Marco's Morning Report — Tuesday, August 18, 2026

Good morning, Marco. Yesterday was the CDC's annual school-vaccination dump, and it landed harder than usual: kindergarten exemptions hit a fourth straight record, and a county-level map published the same day showed most of the country now sits below the measles herd-immunity line. Under that: COVID wastewater doubled month-over-month while the aggregate respiratory dashboard still reads "very low," SHM's new workforce report says two-thirds of hospitalists are using AI and only a third were trained on it, and McLean threw six strong innings in a shutout of San Diego. Coffee, then sleep.

Section A — Top Stories

Kindergarten vaccine exemptions hit a fourth straight record — and the map is now county-level

What happened CDC released 2025–26 SchoolVaxView data yesterday. Exemptions from one or more required vaccines rose to 4.2% of kindergartners, up from 3.6% — the fourth consecutive record year, with the overwhelming majority nonmedical. Exemptions rose in 41 states plus D.C., and 24 states now exceed 5%. MMR coverage slipped to 92.4%, DTaP to 92%, and roughly 280,000 kindergartners started school without documentation of a completed MMR series (CNBC, CBS News, CDC SchoolVaxView). A Washington Post analysis of records from 44 states published the same day added the geography: the share of U.S. counties at or above 95% kindergarten MMR coverage has fallen from 50% pre-pandemic to 28%, leaving at least 5.2 million kindergarten-age children in below-threshold counties.

Why it matters to you The unit of risk is no longer the state — it's the county, and the state average hides it. That matters for your admissions in two directions. First, adult presentations: measles in an unvaccinated or waned adult and pertussis in an elderly patient both arrive as undifferentiated respiratory illness, and both are easy to anchor away from in August when aggregate ARI is reading low. Second, discharge planning: an elderly patient going home to a multigenerational household in a low-coverage county has a different exposure profile than the state number implies.

Action Worth knowing Lee County's number before someone asks you at the bedside. The Post's interactive is searchable by school district — five minutes with it gives you a defensible local answer instead of a national one.

Update: COVID wastewater has doubled since July while the respiratory dashboard still reads "very low"

What's new The gap between indicators widened again. SARS-CoV-2 wastewater concentrations are up 106% in August versus July and are classified "high" nationwide with a significant 21-day upward trend; CDC's Rt model has COVID growing or likely growing in all 50 states as of 8/12. Meanwhile the aggregate acute respiratory illness measure was still "very low" as of 8/14, and COVID-associated ED visits sit near 0.3% of all visits. The West and South are carrying the increase, with California and Texas showing the sharpest upticks (CDC wastewater, CDC respiratory data channel, TODAY).

Why it matters to you Wastewater leads admissions by roughly two weeks, so a 106% month-over-month rise is a forecast for the back half of August and early September — which is exactly the window where the 2025–26 vaccine formula is being retired and the 2026–27 formula hasn't shipped. The "very low ARI" headline is the number your non-clinical colleagues will quote back to you; it's an aggregate that COVID no longer dominates in summer.

Action If you only track one number this month, track the wastewater trend line rather than ARI. And it's worth confirming with infection prevention what currently triggers an admission COVID test and isolation, since the testing posture set in a low-ARI July may not have been revisited.

SHM: 64% of hospitalists now use AI clinically — only a third say they were trained

What happened SHM's 2026 Hospital Medicine Workforce Experience Report is out (free to members, summarized in the August issue of The Hospitalist). 64% of hospitalists report using AI in practice and 73% of those report benefit — but only one-third report adequate training. The most common use is decision support, followed by chart summarization, coding, and ambient listening. The same report covers burnout, workload and autonomy, workplace violence, and leadership support.

Why it matters to you Decision support ranking above ambient scribing is the interesting inversion — most of the public conversation is about note-writing, but hospitalists are reaching for these tools at the point of clinical judgment, which is the higher-stakes use and the one where an untrained user is most exposed. A third-trained majority is a documentation and liability posture, not just a workflow question. It also lands next to April's STAT reporting that large scribe deployments delivered modest and inconsistent time savings.

