TWiV 738 COVID-19 Clinical Update #56

This Week in Virology

Host: Vincent Racaniello

Guest: Daniel Griffin

Aired 03 April 2021

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 738, recorded on April 1st, 2021. I’m Vincent Racaniello. You’re listening to the podcast all about viruses. Joining me today from New York, Daniel Griffin.

Daniel Griffin: Hello, everyone.

VR: This is update number 56. What is the situation this week, Daniel?

DG: It’s not good. Let me just go right into that and then I’ll give my quotation. I have to say, I’m getting tired. This has really been a tough year and it’s disappointing. We’ve been asking people, just give us a little more time. Dr. Jay Varma, he’s a senior advisor for Public Health at City Hall here in New York. I’m going to quote him. He said, “The term I’ve been using is ‘high plateau’.” I think that’s what this is, we’re on this high plateau. The numbers are not going down. If anything, the numbers of new cases are climbing. Number of deaths are sitting at a very unacceptable high. This is not good.

We are going to get through this in the United States with vaccines, but I think an unacceptable number of the loss and unacceptable number of people sick and dead, and I’m going to say, disabled after this, so not good. I have to say, if you’re not frustrated, if you’re not upset, you’re not paying attention.

All right. Let’s go with our quotation on that wonderful positive note. “We have two lives: the one we learn with and the one we live after that.” That’s by Bernard Malamud. I had hoped that at this point we would be past that learning stage, and we would be moving into addressing this with more wisdom, but as we’re seeing, people are, well, I understand, I’m exhausted too.

We’re tired of not hugging the ones we love, not doing the things we like to do. We’re so close. I have to say, there’s been a lot of predictions of the surge in the fall and winter, which we saw. A little bit of a rise here in the spring, which we are now seeing, and then expecting to end up in a much better place this summer. That’s the U.S., that’s very U.S.-centric. I don’t want to be so U.S.-centric. I’ll point out, the rest of the world is not on the way down, the rest of the world, Europe even, is on the way up. Things are not looking good. We really need to move faster with the vaccines. People have probably heard we had a little bit of a setback there this week.

One of the things, as I go through each week, I’m always trying to give all the new information. I also want to always counter what people are seeing in the press, in the media, with what I’m actually seeing on the ground. I also feel like it’s important that I keep reinforcing the current treatment approaches, because I keep seeing people not addressing COVID-19 based upon what we’ve learned over the last year. I sometimes feel like I’m back in March of last year when I see someone show up at, say, one of the non-ProHealth urgent cares, and they get Z-Pak and a whole bunch of steroids on the second day of illness. Let’s go through this.

My section, Children and COVID. People go both ways on this. I am glad that I think I’m getting attention on this. I’m pointing out that children are at low risk, but that they’re not at no risk. I wanted to give some perspective to this. I do try to say that it’s not just about who died, it’s not just who ended up in the hospital, but let’s talk about that. Children have died here in the U.S. from COVID-19. I actually went, before doing this update, to the most current CDC numbers.

I still remember when I first started talking about this and I was saying, “Listen, it’s March, no child under the age of seven has died of COVID.” Well, that’s not true anymore. If you look at zero to four years in the U.S., over 100 children have died. If you go to the next, 5 to 17 years, over 200 have died. When you go a little bit higher, so this is the 18 to 29, and I have an 18-year-old, I have a 20-year-old, over 2,000 have died according to the CDC. That’s just confirmed, that’s just in the U.S.

I want to point out, those are the numbers and that’s what we’re working with. That’s far too many deaths here in the U.S. already. What we’re seeing now with the positive cases is we’re seeing a shift into the younger population. We’re seeing, as I mentioned with the MIS-C, a higher percent of these individuals are ending up in the ICU. One of my colleagues just reached out to me saying where they are 3% of the hospital admissions are now children under the age of 18.

This is not good, but now a little bit of positive news. We heard nice little press release that Pfizer has been testing its vaccine on younger individuals, and we had some data on the 12- to 15-year-old population. This was very impressive. In participants age 12 to 15 years old, the Pfizer-BioNTech vaccine demonstrated 100% efficacy and robust antibody responses, actually exceeding the antibody responses of older individuals, the 16- to 25-year-old population. It was very well tolerated, and they plan to submit both to the FDA and the European Medicines Agency for expansion of their EUA.

