TWiV 747 COVID-19 Clinical Update #59

This Week in Virology

Host: Vincent Racaniello

Guest: Daniel Griffin

Aired 24 April 2021

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 747, recorded on April 22, 2021. I’m Vincent Racaniello, and you’re listening to the podcast all about viruses. Joining me today from New York, Daniel Griffin.

Daniel Griffin: Hello, everyone.

VR: Well, as you requested Daniel, you got the 747. You can have the upper deck.

DG: Okay, I’m very excited. We are TWiV 747. What clinical update number are we up to?

VR: This is clinical update number 59.

DG: Okay, wow. All right. I always have this, it’s actually a recurring hope that I will have nothing to talk about but unfortunately, that hope is yet to come to pass. Let me start with my quotation. We have a lot to cover today. Unfortunately, we have not run out of things to talk about. We’ll start off with a quotation from Hegel. I’ve seen several versions of this but this one I think is straight to the point. “We learn from history that we do not learn from history.” I think that that’s, unfortunately, a little prescient with how we are doing now. I’m hoping that at one point we’re going to break from that.

Last week, I talked about the impact that COVID has had on healthcare workers here in the U.S. When I look at what’s going on around the world, it actually seems like things are pretty good here in the U.S. by comparison, but I was on a call recently with a physician in his 60s. Most physicians tend to work for quite a number of years into their later years. I think it takes us so much time and training to get there but this gentleman in his 60s told me that he was retiring this spring. It really occurred to me that it seems like many of my colleagues, more than sort of an usual year, have been mentioning that they either have retired or are planning on retiring in the coming months.

It was actually a poll I just saw today, so, hot off the press. This was a poll done by the Washington Post and the Kaiser Family Foundation, Frontline Health Care Workers Survey.

They actually found that about 30% of healthcare workers polled right at this point in time were considering no longer working in healthcare. William Bond wrote a really what I thought was an excellent piece in The Washington Post about this titled, Burned out by the pandemic, 3 in 10 health care workers consider leaving the profession. Some of the quotations I found to be actually very emotional, and actually in line with some of the experiences that my colleagues have shared with me.

I thought I’d just start off with this. “You feel expendable. You can’t help thinking about how this country sent us to the frontlines with none of the equipment needed for the battle,” said Sharon Griswold, an emergency room doctor in Pennsylvania. “Most of us got into this to save lives but when death is flowing around you like a tornado and you can’t make a dent in any of it, it makes you question whether you’re making any difference”, said Megan Bronson, a nightshift nurse in Dallas.

Continues to be tough. I saw a lot of discussion about physicians being a bit frustrated, feeling like we’ve done so much and been thrown through so much. We ask little things like, would people wear masks? Would they give us a little more time? People are not necessarily willing to do the little things like wearing a mask and making smarter decisions.

Big focus this last week has been on the J&J pause. I will get back, we’ll spend some time on that.

Children and COVID. There’s continued attention to the risk-benefit of COVID and decisions around children. Summer’s approaching and I don’t know if our listeners know, but I do a lot of advising for camps for summer programs. Schools as well. I really feel like there are important decisions to be made here and I’m just trying to provide information about that. As we go forward, I’m going to make sure we get back to these important decisions. Basically, what can we do to make these activities a safe option, a safe choice for our parents, for our kids?

Pre-exposure period. Here’s an article, SARS-CoV-2 seropositivity and subsequent infection risk in healthy young adults, a prospective study. This was The Lancet and I think we discussed a little bit about this when it was out in preprint but it’s now out there published. This analysis was performed as part of the prospective COVID-19 Health Action Response for Marines study, CHARM, nice acronym there. It was predominantly looking at male U.S. Marine recruits, aged 18 to 20 – 92% of these were men.

Really that’s sort of the makeup of these U.S. Marine recruits. Eight percent were women. They enrolled 3,249 participants and it was a mix. Some of them had had COVID before and were seropositive. Some were not. They look specifically at the 189 seropositive individuals. They went through a whole sort of recruitment-like quarantine process, they made sure they were negative. They kept them for two weeks in a quarantine with checking PCRs, really wanting to verify that when they entered training, they were not PCR positive. I don’t think they were doing this because they were trying to do a study, they were doing this because they were trying to prevent an outbreak but unfortunately, there was an outbreak.

