IDSA’sJournal of Infectious Diseasesprovides a monthly roundup ofJIDpapers with direct relevance to clinicians. Read on to learn more about hepatitis E virus infection in patients from Latin America with chronic liver disease, findings that support expanding tuberculosis care beyond treatment completion and other research ready to inform clinical practice. (Titles and summaries are adapted from the April 2026 issue ofJID.)

HIV Reservoir Dynamics and Bacteriome Composition Along the Gut Axis

Companion editorial:Dissecting the Impact of the Gut Microbiome on HIV Reservoir Dynamics

The gastrointestinal tract is a major reservoir of HIV and home to the body’s most diverse microbiome. Among 24 people in the Last Gift cohort, the relationship between the gut microbiome and HIV reservoir size across the gut axis (duodenum, jejunum, ileum, colon, rectum) was studied. Researchers found that higher HIV transcriptional activity in the small intestine was associated with bacterial richness; the results were opposite in the colon (bacterial richness was associated with low HIV transcriptional activity). Thus, the gut bacteriome may shape HIV reservoir size and activity differently across intestinal segments, a finding potentially important for microbiome-targeted interventions and cure strategies aiming to reduce HIV persistence in gut tissues.

A Threshold in Anti–EBNA-1 Antibody Titers Distinguishes Salivary EBV Shedders From Nonshedders

Counterintuitively, low anti-EBNA-1 antibody titers are associated with reduced risk of Epstein-Barr virus-related diseases. Longitudinal sampling of saliva samples in a cohort of 20 persons (17 typical-range antibody titers; three low titer outliers) identified no EBV shedding in low titer outliers who also had restricted antibody diversity limited to latent and immediate-early antigens. Thus, low anti-EBNA-1 titers identify a distinct phenotype with complete suppression of EBV shedding despite chronic infection, potentially marking individuals with superior viral control and reduced disease risk.

Hepatitis E Virus Infection in Patients With Chronic Liver Diseases: A Latin American Multicenter Study

Hepatitis E virus is a major cause of acute hepatitis worldwide. This multicenter study across six Latin American countries (N = 971 persons) reveals heterogeneous hepatitis E seroprevalence in patients with chronic liver disease (e.g., highest in Chile, 45%, and lowest in Argentina, 4%), with higher rates in cirrhosis and alcohol-related liver disease, confirming zoonotic HEV-3 circulation and supporting HEV testing in patients with unexplained hepatic decompensation or acute hepatitis.

Editor’s note:The following three manuscripts extend our knowledge of the complexity and long-term impacts of infection with tuberculosis.

Cerebrospinal Fluid Hypo-Inflammation Drives Mortality in HIV-Associated Tuberculous Meningitis

Anti-inflammatory corticosteroid therapy improves survival in HIV-negative TBM, but not in people with HIV. Among 149 adults with HIV in Uganda with definite or probable TBM, non-survivors had more severe TBM disease with mortality at 90 days strongly associated withcerebrospinal fluidhypo-inflammation, in particular, low IFN-γ. Those with both peripheral CD4 depletion and lowcerebrospinal fluidIFN-γ had the highest mortality (63%). Although steroids may be appropriate in those with high inflammation, personalized approaches to immunotherapy are likely necessary to improve outcomes in TBM.

Childhood Tuberculosis and Risk of Frailty in Later Life: Evidence From a Nationally Representative Study in Brazil

The life-course impact of childhood tuberculosis, including its connection to frailty, remains poorly understood. Among 8,459 adults ≥50 years in the ELSI-Brazil study (2015-2016), including 74 with self-reported TB before age 15, frailty (phenotype) was assessed and compared using Poisson models before and after propensity-score matching (1:4; 283 controls); mediation also tested chronic obstructive pulmonary disease. Frailty was more frequent with childhood TB (23.0% vs. 8.8%; p = 0.001); after matching, childhood TB was associated with higher frailty prevalence (prevalence ratio, 2.52; 95% confidence interval, 1.43-4.44); mediation through chronic obstructive pulmonary disease was small and not statistically significant. The findings support a life-course approach to TB care.

Persistent Increased Plasmacytoid Dendritic Cells and Inflammation in People With HIV Years After Tuberculosis

People with HIV who have history of cured TB have worse outcomes, including increased all-cause mortality and risk for recurrent TB. The authors tested the hypothesis that persistent immune deficits contribute to subsequent poor outcomes. Sequential studies among 38 Haitian individuals with or without HIV and a history of TB suggest a proinflammatory milieu mediated by TNF persists in people with HIV even years after TB cure. It remains to be determined if the differences stem from preexisting risk factors or reflect the natural history of HIV and TB infections.

In this installment of the Health Equity Series, Mariana Gomez de la Espriella, MD, reflects on hepatitis C care in rural Appalachia, barriers to treatment, insights from qualitative work with patients and providers, and care models to improve linkage to cure this Hepatitis Awareness Month.

My patient, in her early 30s, lay in a hospital bed dying from complications of advanced cirrhosis caused by hepatitis C. She had been diagnosed years earlier but never made it to treatment, her life shaped by the challenges of substance use disorder and the barriers that still stand between diagnosis and cure.

After rounds, I wrote a line in my notebook: “Another patient. Another life lost too early. A cure existed, but we reached her too late.” That sentence has stayed with me.

We have curative therapies for hepatitis C that are safe, simple and highly effective. Direct-acting antivirals cure more than 95% of patients. (1) In theory, deaths like hers should be rare. And yet they still happen.

The gap between diagnosis and cure

Diagnosing hepatitis C is only the first step. The real challenge is ensuring that patients can access treatment. In Appalachian Virginia, where I practice as an infectious diseases physician, that challenge is evident.

To better understand why patients diagnosed with hepatitis C were not reaching treatment in our health system, our team conducted a qualitative study consisting of in-depth interviews with patients living with hepatitis C and substance use disorders, as well as with clinicians caring for them across our region. (2) Patients discussed the heavy stigma of hepatitis C. Many were not surprised by the diagnosis given their history of injection drug use, but they feared judgment from family, the community and health care providers. Some worried about transmitting the infection. Providers highlighted systemic barriers like complex referrals, long waits for specialists and administrative red tape that delay treatment.

Yet the most consistent barriers were not medical at all. Patients and clinicians highlighted transportation issues, unstable housing and no phone access as barriers to attending appointments.

Clinicians noted that patients are most at risk of being lost during the hospital-to-outpatient transition. As one provider noted during the interviews, the period after hospital discharge is often “the main step where patients fall through the cracks.”

These insights highlighted an important lesson: The system is failing to meet patients where they are. Addressing this challenge requires rethinking how care is delivered, prioritizing access, patient navigation, and models designed around the reality of patients’ lives.