They also provided updates on the fact that they are looking at children down to as young as six months of age, so the six months to 11-year-olds. Just to go into just a little bit of weeds, this was a press release, this is not a peer-reviewed publication. In this study, they looked at 2,260 adolescents in this, 12 to 15 years of age in United States, and they observed 18 cases of COVID in the placebo group, zero in the vaccinated group. This is that 100% efficacy against infection. They also reported these robust antibody responses. This data will be submitted for peer-review publication, and when we have that, I will be certain to circle back to it.

Testing. I want to keep trying to reinforce, testing is a major pillar of the current strategy to defeat COVID-19. One of the major employers, Citigroup has actually set up this three-times-a-week in-home testing for its employees. They’re using this $5 per test approach. It’s a rapid self-administered antigen test. It’s applied by the Innova Medical Group.

This is one of those lateral flow, sort of those pregnancy-type tests that people might be familiar with, but instead of peeing on it, you’re going to swab your nose and you put it in a little bit of fluid, and then it runs out. Actually, this is not just the U.S. I was actually speaking to a friend of mine and their colleague in London got their three-month kit. This is a real commitment there to try to use testing coupled with vaccinations, coupled with mitigation, everything we could do to get on top of this.

The FDA also granted EUA to an at-home over-the-counter molecular nucleic acid amplification test. This is called the Cue COVID-19. This is, I’ll say, a cute little test. You get this whole kit with a single-use test cartridge, and this sample one. Basically, you’re going to swab up your nose, you’re going to put it in this cartridge, and then that cartridge is going to go in the Cue Cartridge Reader provided separately. I felt like I’m back in the ’80s with batteries being supplied separately. Hopefully the reusable batteries are going to come with this.

It’s really a battery-operated home testing kit. This gives you results in about 20 minutes. The way they market this is you’re going to swab your nose while you’re getting ready in the morning, go take your shower, brush your teeth, do whatever, come back, make sure your test is negative before you go to work, or school, or any social activities.

According to the FDA evaluation, the test correctly identified 96% of the positive samples from individuals that had symptoms. I thought this was interesting, 100% of the positive samples from individuals without symptoms. Really a very sensitive test for both symptomatic and, as we’re talking here, asymptomatic screening for a return to workplace.

Also, I think it’s an exciting week for testing, the Amazon Real-Time RT-PCR Test for Detecting SARS-CoV-2 also got EUA, and so they’re very similar. The Amazon COVID-19 test collection kit includes a nasal swab, a collection tube, a biohazard bag, instructions, and a sample drop-off. This is not all being done in the home, this is really a home collection kit, which is then being sent out to a lab.

Also, I wanted to give an update on our T-detect T cell test by Adaptive. This is that test that a physician doesn’t order. Actually, the patient will go online. They’ll type in T-detect, and it will pop up the Adaptive website where the patient themselves goes through, answers a bunch of questions, gets a blood test which tells whether or not their T cells or their memory T cells are evident of a prior COVID-19 infection. The hope that, as I discussed before, is that those individuals who could not get a PCR test up front who maybe are now serology-negative can get this test, but then comes the question that I’ve gotten from individuals. “What about someone who’s got a vaccine?” As I mentioned, there are thousands of T cell epitopes that we see that target the spike protein, but there’s also TCRs that target other proteins. Imagine that, there’s other proteins.

I hope everyone enjoyed that. If you listen to the rest of TWiV, you’ll hear our obsession with the spike protein. They’re actually looking at modifying the algorithm, so we will be, in the future, able to tell whether this is a T cell response purely targeted at spike or whether there’s also targeting of some of the other proteins, so we’ll be able to use this also to distinguish vaccination versus vaccination with prior natural infection.

I don’t want to spend too much time on this, there’s been a lot in the press about some overcharging of some of the New York City hospitals with regards to testing, $3,000 per test. I think this is unfortunate and it undermines confidence in testing. So, I’m glad that this is being brought to light. This really needs to be corrected. The CARES Act was supposed to guarantee that individuals could, at no financial risk, go get tested, find out if they have COVID-19 before they spread it to others, so I hope this all is addressed.