Among these 189 seropositive participants, young, healthy, mostly males, 10% of them went ahead to become PCR positive during a six-week follow-up. I just want to point that out to people. People say, “Oh, you’re at low risk.” Actually here were seropositive young, healthy individuals. Ten percent of them went ahead and actually were reinfected during a six-week follow-up period. This was a lower percentage than the people who were seronegative and had never had it before. They actually go ahead and conclude and they say, “Although antibodies induced by initial infections are largely protective, they do not guarantee effective SARS-CoV-2 neutralization activity, or immunity against subsequent infection.”

My takeaway among this was that yes, young, fit adults can get reinfected even with positive antibody tests. Ten percent went right ahead to get reinfected despite having those antibodies. Just a little more support, as if we need it or don’t, for people to go ahead and get infected. Go ahead and get vaccinated, not infected. I see this and I’m hearing it, patients now always try to ask like, “Hey, here we are. It’s April, you’re admitted to the hospital with COVID. What was the story with the vaccine?” I keep hearing, “Oh, I was told I was supposed to wait. I think maybe back in January, I might have had COVID. I’m waiting. I’m told I’m supposed to wait a period of time.”

Don’t wait. Do not miss your opportunity to get vaccinated. Don’t go to the doctor and follow your antibody levels thinking that that offers some evidence that you’re not going to get infected. I had an individual recently, this is an older individual. They were infected in January and here they are back– it’s April, and they’re in the hospital. Just want to say that those positive antibody tests are not really a way for you to decide not to worry and to wait to get vaccinated.

Transmission. Now people are very passionate about this topic and I’m always happy to return here. It gets both love and mostly hate mail. What do we call that? That is constructive criticism which we in science communication are supposed to develop a skill at handling.

What we have learned and what we discussed last TWiV was that the virus is rarely transmitted by surfaces. I think everyone is very comfortable with this sort of calculation, the CDC suggesting that perhaps maybe one in every 10,000 cases was due to fomites or surface transmission. I actually think my favorite most accurate and perhaps least controversial statement by the CDC moves on to, COVID-19 is most commonly spread during close contact and can also spread by airborne transmission.

This is from the CDC page, How COVID-19 Spreads, last updated October 28, 2020. Really nothing new right there but it has been acknowledged that airborne transmission is a possible way that people can get COVID-19. For healthcare settings, it’s important for us to understand when airborne transmission could occur. I’ve tried repeatedly to return to situations outside healthcare settings where we are seeing this as an issue. This is the classic suburban home whereas the CDC points out, these transmissions occurred within enclosed spaces that had inadequate ventilation. Sometimes the infected person was breathing heavily, for example, while singing or exercising.

A little more information on masks, we saw a research letter, Fitted Filtration Efficiency of Double Masking During the COVID-19 Pandemic. This was published in JAMA Internal Medicine, April 16, 2021. The authors looked at double masking, they were reporting on fitted filtration efficacy, FFE. Now, what is that? They explain, and I quote, “In brief, FFE corresponds to the concentration of particles behind the mask expressed as a percentage of the particle concentration in a sodium chloride particle-enriched chamber, measured during a series of repeated movements of the torso, head, and facial muscles, as outlined by the Occupational Safety and Health Administration, quantitative fit testing protocol.” Did anyone really get that?

Basically, what they’re doing is they’re having people move all around, and they’re measuring how much gets through the mask, sort of a percentage of what’s outside and what gets sucked in through the mask. This is actually interesting. This is looking at masks protecting you, where previously we’ve discussed a lot about masks protecting other people. As altruistic as I know all our listeners are, a lot of listeners are interested in how well do the masks protect us. We are not measuring what gets out into the environment, but what gets sucked in through the mask or masks. They concluded that wearing a medical procedure mask underneath a cloth mask provided the best improvement to FFE of all the combinations they evaluated.

They reported that if you’re wearing one of these procedure masks, and then you go add a single cloth mask over one of these medical masks – which actually people can now buy, you can order them, they’re these sort of blown weaved masks – you get an additional four to 14% protection by putting that over there. What they point out, and I think I tried to harp on this as well, it’s really fit, not so much material. That is really a critical factor in masks protecting us. Now, this study had limitations. It was only done on as they say one female volunteer and two male volunteers with shaven faces. I thought that was interesting, they didn’t have the comment there about the female volunteer. It’s also not the result I wanted.

