TWiV 1368: Clinical Update with Dr. Daniel Griffin

Podcast introduction and ID Week arrival

0:00This Week in Virology, the podcast about viruses, the kind that make you sick.

0:09From Microbe TV, this is TWIV, This Week in Virology, episode 1368, recorded on October 21st, 2026. I'm Vincent Racaniello, and you're listening to the podcast all about viruses. Joining me today from Washington, D.C., Daniel Griffin. Hello, everyone. ID Week, right, Daniel? I am down here at ID Week. I just arrived about an hour ago, took the train down, and so our

0:44recording's a little bit thrown, right? We're recording with on a Wednesday night. We'll do a TWIP paper on a Thursday night, and hopefully I'm going to learn a lot here down in D.C. What's on your tie, Daniel? So actually, you know, I think it's a coronavirus. It's got bikes sticking out, like in a corona pattern. Okay. Looks colorful. I'm going with that. It might actually be the flu for all I know. Tomorrow I'm going to

1:16end up with an STD tie, because I only brought so many bow ties, right? And I can't travel anywhere where I might be required to wear a bow tie on a Friday, so without an STD bow tie. But okay, so since I'm in Washington, I thought, why don't I quote one of the founding fathers, Alexander Hamilton. And, you know, maybe this just – am I becoming a pessimist? I don't know. But his quotation, men are reasoning rather than reasonable animals.

1:49Hey, this is a long time ago. So men and women, people were screwed up from the start, really. I'm going to try to just disparage the men, but okay. I think everybody falls under that category, Daniel. Sorry.

Hepatitis B vaccine plans and WHO HPV guidance

2:04Okay. All right. So we've got a bunch of things to talk about that kind of made that seem appropriate one, and really frustrating. But, you know, we read in the news, I read the article as well, but Kennedy's vaccine plan could cause surge in hepatitis B study fines, right? And, you know, not okay just killing kids with the measles efforts, but ending the practice of immunizing all newborns against hepatitis B, as Health Secretary Robert F. Kennedy has recommended, would sharply increase the number of chronic infections and put more than half of Americans

2:39at risk of disease by age 20, according to a new study published. And so here's the study. In Annals of Internal Medicine, we have the article, Projected Effect of 2026 Federal Changes to the Childhood Immunization Schedule on Chronic Hepatitis B Virus Infections in the United States. So here we have analysis where they determined that compared with the universal birth dose strategy, 255 childhood infections, the deferred and shared decision-making strategies would increase

3:15chronic HPV infections in the 2026 birth cohort by 19% from that 255 to 303. And by 83% to 467, if you kind of follow that. So these strategies would also increase the number of hepatitis B virus-susceptible people at age 20. And this is actually 474,001,806 compared with this

3:50universal birth strategy where you'd only have 232. So pretty dramatic increases if we go down this road. This from a man who knows nothing about science. There's no reason to change this schedule. And he's, he's, yeah, he's, he's, yeah, he has no, no proper medical training. It's really unfortunate. Also HPV vaccines. So from the WHO, we have highlights from the meeting of the strategic advisory group of experts stage on immunization, uh, five through eight, October, 2026. This kind of

4:26is something that we brought up a little bit before. Um, but this is the concept of a single dose schedule. So in this meeting of the WHO, they're actually, um, going to hit three bullet points here. So one is they're suggesting that a single dose schedule is the most efficient immunization strategy for cervical cancer prevention in girls age nine to 14. Um, based on review of updated evidence, Sage recommends HPV vaccination of girls age nine to 14 years using a single dose schedule.

4:58This was identified as the most efficient approach to achieve the primary goals of the global strategy for cervical cancer elimination. I'm going to sort of stop there because, uh, maybe you and I can talk about this a little, but, um, you know, my, one of my first thoughts is that, you know, this is talking about a global strategy. Um, and I do think it's important in, um, high resource, um, situations like the United States that we ask ourselves, well, what is the most efficient strategy for, for us here in

5:31the U S? Well, I think efficient is an interesting word. It's not the same as effective. Yeah. Right. So one dose. Yeah. You can probably get more people, but you know, the current dosing, at least in the U S is three doses. So I can't imagine that one is going to be clinically as effective. Yeah. I think that's the issue. Like we thought about MMR, like, Oh, everyone gets one dose. That's great. But if everyone gets two doses, that's better. Um, so I think that's important to sort of

6:03look at the context is a WHO recommendation. This is not necessarily a U S recommendation. We have really a lot more resources here than a lot of places in the world. Some of the stuff I did like, I'll leave in a link to this is they, they talk a lot about catch up vaccination, um, in, uh, women aged up to 25, catch up vaccination, women aged up to 30. Uh, there's also a discussion about targeting other groups, um, such as, such as young men, men in general. So, um, yeah, I just, I just want to

