TWiV 764 COVID-19 Clinical Update #65

This Week in Virology

Host: Vincent Racaniello

Guest: Daniel Griffin

Aired 5 June 2021

pdf of this transcript available (link)

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

[MUSIC]

VR: From MicrobeTV, this is TWiV, This Week in Virology, Episode 764 recorded on June 3rd, 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: Daniel, last time, I think, I asked you when the pandemic would be over. Now I understand Tony Fauci says July. How about that?

DG: Oh, yes.

[laughter]

VR: I don’t believe it because we’re not going to hit the level of immunity. What do you think?

DG: I worry about that question for several reasons. One, every so often I go on social media, and when that question has been bantered about, somebody replied back with which pandemic, pointing out that the HIV/AIDS pandemic is going strong. I think that really goes in-line with the fact there’s this real narrow focus people might have, is the pandemic over in New York City? Is it over in the United States? Is it over in the world? The HIV/AIDS pandemic is not over in New York City or nor the world. I do think, and we’ll talk about this, that rates are going to get pretty darn low in July and August here in the U.S. If you look around the world, this pandemic is far from over.

VR: That’s right. Absolutely.

DG: Let’s start with our quotation. I was thinking of you when I picked out this quotation, Vincent. “If you set out to be liked, you would be prepared to compromise on anything at any time, and you would achieve nothing,” and that was Margaret Thatcher. I’ve just noticed a lot of the recent TWiVs have discussed the viral origins. I’m sure you’re getting wonderful, loving emails in response from all the people that agree with you. Even the ones that don’t, I’m sure it’s very civil discourse.

[laughter]

VR: Right. You got it.

DG: Things here in the USA, I got to say, I’m going to use the word pessimism and optimism here, but I always prefer the truth. People say, “Oh, I just want to look on the bright– I want to actually know the truth.” There were a lot of people with predictive models about where we were headed. One of the predictive models, or the pessimistic model, this was June 1st, the article, “Association of Simulated COVID-19 Vaccination and Nonpharmaceutical Interventions With Infections, Hospitalizations, and Mortality.” That was published in JAMA Network Open.

Here, the authors report on a number of simulations that they were suggesting supported the idea that if we removed masks or all these non-pharmaceutical interventions while the vaccines were being distributed before we got to a high level, that we would see substantial increases in infections, hospitalizations, deaths. We’re not seeing that. What we’re actually seeing across the country is that we actually have continued vaccine update. We’re really seeing an exponential drop in cases, and one of the things that I’ve actually talked to people a lot about.

People asked me, “What did you think about when the CDC made that comment about people with full vaccination don’t necessarily have to wear masks in a lot of situations?” It was interesting to watch, because the number of people being vaccinated, the number of people scheduling to get vaccinated per day, was actually declining. If you actually look at that day when Dr. Walensky came out with this announcement, there actually was an uptick in the number of people going to the vaccine websites to schedule. Then Anthony Fauci said, mused that, boy, I wonder if this might actually be an incentive. There was another uptick in people visiting. Then the President tweeted, and there was another uptick.

People like carrots, the chocolate-covered carrot. The, “Hey, I may not believe in those things, but if I get a shot in the arm, I’m allowed to take my mask off. All right, whatever, I’m not that anti getting vaccinated.” What we’re seeing, and I think to echo this is on the ground here, we are seeing a significant drop in the number of people testing positive. The other day, I think Monday, it was in the 300s in the entire state.

I did get admission this morning with a gentleman in his late 50s with COVID. Unfortunately, there’s a perception going with the, “Oh, the pandemic is ending.” This gentleman was seen nine days ago. He’s a gentleman in his late 50s, he has hypertension. His doctor said, “You got the COVID, but don’t you worry, because the COVIDs going away, the COVID you have is mild. We’re not really seeing hospitalizations or deaths anymore.” [chuckles] I want to point out, no, the COVID in him is the COVID in him. COVID has not evolved into a less virulent pathogen. This person was not offered monoclonals, really was offered nothing other than Tylenol for his fever.

