TWiV 914 COVID-19 Update #121

This Week in Virology

Host: Vincent Racaniello

Guest: Daniel Griffin

Aired 2 July, 2022

pdf of this transcript available (link)

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

[music]

VR: From MicrobeTV, this is TWiV, This Week in Virology, Episode 914, recorded on June 30, 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: Well that’s it for June, Daniel.

[laughter]

DG: That’s true, right this drops July 2, right?

VR: July 2, you’re right, that’s Saturday.

DG: Thirty days has September, April, June, and November.

VR: I always say once June is over, that’s really it for the summer. Before you know it, it’s September. Just very briefly, what do you see in the summer as far as COVID goes? Do you think the numbers are going to stay low or what?

DG: It’s really hard, as I think we’ve said, to know exactly what the numbers are, I mean there’s SARS-CoV-2 everywhere and we’ve got all these people getting together. There’s lots of virus, I don’t think we’re going to have as low a number of infections this summer, but I still am optimistic that we continue to see low levels of hospitalizations and deaths over the summer. Some mixed optimism there, but let’s get into it. The quotation: “The fishermen know that the sea is dangerous and the storm, terrible, but they have never found these dangers sufficient reason for remaining ashore,” and that’s Vincent Van Gogh, I think, but it’s hard to know these days with quotations. [chuckles]

VR: The other Vincent.

DG: Yes, the other Vincent.

[laughter]

Yes, I think part of this is for our listeners and we probably have a number of these listeners that are still shuttered at home, wearing N95s when they drive around by themselves in the car, and hopefully we’re going to be talking a little bit about making decisions, like going back to entering, engaging in different social activities. I am going to talk a little bit about significant risk factors, right? Because as many of us are excited to go forward, there still are a number of individuals that are still ending up in the hospital.

We’re still at that level, I was looking at the New York Times tracker, about 300 COVID deaths a day, about 2,000 a week, about 100,000 plus a year. I mean that’s still kind of crazy that that is in our minds, is like suitable acceptable goal and that’s at current levels. Forget about the fact that we’re going to have a fall in winter when we all get together for the holidays again, but what are the big factors, and it’s really interesting if you look at the hospitalizations.

The biggest risk factor that really stands out if you go to the New York Times tracker, and we’ll put a link into this, is really age, people being over the age of 65, there’s really a separation there, so being over the age of 65, being unvaccinated, that’s really a different population. Talk to your doctor about what are your individual risks and how can you mitigate those, and we always try to keep up on what those measures are. The other challenge, and this is going to lead into the boosters for the fall discussion, is keeping track of all the variants, right?

We’ll put a link into this covid.cdc.gov variant trackers, but basically we’re seeing that BA.5 and BA.4 are really taking over and particularly BA.5 seems to be, if you’re following the horse race, seems to be winning, but this actually came up in some of the discussions. I’m going to talk right here in the front about what happened this week, Tuesday, June 28, the FDA’s Vaccines and Related Biological Products Advisory Committee met and the panel came down 19 to 2.

We’ll talk about those two in favor of redesigning booster shots to also target Omicron or its sub variants rather than simply the original version of the virus and panelists cautions that the recommendation doesn’t necessarily mean everyone should get a tweaked booster. This might only be for older adults, those at high risk of the virus, and I want to sort of temper this with a quotation from Dr. Kanta Subbarao.

VR: Subbarao.

DG: Subbarao?

VR: Yes.

DG: Awesome. It’s good to have you here for the pronunciation.

[laughter]

This physician chairs the WHO committee and they’re virologists. They’re in the stable with you, Vincent. We don’t want the world to lose confidence in vaccines that are currently available. I’m going to pull you in a little bit on this, Vince. I know we’re going to do a deeper dive next week, I’ll sort of promise everyone then. I think maybe Paul Offit’s going to come for a visit, but did you have any thoughts right off here?

