TWiV 749 COVID-19 Clinical Update #60

This Week in Virology

Host: Vincent Racaniello

Guest: Daniel Griffin

Aired 1 May 2021

pdf of this transcript available (link)

Vincent Racaniello: This Week in Virology, the podcast about viruses, the kind that make you sick.

[music]

From MicrobeTV, this is TWiV, This Week in Virology, Episode 749, recorded on April 29th, 2021. I’m Vincent Racaniello and you’re listening to the podcast all about viruses. Joining me today from New York, Daniel Griffin.

Daniel Griffin: Hello, everyone.

VR: How’s this week been, Daniel?

DG: Things are getting a little bit better, to be honest, at least here in New York. It’s a little painful when I look at how things are going in the world, but let’s get right into it because our quotation ties this together. “There are two kinds of guilt, the kind that drowns you until you’re useless and the kind that fires your soul to purpose,” and this is by Sabaa Tahir, a Pakistani-American author.

Right into that question, Vincent, that you asked me, “How are things going?” Here in the United States, in most of the United States, we’ve really started to come off of that plateau. Numbers are going down. We look at the numbers of patients in the hospitals here in New York State and it’s about 60% lower than it was a month ago, so that’s really coming down. It’s often several days that I go without a patient with COVID dying, actually. This is really changing the landscape.

We are not where we were in April of 2020. We’re in April of 2021. It was just announced that July 1st, New York City is going to be fully open, 100% across the board. I think that we are seeing that vaccines are not just a tool, they’re the nuclear option, they really are our game-changer, and we’ll be talking a little bit about that today.

Things are not going well around the world. Around the world, the cases are rising, the deaths are rising. We are still really in the middle of the pandemic. This is why I use this quotation, as exciting as it is here in the U.S., I know, personally, I feel a sense of guilt seeing how much other people are suffering and not wanting to say, let that make you feel useless. Let’s all be asking ourselves, what can we do to reach out now to the rest of the world now that I think we’re really on our own path here?

Children and COVID. I promised last time that I would spend some time talking about camp guidance and we now have the CDC updated guidance for operating youth and summer camps during COVID-19. So just so you know, you can Google CDC summer camp and get this really informative resource here.

When I was younger, people don’t know that I was once younger, I was. My middle daughter, Eloise, actually, I think, looks a bit like I did when I was younger except she’s a lot better looking than I ever was. I used to work as a camp counselor at Camp Jabberwocky. This was a camp out on one of the islands off the coast of Massachusetts for children with cerebral palsy, spina bifida, down syndrome, and other challenges.

I look back on the time that I spent there and I think if we all take a moment, we realize how important camp is for so many reasons, for so many different individuals, and to take an expression of my dad who always says, “Every vacation you don’t take is a vacation you will never take.” Every summer, our kids don’t have an opportunity to go to summer camp, that’s gone. That summer camp opportunity is gone.

I’ve been doing quite a bit of pro bono work. I think I’m starting to push it with my wife. She’s starting to say I need to stop doing so much of that but I really think that this is a critical area, and so I’ve been trying to do my part to help with a number of camps get set up for summer. But let’s go through, what is the CDC telling us and what can we think about for the summer for our children, for our grandchildren depending on where we are in life?

The CDC states that fewer children have gotten sick with COVID-19 compared with adults during the pandemic. Children can be infected with the virus that causes COVID-19, so that’s SARS-CoV-2, they can get sick with COVID-19, they can spread the virus to others, and they can have severe outcomes. Now I think this is an important starting point. Children are at lower risk, but they are not at no risk.

The CDC has a lot of recommendations about how we are keeping our kids safe or how we can keep our kids safe. They recommend that each camp have an emergency operations plan in-place to protect the staff, to protect the campers, the families, and then the communities. Remember, these camps operate in areas, which are often not as heavily populated as other parts. If you bring COVID into these areas, you’re not just exposing the kids and everyone else, you’re exposing the community.

There should be some minimum features in these plans. A lot of the camps, I have to say, are getting these plans up. A lot of them are actually fully in-place because probably expecting money from the parents at this point so they want to be able to have meetings, and actually we had one last night went to well after eight o’clock. First, we met ahead of time to go over our plans and then we spent over an hour with the parents answering questions.

