TWiV 862 COVID-19 Clinical Update #100

This Week in Virology

Host: Vincent Racaniello

Guest: Daniel Griffin

Aired 05 February 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 862, recorded on February 4, 2022. I’m Vincent Racaniello and you’re listening to the podcast all about viruses. Joining me today from Accra, Dr. Daniel Griffin.

Daniel Griffin: All right.

VR: Did I say that right?

DG: Accra, yes.

VR: Accra.

DG: Hello, everyone, including you, Vincent. This is Clinical Update 100. It’s amazing. We’ve been doing this for well, that long.

VR: Two years, Daniel. We do one a week, right? It’s two years.

DG: Yes, we haven’t missed any. We’ve got to go on vacation, Vincent.

VR: Oh, if you want we can skip, sure.

DG: No.

VR: If you want to change to every other week we can do that, too.

DG: All right. We’ll have to– Maybe our listeners can weigh in because this is Clinical Update 100. Welcome to February. I don’t know if people are big groundhog fans, but here in America, for our international audience, we’re not sure about global warming, but we trust a rodent to tell us what’s going to happen in the coming months.

VR: Lovely.

DG: All right. Well, let me start with my quotation. “The surest way to corrupt a youth is to instruct him to hold in higher esteem those who think alike than those who think differently.” This is Friedrich Nietzche. Actually, I’ve been hanging out the last couple of weeks with mostly Germans, interesting enough. German physicians. I’ve been traveling around here in Ghana and I see this as such a pressing issue. Now, we’ve got to somehow do something about this growing divide. We’ve all got to start to have some sort of a dialogue if we’re going to come out the other side of what we’re currently going through.

Let me start off with an update. I like to give our U.S. COVID status update first. It’s mixed back here. Case numbers are dropping across most regions of the U.S. Also, in many regions, the number of new hospitalizations are dropping as well. I have to say, it’s nice keeping an eye on the census that my partners are managing back in the hospitals in New York. We’re seeing a lot less of our consults for COVID. We’re starting to see some other things. I am hoping that the number of deaths per day is peaking. I’m very hopeful that next week on record, I will be able to say that we’re coming down off this peak.

This is not a great peak. The number of daily deaths is already above every wave except that of January 2021, back when we were just starting to get access to vaccines. I think that this is a point when I want to jump in right here in the update and talk about a perspective piece that was published in the New England Journal of Medicine, Challenges in Inferring Intrinsic Severity of the SARS-CoV-2 Omicron Variant.

Now, I still feel like it’s too early to actually know with great certainty about the intrinsic severity of the Omicron variant, but I will say this was actually a nice perspective piece. I do encourage people to go and take a look at this. They were looking through a number of publications and the analysis estimated that Omicron was about 70 to 75% as likely as Delta to cause hospitalizations in an unvaccinated person with no history of SARS-CoV-2 infection. That’s what I’ve been asking for data for a while.

I do think – and a lot of us say – that prior infection vaccinations, these are really what are saving us from being more overwhelmed than we are. The author suggested that this fairly small difference implied that Omicron Alpha wild-type SARS-CoV-2 really have similar intrinsic severity. I think that we just keep building this story. The virus is under no selective pressure to become less virulent. If anything, the way we turn this into a common coronavirus is through vaccinations.

I still think we need to wait a bit to see the hard numbers on deaths. Vincent brought up last time that hospitalizations are tough because there’s a lot that goes into hospitalization decisions. There’s also a lot of testing where a person is hospitalized with COVID, not because of COVID. I think it’s important to repeat that we are seeing many more deaths per day in the U.S. than we ever saw with Delta. The day we recorded TWiV last week, there were, according to Worldometer, 3,444 deaths from COVID that day. Almost all those were among the unvaccinated.

We’ve already reached a peak that’s about 20% higher than we had reached during the Delta wave. My hope is we’re coming off that. This doesn’t continue to climb.