VR: Well, I think that the data saying that we need a variant specific booster are scant and if you look at some of the quotes from the committee members in the press, they’re not really sure that it’s going to make much of a difference. Paul Offit, who’s, in my opinion, one of the best vaccinologists out there. He’s usually very bullish on vaccines in general, but he doesn’t see the need, and part of the problem is all we know is that when you give people the Omicron-based vaccine, and remember, it’s the original Omicron, it’s not BA.4/5 and who knows–

DG: Which is a big issue, yes, which is a big issue.

VR: Who knows what’s going to be around in the fall. All we know is that they induce neutralizing antibodies. We have no idea of how these redesigned vaccines would go in terms of disease, and in fact one of the panel members said, they’re asking us to have a crystal ball and we just don’t know. I think they’re all acting on the side of caution, but there’s really not – it’s not like for influenza where we know, oh, yes, the neutralization titers have dropped below this number. That means there’s going to be more disease, we don’t know that. It depends where you stand, whether you want to be cautious or whether you want to be driven by the data, and I agree with Paul Offit, the data just aren’t there.

DG: Yes, and I think also to sort of reinforce what the discussion was is that the original vaccines continue to do really well at what we want vaccines to do, which is keep people from dying, keep people out of the hospital. Yes, these new updated vaccines, maybe a twofold higher level of these neutralizing antibodies, which is really the difference between Pfizer and Moderna. Should we have just said everyone now gets Moderna? It’s really hard to know, and I think as they were very honest, we’re starting down a new road.

There’s sort of this idea that maybe every fall we’ll be trying to somehow update the SARS-CoV-2 vaccines to keep updated with the variants that are predicted to emerge. We don’t have the same infrastructure we have had with influenza to try to do that, we all know how well we do with influenza. Yes, we’re entering a brave new world and a deeper dive, but it is interesting because now we’re seeing a lot of folks saying, well, boy, maybe I don’t want to get that next shot, maybe I want to wait for the fall, so we’ll see significant impacts, but sort of promise our listeners, expect next weekend a couple episodes to drop with a deeper dive into a booster discussion.

VR: Daniel, can I ask you?

DG: Yes.

VR: If you look at some of the data slides that were presented at the advisory meeting, they look at one of the metrics is hospitalization after COVID infection of vaccinated people, and I think that’s a flimsy metric. I would rather see ICU admission or death, but we don’t have either, and I think the point is there are very few deaths in vaccinated people, so statistically that would be difficult, but in terms of hospitalization, is it a concern that hospitals would be overburdened and therefore, is this one of the things they’re thinking about, OK, if we give them a variant-specific vaccines we’ll cut down on hospitalizations for six months?

DG: So yes, and I think that’s a really good point. Understanding the disease, there’s even a distinction between why are you being hospitalized for COVID-19. Are you being hospitalized because it’s the first week and you’re just an older individual and you just can’t handle this at home, you can’t keep up with the oral intake, that’s quite a bit different, quite a bit different as far as resources than what we saw early on to people getting admitted during week two, that early inflammatory requiring significant pulmonary support, the staffing required to keep someone like that alive, but that actually is part of the calculation and part of the calculation for timing of boosters in the fall, whether it’s the original, whether it’s an updated.

We do want to reduce the strain on the healthcare system on the hospitals. The hospitals are not there to take care of COVID-19 patients. They’re there to do other things. The administrators might think they’re there to make big profits off elective surgery, I hate to say, but we need to keep in mind the fact that if we overwhelm the healthcare system, mortality goes up and it doesn’t need to go up, it just goes up because we can’t handle those volumes.

VR: OK.

DG: Yes, no, these are all important, it’s complex subject, but we do have, say, some really bright people really trying to do the best thing by us all.

All right, children and COVID-19 vaccines. This is really a big thing lately and I do think there’s a reasonable discussion going on here. A lot of parents are asking this question, “Boy, it took you long enough to get those vaccines out, my child’s already been infected, so what’s the point? What’s the point of vaccinating my child after they’ve already gotten SARS-CoV-2?” We’re going to talk a little bit about these studies. The first paper, and actually there’s going to be two papers both published in the Journal of Pediatric Infectious Diseases Society.