This gap between diagnosis and treatment reflects a broader challenge in hepatitis C care. Health equity in this area is not only a clinical issue; it is also shaped by the policies and systems that determine who can access treatment and how care is delivered.

Across the United States, clinicians, public health teams and community organizations are working toward the goal of hepatitis C elimination. Still, one of the greatest challenges remains bridging the gap between diagnosis and cure for the patients most affected by the disease.

Part of this challenge lies in the fragmentation of care across health systems. Patients with hepatitis C often move between emergency departments, hospitals, addiction treatment programs and primary care clinics, with no unified system to track whether they ultimately receive treatment. In the absence of coordinated data systems, the same patient may be tested multiple times in different settings while the critical step of linking them to treatment never occurs.

Fragmented care can lead both to duplication of services and, paradoxically, to patients receiving no treatment at all. Studies examining the hepatitis C care cascade have shown that a substantial proportion of patients diagnosed with hepatitis C are never successfully linked to treatment or cured. (3)

Building the path to hepatitis C elimination

Recognizing these challenges, our team began developing a different approach. We created a registry of patients diagnosed with hepatitis C but never treated, allowing care coordinators and patient navigators to reach out and help guide them through the steps needed to start therapy.

One of our key innovations has been integrating hepatitis C telemedicine consults into a mobile health unit serving rural Southwest Virginia, reducing geographic and logistical barriers to care.

We also expanded treatment capacity beyond traditional specialty clinics by developing a training program that empowers primary care providers to diagnose and treat hepatitis C, enabling patients to receive care closer to home from providers they already know and trust. (4)

Our work has also highlighted another important opportunity for hepatitis C care: the hospital setting. For many patients facing instability or barriers to outpatient care, hospitalization may be one of the few moments when they are consistently engaged with the health system. Emerging evidence suggests that initiating hepatitis C treatment during hospitalization can improve treatment uptake and completion and help prevent patients from being lost during the transition to outpatient care, (5) a gap repeatedly identified by clinicians in our study. (2)

These experiences have reinforced a central lesson: hepatitis C elimination will not happen through medications alone. It will require health systems that prioritize access, patient navigation, and care models designed to ensure patients are not left behind.

I still think about that young woman whose death inspired a line in my notebook.

Every patient cured today represents not only a medical success but also a reminder of what is possible when barriers to care are removed.

As we observe Hepatitis Awareness Month, the promise of hepatitis C elimination is within reach. Achieving it will require ensuring fewer patients fall through the cracks and that no more lives are lost to a disease we already know how to cure.

Learn moreabout the Health Equity Series onScience Speaksand read other posts in theseries.

- AASLD-IDSA. Recommendations for testing, managing, and treating hepatitis C. Accessed March 14, 2026.

- Konathapally M, Henrickson Parker S, Gomez de la Espriella M. Closing the Care Gap: Community-Based Strategies Linking Patients with HCV and Substance Use Disorder in Appalachia.Open Forum Infect Dis. 2026;13(Suppl 1):ofa695.2001.

- Wester C, Osinubi A, Kaufman HW, et al. Hepatitis C Virus Clearance Cascade — United States, 2013–2022.MMWR Morb Mortal Wkly Rep. 2023;72:716-720.

- de la Espriella MG, Peterson C, Faulhaber JR, et al. Empowering healthcare providers in the Appalachian region to manage hepatitis C infection: A descriptive study.Open Forum Infect Dis. 2025;12(Suppl 1):ofae631.2353.

- Denkins J, Babiarz J, Ham Y, et al. Hepatitis C Treatment Initiation During Hospitalization for People Who Use Drugs: A Narrative Review of the Literature.Open Forum Infect Dis. 202512(6):ofaf237. doi: 10.1093/ofid/ofaf237.

InCDC’s 2021 Sexually Transmitted Infections Treatment Guidelines on syphilis, the preferred therapy for late latent syphilis or syphilis of unknown duration is benzathine penicillin G, 2.4 million units intramuscularly, once a week for three weeks, allowing for an interval of seven to nine days between doses even in cases of pregnancy, and up to 14 days in nonpregnant patients. However, theongoing manufacturer’s delay since April 2023has created a supply shortage of this preferred anti-infective drug with estimated recovery expected in December 2027. This has prompted the search for alternative therapies like doxycycline or lentocilin, or an exploration of ways to use the existing supply of BPG more efficiently.

A CDC-ledretrospective studypublished inClinical Infectious Diseasesused CDC National Notifiable Diseases Surveillance System data from 2016 to 2021 to extract information on patients with late or unknown duration of syphilis who were diagnosed in Florida, Louisiana, Arizona, Michigan, North Carolina and Virginia.

The study compared cases who received treatment with 1, 2, 3 or > 3 doses of BPG, and cases who received doxycycline for < 28 days and ≥ 28 days. The study’s primary outcome was adequate serologic response as defined as fourfold decrease in titers between pre- and post-treatment within a 24-month period.

In the study, 18,028 cases met inclusion criteria for analysis, with 80% of cases (14,461) receiving BPG, 18% (3,255) receiving doxycycline, and 2% (312) receiving a combination of BPG and doxycycline; 75% of all cases met the primary outcome. Overall, the likelihood of a fourfold titer decrease did not differ across treatment regimens of 1, 2, 3 or > 3 doses of BPG, or cases who received doxycycline for ≥ 28 days.

Only 1% of the cases received doxycycline for < 28 days, and the study did not report the probability of a fourfold decline in titers by 24 months in this subset.

About 26% of cases received the recommended 3 injections of BPG within CDC guideline intervals, and about 37% of cases received 3 injections of BPG at unknown intervals. Around 11% of cases received only 1 injection; 3% received 2 injections of BPG; and 2% received ≥ 4 injections of BPG.

This study highlights the difficulties in treating late syphilis or syphilis of unknown duration with BPG injections as only 26% of cases received the therapy within the time-sensitive guideline parameters.

However, given this study found no statistically significant difference in treatment effectiveness as measured by a fourfold decrease in nontreponemal titers for cases treated with 1, 2 or 3 doses of weekly BPG injections or with 28 days of doxycycline, perhaps giving a single dose of BPG will improve compliance without sacrificing treatment failures.

Study limitations include using data based on local health department investigations in six U.S. states, which may not have uniform reporting practices, leading to data that may misclassify syphilis stages. Other limitations are discussed thoroughly in theaccompanying commentary, but the study provides good evidence to consider using single-dose BPG or 28-day doxycycline as alternatives to 3 weekly doses of BPG, especially with the ongoing shortages of BPG.

(Pugsley et al.Clin Infect Dis.Published online: Feb. 23, 2026.)

Tick-borne diseases are the most common vector-borne infections in the United States, and Lyme disease has long dominated the conversation in endemic areas. But ticks are carrying more than Lyme disease alone, and co-infections are becoming harder to ignore. New research suggests ticks may harbor a wider mix of pathogens than we once thought, and co-infections in humans remain important to consider in the care of patients with suspected or proven tick-borne infections.

