This Week in Virology
Host: Vincent Racaniello
Guest: Daniel Griffin
Aired 29 November 2020
Vincent Racaniello: This Week in Virology, the podcast about viruses, the kind that make you sick.
VR: From MicrobeTV, this is TWiV, This Week in Virology Episode 686 recorded on November 27th, 2020. 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, everybody.
VR: How was your holiday, Daniel? All good?
DG: Yes, good so far. We’re actually still in the middle of it, hopefully. I still have the weekend to enjoy, but the traditional, I tried to eat a little bit more. I put all the stuff in my plate and I’m like, “Oh my gosh, there’s no room for the turkey.”
VR: It always happens.
DG: You, Vincent, you had a good turkey day, as we like to call it?
VR: I did. I cooked yesterday because my wife is recovering from back surgery. I cooked all day and I didn’t make turkey. I made other things and it was good. I have to say, I learned how to cook through the lockdown. That’s one of the things I did a lot. It paid off. How about that?
DG: All right.
VR: I want to tell our listeners that we’re going to start releasing Daniel’s clinical updates on their own as separate TWiV episodes for those of you who complain that the three-hour TWiVs on weekends are too long. We’ll break it up and I just want you to know that today’s episode, it’s 686, but it’s actually Daniel’s 38th clinical update since we started back in March or so. I think we probably have a ways to go yet. We’ll have more as long as Daniel is willing, of course.
DG: All right, willing and as long as I’m able. Yes, I’m going to try to– With this theme, I’m going to watch the clock. I’m going to make my updates under 30 minutes, right? You listen to these at 2X, that makes it 15. I think we’re going to be good to go. All right. People may have noticed that I never open with the weather, but as I’m recording the same day as everyone else and as my episodes are moving to standalone, I thought I’d make this a little bit special. I’m going to comment on the weather and, like all good weathermen and large ground squirrels, try to predict the future as well.
I know there’s talk of a storm, but I think we’re going to catch a break. All this moisture coming out of the south will probably push east of us. At high altitude, it’ll crystallize, give us what we call snow. Probably some accumulation, but here in the New York Tri-state area, our high will be about 50 degrees F on Sunday, teens at night. Chance of precipitation, about 0% Sunday, but 80% on Monday.
All right, now my quotation, “To improve is to change. To be perfect is to change often.” We are back to Winston Churchill as we head into this dark winter.
All right. The pre-exposure period, vaccines. Expect to hear lots about vaccines in the coming weeks as we shift to the challenge of moving from vaccines to vaccination. Pfizer has gone on ahead and requested an Emergency Use Authorization (EUA). I think this is news that everyone has heard. I was emailing with a friend of mine who works for Pfizer and I will say that my optimism is only growing that we are looking forward to a much better 2021 than we had for 2020.
Yes, I do have friends that work at big pharma and perhaps if you’ve read a copy of our textbook, Parasitic Diseases, you might note that we dedicated our sixth and seventh editions to Jimmy Carter and William Campbell, right? William Campbell won the Nobel Prize for his work on ivermectin.
He’s a buddy at Dixons. He actually worked with Vincent’s wife, I believe?
VR: That’s right. At Merck, Yes.
DG: At Merck, and they were instrumental in bringing ivermectin to the world, which really has been a miracle, critical to treatment campaigns for river blindness and some other devastating diseases. Big and little pharma are actually critical partners right now as we move forward, as we move these vaccines to vaccinations. Are they still big corporations that operate in the capitalist model and answer to their stockholders? Yes. Still trade secrets and proprietary technology? Yes. Does that upset Vincent? Yes. Inventors and producers of might be the most impressive, safest, and effective tools in modern history. We’ll talk about this as we go forward.
Now, people are now asking me specifically whether I would get this Pfizer vaccine if it goes through the FDA and they’re willing to give me the qualifications of, as long as you don’t see any new safety concerns and perhaps it’s going to be available in December. People are also asking a second-level question, “If given a choice, Dr. Griffin, which vaccine would you choose?” I’m very encouraged by these questions. I think people are moving past the question of, “Will I get vaccinated?” to the question, “Oh, which vaccine do I want to get and when might this happen?” Let’s see where we are right now.
