TWiV 859 COVID-19 Clinical Update #99

This Week in Virology

Host: Vincent Racaniello

Guest: Daniel Griffin

Aired 29 January 2022

pdf of this transcript available (link)

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

From MicrobeTV, this is TWiV, This Week in Virology, Episode 859, recorded on January 26, 2022. I’m Vincent Racaniello and you’re listening to the podcast all about viruses. Joining me today from Ghana, Daniel Griffin.

Daniel Griffin: Hello, everyone?

VR: How long did it take you to get there?

DG: It’s about 10-and-a-half hours once the plane actually took off, but it took a while before the plane took off. Then when you land, I have to say this is pretty neat. I’m going to talk more about it next time on my 100th clinical update. You get to the airport, you’ve paid ahead of time. Apparently, they say you’re paying for a PCR, but it’s an antigen test, and there are all these little booths. You get put into each little booth, sit down, you get your antigen test, and they use your passport as the identifier.

Then you wait, and you check on your phone. Your results are ready. You go up, fingers crossed. Only if you’re negative do they let you in the country.

VR: I guess you are negative.

DG: Yes. I understand that if you are positive, it’s not that they don’t let you in, they lock you away in some COVID isolation place.

VR: Daniel, this is update number 99, and I guess for the next one, you’ll still be in Ghana, right?

DG: I will. What I’m going to try to do, what I’m going to plan to do, I hope to succeed, is talk a bit about what I always finish off with – talking about the global situation. I had the chance already this morning to speak to the Dean of the University of Ghana School of Medicine and get some of her thoughts. I’ll be talking to a lot of people as I travel around, so hopefully, I’ll put all that together. That’ll be our clinical update 100 special, a big focus on the global situation.

VR: Sounds great.

DG: Let’s get going. Vincent, we’ve got a lot to cover today. I will start off with my quotation. I’m going to quote Paul Farmer. If people have not read Mountains Beyond Mountains, I recommend it. Paul Farmer’s a bit of a giant in the global health arena and this quotation, “If access to healthcare is considered a human right, who is considered human enough to have that right?” Now, just starting with our focus where things in the U.S. with this “less virulent,” mild variant that’s circulating, things are not good.

I have to say, as I’m learning, the world watches what happens in the U.S. We hit over 3,000 deaths in the U.S. in a single day last week on Thursday, the 20th of January, that was the day we recorded TWiV. Nationally, we are above the Delta wave in average deaths per day in the U.S. Focusing a little bit more on New York, I just left there a few days ago. Last winter here in New York, the seven-day moving average peaked at 205. We’re already past that and we’re climbing. I will say we are still seeing lower hospitalization and deaths relative to case counts.

I’m going to start with a recent MMWR, Trends in Disease Severity and Health Care Utilization During the Early Omicron Variant Period Compared with Previous SARS-CoV-2 High Transmission Periods — United States, December 2020–January 2022. I would like a better analysis where they really break everyone down, CDC if you’re listening, into those groups we’ve discussed previously. I’ll say, what are those five groups? Unvaccinated and no prior infection, unvaccinated with prior infection, and I want to have with time from that prior infection; three, vaccinated, two-dose, no prior infection; four, vaccinated two doses, and prior infection; five, vaccinated with a third booster dose, no infection; finally, group six, vaccinated with a third booster dose and prior infection.

I found this an interesting article, and they do conclude that this apparent decrease in disease severity is likely related to multiple factors, most notably, increases in vaccination coverage among eligible persons and the use of vaccine boosters among recommended subgroups. You can see that in the data, but I’d like to have it broken down even a little bit more.

Right into children, COVID, and mental health. Children certainly are at risk of COVID. We continue to see children get infected, continue to see children hospitalized with COVID-19. When we recorded last week, they haven’t updated this yet, we recorded a little bit early, we were approaching 800 deaths. One of the things about being the Chief of the ID at ProHEALTH is I’ve gotten a lot of opportunities to talk with our pediatricians, whether urgent care physicians go through cases. I recently had a mom asking about a baby.