6:35make sure we just talked about that a little bit. Well, you know, you can go up to 45 based on the clinical trial data. So they're, they're way below that. And I don't think that's fair, but also we saw in that meta analysis that it can help older people as well. And I think studies need to be done to, to formalize that. Yeah. I think, you know, you, you look at the relationship between HPV and a lot of head and neck cancers, right. And also, as we saw the idea that you can get a vaccination after infection. Um, and so, yeah, if anything, instead of like restricting, uh, we probably want

7:11to be expanding HPV vaccination for all the benefits that we're seeing. Sure. All right. The article,

Pertussis vaccination during pregnancy and effectiveness data

7:18the effect of pertussis vaccination during pregnancy on pertussis and diphtheria immunity in children at three and four years of age, published in JID. So, so talk a little bit about pertussis, right? So we're seeing, um, significant problems with pertussis and there's a couple different strategies. Uh, we talk about cocooning or ring vaccination. Um, and this is where not only, uh, you know, a pregnant woman gets, uh, vaccinated, but everyone around them gets vaccinated. Uh, but here is a, uh, it is sort

7:51of a tough one. So this group followed children born to tetanus, diphtheria, acellular pertussis vaccinated and unvaccinated mothers to four years of age. At both three and four years, children born to the, uh, T-DAP vaccinated mothers. So that's the tetanus, diphtheria, acellular pertussis, T-D-A-P. Vaccinated mothers had lower anti-pertussis toxin and anti-diphtheria toxin IgG concentrations

8:23than control children and pertussis toxin seropositivity and diphtheria seroprotection rates were low in both groups. After a preschool, acellular pertussis booster at four years, antibody concentrations increased to comparable levels in both groups. Um, now, is this a concerning difference? So, so we, we can look at the numbers and discuss this a little bit. Um, and you can see, right? So Vince and I, and for those on YouTube, we're, we're looking at the

8:54actual data right now and you, you see, uh, you see these levels that you see them go down and then you see these rises. Now, I think there's a couple comments. I spent a little time trying to think about that. And one of the ones is that this is data from Finland and they have a different D-DAP schedule. Um, now they're giving this combination vaccine at three, five, and 12 months, and then a booster at age four, right? So if you look at the data, you can see, oh, we're, we're seeing these low numbers right before those boosters in Finland. Now in the U S we're doing boosters at two months,

9:31four months, six months, then another at 15 to 18 months and another at four to six. Yeah. There's a reason for that because you can't depend on maternal antibodies for so for four years, right? Yeah. Yeah. So I think that, you know, you look at this and we're seeing something we've described where, you know, sometimes the maternal, um, antibodies can interfere with the early vaccination. But if you're getting a two month, a four month, a six months, and then a 15 to 18, um, I think I would, I would want to see the data here in the U S and that's data we could certainly

10:03get, um, to see if it really is concerning in any way here. Well, I also think we need to know if this is clinically relevant. Do we see an increase in pertussis in Finland, for example, not just the antibody titer is going down, right? Yeah. And I don't think we're seeing a problem. So, yeah. I don't know. I think that's an important comment. And we do know, right, that pertussis vaccines work. We have some really great data from the CDC, the MMWR, effectiveness of diphtheria and tetanus

10:35toctoids and a cellular pertussis vaccine in children aged six months to six years during a statewide pertussis outbreak, Alaska, May through November, 2024. So, um, you know, pertussis vaccines, you know, like so many of our vaccines are pretty incredible in what they've done widespread use of pertussis vaccines in children has resulted in a greater than 90% reduction in the number of annual pertussis cases in the United States, um, after a period of low U S pertussis incidents during and

11:06shortly after the COVID-19 pandemic incidents increased in 2024 data on the real world effectiveness of diphtheria and tetanus toxoids and a cellular pertussis vaccine against pertussis during this disease resurgence, um, are limited. So in response to documentation of a record high pertussis incidents in Alaska during May through November, 2024, the DTaP vaccine effectiveness against pertussis in Alaska children aged six months to six years was evaluated. Now the adjusted, uh,

11:41VE vaccine effectiveness was 96.2% among children who completed the three dose primary DTaP series and 85.3% among those who were partially vaccinated, um, compared with children who received three or more of those doses, the odds of lab confirmed pertussis was 26 times as high in unvaccinated children, 26 times, um, and about four times as high in those who only got one or two doses. Uh, these findings

12:15really reinforce the importance of following the pertussis vaccine recommendations to protect, uh, the children. Um, and so I've actually, I actually brought up for our YouTube watchers to see what, what are the current, what is the current vaccine schedule from the American Academy of Pediatrics? And you can see, you know, the, the, the birth dose, right. If hepatitis B still recommended by our professional pediatric society, uh, protecting the little kids against RSV, you can see a lot of

12:46these other doses in here. Um, you know, I'll just bring up that it was a recent survey that has me a little troubled and it's this rhetoric about like, Oh, all these vaccines, it's just too much, you know, and I even hear this, I was in the hospital the other day. And so I was talking about, you know, like what vaccine should they get? I was like, Hey, you should get your flu. You should get your COVID shot this fall. They're like, Oh, so many vaccines. I'm like, well, what are you talking about? So many vaccines too? Is that so much, you know, I mean, they're just like, well, this and that I'm like, do you get dressed every morning? Like, Oh, my left sock, my right sock,

13:19my underwear, my pants, my shirt, it's too much. I'm like, but you know, a jacket or a hat. Oh, I mean, let's just stop with the sock. That's enough. That's two. Daniel, I'm looking at this. The tetanus doesn't show up until seven to 10 years. What's going on there? Oh, actually, so go down. So we're looking at it all together. One, two, three, four. So here you see diphtheria, tetanus, acellular pertussis, first dose, two months, four months, six months, and then the fourth dose, the fifth dose.