The first is, “Pediatric SARS-CoV-2 Seroprevalence in Arkansas Over the First Year of the COVID-19 Pandemic.” The second is, “Antibody Responses to SARS-CoV-2 and Children with COVID-19.” Both were accepted a number of months ago, but are just coming out now in the June edition of the journal. I got a chance to really look through them and they’re fully peer-reviewed, post-editing. I do think they address a number of topics that have been coming up as pediatricians and other providers discuss vaccination with parents of young children.

Just sort of bullet point a couple of these. One, as I brought up, where most children already infected, if children are mostly all infected, what’s the benefit of a vaccination after a child’s already been infected? That’s one thing that comes up. In this same line is, does an infection give a good immune response in young children? The Arkansas Sero Survey is now dated, but in the second study, the authors found that in children 18 years old and younger, that the 4 and under had the highest antibody responses to infection, and that this lasted for months. I actually think these are reasonable questions, reasonable discussions to have.

We actually saw in the children zero to 4 months that they actually got a pretty good response to vaccines as well, but this is a little bit of a challenge as we’re having these discussions. It’s one thing to jump in there with a child who’s never had SARS-CoV-2 and say, let’s get them vaccinated before they have that first exposure. There’s a lot of unknowns if a child’s already had SARS-CoV-2, they did, however they did, so I think that this is going to be a vaccine where we’re clearly seeing where parents are having discussions with those pediatricians. I think that’s appropriate.

A lot of people are not rushing out, a lot of people are not going to those pharmacies and mass vaccination sites and want to sit down. They want to have that discussion with the pediatrician. There’s certain parents that are jumping ahead, that are saying, “Hey, my child, it’s a no-brainer, I want to get them vaccinated.” There’s other parents who are saying, it’s sort about wait and see, but just to give people a landscape of what’s happening in the pediatric vaccine arena.

VR: Daniel, this table you have here, the different vaccines, I noticed that the Moderna has a magenta label and a purple label. [laughs] Seems to me that would be tough to distinguish, wouldn’t it?

DG: Yes, so now, and this is a bit of a correction, something the keeping straight the vaccine schedules, and we’ll put this in our show notes, a link to it, but keeping straight, what age, what vaccine, what color cap, what is – I know what purple is. I’m not sure I know what magenta is.

[laughter]

Vincent and I will go through this just a little bit. Different products have different age ranges on different caps and different sizes. We’ll start off with the Moderna just to get everyone up to speed on the accurate. Moderna, and this is pretty straightforward, I talked about last time, is in the 6 months to 5 years of age. You’re going to be using the blue vial cap with magenta bordered label. [laughs] OK? For most people, that’s going to be dose one, and then at least four to eight weeks later, you get dose two. We’ve talked a little bit about extending that range out a little bit.

Those who are moderately or severely immune-compromised, you’re actually getting dose one, at least four weeks later dose two, at least four weeks later dose three. Even though right now for most people this is two doses, we’re expecting that there’ll be a recommendation at some point for boosters, third shot, et cetera, we’ll see.

I’m going to stay in the same age range and go roughly the same age range to the Pfizer BioNTech. This is a maroon vial cap with maroon bordered label. This is 6 months through 4 years. This is a little bit different than the other Pfizer schedules we’re familiar with. You get dose one, and then at least three to eight weeks later, you get dose two, and then at least eight weeks later, you get dose three. A correction, it’s not five months for that third dose, it’s only at least eight weeks.

You really could get dose one, three weeks later get dose two, eight weeks later get dose three. You could get it in 11 weeks. Then the rest of the Pfizers is that at least five months. It’s a pretty complicated table. You have to stick this up in the clinic. What I think a lot of pediatrician offices will do is they’ll just pick one product to keep everything straight, but there is an advantage, actually, I’m going to say to having both options.

The Moderna I like the 6 months through 5 years, the ability to one dose, second dose, and then you’re done probably for the time being. Pfizer has the advantage, even though it’s three doses, we saw less fever, less reactogenicity. Certain settings where a pediatrician may want to make that recommendation. I think it’s good that we have options here. I put in the small print, but I actually made it bigger. I’m just going to run through that for everybody.