Now he’s in the hospital. He’s on steroids, he’s on remdesivir, he’s on blood thinners. He’s on oxygen. Just because it’s getting better all over, that individual patient is still at risk of bad outcomes. We’re still seeing hundreds of people dying per day. As rosy as we like to paint the picture, people are still dying every day. Hundreds of people are still dying here every day in the U.S., and around the world. The picture, particularly in lots of Southeast Asia, South America, it’s really not great.

VR: Was he vaccinated?

DG: He was not. I asked him that, and he rolled his eyes and said, “I’m regretting that decision.”

[laughter]

VR: Oh, boy.

DG: If he could go back in time, I think he would have made a different decision, and that’s what he told me. I did start off, I gave him a hard time because he’s not vaccinated, I said, “What are you doing? It’s like wearing bell-bottoms. This is not what you’re supposed to be doing these days showing up with COVID.” He’s, “I know.” Hopefully, he’s going to do well, fingers crossed. We’ll provide him with all the care we can. Hopefully, then he will discuss to other members of his tribe the benefit of vaccine versus the five-day hospital stay, hopefully, five-day hospital stay only.

Children and COVID, as I like to say, children are at low risk, but they’re not at no risk. CDC updated the camp guidance again, May 28th, so what is new? As far as masks, staff and campers who are fully-vaccinated do not need to wear masks at camp, except where they’re required by local legislature. Although fully-vaccinated people do not need to wear masks, camps can be in support of staff or campers who choose to continue to wear a mask. I’m still that guy at the gym wearing a mask. Hopefully, people will continue to support that.

Physical distancing, again, they’re doubling down on this saying people are fully-vaccinated except as indicated. Physical distancing is not necessary for campers and staff who are fully-vaccinated. Hand hygiene, respiratory etiquette, apparently now, Vincent, you no longer have to wash your hands or cover your cough now. Just joking there. [chuckles] You should continue. This is COVID independent, but you should continue to have health-promoting behaviors such as hand hygiene, respiratory etiquette. Remember, respiratory etiquette is not coughing into your hand and offering it to your neighbor for a firm hand embrace.

They do weigh in a little bit on cleaning, improving ventilation, maintaining healthy facilities. They still want you to continue cleaning, disinfecting, and continue to hammer on ventilation recommendations. If it’s a high-touch surface, keep cleaning it. I think that’s good practice over time, but they do say maintain, improve ventilation, open those windows, use the air filters, turn on the fans. All those things that we’ve learned can be of benefit. They do actually weigh in on testing, so people who are fully-vaccinated do not need to undergo routine COVID-19 screening testing.

Then they go in just a little more, if a person’s fully-vaccinated, they’re exposed, but they don’t have symptoms, you do not need to keep testing them or quarantine or isolate them. If they get infected, however, so they start showing symptoms, then you go ahead and you test them because we do see breakthrough there. I’m wondering if Columbia’s going to do away with the testing on that ReopenCU application pretty soon.

VR: I’m waiting. I really am waiting to not wait on line for the bathroom anymore because we’re only allowed one person at a time in the bathrooms.

DG: That can be a challenge for– Welcome to what the other sex has experienced for many years, right?

VR: Yes, that’s true.

DG: They always set up facilities so that– Yes, okay. [chuckles]

VR: We still have distancing and masking requirements here as well. You can’t have more people in a lab that would not allow six feet of distance, you have to wear masks, etc.

DG: Did you upload your vaccine card?

VR: I did.

DG: There’s now a vaccine requirement at Columbia for COVID.

VR: That’s right.

DG: Testing. Never miss an opportunity to test. We still see there being an important role for this in certain contexts. This is modifying a little. What about serology testing? What about that other test? The FDA has actually recommended that we do not check serologies. There’s actually an FDA posting on this. I’m going to touch on this a few times because, just by the way, physicians are not listening to that, nor are patients. We’ll get into that issue in different contexts. What about those rapid tests? There’s been this idea and there was an event, I think, in Washington, a couple of things in Washington that maybe gave rapid antigen testing a bad name or some loss of confidence.

There was an article, “Same-day SARS-CoV-2 antigen test screening in an indoor mass-gathering live music event: a randomised controlled trial.” This article was published in The Lancet Infectious Diseases. This was a randomized, controlled, open-labeled trial, so people knew they’re getting tested, to assess the effectiveness of a comprehensive preventative intervention for a mass-gathering indoor event. This is a live concert, so testing is part of this comprehensive program. What they did is they did same-day screening of attendees with an antigen-based rapid test. They also face masked, adequate air ventilation.