All right. Active vaccination. I know I started off with some negativity but here’s some really positive news. More data from the CDC MMWR, and this is all about real world vaccine efficacy. We had the Interim Estimates of Vaccine Effectiveness of BNT162b2 and mRNA-1273 COVID-19 Vaccines in Preventing SARS-CoV-2 Infection Among Healthcare Personnel, First Responders, and Other Essential and Frontline Workers – Eight U.S. Locations, December 2020-March 2021. So really, this is how well do those RNA vaccines actually work in the real world? In this early release publication, they prospectively followed 3,950 healthcare personnel, first responders, and other essential and frontline workers that completed weekly SARS-CoV-2 testing for 13 consecutive weeks.

Under real world conditions, mRNA vaccine effectiveness of full immunization, so greater than 14 days after second dose, was 90% against SARS-CoV-2 infections regardless of symptom status and just with partial immunization. So, this greater than 14 days after first dose, we were already at 80%. So, we’re seeing a growing amount of real-world evidence regarding the safety and effectiveness of vaccines.

We also had an Initial report of decreased SARS-CoV-2 viral load after inoculation with BNT162b2 vaccine, and this was published in Nature Medicine. The authors here presented data that previously was out as a preprint, describing that in those that had a positive test despite vaccination, the viral loads were about four times lower. So, there was an abrupt change at 12 days after vaccinations that went from an average CT value of 25 up to 27. Remember this, the higher the CT means it takes more cycles to pick up the RNA. So, the 25 to 27 was for the RNA-dependent RNA-preliminaries primers. This roughly translates, this wasn’t set specifically, but about 600,000 down to 150,000 MDU, so Math Detectable Units, or RNA copy numbers. So even a little more encouraging than that initial data that was posted on GitHub that we discussed back in February.

There also were several letters, this was like the week of real-world experience in The New England Journal, such as BNT162b2 mRNA COVID-19 Vaccine Effectiveness among Health Care Workers, Early Evidence of the Effect of SARS-CoV-2 Vaccine at One Medical Center, and SARS-Cov-2 Infection after Vaccination in Health Care Workers in California. Basically, we’re seeing consistently that the vaccines have excellent efficacy at preventing severe disease, symptomatic disease, asymptomatic disease. Even in these post-vaccination infections, the viral load appears to be substantially lower suggesting a major impact on interrupting transmission.

Well, what about lessons learned from the vaccine rollout? I’ve suggested before that instead of focusing on who did what wrong, we should focus on what was done and how we can learn should this not be the last pandemic. A big part of the vaccination issues was the logistics of getting vaccines into arms. There was actually a really nice piece in Politico on March 29th exploring this issue entitled, Biden administration remakes vaccine strategy after mass vaccinations sites fizzle. Really just to cut to the chase on this, once they went to the, say, the traditional approaches, they let the pharmacies start vaccinating. We’ve really seen an escalation in our ability to do an incredible number, millions of vaccinations per day. Their comment was that they’re moving towards this approach.

I wanted to finish this section with my question of, “Where’s Elvis?” I was just in a talk this week where there was an update on the polio vaccination experience that was trickling along, with an uptake of about 0.6%. Then along comes Elvis and he gets his vaccination. Six months later, the uptake was up to 80%. I don’t think we’re quite there yet at that greater than 80%, but I’m hoping that we can all work together to get there.

All right. Passive vaccination. I like to talk about variants of concern in this section, because my biggest concern is the impact on monoclonal therapies and I like to feel that if we were doing a better job with our behaviors of concern, we would be in a little less trouble here, and we actually have a whole bunch of studies going on where we’re trying to update our sequencing, so we have a better sense of where we are with these issues.

Along these lines, we actually got a little more information in the monoclonal arena. I discussed the data for GSK and Vir Biotechnology, and they’ve actually gone ahead and filed an application to U.S. regulators for EUA for their antibody. This was based on the data that I previously discussed, where they demonstrated an 85% reduction in hospitalizations or deaths when their therapy was given in the first seven to 10 days of COVID-19 infection.

Now this monoclonal therapy as I mentioned, it targets an invariant region of the spike protein, so it isn’t something that we’re quite as concerned that the virus will mutate away from as far as efficacy. It also has an extended half-life, may last for up to a year, so we may have broader applications here. Because as we’re learning, not everyone can mount a really good response to the vaccines, not everyone wants to mount a really good response to the vaccines, so this gives us one more potential therapy to use, not only for acute infections, but potentially for the prophylaxis opportunity.