A recent study published inEcospheresheds light on this shift in the northeastern United States. Researchers examined more than 2,000 nymph-stage black-legged ticks (Ixodes scapularis) collected over nearly a decade in Dutchess County, New York. They found that many of these ticks carried pathogens capable of causing infection in humans, and some carried more than one at the same time. (1)

In fact, about 10% of the ticks studied were infected with at least two pathogens. The most common combination wasBorrelia burgdorferi(the bacterium that causes Lyme disease) andBabesia microti, the parasite responsible for babesiosis. (1)

This matters clinically because these infections require different treatments. Lyme disease is typically managed with antibiotics like doxycycline, while babesiosis requires combination medications, usually atovaquone and azithromycin. If a single tick bite effectively transmits both infections, clinicians need to recognize and treat both.

Co-infections can also make diagnosis more challenging. Symptoms may overlap, and illness can be more severe or last longer than infections caused by a single pathogen. Together, these findings reinforce the need to think beyond Lyme disease alone when evaluating patients with suspected tick-borne illness in endemic regions.

Multiple pathogens, one vector

The study also showed just how many different pathogens ticks can carry. More than one-third of the ticks tested were infected with at least one pathogen known to cause human disease. (1) In addition toBorrelia burgdorferiandBabesia microti, researchers identifiedAnaplasma phagocytophilumandBorrelia miyamotoi. Less commonly, ticks carriedRickettsiaspecies, and one tick tested positive for Powassan virus — a rare but potentially serious infection. (1)

One particularly notable finding was the rise ofBabesia microti. Toward the end of the study period, it was detected frequently, in some cases more often thanBorrelia burgdorferiin the ticks sampled. This suggests babesiosis may be becoming more prominent in parts of the Northeast and reinforces the need to consider diagnoses beyond Lyme disease. (1)

This trend isn’t limited to North America. In a Swedish study ofIxodes ricinusticks removed from humans, 43.3% of Babesia-positive ticks were co-infected withBorreliaspp. (2) That suggests co-infections are not just a local issue in the northeastern U.S., but part of a broader pattern.

Why prevention matters even more now

Because a single tick bite can transmit multiple pathogens, prevention remains essential. The U.S. Centers for Disease Control and Prevention recommends several practical steps to reduce tick exposure: avoiding wooded or brushy areas with tall grass or leaf litter, using EPA-registered insect repellents, and treating clothing and gear with permethrin. It’s also important to check for ticks after spending time outdoors, shower soon after coming inside and remove any attached ticks promptly. (3) These steps are especially important in areas where multiple tick-borne pathogens are circulating.

What could change next

The complexity of tick-borne diseases also underscores the need for better prevention tools. As discussed in a previousScience Speaksblog post, several Lyme disease vaccine candidates are currently in development. (4) While there isn’t a human Lyme vaccine available in the United States yet, ongoing research could eventually change that. Vaccines, combined with existing preventive measures, could play an important role in reducing the burden of tick-borne disease.

Why this shift matters for clinicians

Long-term surveillance of tick populations and the potential pathogens they carry are keys to understanding the dynamic risks both within known endemic regions, but also new geographic regions where disease harboring ticks are spreading. Studies like this help clinicians stay informed about which pathogens are circulating locally and how often co-infections occur.

For clinicians, the takeaway is straightforward: Suspected tick-borne illness shouldn’t automatically be assumed to be Lyme disease or any other single tick-borne infection alone. Considering the possibility of co-infection can lead to more accurate diagnoses and better treatment decisions. As tick populations expand and the range of pathogens they carry grows, clinician awareness and prevention will become even more important.

- LaDeau SL, Oggenfuss K, Schmidt A, et al. Ecological dynamics of blacklegged ticks, vertebrate hosts, and associated zoonotic pathogens in northeastern forests.Ecosphere. 2025;16(12):e70508. doi:10.1002/ecs2.70508.

- Amato M, Siller A, Schennach H. Babesiosis and Its Significance in Transfusion Medicine from a European Point of View.Transfus Med Hemother. 2025;53(1):23-43.

- Centers for Disease Control and Prevention. Preventing tick bites. CDC. Updated August 28, 2024. Accessed March 18, 2026.

- Sanicas M. Tick-borne disease vaccines: What clinicians should know in 2026.Science Speaks. Infectious Diseases Society of America. Jan. 5, 2026. Accessed March 18, 2026.

Burn patients pose unique challenges for infectious diseases physicians and for infection control practitioners. Many of us did not have the opportunity to care for burn patients during our fellowship training, and this unique patient population deserves special consideration.

Drawing from the literature and our experiences caring for these patients in a regional high-volume burn center, we offer some key takeaways.

Infection versus inflammation

It can be difficult to determine if burn patients are infected because burn injury itself results in tachycardia, tachypnea, fever and changes to white blood cell count. (1, 2) Multiple studies have shown that the systemic inflammatory response syndrome criteria and Sequential Organ Failure Assessment scores are not helpful identifying infection in this patient population. (3-5, 6). This makes it more challenging to identify when patients are clinically infected from the background of immune activation from burn injury.

Burn wounds cause complex local and systemic inflammatory and immune changes. Damaged cells release damage-associated molecular patterns that increase the activation of the immune response and can cause burn wound deepening, SIRS and multi-organ dysfunction acutely. (7) Studies show that early excision is needed for optimal healing and to reduce vulnerability to infections, although the exact timing of early excision is less clear. (8)

Bacteremia frequently complicates wound manipulation even in the absence of clinical infection. In one prospective study, 44.6% of procedures (50/112) in 28 patients were complicated by bacteremia. (9) Our data from a regional high-volume burn center showed that 5.6% of patients admitted to the burn unit developed bacteremia and that 36.8% of hospital-onset bacteremias occurred after a skin and soft tissue surgical procedure. (10) It can be challenging to distinguish transient bacteremia from clinical infections.

Infection prevention

Burn wounds are heavily colonized with pathogenic bacteria. (11) Wound care has been shown to aerosolize bacterial pathogens and thus patient rooms are likely to become contaminated. (12) As these patients may stay in their ICU room for weeks and even months, more aggressive environmental decontamination may be needed in burn units. Additionally, burn patients have prolonged use of invasive devices such as central lines.

Although studies have shown no benefit for routine line changes in ICU patients (13), the median duration of line placement in the control arm of these studies is much shorter than the median duration of line placement in burn patients. There are many remaining unanswered questions on optimal infection control practices and device management in this patient population. (14)

The most important lesson in caring for burn patients is the importance of collaboration. The complexity and interdependence of so many complications from severe burn injury require experts from almost every discipline. Experts from nutrition, rehabilitation medicine, critical care medicine, pain management, pulmonary medicine, social work, infectious diseases and burn surgery are all essential in the successful management of burn patients.

