0:00

This. Week Enviro a g

0:02

the podcast about viruses the

0:04

kind that make you sick.

0:10

From my grub Tv this is

0:12

to live this weekend viral eg.

0:15

Episode. Ten Ninety Two.

0:18

Recorded. On February twenty

0:20

ninth, Twenty. Twenty.

0:23

Four I vincent rak and yellow.

0:25

And. You're listening to the podcast

0:27

All About Viruses. Joining.

0:30

Me today from New York. Daniel.

0:32

Griffin. Hello everyone.

0:35

says. Leap Day sewn this episode

0:37

will disappear next year right? Is

0:39

that the a while or happen

0:42

should. When

0:44

he got on your dine out in this

0:46

is by by of this my biohazard bow

0:48

tie. So. Those are little

0:50

biohazards. Him as a biohazard, you know

0:52

that serve. Weird thing, They're all right.

0:55

Good. I. Let's jump

0:57

into it. I'm yeah, I try to

0:59

keep these are short, but dad near

1:02

now stuff happens and we need to

1:04

talk about it. So let's start off

1:06

with our quotation because sir as may

1:09

be a tribute to all our listeners,

1:11

the highest activity a human being can

1:13

attain is learning for understanding Because to

1:15

understand is to be free and that's

1:18

by baroque spinoza ab and day. I

1:20

think a lot of people come here

1:22

because they they they want to understand

1:25

the one education they don't. Just want

1:27

a little short little tic toc are

1:29

are a little sound bite. They actually

1:31

want that understanding so hopefully we can

1:33

keep providing it for everyone and hopefully

1:36

some that understanding is going to keep

1:38

everyone safe so that they can. Be.

1:40

Coming back for more. So we'll

1:42

start off with Rsv, an update

1:45

on Rsv and this is good

1:47

news It it looks like things

1:49

continue to drop with that Rsv.

1:51

so really down from that high

1:53

peak and you know in the

1:55

saucer what we're seeing in the

1:58

local area. So good news. Norris

2:00

be front and it this is interesting,

2:02

right? will maybe get a little more

2:05

into this is skill. This impacts some

2:07

of our recommendations, right? So we're getting

2:09

near the end of when we're recommending

2:12

that last trimester vaccination for pregnant individuals

2:14

because you know by the time the

2:16

child is born we might be passed.

2:18

So you know we get sort of

2:21

little bit of regional nuance. Butts really

2:23

marches gonna be where we sort of

2:25

start wrapping that up. March also is

2:28

where where wrapping up a lot. Of

2:30

that the base for this that passes.

2:32

I'm immune to say since I'm now

2:34

Rc vaccinations right? For older folks, that's

2:37

actually something that has a durability. So

2:39

you know if you haven't got your

2:41

speed vaccines you don't think about getting

2:43

at, but not quite as under the

2:45

gun as you were in the in

2:47

the past. The

2:50

slew of going in the right

2:52

direction? still still fairly high though

2:54

still seeing a fair number of

2:56

cases of Us Influenza. but you

2:58

know, across the. Board we are. seeing

3:01

that I'm really starting to go in. A

3:04

positive. Direction from a I from

3:06

a judgment standpoint. Any negative direction

3:08

from a quantitative standpoint. So good

3:11

stuff they are, but again, it's

3:13

it's regional rights. I'm. Right

3:15

here in New York where since

3:17

and I are recording frumps, we're

3:19

really getting down into the low

3:21

levels. A cell.

3:24

we've got some some hot spots

3:26

on. Know what they're doing out

3:28

there in Ohio and Wyoming is

3:30

is going strong. A New Mexico,

3:32

Oklahoma, Arkansas, Young, Texas and Louisiana

3:35

so you're good with your states.

3:37

Daniel Express. Say

3:39

I feel like when I was in school

3:42

you know we had memorized and and enough

3:44

people know but Vincent I have visited every

3:46

single states except for what. And

3:49

land Aca never been Alabama nice to

3:51

work up in Alaska do in hospital

3:53

my side a verse everywhere in the

3:55

world set my feature. I.

3:57

Have been to most states but not. All

4:00

of them. I think they're five or six. I haven't been. To.

4:02

Revel, You gotta. you gotta get on. That

4:04

sent me I will. Sorry, let's jump right

4:06

into Coville we we've before you go see

4:09

how many could what countries have you been

4:11

to? Rattle a Moss? I'm just curious. you

4:13

know I I always forget you know and

4:15

I kind of run through these so I

4:17

try to do a time and a geographical

4:19

spread soaks will start. Canada, United

4:21

States where I live

4:23

at the moment Mexico

4:25

Ma'am going down to

4:28

Panama. The.

4:30

Dominican Republic and little bit into

4:32

he says into Haiti I will

4:34

quite mention that because of poor

4:37

sport or so much of that

4:39

was Sicily done a lot of

4:41

different areas in the Caribbean and

4:44

per rule and then moving over

4:46

to Ireland Iceland. An. England,

4:49

Scotland ran with separates

4:51

you guys they're spray

4:53

ads side Germany, the

4:55

Czech Republic, Moving.

4:58

Farther of Fields or

5:01

Nepal, India, Thailand, Cambodia

5:03

to pay and on

5:06

a visit to China,

5:09

Zimbabwe, Zambia, Donna.

5:11

South Africa. Malawi's.

5:17

i'm forget and stuff but he had

5:19

just serve a smattering potter lots of

5:22

plans never been to australia i've never

5:24

been to australia or new zealand know

5:26

night not yet night and your your

5:28

south american x visitation is just peru

5:30

basically i know i deter any to

5:32

spend more time down there and i

5:34

thank you i rubbed his corzine travel

5:36

a lot and i was writing last

5:39

stuff out so i apologize for that

5:41

the kind of sense that as that

5:43

i didn't know stay in i gotta

5:45

stay in a lot sorry about that

5:47

assessed said people probably who listener like

5:49

by doctor griffin you didn't mention bone

5:51

air you did mention the dutch antilles

5:53

and i'm going to actually be in

5:56

denmark in april so sorry last denmark

5:58

out i've been there belgium yeah I'm

6:00

sure I left bots out. Now,

6:02

Italy. I haven't been to Italy. Last one. I've

6:05

never been to Italy. Yeah. Oh my

6:07

God. You have to go to Italy. Yes. That

6:10

is on the list. Okay. Oh,

6:12

Kenya. I forgot Kenya. Okay. So,

6:15

though, going into COVID, now that we've

6:17

stopped my world travel update, you

6:19

know, a little bit of improvement. We are still, I

6:22

just want to say, we are still at over, we

6:24

are averaging over 200 deaths a

6:26

day still. So you

6:28

know, when we talk about different things, like,

6:30

okay, yeah, that might be better than 2000

6:32

deaths a day that we were seeing in

6:35

the US in the early days, you know,

6:37

just in New York alone. But still, you

6:39

know, 1569 deaths last week, average about 2000

6:41

deaths a week from COVID. That's

6:48

too many. But

6:50

we are, as we talked about with

6:52

RSV and influenza, we're seeing

6:54

from a wastewater surveillance, things are going

6:57

in the right direction in

6:59

most of the country, and actually

7:01

the country as an average. So

7:04

moving in the right direction there.