The Moderna vaccine trial, more than 30,000 participants, participants at 100 clinical research sites in the United States and they reported around 95% efficacy in a diverse population of enrollees. The Pfizer, I think that’s the proper pronunciation per Anthony Fauci, trial has over 43,000 subjects, and a quote right from Pfizer, “43,538 participants with 42% having diverse backgrounds, no serious safety concerns” and about a 95% efficacy as well. The people at Pfizer feel like they’re ready, they’ve got the data to bring this to the FDA.
The FDA is now going to weigh in on this and there’s brilliant people that I trust at the FDA. They’re going to be involved in this review. They don’t really have any pressure that it’s going to force them to go one way or the other. They’re going to be driven by the science. Reports are that if they are given approval by the FDA, there will be over six million doses ready to be given in December and over a billion for 2021 with plans to distribute these doses to the entire world. Not only high income, but also they have a whole equitable access program in place for low and middle income countries.
I wear a lot of hats, as people may know. Before the pandemic, they were really cool fedoras, but now one of my hats is I’m the process expert on the Optum National COVID-19 Vaccine Initiative and I’m the point person for vaccine administration. I think this just helps people to get, how does this move from the news to reality? We’ve been preparing for this. Challenges, yes. Anything insurmountable, no. Pfizer is foreseeing the challenges with the deep freeze. They have special shipping containers that could be re-iced. You can either add dry ice to them, you can add regular ice depending on how long you want to do this.
Not every site has to have one of these, now becoming rare, deep-freeze scientific freezers, but we’ve got freezers, we’ve got record keeping, we’ve got staff. Everyone is really getting prepared for this. Yes, there’s still a few more crucial things that need to happen. We need to see this actually get through the rigorous review that the FDA will put it through. There’ll be an initial EUA. This is not, give it to everyone come December 1st. This is going to be the first rollout and we’re really hoping in the next few weeks, I’m sure Vincent is on board with this, that we actually get access to peer-reviewed articles where we see all the details about these vaccines.
I’m a frontline worker. I see a large number of COVID patients. I’ll probably be opportune for that first phase of vaccine. We also got some news about AstraZeneca and I’m actually going to recommend that people listen to the recent TWiV 685 ‘Pandemicky’, but this was the vaccine, the AstraZeneca, the chimp adenovirus vaccine, better known as the ChAdOx. This is a replication-deficient chimpanzee viral vector based on a weakened version of a common cold virus, an adenovirus. This is something, the adenovirus that causes infections in chimpanzees, but it contains the genetic material of SARS-CoV-2 virus spike protein.
We got interim analysis on 131 COVID-19 cases. Again, I’m going to say, this will be my third time or my second time, listen to TWiV 685 to go into the details because there were really some interesting things going on here. There was one which we now realize was a mistake where people got half a dose and then the full dose, and in that subgroup of a little less than 3,000 folks, we saw 90% efficacy. In the main dosing regimen, 8,895 folks, we saw 62% efficacy. I do want to say, and I think this is something to think about, no hospitalizations or severe cases of COVID-19 in participants who are treated with the vaccine.
To compare apples to oranges, the apples between the different trials is, how does this vaccine do at keeping you from getting any symptoms at all, symptomatic COVID? The mRNA vaccines were in the mid-90s. This vaccine, we’re down about 62% with basically the standard dosing regimen, but if you ask the other question, “If I get this vaccine, is it going to keep me out of the hospital? Is it going to keep me from getting sick?” We’re seeing near 100% efficacy with all the vaccines. I’m going to say very positive stuff. Listen to TWiV 685 ‘Pandemicky’ here to get a more in-depth discussion. More news to follow as we get more information.
Now, after the vaccines, the big issue is going to be vaccine acceptance. Actually, I published a paper a few years looking at this. Who do people turn to when they’re trying to find out about a decision like this? They turn to people they trust. I mean, people trust people, people don’t necessarily trust institutions. Certain people are going to get vaccines and then other people are going to be, “How did that go? Are you okay? Did you turn orange?” We have a lot of fears that might happen to us. I think that we’re going to need to continue with a clear and reliable presentation on what these are like.
I’ll say at this point, what we learned to date, this doesn’t look like it’s your father’s Buick. I think there’ll be a lot of people who traditionally have had concerns about other vaccines to say, “This is completely new. This is a vaccine that I’m happy about.” I sort of hope that’s going to happen going forward. I think that this, so far what we’re hearing is these may be the most impressive, safest, and effective tools that we’ve ever had in fighting an infectious pathogen, and I like to say we’ve come a long way from twirling worms on sticks. Dixon will like that, my guinea worm reference. All right, don’t worry, we’ll talk more about vaccines ahead. The incubation period, the post-exposure period, testing, right?