13:52Yes. I see. And then the other one is greater than seven years. Okay. Yeah. And it's interesting with tetanus, right? So there's a couple of shots. Actually, the tetanus one's perfect because it's got the tetanus and the pertussis. So there are certain shots when you're on something of a scheduled series, right? So you get first shot, second shot, third shot, fourth shot, fifth shot. Oh, my gosh. And then there's this idea that you could extend the schedule and say every 10 years, you should probably be getting a booster there. But then you have these unscheduled boosts, right? Like you go and you step, it's always a rusty

14:25nail, right? I mean, I don't know how many people are stepping on rusty nails, but it's a dirty wound. And then you get another tetanus shot, right? And so like any year later, you step on another rusty nail, right? And you're like, ah, I've already had, you know, I don't need any more of those. I'm overwhelmed. But yeah. And the same as we talked about pertussis, these unscheduled additional boosters might be thrown in there. So if you are getting your second month, you're going to get one, two, three, four, five. Would you get those all in one visit or would

14:58they space them out? They actually have a shot, which is really nice because, you know, a big thing is like getting poked all these times, you know, and if anything, our vaccines have gotten better. So you could actually get these, you know, went to valence, you could actually get shots with five different protections in there. And the nice thing, right? I mean, you think about, we used to like give people what smallpox and just, it was like the whole thing and you get horrible reactions. Yeah. Yeah. Now I'm just thinking about a mom is not going to bring the kid in more than once a month.

15:31I think that's the challenge is like this whole idea, like, let's just spread them out. It's like, oh my gosh, you're going to live at the pediatric office. You're going to be there every month. We're dad, we're dad, not just mom. Oh, you know, let's be honest, right? No, actually I should ask you. So when our kids got vaccinated, my wife would go wait in the car and I would be like the bad guy hanging out with the kids when they got their vaccines. Yeah, I'd go in too, sure.

Global pertussis burden and animal rabies surges

15:57All right. Okay. Global, regional, and national burden of pertussis in 1990 through 2023, a global burden of disease study. So this is a nature paper. And despite longstanding immunization programs, pertussis remains a major cause of vaccine preventable mortality, particularly among infants, right? So I will point out pertussis, it's a bacterial infection. It's not a virus, but this is a clinical update. So we're hitting pertussis hard this time.

16:29Um, here we present a primary assessment of global pertussis incidents, mortality, disability adjusted life years across 204 countries, territories, 1992-204. Now, what I really was, the reason I think I included this was just the number of deaths, right? So in 2023 alone, there were 18.9 million cases, 115,000 deaths. Um, and you know, this is, uh,

17:00not equally distributed. Uh, there's a, a lot of this is concentrated in sub-Saharan Africa where we're seeing about 65% of the global deaths. Um, so really, uh, pointing out, I mean, pertussis is a horrible disease. Not only can it kill over a hundred thousand people a year, um, but you know, it's, it's disaffectionately termed the hundred day cough. I mean, you just keep coughing and sometimes the coughing can be so profound. You actually end up vomiting this post-tussive vomiting that occurs. Okay. All right. Um, this is, this, well, is rabies making a comeback? Um,

17:39so this is New York times, a handful of unusual outbreaks have made headlines, rabid beavers at a Maryland state park, a cluster of goat cases at a North Carolina petting zoo. Officials in several States, including Idaho and Alabama flag surges in animal cases, California set an annual record for rabid bats. I guess they'll get in the Guinness book with that. And last month, the, uh, the CDC issued a national health advisory cited reports of local increases in

18:10human rabies exposures. Um, so, you know, but, but it's okay, right? Because, oh wait, it's not okay. The CDC has lost about 30% of its staff since last year, including, um, members of the rabies team, which no longer has the capacity to advise state officials after hours. So if you're going to get bit by a rabid animal, do it between nine to five Eastern standard time, because they're in, uh, Georgia there, all paused rabies tests came back online by August, 2026. Dr. Ryan Wallace of

18:41veterinary epidemiology at the agency's rabies and pox virus brand said an email. Dr. Wallace did not directly answer questions about the current size of the rabies team, but said that it was fully equipped to respond to rabies questions and requests for technical assistance. I think with the caveat, as long as it's between nine to five, Monday through Friday. Uh, yeah. I, I read this article and there have been no cases of human rabies confirmed this year so far. So that's actually good. You know, so the, the headline is rabies making a comeback. This is all about animal non-human

19:16rabies, right? This is true. Although you could argue that there have been human cases that haven't been diagnosed because the CDC, I mean, the guy won't say how many people work on it. Maybe, maybe it's just one. Well, we've definitely had a lot of, well, personally been involved in a number of exposures this last year, uh, where we've jumped in. And am I getting a little worried about those foxes, which torture my dog? They seem to like, they've decided this is what they do. And, uh, you know, they, they come to the, I think I mentioned this, right. The, I don't think the foxes are rabid,

19:50but you do worry about them, right? They come to the back door and then freak out my dog. And then they just hang out on the other side of the fence because they know she can't get out. So, all right. That's why that's where the word foxy behavior came from, right?

