of quality improvement coaching, educational webinars, electronic health record order sets and documentation templates, clinical algorithms, and communication aids from February 2023 to January 2024. Individual sites were encouraged to use Plan-Do-Study-Act (PDSA) cycles to identify and address barriers to reducing subthreshold phototherapy.

The final analysis included more than 33,000 patient encounters. Subthreshold phototherapy decreased from a median of 48.2% of encounters prior to August 2022 (when the updated AAP guideline was published) to 41.1% during the last 6 months of the intervention, well short of the goal of 10%. A secondary outcome, the median deviation from the phototherapy threshold in subthreshold phototherapy encounters, decreased from 1.57 mg/dL (26.85 μmol/L) to 1.13 mg/dL (19.33 μmol/L). (Of note, the guideline offers the option to consider phototherapy for selected patients when the total serum bilirubin level is within 1.9 mg/dL [32.50 μmol/L] below the phototherapy threshold.) There were no significant changes in hospital length of stay, phototherapy duration, or readmissions for rebound elevation of bilirubin levels.

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This post first appeared on the AFP Community Blog.

Advocacy groups killed the Canadian Task Force. Is the USPSTF next?

If the "third rail" of the U.S. health care system is Medicare, the third rail of preventive medicine is screening mammography. History has shown that North American evidence-based medicine panels are imperiled when they suggest that breast cancer screening can be optional for women younger than 50, even if that happens to be the norm for the rest of the world.

In November 2009, advocacy groups came close to fatally wounding the U.S. Preventive Services Task Force (USPSTF) after it downgraded screening mammography in average-risk women aged 40 to 49 from a "B" (do routinely) to a "C" (do selectively with shared decision-making) grade. Armed with advocacy talking points, politicians from both parties subjected the USPSTF to withering attacks, and Republicans darkly predicted that the health reform legislation then under consideration in Congress (which eventually became the Affordable Care Act of 2010) would lead to widespread rationing of all kinds of health care. Then-Secretary of Health and Human Services Kathleen Sebelius publicly disavowed the recommendations and tried to blame the previous administration for having appointed the members who voted for the changes. Public affairs personnel at the Agency for Healthcare Research and Quality (AHRQ), where I worked, were prevented from assisting USPSTF members with media appearances explaining the recommendations.

The USPSTF eventually recovered and even thrived from 2010 to 2025, becoming more influential and for the most part, managing to keep politics at bay. However, it is facing a different sort of existential crisis under the second Trump administration, not being allowed to meet for the past 16 months and having its support team at AHRQ eviscerated to the point where it's not clear how the panel would function even if HHS Secretary RFK Jr. eventually appoints new members to replace the ones he fired.

Meanwhile, the Canadian Task Force on Preventive Health Care, the original model for the USPSTF, was disbanded earlier this year, a victim of a similar breast cancer screening recommendation that the federal health minister never allowed to be finalized. As Dr. Guylene Theriault, the former chair of the Canadian Task Force, recently wrote in BMJ Evidence-Based Medicine:

The evidence-based guidance conflicted with certain lobbyists' arguments and elected officials' beliefs in the unambiguous positive outcomes of screening. Ultimately, these arguments and perceptions prevailed over rigorous scientific evidence, making it more difficult for a woman to access clear, unbiased information on which to base her decisions. Perhaps naively, the Task Force members and I thought that placing the patient at the center of the decision-making process would be something everyone could agree on. We were wrong.

A recent study in the American Journal of Preventive Medicine documented worrisome trends in primary care associated with the sidelining of the USPSTF and the remaking of the Advisory Committee on Immunization Practices:

Clinicians report that patients are increasingly hesitant about vaccines and preventive services. For example: 64% report patients are confused as to what vaccination guidelines they should follow; 46% report parents are expressing new hesitancy about childhood vaccinations; 36% report patients are declining preventive services they previously accepted. Most responding clinicians (58%) report spending more visit time explaining the evidence behind clinical recommendations, and 61% report patients more frequently are seeking information from non-medical sources.

As the Canadian Task Force is being reconstituted as the National Advisory Committee on Preventive Health Services, the USPSTF may also rise again - but will the next iteration have the necessary resources (in dollars and staff) and editorial independence to write trustworthy recommendations that place patients, rather than politics, at the center? The stakes for patients and public health could not be higher.

Deprescribing statins

If you found out that a medication you had been taking for years was much less effective than previously advertised, would you keep taking it?

An estimated 20 to 30 percent of Americans over the age of 45 takes a statin for high cholesterol, a history of heart attack or stroke, or to prevent a cardiovascular event. Once a patient starts a statin, provided that they don't experience side effects, they usually continue taking it for life. The medication lists of nursing home residents almost invariably include statins. Statin prescribing has been overwhelmingly positive for population health; a recent study credited them with closing the gap in cardiovascular risk factors between middle-aged adults with obesity and those with normal weight. Ultimately, though, an individual reaches a point where a statin is likely to cause more harm than benefit, even if the harm is having to take one extra medication that costs as little as 30 cents per day.