This is a five-month-old with COVID. Initially, got sick, but then was getting a little better. Then at about day 10, started to do poorly again. Fever was back, the vomiting was back, the baby was not breastfeeding well. Babies can have that same pattern, that first-week viral phase, and then they move into that second week, that early inflammatory phase. Unfortunately, children can also go on to have Long COVID.

This is actually unfortunately a pattern we see in some children where they’re sick, start to get better, have that second bimodal phase to the illness, and then some of them go on to develop Long COVID. A big topic that always has pulled on me is the neurological aspect of both acute and chronic COVID, and the paper, Prevalence and risk factors of neurologic manifestation and hospitalized children diagnosed with acute SARS-CoV-2 or MIS-C was recently accepted for publication in pediatric neurology.

Now, in this paper, the authors report on a multicenter cross-sectional study of neurological manifestations in children, so under 18 years of age hospitalized with a positive SARS-CoV-2 test or a clinical diagnosis of a SARS-CoV-2-related condition between January 2020 and April 2021. They’re looking here at 1,493 children, 1,278 with acute SARS-CoV-2, 215 with MIS-C. They report that 44% of this cohort had neurological manifestations. What do they mean by this? While headaches and encephalopathy were the most common, going through, some of these children had strokes, they had cardiac arrests, they had seizures, and they had that really horrible dysautonomia that I’ve discussed previously, where children just can’t even sit up straight without vomiting.

We do have vaccines. They are incredibly safe in our children, so this is really something that we really need to do a better job at. Never miss an opportunity to test. We continue to see this pattern that we’ve talked about, where symptoms now often precede that positive test. I have to say, I’m still waiting for a really good study looking at this. I will say in this section here, the whole “flurona” thing actually maybe had a little silver lining.

I’ve seen some articles where many of us are saying, “Please don’t use that terminology,” but people have woken up to the reality that a person can have more than one infection at the same time. There was a perspective piece, Viral Interference Between Respiratory Viruses, published in Emerging Infectious Diseases, and here the authors discuss the different outcomes, including positive, so additive or synergistic, or negative, so antagonistic interactions. A really interesting discussion of different mechanisms for different outcomes.

As clinicians, really the important lesson here is that a positive test, for one thing– let’s say it’s a positive flu test or a positive RSV, or even if it’s a positive COVID test. That does not preclude that there’s a secondary process going on. Painful to remember the early days when I think– I will not editorialize, but there was this paradigm where people were only allowed to test for COVID if the flu was negative, if the RSV was negative. If everything was negative, then you could test for COVID.

We know very well that a lot of those individuals with flu also had COVID, a lot of individuals with COVID also had other things going on. Let’s move on. I’m going to spend a little bit of time here – surprise, surprise – on vaccination. Just a bit this week, building on data that boosters do not just improve vaccine efficacy against infection, but also that a booster improves vaccine efficacy against disease. We’re seeing data here, but when you look at our experience. When you even look at it compiled for the large healthcare systems, the majority of the individuals ending up hospitalized are unvaccinated. There are some people that have only gotten two shots and end up in the hospital. There are very few individuals that have gotten three shots that end up in the hospital.

There was some nice, I’ll say, infographics from the CDC demonstrating the impact. Here, they say in December, compared to fully vaccinated persons in each group that we’re going to go through here, the monthly rate of COVID-19-associated vaccinations were 16 times higher in unvaccinated adults aged 18 years or older, nine times higher in the unvaccinated adolescence, 12 times higher in unvaccinated adults 18 to 49, 17 times higher in unvaccinated adults 50 and up. You can even break that down, 50 to 64, 65 and up, 17 times higher.