What are the topics that should be in this emergency plan? One, and this is number one, the CDC is saying, “Number one, strongly encourage vaccination for all eligible people.” As I mentioned, this is a game-changer. We are seeing that the vaccines are more effective in real life than even we were hoping when we saw the initial exciting studies.

The other, health screening for symptoms and diagnostic or screening testing. Testing should be a part of the plan. That’s number two right after vaccine, testing. Maybe we’ll get into this a little more, but the government is working with the states and providing testing opportunities for the camps, actually supplying testing in that huge $2 trillion bill that went through.

Use multiple layers prevention strategies. We’re still going to see masking in certain situations, we’re still going to see physical distancing, we’re going to see cohorting. Cohorting is a nice way to break this down so that if there is an issue, it’s not the entire camp. You’re keeping it contained. Then also our focus on the housing arrangements, and I think, it’s great, right up front improved ventilation. Now, I think we’ve been trying to talk about the fact that even though this is a respiratory droplet spread, a respiratory virus, if you take an indoor space, if you don’t have ventilation, you start building up, you start building up. That ‘six-feet-away’ is not going to protect you in an area with poor ventilation. Think about kids sleeping together in these cabins with their staff.

They also want you to start thinking about the fact that not everyone’s risk is the same. Think about campers and staff that might have higher risks. Really, a big push to promote outdoors. I like this. Spending about 20 years of my life out in Colorado, to see that the CDC now is promoting outdoor and lower-risk activities. I know people love that singing in the mess hall. Let’s get that singing outdoors. Traveling to and from, you want to be thinking about that. You don’t want to be creating exposure events on the way to the camp, you also want to think about on the way off.

Cleaning, they mentioned, we’re getting sorted out here. Remember, cleaning was number one in the olden days. We’re realizing this is something you get by breathing not necessarily touching, keep washing those hands. Then they go on to basically go through a lot of other things including where they finish with, “Have a plan in case someone gets COVID-19, have a plan in case someone tests positive.” There’s two sides to this. I’m going to say, “If you get a positive test, if you’re doing a lot of testing, you’re going to get false positives so have a plan. How do I quickly verify to see if this is true? How do I respond to those?”

We’re getting great guidance here from the CDC on how to do this safely. We will have a layer where the states are going to have individual guidance and, actually, mandates for how camps are going to operate, they’re going to give us specific numbers on if you’re cohorting, how big are those cohorts allowed to be? What should be the ratio? I think that’s going to help here. but I think the message here is that we can do this safely. Again, just like the schools, it can also be done unsafely. Ask your camp, “What are your plans? Are you planning on following CDC guidance? Are you planning on keeping my kids safe?” Because as I keep reiterating, children are certainly at lower risk, but they’re not at no risk.

Pre-exposure period. This has been an exciting week as CDC has really been out there this week. On April 27th, the CDC came out with its, “When you’ve been fully-vaccinated, how to protect yourself and others guidance.” Well, I think by the time this drops, I’ll have already talked about this on the news, this “fear of normal.” How do we get back to normal and how can this happen?

What did the CDC have to say? The first, let’s define what does it mean as per the CDC to be fully-vaccinated? They’re using, just to keep it simple, two weeks,. They’re saying two weeks after you finish your vaccine. Two weeks after you did that two-dose Moderna, Pfizer, two weeks after your J&J. People have probably known I like four weeks after the J&J, but I won’t break ranks with the CDC on this one. This is not the day, this is not the night of your vaccine. Vaccines take a little time. So take that time, let your body build up those T cells, those B cells that immune protection. Then what can you do?

If you’re fully-vaccinated. As per the CDC, they’re saying, you can gather indoors with fully-vaccinated people without wearing a mask. That’s pretty exciting. You can gather indoors with unvaccinated people, and they’re saying, without masks. They’re talking about staying six feet apart. They’re also throwing in here, you want to be careful if there’s someone there who has increased risk of severe illness from COVID-19. Then, and I like this part, you can gather or conduct activities outdoors without wearing a mask except in certain crowded settings and venues.