I got a monoclonal vaccine question here that I thought was entertaining that I would share, it’s informative. It was one of our ProHealth internists, Brooke Keane, had this question, and this is coming up more and more. One of their patients, 66 years old, overweight, high BMI, and it’s seven weeks after the second dose of the Pfizer COVID vaccine, they end up exposed to COVID.

A few days later, and I should say, because Vincent’s exposed to SARS-CoV-2, a person who has COVID-19, and a few days later this patient starts to develop respiratory symptoms, gets tested, and has a positive test for SARS-CoV-2. Due to his age and comorbidities, he’s actually treated with monoclonal antibody therapy.

Now, he’s completely fine at this point. I have to say, this is an interesting question, does he go ahead? Does he need a boost? Does he need to be re-vaccinated? This is an area that I think is sort of more of our subtleties, right? For some reason, we do see people who get fully vaccinated, who then go on to get infected. Our therapies, our trials, we’re not 100%.

In cases where monoclonals are given less than two weeks after the second dose, and we’re seeing this, I do recommend re-vaccinating, but here the interval is a little bit longer, because you’re waiting for that person to recover and you’re waiting that three months. But my advice in this case was to actually go ahead, wait that three months and then evaluate the spike antibody levels and actually at that point hopefully we’ll have more information about giving a third dose or in the case of J&J, maybe a booster dose to individuals who get infected despite vaccination.

The incubation/pre-exposure period. I need to keep reminding people that tests do not predict the future, there still is this two to 14-day incubation period. Even when we do that early test-out option, we’re still 20%, 30% of people are becoming symptomatic or becoming PCR positive after that seven days. We want to be careful here. I’ll say, at least here in the New York, particularly the Nassau County area, we’re about a 5% positivity rate. We’re actually above rates where we were in the surge of last summer. This is that critical period of detectable viral replication, the viral symptom phase. This is when I keep shaking my head when I hear the stories of the experiences that my patients who get admitted have had at some of the care centers.

Remember, the first seven to 10 days, that viral symptom phase, this is the time for monoclonals and monitoring. This is not the time for steroids. This is not the time for antibiotics. Once you get into that early inflammatory phase, hopefully all our patients that qualify have gotten monoclonals, but you get into the early inflammatory phase, your patient is monitoring their oxygen level at home with a pulse oximeter. If the oxygen saturation drops below 94% at rest, then it’s time for steroids. I notice a lot of people are giving these Medrol dose packs, which is really just a five-day course of steroids.

We studied dexamethasone, 6 milligrams p.o.q day times 10 days. An equivalent would be prednisone 40, milligrams p.o.q day times 10 days. I’m going to recommend we stick as much as we can with what we studied. I think the 10 days made sense, that’s why it was studied that way. Let’s try to do that. It’s cheaper than the Medrol Dosepak by the way and there are millions of people that are still going to need this therapy in the coming months, unfortunately. Oxygen, that’s when we start looking at oxygen, that’s when we start looking at anticoagulation, and that’s when we consider remdesivir.

I like to point out this secondary infection phase is not until week three. This first admission, it is very rare for them to end up benefiting from antibiotics but some of the recent data we saw is the majority of people with COVID-19 admitted in this country, it was a publication in IDSA, receive a course of antibiotics. I think this is not going to bode well if that’s how we’re approaching this viral disease with overuse of antibiotics. Our next Armageddon will be antibiotic-resistant infections.

The multi-system inflammatory phase, as I mentioned, a trend towards more severity, more ICU level care for our kids. This is where you really have to be careful. You want to have a clear diagnosis and then steroids, IVIG, supportive care.

Then the tail phase, Long COVID. I’m going to say, the best treatment we have so far for Long COVID appears to be vaccination. I got a text the other day from one of my colleagues, Justin Aaron at Columbia, and I thought this was very entertaining. We’re seeing now multiple reports of an increased likelihood of a person getting better, reporting improvement in symptoms, with Long COVID after vaccination and it’s with all the vaccines now.

Initially, we saw it with the mRNA vaccines but we’re seeing it with AstraZeneca in some other countries. We’re seeing with J&J right here in this country. I was on The Brian Lehrer Show and one of the J&J recipients who had resolved symptoms called in, very enjoyable. Justin Aaron was relating an individual who had gone many months without the ability to smell or taste and now was complaining of a super sense of smell. I don’t think that a vaccine gives you super smell powers. I just think this individual had forgotten how smelly the world is and now was complaining about going into rooms and being overpowered by the amount of perfume.