Then here’s the comment on vaccine efficacy of boosters. Here, we have in December, compared to fully vaccinated persons with additional or booster dose each age group shown below. I’m going to go through this. The monthly rates of COVID-19-associated hospitalizations were 44 times higher in unvaccinated adults, 49 times higher in unvaccinated adults 65 years and older.

Let’s go on to another MMWR release, Effectiveness of a Third Dose of mRNA Vaccines Against COVID-19–Associated Emergency Department and Urgent Care Encounters and Hospitalizations Among Adults During Periods of Delta and Omicron Variant Predominance — VISION Network, 10 States, August 2021–January 2022. Now I want to break this down to really look at the comparative efficacy after two doses versus after that third dose or booster.

I am looking forward to the John Mascola episode where I know this will get discussed in depth so I’ll even next time tell people to watch that. Let us start with vaccine efficacy against laboratory-confirmed COVID-19-associated emergency department or urgent care encounters. That’s disease severe enough that you’re seeking medical attention. Now, the authors reported that during the time of Delta, the vaccine efficacy against COVID-19-associated ED and UC, so emergency department and urgent care encounters, after two doses of an mRNA vaccine was initially 86% for the first months, and then it dropped to 76% at six months.

With a third dose or booster, this rose to 94. When Omicron became dominant, the vaccine efficacy against ending up going to the ED or urgent care after two doses initially was down at 52%. After six months, this dropped to 38%. With a third dose, this rose to 82%. Showing that Omicron versus Delta with or without that third dose, what about vaccine efficacy against hospitalizations? In many ways, we’ve talked about that as being this severe disease.

Now during the period of the Delta variant, the vaccine efficacy against COVID-19-associated hospitalization was initially 90% for the first six months, dropped a little to 81% once we got out after six months after dose two, then with a boost we get this back up to 94% for some period of time. During Omicron variant predominance, the vaccine efficacy for the first six months was down at 81%. After six months it drops to 57%, but then we boost, back up to 90% after dose three.

Just getting data now, which I find quite compelling, that not only does the boost for some period of time improve the vaccine efficacy against infection, we may actually, well, I think this data supports, we are getting improved vaccine efficacy against severe disease. Now SARS.

VR: Daniel.

DG: Yes. Go for it, Vincent.

VR: Two things first. John Mascola said that one of the problems with this hospitalization is that about half of the people who are supposedly hospitalized for COVID actually are hospitalized for something else. They get a COVID positive test, but then they’re there for some other reason and he’s not clear that that gets pulled out of this data, so this data may not be so dependable. Second, wait a minute. Now people are saying Omicron is milder, so how can vaccine efficacy against severe disease be going down? I don’t get that.

DG: Interesting, right?

VR: Well, I think the key is it’s not really milder in people.

DG: Yes, it is really tough. People have to stop saying this about, “Oh, it’s milder.” When the rubber meets the road, we’re sitting here in the U.S. with over 3,000 deaths a day. We’re seeing the average over 2,000, we’re seeing the average number of people dying per day in the U.S. right now with Omicron higher than it ever was with Delta. Yes. I have lot of trouble buying this. People are ending up with COVID pneumonia, they’re ending up in the ICU. They’re dying. The word mild, some statistician might in the future at some point tell us that in certain context, it’s milder, but what we’re really seeing is, I think, vaccine efficacy.

I think John makes some good points. A lot of times, people end up in the hospital, they’re put in that room, they have a COVID diagnosis, they’re not even on oxygen. I’m not sure that in the early days we would’ve admitted these people or even kept them in the hospital as long as we do. I think that that’s a good point John makes. Another nice paper, SARS-CoV-2 vaccination induces immunological T cell memory able to cross-recognize variants from Alpha to Omicron. This was accepted for publication in Cell.

This is really a beautiful paper and worth taking the time to go through and look at the paper, look at the figures. I love getting to see the actual flow of cytometry plots with the different T cell subsets being gated on for activation markers. They actually have a very nice graphical abstract that really hits the high points of the paper. It really goes through, and I think you could pretty much look at the start with the graphical abstract, see that they’re looking at a number of different SARS-CoV-2 variants.