The whole goal of this, right, is a lot of these venues were shut down and it was really asking the question, “Can we put together this program, which includes testing, to allow these events to occur in an acceptably safe manner?” These were adults aged 18 to 59 with a negative result, so you were tested, you had a negative result. This was a nasopharyngeal swab collected immediately. Then, if you’re positive, you got to go home. If you’re negative, then you were randomized either to attend the event, or you get sent home. They got to randomize you so this way, you’re actually going to be in that control group to know if whatever positivity is relative to this event or not.

Then they actually also took these specimens and they did RT-PCR, they did cell culture on Vero E6 cells. What did they do? They then eight days after the event, they collected another nasopharyngeal swab. They analyzed this by rapid antigen, by RT-PCR, and they did a transcription-mediated amplification test, a TMA. That’s a very sensitive PCR modality. The primary outcome was the difference in the incidence of the RT-PCR base confirmed infection at eight days between the control group and those people who were sent home. At baseline, let’s say that we had 3% of people in the control group, the people who were set home, and 3% of the people in the experimental group were positive.

There was no significant difference there. The RT-PCR test was positive in one case in each group, and the cell viral culture was negative in all cases. I just want to point out what I’m pushing out here is that so even though you had a positive PCR test that you missed with that rapid antigen test, there was no viral culture growth. This was below, we think, a level of contagiousness. There was no contagiousness occurring at this concert. Eight days after the event, less than 1% of the individuals in the control arm had a positive antigen or PCR test. No one was found to be positive in the intervention group.

Basically, what they’re reinforcing here is that this is another way of approaching these large gatherings. I think you couple this with a dropping incidence and maybe this is why people are, in certain ways, saying we’re getting to the end of the pandemic in certain situations. Active vaccination, never miss an opportunity to vaccinate and vaccines are how this pandemic ends. Moderna has now officially applied for the EUA expansion down to age 12. That was on June 1st. We are expecting an approval later this month. That was announced by Moderna. That’s going to help, right, and people are, “Do we need?” Yes, we need as many cylinders firing as possible.

Pfizer is out there. Pfizer, if anything, has a little more ease. You can get it out there, could sit in the fridge for a month. If you work with other groups, you can somehow deal with the fact that instead of ordering 1,000, maybe only worried about 600. Moderna is a little more convenient– to be completely honest. It’s also a little less user issue. I just relate some issues that I’ve gotten calls about, which are frightening. Well-named, famous academic centers where they didn’t realize that that normal saline needed to be added to the concentrated vaccine. They were actually vaccinating people with normal saline all day and then wanted to know what they should do.

The Moderna, it’s pre-mixed, it’s in the bottle, it’s really, I think, very idiot-proof. Nothing’s completely idiot-proof. What about side effects and efficacy? I’m going to talk a little case here about something that’s been in the press a little bit and people have been asking about, “What about the issue of myocarditis after vaccination?” People may have heard that there was a concern raised initially with Pfizer, “Was there an increased risk, increased incidence of myocarditis after Pfizer vaccination?” Information out of Israel suggesting that maybe there was an increased incidence. Pfizer replying with, “It’s really not above background.”

One of the interesting issues that we saw last year is we actually saw a decline in the amount of myocarditis that we were seeing. We got called on a somewhat regular basis. Seems to be men more than women, so adolescent males, late teens or early 20s. I guess you’re not an adolescent in your 20s, but young men who have a viral illness, and then afterwards, they’ll have a mild inflammation of the heart. You’ll be able to pick this up with some blood tests, troponins will rise a little bit, they’ll have a discomfort in the left chest. We give them ibuprofen, Aleve, things like that for a few days, gets better. They tend to do very well in general.

This was earlier this week. A gentleman, early 20s who had gotten his J&J vaccine, I thought– There was a little twist, four days before. He had had COVID back in December. A lot of folks had COVID back in December. Then four days after the vaccine, he started to develop pain on the left side of his chest, radiated up into the neck and down the arm. His troponins were elevated, as were some other inflammatory markers. We treated him with a couple of days of ibuprofen. The troponins trended down, he started to feel better, and now he’s recovering.

