TWiV 707 COVID-19 Clinical Update #45

This Week in Virology

Host: Vincent Racaniello

Guest: Daniel Griffin

Aired 15 January 2021

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 707 recorded on January 14th, 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 it going, Daniel?

DG: Poorly. Poorly is the word. Not well on many fronts, but let’s get into the weeds. Start with my quotation, “For the world it is drowning in paper.” I want people to think for just a second. When would someone have made that comment? When would they have said, “For the world it is drowning in paper?” This is said by Poirot, an Agatha Christie character in the story– in the book Murder in Mesopotamia, which was written in 1936. One hundred years ago, they thought they were drowning in paper. What do we think is happening now? As we go forward, people will understand why maybe we should call this episode, “Drowning in Paper”.

January 8th, we saw 307,983 as the daily case count for the US COVID cases. January 12th, we saw 4,447 deaths. People should realize, there’s a delay when you see 307,000– almost 308,000 cases. Two, three weeks later, we’re not going to be sitting in only 4,000 deaths. We’re going to be up above 5,000. It’s predicting the future based upon what we know, we really need to start getting this different. A lot of the hospitals– I get regular alerts every morning. How close are we to that critical census where they can no longer do elective surgeries, they have to switch over to full crisis pandemic mode? Actually, we were starting to see hospitals in our area basically reach that.

First one just reached it earlier this week, another hospital is just a few admissions away from being at that level. For the hospitals, this is really difficult. This is how they actually keep the doors open, how they keep the finances out of the red. For a lot of individuals, this is necessary care, so really, really difficult situation we’re in here. Talk a little bit about vaccines. Can you imagine the topic, the interest, the questions are now flooding in about vaccinations? I’m going to try to talk about a few things. One of the big things I think I can bring to the conversation is, what’s it like on the ground? What are we actually seeing? Not what’s being published, not what’s being talked about, but what are we actually seeing?

One of the big conversations, when we were looking at how are we physically going to do this, was the question of how will vaccinations impact testing? As mentioned, we have more COVID right now than we ever had in this country. Testing still is critical, testing saves lives. If we stop testing, we miss an opportunity to pull those people out to prevent them from spreading it to others. We also miss an opportunity to diagnose them earlier, so testing is critical. As we’ve had a lot of conversations, and I’m going to talk about some of those conversations, there seems to at least be a consensus among the people I’ve talked to that we need to be really careful that vaccinations don’t cannibalize our testing capacity.

Two rules, one is new and one is one we’ve held to for a while. One is the vaccination rule which is, “Never miss an opportunity to vaccinate.” This comes from our pediatrician colleagues. Kids come in; they’ve got a little bit of a runny nose. Some providers say, “Oh, why don’t we just wait till the kid is completely healthy?” The child is completely healthy, we’re not treating goats here. If you wait for that child to be completely healthy, you may be waiting a long time, and then they may come in quite ill with a vaccine-preventable illness.

One of the mantras in pediatrics is, “Never miss an opportunity to vaccinate.” Every point of care is an opportunity and a very similar new rule, which is, never miss an opportunity to test. Every time someone comes, has an interaction with a healthcare provider, this is an opportunity to test, to find out if they’re positive, and move forward. I’m going to talk a little bit about how this relates to vaccinations in some of the troubling experiences I’ve had recently about people getting vaccinated, and then finding out that they’re positive. Let me just relate a couple of stories. I’ve talked a little bit about this, but now I’m seeing it more.

Early on what I was seeing was the healthcare professionals. They should know better, they got their vaccine, some of them in mid-December, maybe towards the end of December, and then Christmas day, New Year’s Eve, or New Year’s Day. Exposures, a few days later end up sick with COVID. We’re certainly seeing people get vaccinated, and then shortly after, before they get to that second dose, that 14 days when they have that protection getting vaccinated. A lot of this is education, and I know my large audience is the Optum-Tri-State, the ProHealth Care physicians that listen. Really important. I know that we’re trying to get people vaccinated.

Let’s try get good throughput there, but you want to make sure you reinforce because even healthcare providers. Got a couple of questions yesterday. “I got my vaccine three days later, I went to a restaurant. It was supposed to be outdoor dining, but then it got cold and the tent sides came down. I realized I was indoors.” My quick response was, “So obviously, you got up and left?” No, they stayed and had dinner and wanted to know if there was any protection, three days after their vaccine. Big to reinforce here is that we think you’re starting to get some protection 10 or 14 days after the first vaccination.