7:06

So Daniel, flu, RSV, SARS-CoV-2,

7:08

all trending downwards here at the

7:11

end of February. Yes. Yes.

7:14

And actually, dare I say, as anticipated. Yeah.

7:18

All right. So this was a bit

7:20

of news. We'll spend some time on

7:22

the COVID active vaccination section. And so

7:25

I will start this section with the

7:27

news that yesterday, we're

7:29

recording this Thursday, so Wednesday,

7:32

February 28, 2024, the vaccine

7:34

advisors to the Centers for

7:36

Disease Control and Prevention recommended

7:39

that people ages 65 and

7:42

older receive an additional dose

7:44

of the current monovalent COVID-19

7:48

vaccine this spring. And

7:50

CDC Director Mandy Cohen endorsed

7:52

the group's recommendation. Here's

7:54

a quotation from Dr. Cohen. Today's

7:57

recommendation allows older adults to...

8:00

receive an additional dose of

8:02

this season's COVID-19 vaccine to

8:04

provide added protection, said Mandy

8:06

Cohen. Most COVID-19

8:08

deaths and hospitalizations last year

8:10

were among people 65

8:13

years and older. An additional vaccine

8:15

dose can provide added protection that

8:17

may have decreased over time for

8:19

those at highest risk. Now,

8:22

I'm going to put in a link to the

8:24

slides from this discussion as

8:26

they give an insight into the

8:29

science, but also its

8:31

limitations. So I'm not sure that

8:33

what Dr. Cohen said is

8:35

point by point right on. So I'll

8:37

discuss why I say

8:40

that. So a couple things that they talked

8:42

about. So the

8:44

first thing is do people care? Are people

8:47

65 and older interested

8:49

in COVID vaccines? So

8:51

they have a slide where

8:54

they actually ask people what

8:56

concerns about COVID-19 disease, confidence

8:59

in COVID-19 vaccine safety,

9:01

confidence that COVID-19 vaccine is somewhat

9:03

or very important to protect me.

9:06

And when you look at people 65 years

9:09

of age, we actually

9:11

see that the majority of them feel

9:14

confident in the vaccine safety

9:16

and the vast majority, like

9:18

78% of them actually feel

9:20

that the COVID-19 vaccine is

9:22

an important thing to protect

9:24

them. However, Daniel, the

9:27

numbers of people they

9:29

looked at is nothing.

9:31

That's ridiculous. 65 people

9:34

in one bar. I mean, this is no

9:37

way a section of the US. Come

9:39

on, that's CDC. So

9:42

yeah, we should look at more people. The

9:44

other which, and I think this is interesting, right? Because we're

9:47

going to talk a little bit about what

9:49

do these extra doses do. But I

9:51

want to point out that this is

9:53

on top of really

9:55

broad immunity

9:58

across the... the population. And so

10:00

if you look in the different age groups, and

10:03

they have a slide where they talk about this,

10:05

only 1 to 2% of

10:08

everyone in the United States is, I

10:10

will say, unprotected from an immune point

10:12

of view. And so talking about this

10:15

population 65 years and

10:17

older, we are seeing that

10:20

the majority, 58% have hybrid

10:22

immunity. We are

10:24

seeing that there's some infection only,

10:27

seroprevalence. There's some vaccination,

10:29

about a quarter of 65 and older

10:31

have what they refer to as vaccination

10:33

only seroprevalence. So the idea is actually

10:36

a quarter of these folks have not

10:38

had a COVID infection, that immunity is

10:40

purely from vaccine. So,

10:42

you know, as we always talked about the,

10:45

you know, ACIP and these different

10:47

groups are trying to give recommendations

10:50

about public

10:53

health issues, right, where we often when we're

10:55

sitting face to face, we're talking about an

10:57

individual. So they phrase their

10:59

discussion in the context of what are

11:02

the public health problems that they're trying

11:04

to address. So as we talked about,

11:07

COVID-19 hospitalization peaked in late December,

11:09

early January. However, there still are

11:12

approximately 20,000 new hospital admissions and

11:14

2000 deaths each

11:19

week due to COVID-19. And

11:23

why are they targeting the greater than 65 years?

11:25

These folks

11:27

have the highest COVID-19 hospitalization

11:30

rates. And, you

11:32

know, the age is really a big

11:34

issue when it comes to hospitalization. Also,

11:36

mortality, particularly the 75 years of

11:39

age and older. So they

11:41

looked at some data. So there is some science

11:44

here that they're looking at. And

11:46

one of the things they looked at is something we've

11:48

been talking about is what

11:50

is the durability of protection,

11:53

right? We're not expecting these

11:55

boosts to restore

11:57

protection, restore high antibody levels.

12:00

for a year. We've talked

12:02

about a three to four month expectation.

12:05

And when they looked at the, I'm going

12:07

to focus here on the greater than 65

12:10

folks, you know, you

12:12

see the best, the highest vaccine

12:15

effectiveness, and this is against

12:18

hospitalization, right? It's not infectious, it's

12:20

against hospitalization. You see

12:23

the most significant in the first two

12:25

months. You still see

12:27

solid protection out to 120 days,

12:30

so that's about four months. And once you get

12:32

past there, you really start to see a drop

12:35

in that calculated

12:38

absolute vaccine efficacy against hospitalization.

12:40

And we see a similar

12:42

pattern when we also bring

12:45

in hospitalization and critical illness. Daniel,

12:49

can I ask, in the hospitalization

12:51

VE, the younger people

12:53

do worse in some of

12:55

the, in like the 60 to 119 days and

12:57

120 to 179 days. They do worse than the older people. Why

13:03

is that? Really

13:05

interesting because they have a whole section where they

13:07

talk about immunosurveillance and why it's so important to

13:09

get the old people these updated vaccines. You know,

13:12

if you look at the data, you're starting to

13:14

say, oh, the young people need it even more

13:16

often. Yeah, you know, big

13:18

error bars, I'll give you that. And

13:20

yeah, clearly by the time you get out to 120 to 179, you know,

13:22

the young folks, right, the 18 to 64, it's like coming smack down

13:28

at a vaccine effectiveness back down to

13:30

zero, right? And

13:33

remember, as you said, this is the

13:35

original monovalent and bivalent booster. It

13:37

is not the current omicron

13:40

formulation. Mm-hmm. Yep. So

13:45

that's kind of, I think, part

13:47

of the reality check, right? And

13:49

they acknowledge the reality check. So people

13:52

looking at this and saying, oh, but

13:54

if you get another booster, we might

13:56

restore some degree of protection. Well, as

13:59

they point out, no clinical trial immunogenicity

14:01

data of this additional dose that

14:03

they're talking about right

14:05

now. But they do say, but

14:07

you know, that initial dose does

14:09

get a robust elicitation

14:12

of neutralizing antibodies. And it

14:14

is providing protection against JN1

14:16

and other circulating variants. So

14:20

what are they going to recommend

14:22

here? So here's what it comes

14:24

down to. So the ACIP recommends

14:26

that persons 65 years of age

14:28

or older may receive

14:31

an additional dose of 2023 to 2024.