It does look like there is some connection here. It is a little bit above background. Interesting enough, it’s not above the background of what we used to see when we had viruses circulating freely, and what I described as a typical course. Even what I described is maybe a little more severe where he actually got the elevated enzymes but short-lived. People take the ibuprofen, the Aleve. They have discomfort for a couple of days, it resolves. That is out there. The CDC has basically said, “This is low incidence, it’s a low risk, and it’s not really something that should impact your decisions regarding vaccination.” We’ll hit on that a little bit later as well.

Now, what about efficacy? On one hand, we’re being told not to check serology tests. Then we keep seeing articles talking about serology tests, and then we bemoan the fact that certain populations seem not to be responding. This is a publication that came out looking at patients with rheumatoid arthritis who are taking a medication called methotrexate, which interferes with the immune system. The article was “Methotrexate hampers immunogenicity to BNT162b2 mRNA COVID-19 vaccine in immune-mediated inflammatory disease.”

Actually, I was earlier on a call with Shane Crotty. I brought this up and we talked about this– a little so shout out to Shane Crotty, who’s hopefully helping us understand some of the immunology in this realm. This was a paper that if you really look at it closely, it tells a slightly different story from the title. They looked at the spike-specific SARS-CoV-2 antibody titers from people with immune-mediated inflammatory disease. They found that those were in a range of, people, you have to write these down, but 25 to 737,310. Those on methotrexate 25 to 694,528. I wasn’t impressed by that difference. The median was actually lower. The median, the middle number where people were clustering, was a little bit lower for those on methotrexate.

Then we get back to the question of, “What really is the cutoff for protection?” Was this median difference actually above or below? Is that a question of more protection? I’ll use an example, was this a 95 versus a 99? Once we’re in the 90s, I feel like we’re pretty good. The other thing that I thought was really interesting, if you look at the data, you can see that twice as many people, so 19% of the people not on methotrexate, had prior infection, and then got vaccinated. We know that skews the data. We know that people that have prior infection who get vaccinated are going to have higher numbers. That was 19.2% versus 8%.

Are we getting a skew here? Are we studying people who are previously infected and vaccinated versus people uninfected and then vaccinated? I would have much preferred a study on methotrexate or not in people without prior infection, maybe methotrexate or not in people with prior infection versus sticking all those together. They also looked at T cells as well, again, with the same caveats, but suggesting a lower T cell response in individuals on methotrexate.

This is clearly a hot topic right now because there’s really people would like to know, particularly we will say the higher-risk populations, people with impaired immune system, or transplant patients, or patients with autoimmune diseases, hematological, so those are the blood cancers, lymphomas, leukemias, things like that. They would want to know if they got their vaccine if they actually have protection or not. What is happening right now is that a lot of their physicians are checking antibody levels. If those antibody levels do not come back above a certain level, they’re being told by the physician to act as if they’re not vaccinated. I don’t know if that’s true or not, we don’t know if that’s true or not.

As I mentioned, we’ve had studies where you vaccinate transplant patients and then check what percent have antibody levels. When we discussed, it was about 15% after the first, a little less than 50% after the second. People are going and giving these individuals a third shot. We do not know if that’s required, we do not know what correlates of immunity here. I think we need to know because if we don’t know, people are going to continue to do these things to try to get out in front of the science to try to help these patients. It is really tough because there’s also an equity issue here. We’re talking about people getting thirds when some people in the world haven’t even had firsts.

This is a tough issue, but the reality here in the U.S. is we now have more vaccines than demand. Some of those vaccines each day are going to waste, so do we say, “You guys sign up.” Instead of it going into the trash, horrifies me, it goes into one of these individuals’ arms. Does that make a difference? Again, something we really need to study, so we know what to do for these individuals. The period of detectable viral replication, so I like to say, the time for monitoring or monoclonals. Then I also want to add, where you get your test is where you should get your monoclonals.