Some of the stuff we’re hearing the experience in Israel is a reduction of about 50%, let’s say, but that doesn’t mean 50/50 you’re protected. That means we’re seeing 50% less infections with the same exposure. Maybe you do 30 minutes instead of 15 to get infected. We are not really seeing that protection that we talk about until you are two weeks after the second dose of your vaccine. The protection actually is quite robust, quite impressive. Let’s talk about some new vaccine results. The interim results of phase 1-2a trial of Ad26.COV2.S COVID-19 vaccine. This was published on the 13th, in the New England Journal of Medicine, Wednesday. I think our episode’s going to drop this Saturday, so the 16th, maybe.

Now, we had this information from an earlier press release, but now it came out in the New England Journal, so we have the peer-reviewed journal. I feel like the media is treating this like brand new news which is interesting, but this is a peer-reviewed presentation of the Johnson & Johnson multicenter placebo-controlled phase 1-2 trial. I’m looking at little over 400, 402, randomly assigned healthy adults to receive either a single dose or a two-dose schedule of the Johnson & Johnson adeno vector vaccine.

There were three cohorts. We’ll talk about cohort one. These were adults ages 18 to 55 cohort; cohort three, adults 65 and older. Don’t worry, we’ll get to three. Longer-term data looking at single-dose and two-dose regimens, and the two-dose regimen was collected in cohort two. This is really just looking at cohort one and three, just to let you know. What were the results that we saw published in the New England Journal?

As far as neutralizing antibody titers, they were detected in 90% or more of all the participants on day 29 after the first vaccine dose and reached 100% by day 57. That’s interesting, that the titers continuing to rise. This is not unique for this vaccine. Other vaccines we have out there, you have a continued rise, but just to put this– I guess I’ll put it in context of a Moderna: you get your first dose, 28 days later you’re getting your second dose. Fourteen days later, that puts us at about day 42, compared here today 57 to get to that level of protection. It takes a little bit longer. The second dose, and I think this is an interesting issue– this is a vaccine that is looking at coming out as a single dose.

The limited data they talked about in this paper was that a second dose increased the antibody titer by a factor of about 2.6 to 2.9. Another thing that was interesting in this paper, people are always asking me, “Hey, is there an assay for neutralizing antibody responses? In this New England Journal article The spike binding antibody response, or your total antibody actually correlated with neutralizing antibody. You don’t need that special test. There is a commercially available neutralizing antibody assay. You can, at least, based on this data, just use a normal antibody assay. They also report CD four T-cell responses. We care about that. Already by day 14 you are seeing clear skewing toward the type 1 helper T-cells. There was a nice, robust CD8+ T-cell response. No safety flags I have to say, there was just the usual fatigue, headache, myalgia infection, site pain. Some of the other communications Johnson & Johnson has talked about is the fact that this is a platform they’ve already looked at in over 100,000 people, so this is reassuring. We expect the phase three trial data to come out on Johnson & Johnson before the end of January.

Expect an update on that when it’s available, probably about two weeks from now. Johnson & Johnson is suggesting that they will have EUA request, EUA approval in February. This is I think the most exciting little tale I’ll say on here. As per their agreement, Operation Warp Speed, with the US government, by January 1st, they will deliver 100,000,000 vaccine doses to the US. This is a huge shot in the arm so to speak as far as vaccine doses being available. A little bit about what we’re seeing on the ground, as far as the Pfizer and the Moderna.

We are seeing, I think, consistent with the studies that we are seeing, reactogenicity around the first doses, and we are seeing more significant reactogenicity after the second dose. A person gets a low-grade temperature elevation, they feel crummy and tired after the first dose. They may feel a little more crummy, a little more tired after the second dose. Very few of my colleagues missed work after the first dose. Several of my colleagues missed work after the second dose. That’s just something for people to be keeping in mind as far as the timing on when they get their vaccine relative to what important things they might have to do.