They’re looking at the impacts of vaccination over time. They’re looking at B cells, but they’re also looking at T cells and we do see some preservation of the receptor-binding domain B cell reactivity at six months post-vaccination. We see average being about 71%, with Omicron dropping to about 42%. If you look at the T cell data, the T cell data’s really impressive. There’s really good T cell reactivity at six months post-vaccination, average of about 90%.

Even with Omicron for CD4, it goes to 84%, the CD 8, average 87%, going to 85%, not really much of a difference there. Really, I have to say, encouraging when it comes to looking at the durability of the T cell responses. Vincent, I think recently you tried to with one of your guests say that, is it true that T cells will save us all? I know there’s a pushback.

VR: Well, it’s funny because I think this is one of Alessandro Sette’s papers, right?

DG: Yes, yes. This is out of Scripps. Yes. Alessandro and Shane, and the whole gang.

VR: She certainly talked about this, but for some reason– so I said, “T cells are going to save us,” and he said, “Well, it’s a little more nuanced than that.” I think I got it from him originally, Dan.

DG: Well, like a true immunologist. It’s very complicated, Vincent.

VR: Well, yes. That’s what they all like to say, “It’s very complicated.” Well, really let me know.

DG: There’s a lot of stuff going on. You would never understand.

VR: I understand that there is more to immunology than antibodies and T cells, right?

DG: There is. The nice thing I have to say, we started off and no one cared about anything about their antibodies, “I want to know about my antibodies. I won’t hear about anything else,” and now at least people, I think, are starting to be interested in T cells, and then hopefully this will evolve. We’ll start talking about dendritic cells and B1 cells and natural killer cells and all the rest.

VR: When do you think we’ll talk about Fc receptors?

DG: Oh, non-neutralizing, Fc mediated?

VR: Yes.

DG: That really complicated, Vincent.

VR: Okay. All right.

DG: All right. Well, what I will say is a news brief, Pfizer and partner BioNTech have begun testing an Omicron variant-specific vaccine. They’re doing this in three groups, folks who are completely unvaccinated, so there’s still people out there who are completely unvaccinated, but willing to enroll in a trial of a vaccine. That’s cool. Vaccinated with two shots, and then they’re going to get this, or they’ve already been boosted. They’ve already got that third shot, and they’re going to get this as their fourth shot. That’ll be interesting. We don’t know. Is this going to be better, do we need this, where does this fit in? This will be interesting data that I’ll be curious to see.

VR: Daniel, if in two months we have another variant, what are we going to do?

DG: That’s always the problem, right, with science? You don’t have the answer until you’re a dollar late, or a daylight dollar short. I think that’s the issue. Do we keep chasing variants? Are we quick enough to chase the variants? This is something I think that a lot of us would have been interested in knowing before Omicron became 99% of the sequences.

VR: Seems to me we just vaccinate everyone, and we don’t have this problem, right?

DG: That’s the biggest point. I think if you asked from a– I always say, the most selfish thing we could have done in the developed, wealthier nations was vaccinating the world, because what do you want? Do you want four shots or do you want no new variants? The way to stop the variants is to help the world all get vaccinated.

Passive vaccination, we are starting to use EVUSHELD. This is the AstraZeneca product, long-acting six months where a person who is not able to make those antibodies themselves can be given them passively.

We don’t have enough, there’s only 300,000 doses or so for the whole country, much less the world. Here’s what we have, a lot going on, the period of detectable viral replication, the viral symptom phase. This is the time for monitoring, I’ve said for monoclonals, but those are in short supply. We’ll get to antivirals, enrollment in clinical trials, not the time for steroids or doxycycline, or azithromycin or zinc or aspirin or other unproven or potentially harmful potions. This was an interesting update.