- Burgess M, Valdera F, Varon D, et al. The Immune and Regenerative Response to Burn Injury.Cells. 2022;11(19): 3073.

- Greenhalgh DG. Management of Burns.N Engl J Med. 2019;380(24):2349-59.

- Yoon J, Kym D, Hur J, et al. Comparative Usefulness of Sepsis-3, Burn Sepsis, and Conventional Sepsis Criteria in Patients With Major Burns.Crit Care Med. 2018;46(7):e656-e62.

- Yoon J, Kym D, Hur J, et al. Validation of Sepsis-3 using survival analysis and clinical evaluation of quick SOFA, SIRS, and burn-specific SIRS for sepsis in burn patients with suspected infection.PLoS One. 2023;18(1):e0276597.

- Hogan BK, Wolf SE, Hospenthal DR, et al. Correlation of American Burn Association sepsis criteria with the presence of bacteremia in burned patients admitted to the intensive care unit.J Burn Care Res. 2012;33(3):371-8.

- Yan J, Hill WF, Rehou S, et al. Sepsis criteria versus clinical diagnosis of sepsis in burn patients: A validation of current sepsis scores.Surgery. 2018;164(6):1241-5.

- Korkmaz HI, Flokstra G, Waasdorp M, et al. The Complexity of the Post-Burn Immune Response: An Overview of the Associated Local and Systemic Complications.Cells. 2023;12(3):345.

- Daugherty THF, Ross A, Neumeister MW. Surgical Excision of Burn Wounds: Best Practices Using Evidence-Based Medicine.Clin Plast Surg. 2017;44(3):619-25.

- Vindenes H, Bjerknes R. The frequency of bacteremia and fungemia following wound cleaning and excision in patients with large burns.J Trauma. 1993;35(5):742-9.

- Sood G, Caffrey J, Werthman E, et al. Hospital-Onset Bacteremia and Fungemia in a Regional Burn Intensive Care Unit.Am J Infect Control. 2026. Published online Jan. 28, 2026.

- Ladhani HA, Yowler CJ, Claridge JA. Burn Wound Colonization, Infection, and Sepsis.Surg Infect. 2021;22(1):44-8.

- Bache SE, Maclean M, Gettinby G, et al. Airborne bacterial dispersal during and after dressing and bed changes on burns patients.Burns. 2015;41(1):39-48.

- Cobb DK, High KP, Sawyer RG, et al. A controlled trial of scheduled replacement of central venous and pulmonary-artery catheters.N Engl J Med.1992;327(15):1062-8.

- Siegel JD, Rhinehart E, Jackson M, et al. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings.Am J Infect Control. 2007;35(10 Suppl 2):S65-164.

Curbing the hepatitis C epidemic requires routine screening of thoseages 18-79, routine screening ofpregnant womenand regular screening of those withongoing risk factors. A recent study looked at using mobile telemedicine as a way to identify and treat people with HCV who inject drugs.

ThisstudyinJAMA Network Opentook place in rural areas (Vermont and New Hampshire) in a mobile van that was staffed with a medical assistant who drew blood and two researchers who provided harm reduction. Patients were required to be 18 years or older, have a current or past history of injection drug use, and have health insurance that would cover direct-acting antiviral therapy. Those with decompensated cirrhosis, pregnancy or prior DAA use were excluded.

Patients were seen for screening and enrollment and then had five more visits – one for randomization to telehealth versus referral for HCV care, and four subsequent follow-up visits. Those in the intervention arm had their telehealth visits with van staff present to provide support. Seventy-five people were randomized to each arm. Of note, 70% of the participants had been unhoused in the previous six months, with nearly as many having overdosed in the past and having used opioids within 30 days.

The mobile telehealth arm had 57 of 75 patients (75.8%) with follow-up data; the usual care arm had 62 of 75 (82.7%). In the intention-to-treat analysis, 43 started DAA therapy, and 28 had viral clearance in the mobile telehealth arm. In the usual care arm, 20 started DAA therapy, and 14 achieved viral clearance. Removing those who were lost to follow-up, the telehealth arm saw a viral clearance rate of 62.8% (27 of 43) while the usual care arm saw a rate of 65% (13 of 20).

In short, the difference in viral clearance between the two groups had everything to do with early initiation and reducing the chance of patients being lost in the referral vortex. Interestingly, there was no difference in ongoing equipment sharing between the two groups, perhaps because both groups got the same harm reduction education and support.

There have been several studies looking at whether mobile health vans can improve rates of diagnosis and treatment of various infectious diseases. Not all of them have found statistically positive results. One thing that may have helped uncover a significant difference in this study is that the van travelled to the same sites once or twice a week, making it easy for patients to follow up. Every study has unique factors (e.g., urban versus rural geography, presence of surrounding violence, weather conditions) that make generalization difficult, if not impossible. To me, this means that it’s essential to develop a program that understands the syndemics of the local infection landscape and is flexible enough to adjust and adapt as the program matures.

(Friedmann et al.JAMA Netw Open.Published online: Jan. 26, 2026.)

The diminishing number of infectious diseases physicians is well-documented. Although the number of matched ID fellowship applicants has increased modestly in recent years, the 2025 Match raised significant concerns with only 45% of programs filling available positions, the lowest number since 2014-2015 (1), continuing a trend of declining fill rates.

Meanwhile, many rural and underserved areas have ID physician coverage that has fallen below recommended levels, contributing to delays in diagnosis, inappropriate antimicrobial use and worsening patient outcomes. (2,3) Current estimates suggest that fewer than 10% of U.S. acute care hospitals have on-site ID physician support, with the gap most pronounced in rural areas.

The data are clear: ID expertise is needed. ID consultation has been consistently associated with reduced mortality across multiple types of infections. (4-8) Beyond mortality benefits, ID expertise increases appropriate antimicrobial use, even in hospitals with established stewardship programs. The presence of an ID specialist is associated with both lower total antimicrobial use and lower use of broad-spectrum antimicrobials. (9) This expertise is especially critical as antimicrobial resistance continues to escalate, and inappropriate prescribing remains a significant challenge in hospitals without ID support.

Accordingly, IDSA and the Society for Healthcare Epidemiology of America strongly recommend that antimicrobial stewardship programs be led by ID physicians with additional stewardship training. (10-11) Collectively, these findings highlight the critical need to close the gap in ID care.