There are a couple of interesting things about this vaccine. We’ve talked about the fact about one in 100,000 are having anaphylactic reactions. Nobody has died. This is something that we can treat, we can address. It’s required that all the vaccine administration sites have the appropriate therapeutics and personnel to deal with this. Benadryl an EpiPen, IV famotidine,  steroids, things like that. An interesting thing that we’ve been seeing in the Moderna– it’s what I have. I was searching for a name and I’m going to now call it this seven-day itch. I think if you listen to the prior TWiV, you get a sense of how the immune response works.

First, you have more visceral germinal center development, and that right about day seven is when you get the local germinal center production. About day seven in a minority of people, we’re seeing that the injection site becomes itchy and raised. There is actually a visible redness in the area, got some pictures people keep sending me. Take Benadryl, go to sleep, usually resolves pretty quickly, and occasionally if you really check you can notice that the lymph nodes in the area are a little bit swollen. This is all evidence that you’re getting that that immune response that we really want.

What about eligibility? It has expanded and this expanded really quickly. On Monday, it was down to individuals 75 and older, and I think a couple of hours later, it was individual 65 and older, and this whole phase 1B group, at least in New York. From D.C., from the White House, there’s been encouragement to across the board, really expand access in response to the fact that way too many doses are sitting in freezers. Now expanded in many areas to 65 and older, first responders, all the support staff for first responders, fire, police, investigators, public safety, any sworn civil personnel, anyone involved in corrections, anyone involved in schools.

I think it’s anyone who walks close to a school at this point. Anyone who’s licensed, registered, or involved with childcare, people in public transport, folks in homeless shelters, or working there. Really, public-facing grocery store workers, in-person college instructors, I don’t know if that counts you, Vincent? They’re also talking about expanding it to high-risk medical conditions, people with high-risk medical conditions. The actual details about what those are are unclear, but there’s really a move. I’m going to say it was a nice article in Teen Vogue, an article by Priyanka Bansal called “Botching the COVID 19 Vaccine Rollout in New York.”

It was all about trying to move from this threatening, incarceration, in carceral-type model of, “We’re going to fine you if you have issues,” to, “Let’s really figure out how to get those vaccines into people’s arms.” Hopefully, a more cooperative, “What can we do to get it there? What are the issues? What is happening? What is failing on the ground?” The first is an issue of trust. In December, the Moderna/Pfizer companies had promised and actually delivered on this, that they would produce 20 million doses. January, that would go up to 40 million, February up to 80 million, so really going to increase over time. What happened with those 20 million doses in December?

The first thing is the government held back 10 million, so they’d have enough for that second supply should suddenly the sky fall and Pfizer and Moderna failed to deliver. So, they only sent out 10 million. Once those 10 million ended up mostly at acute care hospitals, the hospitals said, “We don’t trust the government’s going to send us that next shipment, so we’re going to take 10 million, we’re going to take five million and put them in the freezer.” Then there were only five million vaccines even in play, and then they’re trying to, in acute care hospitals, somehow figure out how to vaccinate the acute care, the phase 1A-prime hospital-based ICU, ER, clinicians, and staff. There wasn’t great communication.

Basically, the vaccines would just show up, and suddenly you had these vaccines on hand, and you’re trying to figure out what to do with them. There really was a lot of issues here. A couple of things have happened, and I just want to point of this is true. When you see, “Oh, this hospital has either administered or allocated 62% of their vaccines.” They’re counting it twice. They give one shot. They say, “Oh, we’ve given one shot, but we’ve allocated the other.” You’re counting twice that other shot is sitting in the freezer. We did 32%, but we’re going to count it as 64. That’s what we’re seeing.

There’s now been a push from on high, instead of sitting on half of those vaccines, all the vaccines are going to start flowing. Pfizer and Moderna are basically saying, “We can do this, we’re producing these vaccines, and we want to get those into people’s arms.” There is also, I got to say very frustrating on the ground. There’s a lot of paperwork. There’s more paperwork, and it takes more time to do the paperwork and the electronic uploading than it takes to do the vaccine. I’m just going to provide a personal story.

My mom, on Monday, she is in her 80s, she went to go get the vaccine. It was a Herculean effort. My mother has some health issues at the moment. My wife had to help her. Another individual had to help her– big thing, getting her out, getting her in a car, getting her to the vaccine site. She got to the vaccine site. She needed to be helped to finally get to the area where she could get the vaccine. They show her the information, and she says, “Oh my,” actually my wife picked up on this. “It has your birthday as 1931, they have your birthdate off.” She tells the lady and lady says, “Oh my gosh, we can’t vaccinate you, you stay here.” Goes off to find a manager, comes back about 15 minutes later, the entire line, the production has stopped.

