TWiV 921 COVID-19 Clinical Update #124

This Week in Virology

Host Vincent Racaniello

Guest: Daniel Griffin

Aired 23 July 2022

Pdf of this transcript available (link)

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

[music]

From MicrobeTV, this is TWiV. This Week in Virology, Episode 921, recorded on July 21, 2022. 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: COVID, monkeypox, poliovirus.

DG: Vincent, this is really just transformed into the weekly TWiV Clinical Update. We’ll sure we touch on everything, and my quotation I think you will get: “When angry count 10 before you speak; If very angry, 100,” Thomas Jefferson. I think as we get to number two on my list today, Vincent, we’ll be counting well past 100 because this is something that we’ve been talking about and now there’s a tragedy. Just our update, and we’re going to be mostly talking about COVID, but COVID deaths are back up to above 400 deaths per day per The New York Times tracker.

That’s about 3,000 a week, that’s 150,000 per year at this rate. This is surprising to me, but as surprising as this seems, the majority of the people being hospitalized are still the unvaccinated. Where are we getting these people? Where are they? Shocking that there are still so many unvaccinated people out there. Right here in New York, a heavily vaccinated region, the majority of admissions are still among the unvaccinated. The math with 10 times the rate of hospitalization for the unvaccinated means that until we get greater than 90% vaccinated, we’re not going to see that turnaround. It’s still going to be that math.

Let’s get to the part where Vincent needs to count way past 100. This is really tragic. A case of paralytic poliomyelitis was recently identified in an individual right here, Rockland County, New York, the CDC is consulting with the New York State Department of Health on this investigation. Sequencing performed by the Wadsworth lab, New York State DOH’s Public Health Lab, and confirmed by the CDC shows that this was revertant polio Sabin type 2 virus. This is indicative of a transmission from an individual who received the Oral Polio Virus, OPV, which is no longer authorized or administered in the U.S., where only the Inactivated Polio, IPV has been given since 2000.

This suggests this virus may have originated, did originate in a location outside of the U.S., where OPV is administered. Vincent, you’ve been saying for quite a while now that we need surveillance that we really need to continue to vaccinate our kids because of this concern. Are you just banging your head against the wall?

VR: Actually, I’m pretty calm, Daniel, [chuckles] because [laughter] we have been saying for a while that we should be looking in the sewers because as you saw recently in the UK, they found polio in the sewers, poliovirus RNA, and they do routine surveillance. The use of Oral Polio Vaccine is accompanied by extensive circulation among people without polio, you can find it in the sewage, and then if vaccination coverage isn’t complete, then there are vulnerable people. This individual was not vaccinated. The thing is, it’s a simple solution, just get vaccinated. There’s nothing tricky about it.

DG: Yes, and I think it’s tough because there is this movement as we’re now seeing where a choice is made, “Oh, there’s not much polio, why am I still subjecting my child to this vaccination?” This is why. This child’s paralyzed. You can’t go back. You can’t now give the vaccine. Really, really tragic. Next on our docket is the monkeypox. We’re now up to over 2,000 diagnosed cases of monkeypox here in the U.S. About half of those are right here in the New York area. There’s a couple of reasons. One is we’re actually testing. We’ll leave some links in the show notes to the monkeypox tracker, the New York City monkeypox data.

Just to mention the testing has really – I think as I mentioned last time, we now can just go ahead and test if we want to. To save myself a lot of calls and texts, I don’t know how many I’ll save but I’m going to get this out here. How do you go ahead and approach a patient that you are concerned might have the monkeypox? The first thing we have to do is, we’ve got to move past the circular reasoning. If we’re only testing a certain population, we’re only going to see it in that certain population.

We just had a call this morning at Columbia where we were looking over – Jason Zucker was leading the call – looking over the individuals that we’ve so far treated at Columbia, and over 40 so far have had access to the TPOXX, we’ll maybe mention a little bit about that. The one patient that was outside that population was the one patient that I had tested and actually was positive. If you don’t test women, if you don’t test married men, you’re not going to get a positive test result in those individuals.

A person comes in, have a high index of suspicion, don’t be thinking we’re having a sudden wave of folliculitis. We are having a wave of the monkeypox, we’re doubling the number of diagnoses per week, you want to get in there, and you want to swab those lesions vigorously, send off your HSV, VZV, PCR. That is a swab, and if we’re doing Labcorp, that’s code 139367. You’re going to send that in your universal transport media but you want to also send off the monkeypox. I want to point out Hickam was right, lots of co-infections here. The monkeypox, this is the orthopoxvirus DNA.

