TWiV 886 COVID-19 Clinical Update #109

This Week in Virology

Host: Vincent Racaniello

Guest: Daniel Griffin

Aired 9 April, 2022

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 887, recorded on April 7th, 2022. I’m Vincent Racaniello, and you’re listening to the podcast all about viruses. Joining me today from New York, Daniel Griffin.

Daniel Griffin: Hello, everyone.

VR: Daniel, you ought to come into ‘The Incubator’ sometime.

DG: My wife was asking me that today. She’s like, “Are you going into the city today? I just got this alert that traffic is really bad.”

VR: Well, you would take the train, wouldn’t you?

DG: I would definitely take the train. Well, I would just take the train. Getting in and out of the city in a car is just not the thing to do.

VR: No. All right. This is update 109.

DG: 109. We got a lot to cover today. I’ve got the microphone right here as Dickson wants for better hearing and better audio quality. It does get in the way of my bow tie.

VR: You have to make trade-offs, Daniel, right?

DG: We do. Let us go right to the quotations. This is a double quotation day. “A faith that cannot survive collision with the truth is not worth many regrets.” That’s Arthur C. Clarke. In the same vein, “Religion is a culture of faith; science is a culture of doubt.” I think this is really important. I still remember we talked a little bit about how physicians approach their practice style. I hope people have learned from all of the updates, all of the MicrobeTV podcasts, it’s like we all came from Missouri. “Show me the science”. We don’t just want you to say, “This is what I’m thinking of doing.” We really want to know what’s going on.

There isn’t supposed to be authority in science. The authority in science is truth, it’s experimental data. With that being said, right into our update. We have a few things right up front. BA.2, the omicron stealth variant is now the dominant variant, actually all around the world, but also all across the U.S. In response to this, this week, the U.S. FDA announced that the antibody drug, sotrovimab, is no longer authorized to treat patients in any U.S. state or territory.

We’ll get back to that. Basically, if you’re going to be considering monoclonals, you’re going to be looking at using bebtelovimab for the acute treatment, EVUSHELD for the passive treatment. We’ll keep that there. People, if they’ve been following the news, I was getting a little questioning recently. Nancy Pelosi tested positive. Apparently, she was right next to President Biden. A lot of questions, am I worried about President Biden? Should he be skirting the rules and somehow getting access to some drug that the rest of us can’t have?

We’ll go through this a little bit, but this is going to get into that, “How much do we trust the vaccines? How much do we trust the ability to jump in with therapeutics?” I will just say right up front and we’ll get into this in detail, I am not that concerned about our President, but we’ll get into the details of why I say that as we hit each section. Right up front, and this I think is an important thing, again, you’ve got to keep repeating things. The MMWR early release, “Cardiac Complications After SARS-CoV-2 Infection and mRNA COVID-19 Vaccination – PCORnet, United States, January 2021-January 2022.”

Here, the authors are asking a very simple, but critical question, “Is it safer to get the vaccine or the infection?” Here, specifically in terms of the heart; myocarditis, pericarditis. What did they do? They looked at incidences of myocarditis and pericarditis. Think of this as inflammation of the heart or the tissue surrounding the heart. They looked at this after first, second, or just any unspecified dose of the mRNA COVID-19 vaccines. They stratified this by sex and age. They calculated risk ratios to compare cardiac outcomes.

For every group, the risk of cardiac outcomes was significantly higher after infection. Just to say that again, “Much safer, if you’re worried about your heart, to get vaccinated than to get infected.” Even for that highest risk group, that’s our males aged 12 to 17, after a second vaccine dose, we were seeing about a 1.8 to 5.6, about four times higher risk of a cardiac problem with infection versus vaccine.

I do want to reinforce here, we’re no longer recommending in this age group. Remember, that there is the small print. In this age group, we’re saying for that second dose, don’t do it three to four weeks later, wait 8 to 12 weeks. We see this risk drop even more in favor of vaccination over infection. Then the other, we’re not comparing apples to oranges. One of these issues post-vaccination, the vast majority of the time, it lasts less than 24 hours, it self-resolves while we’ve seen a growing amount of literature on pretty long-term severe cardiac issues, even really pulling some professional and collegiate athletes out of their competition.