20:06Maybe. All right. Screwworm. You know, I kind of keep an eye on this, but oh my gosh, I saw like a bunch of cases so far. Um, already another five cases in October. Uh, so up to 56 cases, but this is all in the U S, um, is in, um, in animals, but we did have our first fly trap detection. Do you see that? Yeah. Look at that. First time whole year. Yep. Um, but human cases, um, in 2025, 837 human cases, including four deaths in eight countries this year, though,

20:42January 1st is September, 2026, 1,355 cases, including five deaths in six countries. Um, Mexico had 592, um, up from 117, uh, Guatemala, Honduras, Panama. So we're having a number of

Ebola spread and measles outbreak context

20:59cases there in human beings. All right. Ebola. Things, things are not going well, right? And it was sort of a series of, you know, Kenya reports, second Ebola case. Kenya confirms third Ebola case. Now we're actually up to nine Ebola cases in Kenya. And we actually got a case, an imported case in Nigeria, um, that was confirmed by the WHO. So if you'll, if you look at the CDC trajectory,

21:29um, it is just rising. Um, and apparently on the ground there in, uh, the DRC, it's actually spreading to new districts. And majority of these people are not being actively tracked. We're up to 9,666 total confirmed cases, 4,649 total confirmed deaths. Wow. And the curve keeps going up. Yeah. It's, there's, there's, isn't even starting to level at all. It's just shooting up. Um, but, uh, you know, we are, we are hearing a little bit about the, uh, the vaccine

22:08trial, the Khomeini or Swahili for hope vaccine trial. Um, and this is the, um, or Vabo, right? So this is the, uh, Zaire vaccine. Um, so we're going to see, uh, how well that does. Yeah. You got some, they have some Bundibugio specific ones for November too, it looks like. Yeah. Do you see, I, I got through that whole section without even saying that. I did it for you. All right. Well, we've got our own, uh, viral epidemic here in the U S U S measles cases grow

22:42by 8% one week for a total of 4,410. That that's out of CIDRAP. Um, and I'll just read from CIDRAP. Measles continues to rip through unvaccinated communities across the United States. And I do want to point out this continues to be a disease of the unvaccinated. Um, and in the New York times, we have a pretty interesting article. The Amish families pushed to undo a vaccine law, then measles arrived. So, um, this is an article that's actually, uh, it's also the New York times.

23:15And, uh, for five years, New York state health department has been locked in a battle with three tiny Amish schools upstate the dispute, whether students must be vaccinated. Amish families say that New York's immunization rules, which allowed no religious exemptions threaten their religious freedom and way of life. Um, there's a whole discussion about this tight knit religious community. Um, and so their interaction with the world, there's even some sort of first person. So David Leslie, in a 33 year old furniture maker, who is Amish said that

23:47his seven children were vaccinated against tetanus, but had not received the MMR because he feared they would be stricken by terrible side effects. Um, I mean, so much of this is who is telling them that who is misinforming them, who is, who is giving them this fear. Um, so there's a, uh, there's a lawyer here involved, a Mr. Sasser, who's a lawyer at the first Liberty Institute. Um, and he, he focuses on these, uh, religious liberty cases. Um, so sort of that going on, but now we've got the context of

24:21just, you know, all these people actually getting measles. And, and so this next article is going to sort of help put this in context because, you know, we hear the numbers of measles. We hear the number of, you know, 10 to 20% end up in the hospital. A lot of these little kids are in the ICU struggling to breathe. Um, then they survive, but now you've got this ticking time bomb. And it's actually talking to a nurse from the Philippines about this earlier this week, um, because in the Philippines, they had some pretty significant outbreaks. And there's this idea that six to 10 years later, you might then

24:56develop this devastating fatal encephalitis. So this is the subacute sclerosing panencephalitis

Subacute sclerosing panencephalitis and measles complications

25:03after measles outbreaks, the Philippines, 2007 to 2022 published in EIS, uh, subacute sclerosing panencephalitis. This is a delayed, almost uniformly fatal complication of measles. Um, the Philippines had measles outbreaks in 2010 to 2011, 2013, 2018 to 2019. Uh, the last was the largest in the WHO, uh, Western Pacific region. Um, now published SSPE data from the Philippines ended in 2015. Uh, but this