14:33

But we're going to

14:36

talk about May in a second here. They

14:39

say that this should be informed

14:42

by clinical judgment of the healthcare

14:44

provider, personal preference, circumstances, you know,

14:46

considering the additional dose based upon

14:48

the person's risk for severe COVID-19,

14:51

the additional dose administered at least

14:53

four months after that

14:55

previous dose. But then there's this

14:57

whole big discussion about the word may.

14:59

Should we really say may, which

15:02

is just sort of like, yeah, you could do that. Or

15:04

should it actually be a recommendation? Is

15:07

this a should? Are they going to

15:09

encourage people? Are they going to say

15:11

in our expert opinion based upon, as

15:14

they acknowledge, very weak evidence, limited amount

15:16

of evidence, but what they do know,

15:21

does the discussion change

15:23

that the recommendation is ACP recommends that

15:25

persons greater than 65 years

15:27

of age should receive an additional

15:30

dose? And they actually,

15:32

an amendment gets introduced, they switch

15:34

the voting measure to the stronger

15:36

recommendation, and we end up with

15:38

a final measure passed with 11 votes for

15:41

yes, one vote no, one abstention.

15:44

So let me get this, so this is

15:46

like an XBB version

15:48

vaccine, basically, which was first launched in

15:50

the fall. Is that correct? Yes, they're

15:52

saying, you know, if you got that

15:54

shot in the fall, and you're 65

15:56

and older, this committee,

16:00

recommends suggests that you should

16:03

get an additional dose. Okay.

16:05

Why don't we have clinical data from that

16:08

first dose in the fall? You had plenty

16:10

of time, you had the respiratory virus season,

16:12

you could have done a great study, why

16:14

don't we have anything CDC? I

16:17

think the biggest, I mean I guess my biggest

16:19

contention is, well so again, we're sort of where

16:21

this is quote unquote expert opinion, what they call

16:23

the Delphi consensus, where you get a whole bunch

16:25

of people in a room and say we don't

16:27

actually have data but we're going to recommend you

16:29

do this. And then, you

16:31

know, because the big data is

16:34

will this additional dose give

16:36

us that extra, will it restore somehow this

16:38

protection that we know? I

16:41

understand that, but they didn't even look for

16:43

the first dose to see if- In this

16:45

discussion, right, where's the slide with the data

16:47

on, you know, because we talked about some

16:49

data on the current, but where was that

16:51

in the slide deck? Yeah. I

16:54

mean, I don't want to

16:56

be anti-vaccine, but I would like,

16:58

I don't think if you make

17:00

recommendations without scientific data supporting them,

17:03

you're eroding confidence in vaccination,

17:07

and that's not good. Yeah,

17:09

I think, you know, interesting, and I

17:11

spent a little time, but I actually when you

17:13

talk about this May versus should, I like

17:16

the May, but again, maybe this has a

17:18

legalistic implication. So if you look at it,

17:20

you say, listen, you're over 65, you're interested

17:23

in getting another vaccine, we think you're going

17:25

to get a boost in antibodies for three

17:27

to four months, it's been past four months.

17:29

We've talked about individuals, they have a discussion

17:31

with their provider, and then they try to

17:33

go get the vaccine and the insurance companies

17:35

say, nope, you're not eligible, our system doesn't

17:38

allow that to happen. By

17:40

giving a should recommendation, does it

17:42

increase the access? I don't think we're going to get

17:44

an onslaught. I think we're going to get a few

17:47

percent of our population going for this extra dose. And

17:50

you know, how much of this is sort

17:52

of opening up the public health access to

17:54

these additional doses versus how strong

17:56

is this this should I mean, we probably

17:58

need like a third word, you

18:00

know, this sort of a soft should

18:03

versus a, you know, thou

18:05

shall. About

18:07

must. That's a good one

18:10

too. I don't think we

18:12

like shall and must in America. No. Yeah,

18:15

but I think, you know, this is gonna be out there,

18:17

people are gonna be discussing it. Yeah,

18:19

and there are certain patients that this

18:21

makes sense, we think, and again, just

18:24

putting it in the couch. But yeah,

18:26

this is always that challenge. We have

18:28

to be careful what we make should

18:30

vaccine recommendations, because after a

18:32

while, you know, it's the boy

18:34

who cried wolf. They want to see the science. They

18:37

want to see that this is really making a difference.

18:40

Is there any negative of

18:42

getting a booster in

18:44

the spring? Yes, I think that's

18:47

the great thing is they talked a lot

18:49

about, you know, is there a downside? Is

18:51

there a risk? And the overwhelming realization,

18:54

the discussion was that these

18:56

are incredibly safe vaccines, right?

18:58

I mean, they're biologically

19:00

impactful. So you know, it's not

19:02

zero risk, but that risk is

19:04

incredibly small compared to the potential

19:06

upside to boosting those antibodies, maybe

19:08

even some kind of a T

19:10

cell boost for some period of

19:12

time. So that's really what's

19:15

risk benefit discussion. But if you're, let's

19:17

say, 22 years old,

19:19

and you had a COVID infection like

19:21

so many people did during January, you

19:23

know, I think it makes sense to

19:26

focus on a higher risk group. So

19:29

one person voted no. Do we know who that

19:31

is? I wanted to find out who is the

19:33

no and who is the abstention. So we

19:36

may have to play back the tape to find out who

19:38

that was. And then I thought about, well, I probably shouldn't

19:40

find out and mention it. I'll look at my own time.

19:45

No, I mean, it's always curious to know why

19:47

someone voted a certain way. Yeah. Well,

19:50

they what's really nice, and I should go back and

19:52

sort of, you know, just spend a little time looking

19:54

at that is that they get their reasoning. They say,

19:56

this is why I abstain. This is why I said

19:58

no. and

20:00

then they get their sort of, you know, let me

20:02

explain why I said that. And that can be really

20:04

informative. And

20:06

the other I should say at the

20:08

same sort of context in the slide

20:10

deck was also this question that they

20:13

asked, you know, percentage

20:15

who say they are taking each of the

20:17

following precautions because of COVID-19 this fall and

20:19

winter. So it's actually a survey that was

20:21

done back in the fall. And,

20:23

you know, there's this perception that no one

20:26

cares about COVID anymore. But

20:29

actually, if you look through some of the

20:31

responses, you know, a significant

20:33

percent of people are avoiding

20:35

large gatherings. Some

20:38

people are still wearing a mask in

20:40

crowded places. Some people are making decisions

20:42

to avoid travel. Some

20:45

of us are still avoiding dining

20:47

indoors at restaurants. There's

20:49

still a percent of our population that are taking

20:51

a COVID test before visiting with friends or family.

20:54

And if you say, are you doing anything,

20:56

you know, a solid, solid percent of folks.

20:58

So they're not necessarily publicizing this, but they're

21:00

making decisions to try to keep themselves in

21:03

their loved ones a little bit safer. Now,

21:06

this is an interesting, I think this plays

21:08

right into our discussion is the brief report.