There’s a PCR, you’re going to use a non-cotton swab. It’s Labcorp code 140230, two swabs you’re going to send those off in sterile containers. I do want to point out, as Hickam we’ll get to him again, we are seeing lots of coinfections, so look for other sexually transmitted infections. Test for HIV, test for syphilis, consider sending off that urine, and actually we say three location testing for the GC chlamydia and trichomoniasis. Again, use your judgment, but to reinforce, we are seeing lots of coinfections. We went through that this morning.

Hickam was right again. A patient can have as many diseases as they damn well, please. I can’t believe we didn’t learn this lesson. I remember the early days of COVID, unless they had a ticket from Wuhan, you couldn’t test them. If they had something else, they couldn’t have COVID at the same time. Here, we repeated the same issue again, while the CDC was rationing tests. If you got a positive herpes, if you found some other disease, you could not go ahead and get that monkeypox. Where do people get this idea that you can only have one thing at a time?

Reminder on transmission, monkeypox spreads in several different ways. This can spread from person to person, direct contact with infectious rash scabs or bloody fluids, respiratory secretions during prolonged face-to-face contact or during intimate, physical contact such as kissing, sex, or cuddling. You can even get this cuddling. Touching items such as clothing or linens that have previously touched the infectious rash or body fluids, pregnant people can transmit the virus to their fetus through placenta.

I anticipate that those will be like the early days of COVID, we’ll start getting all these PCR studies on viral material, on all these areas. Let’s not repeat the same mistakes. We don’t just want PCR, we want, shall I say, plaque assays, Vincent?

VR: Yes. [laughs]

DG: I will point it is also possible for people to get monkeypox from infected animals, either being bitten, scratched, preparing their meat, et cetera. We had an individual this morning who actually got bit on the ear and that was where the monkeypox appeared. That was the end of the contact because this gentleman did not enjoy that being bitten on the ear, but here’s what’s going to kill us. Right now, we’re struggling to tell people with COVID that they have to isolate for five days, and continue to use precautions for another five, because a lot of folks are still contagious.

With the monkeypox, you may continue to transmit for up to four weeks. The CDC is saying, “No sex, abstain from that close intimate contact for four weeks.” Other recommendations are out to eight.

VR: Daniel, at least you can go outside, you don’t have to stay home, right?

DG: Yes, you can go out, you can do these things, just no cuddling or other intimate activities. Children and COVID, getting back into the COVID realm. Remember those vaccines are out there. You want to really get on board, get those vaccines in time for the start of the school in the fall. I would love if our kids could go back to school without mask mandates. We’ll talk about a gentleman who recently got infected and has the benefit of vaccine protecting them, so vaccines are great. Testing, remember, use those tests intelligently. Remember there’s more out there, not just COVID and you can have COVID and other things at the same time.

All right. We’ll talk about active vaccination, and don’t worry we’ll mention President Biden at the end. Amy sent me the preprint, “SARS-CoV-2 Variant Vaccine Boosters Trial: Preliminary Analysis.” These are the results of a phase 2 open-label, randomized trial that enrolled healthy adults previously vaccinated with a SARS-CoV-2 primary series and a single boost. Eligible participants were randomized to one of six arms and these were Moderna COVID19 mRNA vaccine arms; the Prototype mRNA-1273, that’s the original; the Omicron BA.1+Beta one doss; the Omicron BA.1+Beta with two doses; the Omicron BA.1+Delta; Omicron BA.1 monovalent; and Omicron BA.1+Prototype.

They went ahead a neutralization antibody titers, the ID50 were assessed for, the ancestrals, the D614G, Delta, Beta, and Omicron BA.1 variants and Omicron BA.2.12.1 and BA.4 and BA.5 subvariants 15 days after vaccination. Can you guess what are we going to measure 15 days after vaccination? They’re going to look at the gene geometric mean titers against all these different ones. They’re going to look at D614G with similar across arms and ages and higher with prior infection for uninfected participants, Day 15, Omicron BA.1, GMTs were similar across Omicron-containing vaccine arms, 3724-4561 and higher than Prototype which is about 2,000.