The role of telemedicine

Telemedicine offers an effective and efficient, evidence-based solution to bridge the gap between workforce shortage and clinical need. ID telemedicine (Tele-ID) allows ID physicians to care for both inpatients and outpatients remotely through live audio-video visits and e-consults. (12) IDSA supports its use to deliver timely, high-quality infectious diseases care — particularly in resource-limited and underserved settings, where ID is needed the most. Further, IDSA supports Tele-ID use across clinical care, research, education, antimicrobial stewardship, infection prevention and outpatient programs including OPAT. (12)

Tele-ID has proven to deliver the benefits of ID expertise across many clinical settings. (13) It has been shown to have significant impact at rural medical centers that are without local ID support (14), decreasing transfer rates to tertiary centers by up to 60% and reducing hospital stays by an average of 1-2 days. (15) Emerging data show that a robust Tele-ID model leads to same or even improved outcomes compared to in-person traditional coverage models. (16) Expanding its benefits beyond clinical consultation, Tele-ID has also been shown to provide antimicrobial stewardship support in small community hospitals. (17)

On a personal note, Tele-ID isn’t theoretical — it has become my everyday work. I connect with patients through live audio-video visits, and on-site nurses support physical exams using Bluetooth stethoscopes and high-definition portable cameras. I have been able to build strong working relationships with hospitalists in rural areas, supporting clinical decisions and teaching ID principles during real-time case discussions. Bringing ID expertise to these communities is personally fulfilling and helps to provide ID medicine where access to specialists is limited.

Policy and reimbursement challenges

Despite its promise and evidence base, Tele-ID faces major policy and reimbursement threats.

Reimbursement remains inconsistent, particularly for e-consults, which face coverage limitations despite their demonstrated efficiency and impact. Recent changes to Medicare telehealth policy have sharply reduced coverage for nonbehavioral telehealth services, especially for home-based care, limiting how ID physicians can deliver and bill for telemedicine. IDSA has highlighted that the expiration of COVID-era telehealth flexibilities has reduced ID access for many patients and introduced significant uncertainty for clinicians, with ongoing policy shifts requiring continued monitoring and advocacy. (18)

Following the expiration of COVID-era flexibilities, Medicare telehealth policy was extended through March 31, 2025, and subsequently through Dec. 31, 2027, by recent legislation, though uncertainties remain about long-term policy. The temporary nature of these extensions continues to create instability for ID practice planning.

These challenges matter for the future of ID practice. Without sustainable reimbursement and supportive policy, hospital systems may be unable or unwilling to maintain Tele-ID programs, even with data showing that patient outcomes with Tele-ID are comparable to in-person care and with improved access.

Paths forward for telemedicine and ID

Tele-ID is transforming the practice of ID by offering a flexible, remote care model that appeals to many physicians, including myself. It enables ID specialists to reach underserved communities, support hospitals without local expertise and help close critical gaps in care while maintaining a sustainable, high-impact career.

Integrating Tele-ID into fellowship training can ensure the next generation of ID physicians is prepared to meet evolving patient needs and strengthen the specialty’s workforce. Expanding Tele-ID rotations in fellowship programs and increasing Tele-ID’s visibility at national ID meetings can attract more trainees to the specialty and equip them for modern practice. By providing hands-on experience in remote care, these initiatives help trainees develop the skillsets and adaptability needed to deliver ID care in diverse settings.

Telemedicine, whether embraced or resisted, has become an integral component of modern medical practice. ID is uniquely positioned at the forefront of its adoption. To fully realize its potential, we must move beyond describing its benefits and advocate for policies and sustainability in our everyday practice and education. This includes advocating for permanent Medicare telehealth coverage, consistent reimbursement for both live visits and e-consults, and state-level parity laws that ensure private payers reimburse telemedicine services at rates comparable to in-person care.

Additionally, we must continue to expand training in Tele-ID and prepare trainees for future Tele-ID practice. In doing so, we can strengthen the ID workforce, improve access to care and ensure that our specialty remains at the forefront of medicine. Whether you are a practicing ID physician, program director or trainee, consider how you can contribute: Advocate with your hospital leadership for Tele-ID infrastructure, support policy efforts through IDSA or seek out telehealth training opportunities. The future of ID access depends on our collective action today.

- Infectious Diseases Society of America; Pediatric Infectious Diseases Society. IDSA and PIDS statement on 2025 infectious diseases fellowship Match results. Dec. 3, 2025.

- Chandrasekar P, Havlichek D, Johnson LB. Infectious Diseases Subspecialty: Declining Demand Challenges and Opportunities.Clin Infect Dis.2014;59(11):1593-1598.

- Perez C. Telemedicine offers solutions for the rural disparities in infectious disease (ID) care delivery.Open Forum Infect Dis.2025;12(2):ofaf052.

- Tang G, Huang L, Zong Z. Impact of Infectious Disease Consultation on Clinical Management and Outcome of Patients With Bloodstream Infection: A Retrospective Cohort Study.Sci Rep.2017;7(1):1-9.

- Lee RA, Vo DT, Zurko JC, et al. Infectious Diseases Consultation Is Associated With Decreased Mortality in Enterococcal Bloodstream Infections.Open Forum Infect Dis.2020;7(3):ofaa064.

- Mejia-Chew C, O’Halloran JA, Olsen MA, et al. Effect of infectious disease consultation on mortality and treatment of patients with candida bloodstream infections: a retrospective, cohort study.Lancet Infect Dis.2019;19(12):1336-1344.

- Bai AD, Showler A, Burry L, et al. Impact of Infectious Disease Consultation on Quality of Care, Mortality, and Length of Stay in Staphylococcus aureus Bacteremia: Results From a Large Multicenter Cohort Study.Clin Infect Dis.2015; 60(10):1451-1461.

- Goto M, Jones MP, Schweizer ML, et al. Association of Infectious Diseases Consultation With Long-term Postdischarge Outcomes Among Patients With Staphylococcus aureus Bacteremia.JAMA Netw Open.2020;3(2):e1921048.

- Livorsi DJ, Nair R, Lund B C, et al. Antibiotic Stewardship Implementation and Antibiotic Use at Hospitals With and Without On-site Infectious Disease Specialists.Clin Infect Dis. 2021;72(10):1810-1817.

- Barlam TF, Cosgrove SE, Abbo LM, et al.Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America.Clin Infect Dis.2016;62(10):e51-e77.

- Dellit TH, Owens RC, McGowan JE, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship.Clin Infect Dis.2007;44(2):159-177.

- Young JD, Abdel-Massih R, Herchline T, et al. Infectious Diseases Society of America Position Statement on Telehealth and Telemedicine as Applied to the Practice of Infectious Diseases.Clin Infect Dis.2019;68(9):1437-1443.

- Li SK, McCreary EK, Khadem T, et al. 101. Impact of an Integrated Tele-Antimicrobial Stewardship Program at a Rural Community Hospital.Open Forum Infect Dis.2021;8(Suppl 1):S164-S165.

- Tande AJ, Berbari EF, Ramar P, et al. Association of a Remotely Offered Infectious Diseases eConsult Service With Improved Clinical Outcomes.Open Forum Infect Dis.2020;7(1):ofaa003.