25:37group reviewed all 20 children admitted with SSPE to a tertiary pediatric hospital in, uh, Cuisine City, uh, during 2007 to 2022, an estimated year of measles infection. Um, and there's some, some nice, uh, data where you can actually see that periods of time when, and it's these ivory bands mark the periods of reported nationwide measles outbreaks. Um, and then you can actually see the, uh, the SSPE admissions by year in, in blue. Um, yeah, the number of cases in measles are in maroon. Um, and the,

26:15the authors point out that because SSPE is latent for years after initial infection, those cases most likely represent the leading edge of a post outbreak wave. Um, and additional cases may emerge over the coming year. So with continued measles outbreaks in the U S I mean, we've, we've got to anticipate that we're going to see a number of these little kids dying of SSPE in the years to come. Of course. No question. Yeah. So I got that book, Vincent, that book about the Faroe Islands.

26:47Mm-hmm. I think it's, it's over there on that. Let me grab it. I'm going to grab it.

26:57All right. I'm back, back with my book. So there you go. Yeah. So it's, it's little, it's little, it's a paperback. You can get it through Amazon. You get the paperback. They even spent twice as much on a hardcover copy if you want. Um, but it really, it's, uh, it's pretty impressive about that lifelong immunity described. Um, basically the folks who had measles when they were little, when measles came back, they didn't get it. So this is great that they're still selling this book. Is that, I mean, I think it's this new, like print on demand. So with this new

27:33print on demand, you can just, uh, well, it says published by Laguerre street press. Um, so yeah, no, they're still, they're still publishing it, which I think is really great. Um, and there is a nice, there's a nice article. I'm going to leave a link to the article in the New England Journal of Medicine and this, you can actually go through and it really, uh, gives, uh, some really, uh, you know, interesting, um, well, it really, it recaps the whole book, um, about the, the folks who ended up, uh, getting the measles there in the Faroes.

28:04It's great. Did you, did you start reading it? Um, I have not, that's, I'm so excited. That's what I'm going to do after, you know, everyone else will go to sleep, but I have got my reading. Yes. And you can report on it in the future. Uh, you know, I think we're doing, uh, some talks up at wheel Cornell and I might talk a little bit about this when I'm up there. Yeah. In a couple of weeks, we're doing an update there. Yeah. Yeah. So I'm looking forward to that. Um, all right. Um, okay. So I'm going to leave in a link to, we also have the global and regional burden of measles and

28:38vaccine coverage, um, a global burden of disease study. And this was published in the New England Journal of Medicine. So, um, I'm going to leave that in. Uh, we just have so much to cover that I don't want to, uh, uh, drown everybody, you know, and, uh, but, uh, Pennsylvania, uh, things are not going well there. I actually gotten to the point now where there was a, uh, Pennsylvania state department issued this guidance for measles and pregnancy and congenital measles. I'll leave a link into that. Uh, but it walks through, like, what do you do? Uh, you know, one, ideally you get everyone

29:11vaccinated ahead of time, but if you don't, what happens when a pregnant woman gets measles? Uh, what happens is as far as what you might do, you know, cause these are, these are replication competent, um, attenuated, uh, vaccines. So we don't actually, uh, vaccinate, uh, someone while they're pregnant, uh, then what to do. Uh, but really a warning for a warning for everybody, but also some guidance for, uh, patients and physicians on what to do. Uh, yeah. All right. CDC ignored requests

Measles testing delays and tracking numbers

29:46from states to validate a new measles test. Well, that's, that's helpful. Health officials in California and Washington facing outbreaks in measles this past spring asked the CDC to validate tests that could diagnose 500 cases in eight hours. They did not hear back for two months officials. So next time you're on the, like, you know, waiting for the cable guy, at least it's not two months, right? Officials from the West coast health Alliance, California, Washington, Oregon, Hawaii recounted the experience this week in a letter to Dr. Erica Schwartz, the CDC's new director.

30:19Uh, this is just, uh, yeah. They said CDC response was they had other competing priorities. Really? Measles outbreaks is not a priority. It would be if you had enough people because the jerk didn't fire so many of them. Folks, what are you thinking? Please. I'm talking to you voters. There's, there's no reason to keep this guy in office.

30:50All right. So, uh, Johns Hopkins measles tracker, we are up to 4,603. And, uh, those of you watching on YouTube can see the, see the map, see where a huge cluster, right? In Pennsylvania, really driving a lot of this. Um, and if you look specifically at another 108 cases in Pennsylvania, you're up to 1,317 in Pennsylvania, um, New York, New York. We got our own measles problem going here. We got

31:20162, actually a couple of cases out in Nassau County. That's why I had to go to Washington and run down South. Um, and I really like New York city. Look, look at this banner, spread the truth, not measles. I like that. The measles vaccine is safe and effective. Um, cause we've got seven

Influenza and COVID-19 epidemic trends

31:41confirmed cases in New York city so far. All right. The flu just, just starting to get some activity, right? We're just starting to see a little bit down in, uh, Louisiana. So we're already starting. It's a, you know, if you look at the, uh, epidemic trend from the CDC, we're just starting to have that, uh, uh, flu activity start to come up. So it looks like it's a little early this year. Um, so it's still, you still have that opportunity, right? To get your flu vaccines. If you're 65 and