I will mention that a subset of samples from uninfected participants in four arms were also tested in a different laboratory at Day 15 for neutralizing antibody titers for all these different variants. I will mention that there are approximately one-third of the BA.1, for the BA.4, and the BA.5. Higher BA.1 titers were observed that the Omicron-containing vaccines compared to Prototype vaccine and the titers against BA.4 and BA.5 were lower than against BA.1 for all candidate vaccines.

 All right. I sort of like having these data in front of me while I talk about the preprint, “Novavax NVX-COV2373 Triggers Potent Neutralization of Omicron Sub-lineages.” Well, I like that title. It’s a little bit leading so let’s see what the preprint suggests but here, what we found is that after two doses, Omicron sub-lineages BA.1 and BA.4 were resistant to neutralization by 72% and 59% of samples. However, after a third dose of Novavax, they observed high titers against Omicron BA.1 and BA.4 but what were those high titers? Remember those numbers from up above? The GMT for BA.1 was 1197 and against BA.4, it was 582. What to make of those? I’m not sure. I will mention that Novavax has a contract in place to produce its own Omicron-specific boosters. Expect more data from them on boosting with an Omicron-specific Novavax.

On Novavax, the CDC recommends Novavax’s COVID-19 vaccine for adults. Number four, on Tuesday, 7/19/22, the CDC Director Rochelle P. Walensky endorsed the CDC ACIP practices recommendation that Novavax’s COVID-19 vaccine be used as another primary series option for adults ages 18 and older. Then, I was a little bit disturbed. Novavax’s COVID-19 vaccine will be available in the coming weeks, not now, not tomorrow, but in weeks. Still waiting on that.

I have a list of patients that every time there’s something about Novavax in the news, “Is it here? Can I get it? Is it here? Can I get it?” still weeks away.

VR: Daniel, I understand that Europe has plenty of doses, but we don’t because they got them initially. Now, they have to produce it for the U.S.

DG: Yes. Part of the hold-up was this manufacturing issue, which is, I don’t want to downplay that, you want to make sure that product you get are up to the manufacturing standards of the FDA. We’re done waiting and it is true, I am optimistic. There are millions of folks who we hear are just waiting for this vaccine and then they’ll get vaccinated. That would be nice. That would be nice. We’ll continue with that optimism. Remember our passive vaccination, Evusheld? I did get some communications from my rheumatology colleagues about the low dose methotrexate.

Maybe I’m a little more pro-Evusheld than everyone out there but remember, this is sitting on shelves, this is another therapeutic to consider in those folks with moderate to severe immune compromise or those folks that can’t get vaccinated.

All right. Now, we move into the early viral, upper respiratory, non-hypoxic phase that first week of illness when people have, mild or moderate non-hypoxic COVID. We just heard about a famous individual today who got diagnosed this morning. When this drops, it’ll be two days, it’ll be old news, but Vincent, I don’t know if you’ve been following the news on Biden.

VR: I did hear that, yes, and I immediately thought that – [crosstalk]

DG: A 79-year-old individual –

VR: – that Daniel’s going to prescribe Paxlovid, right?

DG: [chuckles] Yes. Well, shouldn’t we wait to see, shouldn’t we wait to see if he progresses? Shouldn’t we give him four or five days, so the efficacy of Paxlovid is less, and he has a chance to develop an immune response, Vincent?

VR: That’s a good way to put it. No, he’s in his 80s, we should not wait.

DG: Yes, and that was what I thought was nice. In all the coverage, this is a gentleman who’s been vaccinated, so 90% reduction in progression, he was started on the Paxlovid. No one’s given him bad advice about waiting because we do know that you wait and we’ll get to some data on that, coming right up here. He is vaccinated, he’s on the Paxlovid, 99% reduction in his risk of progression. Here’s an individual with less than a 1% chance of progressing to severe or critical COVID. I expect things to go quite well there.

All right. Number one, just like the president, you can get Paxlovid if you are eligible, if you have high risk features. The correspondence published in The Lancet Infectious Diseases, “Paxlovid in Patients Who Are Immunocompromised and Hospitalized with SARS-CoV-2 Infection,” reinforces that those folks recommending waiting to let the immune response respond are not giving good advice. We saw that therapy in the first three days gave us an 89% reduction then drops to 88% out to day five. What about waiting until folks end up in the hospital?