We’re seeing some changes in which monoclonals are recommended in certain areas. The increasing rate of the variants, I’m going to use the old terminology here, P.1 and B.351. Should I translate those into our Roman numerals for our–? That would be the P.1 or the gamma variant of concern. That would be the B.1.351, that’s the beta. [laughs] Basically, what they’re saying is, these clinically-relevant important changes are suggesting that we should be switching over to Regeneron instead of the Eli Lilly monoclonal antibody in eight states. Really, there’s an anticipation that as we see more of these variants– This is why I care about the variants, to be honest, it impacts therapy.

David Ho, a long time ago just said, “Dan, just start using Regeneron. You don’t have to worry about this.” Now, we have more products on the horizon. We’ve got Vir, GSK which basically now in the EUA fact sheet, they actually have data on the ability of the different monoclonals to have efficacy with different variants out there. This is usually not being made at the bedside. We were talking earlier today with a number of physicians. This is being made usually by the pharmacists at some of the infusion centers, at some of the hospitals, at some of the regional distribution, basically, which monoclonal they have in stock.

It’s going to be on us to make sure that when you send your patient for monoclonals, that they’re being treated with a monoclonal which is appropriate for what’s going on in your regional area. The early inflammatory phase. The COLCORONA article finally came out as a peer-reviewed article. “Colchicine for Community-Treated Patients with COVID-19 (COLCORONA): A Phase 3, Randomised, Double-Blinded, Adaptive, Placebo-Controlled, Multicentre Trial.” This was published in The Lancet Respiratory Medicine. We did cover this before at its preprint state, but here it is.

This is a Phase III, randomized, double-blind, adaptive, placebo-controlled, multicenter trial done in Brazil, Canada, Greece, South Africa, Spain, and the USA by the Montreal Heart Institute. The primary efficacy endpoint was the compositive death or hospital admission for COVID-19. Cut to the chase, they failed to show any statistically significant benefit for Colchicine in the treatment of COVID-19, but there was a significant increase in diarrhea. Now the plot does perhaps thicken. If you really start reading through the discussion here, they report that due to a lack of reagents, a lot of these cases– They were never able to actually test and confirm that it was COVID.

A lot of the cases included in the analysis never got a PCR test, a clinical diagnosis. The authors then, I’m going to say, data-mined. You’re not really supposed to do this. They went through and data-mined and suggested that if you then only look at people with PCR positivity cases, then you could show a benefit to Colchicine, so this story may continue. I’ve noticed that we’ve been getting a little bit too long, I’m going to say, so I’m going to go right to the tail phase here. We still have a very limited understanding of mechanisms behind much of what we are seeing in this population.

With the pulmonary issues and neurological issues being very common, we did see what I hope is the first in a line of articles giving us a little better understanding of what’s going on with long COVID. This was the article, “Small Airways Disease is a Post-Acute Sequelae of SARS-CoV-2 Infection.” This was posted as a preprint. The authors looked at adults with confirmed COVID-19 who had remained symptomatic more than 30 days following the acute onset of symptoms. Symptoms, pulmonary function tests, chest computed tomography, so chest CT findings, were compared across different severity groups to healthy controls.

CT images were analyzed measuring regional ground glass opacities (GGO). They actually measured regional air trapping, they had a special algorithm for this. They looked at 100 patients, 67 of them were ambulatory, had never been hospitalized. They report that the pulmonary function testing revealed restrictive physiology, so the lungs were not expanding as much as restriction there, in the hospitalized and the ICU groups, but normal in the ambulatory group. Among the hospitalized and ICU patients, the mean percent of the total unclassified as that ground glass opacification was 13.2% and 28.7%.

13.2% unhospitalized, 28.7% in the prior ICU patients respectively, and was higher than in the ambulatory. Ambulatory patients, you’re only seeing about 3.7%. They were suggesting here that air trapping, this small airway disease, was a significant issue in a lot of these individuals. It could be quantified by CT, and it did actually correspond to initial severity. I think that’s helpful because we’re starting to try to understand what is going on. This is definitely a mixed group of patients here. What I want to say too is long COVID has become a major issue for our society, and actually for employers.