- Monkowski D, Rhodes LV, Templer S, et al. A Retrospective Cohort Study to Assess the Impact of an Inpatient Infectious Disease Telemedicine Consultation Service on Hospital and Patient Outcomes.Clin Infect Dis.2020;70(5):763-770.

- Gupta N, Bariola JR, Mellors JW, et al. In-Person Versus Tele-Infectious Disease (Tele-ID) Care: Is One Better?Open Forum Infect Dis.2022;9(8):ofac410.

- Vento TJ, Veillette J, Gelman SS, et al. Implementation of an Infectious Diseases Telehealth Consultation and Antibiotic Stewardship Program for 16 Small Community Hospitals.Open Forum Infect Dis.2021;8(6):ofab168.

- Infectious Diseases Society of America. Medicare Telehealth Restrictions and Extension Updates Beginning October 2025: Impacts and Implications for Infectious Diseases Physicians and Their Patients. 2025.

WhileLegionellahas long been the bane of infection control practitioners, the diagnostic tools used in identifying clinical disease have evolved over the years, as has its clinical impact.

A recentarticleinClinical Infectious Diseasesprovides a snapshot of 344 episodes ofLegionellapneumonia managed through the Mayo Clinic from January 2019 to September 2025. Median age was 66.6 years with 45.1% immunocompromise. Intensive care unit admission occurred in 36.1%, and mechanical ventilation in 22.7%. Thirty-day and 90-day mortality were 11.9% and 16.6%, respectively. Cirrhosis (odds ratio, 10.2; 95% confidence interval, 2.15-48.3) was the strongest risk factor for 30-day mortality; age, immunocompromise and lymphopenia were also independent risk factors. Gastrointestinal symptoms were reported in 27.6% and pleural effusion in 64.1%. Higher incidence was observed in summer/early fall. Levofloxacin was the final antibiotic in 48.6%, followed by azithromycin (in 36.9%).

Legionellawas identified by urinary antigen in 51.5%, with PCR testing of respiratory specimens in 52.9% and culture in 25%. Among the 121 patients that were either PCR-positive or culture-positive and had urinary antigen testing, the urinary antigen was positive in only 31 (25.6%). PCR and sputum positivity were high among patients who underwent bronchoscopy with bronchoalveolar lavage: 156/162 (96.3%) and 30/31 (96.7%), respectively.

This article clearly highlights thatLegionellapneumonia is often severe and associated with poor outcomes, particularly in patients with cirrhosis. Utility ofLegionellaurinary antigen (which only detectsL. pneumophilaserotype 1) appears poor compared to PCR and/or culture from bronchoalveolar lavage. However, a significant proportion of PCR testing in this study was done via a laboratory-developed test that was routinely included as a part of a standardized immunocompromised host panel for bronchoscopy specimens, so sites that do not have similar protocols may have different diagnostic yields.

One notable issue to consider as more hospitals aim for LEED “green” building certification is the incidence of low-flow water states that can encourageLegionellacolonization of water systems, so heightened awareness to mitigation strategies and clinical disease diagnosis is likely in order.

(Pulsipher et al.Clin Infect Dis.Published online: Feb. 21, 2026.)

IDSA’sJournal of Infectious Diseasesprovides a monthly roundup ofJIDpapers with direct relevance to clinicians. Read on to learn more about how autoantibody screening could help identify high-risk patients early for effective treatment of COVID-19, the benefits of embedding a TNIC approach in vaccine trial designs and other research ready to inform clinical practice. (Titles and summaries are adapted from the March 2026 issue ofJID.)

The Diagnostic Value of Soluble Epstein-Barr Virus BZLF1 Protein in Posttransplant Lymphoproliferative Disease Among Solid Organ and Hematopoietic Cell Transplant Recipients

Post-transplant lymphoproliferative disorder is a serious complication of solid organ transplant and hematopoietic stem cell transplant recipients and is often associated with Epstein-Barr virus reactivation. The soluble Epstein-Barr Virus BZLF1 (sZEBRA, nuclear immediate-early antigen) protein plays a role in EBV reactivation and immune evasion potentially leading to post-transplant lymphoproliferative disorder. Combined with EBV PCR, elevated sZEBRA levels were strongly associated with PTLD and may serve as a biomarker to identify PTLD.

Autoantibodies Against Type I Interferons Are a Prominent Feature in SARS-CoV-2 Fatal Disease and Hospitalization

Autoantibodies have been implicated as key players in COVID-19 pathogenesis, with evidence of impacting disease severity and poor outcomes. In a well-controlled study, autoantibodies against type I interferons, MPO and ACE2 were associated with COVID-19 severity and poor outcomes (including mortality), showed increasing titers over time and correlated strongly with SARS-CoV-2 IgA/IgG in hospitalized COVID-19 patients. An important future goal is exploring the impact of autoantibodies in long-term immune dysregulation and post-acute sequelae in COVID-19 survivors.

Interferon-Gamma Production Defects Characterize Immune Responses in Patients With Chronic Pulmonary Aspergillosis

Little is known about potential underlying immune defects that might predispose patients to developing chronic pulmonary aspergillosis. While polymorphonuclear function and several cytokines did not differ between individuals with CPA and controls, those with CPA displayed an impaired IFN-γ and (more restricted) IL-17 response, as well as increased IL-1RA responses suggesting adaptive immunity/lymphocyte defects as contributors to CPA pathogenesis.

Anti-HBs Immune Complex Levels: A Novel Marker of Hepatitis Flare Following Nucleos(t)ide Analog Withdrawal in HBeAg-Negative Chronic Hepatitis B

Humoral immunity may play a key role in the immunopathogenesis of chronic hepatitis B. Discontinuation of nucleos(t)ide analogue therapy can promote HBsAg seroclearance but also carries a risk of hepatitis flare. In this multicenter prospective cohort study, serum HBsAg-immune complexes (HBsAg-ICs) were detectable in 97% of participants at the end of treatment. Low HBsAg-ICs levels at the end of treatment predicted hepatitis flare following nucleos(t)ide analogue withdrawal in HBeAg-negative chronic hepatitis B. Dynamic increases in HBsAg-IC levels during ALT flares were observed, supporting the role of humoral immunity in flare pathogenesis.

A Test-Negative Design for Immune Correlates Approximates a Traditional Exposure-Proximal Design but Requires Far Fewer Blood Samples

Traditional vaccine clinical trials sample blood from all participants. In contrast, the test-negative immune correlates design only samples blood from participants who develop symptoms. This study compared traditional to TNIC methods in the mRNA-1273 SARS-CoV-2 vaccine efficacy clinical trial. The authors found the TNIC design that measures antibody provides similar results to the usual immune correlates design but requires far fewer blood samples. The TNIC design is attractive for outbreak settings and may be useful for T-cell correlates.