I will say at this point, and a lot of our listeners may know, these last two weeks I’ve been in Ghana, a country in West Africa. As we go through the different sections, I’ll be talking a bit about what I’ve heard on the ground talking to the dean of the medical school, a lot of clinicians.

I do want to point out, this is just a small glimpse into the global situation. What I’m hearing about in India, on the ground in Bangladesh, other countries, is actually quite different. Even here in Sub-Saharan Africa, there are 50 countries. The comments I make give a little bit of a peek into the worldwide situation. By no way is Ghana reflective of every country outside of the U.S., any country in Sub-Saharan because there’s just a lot of difference.

All right, let’s get right into children. I think this is really important. Children are at risk of COVID. Just to give some numbers here, we’re always about a week behind. Good numbers have to be pulled together. As of January 27, if you look at the CDC and the American Academy of Pediatrics, you can get some numbers here. We’re up to about 36,000 pediatric hospitalizations due to COVID. Over 800 children have died in the U.S. I want to make a point here, most of those children have died since August.

This is an average of about two children dying every day here in the U.S., or here in the U.S. over the last several months. Just to put Omicron in perspective with regards to children, in January alone in the U.S., just in one month, we saw over 7,000, about 7,000 children hospitalized with COVID and 70 children died from COVID. This is all Omicron. Just when you use the word mild, I want people to think about that, particularly when they start talking about decisions regarding vaccination.

We did hear, and it’s exciting, that Pfizer applied to the FDA for a two-dose vaccination series for children under five while they’re continuing to study the third dose series. If our listeners remember, we discussed a little bit, we do not have a lot of great information on this, but children six months to two years did reach this goal antibody level that they were looking at. Children two to four had lower-than-hoped-for levels. Now, the FDA encouraged the submission of this application.

In the next 10 days or so we should probably get information, the document that’s going to be submitted to the FDA for a review. As we have more information, as we have more science, people are writing articles now. What has changed? Well, we don’t know yet. When we know what has changed, when we know what drove this application, I’m certainly ready to share that with our listeners.

A couple of things I wanted to talk about here. I’m going to be attending a meeting for our ProHEALTH pediatric group. A lot of questions are coming up. I just want to give our listeners just a really brief preview here. Just going to go through some of the top questions that I got over the last two weeks here from our pediatric colleagues. One is the question, “A number of parents are balking at the idea of a booster in teenage boys. In particular, what is the risk versus benefit? Should we be encouraging that? What’s going on?”

I just want to point out the biggest issue here is we are not seeing safety issues with the third doses, the myocarditis. The other concerns that were raised really filtered out. The third doses are being incredibly well tolerated. I’m going to actually use the cross-pollination, I’m going to encourage everyone to listen to “IMMUNE 52: B cell Boot Camp with Gabriel Victora.” I actually listened to that as I was navigating some traffic getting into Accra earlier today.

I think in many ways– and everyone, listen to that, I think we may be coming down to this really being a three-dose vaccine series. It’s really interesting to hear the conversation about this idea of a prime rather than the supercharging of that initial germinal center and then this boost at about six months. Could we have just done the shot initially and another shot at six months? Perhaps, but we may be really ending up with just three-shot series across the board.

The other question we are seeing, “All the rules breaking down around, do you see Omicron as a final step in normalcy?” This is I think an important question to answer with the science. Much of what we’re hearing here is this concept that, “Oh, Omicron is now mild, COVID has turned into a common coronavirus.” I just want to remind people of what we already mentioned. We are still seeing over 2,000 people dying every day here in the U.S. We’re seeing over 10,000 people dying around the world every day. this is currently more people than we saw with any other wave except for that January 2021 wave. We really are not in a good situation. The way we get back to normal is with more vaccinations or back to whatever the new normal will be.