VR: Daniel, the long-term effects of myocarditis, pericarditis, is that only seen after infection and not with vaccination?

DG: That’s really true. It is incredibly rare for one of the pericarditis, myocarditis post-vaccine issues to be anything more than a 24-hour self-limited, but we’ve certainly seen people continue to have cardiac issues post-infection for months now, we’re actually out about a couple of years for some individuals.

VR: I guess this is a case where a cardiologist should know what they’re talking about, right?

DG: Which cardiologist are you talking about, Vince?

VR: No, I’m just talking in general.

DG: I think I know who you’re talking about. Anyway, let’s go right into children, COVID, and other vulnerable populations. Children are at risk of COVID and one of the areas where they can suffer is long COVID. I thought that this was a good paper for just letting people appreciate some of the suffering, some of the symptoms, some of the morbidity that children who don’t die, who perhaps don’t end up in the hospital, but survive an acute COVID infection.

This was the paper, “Clinical characteristics, activity levels and mental health problems in children with long coronavirus disease: a survey of 510 children.” This is really a description of data derived from the ‘Long COVID Kids Rapid Survey 2.’ There’s certainly a selection, a participation bias here. I don’t think these should be numbers to hold anything to. Really, just a glimpse into what are we seeing in children that have long COVID.

They found in this cohort that the participating children had persistent COVID for a mean of 8.2 months. The most frequent symptoms were tiredness, weakness, fatigue, headache, stomach pain or cramps, muscle aches and pains, muscle joint pain. About half the kids had the post-exertional malaise that we’ve talked about. Really critical to appreciate that in management. Also, problems with rash, unexplained irritability, dizziness, and about 95% of the children had at least four symptoms. Just to say, this is just a glimpse. These are not numbers to hang your hat on, but we, unfortunately, have thousands and thousands of children that have survived, but are continuing to suffer after acute COVID.

Testing. Never miss an opportunity to test. This is interesting. We certainly have a large uptake of testing at home. I will say a lot of providers, if it’s a compelling story, symptoms, exposure, positive home test, we’re not necessarily recommending those individuals go and get a confirmatory test. A lot of the positives are off the radar, so to speak. We also heard, and this, I think, is very exciting, that there may be some combination at-home tests that are going to allow people to test for both COVID and influenza, say, in the comfort, safety, convenience of their own home. I’m very excited about this.

One of my hats that I wear is I do a bit of consulting and advising for the UnitedHealth Group. I guess it’s the UnitedHealthcare Medicare Advantage population, about 6 million individuals, Medicare age, part of our Well at Home program, where we’re trying to really keep these people alive, keep them healthy. Really, the at-home COVID tests were tremendous this last year. We coupled that with at-home delivery of monoclonal antibodies. This year, coming winter, we’re expecting to couple that with some of the oral antivirals, but boy, if we could also have flu tests thrown in there, that’s really going to be great. Roche was announcing, but Roche is not the only company working on this– I’m excited, I think, as a clinician, I’m also excited as a participant. You know what, one day I might get the flu and I would love to be able to test at home and then not go to work, not go to the office, not go somewhere where I might expose others. Also maybe I can get therapy.

VR: Daniel, when you get a positive flu test, what are you going to do? Are you going to go seek medical care? If you wanted an antiviral for influenza, do you have to be retested at the office? How is it going to work?

DG: Yes, you don’t have to. I will say that the Well at Home program, which is kind of cool, we had about 500,000 people in a pilot part of this and they actually had these at-home– It was a Bluetooth-enabled box that had Tamiflu in there. If you were within that first 48 hours, the story was consistent. A positive flu test, this is our paradigm we’re hoping for. You could hit the button and out the little tray would come with your Tamiflu, you could get started right away.

VR: It’s like a morphine push.

DG: [laughs] This is to make you feel better, not to hurry you on your way. I think we have exciting technology in the future. I think a lot of people are realizing, boy, a lot of stuff can be managed quickly, efficiently without having to get into a doctor’s office, sit there, wait two hours. Boy, that’s the last thing I want to do when I think I might have the flu.