I have to say, I hate to have to wear two masks, I would prefer it if they demonstrated that just wearing that procedure mask was great stuff but that’s the problem with science. You get the truth, not confirmation of what you want to be the truth. I thought I would throw a case in here of a woman that I’m currently taking care of who is 100 years old, she’s in the hospital. I was asked, “What happened? Who went to kindergarten and learned that they should share?” She described that she was living in her home, she was waiting to get vaccinated because she just hadn’t been able to navigate the system and then one of her family members who had COVID came to visit her.

This family member visited her indoors. She actually said it was about 20 minutes, they were nice and close, they were within that six-foot zone. Nobody was wearing a mask and yes, about five days later she started to feel poorly, went on to test positive for COVID. Now she’s in the hospital on increasing amounts of oxygen, new-onset atrial fibrillation, she’s now developed delirium. This is the story we usually hear, is that two people are within a certain period of time, the suburban home is really a deathtrap, and they’re not wearing masks and I’m not quite sure I understand why someone who has COVID would be visiting their 100-year-old family member.

Testing. Never miss an opportunity to test. It’s been a long time coming, but we now have access to in-home rapid antigen testing thanks to BinaxNOW. We have this $25 test available here in the U.S. Recently this is something you could order on the computer and have sent to your home in six packs, 10 packs, 1,000 packs, actually. They are now coming to a pharmacy near you. They do not require physician access. They are not Lick-A-Sticks. These are lateral flow antigen tests. They involve you swabbing the front of your nose with one of these little Q-tips and then sticking it into this prepared card and waiting about 15 minutes. There’s a little bar scan code there that you use your phone to scan in your computer.

These actually started shipping to the major pharmacy chains on April 19, so really going to improve people’s access to testing. It’s still not at the price point that we would all like, we would like the test to be cheaper. People have actually gotten pretty comfortable with the nose swab so I’m not too concerned that it needed to switch over to a Lick-A-Stick, but we would like it to be less expensive because if you think about this, this is going to be an equity issue again. For some people, $25 to get a test is no big deal, for many of us $25 a test starts to add up if it isn’t already a barrier just right off the bat.

Active vaccination. Here we are, never miss an opportunity to vaccinate, never waste a vaccine dose. In the U.S., we have now shifted from arms searching for vaccines to vaccines searching for arms. We are approaching in some parts of the country that time where really vaccine hesitancy is going to be the next great hurdle. Here in New York, we saw Executive Order 202.102. Now, what is that all about? Effective April 19, as per this executive order, they eliminated the $100,000 civil penalty for failure of a provider to administer their allocated COVID-19 vaccine within seven days of receipt. I don’t know if people are aware of this but here in New York, if I as a provider were to accept 100, 200 vaccines, I had seven days to get those into arms. If I did not report and get those into arms within seven days, I could face up to $100,000 civil penalty.

I have mixed feelings about this. One is, it’s nice not to have that hanging over my head but I am hoping those vaccines don’t end up just sitting in refrigerators. I will point out, Moderna when it arrives, you pop it in the refrigerator. While it can stay there for 30 days, it shouldn’t. Pfizer comes in those thermal shippers which you can reload every five to seven days with dry ice. Once you take them out, they can actually sit in the refrigerator for up to five days. We’re hoping that extends a little, they’re just waiting to get approval. We’re not at J&J yet, stay tuned.

We did get an update on the impact of vaccinations in the long-term care facility settings from the CDC MMWR, Postvaccination SARS-CoV-2 infections among skilled nursing facility residents and staff members – Chicago, Illinois, December 2020 through March 2021. The authors reported here on 7,931 skilled nursing facility residents and 6,834 staff members that had received two doses of COVID-19 vaccination in 75 Chicago-based skilled nursing facilities. In this group, they reported – I’m going to use the word “only” – 22 possible breakthrough SARS-CoV-2 infections among the fully vaccinated persons greater than 14 days after their second dose of COVID-19 vaccinations.

Two-thirds of these 22 were asymptomatic, a minority of persons with breakthrough infections experienced mild to moderate COVID-19 symptoms, two of the 22 required hospitalization, and one death did occur. There were no facility-associated secondary transmissions in this study. I think this is really encouraging seeing thousands of people being vaccinated and seeing such a small number but it does, as I like to point out, you are not bulletproof. There were two of these individuals that required hospitalization. One person did die from COVID-19.