An expert panel at Deprescribing.org, which previously published evidence-based guidelines on discontinuing proton pump inhibitors, antihyperglycemics, and antipsychotics, among others, recently added statins to its deprescribing guidelines. A synopsis of the guideline is available as an algorithm on their website. In adults over age 65, several factors may prompt a conversation about discontinuing statins: frailty, pill burden, functional limitations, cognitive impairment, complex care needs, and advanced illness (e.g., cancer). A person with a terminal illness who isn't expected to live for more than a year is an ideal candidate for stopping a statin, but some patients with longer life expectancies may reasonably decide to discontinue them based on their personal goals and the value they assign to preventing future cardiovascular events.

None of this should be particularly controversial, but I would have gone farther if I had been on the guideline committee. The replacement of the Pooled Cohort Equations with the PREVENT calculator has resulted in many adults now having a significantly lower estimated risk of cardiovascular events. That should have prompted a reconsideration of statin use for patients whose new risk estimate fell under the threshold for statin initiation. Instead, as I discussed in a Medscape commentary, the American College of Cardiology / American Heart Association simply moved the goalposts, recommending statin initiation (and continuation) at lower thresholds:

Although these changes make it unnecessary to have potentially awkward conversations with patients about why they may no longer need medications that they’ve been taking for years, moving the goalposts is not warranted by primary prevention RCTs, which generally enrolled persons with 10% or greater 10-year risk. Even if one assumes that the relative benefits are the same, patients deserve to be informed about their lower risk estimates so that they can weigh the higher numbers needed to treat before deciding if starting or continuing statin therapy is worthwhile.

I went on to make a deprescribing recommendation that I expect many cardiologists and primary care physicians will disagree with:

Patients at lower risk [based on the PREVENT calculator], particularly less than 5%, should be offered the option of discontinuing statins, keeping in mind the “risk enhancers” listed in the ACC/AHA guideline, which may suggest that the calculated value underestimates their true risk.

Statins haven't become less effective in relative terms, but changes in risk estimates mean that the absolute risk reductions in cardiovascular events and deaths that patients can expect from these drugs are smaller than they were before. And that means that in some cases, deprescribing statins may be a clinically appropriate action.

Screening for type 1 diabetes: what would the U.S. Preventive Services Task Force recommend?

It has now been 15 months since the U.S. Preventive Services Task Force (USPSTF) last met. In the interim, several members' 4-year terms expired, and HHS Secretary RFK Jr. fired the two remaining Vice Chairs, leaving the USPSTF leaderless and without a voting quorum. Although much of the work of the Task Force occurs on conference calls in between scheduled meetings, no new recommendations can be debated or finalized in the current situation. Even if new members with appropriate qualifications are eventually appointed, the future of the USPSTF remains uncertain. So when a new study suggests that a screening test could be beneficial, clinicians and medical groups can only make their best guess about what the USPSTF might recommend based on the evidence.

Unlike prediabetes and type 2 diabetes, the USPSTF has never evaluated screening for type 1 diabetes in the general population. There are two major rationales for screening. First, a large percentage of persons are not diagnosed until they develop symptoms of diabetic ketoacidosis (DKA), a life-threatening situation that invariably requires hospitalization and frequently a stay in the intensive care unit. Second, a therapy exists that delays the onset of the disease in children determined to be high risk. Although the Centers for Disease Control and Prevention and expert groups recommend screening relatives of persons with type 1 diabetes with autoantibody tests, the vast majority of persons who are diagnosed have no family history.

The ideal type of study to establish the benefits and harms of screening for type 1 diabetes would be a randomized trial where participants were randomly assigned to screening or control groups and followed for important clinical outcomes such as DKA, diabetes complications, and mortality. But type 1 diabetes is not nearly as common as type 2, and thousands of participants would need to be followed for years to detect a statistically significant difference in outcomes. This large-scale study would require an investment of money and resources that no private or public funder has thus far been willing to support.

Instead, individual screening programs have been implemented in various locations around the world. Some are focusing on screening relatives of persons with type 1 diabetes, while others are screening the general population in primary care settings. One of the latter programs in Germany was established in 2015 and recently reported 10-year outcomes in a paper in JAMA. Out of more than 220,000 children screened, 590 (0.3%) had autoantibodies but no clinical symptoms. After 5 years, 36% of those with positive screens had progressed to clinical type 1 diabetes, representing 81% of all children who ultimately received this diagnosis. Of note, the progression rate was similar in children with and without a first-degree relative with type 1 diabetes.

Without a comparison group, we don't know how these children would have fared in the absence of screening. Did some of them avoid a traumatic hospitalization for DKA or receive therapy that gave them a few more years without clinical symptoms? Conversely, did they or their loved ones experience negative psychological effects from being a given an early diagnosis, particularly the 64% who had not progressed to clinical diabetes after 5 years? The researchers don't say. My guess is that the USPSTF would have deemed this study to be insufficient evidence to assess the balance of benefits and harms of screening all children for type 1 diabetes. Absent a formal evidence assessment, though, I suspect that many well-intentioned experts will push prematurely for screening to take place anyway - which is why the Task Force needs to be restored and reconvened without further delay.