In this report, they found that no vaccination, delayed Paxlovid treatment greater than five days after diagnosis, and immunocompromised condition were independent predictors for prolonged viral elimination. There were 35 patients who were immune compromised in this cohort, including three recipients of solid organ transplants, seven with autoimmune rheumatic conditions, three with hematological malignancies, and 22 with malignant solid tumors. They found that Paxlovid prescriptions within five days of diagnosis had a faster clearance of viral load as measured by viral gene replication and a shorter time to viral elimination in patients who are immune compromised.

They’re giving us numbers of 13.67 days versus 19.17 days. The correlation between timing of Paxlovid initiation and viral elimination was linear in the study. Just remember, first three days, 89% reduction, you get it on day four and five; 88% reduction, still pretty good. You wait past five days and you’re starting to see drop in efficacy. The science does not support waiting and seeing. All right, number two, remdesivir. We have the early three-day treatment data about 87% reduction in progression. Not a bad next choice for those folks with drug-drug interactions and we heard the president actually, for a period of time, will be stopping his direct oral anticoagulant and his statin therapy, which is what we recommend. That’s an easy way to approach it. Number three, bebtelovimab monoclonal therapy. This is number three. As I mentioned, we have limited direct efficacy data here, but number four, molnupiravir, last and least with only about a 30% reduction in progression. Remember, no steroids, no antibiotics, no ivermectin, no flu vaccine, no colchicine, no zinc, no high dose vitamin C.

Remember, there are impacts in terms of opportunity costs. I had a lady recently, I was taking care of the husband, the lady was out there in the community. She was getting a bad advice. She was following a COVID protocol that involved some of the components in the above list. I really wanted to remind people of the nocebo effect. I don’t know if people are familiar with the nocebo, but a lot of this communication, if you suggest to someone that something will do harm and we’re hearing a lot of negative press about effective things, then you may end up. Remember, the nocebo is the placebo’s evil twin.

All right. We do have an update to the living WHO guidelines on drugs for COVID-19. This was published in the BMJ but it is behind a paywall. The latest version of the WHO living guideline provides two new recommendations for patients with non-severe COVID-19. A, a recommendation against the use of fluvoxamine except in the context of a clinical trial, and B, a strong recommendation against the use of colchicine.

All right, more results from the ACTIV-6 trial, “Inhaled Fluticasone for Outpatient Treatment of COVID-19: A Decentralized, Placebo-controlled, Randomized, Platform Clinical Trial.” We have this data as a preprint and this is this whole concept of repurposed drugs which was very exciting. The idea that maybe heartburn medicine or my horse’s chocolate-flavored deworming paste had the magical ability to cure COVID if we just wash it down with a little bleach and a few flashlights. Non-hospitalized adults aged greater than equal to 30 experiencing greater equal to two symptoms of acute COVID for less than seven days were randomized to inhaled fluticasone. This is a steroid inhaler, 200 micrograms once daily for 14 days or placebo. This is using an inhaled steroid.

The primary outcome was time to sustained recovery defined as the third of three consecutive days without symptoms. I think this is essential. We’re looking at people feeling better. Secondary outcomes included composites of hospitalization or death with or without urgent care or emergency department visits by day 28. Now, what did they find of those eligible for the fluticasone arm? Six hundred fifty-six were randomized to and received inhaled fluticasone, 621 received concurrent placebo. There was no evidence an improvement to recovery with fluticasone compared with placebo.

Three participants in each arm were hospitalized, no deaths occurred, and adverse events were uncommon in both arms. In this study, it appeared that treatment with inhaled fluticasone, inhaled steroids for 14 days did not result in improved time to recovery among patients with COVID-19 in the U.S. I do want to point out, I presented this data ,and one of the questions right away was, it doesn’t seem like it does any harm so maybe if I have a patient, I can give it to them and it will help them feel better. This was a study asking, will this help them feel better? What did they find? No. Don’t do it.

All right, keep your hands in your pockets and remember, isolated for the infected. I keep reinforcing this. I’m very interested to see what happens six days from now. The first five days, isolation for the infected. That’s when the people are the most contagious. This is not a great time for those photoshoots to show someone smiling and happy and healthy. This is when the person is most infectious. The first five days, 85% of the transmission occurs. Day six through 10, the current CDC recommendation is you can be out and about but you should wear a properly fitting mask because there may be continued transmission past then. Day six through 10.