Those individuals thinking about their children getting vaccinated, the current recommendations complete the primary series with the same product. There is this comment about potentially delaying a primary series. We talked a little bit about whether that’s an eight-week delay or whether or not you’re going to delay a little bit longer, maybe out to three months. Again, that’s a challenge during a time when we’re seeing so much infection on a recent call where if you delay three months, then you’re the doc who has to answer the phone call with, so-and-so just got infected at two months, they didn’t make it to three, why’d you tell us to wait?

That’s just going to happen, but then I think the big thing I wanted to point out here is that recommendation of an eight-week interval may be optimal for people who are not moderately or severely immunocompromised in that ages 6 months to 64 years, particularly for those males aged 12 to 39. There might be some advantage to waiting a little bit longer. That actually may in a large part be why we’re now recommending across the board that third dose, because we gave that first two so close that prime-prime, not really a prime boost like we initially had hoped.

VR: Daniel, the recommendation for three months from symptom onset, if you had previously SARS-CoV-2, is it different from adults?

DG: No, it’s kind of across the board. It’s this idea, again, as we’ve talked about the basic immunology, that if you can wait that three months, if you don’t get infected during the three months, maybe you’re going to get a better boost. We’re starting to acknowledge, recognize, and we – I don’t really mean we, I mean the authority figures that be, that getting an infection actually does have some impact on our immunology, on our protection, on our ability to respond to future infection. This is that idea of starting to think about that infection as somewhat of a boost, and then getting your next boost three months later.

All right. It is the time of camps and schools and the letters have already started going out. People probably know that I give advice, I give guidance to a number of these camps. I’ve been doing it for free for a while, actually. I didn’t realize that camps were so profitable. [laughs] I had to rethink about pro bono work. I’ll start charging, [chuckles] or maybe I’ll encourage them to donate to Parasites Without Borders, but let me bring people up to the current state of things.

I’m going to mention the CDC guidelines, actually going to say here in New York, New York State is right in accord. You might have some slightly different variation depending on what state you’re in, but the CDC guidelines, they’re really split, depending upon whether an individual is up to date or not with their COVID-19 vaccines.

This means not only that primary series, but if you’re supposed to get the third or that fourth shot, that’s required to be up to date. If you’re up to date, and there’s been an exposure, then the campers, the children, the adults, anyone involved does not need to quarantine unless they develop symptoms, even if they don’t develop symptoms, recommendation to get tested at least five days after the last close contact, watch for symptoms for 10 days.

I mean we’re always watching for symptoms, but if you do get symptoms, you want to isolate immediately. You want to find out if that’s COVID or not, and then you’re going to go ahead with precautions and isolation for the infected, but if you are not up to date, this is a problem. This is sort of the stick part of the guidance, then that child must be pulled out of that setting, they must quarantine for at least five days from exposure, must wear a well-fitting mask when around others. Then again, even if they don’t have symptoms, you want to get that test at day five and it sort of goes on. There’s really this bifurcation here on whether or not the children are up to date.

This was sort of our encouraging everyone just get up to date so that we don’t have to worry as much about quarantines, that we can move forward because, boy, missing five days, missing a week of camp is really tough for these kids who are finally out there trying to enjoy their summers. I like to echo, use those tests intelligently. Remember, if it doesn’t make sense, go ahead get another test.

I’m going to jump into active vaccination and just a little, a couple articles here we’ll talk about, really just keep reinforcing our guidance here. We have another article addressing the increased risk of death for COVID-19 infection during pregnancy. The article, “All Cause Maternal Mortality in the U.S. Before vs During the COVID-19 Pandemic.” This is published in JAMA Network Open.

In the U.S., maternal deaths increased 33.3% after March 2020, corresponding to the COVID-19 onset. This is higher than the 22% overall excess death estimate associated with the pandemic. This is a particularly high risk population. Those fertility specialists, those people out there who are encouraging women to wait until after, that’s not good advice. It’s not good advice for the mother. It’s not good advice for the unborn child. It’s not good advice for the child who will be born without that passive protection.