Really, doubling down on what we’ve learned. If you are vaccinated, you are at much lower risk. If you’re outdoors, that risk is about 20-fold lower than indoors. We’re starting to see things coming back. If you travel within the United States, as per the CDC, you do not need to get tested before or after travel or self-quarantine. Remember, this is for the fully-vaccinated. They do make some comments about international travel. Really, the U.S. is going to put a lot of onus on you, you’re going to be needing to look at what international destination you might be traveling to.

What should you keep doing for now if you’re fully-vaccinated? I think there was a wonderful beer commercial where the guy’s all excited. He’s getting his vaccine, and then he’s going to go to the bar and do all these other things. Well, what do they want you to keep doing? They say you should still protect yourself and others in many situations by wearing a mask that fits snugly.

Let’s say your indoor public setting, there’s a large number of people, there’s going to be unvaccinated people, including children, they point out, from multiple households. You’re still going to be wearing your mask in certain circumstances. You’re visiting indoors with an unvaccinated individual who’s at increased risk. We’re saying, “Boy, vaccination really makes you a much lower risk of transmitting to others, it does not make you no risk.” In this case, if the stakes are high, they say you should still be avoiding those indoor large gatherings. You don’t want to go to that packed facility yet. At some point, maybe that will come. Also, as we know, they still have a mask requirement if you travel. Even if you’re fully-vaccinated, you’re still required to wear a mask when you’re on a plane, on a bus, on a train, other public transportation.

They still want you to watch out for symptoms. As we’ve seen, we do see breakthrough symptoms. Fully-vaccinated people can still get COVID-19. If you have symptoms, you’re still going to go, don’t stop testing, you’re still going to go get tested. I encourage everyone to go to the CDC site, really look through this. For some people, it’s going to take a little time. I think other people just jump in the deep end of the pool and they’re good to go. For one, I will mention, I have a little trepidation. I still have a fear of normal. It’s going to take me a little time to ease back into things even though I’m fully-vaccinated.

Transmission, I always like to have a section where I push people’s buttons and get some criticism, so this will be it. In many ways, I think going through the camp and the vaccinated guidance really helps us to answer a lot of the questions about transmission. People are not, I think, as focused on the words as they are and really understanding different circumstances and how to behave and how to be safe in those situations.

I actually step out here and say, I think there was a disservice done early on with the whole “Is it airborne?” discussion. Then, perhaps, the immortal words of Roxanne Khamsi, maybe these will now become immortal, headline of one of her pieces, “They Say Coronavirus Isn’t Airborne – but It’s Definitely Borne by Air.” The word ‘airborne’ means different things to different scientists and that confusion needs to be addressed. I always like to bring this back around again, surfaces are low risk. Remember, lots of hygiene theater, way too much bleach. Maybe one in every 10,000 cases came from surfaces. Outdoors is much safer than indoors, about 20-fold safer. Masks are effective for the wearer and those around us. Air exchange is critical for indoor risk. Time matters and it is cumulative for exposures. Vaccines are not just tools, as we’re seeing, they’re really the nuclear option for ending the pandemic. Once people are fully-vaccinated, once we get a larger percentage of our population fully-vaccinated, things do change, things do really change in a positive way.

Testing. Never miss an opportunity to test. As we talked about the camps, as you saw it, number two right after vaccination was testing. I want to keep reinforcing, we’ve seen a lot of publications on this, I had one out there with some of my colleagues at UHG, testing is a critical part of this multilayered approach to opening camps, schools, businesses, and other venues. We should be doing more, not less testing. We are doing less testing, to be honest. The data is really compelling here. One of the things that is compelling is we want more frequent, so frequent testing, rapid results. We want to avoid those resulting delays. With testing, more is better.

Active vaccination. This has been a busy area, never miss an opportunity to vaccinate and never waste a vaccine dose. We’re starting to get to the point here in the U.S., it’s like throwing away food. Don’t throw that dose in the trash, let’s get it in someone’s arm. We’ve definitely shifted here in the U.S. and I’m seeing this first-hand, from arms searching for vaccines to vaccines searching for arms.