Question number three is the last question, “Parents are telling us it’s not worth vaccinating their children because they’re such low risk, especially with Omicron.” This is very concerning and I think I want to ask people to think about their words. Words matter and I think it’s very concerning because we keep hearing this concept that the virus has become less virulent. It’s now milder. Remember the numbers we’ve already talked about. Most of what we are seeing in terms of hospitalization and deaths, if not all, can be attributed to vaccinations and recent prior infection.

Unfortunately, we have so few kids getting vaccinated that if we don’t do something different, we’re going to continue to see children hospitalized. We’re going to continue to see children dying every day. Don’t forget Long COVID. Just to remember those numbers, over 800 children have died from COVID. Most of those children have died since August. Vaccines are becoming available. Just to hit that there and don’t worry, I’m going to actually talk a little bit about, well, as we already mentioned, we may be getting vaccines for those under the age of five.

Testing. Never miss an opportunity to test. Just a reminder that tests are validated only for specific procurement sites. We still have people sticking nasal swabs in their throats after repeated negative nasal collections. I recently had this story that was shared with me, which I think is helpful and illustrative. An individual had a negative nasal antigen test, but decided to be extra safe and did one of those throat swabs and then ran it on a test that was validated for the nares. This was then positive. A PCR test was done. This was then negative. I want to point out many sodas, many juices can give you false positives.

Apparently, this is a way that some students have discovered how a get out of class. There’s actually a pre-print, Soft drinks can be misused to give “false positive” SARS-CoV-2 lateral flow device results. You hear these stories, “Oh, the person tried, they did this, they did that. Finally, they got that important positive test.” The tests are not designed to be stuck in all these places. Anyway, okay. Stick those swabs where they’re supposed to be stuck.

Pre-exposure period. Non-pharmaceutical interventions. This I’m going to talk a little bit about the experience here in Ghana. I’ve had a chance to have a lot of great conversations with different local Ghanaian physicians asking them about perceptions of things. Now, one of the very interesting conversations that has come up repeatedly is around the fact that many people here in Ghana live much of their life outdoors. There’s actually a different perception here in Ghana than I was used to in the U.S. I learned quite a bit.

In the U.S., people who are economically advantaged have been able to protect themselves. A lot of, I’ll say those who are more challenged, working in supermarkets, maybe landscapers who pack a number of people in a truck together, crowded indoor homes where you might have multi-generational families or even multiple families living together. But in Ghana, there’s a reverse economic. It’s actually a bit of a privilege to be able to work in an office. Many Ghanaians live almost their entire life outdoors. They sleep outdoors. There’s been an interesting perception and a different distribution of individuals that are getting infected. Really getting a lot of– outdoors is safer than indoors, working towards folks here in Ghana. Just want to mention that. Just remember, outdoors is safer than indoors.

Vaccinations. We need to stop scaring the wrong people. Never miss an opportunity to vaccinate. I feel like maybe people are going a little overboard on “never miss an opportunity to vaccinate,” but we’re going to get to fourth doses in a minute. A couple of highlights, and these are exciting. On January 31, the U.S. FDA approved the Moderna COVID-19 vaccine. It’ll now go by the name Spikevax. This is now a fully approved licensed vaccine for the prevention of COVID-19 in individuals 18 years of age and older. It is not experimental. It is fully approved, licensed.

Now, Novavax. I still remember when Vincent asked me, “When is Novavax going to be approved?” I was like, “Maybe by the end of the year.” Well, Novavax recently submitted a request to the U.S. FDA for EUA – emergency use authorization – of their COVID-19 vaccine. This was on January 31, so sometime in February we’ll hear the response to that. As people remember, the data on efficacy was really excellent. It’s now going to be a question of manufacturing and getting through the FDA and that really careful due diligence that we trust the FDA to do for us.

An article, Associations between adverse childhood experiences, attitudes towards COVID-19 restrictions, and vaccine hesitancy, a cross-sectional study was published in The BMJ Open. I think this is an important paper because I think it can help inform us as clinicians. I think it can help inform us really just as human beings have conversations around vaccines. We may have a lot of prejudice, a lot of preconceived ideas about why people are concerned, why people have vaccine hesitancy, and what the authors looked at here was the impact of adverse childhood experiences on vaccine hesitancy.