Then they come up with a solution that they’re going to put a line through the one, put in the correct digit. My mother will initial it, now they will vaccinate her. We really need basically a loosening up. A couple of our sites, I think I’ve described the ProHealth experience, had issues uploading the HL7 file to the New York State Information Immunization System. Their response was of course, instead of, “Hey, we’re going to send an IT person. Let’s figure out how to make this happen.” Was, “We’re not sending you any more vaccines until you fix your IT issue at that site.” So, really back to the Teen Vogue article.

We need much more of a cooperative, transparent model. We don’t need to worry about HIPAA and paperwork and electronic uploads. We need to get those vaccines in arms. I have to say down here on the ground, those vaccines are sitting in freezers. There are thousands of vaccines sitting in freezers here, and there’s a lot of organizations that are ready to get those vaccines in arms. We need to basically, here at a low level need some help there. What about AstraZeneca? People are asking about that. “Why are we not giving this a life-saving AstraZeneca out there?”

I think I’ve talked about this a little bit before. AstraZeneca and the FDA have had some challenges. We don’t have the safety, we don’t have the efficacy data that the FDA would like to see. AstraZeneca has not been as transparent and cooperative as the US FDA would like. Just to point out that the issue right now is not a shortage of vaccines. It’s an issue getting the vaccines we have into arms. We expect there to be a lot more vaccines to be flowing in the next few months.

What about mutations and variants of interest? I can’t see Vincent’s face when I say that, but I can just imagine it. Some interesting issues I’m going to talk about when we get to passive vaccination there. But this is a growing concern. What is going on here? Do we have surveillance systems in place that are going to tell us that something is happening? I think the U.K. was doing quite a bit of sequencing, South Africa is doing quite a bit of sequencing. There’s a call to do more sequencing here in the United States. More surveillance so that if there is a change in the genetic code that results in a change in the amino acid sequence, that results in something that can affect the biology of the virus. We need to know about it.

I think there’s also a growing appreciation that we maybe were a little bit relaxed in thinking that coronaviruses didn’t change very much. There are some interesting data now suggesting that actually over time, coronaviruses can actually change, can adjust their biology.

A few vaccine FAQs to hit here before we move forward. The big one I get all the time is, “When can I stop wearing my mask? I get vaccinated, can I stop wearing my mask?” There is a science, and there is a moral aspect to this.

I was giving a talk for the large ProHealth pediatric group a couple of nights ago, I think this was Tuesday night. Jay Berger asked this question, a very poignant question. “Dan, once I have my vaccine, you have your vaccine, and one of our friends has their vaccine, and it’s been a couple of weeks. Can the three of us sit in a room together, have a drink, take off those masks? Can we do this in public? Can we do this when we go to a party, for instance?” Well, here is the thing to say. If you’ve been vaccinated, it is offering you protection, but there’s only preliminary evidence that it is decreasing the amount of virus that you might spread to other people.

Getting vaccinated does not mean that you will not get virus, and that you will not potentially spread it to others. The other side to this, I’ll say the moral issue is, let’s say, it’s next September, and everyone who wants vaccine has gotten their vaccine and had that time to develop immunity. The only people out there not getting vaccines are people who have decided not to get vaccines. Do the people who have gotten vaccines, are they required, should they still have to wear masks to protect people who have decided not to get vaccinated? Now, as a physician, in the healthcare setting, I think that we’ll have to continue to wear masks, but if you go to that party, that’s much more of a moral decision.

“Can I stop getting tested?” This relates right to the first one. If you get vaccinated, it really comes down to the question of, “What is the point of that test?” A lot of settings require people to get tested on a regular basis, and in those settings, they’re actually a lot more concerned about you getting the virus and spreading it to others. If you’re working in a long-term care facility, if you’re working with patients, if you’re working in a setting where you might expose people who either have not been vaccinated or, I’m going to add to this group, people who have an issue with mounting an effective response and are still vulnerable, then the mask-wearing continues.