Action A fifteen-minute group agenda item: what AI tools are sanctioned on your unit, who owns training, and what the documentation expectation is when decision support informed a call. Nights is where this is least supervised.

Section B — The Debate

Should states eliminate nonmedical exemptions from school vaccine requirements?

Yesterday's CDC release — a fourth consecutive record exemption rate, with increases in 41 states — reopened an argument that had been running quietly all summer. Florida makes it concrete: the state's surgeon general announced last September that Florida would end all vaccine mandates, and as of last week (Jacksonville Today, WUSF) every requirement is still standing while hesitancy keeps climbing.

For elimination

Nonmedical exemptions aren't a neutral accommodation — they redistribute risk onto children who can't be vaccinated, and they cluster, which is why a 4.2% national number produces schools where an introduction becomes an outbreak. That's the core of the American Academy of Pediatrics policy statement Medical vs Nonmedical Immunization Exemptions for Child Care and School Attendance (lead authors Jesse M. Hackell, Sean T. O'Leary, Kyle Brothers and colleagues), which holds that nonmedical exemptions are "contrary to optimal individual and public health" and should be eliminated. AAP president Susan J. Kressly, MD, frames it as a collective-benefit argument rather than a compliance one: "when everyone can be immunized, it's harder for diseases to spread in our communities" (AAP News). The empirical claim underneath is narrow and testable: states that tightened exemptions saw coverage recover, and the current resurgence is the worst in 35 years.

Against elimination

The strongest version isn't about vaccine safety — it's about who holds the decision. A school-attendance requirement makes a medical intervention the price of a public benefit, which converts a recommendation into coercion and, on this view, corrodes the consent framework that the rest of medicine runs on. Joseph Ladapo, MD, PhD, Florida's surgeon general, puts the question as one of standing rather than science: "Who am I, as a government, or anyone else — who am I as a man standing here now to tell you what you should put in your body? Who am I to tell you what your child should put in your body?" (Florida Politics, NBC News). The practical argument that follows: mandates buy the last few percentage points of coverage at the cost of trust, and parents pushed rather than persuaded disengage from the whole schedule, not just the disputed shot.

Where it might land Florida can't resolve this administratively. DTaP, MMR and polio are mandated by statute and would require the Legislature, which next convenes in January; Hib, hepatitis B, varicella and pneumococcal sit in Department of Health rule and can move through rulemaking. Watch those two tracks separately.

Section C — On My Radar

Mets 5, Padres 0. Nolan McLean went six against Walker Buehler with the outfield defense doing heavy lifting behind him; Luis Robert Jr. worked an eight-pitch at-bat for the sacrifice fly that made it 2–0. New York has now won nine of its last 12 and opened the series against a San Diego club that came in 67–58 (Amazin' Avenue, ESPN box score).

Roster churn: the Mets designated Gabriel Arias for assignment after two games to make room for Christopher Morel (Mets game notes).

Tropics: Invest 94L, midway between Cabo Verde and the Lesser Antilles, is holding around a 40% development chance; a depression could form late this week or over the weekend, but strong upper-level winds sit east of the Lesser Antilles and no Florida impact is anticipated at this range (WFTV, Track the Tropics).

Cuba: Sunday's peak-demand deficit left up to 67% of the island without power simultaneously, following the sixth nationwide grid collapse of 2026 on August 2–3. Cuba needs roughly 100,000 barrels a day and produces about 40,000 domestically; independent forecasters now project a contraction of up to 6.5% this year on top of a 15% decline between 2020 and 2025 (CNN en Español, Al Jazeera, CBC).

Puerto Rico: the 48-hour rotating rationing is now affecting more than 500,000 people across seven of the most populous municipalities — San Juan neighborhoods plus Carolina, Juncos, Gurabo, Trujillo Alto, Canóvanas and Loíza. July was San Juan's driest month in more than 120 years; roughly 65% of the water AAA produces is lost or unbilled, much of it to leaks, and AAA's unionized workers walked out over $10.50/hr wages (NPR, Yale Climate Connections).