They found that increasing adverse childhood experience was independently related to low trust in COVID-19 information. They reported that they found vaccine hesitancy was three folds higher in individuals that had four-plus adverse childhood experiences compared to those who did not. I think this is important to realize a little bit of sensitivity here. There may be a reason why that person doesn’t trust authority figures. There may be a reason why that person is not excited to go to one of these big mass vaccination sites with military presence. Just maybe a little bit of compassion here. I think that that was what I took away from this, is that these are not bad people. A lot of these people have had difficult experiences, they have trust issues, so you’re not going to help them by shaming and berating them.

Now I want to say here, while we’re talking about vaccines. A big issue that I have heard repeatedly in Ghana is that the amount of mainstream media and social media coverage of the anti-vaxxers is actually having an impact, a new experience here in an area of the world where people were usually very positive and accepting regarding vaccines. I think it’s important that we note, not only mainstream media, but social media is really giving a lot of air to these individuals. Giving them a lot of, shall we call it, earned media coverage.

For the first time, at least according to a lot of these clinicians, they’re starting to have conversations, starting to hear, “Oh, but this German physician, if they’re concerned about it, well, then why should we be doing it?” Just think about that when you’re having these discussions. I also want to briefly mention the preprint. I’m going to make sure I pull Vincent in on this. Protection by 4th dose of BNT162b2 against Omicron in Israel. I do feel like this is very early data. Many people have already commented on how difficult and probably not a sustainable public health approach to be vaccinating people every four months.

In this study, they looked at individuals getting a fourth dose four months or more after that third dose. They reported that the rate of confirmed infection was lower in people 12 or more days after their fourth dose than among those who received only three doses by approximately a factor of two, the rate of severe illness was lower by a factor of four.

Actually, go ahead, listen to that IMMUNE episode that I’ve referenced before because it’s a little bit of a discussion. What is actually happening when you’re looking at people so shortly after a fourth dose? Are you just getting some sort of a boosting? You’re not really having enough time for much of a terminal center maturation.

Now I have to say, I’m going to pull Vincent here in a second, if my fourth dose perhaps is in fall of 2022 and my fifth dose is perhaps in fall of 2023, maybe that’s reasonable. Maybe if my fourth, fifth, et cetera, doses are once yearly shots, but I’m not really sure how tenable this strategy is of giving people fourth doses when so many people in the world have not even had a first dose. I think we’re getting to a point of diminishing returns. Vincent, do you have a comment on this fourth dose?

VR: I do not understand what Israel is doing here. As Paul Offit would say, there’s no evidence that protection against severe disease is diminishing. Why a fourth dose is needed is unclear to me. Now, you check the response so close after the fourth dose, as you say, it’s almost irrelevant. That’s not when you want to see it. You want to see it six to eight months after. Did it really make an impact on severe disease? I would suspect not. I agree with you. It is not a sound public health strategy to do repeated dosing, especially when severe disease is not going up. It doesn’t make any sense to me.

DG: Okay. All right. It’s nice that we’re on the same page. Okay.

VR: Daniel, you know that Pfizer and Moderna all have variant-specific boosters in the ready. I suppose it’s good to be ready, but if severe disease doesn’t go up, I don’t see the need for it, but then again, Daniel, I don’t participate in any committees that make the decision. It doesn’t matter but I must point out, Daniel, that over the years, we have been right on many things, starting from, you can’t figure out disease severity so quickly, which you just confirmed by this New England Journal article that vaccination impacts– shedding that PCR and infectious virus is not the same. Basic virology comes to the rescue. That’s the way I look at it.

DG: Yes. No, well, I think there’ll continue to be a place where IMMUNE and TWiV and giving people the science instead of just the sound bits.