Since we last talked, actually this dropped after the meeting, but what happened with the J&J vaccine? There was a meeting Friday, April 23^rd, I asked my partners to cover so I could listen to this. That just raises my geek factor, I guess, that I wanted to listen to this all day. A summary came out. We saw published April 27th in the MMWR, “Updated Recommendations from the Advisory Committee on Immunization Practices for the Use of the Janssen (Johnson & Johnson) COVID-19 Vaccine After Reports of Thrombosis with Thrombocytopenia Syndrome Among Vaccine Recipients,” United States April, 2021.

In brief, the Advisory Committee on Immunization Practices concluded that the risks of resuming Johnson COVID-19 vaccination among persons aged equal to or greater than 18 outweighed the risks and reaffirmed its interim recommendation under the FDA’s emergencies authorization, but included a new warning for rare clotting events among women aged 18 to 49 for this thrombosis with thrombocytopenia syndrome, or TTS as we’ll be referring to it, or as other people refer to it as VITTS, Vaccine Induced Thrombosis With Thrombocytopenia Syndrome.

What did we know? What did we learn from this publication and from the meeting? Nearly 8 million, so 7.98 million doses of the Johnson COVID-19 vaccine, had been administered in the United States and the Vaccine Adverse Event Reporting System, so VAERS, received at the end of this prior to these 15 reports of the TTS after vaccinations with the clots located, I think this is important, in the cerebral venous sinuses, and other unusual locations including the portal vein, the splenic vein, and a combination of venous and arterial thrombosis.

These 15 reports were confirmed by physician reviewers at the CDC and the FDA. They went through and reviewed this, including having hematologists involved in the review. Thirteen of the cases occurred among women aged 18 to 49. Two occurred among women aged 50 or older, and no cases post-authorization reported among men. Remember there was a man in the trial, but he was not in this 15- person study here.

The TTS reporting rates were seven cases per million and the Johnson COVID-19 vaccines were administered to 18 to 49. We had 0.9 per million in the age greater than 50 years. Then they broke it down into different subgroups, which I’ll go through actually. What I’m going to do here is I’m going to jump to– I’m going to give John Hittsome credit here.

John Hittat UnitedHealth Group actually made some tables for me. Wasn’t really for me, they’re for the whole group, our National Vaccine Advisory Panel. What were the cases of TTS per million vaccinations broken down by age? All age groups 1.87, if we looked at people under 50, it was 7 per million, over 50 it was 0.9 and then you can break it down into other age groups as well.

Then there was this other, and this came up, “Were there certain comorbid conditions or maybe certain medications that we should be thinking about? What about obesity?” 7 out of the 12 had obesity, eight did not. What about oral contraception? Two were on oral contraception, 13 were not, hypothyroid two, hypertension two, no recent pregnancies. Interesting enough, no history of prior clotting disorders in this population.

At the end of the report, and I’m going to even make some comments here, they basically went ahead and they said, “Okay, we are going to put this back out there, we’re going to put a warning on there, and we’re going to allow this to be a patient decision ultimately.” I have to admit, when I’ve talked to a lot of physicians about this, not all of them were as excited as, I should say, I was and I think this is interesting. Physicians like to be the ones who get to make decisions and so here we’re basically saying, “No. The patient will get the right.” Certain physicians say, “I would feel better if we did not use this vaccine in women under the age of 50.”

I think that really, take it as it is, they’re saying that’s not the physician’s decision. Here are the facts, it’s the patient’s decision, and we actually may be starting to move into a realm where before we said take whatever vaccine you have the opportunity to take, now we’re starting to see patients have preferences based on certain things. A patient the other day, this was a woman in her 40s, she had a prior history of a pulmonary embolism. We had a discussion and she suggested to me that she would prefer to do a Moderna over the J&J vaccine, I think that that’s completely reasonable.

If we’re looking at challenges, we’re getting more vaccine uptake, giving people choice, letting them have agency. I think that that’s more important than physicians getting to have the final say on everything here. We continue to have our vaccines against the variance race or what I like to call vaccines against the variance of concern as well as behaviors of concern.