All right, the pre-exposure period. Just to reinforce, the same things that we’ve been talking about are still there. We’ve talked a little bit about masks. Some people don’t like masks. Some people don’t like being told to wear masks. I think, Vincent, you would probably fall into that category. No one likes to be told what to do, but if you feel safer wearing a mask, you’re welcome to continue to do that. Don’t shame people that are wearing masks. I was giving my parents a hard time. Apparently, this last weekend, they went to an Irish funeral. It’s like an Irish wedding except one less person is drinking, we like to say. “Everyone was there, no one was wearing masks, we felt silly so we took the masks off.”

Oh my gosh. If you’re at an Irish wedding and there are 200 people jam-packed into a room, a bunch of O’Connells and Griffins and you are a higher risk individual, wear that mask. Do what you need to do. Spend more time outdoors. That’s a big one, and that’s going to be easier as we get into the summer, into the warmer weather here. Better ventilation, that continues to be key. Remember, this is the time to be getting those vaccinations in there.

Let’s get right into active vaccinations. Never miss an opportunity to vaccinate. I was very excited. April 6th was the day for discussing boosters. What I did, Vincent, is I waited until it was over and then my plan was I was going to listen to the eight-hour meeting at 2X. This way I could listen to everything in four hours. It wasn’t that exciting. I was a little disappointed. I was all excited. I figured I’d listen to this while I’m cooking dinner. I was going to be grilling outside.

It started off with a little bit of a brush-up. There was something about this fourth dose decision that you didn’t really convene us and they got the, “Oh, we were saving you guys for the important decisions.” I was like, “Okay,” but then a bunch of, “What are we going to do as far as a timeline? Are we going to get different coronaviruses for the fall?” And a lot of, “If we’re going to do that, we’ve got to really get going on the research.”

There certainly was a discussion about the idea of recommending vaccinations every four months. It’s just not really particularly tenable and reinforcing, because this comes up a lot, people keep asking me, “Where are those new improved booster-specific variant vaccines, Dr. Griffin?” We’ve discussed the data and it actually looks like the current mRNA vaccines continue to be very effective, so there’s discussion too, we’re not sure that there’s any new better vaccine out there compared to the ones that we’re currently using. I don’t know, Vincent, if you enjoyed or failed to enjoy any of this meeting?

VR: Yes, I think they basically said, “If we want a new vaccine by the fall, we need to have it tested by May,” because as you know, the flu vaccines are distributed in the fall, and they begin deciding in January which one to pick. I think you have reservations that were all correct, but the main message is, “If we want to make something, we need to get going.”

However, so far, it looks like our vaccines are fine and there’s no need to change. It’s a tough situation, because if you wait and do nothing, then something different happens in the fall, a new variant which even further evades, you have a problem. However, I don’t think that’s happening because I feel that the T cells are giving you the disease protection and those epitopes are not going to change.

DG: All right, you and I are on the same page there, Vincent. I’m feeling reassured. The article, “Protection by a Fourth Dose of BNT162b2 against Omicron in Israel” is now published in The New England Journal of Medicine. We talked about the preprint and no surprises from what we discussed before, concerns about the comparison groups. What I will quote, “Protection against confirmed infection appeared short-lived, whereas protection against severe illness did not wane during the study period.” We’re continuing to see, I think, this paradigm where you can get a bit of a boost in those antibody levels, maybe boost your vaccine efficacy against infection, but yes, protection against severe illness looks to be fairly durable.

We also heard from the European Centre for Disease Prevention and Control and the EMA’s COVID-19 Task Force, both concluding that it was too early to consider using a fourth dose of mRNA COVID-19 vaccines in the general population. Both agencies did agree that a fourth dose could be given to adults 80 years of age or above, but then they noted that there is currently no clear evidence in the EU that vaccine protection against severe disease is waning substantially in adults with normal immune system aged 60 to 79 and thus no clear evidence to support the immediate use of a fourth dose.

Really reassuring. I was talking, I’ll say, reassuring some of the nurses earlier today. There was an email that went out by one of our local large healthcare systems, which they interpreted as, “Oh, now they’re going to force us to get a fourth shot.” I don’t think anyone is going to be forcing people to get fourth shots in the immediate future. There’s access out there, but still not really a large push.