Just to give people– the things are about to change again. The CDC is going to give us some new recommendation. That’s okay, as Churchill told us, to change is to improve. We now know a bit more about the time from exposure to the time when you can actually pick up someone who is infected. We’ve said that you get exposed. Two to 14 days later, you might get sick, but a test can pick up that you’re going to get sick, usually two to three days before you get sick. There’s some science that backs up this new recommendation that we’re expecting to see in the coming days, weeks, going from instead of lock yourself away for 14 days, which my wife has always said is excessive, to maybe just post-exposure, seven to 10 days, a negative test to close out that window. We’ll see where this goes. There’s science here. As we learn more, it’s reasonable to update our recommendations if they’re based on science.
Viral symptom phase, Remdesivir. It seems like so long ago, right, that Vincent and I discussed this on our last episode, but it’s gotten more attention. There was an article published in the BMJ back in October. It sort of sat there for a while, but then it got picked up by the media. This was the preprint of the WHO Solidarity trial. Basically, what they said, “We suggest against administering Remdesivir, in addition to usual care for the treatment of patients hospitalized with COVID-19, regardless of the disease severity. Weak or conditional recommendation.”
Then, basically, they say their guideline development group, the GDG panel, found a lack of evidence that Remdesivir improved outcomes that matter to patients, such as reducing mortality, need for mechanical ventilation, timed clinical improvement, and others. This was put forth as, it’s going to shorten your hospital stay. Hospitals care about that. Patients were like, “Boy, $3,000 for a slightly shorter hospital stay, and you’re charging me $3,000?” Et cetera.
Now, just to give all sides of this, the IDSA, the ID Society of America does. Their guidelines do recommend the use of Remdesivir. They give certain criteria. The United States NIH treatment recommendations do include Remdesivir.
Regarding Remdesivir, we had a discussion, “Is it a miracle drug? No. Does it make a difference? A soft maybe.” Just to put all that in context, we’re learning more and the evidence supporting Remdesivir is certainly not overwhelming.
We just got EUA for another drug. It’s a drug combination, falling here right on the heels, Baricitinib, and this is used in combination with Remdesivir. This is a janus kinase inhibitor. An interesting new therapeutic. It blocks the activity of one or more of a specific family of enzymes that interfere with a pathway that leads to inflammation. This is groundbreaking, overwhelming, compelling data that this was associated with a one-day shorter time to hospital discharge. A little bit of sarcasm there. I’m not particularly impressed about having to learn about a new drug and all its potential side effects when all they’re promising me is maybe a one-day shorter time to hospital discharge for my patients.
“Monoclonal antibodies for COVID, hard to pronounce, even harder to give.” I love that headline because it’s really true. I used to be involved in actually the naming of drugs. Prolia, Vioxx, I mean, the days when we used to name things properly. There was an EUA, another EUA for the second monoclonal, the REG-CoV2. This is the Regeneron monoclonal cocktail. We’ve got two monoclonal antibodies in there. We do not have the same nice paper in the New England Journal of Medicine as we did for the Eli Lilly product, but from what we hear, the efficacy and safety looked to be rather similar.
The data to date was pretty impressive. This was Phase 1 and 2, this was not a Phase 3, but 70-75% of people seem to not require hospitalization, a 70-75% reduction if you got this therapy within the first week. The Infectious Diseases Society of America (IDSA) is not yet recommending the monoclonal antibody therapy, saying we really just don’t have a lot of data. People are excited though. The National Institutes of Health (NIH) is also saying, at this time, there isn’t sufficient data to recommend for or against this. A lot of people are saying, try to do this in a trial.
There is through the EUA access to this through really the same Remdesivir network. I think I mentioned I’m going to be the PI on really it’s a post-trial access. We’re not going to have a placebo group, but we’re going to be trying to give this to people in the home. We’re going to be trying to monitor to see, are we seeing the same compelling efficacy that we saw in these early trials?