We also had an update on mRNA vaccine safety in pregnant women. This is huge. We can now say that, yes, these vaccines have been studied in pregnant women. In the New England Journal of Medicine on April 21, we saw the article, Preliminary findings of mRNA COVID-19 vaccine safety in pregnant persons. The authors reported on 35,691 v-safe participants, 16 to 54 years of age, identified as pregnant and found no safety signal. I think this is really critical where we’re looking now at over 35,000, so this is the same number of total participants in the early trials.

We are not seeing safety signals and this adds on to the data that a person who is vaccinated during pregnancy can pass on protection to their, at this point unborn, and later, born child. I think that that’s going to help.

Back to the J&J controversy. A couple things I have to say here. There was an Axios-Ipsos poll, and they reported that over 90% of the public is aware of the pause. They reported that the 91% awareness level is considered on par with or even a cut above awareness of who won the Super Bowl. I tested this this morning in the ICU, and we all got it wrong. We knew it wasn’t the Patriots. One person thought it was the Chiefs, I actually don’t know if that’s true.

I will say they also reported that about 88% of the people that said they were aware of this actually felt that the CDC and FDA were doing the responsible thing. Now, when this episode becomes available, the emergency meeting of ACIP will have taken place, we’re recording this on Thursday night, so that’s hopefully going to happen Friday, and then this will drop Saturday, not as early in the morning as it used to but I understand that. We will hear what they have to say. I won’t weigh in. I’ll guess on what they’re saying. The hope is that they’re going to allow us to continue to use this vaccine, that there will be a warning so people are aware of what the risks are, should they choose this as an option versus the other vaccines.

We’re hoping, I say as providers, that there isn’t any restriction that is forced on us, that this is something that we allow patients and providers to have a dialogue about. I bring up my daughter, Daisy Griffin, who’s been tweeting about this, and putting out relative risks of other things. Some of her comments, “Daddy, if I or one of my friends have to drive like an extra hour to get one of these other vaccines, I’m not sure that the risk of the vaccine is really a great thing relative to the risk of us being in a car an hour each way, half an hour each way.”

We are hoping that we continue to have access because yes, I did say last time that we still have plenty of vaccines but not all the vaccines are used in the same way. When we had the J&J shut down, instead of people being vaccinated on their way out of the hospitals here in the New York area, they were basically given a piece of paper with an email address to try to arrange their vaccination. We also were using these kitchen workers, people in harder-to-reach populations who really had trouble coming for two sessions. There’s an equity challenge here so we’ll see what happens.

Europe’s health regulator, the European Medicines Agency, the EMA, on Tuesday, April 20, recommended adding a warning about rare blood clots with low blood platelet counts to the vaccines product label for J&J, and said that they felt the benefits of the one-dose shot outweighed its risk. We’ll see what happens here in the U.S.

The incubation period. The post-exposure. You’ve been exposed. Remember, tests do not predict the future, there is a two to 14 day incubation period but they can help us detect infection prior to contagion. Now that we have more testing, once someone has been exposed, if they’re doing a $25 test every day, you can quickly detect before they spread to other people.

I think cheaper, better access to tests are going to really help us. Do not stop testing. Never miss an opportunity to test. We’ve got to keep doing that. Now, what about the period of detectable viral replication? Now you’re starting to have symptoms, it’s that first week, I like to say this is the time for monitoring and monoclonals. We actually got some interesting evidence here on passive vaccination. There was what I think was a very nice article. The article was entitled, Real-World Experience of Bamlanivimab for COVID-19, A Case-Control Study. This was accepted for publication in the Journal of Clinical Infectious Diseases.

The authors– I actually reached out to them earlier today so hopefully they’re going to give me a little more information, I have questions. But, they conducted a retrospective case-control study across the single healthcare system of non-hospitalized patients aged 18 years or older with documented positive SARS-CoV-2 testing, risk factors for severe COVID-19 and referrals for bamlanivimab via emergency use authorization. This is back when we were doing just bam-bam before we had shifted to the monoclonals. They looked between November 20, 2020, and January 19, 2021, at 218 patients that received bamlanivimab and 185 who were referred but something stood in the way and they ended up not getting drugs.