Feel reassured that the three doses, my gosh, even two doses, really pretty impressive. When did a 90 become not good enough for a vaccine? On that front, I’ll also say passive vaccination. If you have that individual and you’re not certain, you’re not confident that those vaccines are providing that protection, we have EVUSHELD. I think people need to go to covid.gov and they need to find where they have accesses.

I really think we’re underutilizing it. Well, I felt like I was doing a good job and then I just had a patient today, actually, late yesterday who tested positive for COVID. I was realizing I probably should have considered them for EVUSHELD. This is out there. It’s sitting on shelves. Let’s make sure we consider that. This will bring me back to Biden. The period of detectable viral replication. You’ve done everything, you’ve gotten vaccinated, you’re trying to be careful, but now you get a positive COVID test.

I like to say the time for monitoring, monoclonal, antivirals, perhaps enrollment in clinical trials, you don’t start those steroids in that first week, you don’t put them on zinc, you don’t put them on antibiotics, no doxycycline, no azithromycin, no aspirin. These things are not helpful, but what can we do? Again, these therapeutics are sitting on shelves, there’s no shortage. They’re actually incredibly well-tolerated.

I’m going to tell you a story that disturbed me. I try not to get upset. I try to stand back emotionally. I got a call yesterday from one of the hospital-based physicians that I know. A family member of theirs, a relative who has high-risk conditions, but is a student at an Ivy League university in our general area, I won’t mention the place, but they went to Student Health with an acute COVID infection. They were feeling crummy, they tested positive just the first day or two of symptoms and they asked, “Are you ready for this?” They asked, “What about PAXLOVID? Would I be a candidate for PAXLOVID?”

The practitioner at this prestigious university said, “Yes, I don’t really prescribe that. I’m not sure how comfortable I am using that. Why don’t you reach out to your endocrinologist, see if you can schedule a telehealth visit and maybe they can see if that’s right for you.”

VR: I’ve heard that. Here’s another one. One of our listeners wrote that she’s at-risk so she said to her doctor, “If I get infected, could I get PAXLOVID?” He said, “What’s that?”

DG: Ouch. Number one. What is the number one thing we recommend? It’s PAXLOVID, and there’s only a couple things you need to know. One is, are they high-risk? All these therapeutics, and I know everyone’s not happy about that, but at this point, they’re reserved for high-risk individuals, is this person high-risk? In this case, yes, the person was high-risk. Second is, what medicines are they on? Are there any interactions that we have to worry about that would prevent us from using PAXLOVID?

Number three, what is their kidney function? Number three, I want to just add something, because we had this done recently. We had a patient, they were started on PAXLOVID, the basic metabolic panel was sent off, we then adjusted it the next day for renal function, so not a big deal to get that first dose in while you’re waiting for those labs to come back. PAXLOVID, incredibly well-tolerated. I have to say from personal experience, patients are telling me almost the same as the monoclonal experience. Boy, within 48 hours, I felt so much better.

People really feel better. These are incredibly well-tolerated. There’s lots of supplies out there. If your doctor’s not aware of it, get a new doctor, sorry to say that, but you can go to covid.gov and you can actually look in your area code. I had a physician the other day and his comment was, “Oh, PAXLOVID, I hear that’s really hard to get.” I showed him on the locator that within a five-mile radius, there were thousands of doses. These are out there.

PAXLOVID is the number one recommended. That’s about a 90% reduction in progression. Let’s think about this. You’re a high-risk, let’s say you’re a high-risk with a 20% chance of severe disease, now you’ve got your three mRNA shots, so about a 90% reduction, now you’re down to about 2%. You get put on PAXLOVID at the appropriate time. Now you’re down to a 0.2% chance of ending up in a hospital. We’re really making some progress here. If you can’t do PAXLOVID for some reason, we have bebtelovimab, if we’re going to use monoclonals, let’s use an effective one.

A little bit concerned that it took the FDA pulling an ineffective one away because people were still using it. We need to be up to speed and use what works. Physicians should be knowing this. Remdesivir is the other choice in that first five days, that’s the three-day outpatient therapy, and we also have molnupiravir, that’s about a 30% reduction. Not as impressive as the others, but no drug interactions, no renal adjusting. You just need to be careful around women of childbearing age, children. Get that pregnancy test, make sure you have that issue covered as well. Go to covid.gov, because these therapies are out there.