Another randomized control trial on plasma in the New England Journal of Medicine that, again, did not observe a benefit. This was a randomized trial of convalescent plasma in COVID-19 severe pneumonia. They did this trial the right way, I want to say. They tested and they made sure that 95% of the transfused convalescent plasma units had a high level of anti-SARS-CoV-2 antibodies, titer of at least one to 800.
They got this to people, on average seven days after symptom onset. So this was not late-stage people in the ICU. They did the trial the right way and it did not show benefit. I think we’ve gotten clear evidence that this is not a therapeutic with a major role. Maybe it’s time to sort of shift those resources in other directions.
The early inflammatory phase– Remember we’ve kept that the same for now. I spoke to a medical theoretician that I know, medical theoretician, that’s actually a job. He gets money and he just has ideas. Then he shares them with people. It’s my, say my friend, Lee Shapiro. We had one of these late-night discussions. I think this is him working, talking to me about his theories about what’s really going on during this phase and we talked a little about the IL-6 and the lymphopenia, and he’s not enamored with calling it a cytokine storm.
It was really funny because right that next day, my preprint, Cytokine storm of a different flavor: the different cytokine signature of SARS-CoV-2 to the cause of COVID-19 from the original SARS outbreak came out as a preprint. I told him, I would rethink whether I would continue to use the term cytokine storm, but admittedly, we still have a lot to learn here.
One of the things we’re doing during this phase, this is when people end up usually in the hospital, not only do we check the COVID-PCR, and they fail to give me the CT values because we still do not have an FDA-approved test for that, but we’ve also started looking at antibodies in almost all the patients admitted. Trying to get a sense of is the person coming in early, where we think they still have a high level of virus, but before they end up with an antibody response, or are they waiting a little bit longer and coming in sort of late in the end of that second week?
There was a preprint, SARS-CoV-2 viral load on admission is associated with 30-day mortality. Here, we saw patients that required hospitalization prior to an antibody response tended to have the highest viral loads and they also had the highest risk of death. I’m not sure what to make of this. Is this really just telling us as we’ve seen, the earlier you get sick, the worse you’re going to do if you get sick and come to the hospital before you’ve even had a chance to mount antibodies, or is there sort of more information here?
I would love to have a quantitative viral load. Also, a reliable quantitative serology to start trying to put this together. Perhaps our leaders remember the once or twice I mentioned the CT values and how both Anthony Fauci and Vincent somehow get access to these.
A little more buzz about anticoagulant dosing. The current recommendations by the major societies is universal prophylactic dosing of anticoagulants. You put people on something to keep them from getting the clots and then only in specific patients do we consider escalation a risk-benefit analysis.
A paper was published in thrombosis research, The effect of anticoagulation on clinical outcomes in novel coronavirus COVID-19 pneumonia in a US cohort. It was retrospective and I wasn’t– and I’m not going to say I felt that this was high quality evidence, but it was more on lines of what you would expect. The people that we worry more about that we escalated the doses on, those tend to be the people with the worst outcomes. People that we’re not so worried about that we’re using low dose, they do better. I think really what you’re seeing here is just an indication of the people we escalate therapy on are the people we’re worried about. I think the literature still supports the current guideline recommendations.
All right, secondary infection phase. This is when you use antibiotics maybe as opposed to early on when we’re using way too much and having discussions about a concept of a new ratio, right? Everyone knows the neutrophil/lymphocyte ratio. Now we have the concept of a ferritin/procalcitonin ratio. This is the idea that with all the inflammation triggered by COVID-19, by that virus, SARS-CoV-2, the cause of COVID-19, not only do we see the ferritin go up, but sometimes we’ll actually see procalcitonin go up.
This is a marker that people have associated with bacteria, but how do you tell the two apart? How do you tell my patient is having progression of this inflammatory cascade or my patient has a secondary process? We’ll see going forward, but this is another suggested tool for people to start looking at. You do a ratio of the ferretonin, of the ferritin over the calcitonin, and basically the higher that ratio, the more likely it’s COVID, the lower that ratio, the more likely it is that you’re starting to deal with a secondary bacterial infection. This seems to be what I’m seeing. It’ll be interesting for more physicians, more of us to share our experience here.
The multi-system inflammatory phase. Nothing too exciting that I’ve run across in the last week here, so we’ll move right on. We’re almost done. For those busy clinicians, this is our tail phase. Recognition and research. Again, Dr. Fauci talked about this in an interview and according to him, something on the order of 20% to 30% of people who had a symptomatic form of the virus, even without necessarily progressing to serious stage, not everyone needs to go to the hospital, but 20% to 30% have what some people are calling a post-COVID syndrome, a tail of COVID, a long-term COVID.