32:13over, right, then you're going to want to get one of the, uh, the high dose or the senior specific, um, vaccines. So make sure you ask, uh, we've got our egg-based vaccines. We've got our cell culture, recombinant protein, nucleic acid-based vaccines. They're all dry this year. They're all, they've got a couple of different A lineages and they've got one B. They, they've only got the Victoria lineage because the Yamaguchi, is that how that is? Yamagata. Yamagata. Yamagata. Yamagata. Yamaguchi is

32:48the, is the restaurant in town. I'm going to end up at the wrong place. I'm going to end up getting a vaccine instead of a good, you know, Japanese dinner. But Daniel, on this epidemic trend, COVID is going down, but in the sewers, it's going, in the wastewater, it's going up. Yeah. It's interesting. This is the percent of positive tests. And it's interesting. People don't want to get tested for COVID, right? So you can't get a positive test if you don't consent to get tested. That's true. Yeah. It's a bit of an issue. We're going to talk, we're going to,

33:19we're going to get to COVID here in a second. And I say in just a second, because, you know, we're really not much going on. RSV is still quiet, which, you know, usually by this time of year, we start to see activity in Florida. So we'll keep an eye on that. But yeah, let's look at our COVID. I have to say, I had a number of folks in the hospital this weekend, this early part of this week. And yeah, we look like, you know, we're bouncing all around, but we're bouncing all around on our way up. We're down. We're down. I don't know. I could imagine this being the midpoint of this

33:57little outbreak and now it's going down. Yeah. You know, it's hard. You know what the hardest thing to predict is, Vincent? The future. You got it. You got it. All right. If you look at our map, you can see that the activity is concentrated in certain parts of our country. Yeah. The 50 somewhat United States. All right. So, you know, remember all the things we've talked about, you know, masking, avoiding high-risk situations. We now have, if you actually end

34:28up in one of those situations, we have Zocova and Strelvir post-exposure prophylaxis. You know, in general, about a 50% reduction in getting COVID if you take post-exposure prophylaxis. That's a Scorpio PEP trial. And it's up to like almost 70% in the high-risk folks. So we've got things to do there. They charge too much, I should mention. You know, the early viral phase, right? We still have early antivirals that we can be doing. But let's get to late phase past long COVID because we actually

35:04have, I'm going to say, an interesting trial. We'll tell you how interesting it is. So, Vincent,

Long COVID clinical trial analysis

35:11are you ready for this? I'm ready. Let's go. This is our last paper and then we're going to get to emails. In the Annals of Internal Medicine, we have the effect of fluvoxamine and metformin for fatigue in patients with long COVID, an adaptive randomized trial. This is the REVIVE together. And so the trial was conducted at 22 participating outpatient sites in Brazil between October 23 and February 2025. And we've talked about the results of several adaptive trials over the last few years.

35:43So trying to like bring people up to speed of what is an adaptive clinical trial? And this allows researchers to make pre-planned changes to design, not just any, but certain pre-planned. So you can adjust the sample size, you can drop ineffective treatment arms, you might modify patient selection rules. And this is all sort of pre-specified, but then based on interim data while the trial is still running. So, you know, if one of the things just isn't working, you just, you stop. You just say,

36:15we're not going to do that anymore. So patients were randomly assigned in a one-to-one-to-one ratio to get fluvoxamine, metformin, or matching placebo. You got this web-based randomization system. Placebo tablets were manufactured, so you couldn't tell which was which. And you end up getting something twice daily for 60 days. So some folks are getting extended release metformin. Initially, it was 750 BID, but this is that adaptive. It was some issues with tolerance. They dropped it to 500 BID.

36:49Oral fluvoxamine, that was 100 BID. Or placebo, placebo BID. And they do this for 60 days with follow-up. Now, they're going to do this FSS score. So basically, people are going to, you know, nine items are going to ask them about fatigue severity scale. And so you're going to score things, from one to seven higher levels is more fatigue. Now, the trial enrolls 399 participants. You end up

37:21with a number in each different set. Now, they found fluvoxamine for long COVID-related fatigue reduced fatigue severity as measured by the FSS with a mean treatment effect of 0.43 at day 60 and a sustained effect of 0.58 at day 90. Now, those are small, right? That's like half of a point. And then this is like, this is the one that gets headlines. These effects both have a posterior probability of

37:54superiority of 99% compared with placebo. Improvements in health-related quality of life assessed by the EQ5D5L were also observed at day 60 and 90. So let's look at the data. Let's look at figure two. And so you've got figure two. And they've got these box plots. And they're going to show the distributions of individual items. They're doing this fatigue severity scale here. Um, and you're going to end up, and this is for folks who are looking at this, um, on, uh, YouTube,