21:11

US vaccine mandates did

21:13

not influence COVID-19 vaccination

21:15

rates, but reduced uptake

21:17

of COVID-19 boosters and flu

21:19

vaccines compared to bans on

21:21

vaccine restrictions. I mean,

21:23

that's like all right in the title published

21:25

in PNAS. So here

21:27

the investigators use state level data

21:30

from the CDC to ask

21:32

the question, they say, to test whether

21:35

vaccine mandates predicted changes in

21:37

COVID-19 vaccine update, as

21:40

well as related voluntary behaviors involving

21:43

COVID-19 boosters and seasonal

21:45

influenza vaccines. So they

21:47

suggest that the

21:49

results showed that COVID-19 vaccine

21:51

adoption did not significantly change

21:53

in the weeks before and

21:56

after states implemented vaccine mandates,

21:59

suggesting that did not directly impact

22:01

COVID-19 vaccination. So I was a little

22:03

surprised by that, interesting. Compared

22:06

to states that banned vaccine restrictions, we've

22:08

discussed a few of those. States

22:11

with mandates had lower levels

22:14

of COVID-19 booster adoption. So

22:16

say that again. States with mandates

22:18

had lower levels of COVID-19 booster

22:21

adoption, as well as adult and

22:23

child flu vaccination, especially when residents

22:25

initially were less likely to vaccinate

22:27

for COVID-19. So

22:30

just a little closer look at the

22:32

findings. So first, the investigators report. There

22:35

was no statistically significant difference

22:37

in weekly COVID-19 vaccination rates

22:39

before and after the

22:41

imposition of a mandate. They

22:44

then go on to look at COVID-19 boosters,

22:47

and both adult and child flu

22:49

vaccinations. And there's a number of

22:52

different charts. You

22:55

look at COVID-19 booster proportions,

23:00

and you've got states where the

23:02

COVID-19 vaccination rate, they've got it

23:04

with standard deviations. I

23:08

have to say, a lot of

23:10

potential confounders here, but it does

23:13

raise this issue about when you

23:15

start mandating things versus

23:17

approaching vaccine

23:19

decisions with an educational campaign,

23:23

there's a potential risk of

23:25

mandates having kind of this negative

23:27

response from the public. I don't know if you had

23:29

any thoughts on this, Vincent. I

23:32

mean, I think it's a backlash against

23:34

mandates, but who's covered in these mandates?

23:36

Is it just for school or is

23:38

it a broader population? So

23:41

as we saw in New York,

23:44

different populations. So initially,

23:46

it was healthcare workers, but we

23:48

also saw schools, we saw different

23:50

occupations. So yeah, really a lot

23:52

of different situations where the vaccines

23:55

were mandated. I

23:57

mean, I think mandating...

24:00

for school entry is a great idea,

24:03

but I think as this study shows,

24:05

maybe in a broader population. I

24:07

mean, healthcare workers, the

24:09

hospitals, the healthcare institutions should have their

24:12

own flexibility, I think,

24:14

right? But when you

24:16

go to a broader population, I think there's a

24:18

backlash. Yeah. And I

24:20

think, you know, we worry, right? We're seeing issues

24:22

with measles vaccination rates. We're seeing this sort of

24:25

spillover into other areas, and so. So in your

24:27

place, Daniel, in your hospital,

24:29

does your hospital mandate vaccination, or does it

24:32

come from the state? So

24:34

early in the pandemic,

24:37

that's interesting. It came from both,

24:39

right? So you had it mandated,

24:42

and then you had, dare I say

24:44

it, enforced by the different healthcare facilities.

24:46

And then interesting, there was kind of

24:49

this rebound after the fact where things

24:51

got lifted, and then a lot of

24:53

people who were let go because they

24:55

had not gotten vaccinated were then, you

24:58

know, re-employed. Very interesting dynamic

25:00

going on there. And

25:02

actually, I should mention this. I don't know

25:04

if you've been following the meetings. They were

25:06

Wednesday, February 28th, and then it'll

25:09

be also the 29th today,

25:11

there's meetings going on. But

25:14

there was that plan to discuss novel

25:18

OPV2 in the US. Did you, I don't know

25:20

if you caught up on this. Dr. Sarah Kidd

25:22

was going to be leading the discussion about the

25:24

potential of using that here in the United States.

25:27

This is dead in the water. It

25:31

is not happening. If they think

25:33

they're going to reintroduce OPV in the US,

25:35

they're out of their minds. They don't know

25:37

biology. They don't know public health. They don't

25:39

know history. This is not happening. This

25:42

virus causes paralysis in kids. You think that's

25:44

going to work in the US? Well, we

25:46

have IPV, which doesn't

25:48

cause paralysis. It prevents it. We don't see

25:51

any logic in talking about this and even

25:53

putting it on the agenda. What is the

25:55

purpose? You know what it is, Daniel? IPV

25:57

doesn't prevent transmission of polio.

26:01

And they're thinking, well, NOPV2 might for

26:03

a short period of time. But

26:06

the negatives far outweigh that. I

26:09

think IPV should be used globally,

26:11

frankly. Yeah. I do too. And

26:13

I, you know, and what they'll say, oh, but it's so

26:15

expensive. It's, come on, you know, we're building aircraft carriers. Yes,

26:19

indeed. All right. So

26:21

moving to COVID early viral

26:23

phase, number one, right, NIH treatment

26:26

guidelines, et cetera, IDSA,

26:28

PexLovit. Another

26:30

nice meta-analysis effectiveness of neurometrolvir,

26:32

ritonovir on severe outcomes of

26:34

COVID-19 in the era of

26:37

vaccination and Omicron, an updated

26:39

meta-analysis published in Journal of

26:41

Medical Virology. And I do

26:44

want to point out there are lots and lots

26:46

of studies now. So don't let someone just cherry

26:48

pick one. And here they're going to look at

26:50

32 studies included in this

26:52

meta-analysis. And they're

26:55

going to do pooled risk

26:57

ratios. Basically, we are seeing

26:59

neurometrolvir with a mortality pooled

27:02

risk ratio, 0.36, hospitalization When

27:07

you combine them together, 0.52, progression to severe disease,

27:10

0.54. And

27:14

then you see subgroup analysis

27:17

on vaccinated patients

27:19

as well. You're

27:21

seeing a lower effectiveness on mortality

27:23

in that group, but

27:26

similar effectiveness when you look at

27:28

hospitalization, hospitalization and or mortality or

27:30

progression to severe disease. So

27:33

the authors comment, and

27:35

I'll agree with this, this

27:37

updated meta-analysis robustly confirms the

27:39

protective effects of neurometrolvir on

27:41

severe COVID-19 outcomes. I

27:44

think, you know, close to about a 50% reduction. So

27:48

when people start talking about, oh, maybe they're charging

27:50

too much and we should get the price down, yeah,

27:52

that's great. And even in vaccinated

27:54

patients, as we see here, even

27:56

in the time of Omicron, we're

27:59

seeing that this is really an effective

28:01

tool that we should be using. Number

28:04

two, Remdesivir, as we've discussed, not

28:07

getting quite as much use. And

28:10

number three, Molyneux Purivir. So

28:12

what about Molyneux Purivir? The article,

28:15

Randomized Control Trial of Molyneux Purivir,

28:17

SARS-CoV-2 Viral and Anybody Response in

28:20

At-Risk Adult Outpatients was published

28:22

in Nature Communications. In

28:25

this study, non-hospitalized participants

28:27

within five days of

28:29

SARS-CoV-2 symptoms were randomized

28:32

to receive Molyneux Purivir.