Now, early inflammatory phase. Let’s say you’ve gone all the way, now the person has ended up in the hospital, what do we do here? We have some new things here. Number one, steroids, at the right time in the right patient. I’m going to go through each one of these. First, if a patient is hypoxic, so the oxygen saturation has dropped less than 94%, then they’re entering into that early inflammatory phase, this is the patient in whom we recommend steroids.

This would be dexamethasone 6 milligrams a day. Oral is fine, and as we know, if they improve, we’re going to be able to stop, we don’t discharge them on this. What about higher doses? Should we be starting on higher doses? The article, “Long-term outcomes of dexamethasone 12 mg versus 6 mg in patients with COVID-19 and severe hypoxemia,” looked at this issue. Basically, no statistically significant benefit to bumping it up to the 12 milligrams, so 6 milligrams we recommend across the board. On a case-by-case basis, you might consider escalating, but the starting dose of 6 looks like it’s the right place to start.

What do we do if we’ve started those steroids and they progress despite steroids? We can then jump in with further immunomodulation. This was triggered in a bit by listening to some of the other TWiVs and we recommend Tocilizumab, that’s the monoclonal antibody that is an IL-6 receptor inhibitor. A number of studies showing mortality reduction, reduction in progression to requiring mechanical ventilation, but a couple things that are critical– You need to be doing this in a background of steroids. If you give Tocilizumab without steroids, you’re actually increasing mortality by maybe about 10%.

You need the background of steroids, you add the Tocilizumab, but you need to add the Tocilizumab before they escalate to high-flow nasal cannula or before they’ve been in the ICU for more than 48 hours. Again, we’re going to lose our benefit there. We did hear on April 4th that the U.S. FDA has granted priority review to Roche’s Actemra, that’s Tocilizumab, for the treatment of COVID-19 in hospitalized adults. If approved, Tocilizumab will be the first U.S. FDA-approved immunomodulator for the treatment of COVID-19 in hospitalized patients.

One of the things that was noted, since the beginning of the pandemic, more than 1 million people hospitalized with COVID-19 have been treated with Tocilizumab worldwide. I should mention that other immunomodulation therapies have been tried. The only one that’s still standing is baricitinib. This is the Janus kinase inhibitor. This can actually be given to individuals who for some reason cannot be on steroids. We’re not doing a lot of that just to be fair here in the U.S. Other immune modulation approaches such as using Anakinra to target IL-1 have either not shown benefit or the trials have been stopped for futility. Important stuff.

What about anticoagulation? Number three, not antiplatelet, but anti-clotting medications. Right now, ICU level patients, the recommendation is for prophylactic intensity anticoagulation. Non-ICU floor patients, interesting enough, current recommendations based on low-quality evidence is to consider therapeutic intensity anticoagulation, preferably with low molecular weight heparin, that’s what’s been in most of the trials, but the qualifier, an individualized assessment of the patient’s risk of thrombosis and bleeding, is important when deciding on anticoagulation intensity.

A little bit more on the multi-system inflammatory phase. Just a reminder, this is that syndrome where an individual, and we’re going to talk about children today, had acute COVID and then three to four weeks later, either after an asymptomatic, a mild, or either a symptomatic acute COVID, they then have this secondary inflammatory phase. “Short-term Outcomes of Corticosteroid Monotherapy in Multisystem Inflammatory Syndrome in Children” was just published in JAMA Pediatrics.

Remember, this is a syndrome where a number of the children may have issues with cardiac function, they may develop fever, they may develop manifestations that look like a vasculitis, very similar to a Kawasaki-type presentation. But in this case, also with shock with drop in blood pressure. To date, people have been treating the syndrome with steroids, with IVIG, or sometimes both. These are the results of a retrospective cohort study where they looked at 228 eligible patients, but then they analyzed 215 looking at whether or not corticosteroids alone or corticosteroids with IVIG would be a preferable way to approach this.

They did propensity weight scoring, sorry, to tell people what that is, that’s when you’re trying to say, “Boy, the people who just got steroids were probably not as sick as the people that immediately got corticosteroids and IVIG,” and that looked to be true, so trying to match that. What they noted was that the rates of initial treatment failure with straight corticosteroids or corticosteroids plus IVIG, once they did the propensity weight matching, were pretty similar. They suggested it seems reasonable to start with corticosteroid monotherapy, then potentially add IVIG, if the patient is continuing to have issues and why, why not just throw IVIG and steroids at everyone?