38:30watching the video. So, uh, the placebos in white, fluvoxamine's light green, uh, metformin's, uh, medium green for the 500. That's a darker green for the 750. And then they've got it zero, 30, 60, 90 days. Um, and you know, you could, a lot of overlap here, right? What really bothers me is they have three treatment categories. They have fluvoxamine, they have metformin at 500 and

39:01at 750. And the results are all the same. There's no difference. Pretty darn similar. Why is that? I mean, so, um, it's such a small difference. It's the statistically significant difference. So, and, and how big is 0.5? So this is like going from, you know, I agree fatigue interferes in my work to I, I somewhat agree that fatigue interferes in my work. But Daniel, the placebo goes down as well in, in fatigue score. Yeah. You see the open boxes are

39:32placebos and at 90 days they are indistinguishable from the treatment arm. Except a statistician can tell them apart. And I think that's what has me a little bit, you know, we are seeing, well, interesting. It seems like if you do something, if you get people in this trial and you meet with them and you acknowledge them and, um, everyone seems to be getting better, but it's really subtle. It's statistically significant. Um, I mean, these are drugs with very different, uh, targets, right? Yeah. Yeah. So it doesn't, and the placebo has a

40:09very different target from both of them. So I don't, this does not make a lot of sense. Would you prescribe these based on these data? So metformin, no. Um, you know, would I consider a trial of fluvoxamine? It's reasonable. Um, but then again, you've sort of each individual, I mean, because if, if you're seeing this difference of 0.5, then, you know, some people are getting worse, right? Well, fluvoxamine is an SSRI, right? Maybe part of this fatigue is depression, right?

40:39Yeah. And maybe if you help with certain, you know, and maybe if you're better at selecting which people you're going to consider fluvoxamine, you might do that. Um, yeah. Yeah. I just, I know this has got a lot of attention, so I want to at least just look through it. I am not impressed at all by these data. I'm not either. I'm just, I'm disappointed to be on it. Yeah. I mean, we would like to find something that works, but we really, we really would. And I'm glad this is in the news again, right? And this should be in the news again. There was that marathoner, right? Who's now like bedridden. Um, and this should be in the news. Why should it be in

41:12the news? Because there are so many people suffering and the current folks, they said that spending money researching long COVID was a waste of money and the money should be spent on other things. Yeah. Who said that? Uh, that those are the people, uh, you know, McCary and the people involved with HHS. I don't understand what you're doing folks. Yeah. So, I mean, all the folks out there that are struggling, having a tough time, you know, now's your chance

41:42to vote for science. Make your vote count. Um, as we've been saying for, um, years now, no one is safe until everyone is safe. Um, you know, we're, we're actually getting pretty close right to the end of our, uh, American society of tropical medicine and hygiene fundraiser. Um, we're hoping to double your donations because, uh, well, this is it. October is it August, September, October, um, because we're trying to raise money for the Dixon-Depamier five-year

42:12one health lecture series. Um, and we also want to support American society, tropical medicine and hygiene, um, and help, uh, bring folks from those lower and middle income countries so they can, um, come to the annual meeting, they can network, and they can, uh, move their careers forward. So go to parasiteswithoutborders.com and click the donate button.

Listener questions on COVID vaccine recommendations

42:32It's time for your questions for Daniel. You can send yours to danielatmicrobe.tv. Ellen writes, what the is going on with the medical community in this country? I have an undergraduate degree in microbiology from University of Florida. While, while there, I spent three years in infectious disease research at the School of Medicine. While in dental school at Emory, I worked at the CDC the summer between my freshman and sophomore year. The summer Legionnaires broke out in Philadelphia. I've been listening to your podcast for the past five years, as well as

43:05others. I've also been writing a regular infectious disease update for the past five years at the facility. I provide volunteer services, 16, 17 years now. I'm hearing from neighbors that their physicians nationwide, and especially in the New York area, are not recommended anyone receive the current COVID vaccines. In addition, there was a super spreader event in my community a couple of weeks ago, where more than a dozen people caught COVID from a neighbor at their home during a particular small event. A friend of ours who attended the event tested positive. She followed

43:38the advice I previously gave her and her husband and called her HCP's office for Paxlovid. The doc was out of town, and the nurse practitioner called in the prescription immediately for her. Her husband did not test positive, so I suggested they get a Zokova prescription. The NP refused, as she had never heard of this medication. Since he and his wife were both due for their COVID vaccines, I suggested he go ahead and immediately receive the vaccine, which he did. Both our friend and her husband did great. However, she told

44:09us that none of the other people were able to get Paxlovid prescription from their PCPs because the doctors didn't think it was necessary or said it wasn't done anymore. So please tell me what's going on there. So please tell me what's going on out there, doctors. Thank you in advance. I really enjoy listening to your broadcasts and find them extremely informative. Yeah, Alan, this is really frustrating. So yeah, one of the things I'm going to be doing here at ID Week, and actually by the time this drops, I will have done this at ID Week. It's like five hours on Thursday and two and a half hours on Friday as a