28:34

We've got 253 or

28:36

not, 324. They

28:38

studied viral and antibody dynamics,

28:40

the effect of Molyneux Purivir

28:42

on viral whole genome sequence

28:44

from 1,437 viral

28:47

genomes. All

28:49

applaud, not just PCRs, they actually

28:51

collected swabs in viral transport medium

28:55

and then cultured these on CalU3

28:57

cells using a

28:59

high-throughput culture method with

29:01

screening over seven days for evidence

29:03

of cytopathic effect and

29:06

the presence of SARS-CoV-2 bilateral

29:08

flow immunochromatography

29:10

and PCR.

29:13

They really recover a viable virus.

29:15

Now, the positive culture rates for

29:17

samples collected during the treatment, two

29:20

through five, was 10.4% with Molyneux Purivir

29:22

versus 15.2% for

29:27

the not getting. They say usual care, but I'm

29:29

going to say people that didn't get treatment, I

29:31

hope that's not the usual care. It

29:33

says ithromisin, Daniel. Steroids,

29:36

don't forget. Horse paste. Oh

29:40

my gosh, post-treatment viability, days

29:42

six through 20 dropped to 5.1% for Molyneux

29:44

Purivir and

29:47

2.5% for usual care.

29:50

Now, they reported that Molyneux Purivir was associated with

29:52

lower anti-SARS-CoV-2 spike

29:55

antibody titers. Serial

29:57

sequencing revealed increased mutagenesis,

30:00

with molyneux pyrovir treatment, dare

30:02

I say, as expected. I

30:04

think their conclusion is we should give more

30:06

and more days of molyneux pyrovir, but, you

30:09

know, yeah. Is it

30:11

what we want to know the

30:14

effect on progression to hospitalization, not

30:17

positive cultures? I

30:19

agree. I agree. And we have good

30:21

data that molyneux pyrovir, though not as

30:24

effective as Pax Loved, not as effective

30:26

as Remdesivir, is

30:28

an effective treatment, and it should be if you're

30:31

not on one of the other two, the usual

30:33

care. All

30:35

right. Convalescent plasma, just so

30:37

Arturo Casadevelle remains my friend,

30:39

I'll keep mentioning that. Isolation

30:42

for the infected. You know, we

30:44

talked a little bit last week about

30:46

rumors, rumors that

30:49

the CDC might be coming out with updated

30:52

guidance in, I think, April. You

30:54

know, so far the CDC has not said

30:57

anything, but, you know, a few states have

30:59

actually started to change their guidance. So just

31:01

echoing that the science has not changed, but

31:03

some of the guidance has. And

31:07

second week, the cytokine storm week. So

31:09

remember, steroids at the right time, in

31:11

the right patient, at the right dose,

31:13

and for the right duration. And

31:15

this is after the first week, and

31:18

in patients with octrations, saturations less than 94%.

31:22

We discussed a meta-analysis where they suggested

31:24

that six days was adequate. Just

31:27

will nod that the ID Society, NIH

31:29

treatment guidelines, still have 10 days in

31:31

then. Number two,

31:33

anticoagulation guidelines from a number

31:35

of organizations, including American Society

31:37

of Hematology, Culinary Support,

31:40

Remdesivir, still in the first

31:42

10 days, immune modulations in

31:44

some cases. And yes,

31:46

let's avoid those unnecessary antibiotics as

31:48

listed by Vincent. Even

31:51

though it tastes like chocolate. If you like the taste

31:53

of chocolate, go get yourself some dark chocolate. You don't

31:55

need to have the paste. All right,

31:58

COVID-19, the late phase, pass. Long

32:00

COVID. We have a fair

32:02

number of things here. The

32:04

article, Spontaneous, Persistent, T-cell Dependent,

32:07

Interferon Gamma Release in Patients

32:09

Who Progress to Long COVID,

32:11

was published in Science Advances.

32:14

And not only did I run across, but this was

32:16

sent to me by one of my patients as well,

32:18

a fellow sailor. But let us

32:21

start with the study design. So,

32:23

Unexposed Donor Samples, we've got 54,

32:25

were recruited by the

32:27

National Institute for Health Research,

32:29

BioResource Cambridge, through the

32:32

ARIA, so the Antiviral

32:34

Responses in Aging. Kind

32:37

of a cool acronym. This cohort

32:39

was recruited before October 2019, so

32:41

no participants were exposed

32:44

to SARS-CoV-2 infections. The

32:47

COVID confirmed hospitalization patients, different

32:49

group, right? And this is N of 51,

32:51

day 28. N of 20 for day 90. N of 40 for day 180, were

32:57

enrolled following admission to Addenbrooke's

33:00

Hospital, Royal Papworth

33:02

and Cambridge and Peterborough Foundation Trust,

33:04

where they confirmed diagnosis of COVID-19

33:07

via positive RTQPCR.

33:11

Then they enrolled long COVID study patients. We've got

33:14

N of 55 there. Now, this cohort

33:18

had symptoms that had persisted for

33:20

at least five months after COVID-19

33:22

that could not be explained by an

33:25

alternative diagnosis. As

33:27

some patients were infected before routine testing

33:29

began, a positive

33:31

RTPCR result, antibody

33:34

seropositivity to nuclear capsid, or

33:36

a positive IL-2 response to

33:38

M and N peptides was

33:41

required as proof of SARS-CoV-2

33:43

infection. The

33:45

investigators detected persistently high levels

33:48

of interferon gamma from peripheral

33:50

blood mononuclear cells of

33:53

patients with long COVID using what

33:55

they refer to as a highly

33:57

sensitive fluorespot assays. These

34:00

are not, I will comment, you

34:02

know, routinely available. But

34:04

this interferon gamma release was seen

34:06

in the absence of ex vivo

34:08

peptide stimulation. Explain what that means. Normally,

34:11

let's say you wanted to ask if, oh, has

34:13

this patient been exposed to tuberculosis or something and

34:15

you're looking for memory cells. You

34:17

would draw their blood, get

34:20

those white cells. You're

34:22

really focused on the memory T

34:24

cells. So expose them to a

34:26

peptide from the pathogen that triggers

34:28

the interferon gamma release. Here

34:31

we're seeing that this interferon gamma

34:33

release is occurring in

34:35

these folks with long COVID even without the

34:38

peptide stimulation. And

34:42

we see that the interferon gamma release

34:44

was CD8 positive T cell mediated and

34:47

dependent on antigen presentation by CD14

34:50

positive cells. Now, I mentioned a

34:52

couple things. One

34:55

is that this is not commercially available. You

34:57

do see separation with some degree of

35:00

overlap. We are starting to see some

35:02

separation here between the unexposed and the

35:04

folks with long COVID. They

35:09

followed the long COVID cohort for up to

35:11

31 months after the

35:13

acute infection. And during

35:16

follow-up period, I'm going to say this

35:18

is what I thought quite interesting, a

35:20

considerable number of the patients experienced resolution

35:23

of some, if not all,

35:25

of their symptoms either spontaneously

35:27

or some folks are doing this after they

35:29

get a SARS-CoV-2 vaccination.