These were the controls in this study. The 30-day hospitalization rate was significantly lower among patients who received bamlanivimab, 7.3% versus 20%, relative risk 0.37, p-value here of 0.001. This was a real-world reduction of greater than 60%, with a very simple well-tolerated treatment. If you dig down through this data, I think you may underestimate the impact because if someone has more severe risk factors, there’s a little bit more of a push to make sure they do go ahead and get that treatment, people at lower risk so there may have been some impact there.

Another thing that really caught my attention, the author’s comment on something that they felt highlighted health inequities, they reported that they found White English-speaking patients were more likely to receive therapy. Even though the materials are available in Spanish, we are not doing a great job of making sure this therapy is out there. We’ve been moving as mentioned past just bam-bam, we’re now using cocktails and looking at second-generation monoclonals in trials that are looking for EUA. I was actually on a call recently with Ben Wiegand and across the country looking at when, it was early mid-March that we switched using cocktails across the country, and I think we’re feeling that that was an excellent decision. None too late, not too early definitely.

Now, I also was on another call with, I’ll say a member of the formerly called Operation Warp Speed, and I feel like it’s like Prince or something, they needed a new name before. One can take this as a glass half full or empty, but over 400,000 monoclonal antibody treatments have been given to date when I was on this call, more are already purchased by the U.S. government and waiting to be administered. A couple things here, that is small. I look at 400,000 and I say that’s enough for about a week of people getting infected.

The whole IV infusion approach is a barrier, so there are some ongoing studies looking at both subcutaneous and intramuscular injections. I think people can envision a world where one is diagnosed, whether this is an ER, an urgent care, a primary care office, immediately offered an injection right there at point-of-care with these really impressive efficacy points.

The early inflammatory phase. This is if you’ve gotten through that first week, you’re entering into that second week. If the room air saturation – so, your pulse ox gets below 94% – this is when we consider steroids, remdesivir, anticoagulation for hospitalized patients.

I wasn’t sure where to put this paper but I thought I would throw it in here. There was an interesting and I will say concerning paper out of Columbia University published in Brain, and it was, COVID19 Neuropathology at Columbia University Irving Medical Center/New York Presbyterian Hospital. The authors presented the clinical neuropathological and molecular findings of 41 consecutive patients with SARS-CoV-2 infections who died and underwent autopsy in our medical center.

Here’s the first caveat. Remember, these people all died so this may not be what is going on in every person with COVID’s brain. Neurological examinations were done of 20 to 30 areas of each brain and they saw hypoxic-ischemic changes, these areas not getting enough oxygen, not getting enough blood supply. They saw this in all the brains, they saw large and small infarcts. Think of those as strokes. Many of these appeared hemorrhagic, so bleeding into the brain. They also saw activation of the microglial cells with microglial nodules and accompanied by neuronophagia, most prominently in the brainstem.

Neuronophagia, so that’s our word for today, that’s actually the microglial cells, so the immune cells in the brain are actually eating your neurons. Really a frightening thing to be happening here. They reported that they saw only sparse T-lymphocytes, so T-cells in either perivascular regions or in the brain parenchyma and many of the brain cells as would be expected contained atherosclerosis, so hardening of the large arteries, arterial sclerosis. But none had any evidence of vasculitis, so inflammation of the blood vessels. Now, they went on to examine multiple fresh, frozen, and fixed tissues from 28 brains for the presence of viral RNA and protein using a whole bunch of techniques and antibodies directed against the spike in nucleocapsid regions of SARS-CoV-2.

The PCR revealed low, very low, but detectable viral RNA levels in the majority of the brains and they performed something called RNA scope, which is an in situ hybridization technique looking at immunohistochemistry. This all failed to detect viral RNA or protein in the brains. Maybe people listened to TWiV 746 where there was a whole discussion about how virus can sometimes get into the brain or not. These authors concluded that these findings suggested it was really not virus getting into the brain, it was really microglial activation, these microglial nodules, this neuronophagia, these immune cell-eating nerves that was really causing what was going on and not direct viral infection of the brain parenchyma. There also was probably a synergistic contribution from the hypoxia and the ischemia.