“How long after infection can I get the vaccine?” Now, this comes up a lot. Someone gets the infection, it’s been about three weeks, they’re feeling better, “Can I get the vaccine, or do I have to wait three months?” The three months was thrown out for monoclonal antibodies, it was thrown out for a deprioritization, when it was really limited supplies. We’re recommending that if you have access to get vaccinated, if your ticket comes up, you do not need to wait the three months. You can wait the three months because we have learned that you’re very low-risk of being re-infected in those three months.

A recent study in the U.K., maybe I’ll get to it, out to six months, about 86% or 83% less likely to get infected, so now, we’ve moved not into, “Do people get re-infected,” but “Over what course of time, what percent reduction in likelihood of being infected do you get?” I always want to make sure I talk about my Bamlanivimab, “BamBam”, Bamlanivimab. I’m just breaking that down into what is the crazy notation. This is a -ab at the end, monoclonal antibody, different from an -ib, inhibitor. I still remember that This Week in Parasitism, where Vincent and I confused an -ib with an -ab, very upsetting to me, but we’ll move forward.

A couple of things we’re seeing here, and this relates to the variants. There is some concern with a monoclonal, whether it be a single monoclonal or two monoclonals in a cocktail, that you are only targeting one or two of what we think are 20 different epitopes, targets, on the spike protein. This becomes much more of an issue. “Will my monoclonal antibodies still work when there is a change in the genetic code, when there is a change in the spike protein?” I can give you a little bit of data. I will say that Eli Lilly is actively looking at this. Regeneron, with their cocktail, is looking at this, the U.K. B.1.1.7, we’ll call it the U.K.-variant, looks like it is not an issue.

There might be an issue with one of the epitopes with the South African variant, but this is the whole concept that we have not just one monoclonal targeting one site, but we have the ability to use cocktail therapy. This is also really important also from a surveillance point. At least, with some of the companies, we’re already talking about starting to do some sequencing of the virus in individuals that do well. In individuals that don’t do well so that as soon as it starts to be an issue we know. Really having a sense of, “Where’s the epitope that’s being targeted so that we can stay on top of this?”

We don’t want to start having people fail monoclonal therapy only later to find that we’re actually trying to give a therapy that’s binding an epitope which has now been changed.

Early inflammatory phase. We’re learning a little more about the encephalitis. Actually, there was a nice article, in CID, Clinical Infectious Disease, SARS CoV-2 encephalitis is a cytokine-release syndrome evidence from cerebral spinal fluid analysis. Actually, they went ahead and described that the encephalitis was associated with glial activation, neuroinflammatory markers, so really interesting getting more in the lines of what I think we’ve thought over time. People have not really detected virus in the CSF, but it looks like this is an inflammatory driver here.

The multi-inflammatory phase. I want to reinforce what we’re seeing here. The inflammatory part of this disease can often be bimodal. People come in, they often come in during that second week, when they’re starting to have their early inflammatory phase and have trouble breathing, hypoxic, increased respiratoryrate. We get them through that, we feel that they’re better, and they go out the door, but as I’ve tried to remind people, about 10% of people will come back. They will come back during this, we’ll say, late-week three, four, the late or the multi-system inflammatory phase.

It’s really critical that people appreciate, this is when you can either have a resurgence of the inflammatory response, you can have secondary infections, you can have clots. You really need to sort this out. Some individuals never even end up in the hospital during the early inflammatory phase, and we just see them during this late inflammatory phase, so really critical to do this. I’ll hit this again but this is why we don’t want to just clap those folks out the door. We want to make sure they have good close follow-up, so that if they have an issue, they can be treated, they can be linked to care.

The tail phase. I always want to make sure I spend some time on this, but persistent poor health post-COVID-19 is not associated with respiratory complications, or initial disease severity. This was a study out of Ireland, and it actually highlighted that even people with mild outpatient disease can have prolonged issues. I think that’s critical. We talked about an article last time where when people were really ill, when people are in the ICU, that there actually was an increased risk of cognitive issues, and more severe with more severe disease.

Another article in the Lancet, “Six Months Consequences of COVID-19 in Patients Discharged from Hospital: A Cohort Study.” Here, they looked six months out, and what did they see? Fatigue or muscle weakness in 63%, sleep difficulties 26%, anxiety of depression 23%. The median six-minute walking distance, less than the lower limit of normal, and about 20% to 30% of individuals. Just for all the people that have this idea that you live or you die, unfortunately, this is what I’m quite concerned about. People talk about, “Economics,” and “We’ve got to really keep everything open.” You know, we really have to be careful that we’re not creating– I look at those 300,000 individuals who get infected in one day, what percent of those individuals are going to die? That’s one thing.