35:31

And they measured the unstimulated

35:33

interferon gamma release in patients

35:36

with long COVID before and

35:38

after vaccination. And they

35:40

found a significant decrease in the

35:42

interferon gamma after vaccination that actually

35:45

correlated with symptom resolution. So

35:48

interesting correlation, but the investigators point

35:50

out in their discussion that at

35:52

this stage it's not clear whether

35:54

the interferon gamma is a mediator

35:56

or a biomarker of long

35:59

COVID. But yeah, interesting. So

36:03

as an immunologist, Daniel, what do you make

36:06

of this? Well,

36:08

so normally when you

36:10

turn on your immune system to

36:12

fight the pathogen, it's

36:15

sort of a dangerous thing, right? You're unleashing

36:17

the hordes, and now you've got to somehow

36:19

get them to stop. It's all over. Stop

36:23

being turned on, stop being activated.

36:25

You want your CD8 positives, your

36:28

killer T cells, your cytotoxic T

36:30

cells, you want them to turn

36:32

off. You expect that interferon gamma

36:34

activation to settle down. And

36:37

we're not seeing that. So from a mechanistic

36:39

standpoint, it makes a certain amount of sense.

36:42

And interesting that you vaccinate them,

36:45

which we're hoping sort of helps steer

36:47

the immune response in the right direction,

36:50

maybe even clearing some remnant material

36:52

that might be driving that stimulation.

36:55

You see the T cells turn off like

36:57

you're hoping. The people feel better. Mechanistically,

37:00

this might make some degree of sense. But

37:03

do you think that there's antigen present peptide

37:05

or the T cells messed up in

37:07

some way that's just cranking that? I

37:10

could buy either, and I don't know. I don't know

37:12

which. All right. Imagine

37:14

I said I don't know. Even though I went to medical

37:16

school, I still remember how to say that. All

37:20

right. The article,

37:22

Blood, Brain, Barrier, Disruption, and Sustained

37:24

Systemic Inflammation in Individuals with Long

37:26

COVID-Associated Cognitive Impairment was published in

37:29

Nature Neuroscience. So maybe we have

37:31

a theme here, like this ongoing

37:33

systemic inflammation that should be shutting

37:35

down in dozens. So

37:38

here, participants included patients who had recovered

37:40

from COVID-19, male or female, aged 18

37:42

and above, with or without neurological symptoms.

37:46

Patients with long COVID with symptom

37:49

persistence over 12 weeks from

37:51

infection were also recruited. And

37:54

here, they're going to use this

37:56

dynamic contrast-enhanced magnetic resonance imaging to

37:59

assess. blood-brain barrier

38:01

disruption. And I think you guys may

38:03

have even sort of discussed a little

38:06

bit of this on the deep dive

38:08

recent COVID. But

38:10

they assess this. They

38:13

then did transcriptomic analysis of peripheral

38:15

blood mononuclear cells to look for

38:17

a dysregulation of the coagulation system

38:20

and the adaptive immune response in individuals

38:22

with brain fog. But

38:24

sort of an interesting suggestion that

38:26

there's some kind of ongoing systemic

38:28

inflammation and maybe some ongoing blood

38:31

barrier disruption. All

38:34

right, more to come. The article, Prevalence

38:36

of Persistent SARS-CoV-2 in a Large

38:39

Community Surveillance Study was recently published

38:41

in Nature. And

38:43

here the investigators identified 381 individuals with

38:47

SARS-CoV-2 RNA detected by PCR at

38:49

low CT values persisting for at

38:51

least 30 days, of

38:53

which 54 had viral RNA persisting

38:56

for at least 60 days. In

38:59

some individuals, they identified many

39:01

viral amino acid substitutions. They

39:03

say indicating, I'm gonna change that to

39:06

suggesting periods of strong positive

39:08

selection, whereas others had no consensus change

39:10

in the sequence for

39:13

prolonged periods consistent with weak selection.

39:16

All PCR data, no viral culture,

39:18

no plaque assays, no

39:21

real ability to distinguish remnant RNA

39:23

from replicating virus. What's

39:25

exactly going on here? Does that

39:27

persistent RNA drive any kind of

39:29

ongoing immune activation? Vincent,

39:32

any thoughts? I heard

39:34

Viviana Simon yesterday give a talk

39:37

about her study at Mount

39:39

Sinai, where they followed a population

39:43

of immunosuppressed patients

39:46

and they see long-term production

39:48

of virus in that patient population. So

39:50

I wonder in this one, how

39:53

many of these are immunosuppressed? Because

39:55

I do understand that immunosuppression, it

39:57

can happen in many forms. leads

40:00

to inability to clear virus. So

40:03

it reproduces and it sustains changes.

40:05

It evolves in the patient over

40:08

time. So this is only

40:10

surprising that it's not in

40:13

an immunocompromised population or maybe they

40:16

say it in the paper, I'm not

40:18

sure. Or maybe somehow you're identifying individuals

40:20

who have some type of immune issue,

40:22

right? Why is it persisting in them

40:25

and not in other people? Is that,

40:27

and again, we're sort of left with not really

40:30

knowing if this is replicating virus or if this

40:32

is just RNA that isn't being

40:34

cleared. Well, in her study, they did, they

40:36

were able to culture virus from these individuals,

40:38

right? They didn't quantify it, but they could

40:41

do cell culture positivity. And

40:43

many of them were treated with Pax lauvadin.

40:45

Five days was not sufficient. So

40:47

it could be that in this patient population,

40:49

you need longer treatment, right? Yeah,

40:52

and in some immunosuppressed populations,

40:54

it's not a, it's a high

40:56

RNA copy number. It's

40:59

not these. So

41:01

her study was done in New

41:03

York at Mount Sinai and they

41:06

see spike changes arising

41:08

before they appear in the

41:10

general population. Interesting, interesting.

41:13

And that's always been one of the

41:15

concerns, right? That people are

41:17

actually producing these changes, sort

41:23

of giving the virus a fitness, chance

41:25

to improve fitness in the host and

41:28

then potentially, yeah. But you know what's

41:30

interesting? So these, some of these amino

41:32

acid changes are lead

41:35

to immune evasion of two

41:37

antibodies, right? But these patients,

41:40

these patients do not make

41:42

antibodies to the virus. But

41:44

there's still, yeah, that's really

41:46

interesting. Like,

41:49

that's fascinating. Maybe it's just fitness

41:51

and that happens to be similar

41:53

changes that cause immunization. That

41:57

would be the only sort of evolution. What would

41:59

drive that evolution? It has to be some fitness

42:01

advantage to be, but it is interesting because we

42:03

normally would say, oh, well, obviously it's immune evasive.

42:06

It's being selected by the antibodies, but there's no

42:08

antibodies there. So it's not fascinating.

42:12

So a small but encouraging study,

42:14

long-term outcomes of hyperbaric oxygen therapy

42:16

in post-COVID condition, longitudinal follow-up of

42:19

a randomized controlled trial published in

42:21

Scientific Reports. Now

42:23

context back in July 2022, this

42:26

group published the article, hyperbaric

42:29

oxygen therapy improves neurocognitive functions

42:31

and symptoms of post-COVID, randomized

42:33

controlled trial, also Scientific Reports,

42:37

where they reported improvements in a

42:39

number of symptoms with hyperbaric oxygen

42:41

therapy, which they attributed

42:43

to increased brain perfusion, neuroplasticity.