I’ve been in a number of calls in the last couple of weeks here, where a lot of our large employers have realized that a chunk consistent with the literature, 10% or more of their individuals who had COVID, are now having difficulties returning to the workplace in full-capacity. I’ve been asked to help with identifying these; PASC, post-acute sequelae of COVID, Centers of Excellence. This is really a challenge. We’ve all heard of centers of excellence. That should not just be a marketing term. This needs to be a center that can demonstrate some sort of excellence, some outcomes that are excellent compared to the other options that a patient might have.

We’ve talked a little bit about what criteria there should be here. I’d love to hear some impact from people here. I feel like we’re in the early days of long COVID much the way we were in the early days of COVID about a year ago. What works, what benefits people, and we’re getting a lot of input from patients on this. The CDC is hopefully going to come out with their guidance soon, which we’ll discuss. One of the things that seems key is that a multi-disciplinary team is in-place. This gives a patient access to pulmonary, neurology, psychiatric, infectious disease, and other specialists with experience treating acute as well as long COVID patients.

I shy away here from narrow focused programs, which just look at post-ICU, just post-hospital, or just really roll these people into a pre-existing or expanded rehabilitation program. It is much more than just post-ICU rehab. We’re also looking at this. I think it’s important that we truly have centers. You need a critical number of patients because we are still, as clinicians, learning from the patients. This is a dialogue. We don’t know the answers yet. As you interact with a larger volume of patients, you can learn quite a bit more. We also want, and this ties directly in, centers that can connect patients to clinical trials. We are still learning. What is the plural of anecdote? It is not data.

Not only do we feel like we’re learning as we treat these patients, but we want to get these patients connected in clinical trials so we can really formalize that into real science, real data so we know how to help these folks. Telemedicine capability is really of great benefit for these patients. We think of that as probably essential for some of these centers. What are those measures of excellence? What are we hoping to provide for these patients? One which is huge for a lot of our patients, they want to be back to the ability to perform those things they did before. They want to get back to work, they want to get back to that prior function.

They want improvement in symptoms. If it’s trouble breathing, if it’s brain fog, if it’s headaches, if it’s fatigue, they want improvement in symptoms. These centers should actually be providing good patient satisfaction. We want centers where this experience is positive because, boy, these patients have been through an incredibly difficult time with a lot of dismissiveness. Let me close there before we go to emails and thank everyone for continuing to go to parasiteswithoutborders.com, and please do that. Drop whatever you’re doing. If you’re driving, pull over to the side of the road on your smartphone, go to Parasites Without Borders and click “donate” and help us do the work we’re doing.

Also, help us continue to support FIMRC, Foundation for International Medical Relief of Children. This is a fantastic group. I will throw in, I know there’s been a lot of discussion of cattle on the other TWiVs. I may be one of the only TWiV hosts who actually owns cattle. Does anyone else own cattle? [chuckles] I have a milk cow, Briany, and I also have a heifer, Mary, in Uganda. I am hoping that we can get this pandemic going in the right direction so I can get back there to Uganda to the FIMRC clinic there, see my cows, see my friends. Help us with your support.

VR: Yes, you have mentioned that a few times, your cows in Uganda. It’s very cool. Not cows, they’re both cows, right? One’s a heifer and one’s a cow.

DG: One is a cow. You got to be, what? Over the age of three, you got to have had a baby. She’s a milk cow, that’s the mom. Mary is just a heifer. She’s a little over a year old.

VR: Never had a baby, right?

DG: Never had a baby yet. Give her a couple of years, Vincent. [chuckles]

VR: You bet. Time for some questions. If you’d like to send one in to Daniel, it’s daniel@microbe.tv. First is from Kevin. “My son is 12. We got him his first dose the weekend it was available. He’s due for the next dose June 5th. I’m reading in some places that perhaps delaying the second dose a few weeks, months, might lower the myocarditis risk that some kids are experiencing. I’m assuming this would violate the never miss a chance to vaccinate credo. Wanted a direct answer from someone I have grown to trust on this issue. I’m not considering permanently postponing. I just wanted your opinion. Please, treat this as you were in my shoes as his father.”

DG: All right, Kevin. I’m actually pretty much in your shoes. I have a 15-year-old son, Barnaby. He is scheduled for his second dose tomorrow afternoon. As I mentioned with the myocarditis, it’s incredibly rare. The cases are mild. It’s something that we can manage with just a couple of days of really over-the-counter anti-inflammatory medicine. The risk of continuing to have your son, my son, unvaccinated is significant compared to this risk. Don’t go ahead, don’t miss your opportunity. Don’t delay. Once this is in, we’ve seen data saying that, boy, these adolescents have really robust protection over time. Hopefully, for them, this may be the last time. This may be years and years of protection.