What percent of those individuals are going to have sleep difficulties, anxiety, depression, the inability to work, to be productive, and actually even to have social and family interactions? Really tough year, and I want to point that out.

Then, our fundraiser. We’ve got a little bit. We’re about halfway through January, so we’re about three-quarters of the way through our Peace Corps HIV and AIDS Program fundraiser. If you get the time, drop what you’re doing. Unless you’re driving, don’t drop what you’re doing.

Got to parasiteswithoutborders.com and help us continue our work, and help us support the Peace Corps.

VR: Daniel, on Monday, New Jersey changed its vaccine regulations to include anyone over 65. It doesn’t matter what you do. Anyone. I’ve got an appointment for next Tuesday because of that. If I were in New York, I probably couldn’t get it yet.

DG: No, New York actually, is the same. New York has gone 65 and up. Now, you couldn’t get in New York just because we have issues, not because of an age restriction.

VR: You had mentioned student-facing educators over 65, but you’re saying all 65 and over in New York as well as New Jersey, right?

DG: Yes, in New York it first went to 75 and very quickly went to 65. I didn’t realize you were over 65, Vincent, because you look so young and vital.

VR: Thank you very much. Thank you. All right, we have a few emails for you. Samantha writes, “I’m a clinical lab scientist in California. I have a question about CT values from PCR testing in our lab. A few months back, I read that the FDA was forbidding hospital labs from releasing CT values because they could potentially be misrepresented, or could possibly misrepresent the true patient condition. For example, a good sample versus a poor sample. After listening to Dr. Griffin’s update, it seems as though the FDA has reconsidered its position on CT. We currently run our SARS-CoV-2 testing on an instrument called BD MAX.

It gives CT values in the test report, but we report only positive or negative to the providers. We’re in the process of validating a second PCR analyzer made by PerkinElmer, but I don’t know much about it except it’s more sensitive to smaller amounts of viral RNA than the MAX. Long story short, how can we get the CT information out to our medical team with the appropriate interpretive information to go along with it? I imagine that a majority of our providers won’t fully understand the result that reads something like positive CT-32 or something along those lines. Any input is appreciated.”

DG: No. This is fantastic, and this is why it’s so important to talk to people that are on the ground. When the CDC changed its guidance, when the FDA changed its guidance and said, “Oh, yes, you’re welcome to share this information.” Then it was in the New York Times. There was, “Oh, yes, you’ve been able to share it all along.” Well, that messaging was not clear. The messaging that was out there, the messaging that people received was, “You can’t share those CT values.” Now the messaging is, you can share those CT values, and the question is, “How do you do it?” I do think it’s really important that we put this in the reports.

We’re super busy. Currently, what I have to do, what a lot of the providers have to do, is we have to pick up the phone, we’ve got to call molecular, we’ve got to give them the information, we’ve got to get to the right person. It takes a really long time to get that number. It would be fantastic to have it in the report. Now, the way results are reported is really interesting. We have sometimes where they do a sputum and they say, “Oh, normal floor,” and then at some centers in bold they say, “MRSA and pseudomonas not detected.” That gives a little tip to the clinician on what they might do.

My suggestion here for all who are listening, go ahead, still report it as positive, but then put in the print below it some ranges. Level a little information about– we are running our cycles out to let’s say it’s 40 cycles, whatever it might be, and then just put what the CT value actually is. Then, over time, we’ll continue to educate like a viral load with HIV, like a viral load with hepatitis C, we’ll be able to make sense of what those numbers are. It’s also critical that you put in the analyzer because there is a little variability from center to center. There’s variability from machine to machine, and as long as you know that, oh, this is a PerkinElmer that was run on.

We have the same issues with antibody index, antibody levels, PT prothrombin INR. Yes, I would love that if I’m able to look, and I’m able to actually see positive-negative, and then below it could be that CT value.

VR: Paige writes, “Hi, Dr. Griffin. Should people who test positive for COVID-19 or had positive antibodies still get vaccinated? I know the answer is yes, but I want to know why.”