All right, let’s continue here. Let’s go to passive vaccination. We still have EVUSHELD. Limited Quantities. We’ll see. Going forward. It’s tough when I hear some of the studies about the other monoclonal antibody trials now are in the time of Omicron. Are those even relevant?

But let’s jump into the period of detectable viral replication, the viral symptom phase. The time for monitoring monoclonals, antivirals, enrollment in clinical trials. Not the time for steroids, doxycycline, azithromycin, zinc, aspirin, or any other unproven, potentially harmful potion. I’m going to start with the correspondence, Efficacy of antibodies and antiviral drugs against COVID-19 Omicron variant, published in the New England Journal of Medicine. This was from a number of authors. I’ll say the reassuring aspect of this publication was regarding the small molecule antiviral agents. I’m going to focus on that.

Now, one of the things that many of our listeners may not realize is that in addition to changes in the amino acid sequence of the spike protein, we always talk about spike. The Omicron variant also has changes in both the RNA-dependent, RNA polymerase, and the main protease of SARS-CoV-2. Now, these are targets for some of the antiviral drugs, such as remdesivir, molnupiravir, and the protease inhibitor.

Here they’re looking at PF-07304814, 5. Now I would’ve preferred if they tested PAXLOVID, the oral antiviral, but very similar here, and we already have reassuring data on that from Pfizer. But just in brief looking at this, the results suggested that all three of these compounds continued to show efficacy for treating patients infected with Omicron variant. Just to share, the Pfizer information that was actually shared via a press release on January 18, also where they reference a number of preprints. I’ll mention it as well.

Nirmatrelvir, an orally active Mpro inhibitor, is a potent inhibitor of SARS-CoV-2 variants of concern. Basically here, they comment, sequence analysis of Mpro and coded by the variant showed about 100% identity of active site amino acid sequences reflecting the essential role of Mpro during viral replication, leading to ability of nirmatrelvir to exhibit potent activity across all the variants. I have to say that speaking to many physicians all across Ghana, that’s been a wonderful thing about this experience.

Every day, I’ve had a chance to talk to some of the local physicians here, and I’ve really been impressed. One physician put it very nicely. For most people here in Ghana, because we have a relatively young population and a low incidence of comorbidities, patients usually do well. I did hear that sometimes a patient might get antibiotics because they had purulent sputum and a provider was concerned that there might be a bacterial co-infection, but in general, this was an exception.

There seemed to be a widespread belief among the clinicians I talked to that antibacterial agents, antibiotics were not appropriate for a viral infection. There also didn’t appear to be widespread use of, I will say, unproven therapies outside the recommended ones. Now, there isn’t great access to many of the therapies that we have and just to restate the hierarchy back in the states based upon efficacy, PAXLOVID as first-line, sotrovimab as second-line, remdesivir– remember that’s that three-day outpatient approach, 200, then 100, 100– and molnupiravir, if there are no other options available.

All right, I’m going to jump ahead to the tail phase, Long COVID. I think it’s worth mentioning the article, Multiple Early Factors Anticipate Post-Acute COVID-19 Sequelae. This is a very complex paper published in Cell, appropriately complex, as we would expect from a paper published in Cell. I’ve already downloaded this to my computer because I plan on really going through this in detail on my flight back to the states. A fun guy, if you want to sit next to me, you can look over my shoulder. But no, only if you keep your mask on and your distance. They did report finding four PASC anticipating risk factors at the time of initial COVID-19 diagnosis. One, having Type 2 diabetes. Two, it’s a little bit interesting, SARS-CoV-2 RNAemia. Three, EBV virus viremia. And four, specific autoantibodies.

They did mention that in patients with gastrointestinal PASC SARS-CoV-2 specific and CMV specific, CDA positive T cell exhibited unique dynamics, during recovery from COVID-19. They went ahead and did some interesting work on immunological signatures. I’ll take a look a little bit more closely at this, but it’s exciting that maybe we’re starting to get a little bit more information. I’m going to wind up here by spending a little time talking about how no one is safe until everyone is safe.