All right, there’s a question I know has come up a lot, a little science to help us with our recommendations about what we should do with those immunosuppressive medications and vaccines. The article, “Effect of a Two-Week Interruption in Methotrexate Treatment versus Continued Treatment on COVID-19 Booster Vaccine Immunity in Adults with Inflammatory Conditions.”

The VROOM study, a randomized open label superiority trial, was published in The Lancet Respiratory Medicine, a two-week interruption of methotrexate treatment immediately after COVID-19 vaccination with a booster result in any sustained increase of more than a twofold in antibody response. That sort of two-week thing we’ve been going with, we picked it out of a hat. Well, it made sense from what we understand about the immunology. Go ahead and get that vaccine, interrupt the methotrexate treatment for about two weeks, we’re actually going to get a better antibody response here.

Continue to remind everyone of Evusheld, the Evusheld folks, maybe they have to do a better PR, maybe a social media campaign, get the word out. This is that other therapy. We talked about an almost, an 85% reduction and even symptomatic infection in these high-risk individuals for about six months. We’re actually going to be getting to that six months pretty soon. We’re going to have to figure out, do we give people another bit of a boost?

Paxlovid, we’ll be talking a little bit here about Paxlovid. This is in the news recently. I don’t know if you heard about this, Vincent, but Anthony Fauci, he got the COVID. He’s doing the right stuff, got his vaccines, got the Paxlovid. He’s, well, certainly over the age of 65, even over the age of 80. Even though he’s a fit, active man, he was considered high risk and was started on the Paxlovid, did well. Then during that second week, he had what we’ve described, the onset of symptoms that he said were worse than the original first few days. He, like Stephen Colbert, got another five days of Paxlovid.

VR: Is that in the EUA, Daniel?

DG: It is a little bit weird. It is not in the EUA. [laughs] The FDA has very clearly said that there’s no science to support that. We will perhaps discuss that in a little more detail next time, but it is curious, right? I think it – I mean I don’t want to criticize Anthony Fauci, but it does send a very confusing message out there.

VR: Man, for sure, and maybe that his symptoms would have subsided without the second course of Paxlovid, right?

DG: Yes. I think we’ve got to ask what was the goal of that second course of Paxlovid? Maybe there’s more that we don’t know about. We’re going to talk next time, tell people ahead of time about what is going on with Paxlovid, what is going on with molnupiravir, what is going on with no therapy at all with regard to these symptoms during that second week, those symptoms or positive tests out to 30 days? Is this really Paxlovid rebound? Is this just COVID rebound? What should we be doing about it?

Number two, Remdesivir. Remember that outpatient IV therapy? Vince and I were actually on a call where we saw the data of those people who are getting treatment, only about 0.3% have access to this. It’s really unfortunate because this is no drug-drug interactions, no renal issues, 87% reduction in progression, it’s just an operational challenge. Somehow this has got to be done in a capitalist society where someone can make money off giving people actually the appropriate therapy.

Remember, this is the only therapy we have for those little kids down to 28 days of age. Bebtelovimab still number three, and it’s at number three because we just don’t have the efficacy data to help guide us here. Last and least, molnupiravir, only about a 30% reduction.

I will just say when it comes to the early inflammatory phase, we’re not seeing many improvements here, we’re still steroids, anticoagulation, pulmonary support, maybe remdesivir if early, sometimes additional immune modulation. Avoid those unproven therapies. Actually, I will say next week, we may have more to say about one of those unproven therapies. I actually have an embargoed article that I can’t discuss quite yet, but whet your appetites, everyone who wants to send me some hate mail, you can start writing it now. You can imagine what it will be on.

All right, the long phase, the tail of COVID, continuing to be a challenge. We did talk last time about some encouraging data with regard to vaccination and Omicron, but this continues to be a huge challenge for millions of individuals.