42:46

So here the authors performed follow-up on

42:49

that cohort. The protocol

42:51

involved, are you ready for this? 40

42:53

daily sessions, five sessions per

42:56

week in a two-month

42:58

period. The protocol

43:00

involved breathing 100% oxygen by

43:02

mask at 2

43:05

atmospheric to ATA for 90 minutes

43:08

with five-minute air breaks every 20 minutes,

43:11

compression decompression rates. 79

43:14

patients were randomized to either getting

43:16

hyperbaric or a sham in the

43:18

original study. Out of the

43:20

40 patients allocated to the

43:23

hyperbaric arm, 37 completed the

43:25

intervention, performed the short-term

43:28

evaluation. Of these, six

43:30

declined their participation on any long-term

43:32

evaluation. And accordingly, a

43:34

total of 31 patients received

43:37

the hyperbaric oxygen therapy,

43:39

had both short-term and

43:41

long-term post-treatment evaluations, and

43:44

they're included in this current study analysis.

43:47

A few limitations that before we look at

43:49

the data, you know, let's point out the

43:51

sample size ends up becoming relatively small

43:53

with 31 patients in total. Second,

43:56

the primary endpoint in the original

43:58

study, cognitive function. function as well

44:01

as brain imaging were not evaluated

44:03

in this current longitudinal evaluation. Since

44:06

the original sham group after completing the

44:09

study protocol were offered to be treated

44:12

with hyperbaric oxygen, most of them received it,

44:14

69 percent, so they really

44:16

couldn't serve as a proper control group.

44:19

Now, they did, however, report that based

44:21

on response to a short survey, there

44:23

appeared to be encouraging long-term improvements in

44:25

quality of life, quality of sleep, psychiatry,

44:28

and pain symptoms, and they're

44:30

using this SF36, this short

44:32

form 36 questionnaire. And I'll

44:35

leave a link to it so you can kind

44:37

of look at what they're asking. But if you

44:39

actually look at the data, not, you

44:42

know, a statistician will tell you that

44:44

this is interesting, but

44:46

you're not really seeing any huge difference. And

44:48

really, when you compare short term, long term,

44:51

really looks about the same, and there really

44:53

is no statistically significant difference between those two.

44:56

And is this hyperbaric therapy

44:59

really practical on a big scale, Daniel?

45:02

I know patients are doing

45:04

it, you know, patients are desperate yet. Is

45:07

it really practical, are we going to have

45:09

the hundreds of thousands, millions of people with

45:11

long COVID end up in these hyperbaric oxygen

45:13

chambers? It doesn't

45:15

seem, and particularly when the impacts

45:17

that we're seeing are as subtle as we're seeing on

45:19

the SF36. I'm not

45:22

sure that this is really going to be a

45:24

therapy for the

45:27

masses, dare I say. All

45:29

right, I will close it out there with

45:31

no one is safe until everyone is safe.

45:33

We're in our American Society of Tropical Medicine

45:35

and Hygiene fundraiser, where for February, March, and

45:38

April, we'll double your donations up to a

45:40

maximum donation of This

45:43

is mainly going to go to scholarships

45:45

for women from low,

45:48

middle income countries to

45:50

go to the annual meeting

45:52

and hopefully allow them to make

45:54

some connections and further their careers.

45:56

So go to parasites.org.com and click

45:58

donate. It's

46:01

time for your questions for Daniel. You can

46:03

send them to daniel at microbe.tv. Theodore

46:06

writes, I am a

46:09

46-year-old doctor taking biologics

46:12

for plaxoriasis and anti-IL17

46:14

monoclonal. Am I considered,

46:17

as I am considered immunocompromised, automated system

46:20

for COVID-19 appointments allowed me to do

46:22

more than one shot per year. I've

46:24

been doing two vaccines per year. My

46:27

question is, do I really need more than one

46:29

shot of the same vaccine each

46:32

year? Does Cosentix, which

46:34

is also taking, make me so

46:36

immunocompromised to need more than one

46:39

or am I exaggerating? Colleagues that I've asked

46:41

gave me a spectrum of answers of from

46:43

you don't really need it to be revaccinated

46:45

if my antibody levels drop below 10 IUs.

46:50

All right. So

46:52

this is a great question. And your timing is perfect. I

46:55

know, Vincent, you sort of knew the timing

46:57

on the ACIP meeting this week. But

47:00

this is in line with the current recommendations.

47:05

As we've talked about, low

47:07

level of certainty, not a lot

47:10

of data to guide us here. So this is

47:12

kind of an expert opinion approach. But the idea

47:14

with the vaccines is you get this three to

47:16

four month boost in antibody levels,

47:19

T-cell, basically boost in our

47:21

immunity, some boost in protection.

47:24

We have that data we discussed where it looks

47:26

like you start to wane and lose that protection

47:28

when you get to 120 days. This

47:31

idea about spacing them four to

47:34

six months apart makes

47:36

a certain amount of sense. But as we're

47:38

talking about, we don't have tremendous data. And when someone

47:40

gives you a cut up and say, I'm going to

47:42

say at this random antibody, I don't know where they

47:44

make that stuff up. But

47:46

we certainly don't have that degree of

47:49

understanding that we can look at

47:51

antibody levels and really pick who should

47:53

and when get a next booster. Jason

47:57

writes, my wife

47:59

is pregnant. and just entering her third

48:01

trimester. It was my understanding

48:03

that the recommendation was for pregnant people

48:06

to get the RSV vaccine in their

48:08

third trimester. We asked my wife's OBGYN

48:10

about getting the vaccine, and the

48:12

doctor said they were no longer giving it

48:14

to pregnant people now because it's beyond RSV

48:17

season and no longer available.

48:19

I looked on the CVS website, and

48:22

CVS will still give the vaccine to

48:24

pregnant people, so I know it's available.

48:26

I could make an appointment for later

48:28

today. Thus, I'm confused about being advised

48:30

that it's no longer available. My question

48:32

is whether the advice

48:34

not to get the vaccine in the third

48:36

trimester is correct. Is there a downside to

48:38

getting the vaccine? The only reason I could

48:41

imagine not to get it is if immunity

48:43

passed to the child was not expected until

48:45

the last until the next RSV season. Well,

48:47

that goes against my understanding that the vaccine

48:49

is fairly durable, though perhaps that is not

48:52

true for the baby. I'd appreciate

48:54

any clarification. If there is a benefit, we could go

48:57

back to the OBGYN and push back on the issue.

48:59

Obviously, if there is a benefit, I want to make

49:01

sure the baby is protected. Yes,

49:04

this is great, and, you

49:06

know, thanks for setting this in. And the timing is good,

49:08

too, because as we talked about, we're getting near the end.

49:11

RSV is on the way down, but it's not

49:13

gone, right? So we're recording this

49:15

on leap day. Is that what that's called?