Now, I spent the last two weeks here in Ghana in West Africa, and I first got to speak to the Dean of the University of the Ghana Medical School, Dr. Margaret Lartey. As I mentioned a little bit early, she shared with me this whole dynamic, really seeing more indoor transmission, significantly less outdoor transmission, and this significant impact on who gets COVID and also actually a perception around this.

This is the disease of the privileged. Maybe this is going to be helpful in certain ways because it does look like vaccines are being used, are being accepted to some degree here in Ghana. Then maybe a correlation between people being at higher risk, potentially getting more access to vaccines but this continues to be a disaster worldwide. We have people here getting fourth doses, as we mentioned, while many of the world has not gotten that first dose, many parts of Sub-Saharan Africa are still vaccine deserts. Unfortunately, with the reach of media and social media, we’re actually starting to hear a lot of vaccine hesitancy that is being derived from this misinformation that is just being echoed around. I want everyone to think about that. The way we end this pandemic is not giving people fourth and fifth doses when someone hasn’t even had a first dose.

Along these same lines, I will say, we just finished our MicrobeTV three-month fundraiser and it went incredibly well. Thank you so much. Now we are switching over to our February, March, and April fundraisers. Donations made to Parasites Without Borders will be matched and doubled by PWB up to potentially $40,000, a minimum donation of $20,000. This is going to be donated to the American Society of Tropical Medicine and Hygiene and included in here will be scholarships for those wanting to travel to the annual meetings. These will be annual meeting travel awards to attend the 2022 meeting in Seattle, Washington. These are going to be prioritized for females from low-income countries who might not otherwise be able to attend.

We still have our internship opportunity. We’ve actually gotten a lot of interest, so we have a lot of applications. We’re already starting to do some interviews. Continue to send those letters to daniel@microbe.tv

VR: It’s time for some questions for Daniel, you can send yours to daniel@microbe.tv. Anthony is a family physician in Rhode Island who has a patient in her forties who suffers from advanced atopic dermatitis. “She contracted COVID in late September. She was unvaccinated, so we arranged Monoclonals. Her illness was mild. Three months later, she got her first Moderna shot. Unfortunately, she experienced a fairly severe flare of eczema shortly afterwards. After two ER visits and one with a colleague of mine, she was seen by a dermatologist who started her on methotrexate, which has helped tremendously.

She is reluctant to receive any more vaccines given her experience, but now she’s immunosuppressed. I would like to arrange a second vaccine, but doing so raises questions. What should I advise her about methotrexate, which has been helpful? Can I be reassured that a single vaccine is enough given her infection? Is the three-month window between infection and vaccine not long enough to generate an adequate long-term immune response? How would you counsel her?”

DG: This is tough, and we do see this. Individuals can often have really strong negative reactions to the vaccines. I should say this is uncommon but as described, we definitely see this, and so in this individual, it’s a complicated discussion. Now, this individual’s autoimmune suppression– so how much benefit are they going to get? There will be some decreased efficacy. This is, I’ll say, certainly one of those times when you want to be thinking about something like EVUSHELD. It may also be a time when you think about something like Pfizer.

It sounds like you probably have a lot of the right people involved in this case, because one of the things you want to look at too is just the mechanism of what triggered this. Is this an individual who maybe is going to tolerate a Pfizer vaccine? Is this an individual, maybe you’ve considered a J&J or, very soon, maybe the Novavax is going to be an option? I don’t think this is one of those where you can just give a broad recommendation across, you really need to focus on this individual and what’s best for them.

VR: Mary writes, “I occasionally use Fluticasone Nasal Spray. Glad to hear in your last update it’s okay that if I get COVID I can use it, but I’m wondering if the spray could in any way interfere with accurate results of an antigen test on the same day that one uses the spray.”