Now we’re going to move on to the tail phase, Long COVID. We had a long episode last week so I saved this one for now. Is it a bit of good news to end on? Let’s see. In the JAMA Network, open the article, Mortality among U.S. patients hospitalized with SARS-CoV-2 infection in 2020 was published. This was a retrospective cohort study including patients who were hospitalized for at least one day at one of over 200 U.S. acute care hospitals between March 1 and November 21, 2020. They reported on 503,409 admitted patients and found that in-hospital mortality declined across all age groups during the period evaluated.

Overall, in-hospital mortality peaked in April of 2020. I think we can remember that horrible month where the in-hospital mortality was 19.7% and then decreased significantly to November, where it was down to 9.3%, still unacceptably high. Really nice article. Go ahead and I’m going to actually say, “Once you finish this or you’re driving or stop”, look at this article. They have a really beautiful figure where they show that this trend was apparent for all age groups. The older you were, the higher the mortality, thus the greater the decrease. This was apparent across all age groups. We are doing better at all ages.

The mortality that we’re seeing is lower in hospital and this is reflected in part because we have younger people, but it also is that we are getting better at taking care of these people, at an individual age-adjusted, we are decreasing the mortality. I’m going to end on that note before we go to emails.

We are nearing the end of our fundraiser donations made to Parasites Without Borders. Go to parasiteswithoutborders.com. We are going to contribute to the American Society of Tropical Medicine and Hygiene. I think I left out hygiene last time, and we never want to leave out hygiene.

We are going to, and I think we’re going to get there, give them $40,000 to support three travel awards helping women, qualified early-career investigators working in tropical medicine, to attend the annual meeting. Help us support these. It’s actually women, low-income countries, coming to this meeting and help do what we can to address some of the inequities.

VR: Time for a few emails for Daniel. If you’d like to send one, send it to daniel@microbe.tv. First is from Avital, who is a single mom with a seven-year-old daughter, just got her second shot of Moderna. She sends a picture of getting the shot with her TWiV t-shirt. That’s becoming a thing. People are sending us their photos with their TWiV t-shirts. Wonderful, love it. “In a couple of weeks”, she writes, “when I’m fully vaccinated, we’re going to go fly back home to Montana, my daughter will go to camp. The camp is doing all the right things, wearing N95 masks, face shields on the plane. The summer camp is outdoors with COVID precautions. However, I know her risk of exposure will be increased. In the case of an infection in a child, what would you suggest as far as a course of treatment to try and avoid the inflammatory syndrome which sometimes occurs? Also, do you have any general guidance for vaccinated parents with unvaccinated children?”

DG: All right, so there’s a lot there. I think you hit several points. I like the fact that you’re wearing the KN95s on the airplanes, in the airports. I think we try to point out, as per the CDC, there’s a respiratory droplet component of transmission. There also can be an airborne component of transmission, particularly when you’re in these crowded indoor spaces and you’re not aware of how good the ventilation is going to be. If a child gets COVID-19 that first week, one of the interesting things that’s come up several times, would they benefit? Would we reduce the risk of them getting MIS-C?

Is there anything we can do to prevent them to lower that risk? It is a low risk, I do want to point that out, but we don’t have a lot of great recommendations or proven therapies that we could do during that first week. Just like an adult, if they move into that second week and start having low oxygen saturations, then we extrapolate, and a lot of clinicians would actually consider a weight-based adjusted dose of steroids, oxygen support. If they get into week four, unfortunately, I’m not going to say that we have any great evidence that we can prevent that, and part of that is the low risk relative to the risk of us doing anything, then there have been treatments that are suggested.

The camp, it sounds great that they’re doing all the right things. I was doing an interview recently where I talked about, how do you know that the camp is doing the right thing? Testing. There is now testing that is being paid for, provided for by the government. If your child is going to a camp and they have a testing program ahead of time to make sure kids don’t show up with the virus and then they have testing programs in place once they arrive, I think of that as a marker. These are tests that the camp does not have to pay for, our tax dollars have already paid for these.

If the camp is taking advantage of that program, I think it shows that they’re being proactive, taking this seriously. That’s probably the best thing you can do for your child. What is the best way to make sure a child does not have issues with COVID? It’s to make sure they don’t get infected with COVID, and that should be a way of keeping them safe.

VR: Avital points out that she’s heard rumblings of a Pfizer pediatric trial being set up in Pittsburgh where she lives and she’s hoping to enroll her daughter in that trial.