We actually got two, what I think are encouraging, preprints that became available about the New York variant.It’s nice that we have our own variant.“B.1.526 SARS-CoV-2 variants identified in New York City are neutralized by vaccine-elicited and therapeutic monoclonal antibodies.” And that was available as a preprint. We also had, “Detection and characterization of the SARS-CoV-2 lineage B.1.526 in New York.”

Now, basically, both papers demonstrated that vaccine sera showed a little bit of a decrease, but remained at an elevated and protective level. Convalescent plasma did not fare as well. The monoclonal cocktail by Regeneron continued to be effective. I think the take-home message here was that the vaccines still work against the variants, don’t count on protection after natural infection quite as much as counting on the protection that we get with vaccination.

The period of detectable viral replication, you test positive. This is the time for monitoring in monoclonals so far. I think it’s important that although this may not impact our daily clinicians as physicians, we do pay attention to what’s happening around the world; maybe it will swing back, maybe it will affect us, but I think it’s also important for us to be aware of what’s going on.

There was an article, “The Global Case-Fatality Rate of COVID-19 Has Been Declining Since May 2020,” published in The American Society of Tropical Medicine and Hygiene Journal. What’s happening here? The authors collected daily COVID-19 diagnosis and mortality data from the WHO’s daily situation reports and reported that based on this data. The weekly global cumulative COVID-19 Reported Case Fatality Rate, so that’s that RCFR, I feel like we’re going back when we were first learning about the difference between case fatality rate and reported case fatality rates.

These are cases reported, we have it documented that this is COVID-19. What percent of those individuals die? We know that the actual case fatality rate is probably higher where the actual infection fatality rate is probably higher, but we reached a peak of 7.23% in the last week of April, April 22 to 28 in 2020, so it’s right about a year ago.

This was followed by a strong declining trend up until the 53rd week, so post-peak like after this peak. We ended up down at 2.2% in the last week of December 2020. Now, why did this happen? They had a couple of suggestions, so that’s the data. They suggested that part of this was an increased rate of infection in younger individuals, we know that younger individuals have a lower case fatality rate.

They also looked at a map of regional reported case fatality rates. Yemen for instance, where I believe Dixon likes to go salmon fishing, they had a reported case fatality rate of 30% April through December of 2020, while, by comparison, the reported case-fatality rate overall in the U.S. is 2% for all cases with an outcome. I recommend people take a look, it’s worth looking at the different figures and seeing what’s happened over time.

I keep saying, this is the time for monitoring and monoclonals, but I’m hoping that this will change. We keep hearing from Pfizer that by the end of the year, they’re promising us an oral covid pill. Now what do we know about this? They’re talking about a Phase I study of a very catchy PF-07321332. What is this and what do we know?

A little background here: SARS-CoV-2 produces two large viral polyproteins, these are really long proteins that are going to need to be chopped up, so PP1A and PP1AB, and these are processed by two virally-encoded cysteine proteases. Now, the main protease is also called 3C-like protease, so 3CL protease or 3CL pro, and there’s a papain-like protease.

We initially heard about this product, or targeting this with an intravenous preparation, it was PF-00835231, there will be a test at the end, this was a preprint back in February entitled,“Discovery of a Novel Inhibitor of Coronavirus 3CL Protease for the Potential treatment of COVID-19.”Now Pfizer is suggesting that they’ll have the other catchy, PF-07321332, on the market by the end of this year. They have started a Phase I trial. Hopefully, we’re going to have more tools.

We also have been hearing from Merck and Ridgeback Biotherapeutics that they’ve been working on Molnupiravir and this is a different way, a different small molecule potential oral pill that can be used as an antiviral. This is a ribonucleoside analog that they have found inhibits replication of multiple RNA viruses.

This is something they’ve been working with for a while. People who are familiar with HIV and AIDS treatment, think of this much like AZT, where you’re getting one of those building blocks of the RNA, so an A, a C, a G or U, we target all these in HIV. And you replace one of these with an analog, which then gets brought in and interferes with the virus replication. As we find out more about this I will certainly share that information.