A lot of people seem to think day six, off with the mask, I’m done. We’ll see what happens. All right. That second week, people seem to forget that first week is that viral symptom phase, the nonhypoxic, mild to moderate. The second week is the early inflammatory, lower respiratory hypoxic phase. With vaccines, with early treatment, hopefully, people are avoiding the hypoxic component there. This is when you consider things like steroids, anticoagulation, pulmonary support may be remdesivir, et cetera. This is not necessarily a treatment rebound. We’ve been seeing this for two years.

People have a week of viral illness and then just like Ian Lipkin that second week, then they get the COVID, that is part of the natural history. We want to keep our eye on the Long COVID that we’re still seeing. There’s going to be a lot coming out in the press because a lot of people are getting frustrated. Where’s that money? Where’s all these evidence-based therapies? Let’s continue to work with those folks. As I like to close every time, no one is safe until everyone is safe.

We have a lot of folks out there in the world without access to vaccines, without the education that makes them excited to get those vaccines, so right now is when I want everyone to pause, pull over, go to parasiteswithoutborders.com. We’re getting right to the end of our Foundation International Medical Relief of Children fundraiser. During the months, May, June, and July, donations made to Parasites Without Borders will be matched and doubled up to a potential donation of $40,000 for FIMRC’s clinic there in Bududa.

If we can really get a good push here in this last week of July, I’m going to encourage the directors to maybe be even a little more generous if you can help us do that.

VR: Time for your questions for Daniel, send them to [email protected]. Carrie writes, “I’m a 42-year-old pregnant woman, no health conditions other than celiac disease, food allergies, and mild asthma during wildfire season. Due October 8, I have been vaccinated three times with Moderna. Last dose, almost one year ago. You mentioned a few weeks ago that Paxlovid would be an important consideration for pregnant women who test positive even with no other high-risk conditions because our oldest will be starting kindergarten. this August. Our exposure level is about to skyrocket. I asked my OB about my risk in Paxlovid. He seemed to be unconcerned, confirmed I was vaccinated, and boosted, and said ‘You will probably be fine.’ “

DG: Yes. I’m glad someone put the quotes around the probably. This is the issue and we keep coming back to this is, women who are pregnant, pregnant individuals, they are at high risk. They’re at high risk of ending up in the hospital. We’ve seen double the risk of losing the baby during the pregnancy if a woman gets infected with COVID. There’s even been some impacts on looking at children who are born to women who have COVID, interesting the timing there on what trimester puts the highest risk. A pregnant individual is at high risk. There’s someone that we definitely want to consider treatment.

If you look at the EUA for Paxlovid, there’s a section, I’ve been asked this question enough I know which section, it’s Section 8.1 and it goes through all the data. The nirmatrelvir and the ritonavir, there’s two components in Paxlovid that we have concerns about. So, the nirmatrelvir, we have a lot of animal data. We’ve looked at that. There’s no concerning signal even giving doses much, much higher than we give to human beings. We now have a growing experience having treated women. The big thing here is getting the COVID during the pregnancy is not good. It’s associated with significant risks. We are not seeing concerns on the other side.

Now, if you’re not excited about Paxlovid, if you and your physician are uncomfortable, remdesivir is another option and there also is monoclonals. Recently had a discussion and there was some hesitancy that the dad was a physician. We went ahead with bebtelovimab. Really the big thing is consider treatment. Don’t just say y’all probably be fine because then when you lose the baby, then when you have a bad outcome, you missed your opportunity to prevent that.

VR: Just to conclude, pregnancy does put her under high risk. She should be an advocate for Paxlovid or remdesivir or monoclonals. Correct?

DG: Yes, agreed. Not molnupiravir but yes, would recommend treatment.

VR: All right. Genevieve writes, “My father is 80, fully vaccinated, two boosters, uses the local VA hospital for his needs. He has not contracted COVID yet. I want to have a plan in place in case he does, but I’m having a hard time navigating the resources available from the VA. He is on lifelong Xarelto due to history of two DVTs. He will not be a candidate for Paxlovid. Do you have any suggestions as to finding out what therapeutics are available at my local VA? We live in Oregon.”

DG: Yes, that’s interesting. I think maybe it’s good that we’ve got President Biden here in the picture. Xarelto is one of those direct oral anticoagulants. You take it to prevent the recurrence of the DVT. There is an interaction with Paxlovid. What did President Biden’s physician advise? Advised stopping that medication for the five days and then restarting it after the five days. Is there really a high risk with stopping it for five days? You’ve got to weigh that risk versus the risk of not treating the COVID, not getting that 90% reduction so that’s one thing to consider with the physician.