The FDA revised the authorizations for two of the monoclonal antibody treatments, the bamlanivimab, etesevimab, that’s the Eli Lilly cocktail. The casarivimab, imdevimab, that’s the Regeneron, the REGEN-COV cocktail, to limit their use to only when the patient is likely to have been infected with or exposed to a variant that is susceptible to these treatments. That seems obvious to me, right? Let’s not use these if we don’t think they’re going to work.

They then go on to clearly state, and it actually took this, “Data show these treatments are highly unlikely to be active against the Omicron variant which is circulating at a very high frequency throughout the United States. These treatments are not authorized for use in any U.S. states, territories, and jurisdictions at this time.” I mean, it’s painful that the FDA had to state the obvious and say, “Let’s stop using something that is not effective.” 99% is Omicron, 99%, these are ineffective.

We do have some effective therapies and they are recommended in order of efficacy. Number one, PAXLOVID. Number two, sotrovimab, that’s our monoclonal that still works. Remdesivir, but remember, we’re going to go a little more into this, that is the three-day outpatient IV. And, molnupiravir. Now, previously, as we talked about with remdesivir, there was this odd situation where the FDA– actually, the NIH was recommending the off-label use of remdesivir.

Well, now we have an update from the FDA. In a press release from the FDA, we heard that the FDA has expanded the approved indication for VEKLURY, that’s remdesivir to include its use in patients who are not hospitalized, have mild to moderate COVID-19, are at high risk for progression to severe COVID-19, including hospitalization and death. This is also the other change, the EUA has been updated to authorize the drug for treatment of pediatric patients weighing down to 3.5 kilograms. Before, we had this 40 kilogram cut up.

Now you can go down to 3.5 kilograms, you go down to pediatric patients less than 12 years of age. Remember, this is the new indication. This is that 200 milligrams on the first day and that 100 milligrams on day two and 100 milligrams on day three. This is, in the 80s, almost a 90% reduction in the progression that ended up in hospital.

I always feel like I have to throw a reminder here. If people are being treated with those Medrol dose packs of steroids and antibiotics during that first week, this is specifically discouraged. This is not helpful. There’s data showing this is harmful. If a provider is still excited about ivermectin, fluvoxamine, metformin, or some other therapeutic, enroll these folks in a clinical trial.

Let’s move on to the early inflammatory phase. Remember, this is the time we start thinking about immune modulation, when people often end up in the hospital. As we’re seeing now there’s an overlap here with remdesivir, but most of us are not using remdesivir if it’s been more than 10 days since symptom onset.

Really, the whole concept, which I’m glad that people are focused on treating the viral phase with antivirals, and then thinking about immune modulation when we go into that early inflammatory phase. An update on anti-coagulation at time of discharge from hospital. The individuals made it through that hospitalization, it’s time to go home or we can give them a whole bunch of blood thinners, anticoagulants. Well, we have a new update from the American Society of Hematology.

The American Society of Hematology guideline panel suggests that outpatient anticoagulant thromboprophylaxis not be used for patients with COVID-19 who are being discharged from the hospital and do not have suspected or confirmed venous thromboembolism, VTE, or another indication for anticoagulation, conditional recommendation based on very low certainty in the evidence about effects. Then this is qualified. I’m on this panel. I’m the kind of guy who likes to qualify things.

The panel acknowledged that post-discharge thromboprophylaxis may be reasonable for patients judged to be at high risk of thrombosis and low risk of bleeding. They have a really nice infographic but it’s really straightforward. Don’t discharge them on anticoagulants unless they are at high risk unless there’s a specific indication. Unfortunately, I’d say some of the healthcare systems, this is the guideline. Everyone’s being sent down on $600 worth of anticoagulation, which is not recommended currently.