DG: Yes, the answer is yes, and the reason is as we’ve talked about several times is some natural infection provides some protection against re-infection. But it only lasts for a certain period of time, and over time your chance of getting reinfected diminishes. It certainly does not provide what we think is going to be a 94% to 95% protection out to a year or two which is what Moderna is starting to suggest. We don’t think it’s going to be close to 100% protection against severe COVID. The reason you want to get vaccinated is you want that really high-level protection that vaccines can produce, because you do not want to get a second infection.

Yes, several of the second infections have been mild, but I always like to remind people some of those second infections have been quite severe. We’ve had people with mild first infection, severe second infection. I was just doing a talk this afternoon on a call with our urgent care physicians in the Tri-State Area and I was speaking with Bonnie Simmons, and that at some of the sites they had done I think 5,000 tests. She was relating one of the sites that is over by the Verrazano Bridge, avoid any HIPAA violations. That one site had done 100 tests.

One of it was a family. The whole family came in, the whole family was sick. They all tested positive. They had actually been sick and positive at that same facility back in April. We are certainly seeing re-infections.

VR: Terry writes, “Dr. Griffin, recently, you stated patients who receive monoclonal antibody infusion for COVID should wait 90 days to get vaccine. What’s the harm in getting the vaccine 30 or 60 days after the infusion? I understand the vaccine may not be as effective at producing an immune response but aren’t you taking a risk of the patient getting reinfected with COVID if you wait 90 days?”

DG: This is a fantastic question. We’ve actually had individuals– I had a husband and wife where the wife went ahead, and she got the monoclonal antibodies but the husband didn’t want to because he wanted to get vaccinated. He’s now in the hospital. The issue is the monoclonal antibodies, we’ll use Bamlanivimab half-life of about 21 days, say, Regeneron the cocktail half-life in the mid-20s. Once you get these antibodies and this is being studied, but we think it’s true, once you get these antibodies, for three months you have a high enough level that we do not think you can be infected or re-infected.

The idea here is a person gets infected, they get their monoclonal antibodies, they actually are immunized for three months. Then at the end of the three months, as I like to point out, there will be less COVID circulating, there will be shorter lines. The reason I say waiting is, you might as well wait, you’re already immune, you’ve already been immunized passively, wait those 90 days. Let those antibodies get out of your system, and then go ahead and get your vaccine.

VR: All right, one more because this one is more of a comment. Hugh writes, “Thank you for your comments about penalizing versus helping vaccine administrators. I cringed when I heard Governor Cuomo threaten providers who vaccinated out of order with $1 million fines and loss of license. Granted he was worried about the wealthy and influential jumping the line, the unfairness, and the terrible public perception of that, but such a massive threat also operates in terrorem. It shifts the risk of even inadvertent error to the providers. What documentation of eligibility must be presented to protect the provider from this dreadful liability?

If I vaccinate someone who is not yet eligible, is it a status crime regardless of what the patient said or my intent? Where I in New York I might let thawed vaccine go to waste rather than risk this wrath. In D.C., a grocery store pharmacy had ready vaccine after all the healthcare workers present had been vaccinated. At the end of the day, rather than let it go, they announced overhead that anyone wanting a vaccination should report to the pharmacy. We need strong leadership to get through this. We also need thoughtful and foresightful leaders. Thank you for your updates.” Hugh is both an MD and a lawyer.

DG: I appreciate this, Hugh. We have made it so hard and so difficult, and all these trust issues that the majority of vaccine produced in our country is sitting in freezers. It’s not in people’s arms. This carceral approach just doesn’t make sense. Yes, the abuse has happened anyway, and I don’t think anyone will get fined. I think we’ve spent so much time and so much effort focused on equity, and who should be in the front of the line that the line’s not even moving. There’s no point, as I like to say, being tenth in line in a line that is not moving. I’d rather be a hundredth in line on a line that is moving really quickly.

Yes, we really have to ask, “How can we help make this work?” We really need to get those lines moving and instead of addressing issues with threats, let’s address these issues with offers of help. How do we make it work?

VR: It’s crazy that not every dose is not in an arm.

DG: It is amazing.

VR: All right, that is COVID-19 clinical update number 45 with Dr. Daniel Griffin. Thank you, Daniel.

DG: Thank you, Vincent, and everyone, be safe.