You got to come up with the right name here, but he also let people know and I’m going to let people know as well, he let people know that there are now large research programs underway to understand what’s happening and try to come up with therapies that help these individuals. I’ve got a large trial, United Health Group, that I’m working with. Just to let everyone know, we’re paying attention to this growing number of people. We’re trying to sort out exactly what’s going on.
Our end of our old and the beginning of our new fundraiser. I’m wrapping it up here before the emails. When this show comes out, it will be right before World AIDS Day, which is Tuesday, December 1st. I was looking through my pictures. I’m usually off somewhere in the third world or the developing world or outside the U.S. when this happens. I was looking back, I’m either in Uganda or I’m down in Central America somewhere or in some island in the Caribbean, but here I am, home. We’re going to finish off, couple more days left here for our TWiV fundraiser. Everyone jump in, take advantage of that match to help support MicrobeTV.
Come December 1st, we’re going to be shifting over and we’re going to be starting our World AIDS Day-themed fundraiser and we’re going to be fundraising for the Peace Corps HIV and AIDS program. Again, it’s going to be the same concept. Go to www.parasiteswithoutborders.com, make a donation there and we will double it up to a total donation to the Peace Corps HIV and AIDS programs of $40,000. Part of why we’re doing this is with all the focus on this virus, there’s been a significant neglect of people suffering from the other virus. Just trying to do our part and please help us in that effort.
VR: Very nice. Yes. November is almost over and we thank you a great deal, Daniel, for doing that matching fundraiser for MicrobeTV. Really will help us out. Are you ready for some email?
DG: I am, I am. We’re right here with about four minutes to go, Vincent. We’re going to keep this right on.
VR: All right, we’ll make it quick. Daniel said, “Since April, when you mentioned in TWiV 600 that taking an inhaled steroid might not be the best thing, I’ve stopped using it for his sinus inflammation. I’m wondering if you have an update whether this is still an issue, whether he should still discontinue his FLONASE or not?”
DG: Yes, you may start reusing your fluticasone propanate, or your FLONASE. Again, back in the days when people knew how to name things. We were concerned. Early on, we did not know a lot and so we erred on the side of caution which was reasonable, and there was even a discussion here about, “Are we really erring on the side of caution?”, because now people are going to have their allergies on control, they’re going to show up for their COVID test.
No, most of us have started slowly introducing this. People are using FLONASE. No signal has come up that this is an issue. I think across the board it’s better to control those allergies than think you’ve got COVID and then go for a test when you should be just staying in the safety of your own shelter-in-place situation.
VR: All right. Now David sends a link to an article by Paul Sachs which you mentioned earlier today, Bamlanivimab for COVID-19. “Hard to pronounce, even harder to give, and it describes three barriers, three-hour treatment time, serious side effects. The way Dr. Griffin talks on TWiV, these barriers can all be overcome. Is that correct?”
DG: That is correct. David, I appreciate you sending this in. Yes, I love the title, right? Hard to pronounce, even harder to give. It is an issue, right? Because the way they sent this out was not great, but you work with what you have. They sent this to acute care hospitals and this is an outpatient medicine. Suddenly, the acute care hospital is trying to figure out how to do outpatient medicine and there also is, there are a couple of barriers that I don’t think Paul Sachs may have even noticed or be aware of.
We’ve started doing this. I already have had several patients receive this therapy. The local hospital networks have set up an access site. You call a number, you go through a whole bunch of hoops, because we’re not busy enough already. You need PCR confirmed, not a rapid antigen. That’s a rule that they put in place. That PCR has to be within three days of the time it was procured to result it. Our average resulting time is four days. This has become an issue, probably they had one person, one of my patients, three days and two hours and they were ready to reject them like, “Come on, two hours, that’s a rounding.”
Then they have to go somewhere and as mentioned, there’s the whole process of getting set up and then the medicine runs in over an hour, and then there’s a two-hour observation period of time. A lot of the hospitals are using this, are using an ER room. The ERs are already overflowed. We don’t really have that extra ER room. Tents are being set up to do this in an outpatient setting.