No one is safe until everyone is safe. As some of our listeners might know, I mentioned this early on. I’m currently in Ghana, in West Africa. Next week will be our 100th clinical update. Anticipate that being a special global-focused episode. I did want to actually talk about the WHOs executive board is meeting in Geneva this week, to set the agenda for the World Health Assembly in May. During the address to this group by the WHO Director, General Tedros Adhanom Ghebreyesus, basically saying, “It’s dangerous to assume that Omicron will be the last barrier or that the world has reached the end game of the pandemic.”

He warned that conditions are ripe for more COVID variants. I think we’ve talked repeatedly, the way to combat this is more vaccine equity. I’m going to finish on that note, but remind everyone this is going to be our last episode in January. During the last few days of this month, donations to PWB will be increased and given to support MicrobeTV. Thank you so much. Everybody’s been great. I think we’re going to be able to be much more supportive than we initially had hoped but you can also go right to MicrobeTV, which is now a 501(C)(3), or go to parasiteswithoutborders.com, click on that donate button, and help us continue to do all this great work. Thank you.

VR: We also have an internship available and if you’re interested, you could check out the description at parasiteswithoutborders.com. If you want to send in an application, daniel@microbe.tv.

Time for some questions for Daniel. You can send yours to daniel@microbe.tv. We have one from Kip and Laura who are two PharmD’s in San Francisco. They have a real Lulu of a case and wish to know if you’ve heard of this possible adverse reaction. “57-year-old endodontist, June 2020, uncomplicated COVID, three doses of Pfizer, six and a half days after dose three started acting whacked out in his office, thought he was having a stroke, severe auditory and visual hallucinations, rushed to the ED, systolic blood pressure over 200, CT negative, MRI noncontributory, further workup inflammation of the lining of the brain. Terrible hallucinations continued two days after admission received, first IV steroids within hours symptoms resolved 95%. One more dose IV steroid discharged within a week.

I see there are scattered case reports of acute encephalopathy following mRNA vaccine. It appears this adverse reaction is rare. I’m interested to hear what you have heard. We don’t want to add more fears to an already vaccine-hesitant culture, but if this problem is happening, clinicians should be made aware so that prompt therapy can be initiated. Pleased to let know how valuable you and the TWiV team are to so many.”

DG: As you mentioned, there are a few rare case reports. Actually, as I was listening to this I was thinking, “you’re going to try steroids, et cetera.” That, in these rare scenarios, has been how it’s been approached. The thought, and it’s hard to confirm this at this point, is maybe this is some off-target antibody response. I think that this may be one of those rare– but again we’re talking about one-in-a-million type incidents. The big challenge now is going to be, what do you do going forward?

If this is an off-target antibody response to seeing spike, what if this person goes ahead and actually gets infected with SARS-CoV-2, develops acute COVID? Would that trigger this?

What are going to be the challenges going forward with vaccination, is this an individual that might be a candidate for something like EVUSHELD Certainly individuals like this, you want to get involved, you want to talk to an allergy immunologist, you want to talk to infectious disease specialists that have seen cases like this to help you move forward.

VR: Beth, who is fully vaccinated and boosted writes, “Our question has to do with corticosteroids such as inhaled asthma medicines, beclomethasone, propionateand also nasal allergy sprays like fluticasone. If a patient takes these drugs regularly, should they stop taking them if they get COVID? I believe you have said steroids are contraindicated during the first week of an infection. I also seem to recall there were early ports reports in 2020 that drugs like fluticasone may prevent serious disease. Can you clarify?”

DG: This is a great question for updating our perspectives. Early on, we really didn’t know– the early reports out of China I think really scared us, “don’t use steroids.” There actually are some ongoing studies now using inhaled corticosteroids. Is there some potential benefit in the localized area? Early on, we were telling people not even to use those nasal steroids because we were concerned.

At this point we’ve come to where we– if someone has allergies, if someone wants to use those nasal steroids, this is something we’re comfortable recommending they continue, they don’t have to stop. It’s the oral, it’s the parenteral, it’s the higher dose steroids that we worry about, and the inhaled steroids, like the fluticasone you talk about. There’s a budesonide inhaled steroid trial ongoing, actually several ongoing. If that’s what it takes to keep a person out of the hospital, to keep their asthma under control, it’s reasonable to continue.