All right. Let us finish off here with the tail phase, long COVID or post-COVID. I think I’m going to call this, it is not just about long COVID. Early on, I thought against this narrow view, what people thought about COVID, “You’re either going to live or you die and that’s the end of it.” Still, unfortunately, I hear to this day from physicians, just this idea that people who are suffering, oh, it’s all in their head. But I think people are now appreciating, many more people are appreciating, that it can be a lot more than two weeks once COVID gets into your system, so to speak, but there’s also an appreciation that maybe there’s something more than even just long COVID.

I think this is a little discouraging, but in Nature there was the article,“High-dimensional characterization of post-acute sequelae of COVID-19.” Now what is this about? The authors in this article used the national healthcare databases of the U.S. Departments of Veterans Affairs to systematically and comprehensively identify six-month incident sequelae, including diagnoses, medication use, laboratory abnormalities in 30-day survivors of COVID-19, so this is a really robust database. This cohort was 5,808,018 participants. This is a really robust data set that they were looking at. Within those alive, they were looking at the COVID-19 group selected having a COVID-19 test that was positive before March 1st, 2020 and November 30 or between, I should say, between March 1st, 2020 and November 30th, 2020. In this large set, they identified almost 100,000 individuals and then they’re going to look at these individuals. What did they find?

This study identified a significant increase in problems in this population that affected the respiratory system, the nervous system, neurocognitive disorders, mental health disorders, metabolic disorders, cardiovascular disorders, gastrointestinal disorders, malaise, fatigue, musculoskeletal pain, anemia. This population had an increased use of many medications, particularly pain medications, opioids, non-opioids, anti-depressants, anxiolytics, anti-hypertensives, oral hypoglycemics, and they had evidence of laboratory abnormalities in multiple organ systems.

What I think I’m going to just really point out here is that this analysis is suggesting that even people who do not identify or get classified as long COVID, there’s really a lot of outcomes in addition that we’re seeing are an increased incidence. This is actually worth looking at this paper, I will say. It’s available in Nature. There’s actually a gradation. Non-hospitalized, hospitalized, admitted to the ICU. The more severe your COVID, the higher incidence we were seeing of all these different disorders. I think that we’re seeing elevation in the non-hospitalized as well, but increasing with more severity of disease.

I’m going to finish up on that note and we are switching– When this drops, it will be May 1st. Thank you everyone who supported the American Society of Tropical Medicine and Hygiene. We are now going to support Foundation for International Medical Relief of Children. Again, this is going to be a three-month campaign. To be honest, they’re struggling. This is an organization that is supported through volunteers, younger individuals excited about global health signing up, contributing, going to all these parts of the world. They need our help, they need your help. Take a moment, go to parasiteswithoutborders.com and help us support that. We’re going to do the same thing we’ve done before. We’re going to double those donations. We’re going to try to get up to $40,000 to support FIMRC and we’re going to do this over the next three months. Help us.

VR: Time for some email for Daniel. If you want to send one, [email protected]. Sarah in Tallahassee writes, “Are the monoclonal antibody therapies appropriate for patients who have already been vaccinated?”

DG: That’s a great question. We are certainly giving monoclonals to people that have already been vaccinated. Or I should word it, we are not restricting them. We are not taking a person who’s vaccinated and not allowing them to have the monoclonals. There’s a couple of reasons here. One, if you think about it, there’s usually something going on when a person has a breakthrough infection. We’ve certainly seen people, they get vaccinated and then they go ahead and they get exposed. It’s really straightforward if they just got the vaccine, but we’re seeing people that might be weeks out.

Some people, particularly our older members of our society, people with certain immune issues, they may not have the ability to develop that robust immune system. We’re going ahead, we’re seeing good experiences as we get more numbers. I think we actually closed one of my studies. Hopefully, we’ll be getting some data out there showing and demonstrating what’s the efficacy in different populations including this particular population.

VR: All right, we have a letter from Mike, who is an infectious disease physician in Tacoma. “In your most recent clinical update #747, you mentioned in your reply to the retired health and safety professional listener’s question as to why authorities are not recommending N95 respirators to the public that you would recommend such masks in certain high-risk situations or high-risk environments. You then relayed your own story of how you recommended to your family members to wear KN95 masks when they flew on an airplane.