I have to say, people are using a little bit more perfume than before. Maybe because everyone’s wearing masks and they’re trying to overdo it and here’s someone who now got his sense of smell back. It’s encouraging to see these people getting better. There’s a real drive for these people with Long COVID to want to get an opportunity to get vaccinated. We’re seeing, fortunately across the country, a dropping in the age for eligibility, an increase in the supply for the vaccine. I think I’m going to end here on what is more of a positive note than I started, but we’re still not quite there.

I do want to say, we’re very U.S.-centric, I think, because here we have vaccines, here things are getting better but a lot of the world is struggling. This isn’t just Asia, this isn’t just sub-Saharan Africa, this isn’t just South America. This is Europe, this is many places throughout the world.

I’m going to say, as I conclude, thank you so much for all the support to date. Continue to go to parasiteswithoutborders.com and support us because we are committed that we are going to give $40,000 to American Society of Tropical Medicine and Hygiene to support scholarships for early-career women from low-income countries to attend this fall meeting of the American Society of Tropical Medicine who otherwise would not be able to attend.

VR: All right. It’s time for some email. If you want to send Daniel a question, it’s daniel@microbe.tv. Christian sent a link to a preprint describing some of the initial thrombotic events associated with AstraZeneca vaccination. I wonder, Daniel, if you had any thoughts on the nature of those events and what that means.

DG: Sure. It’s a challenge. I’m doing a talk later this week for the G6PD community. They’re quite concerned about, is there one vaccine that might be safer for people with certain comorbidities, certain people with red cell disorders? I have to say, it’s really tough because as we talked about this, this is one of those where they said the preponderance of scientific evidence does not support a connection between these clots and vaccination, the rate is that which is seen, background rates. We don’t know but despite that, despite it only being about a one in a million phenomenon, which is what we see in the unvaccinated population, there’s a lot of names, there’s a lot of descriptions, there’s a timing. This is happening seven to 14 days after. I leave it there.

I do not know if this vaccine is causing these phenomena. I don’t know if this is just something when you give 30 million vaccines, you see 30 events. I always like to talk about the dog bite thing. People who didn’t get vaccinated were more likely to get bitten by dogs. I do not think vaccinations prevent you from getting bitten by dogs. I do not know and it’ll be interesting to explore. Thirty cases is very hard to give you enough evidence to really make a connection or understand this phenomenon well.

VR: Daniel, in Denmark they recommend pulling the syringe back to make sure you’re not in a blood vessel. Is that important to do?

DG: Yeah, we do that everywhere. Actually, when I posted getting my vaccination, the pharmacist was doing– I think maybe she was nervous because she was on camera. But that’s what you’re supposed to do to make sure you’re in the muscle and not in the blood vessel. You put it in, you draw back a little on the syringe, make sure there’s no blood coming back and then you give your IM injection. Actually, we recommend that everywhere. I know actually that was specifically the idea that, oh, because if it goes in the blood maybe that’s what triggered those 30 events. I don’t think there’s a connection there but yes, you want to properly give an IM injection.

VR: Okay. All right. Emma writes, “My mom is on multiple rheumatoid arthritis medications and she lists a bunch that suppress her T cells. Received first Moderna vaccine a few weeks ago. She did talk to the rheumatologist before vaccination, they did not suggest any changes to her medication. Now she found out that the American College of Rheumatology recommends stopping abatacept one week prior to and one week after the first dose but continuing the medication for the second dose. Do you think she will have a strong immune response to the second dose even if her first may have been dampened by the RA medication or would stopping abatacept one week before and after the second dose be the best option?”

DG: Wow. That’s a good sophisticated question. Abatacept is actually a drug we use for treatment of a lot of autoimmune diseases. Ones where we think there’s a T cell issue and basically, you’re targeting something called CTLA-4, which is a co-stimulatory molecule. The question here is we’ve all learned that it’s not just about B cells, it’s not just about antibodies. We want to see a nice robust T cell response and here is an individual who actually is on a drug that is interfering with appropriate T cell response.

One of the first things I always want people to think about is the pharmacokinetics of this therapy. You give a therapy, and a lot of people I think maybe they learn this with tocilizumab, you give that therapy and it doesn’t just work for one day. There’s a certain half-life, a period before elimination. The period, the half-life of elimination for this drug is about two weeks, which is actually interesting when you think about gaps between them. Ideally, you want to have as much of a gap as you can but you’re balancing this against not treating the disease.