Hormuz: the 60-day negotiating window expired yesterday with no agreement. Trump called making the strait U.S. territory "a great idea" — "we control it with the blockade" — while Energy Secretary Chris Wright described it as still a conflict zone with disrupted traffic; Iran says it is finalizing a joint statement with Oman on managing shipping. MarineTraffic logged three commercial transits in 24 hours (Washington Post, CNN).

Movies & TV: The Bone Temple — Nia DaCosta's direct continuation of 28 Years Later with Ralph Fiennes and Jack O'Connell — is drawing the best notices of the month, and Union County (Will Poulter and Noah Centineo as brothers in court-mandated rehab) is the quiet critical favorite. McConaughey's Oklahoma honey-farm thriller The Rivals of Amziah King opens Friday with strong SXSW reviews. Lanterns continues weekly on HBO Max (Rotten Tomatoes).

Golf tech: no new developments in the last 48 hours — 18th straight day. The pipeline is unchanged: Shot Scope's $200 LM1 with its ball-free speed-training mode and the sub-$800 Par Breaker Swing Pulse X10 still define the entry tier, and Uneekor's AI swing analysis remains the software story (The Golf Wire).

Section D — Trends to Watch

Vaccination policy is now decided at three levels at once, and the operative one is the county. A federal executive order sets recommendations, state legislatures and health departments set requirements on separate tracks, and actual coverage varies enough within a state that the county map — not the state average — predicts whether an introduction becomes an outbreak. Expect more reporting to move to that resolution.

Clinical AI crossed majority adoption before the training infrastructure existed. Two-thirds of hospitalists using it, one-third trained, and decision support outranking ambient scribing means the highest-judgment use case is also the least governed one. The policy scramble will follow adoption rather than lead it.

Aggregate respiratory dashboards are losing their signal in August. Wastewater up 106% month-over-month while composite ARI reads "very low" is not a contradiction — it's a measurement mismatch, built for a Nov–Feb season that COVID no longer keeps. Pathogen-specific curves and aggregate curves will keep diverging until the summer peak is designed into the instruments.

Section E — Ideas & Opportunities

Get a local number. Pull Lee County's kindergarten MMR coverage from the Post interactive so you have a specific answer when a family asks whether "it's bad here." It also sharpens your own index of suspicion for adult measles and pertussis presenting as undifferentiated respiratory illness.

Fifteen-minute group item: which AI tools are sanctioned on your units, who owns training, and what documentation is expected when decision support informed a call. SHM's report is the citation that makes it a policy conversation rather than a preference one.

Post-nights watch: The Bone Temple if you want DaCosta's dread, or Union County if you'd rather something quiet and human. Lanterns stays weekly on HBO Max.

Section H — Background / Already Covered

Older than 48 hours or previously reported — expand if useful

COVID vaccine formula gap (8/17): Kaiser no longer offers the 2025–26 formulation and the 2026–27 formula isn't expected until late September, leaving a roughly six-week coverage hole that lands squarely on the current wastewater rise.
Measles (8/13 → 8/16): 2,566 confirmed cases and 38 outbreaks as of 8/13, 94% outbreak-associated; the U.S. National Verification Committee convenes this month and PAHO reviews elimination status in November.
Childhood vaccine executive order (8/13): "Delivering Gold Standard Childhood Vaccine Recommendations," issued 8/10, narrowed the recommended schedule and shifted several decisions to shared clinical decision-making. Yesterday's exemption data is the first coverage read since.
HCA Florida Cape Coral Hospital (8/16): $300M, 322 SW Pine Island Rd, three stories and 200k sq ft — still the biggest local structural story of the month.
Cuba sanctions (8/17): Rubio sanctioned five entities and eight individuals tied to military procurement, continuing the tilt from military options toward sanctions and fuel pressure.
Candida auris (8/12): 3,437 clinical cases across 27 states through the week ending 7/25 — still worth an admission-screening conversation with infection prevention for SNF and LTACH transfers.

A record set in kindergarten classrooms, a sewer sample that saw it coming, and McLean carving up San Diego with help from the outfield. Sleep well, Marco.