India’s COVID-19 burden has transitioned from acute pandemic management to long-term sequelae care. Among these, long COVID, also known as post-COVID condition or post-acute sequelae of COVID-19, has emerged as a clinically heterogeneous and operationally challenging entity. For infectious diseases specialists, long COVID raises important questions around pathophysiology, surveillance, reinfection and continuity of care in a population with high exposure density and comorbidity burden.

Case definition and diagnostic framework

Per the World Health Organization definition, long COVID is a condition characterized by persistence of symptoms beyond three months of the acute phase of COVID-19, lasting at least two months and not explained by an alternative diagnosis. (1) This definition is particularly relevant in India, where overlap with endemic infections (e.g., tuberculosis and dengue), nutritional deficiencies and chronic noncommunicable diseases complicates attribution. Importantly, long COVID may follow mild or asymptomatic infection and is not restricted to hospitalized cases. (2)

Epidemiology and relevance to India

Global estimates suggest that 10% to 30% of individuals infected with SARS-CoV-2 develop persistent symptoms. (3) Extrapolated to India’s scale of infection, this implies a substantial and ongoing clinical burden. Recurrent infections, circulation of immune-evasive variants and uneven vaccine uptake in early waves may further amplify risk. Indian cohort data remain limited, but available hospital-based studies indicate persistence of fatigue, dyspnea, weakness, myalgia, ageusia, neurocognitive symptoms and psychological morbidity after discharge from hospital. (4,5)

Long COVID is best understood as a syndrome with multiple overlapping phenotypes rather than a single disease entity:

Fatigue and post-exertional malaise

Debilitating fatigue and post-exertional malaise are the most frequently reported features, characterized by symptom exacerbation following physical activity. (6) This phenotype has implications for rehabilitation strategies, as indiscriminate graded exercise may exacerbate symptoms in a subset of patients.

Respiratory sequelae

Persistent dyspnea, reduced diffusion capacity and exercise intolerance may follow even moderate disease, reflecting residual parenchymal changes, microvascular injury, airway hyperreactivity or dysfunctional breathing patterns. (7)

Neurocognitive and neurological manifestations

Patients commonly report “brain fog,” memory impairment, sleep disturbance, headache, anosmia and dysautonomia-like symptoms. Neuroinflammatory mechanisms, endothelial dysfunction and autonomic imbalance have been proposed. (8)

Cardiovascular and autonomic involvement

Palpitations, orthostatic intolerance, inappropriate sinus tachycardia and chest pain are increasingly recognized, sometimes resembling postural orthostatic tachycardia syndrome.  (9)

Psychological and psychiatric sequelae

Anxiety, depression and post-traumatic stress disorder may coexist with somatic complaints, particularly after severe illness or intensive care unit admission. (10) These should be evaluated as integral components rather than secondary considerations.

Pathophysiological considerations

Multiple, potentially overlapping mechanisms have been proposed, including viral persistence or antigenic remnants, immune dysregulation, autoantibody formation, endothelial dysfunction, microthrombosis and reactivation of latent viruses. (11) For infectious diseases specialists, these hypotheses reinforce the importance of longitudinal follow-up and careful interpretation of inflammatory and immune markers, while avoiding over-investigation in clinically stable patients.

Diagnostic and management challenges in India

From a clinical standpoint, long COVID in India presents several challenges:

- Fragmented care pathways:This leads to patients cycling between specialties due to lack of coordinated oversight.

- Resource constraints:This limits access to advanced imaging, pulmonary function testing and autonomic studies.

- Overlapping endemic diseases:This necessitates vigilant exclusion of alternative diagnoses, such as TB, anemia, thyroid disorders and uncontrolled diabetes.

A pragmatic approach emphasizes structured clinical assessment, judicious investigations guided by red-flag symptoms and early referral to multidisciplinary care when available. (12)

Implications for infectious diseases specialists

ID physicians are uniquely positioned to lead long COVID care in the following ways:

- Establishing post-COVID follow-up pathways within infectious diseases or general medicine clinics

- Educating patients and colleagues that persistent symptoms do not imply ongoing infectivity but may reflect post-infectious sequelae

- Collaborating with pulmonology, cardiology, neurology, rehabilitation and mental health services

- Contributing to surveillance and research efforts to generate India-specific data on risk factors, reinfection and outcomes

Long COVID represents the chronic phase of the COVID-19 pandemic and is likely to remain a significant clinical entity in India. For infectious diseases specialists, it demands a shift from outbreak-oriented care to longitudinal, patient-centered management. Developing standardized follow-up protocols, integrating multidisciplinary care and generating robust Indian data will be essential to address this emerging burden effectively.

- Soriano JB, Murthy S, Marshall JC, et al. A clinical case definition of post-COVID-19 condition by a Delphi consensus.Lancet Infect Dis. 2022;22(4):e102-e-107. DOI: 1016/S1473-3099(21)00703-9.

- Nalbandian A, Sehgal K, Gupta A, et al. Post-acute COVID-19 syndrome.Nat Med. 2021;27(4):601-15. DOI: 1038/s41591-021-01283-z.

- Huang C, Huang L, Wang Y, et al. 6-month consequences of COVID-19 in patients discharged from hospital: A cohort study.Lancet. 2023;401(10393):e21-e33. DOI: 10.1016/S0140-6736(23)00810-3.

- Tomar BS, Singh M, Nathiya D, et al. Prevalence of symptoms in patients discharged from COVID are facility of NIMS hospital: Is RT-PCR negativity truly reflecting recovery? A single-centre observational study.Int J Gen Med. 2021;14:1069-78. DOI: 10.2147/IJGM.S295499.

- Kulkarni MV, Nayse VJ, Bansod CM. Persistent symptoms and functional health status among Covid-19 patients after discharge from a Covid hospital.J Family Med Prim Care. 2023;12(10):2496-500. DOI: 4103/jfmpc.jfmpc_663_23.

- Twomey R, DeMars J, Franklin K, et al. Chronic fatigue and post-exertional malaise in people living with long COVID: An observational study.Phys Ther. 2022;102(4):pzac005. DOI: 10.1093/ptj/pzac005.

- Kersten J, Wolf A, Hoyo L, et al. Symptom burden correlates to impairment of diffusion capacity and exercise intolerance in long COVID patients.Sci Rep. 2022;12:8801. DOI: 10.1038/s41598-022-12839-5.

- Stefanou MI, Palaiodimou L, Bakola E, et al. Neurological manifestations of long-COVID syndrome: A narrative review.Ther Adv Chronic Dis. 2022;13:20406223221076890. DOI: 10.1177/20406223221076890.

- Bisaccia G, Ricci F, Recce V, et al. Post-acute sequelae of COVID-19 and cardiovascular autonomic dysfunction: What do we know?J Cardiovasc Dev Dis. 2021;8(11):156. DOI: 10.3390/jcdd8110156.