DG: Often we recommend that people blow their nose right before because you don’t really want anything up there interfering with the assay but no, otherwise that’s fine. I just had to have my COVID test before I fly back. Blew my nose, went ahead and got the swab. That’s what I would recommend. Go ahead and blow your nose, and then go ahead and get that test done.

VR: David writes from Florida, he’s had two COVID infections and he’s been triple vaccinated as well as his wife and mother-in-law and they all live together. His concern is their son six years old, just got his second Pfizer dose. “I wear a mask to work and in public, is this overkill? I don’t want to asymptomatically spread it to my son before his full vaccination nor to my unvaccinated workers. Are there data to justify my response or am I going overboard?”

DG: Actually. Perfect timing. Next time I’m going to be talking a little bit more about masks. I just saw another nice publication. You’ve got to look at your risk tolerance here. You’re so close, your son is just starting his vaccine series. There’s still going to be a little bit more time right before that second one really kicks in, then you can start making some decisions. I think a couple of really positive things are going to happen. That second dose, couple weeks are going to go by, we’re really seeing excellent protection against severe disease in this age group. We are seeing a significant reduction in Long COVID. It’s not gone. Actually, a couple of the people I’m traveling with actually have Long COVID when they got infected post-vaccine, so there’s no zero risk. We’re also seeing a drop in case numbers. I think in the coming month, you’re going to be able to start making slightly different decisions.

VR: Our last email is from Lisa who writes, “I wonder if you can speak regarding the benefit versus risk of boosting a 16 to 17-year-old male, who is in the highest risk group for myocarditis as an adverse effect. I read your article. You mentioned recently effectiveness of a third dose of mRNA vaccines against COVID-associated emergency department and urgent care encounters. I was concerned to read that VA against ED and UC once Omicron predominate was down to less than 40% by six months in adults and VA against hospitalization only 57%. The last date I saw a VA for adolescents was four, maybe five months after the vaccine. Effectiveness at 12 to 15-year-olds was very high with no change. I’ve not seen an update that was pre-Omicron. I have a 16-year-old boy, thin with no medical problems.

Had a second dose seven months ago had never had COVID. I’ve been reassured by your reports that kids with COVID ending up in hospital are unvaccinated, but this data gives me pause. I don’t want my kid to need emergency care either. Do you have any data on the prevalence of teens with COVID showing up at EDs and are you aware of any updated VA stats in adolescents past four to five months and ideally since Omicron? What would your recommendation be for booster or not? At this point, I’m weighing two small risks, risk of myocarditis versus a little bit unknown to me, risk of ED/UC hospitalization, if he has a COVID infection.”

DG: No, this is excellent. It goes back to the questions that I addressed early on, and that I’m sure I will be addressing and having lots of conversations when I talk to the pediatricians Monday night. One is the myocarditis. We are really not seeing after third doses, which is really reassuring. I’m going to say that is not a significant risk. It’s something we’re seeing after those second doses. We’re not really seeing it after third doses, so incredibly low risk. The other thing I want to comment is the difference in myocarditis post-vaccine versus myocarditis that we see with COVID. The vast majority of the myocarditis we see associated even with that second dose tends to be mild, tends to self-resolve within a day, and is incredibly rare for it to be anything like the myocarditis we see with COVID infections.

The COVID infections, when we look at athletes, et cetera, we’re actually seeing a significant myocarditis component to actually getting infected with COVID. COVID is here to stay, you’re really at this point choosing not a risk of getting infected, but really when your child is getting infected, it’s really a question of, do you add a booster before that happens? I think it’s Paul Offit who says, “you’re making a decision either way,” and we’re encouraging people to get that third dose across the board.

VR: That’s COVID-19 clinical update, number 100 with Dr. Daniel Griffin. Thank you, Daniel.

DG: Oh, thank you. Thank you, everyone, for listening. Be safe out there, and let’s all work together to get the rest of the world safe.

[00:38:12] [END OF AUDIO]