You want to have that plan in place. Can you just stop a medicine for five days whether it’s a statin or whether it’s one of these oral-acting anticoagulants? Then, you moved out. Not a lot of access to remdesivir, unfortunately. I think Vincent and I saw some of the data, it’s less than 1% of treatment is with IV remdesivir, just not well operationalized. Number three, you do have the monoclonals, bebtelovimab, but again, you’re going to need to get a sense of where can you access that. Number four, last and least, but still there, molnupiravir is another option.

This is something we feel comfortable with in individuals as described. You don’t have to worry about the drug-drug interactions, you don’t have to worry about renal function. That’s another consideration. There are certain therapeutic locators that you and your doctor could look at. There’s ArcGIS therapeutics locator for COVID. Just Google COVID therapeutics ArcGIS, A-R-C-G-I-S. That can give you a sense of where the resources are in your area.

VR: The last one from Bistra, “I’ve been trying to understand what’s the protection of previous infections from getting infected and reinfected right now, and the risk of complicated illness from repeat infections. I want to advise my elderly parents 83 and 79 as they live in a country with poor pandemic response. They have two AstraZeneca doses, one Pfizer booster. Just recovered from COVID with somewhat mild illness without the need for hospitalization. What’s the next steps for them? Continuing to mask even though no one masks where they are?

They need physiotherapy appointments. They want to see friends, they need some socializing. How much should they avoid that? Should they get a fourth booster? In general, what does natural immunity coupled with vaccination do for us?” I think that the overall question, Daniel, is how well protected are you in that age group with both vaccine doses and natural infection?

DG: Yes, and I think that this will echo back to, it’s great that we have a 79-year-old gentleman who just got infected that we can keep reinforcing and hopefully, Vincent and I, we’ve done a good job of reinforcing this. The vaccines continue to provide about a 90% reduction in your risk of severe disease. When you really get the data, when you remove out the immunocompromised, and you really look at the numbers, we’re seeing they continue to endure. With Omicron, we really moved to, “You need that third shot.” In particular, people who are advanced aged, immunocompromised, OK, we’re seeing data on the fourth shot.

Then, the big thing is also looking at even get that lower with access to therapeutics. This doesn’t do away with the nonpharmaceutical interventions. Make smart choices. I think maybe as a society, it makes sense for us to make smart choices. If you’re going to be giving an 84-year-old woman an award for something, do you really need to have that in an indoor crowded setting? Can’t we have that outdoors with good ventilation? Let’s just start thinking about things. We lose a lot of people to respiratory pathogens, to flu, to COVID, to all these other things.

Maybe we as a society and we as individuals can find some sort of common ground for things to be a little bit more reasonable because we do. We can’t continue to be socially isolated. I’m not sure I need to shake people’s hands but I think we do need that social interaction. We need to figure out a way to do that intelligently and with a reasonable risk ratio.

VR: I keep going back to your original statement last week and echoed this week. Most of the people dying are either unvaccinated, immunosuppressed, or over 75, and we could save most of them with Paxlovid, remdesivir, monoclonals given early. With that, you can move forward and take care of this vulnerable population.

DG: You really can. The majority of deaths that we are seeing are avoidable. We could drop that 90% with vaccinations. We could drop that another 90% with early treatment, we can drop in certain populations another 85% with Evusheld. We have the tools, we just have to do them.

VR: That’s why there’s an opinion in The New York Times saying, “Oh, the pandemic COVID looks very grim,” but they failed to note that you could prevent most of these deaths even if we don’t know why the vulnerable population is so vulnerable, we could still prevent them. That’s important to remember.

DG: You’re going to get as many readers, Vincent, if you just tell the truth, you need to be dramatic but I think we’re moving past that.

VR: [chuckles]

DG: Don’t worry, if you want to get interviewed, talk to people about the monkeypox. We need to stop being so–

VR: Or polio.

DG: Or polio, yes.

VR: Or parechovirus, that was in The Times this week as well.

DG: Yes. I think we discussed that on the ID Puscast, the Infectious Disease Puscast, so if people want to hear about parechovirus and the recent report, whether or not they’re something to worry about or not, please tune into the ID Puscast.

VR: That’s COVID-19 clinical update number 124 with Dr. Daniel Griffin. Thank you, Daniel.

DG Oh, thank you and everyone be safe.