They commented that there were many disadvantages associated with IVIG therapy, such as high cost, potential shortages, interference with other serological diagnoses, need to delay, they say live viral vaccination, so I’m going to say replication requiring viral vaccinations. They also commented that corticosteroids are inexpensive, potentially effective in short courses. Just a little bit more information, nothing guideline world-changing, but we don’t really have a lot of data on the multi-system inflammatory in children, so it’s nice to get a little data there.

The tail phase. We’re almost to the end. I think I’m going to keep it short today. COVID is not just a two-week viral illness for many people. This week, actually, before President Biden was exposed to COVID, he issued a Presidential Memorandum directing the Secretary of Health and Human Services to coordinate an interagency national research action plan on long COVID-19. What does this new proposal include? One, delivering high-quality care to people with long COVID by supporting research into possible treatments, and passing that learning across the country. So research and also an educational component.

This included $20 million in the next fiscal year to investigate how healthcare systems can best organize and deliver care for people with long COVID-19, also, expanding and supporting 18 long COVID-19 clinics that have already been established by the VA, educating doctors and nurses about the condition and how to help patients. I like the fact that there’s an educational component, improving insurance coverage, considering long COVID a potential cause of disability and entitling sufferers to protections under disability right laws and providing affected students with educational support, strengthening protections for workers, and then $25 million in research funding.

There’s a nice article about this in USA Today by Karen Weintraub. It’s worth looking at this. There’s a lot more in there. What is going on in the rest of the world? This is where I’m going to actually say I read this, but I want you to read this as well. There was an article published in The Journal of Infectious Diseases, “Concept of Classical Herd Immunity May Not Apply to COVID-19.” This was written by David M. Morens, Gregory K. Folkers, Anthony Fauci.

This article, it’s seven pages, it’s double-spaced, it’s a very manageable read. I thought it was a very interesting exploration of our understanding of the concept of herd immunity over time and gave a realistic assessment of what the future might hold for us and COVID. David M. Morens is the Senior Scientific Adviser to the Director of the National Institute of Allergy and Infectious Disease. Gregory K Folkers is Chief of Staff to the Director, NIAID, and Anthony Fauci is the Director.

A couple of other things, and this is really where we’re going to close. Not exciting, a little bit discouraging, we heard that the African Union and COVAX decided not to obtain more of the vaccines, really struggling with getting those vaccines into arms. They are grappling with lack of funds, hesitancy, supply chain challenges, a number of other factors. Per the WHO, only about 15% of the continent’s population is fully-vaccinated, we’re talking about Africa here, compared with a global average of 57%.

Only about half of the vaccine doses have even been administered, so only about 400 million of the 700 million doses Africa received have been administered. About 300 million doses just sitting there not delivered. Really, the challenge is you can’t just drop vaccines on a continent. There’s a whole complexity to getting those vaccines into willing arms. Continues to be a huge challenge.

Along those lines, I want everyone to pause the recording right now, pause what they’re listening to, pause the YouTube, pause the podcast, go right to parasiteswithoutborders.com, click the “Donate Button.” Every small amount helps, but as a reminder, throughout the months of February, March, and now April, this is our last month, donations made to Parasites Without Borders will be matched and doubled up to a potential donation of $40,000 to the American Society of Tropical Medicine and Hygiene with focus on scholarships for females from low and middle-income countries who might not otherwise be able to attend the annual meeting 2022 in Seattle, Washington.

VR: It’s time for some listener questions for Daniel. You can send yours to daniel@microbe.tv. Albert writes, “I’m returning to the U.S. from two years in Mexico. I’m 75, mild hypertension, BMI of 30, asthma, and AFib. I got two shots of Sinovac in June and July and AstraZeneca booster in February. None of these vaccines is FDA-approved, so technically, I am unvaccinated in the USA. Would you recommend I get an mRNA booster, a fourth shot?”