I am going to close here with looking globally. Remember, no one is safe until everyone is safe. Thinking about the world actually plays a part in our discussions about what we’re going to be doing with vaccines going forward. What’s the narrative? What’s the message? What’s the science?

Right here, I want everyone to pause the recording, go to parasiteswithoutborders.com. You can actually go to microbe.tv as well if they want to donate there also. Really help us support what we do. If you go to parasiteswithoutborders.com, this will be July when this drops. For the rest of July, we’ll be doing our three month. This will be the last month of our three-month fundraiser for Foundation for International Medical Relief of Children. We’re going to be doubling those donations to get up to a potential donation of $40,000. Our fundraisers really focused on our clinic in Bududa District of Eastern Uganda.

VR: Time for your questions for Daniel. You can send them to daniel@microbe.tv. Catherine writes, I’m a pediatrician in Wacko, Texas or Waco, I don’t know how to say it.

DG: Yes, it’s Waco

VR: [laughs] Waco.

DG: I think it’s Waco. That was a slip, right?

VR: Sorry.

[laughter]

VR: Who has a patient who was diagnosed with severe MIS-C in October of 2021. He thankfully has had a full recovery and has been released to play sports by cardiology. His father is concerned because the entire family including this 11 year old came down with SARS CoV-2 infection earlier this month, his case was mild, but that was true of the last episode, which resulted in MIS-C. Dad is wondering about recurrent risk of MIS C with repeat infections.

Child’s not vaccinated, although I’ve encouraged them to get them vaccinated for SARS CoV-2 as soon as possible. We don’t have the vaccine in our clinic, but the local health department does. That is a whole other concern. As we have asked to have vaccine in our clinic for over a year with no movement from the corporate hospital system to allow this. Very frustrating for my partners and me. I appreciate your help in this matter as I have not been able to find any recurrence risk data for MIS C.

DG: I think there’s two points here that are – well, three points I’m going to go. One is that we are closely following individuals that had MIS-C. This is this multisystem inflammatory syndrome of children, we also see it in adults. The “risk” is considered very low. We’re really not seeing recurrent MIS-C, so that’s encouraging. The other, though, is what about this inflammatory syndrome post-vaccine?

I actually have reviewed a number of publications, reports. When you really start looking through, it’s very hard to find individuals who have this triggered by vaccine. Usually, there’s once you start digging through a case, you realize they actually had COVID, and so they may have gotten a vaccine and then they got SARS-CoV-2 infected, then developed issues later on. It’s very hard to see a vaccine-induced MIS-C. I’m not going to say it doesn’t happen. I’m not going to say at some point, there might be some rare presentation. These are individuals that we encourage to be vaccinated because the MIS-C is really a phenomenon that is well described in association with SARS-CoV-2 infection with COVID-19. We’re really searching hard and not seeing any significant signal in post-vaccine.

Then the third, this is, how frustrating that there’s such a challenge to getting vaccines, and this is one of those issues and I’m going to on the next episode start with a little bit lessons learned, here we are two years in, have we not learned? You really need to get the politicians and the large things out of the way. If a pediatrician wants to order vaccines, they should be able to just go online, they should be able to call their office manager, they should get those vaccines in the clinic. We need to remove the barriers, right? Hard to get a vaccine. We really need to streamline access to vaccines. You don’t need paperwork. You don’t need bureaucracy. You don’t need people standing between individuals and vaccines.

VR: Emily writes, “Thank you so much for continuing to produce this content. As a microbiology virology PhD candidate, many friends and family have been asking me for COVID medical advice that I’m, of course, not comfortable giving. I often say I’m not an MD and then recommend your TWiV episodes as an alternative. I share in your frustration with some providers being hesitant to prescribe Paxlovid and instead defaulting to antibiotics, which brings me to my question, that relative tested positive for SARS-CoV-2, and per my advice called his primary care to ask about Paxlovid. Instead, he was given a prescription for prednisone and azithromycin along with a warning of the potential side effects of Paxlovid.