VR: Josh in Toronto writes, “Our 75-year-old mother has been diagnosed with plasma cell leukemia, has been hospitalized for observation. Started on dexamethasone, about to begin bortezomib and lenalidomide. She has received one dose of Pfizer in March, second dose has been delayed in Canada till July. Has been offered a second dose now. Is this recommended as her immune system is very taxed at present? And will her shot be compromised by chemo treatments? Curious about your approach in this scenario.”

DG: She’s on a number of medicines, so she has what I talked about the blood cancer, a plasma cell leukemia. I think I threw lymphoma in there, but really your leukemias are your classic blood cancers. She started here at dexamethasone, the steroids which we think also interferes with B cell function. She’s on bortezomib, a proteasome inhibitor, so that’s also going to affect her immune cells, and she’s on lenalidomide. Yes, this is basically a whole concoction designed to mess with B cells plasma cells. Plasma cells are really differentiated B cells.

When she gets vaccinated and you go, we’re not supposed to check her antibody levels three or four weeks later, they may be low. They may still be low right now. We still encourage people to get vaccinated. It may be that at some point in the future, as I discussed, this might be a population that is eligible either for a third dose or maybe is a population that is eligible for prophylactic antibodies. The vaccine that she gets, it’s not going to be harmful, it may be beneficial. We just don’t know how beneficial it is. This would be a context where we would say definitely, this is a high-risk person. I would encourage the vaccination. The benefits would far outweigh the risks.

VR: Lee writes, “I feel a complication with a prior disease I had when I was a child, mononucleosis Epstein-Barr, has something to do with why the vaccine made me ill for six weeks. Is there any information on this? Anyone I could talk to? The vaccine is so new. None of the doctors I’ve talked to, locally, have any idea. They only suggested that the vaccine triggered something that was dormant to become active again. I had all the symptoms of mono again plus some other neurological symptoms.”

DG: Yes. I’m happy to help and, I’ll just actually offer, we have our post-COVID care center where we actually have also opened up and said, “We’re willing to talk to people and help people who have vaccine reactions.” Often, I’ll jump in and help on issues like this. Again, we don’t have great science here, but we are starting to get enough experience that, hopefully, we can offer some help. People can just go ahead and they can call 1-516-42COVID.

Also, I do telemedicine consults across the country, so they can call 516-656-6500. My staff is killing me because I am working very late doing all this telemedicine, but I’m happy to help. This is a tough time. If I can help you navigate post-vaccination issues, I’m happy to step in and do that.

VR: Jennifer writes, “My mother went through breast cancer treatment. Has been in remission five years. However, she was left with peripheral neuropathy affecting her legs. Additionally, she had COVID in February. She asked her primary care MD if she should get the COVID vaccine and the doctor’s answer was, ‘I had to get it, so it’s up to you.’ I’m not sure that was the most effective response. My mother looked online for information. Of course, she found lots of disinformation. She’s hesitant to get the vaccine. She’s concerned it will worsen the neuropathy. Can you please provide guidance that will enable her to make a proper decision?”

DG: This is one of those situations and, hopefully, the physicians are listening, that if you leave a vacuum, someone else will fill it and it won’t really be the person you want to fill it. I think that’s what we’re seeing here. Not really a great answer, doctor. [chuckles] This is a priority. I really think when you look at this individual with this story, this is a person if you get them vaccinated, you may be saving their lives. You want to have this discussion.

Here’s what I’m going to say. Breast cancer treatment, remission for five years, that’s when we say that’s behind us. Peripheral neuropathy, we are not seeing any issues here in the story that makes me suggest there’s any reason to delay. This is an individual where I’m going to say I encourage you to get vaccinated.

VR: That’s COVID-19 clinical update number 65 with Dr. Daniel Griffin. Thank you, Daniel.

DG: All right, thank you. Everyone, be safe.

[music]

[00:40:13] [END OF AUDIO]

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