49:17

February 29th, but this will be getting dropping,

49:20

right, as we get into the beginning early

49:22

days of March. We're

49:24

getting right at the end, depending upon different

49:26

regions, you know, as far as by the

49:29

time a person delivers, by

49:31

the time the baby is born, will

49:33

the RSV activity really be down? There's

49:36

a downside, but you sort of getting into

49:38

this timing issue. So you can think about

49:40

when's your due date, maybe you're going to

49:42

deliver early. What if you deliver early and

49:45

you deliver in mid-March? We still have some

49:47

RSV activity. We're still doing bay forties in

49:49

certain regions. There

49:51

isn't a big downside as you bring up.

49:54

I'm not sure you even need to go back to your doctor, right? I

49:56

mean, this vaccine is going to

49:58

be available because it's not just. for folks

50:00

in their last trimester. It's also one of

50:03

the two options for adults. So

50:05

it's gonna be around, it's gonna be an option. And

50:08

so, I think that you've gotta

50:10

just sort of look at risk

50:13

benefit. If

50:15

you ran out this afternoon, and maybe that'll be

50:17

Saturday afternoon when this has dropped,

50:20

I still think you're kind of within that

50:22

window, but yeah, you're getting pretty close to

50:24

the end of when RSV won't be a

50:26

concern this season. You bring up another, which

50:28

is, how long will those antibodies response? How

50:30

long will that protection last? Well, we have

50:32

our studies in adults showing a durability of

50:34

the vaccine out to two years. But

50:37

what we're talking about here is

50:39

protection for the newborn, and will

50:41

whatever amount of immune

50:44

protection you transfer to that child, will

50:46

that still be viable next winter? Probably

50:48

not. So your child is probably gonna

50:50

be a candidate for Bay Fortis or

50:52

Seba map in the fall. Michelle

50:55

writes, my college-age son recently

50:58

came down with mononucleosis while

51:00

away at school. He's doing well after two weeks.

51:03

My question is, how long is he contagious? I

51:06

think I read that he could have virus in his saliva for up to

51:08

18 months. I'm currently

51:10

on adalimumab, Humira for IBD Crohn's

51:12

disease. Since he graduates May 11,

51:16

I obviously would like to go to his

51:18

graduation and have him stay home with us

51:20

for a week or so, but we wouldn't

51:22

want to risk me catching the disease as

51:24

I'm immunosuppressed. How easily can you catch mono?

51:26

And how contagious would he be three months

51:28

out? Can the virus travel in air?

51:30

I don't know if I've had mono myself before,

51:33

but I would think that by 61 years old,

51:35

I should have been exposed at some point. Is

51:37

there a test to see if I have some

51:40

immunity? Okay,

51:42

these are great questions. So mono,

51:45

in general, the most common cause

51:47

of mono is infection with Epstein-Barr

51:49

virus, but that's not the only

51:51

cause of the mono syndrome, the

51:53

clinical syndrome, like CMV. There's other

51:56

triggers. So that would be the

51:58

first question, is clarifying for yourself. Is

52:00

this an acute Epstein-Barr virus

52:02

infection? If it

52:04

is, we'll talk a little bit about

52:06

that. If it is, it usually takes

52:08

a few weeks from exposure to the

52:10

onset of symptoms. By that time, a

52:13

person is usually showing a positive IgM,

52:15

a positive IgG. During

52:18

the acute mono symptom

52:20

phase, people tend to

52:22

be contagious. You can actually, even during

52:24

that period of time, you can pick

52:26

up the EBV DNA in a blood

52:28

test. They have a myremic phase,

52:32

unlike some other pathogens, like

52:34

West Nile virus, where we've really got to

52:36

look for antibodies, because human beings do not

52:39

get a tremendous amount of myremia,

52:41

unless they're immunocompromised. Now,

52:44

when that acute symptom

52:46

phase declines, and maybe they develop

52:48

that mono, people who are feeling

52:50

crummy for a couple of months

52:52

afterwards, that usually tends

52:55

to move into a post-infectious

52:57

sequelae. The serum

52:59

EBV DNA will turn negative. The

53:01

person is no longer contagious at

53:03

that point. There are some

53:05

individuals who are contagious for

53:07

several weeks. There are rare

53:10

individuals who remain contagious for

53:12

months, who maintain an

53:14

elevated EBV DNA in

53:17

the serum, in the saliva. So a

53:19

really easy thing to do here is

53:21

clarify, is it EBV or not, or

53:24

CMV, for instance, and do a serum

53:26

viral DNA test? If it's negative, you're clear

53:29

and can move forward. Lewis

53:31

writes, I'm traveling to Argentina

53:33

in April for two months. I got the

53:35

flu vaccine in August. Should I get a

53:37

second flu shot as I'm going

53:39

to the southern hemisphere as flu season begins

53:41

there, or should I get a flu shot

53:43

there? Is it the same flu shot? Yeah,

53:47

so it's the same flu shot.

53:49

And you raise something that we have really

53:51

good data on with influenza vaccination. As you

53:53

get the initial protection, let's say two to

53:56

three weeks after the shot is really when

53:58

it tends to peak. And then

54:00

you lose, I'm going to throw this number, you say

54:02

about 10% per month. It was a recent study where

54:04

it was 8%, sort of a range there. But

54:07

nowadays, you got it, let's say, August,

54:09

so September, October, November, December, January, February.

54:12

We're getting to the point where most

54:14

of that protection, which does correlate in

54:16

the case of influenza with antibody levels,

54:19

where most of that protection is waned. So

54:24

no, I think it's reasonable to get another

54:26

flu shot. It makes sense. You

54:28

just figure out whether it's cheaper or easier for you

54:30

to get it here or down there. Still

54:33

using the same. But we

54:35

do know that when there's a meeting this

54:38

spring, coming up pretty soon, there's going

54:40

to be recommendations for an update of

54:43

the vaccines. And one of the influenza

54:45

B will be removed. So

54:47

we're going to be down to a trivalent,

54:49

because that one has gone extinct like the

54:51

dinosaurs. And

54:53

Jeff writes, at the end of the last episode,

54:55

with reference to the CDC guidance

54:58

on five days of isolation following

55:00

COVID infections, it sounded as if

55:02

Daniel Griffin said, the science has

55:04

not changed. The public guidance has.

55:07

But it does not appear that the CDC

55:09

has changed its recommendations on the

55:11

website. And although I've heard a lot of

55:13

speculation in the media, I have not heard

55:16

any official announcements of a change. Can Dr.

55:18

Griffin please clarify? As a clinician, I want

55:20

to give patients the most up-to-date information

55:22

I can. Recently, I've been saying that

55:24

there's been discussion about changing the five-day

55:27

rule, but that nothing has changed on

55:29

the official guidance. Is this accurate, or

55:31

has the official guidance changed? Yeah,

55:34

so you're right on. Just

55:36

word that sense. The official guidance from

55:38

the CDC has not changed. And

55:41

when the people that broke those stories

55:44

reached out, the CDC said, no comment.

55:46

I can neither confirm nor deny. They

55:49

plan to have an updated statement in

55:51

April. It could be the same statement.

55:53

It could be a different statement. So

55:55

as mentioned, the guidance has changed certain

55:57

places. Certain states have said certain things.

56:00

The science hasn't changed and you

56:02

are correct. This official CDC guidance

56:04

has not changed. That's

56:06

Twiv weekly clinical update with Dr.

56:09

Daniel Griffin. Thank you, Daniel. Thank

56:11

you. And everyone be safe.