What would you recommend a patient in this situation does other than not fill the prescription? I feel awful disagreeing with his primary care, but taking immunosuppressive steroids less than 24 hours post-positive test and subjecting yourself to those side effects seems questionable at best. I understand this is part of a larger informed consent and patient advocacy conversation, but you keep mentioning some suboptimal treatment plans that people are being subjected to, I think it would be useful if you touch on what a patient in this type of situation can do to advocate for themselves.”

DG: This continues to be, for me, an incredible challenge, is trying to basically spread the knowledge. Let’s talk a little bit about this physician, has good intentions, hopefully as they are, is really giving bad advice. We’ve talked about this. We’ve talked about a couple study. One was the, Steroid Use in Non-Oxygen Requiring COVID-19 Patients: A Systemic Review and Meta-Analysis,” where they showed that if you give steroids in that first week to patients who have mild disease, so that’s that first week, oxygen’s at greater than or equal to 94%, there was a six-fold increase in progression to severe disease and hospitalization, there was a 35% mortality increase.

There was another study, and this was, “The Association Between Pre-Exposure to Glucocorticoids and Other Immunosuppressive Drugs with Severe COVID-19 Outcomes,” Clinical Microbiology and Infection. Here we saw when they got on steroids, that was the greater than 20 milligrams per day of prednisone or equivalent, the associated hospital admission odd ratio increased 2.5, cardiac events increased about double, pulmonary embolism risk tripled, mortality was up about 3.5 fold due to COVID-19. This is bad advice and it’s tough.

I mean, it’s very hard, and I know I spent a lot of time trying to keep up on the literature here. This is one of those knee-jerk reactions that I continue to educate against, let people know, this is bad advice. This person would be better off not following the advice of this clinician. In situations like this, this is a barometer of the commitment to ongoing medical education of that provider, I hate to say. If you get this advice from your clinician, you probably need to switch. You probably need to find someone who is committed to keeping up with the literature and not recommending harmful interventions.

VR: We had a number of emails about the intervals of Pfizer vaccine, children under 5 years, which you corrected previously.

DG: Well, thank you. [chuckles] I mean I’m glad, to get this out here, and if I make a mistake, which I do make mistakes, hopefully not as many or as egregious as giving people steroids and antibiotics in the first week. Let me know, I’m always happy to take the helpful criticism.

VR: Everyone was very civil about it, saying, we want to have the right information out there, so thank you. Finally, our last one is from Carlos, “Thank you for all of your help with all things COVID-19 related. I’m a general internist in the community and I truly appreciate your expertise. My question is related to vaccination and pregnancy status. Does the recommendation for a fourth mRNA dose booster different pregnancy, specifically, should a pregnant woman who has received three doses of mRNA vaccines receive a fourth dose at this time? I recognize a COVID infection and pregnancy can be considered high risk, but I also don’t typically think of pregnancy as a reason to obtain a fourth dose. I just wanted to make sure I was thinking about this correctly. I look forward to next week’s update. Stay safe.” [laughs]

DG: Thanks, Carlos. We’ve covered the science on this a few times. These are licensed vaccines, so we can start thinking through, start using science to judge us and making individual decision about our patients. As we’ve talked about, if an individual who’s pregnant, gets vaccinated and let’s say last month before they deliver, we do have some compelling evidence that that is going to provide protection for the newborn for the first six months of life until they’re eligible to get vaccinated themselves. That is a reasonable thing to consider.

I think, as we’ve mentioned, pregnant individuals are at higher risk of bad outcomes. They’re higher risk of ending up at the hospital. We discussed the concerning mortality. We also discussed the increased risk of losing that child. We’ve also discussed the increased risk of neurocognitive development issues should that woman get infected during that last month, that last trimester. This is something where I think it’s reasonable to have that discussion about possibly doing a fourth dose during that last month before delivery.

VR: That’s COVID-19 clinical update number 121 with Dr. Daniel Griffin. Thank you, Daniel.

DG: Oh, thank you, and everyone, be safe.

[music]

[00:37:49] [END OF AUDIO]

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