Our next one is from Gordon. “Thanks for the good discussion on the use of fit masks. I’m puzzled by the reluctance of authorities, including yourself, to recommend the use of N95 respirators. If you’re trying to protect yourself against a potentially fatal infection, wouldn’t it make sense to use the highest level of reasonably obtainable protection?

I know N95 respirators were in short supply in 2020, but I think that’s no longer an issue. You can certainly buy them on eBay. Here in La Paz, Mexico, I can purchase a Chinese KN95 at any pharmacy for $2. The ones I use appear to be well made with the same materials you would find in a 3M N95. Is it that old bugaboo we don’t have the data to show they are needed or better? Personally, I’m not relying on a cloth face mask that meets no mandated quality control or performance standards to protect me, but then what do I know? I’m just a retired health and safety professional.”

DG: Just a retired health and safety professional. I think you’re on point with this. The data is out there, we have a lot of evidence about different masks and their impact upon your safety. If you told me, “I’m a person who’s immunosuppressed. I’m 92 years old. I’m planning on going to a big indoor gathering.” Yes, I would want you wearing an N95 mask. I don’t see a problem with recommending that at all.

If we’re talking about physicians working in a setting where we have good air exchange, if you’re going to be outdoors, able to distance yourself, then I’m not sure you need to wear the N95. As I think I mentioned, the woman traveling on an airplane when my wife and daughter, actually Eloise, I think this time were on an airplane at one point. I advised them and they went ahead and listened to me, crazy as that sounds, and they wore a KN95 the whole time that they were in transit.

Once they got to the other side and were outdoors, off came the mask. My son, Barnaby, tells me that his mile time is impacted negatively when I have him wear a KN95 on the cross-country course on the track. No, I think that the data is out here. The N95 does offer more protection. I think as we talked today, if you’re going to wear one of these surgical masks, it looks like if you throw a cloth mask over it, you can increase your protection as well.

We’re still in the middle of a pandemic. There are areas in our world and even here in this country where the rates are unacceptably high and the risks are unacceptably high. I think the science is out there to say that there are more effective masks that can decrease that risk.

VR: Teresa writes, “I’m a nurse working in Canada. I was not given the Pfizer vaccine because I had an anaphylactic reaction to depo lidocaine injection for a frozen shoulder which does contain PEG, polyethylene glycol. Doctors felt it could be a preservative that caused the reaction. I was then given the AstraZeneca vaccine and now fall into that category of 55 and under, questionable about getting the second dose. What can be done for someone like me? Do you feel there will be a change in the Pfizer vaccine and removing this ingredient? Now I’m worried. I won’t be able to get any other vaccine. Any ideas?”

DG: This is an excellent question and I think hits that really practical advice here. When they’ve looked at the AstraZeneca, the people who are having the reactions are having them after the first dose, we’re not seeing that then they go ahead and have them after the second dose if they tolerated the first one. The current recommendations are that if you tolerated the first AstraZeneca dose, it is fine to proceed with the second AstraZeneca dose, I’ll say that. You can’t really take the PEG 2000 out of the Pfizer or the Moderna. It’s actually part of that liposomal packaging.

It’s not a preservative in that setting. If you had an issue with the Pfizer, with the Moderna, I think it’s reasonable to look at the adenovirus vector vaccines completing your AstraZeneca here, J&J for individuals in other settings. I think we’re hoping – fingers crossed – that we’re going to hear about Novavax coming out as well. That’s our pure protein Shingrix technology being applied now to COVID. That we’re thinking another option for people that have had issues with other vaccines. Looking forward to not only more and more vaccines in the world, not just here in the U.S. but also looking at vaccines that have different safety profiles, may allow people to have a little more selection and I see that as positive for several things. One is that if people have the ability to have a choice, if they have that agency, I think it helps.

It helps with vaccine hesitancy. People don’t want to be told this is what you got when you sign up, you get what we tell you. People like to have some involvement in the decision-making. I think that’s really positive. I will say, we may have too many vaccines here in the U.S. We may have a glut. I liked an analogy I heard that yes, it’s fine to put that oxygen mask on yourself first before you help everyone else, but don’t leave four oxygen mask sitting in your lap, let’s get those oxygen masks on everyone as well.

VR: That is COVID-19 clinical update number 59 with Dr. Daniel Griffin. Thanks again, Daniel.

DG: All right. Thank you so much and everyone, be safe.

[00:42:46] [END OF AUDIO]

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