- Schou TM, Joca S, Wegener G, et al. Psychiatric and neuropsychiatric sequelae of COVID-19 – A systematic review.Brain Behav Immun. 2021;97:328-48. DOI: 1016/j.bbi.2021.07.018.

- Davis HE, McCorkell L, Vogel JM, et al. Long COVID: Major findings, mechanisms and recommendations.Nat Rev Microbiol. 2023;21(3):133-46. DOI: 10.1038/s41579-022-00846-2.

- Kumar G, Bhalla A, Mukherjee A, et al. Post COVID sequelae among COVID-19 survivors: Insights from the Indian National Clinical Registry for COVID-19.BMJ Glob Health. 2023;8(10):e012245. DOI: 10.1136/bmjgh-2023-012245.

Recent changes in pediatric vaccination schedules from the U.S. Department of Health and Human Services have coincided with measurable declines in routine childhood immunization coverage across the U.S. (1) These changes reflect a shift toward vaccination frameworks modeled in part on Denmark’s health care system, which differs substantially from the U.S. in access, care and overall coordination. Denmark’s population is highly homogenous, and health care is universal. This is a stark contrast to the U.S., a country with a largely diverse and uninsured population. (2)

In an already fragmented U.S. health care landscape, where outcomes vary person to person, prevention is increasingly moving away from population-based strategies towards individual risk assessment and decision-making. Combined with shifting federal and state guidance and the growing visibility of vaccine-skeptical rhetoric via social media, families are left uncertain about vaccine safety, necessity and timing.

This uncertainty has tangible consequences in pediatric populations for conditions such as hepatitis A and B, respiratory syncytial virus, influenza, rotavirus and meningococcal disease. Childhood vaccinations against all of these are now recommended only for high-risk populations in the HHS vaccine schedule. (3)

Implications, access barriers and consequences

Declining vaccination coverage has national implications, but its effects are unevenly distributed across communities. Geographic location, health care access and socioeconomic factors strongly influence whether children receive routine immunizations on schedule. Rural areas, under-resourced communities and regions with limited pediatric care infrastructure face barriers, including fewer providers, transportation challenges and inconsistent insurance coverage. (4)

These access barriers, paired with misinformation, may result in further delays for previously routine vaccines. These gaps increase infectious disease susceptibility within already vulnerable populations and create conditions for outbreaks of diseases once considered well-controlled in the U.S., particularly among infants and immunocompromised individuals who rely on community immunity for protection.

For infectious diseases physicians, the consequences are increasingly visible in both clinical and public health settings. Lower pediatric vaccination rates translate into a higher likelihood of encountering vaccine-preventable infections, larger and more resource-intensive outbreaks, and increased demand for public health coordination. (5) Clinicians are tasked not only with diagnosing cases of vaccine-preventable disease but also with treating vaccine-preventable disease while navigating care in settings where trust in traditional medicine may be limited.

The unique role of ID physicians

Combating vaccine misinformation requires a multifaceted response in which ID physicians play a central role. At the clinical level, open discussion around vaccinations and disease risk can counter uncertainty before hesitancy becomes refusal. Beyond individual encounters, collaboration with public health partners, engagement in science-based public communication and advocacy for policies that improve access to routine immunization are essential. While misinformation spreads rapidly, coordinated and credible messaging from trusted health care professionals remains one of the strongest defenses against the resurgence of vaccine-preventable disease.

The relationship between declining vaccination coverage and rising infectious disease risk is not new. What is new is the speed at which misinformation spreads and its measurable impact on population immunity. As clinicians trained to diagnose and treat infectious conditions, ID physicians are uniquely positioned to recognize this moment for what it is: a preventable resurgence driven not by scientific uncertainty, but by failures in communication, access and trust.

- Centers for Disease Control and Prevention. (2025). Vaccination Coverage and Exemptions among

- Schmidt M, Schmidt SAJ, Adelborg K, et al. The Danish health care system and epidemiological research: from health care contacts to database records.Clin Epidemiol.2019;11:563-591.

- U. S. Department of Health and Human Services. (2026). Decision memo: Adopting Revised Childhood and Adolescent Immunization Schedule.

- Lv X, Long A, Chen Y, et al. Socioeconomic Disparities in Childhood Vaccination Coverage in the United States: Evidence from a Post-COVID-19 Birth Cohort. 2025;13(12):1256.

- Brumbaugh KQ, Gellert F, Mokdad AH. Understanding Vaccine Hesitancy: Insights and Improvement Strategies Drawn from a Multi-StudyVaccines. 2025;13(10):1003.

In a June 2025Science Speaksblog post, I wrote about the unacceptably low rates of screening for hepatitis C virus in pregnancy. I see a lot of young women with HCV who have been pregnant and are shocked that they weren’t screened by their obstetrician. Since 2020, the Centers for Disease Control and Prevention, followed bymultiple medical societies, has recommended that pregnant people be screened for HCV with each pregnancy, but we are screeningless than 40%of them.

In annew studypublished inOpen Forum Infectious Diseases, researchers looked at all pregnant women who tested positive for syphilis in West Virginia between Jan. 1, 2019, and Dec. 31, 2023. They interviewed all women with a positive syphilis test to collect other information: age, race, syphilis diagnosis and treatment, past-year incarceration, past-year substance use and birth outcomes. Both syphilis and HCV are reportable conditions, so they cross-referenced those records.

They found 161 pregnancies with a positive syphilis test; 69 (42.9%) had laboratory evidence of a past or present HCV infection. Of these, 38 (55.1%) had active HCV during this pregnancy. While approximately one-third of all patients had an unknown incarceration or drug use history, 21.7% of women with HCV were incarcerated in the last year versus 5.4% who did not have HCV. In addition, 50.7% of the patients with HCV reported drug use in the prior year versus 15.2% who did not have HCV.

Discrepances were also seen with syphilis treatment adherence, with those with HCV being more nonadherent to treatment (40.6% vs. 14.1%). Unsurprisingly, the group with HCV also had higher rates of congenital syphilis (59.4% vs. 28.3%).

This association between syphilis and HCV is somewhat surprising. HCV is not considered asexually transmitted diseasewith heterosexual spread. The authors of theOFIDstudy highlighted higher rates of substance use and incarceration in the co-infection group. Not only does this study reinforce the need for universal testing for both syphilis and HCV in pregnant people, but it is a call to clinicians to ensure close follow-up during syphilis treatment for those who are positive for both syphilis and HCV.

Further studies could look at whether linking patients with substance use disorder into treatment would improve syphilis treatment adherence and reduce the rates of congenital syphilis.

This study starts to uncover the syndemics of infectious diseases in pregnancy and may provide a glimpse into how to improve health care for pregnant and postpartum patients and their families.

(Hudson et al.Open Forum Infect Dis. 2025;12(12):ofaf716.)