This is what we’re doing a lot of times. We’re I guess, on the fly, making these recommendations and we’re saying, if you can space this out, great. We definitely recommend people with immunosuppressive conditions go ahead and get vaccinated. We are concerned that they may not get as robust a response as we would like. The more you can space it away from those vaccines, the better. Just think about it, if you space it two weeks away, you’ve only gotten down to about half the therapeutic level.

I’m going to leave this with, this is going to have to be a judgment call. The more you can space these therapies away from either the first or the second shot, the better.

VR: Kim writes, “I have two little ones. Two and a half years, 12 months in daycare three days a week. There have been cases, though not in their classrooms. It’s scary as heck nonetheless. I’m wondering if clinicians will recommend routine antibody testing for youth at some point. There was a toddler in the center who had MIS-C. He’s out of the hospital and home. There was an exposure but never tested positive. No one can be sure that daycare’s where the exposure happened, but timing of MIS-C was five weeks after the classroom was quarantined. It’s a nerve-wracking time to be a parent. I’m hopeful that the Moderna youth trials will go well. I don’t know how I’m going to mentally take another year of this anxiety.”

DG: Yes, I know it’s tough. The biggest thing here is, when can we get our younger individuals vaccinated? We’re saying we’re going to have enough vaccines for all our 16 and up by the end of May. We anticipate by the time we get into June, I’m going to try to be honest, I’m not going to do the under-promise, over-deliver, I’m going to do the honest, we hope by June we have an extension of the EUA to allow us to get down to our 12-year-olds, so 12, 13, 14, 15 in addition to 16 and up. So, June, we can we can really offer vaccinations to that population, June and July.

As we know, ongoing trials are getting us all the way down to six months. That’s going to be critical. Really, what’s more important than antibody testing in most situations is trying to detect the virus, trying to test as many people. There really is a big effort and a lot of finance behind this to more rapid testing in addition to PCR testing. The more tests you do, the more likely you’re going to pick things up. Yes, unfortunately, with the MIS-C as was pointed out here, a lot of times we don’t even catch that acute infection in kids. They start getting sick and we realize it’s MIS-C because we pick up the antibody tests.

VR: One more from Ellen. “I have a friend in Paris just short of 65 years old, had COVID last March. March 3rd this year was diagnosed again, this time with the U.K. variant. On March 21, three weeks after diagnosis, RT-PCR symptomatic still. Her antibodies were tested, were almost nonexistent. She’ll be getting the vaccine shortly, AstraZeneca, and I advised her to have them test it again three weeks after the second dose. If she still has few or no antibodies, would she be a good candidate for monoclonal antibodies? She’s concerned long term that without antibodies she will be liable to reinfection forever. Should she get tested for T cells, although from what I understand from Sette, they will not protect her from infection?”

DG: Actually, very sophisticated. Those are interesting ideas. We have the idea that the antibodies prevent you from getting infected, that the T cells very quickly clear. The kinetics, people may not know the kinetics. I always joke about this to people. They know how long a red cell lasts, but they don’t know how long a T cell last. They don’t know how long it takes for the T cell response to fire up. The T cell response, we know from the T-detect studies from the Adaptive Group about day three to four you have T cells ramping up. They ramp up pretty quickly.

We don’t know how much of the protection from the vaccines come from T cells or how much comes from antibodies. Going forward, I would envision there being certain individuals, particularly we talked about the person on abatacept, where maybe they’re going to have an issue with their immune response, particularly a person who’s maybe on Rituxan, a therapy that interferes with B cells. In addition to vaccination, maybe these people are going to get a monoclonal cocktail or a Vir GSK variant, non-shifting targeting monoclonal once a year.

I don’t think we know yet but I think these are excellent questions that are being looked at. Some people, if the prevalence stays as high as it is, may still need something beyond just the vaccination. The hope is that we get so many people vaccinated that chance of exposure becomes minimal, but that will take, as was mentioned, not only getting all the adults vaccinated, not only getting the adolescents vaccinated, but getting the kids vaccinated as well.

VR: That’s COVID-19 Clinical Update #56 with Dr. Daniel Griffin. Thank you, Daniel.

DG: Thank you so much. Everyone, be safe. We still have a rough April ahead of us here. I know Easter, this is going to drop on Saturday right before Easter. Be safe. Keep those group sizes down.

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