Serious side effects? I’m going to say no, actually. We only saw about 2% of people even notice that they’re getting the medicine and the notice was you got some facial swelling, you got some itching, an allergic reaction that very quickly responded to Benadryl. Not an issue there.
The way we’re going to overcome those barriers is what I mentioned, United Health Group has actually set up a trial. We’re coordinating with Eli Lilly, we’ve been on a lot of talks with the FDA. What we’re going to do, we’re going to start by targeting our senior population. These individuals will get testing for COVID at home and then if that’s positive, we’re going to send out an infusion nurse to actually administer this in the comfort of their own home.
Yes, there are barriers, but we’re going to make sure we get over those and make sure there’s access. Right now, there’s just a few thousand doses in the whole country. It’s not quite that everyone can get access, but give us a little time and this is going to be a therapy that people do not have to pay for, that they can get in the convenience of their own home. Details to follow.
VR: Robert is a professor at Boise State University. He’s going to teach a microbial physiology lab in person, January 11th. “They will be masked, well-spaced, 12 students per lab; however, the numbers in Boise and the rest of Idaho continue to surge. Any thoughts on running the lab in the safest way? I could press to go remote. I suspect I’m not alone in my concern. By the way, I nearly died of COVID-19 in December, January. While I may have some risk, I’m more concerned about the students. Thank you.”
DG: Robert, this is a great topic that you swing us into. This is something that I’ve said now that we have the data to support this. It looks, actually, as though the schools can be a very safe place as long as they’re set up properly. A couple things you’ve mentioned. One is the students must all be masked and actually wearing that mask, not with the nose sticking out, not under the chin, but properly wearing a mask that fits them. Well-spaced, at least six feet between people. You didn’t mention but I’m going to bring this up as well, you need appropriate ventilation systems. Otherwise, you’re sort of closing it in and that’s not great.
Here’s what I’ll say. You can do this safely. We’ve seen this now, millions of school children, millions of school older not-so children, you can actually do this. When we look at teachers are concerned. I think this is fantastic that you’re focused on the students, but let’s focus on the teachers as well. We know the students can be safe, but the teachers can be safe, too. They can keep that distance, they can wear the mask, they can make sure that they have the things that they need. If they don’t, make a fuss because this can be done safely. As I like to say, close the bars but keep the schools and the churches open and their windows open and keep the group sizes down.
VR: All right. One last email which is just a nice Thanksgiving story from David. A big TWiV fan, never misses an episode. TWiV helped his family during a difficult time. “On Thanksgiving morning, we learned that our nanny had tested positive for COVID. As a result, my wife, two young kids, and I all wanted to get tested. However, it was Thanksgiving and many places including our doctor’s offices were closed.
This is where TWiV came to the rescue. Earlier in the fall, Daniel Griffin had mentioned on his podcast that the ProHealth Organization was partnering with schools in the New York area to help with testing. After hearing this, I connected my school with ProHealth. They formed a partnership. As a result of that partnership, my whole family was able to get tested on Thanksgiving morning. We all tested negative on the rapid test and are awaiting PCR results. However, it’s still relatively early, so we will get tested again this weekend. If it weren’t for Dr. Griffin’s appearances, I never would have been able to get my family tested. If it weren’t for the knowledge I have learned on TWiV, I would be a lot less prepared for my current COVID scare. As a sign of my thanks, I made a donation to Parasites Without Borders. Thanks to all of you and your team for what they do. David.”
DG: That is really nice, David. Almost a tear to my eye. They should make a movie, right? [chuckles] I’m glad that we can be of help and particularly thank Vincent for making all this happen.
VR: That is our weekly clinical COVID-19 report. You can find it at Microbe.tv/twiv with all the other episodes. It’ll have its own number, of course. I made a brand new email so you can send questions for Daniel. It’s firstname.lastname@example.org. How about that, Daniel? You have your own MicrobeTV email.
DG: This is like your Thanksgiving present to me. [chuckles]
VR: If you’d like to support us, you have until the end of November to go to www.parasiteswithoutborders.com. Daniel Griffin is at www.parasiteswithoutborders.com, Columbia University Irving Medical Center. Thank you, Daniel.
DG: My pleasure as always. Everyone, have a great weekend.
VR: I’m Vincent Racaniello. You can find me at virology.blog. You’ve been listening to This Week in Virology. Thanks for joining us. We’ll be back soon. Another TWiV is viral.
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