We’re a lot more comfortable with these therapies than we were early on as we’ve learned more.

VR: Adeva writes, “I work in an outpatient COVID clinic. One of the issues that remains unclear is care for patients that are newly infected and require oxygen but not hospitalization. I understand that they do not qualify for monoclonal antibodies, I know typically steroids are not recommended if patients are not on oxygen, but there’s data to prescribe steroids inpatient if an oxygen, but questionable outpatient. Will you please go through the data and recommendations, specifically the timing? Is it best to wait 10 days in order to not potentially prolong shedding? I also suspect that many of these patients should probably be hospitalized, but haven’t been due to lack of local resources.”

DG: This is great. This is a little more challenging with the change in kinetics that we’ve seen with Omicron. Initially, what we saw was, seven days would go by, and then I guess your seniors, people at the most comorbidities, you’d start seeing them at about day eight start to become hypoxic, the oxygen would drop. Some of our younger individuals with less comorbidities, they wouldn’t start to have their oxygen levels drop until about day 13, so the end.

Unfortunately, now we’re seeing this situation with Omicron where it’s day six and the person is already with an oxygen saturation below 94, maybe it’s 91, maybe it’s 90. This is tough because now we’re looking at data from the other variants, we’re looking at a real separation, the viral kinetics. I’m going to say mRNA copy numbers are on their way down we’re thinking the viral replication is shutting down. Now you’re starting to get this early inflammatory phase almost two separate.

Reasonable to start those steroids as we got into that second week. It is a little bit trickier now because we have data showing that if you start those steroids too soon, people do really poorly. It was a six-fold increase in progression, so we do want to hold off. I personally would hold off until about day seven, that would be the earliest I would think about starting those steroids. It’s a little tricky.

The WHO has I think really weighed in on the most important but least reliable bit of data is history. So someone says, “Oh, I’ve only been sick for three days.” They’re already hypoxic, probably getting to about day seven by then. We certainly have individuals where they’re out of the hospital, it’s about day seven, they’re started on steroids, we’re starting them on the home oxygen therapy, and then trying to keep those folks out of hospital.

VR: Our last email is from Mario who is a family medicine doc in Los Angeles and says your videos are informative for his practice. “I have a 15-year-old daughter, vaccinated, not boosted, contracted mild COVID on December, recovered now. Are there any data that we can look at to say a booster is not advantageous for a previously vaccinated teen with two COMIRNATY doses after recently getting COVID? Presumably, she has protective antibodies against Omicron and probably developing cell-mediated immunity, so she wouldn’t need the extra antibody boost that the vaccine would give to her. Or, would she benefit from the extra antibodies and the cell-mediated immunity from the vaccine?”

DG: This is a great question and we don’t completely know. We don’t have the data as granular as I would like but here’s my thought on this. When someone ends up getting infected with SARS-CoV-2, so they get a case of COVID-19, we don’t really know the dose relative to what their immune system is seeing. I think this would be if your child had two doses and then they went and they saw the doctor, the doctor’s like, “I gave them a little bit of vaccine.” You’re like, “You should give them the full dose.”

“I don’t know maybe, I gave them a little. I’m not really sure. I didn’t look. I just drew, I was looking the other direction.” You don’t know if they’ve gotten that third dose. In our recommendations, we don’t necessarily count that infection in our recommendations about vaccines or about boosting. The other part of the question, which is I think the important question is, how old is your child? How important is a booster in an individual in a younger age group? At this point, as you’re well aware, it’s boosters for all. I think the younger an individual the less benefit we get from continued boosting

VR: That’s COVID-19 clinical update number 99 with Dr. Daniel Griffin. Thank you, Daniel.

DG: Oh, thank you and everyone, be safe.

[00:38:43] [END OF AUDIO]