The listener mentioned that he thought the KN95 Chinese mask available to him locally were likely made of similar materials and of similar quality to the 3M N95s. When they first came out, I was initially confused by the different KN95 designation on the respirators that were advertised from overseas and have been following the U.S. government’s evaluation of these masks since the time. Unfortunately, such U.S. government testing has revealed that the overseas KN95 testing standards for such overseas masks have not been rigorously quality controled, many did not reliably come close to 95% filtration efficiency.”

Mike provides a CDC link to a report on these masks. Thus, in the interest of being fully-transparent to the listener who wrote in, and to the public, I would suggest that KN95 respirators may provide you with more protection against SARS-CoV-2 than a cloth mask, but are overall not as quality-controlled than would suggest the listener and that the public consult the above web link for more information.

DG: That is excellent. Thank you so much. I always like to point out that this is not really a one-man show and stuff like this is super helpful. I’m starting to feel like should I have shared one of my N95s or two of them with my daughter and my wife, but no, this is really well-taken. I think that as we go forward, I’m actually surprised at this point that we don’t have better certification. You get a mask and it’s got a certain stamp or a certain– we have certifications for organic foods where the certifications to help us with masks, which actually are keeping us safe and saving lives. No, excellent point, everyone. I’m glad that this was sent in.

VR: We have an email from Vincent who is also a physician. “Two questions. I recently immunized a 49-year-old lady who has a history of Parkinson’s and an active left septic bursitis with J&J. Should I have held off due to her bursitis or was I right in doing so?” Let’s take that one first, Daniel.

DG: You did the right thing. Never miss an opportunity to immunize. I’m hoping you didn’t put the immunization in that bursa. Maybe you did the other arm, that would make a little sense. I got a question earlier today and actually it was about, every so often we see people, we’ve got people doing vaccines that maybe have never done them before and somehow they get in the bursa, which is actually usually a challenge because we’re trying to learn to do that for other reasons.

Try not to get it in the bursa. Do the other side if someone has bursitis. If they get it in the bursa, probably still are going to get, we hope you’re still going to get the protection. I think it would make sense that you will, but no, I don’t think something like a bursitis– we really have to be careful not let little things keep us from getting a person vaccinated. I think you did the right thing. Now, hopefully, I laid out the risks with J&J, really small.

VR: Yes, and then his next question is about J&J. “Does it stand to reason to treat with aspirin prophylactically or just wait it out?”

DG: Yes. I’ve actually had this conversation with a lot of clinicians. It really is excellent, it’s a good question. If you start doing the risk-benefit, and this was interesting, I started asking people, “What if you tell someone to take an aspirin every day?” 1% of those people will have a GI bleed within the year. We can pull aspirin off the market when that happened. You are better off doing nothing. First, do no harm. You are more likely to cause problems to someone after a J&J than you’re going to provide any help by throwing aspirin or anything at them. Go ahead, get them vaccinated and then if they have a severe headache, that one in a million, we’ll pick it up, we’ll treat them properly.

VR: All right, one more from Chris. “In your recent clinical update you said, responsible summer camps should be doing testing because there’s funding for it now. I’m on the board of a summer camp, this is good news, but I can’t find any information. Can you please point to more information about this?”

DG: Okay. Actually, I’m going to say this slowly because we’ll be giving this person a bunch of emails hopefully. I’ve been working with a woman, Phoebe, for about the last year helping promote access to and coordination for particularly rapid testing but testing in general as a solution. Phoebe has worked with the rapidtests.org, also worked with a lot of different foundations and actually did a lot to push for funding in these bills. I can give her a little credit for that now.

Now, I asked Phoebe previously and she said yes, that I could share when people had questions like this. Her email is [email protected]. If you’re a summer camp, if you’re looking for ways to get access to testing, shoot her an email. She’s not in this to make any money. I think she must make money as a radiologist or something. She’s just there to help doing all these efforts pro bono. Reach out, let’s make sure that that money actually is spent, that that testing keeps our kids safe.

VR: That’s COVID-19 clinical update number 60 with Dr. Daniel Griffin. Thank you, Daniel.

DG: Thank you so much and everyone, be safe.

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