DG: This is tough. There’s two questions here, and the first one is harder. What is the science here? Are you protected with two Sinovacs and AstraZeneca? What degree of protection do you have? I’m not sure I can peg that for you. You probably have a pretty reasonable degree of protection, in all honesty. The second is checking the box, what makes you qualified? It’s a bit of an issue, going to different venues where vaccines are required, mandated. What do you have to do to check that box? That’s really a second regulatory question.

If you got an mRNA shot on top of what you’ve already had, would that allow you to be considered? The Sinovac, I don’t think is recognized by the U.S., but really have to check through, maybe have your doctor help you, what do you have to do if your goal is to check that box and be considered vaccinated? Right now, this is tough and I’ve definitely talked to people who got, for instance, the Russian vaccine, which is not considered acceptable at this point. Really two sides of this. The science, are you protected? Probably to some degree. The second, what do I have to do to check that box?

VR: Mike writes, “I’m a retired family physician who has become addicted to TWiV. I recently read an interesting post on Medscape about post-operative infections after epidural or joint injections using longer-lasting steroids like triamcinolone. These injections double the incidence of post-op infections for up to 90 days after the steroid was given. The question is, ‘Has the impact of longer-acting steroids been studied in relation to COVID infection outcomes in unvaccinated, vaccinated, and boosted patients?’ It seems likely to me that the same effect seen in the meta-analysis quoted in Medscape would also apply to diminished immune protection for COVID patients.”

DG: I haven’t seen any studies that specifically looked at that in the context of COVID, but it makes sense. This is a person, an individual, who’s on steroids, on long-acting steroids for this period of time, and if we’re seeing evidence of that to the point where their risk of infection is doubled, well, they’re immune-compromised to that degree. I would think that it would be reasonable to extrapolate, though I don’t know any specific studies that have targeted looking at this population.

VR: Bonnie writes, “The reporting that I hear about masking is so all over the place right now. I don’t know if my question is foolish or not. Before the pandemic, I used to volunteer at a correctional facility, and I’m looking at returning to volunteering. I went back last week to get fingerprinted and as it happened, the facility had just decided to end its masking policy. Those of us in the fingerprinting group were encouraged not to mask although I kept my N95 on anyway.

My concern is our state puts vaccination rates for inmates of correctional facilities online. I know that the rate of vaccination in this particular location is around 44% for two mRNA doses, 46% for just one. The volunteers on the other hand are generally double-vaccinated and boosted. I understand that having been vaccinated, I should not worry overly about myself, however, aren’t unvaccinated people still quite vulnerable, and thus shouldn’t I and other volunteers still mask when visiting this facility for the protection of the inmates who we meet in a fairly small, not well-ventilated room with eight or nine people? They don’t see visitors in-person except for volunteers.

I work at home and don’t spend a lot of time around other people, but I still wonder if unmasked, I would be putting inmates at risk. Previously, the inmates were provided with masks, but apparently, they’re no longer wearing masks now that the facility has decided that it’s unnecessary. As someone who travels around the world, you must personally face this question a lot. What is your solution for keeping the people around you safe if they’ve not been vaccinated? Are you wearing a mask when treating unvaccinated patients and if so, do you have thoughts about how to diplomatically explain to others why you are doing so? I know you must receive too many questions to be able to answer them all, but if you have time for this one, I’d appreciate it.”

DG: This is a great email, so thank you. No need to apologize for asking excellent questions. You bring up the two sides to mask-wearing, but you’re really focused on the side of, “Does wearing a mask yourself serve as source control, should you become infected, should you be speaking, should you be within that range where you might be transmitting to another person or even in a poorly ventilated room where, boy, you don’t even have to be that close because you’re there long enough?”

Wearing a mask is source control. That’s why surgeons are wearing masks when they’re operating. That’s why I still wear a mask when I’m taking care of patients. It’s really source control protecting the other individual. I think that’s very thoughtful. If you are willing, if you’re interested in doing that, I actually think that should you end up being infected with SARS-Covid-2, should you have COVID, symptomatic or asymptomatic, you wearing a mask is going to actually protect the inmate. I encourage you to do that if that’s something you’re willing and interested and able to do.

VR: That’s COVID-19 Clinical update number 109 with Dr. Daniel Griffin. Thank you, Daniel.

DG: Oh, thank you so much, and everyone, be safe out there.

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[00:40:05] [END OF AUDIO]

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