44:45sort of a Lucy booth, information booth, where you can just come up and we can talk about COVID. And I'm hoping this is an opportunity to educate, get people up to speed on COVID. And there seems to be this kind of, you know, I'm done with COVID, but COVID's not done with you. You know, we want to just think that COVID is now, you know, a simple cold, but it's not. You know, we had tens of thousands of people die last year from COVID. You know, I ended up with a number of people in the hospital

45:19this week for COVID. And it just, people just, they want it like, oh, but it's mild. I'm like, they're in the hospital, they're on oxygen. I don't know what's mild about that. You don't, you don't end up in the hospital on oxygen from the cold, from a common cold. And not only is there that. So not only do we see over a million people seeking medical attention each year for COVID, not only do we see hundreds of thousands of people end up in the hospital, not only do we see tens of thousands of people die each year from COVID, but we have long COVID, which we talked about people,

45:54marathon runners who now are like bedridden and their dreams and their life are destroyed. We have people who get COVID and now your chance of getting diabetes is more than doubled. It's about 2.5 when you look at all the data put together. We've talked about increased risks of strokes and heart attacks. And you know what? If you get a vaccine, you can prevent the disease. You can reduce your risk of COVID-19 symptomatic disease in half. You can reduce your risk of a stroke, of a heart attack,

46:26of ending up in the hospital. You can reduce your risk of dying. You know, it's quick. They poke you with the needle. You get your vaccine. They're incredibly safe. If you don't like the mRNA, you've got the Novavax, the Sanofi, Novavax, Nuvaxavid. So we got options out there. And so I just worry, I worry that a lot of physicians, rather than following the scientific literature, rather than talking to experts and physician thought leaders, they're just watching the news and kind of

47:00following what everyone else is doing. Ruth writes, currently shivering after having just

Listener queries on statins and flu vaccine options

47:06had flu and COVID vaccines and an immune response. Odd question from me. My cardiologist called my cholesterol levels very generous, and I'm contemplating taking statins. The only downside for me is that apparently they kill off all the archaea that are lurking in my guts, which I've learned from various TWIVs and a great program from BBC Radio in our time. Anyway, should I take statins and as a side effect kill off my own personal archaea of rare and ancient origin? It feels like a sad step to take. Well, so Ruth is probably a meat eater, right? If she had this significant shivering response,

47:43right? We talked about that last time. Yeah. It's also probably why her cholesterol is so high, right? Because, you know, if she switches to a plant-based diet, it's really interesting. Yeah, you are correct. There is some data that statins can affect the microbiome. There's kind of the other interesting that the microbiome can actually impact how well the statins work, right? And that's why we talk about if you're going to take statins, you all should consider, you know, making those quote-unquote lifestyle changes. I think that, you know, in the scheme of things, there's good data

48:16that statins are going to reduce your risk of a heart attack, your risk of a stroke. So, you know, it might be worth sacrificing some of your personal archaea for the increased quantity and quality of life you might get from that. Ruth says they kill off all the archaea. I don't think it kills all of them off. Not all. Not all your own personal archaea. Christine writes, at the risk of being redundant, could you please provide clarification about the influenza vaccines currently available?

48:47I was disappointed to learn that all my options, I am not yet 65, were versions of a trivalent vaccine. Each option omitted one of the flu B variants. I understand that flu block has a higher concentration of antigen. Also, I've learned that in order to receive flu zone high dose, folks under 65 need a doctor's note in addition to paying out of pocket. I'm both a nurse and grandmother of an infant. I'd like to be as well protected as possible for the upcoming respiratory virus season.

49:16Yeah, so Christine, this is actually good. We were talking about this a little bit earlier, is, you know, one of the things that happened during the pandemic is one of the flu Bs is gone. So the quadrivalent vaccines, you don't need them anymore. They don't make them. Everything's trivalent because the Yamagata vaccine, the Yamagata B, it's gone. It's not something you have to worry about. So you don't need to vaccinate or protect yourself against something that isn't out there. So the different vaccines are going to have the different A and they're going to have the one

49:47remaining B out there. Let's see. Yeah, so I think the other is the 65. Yeah, let's run through all these, all the different vaccines that are out there. I've got that. I'm going to zip up to my notes, right? Okay, so here we are to the different, what is going to be in them. So depending on whether you get egg or the others, they're going to be different. So the egg-based vaccines is going to have the influenza A Missouri, the influenza A Darwin, and the influenza B Tokyo, which is a Victoria

50:22litage. The other option in addition to the egg-based or egg attenuated, as I disparage them, the cell culture, recombinant protein, or nucleic acid, right? There is an mRNA vaccine out now. These are going to have the also influenza A Missouri, influenza A Darwin, but the one difference is these are going to have the influenza B Pennsylvania as their Victoria lineage. And the big thing for you to ask about is if you are 65 and over, you're going to want one of the ones that

50:53are specifically for the seniors. It'd be high dose or maybe the adjuvanted. Barb writes, I was hoping you could review the COVID vaccine options. As I understand, there are four, Omirnaty, SpikeVax, Mnex, Spike, NuVax, Ovid. And she writes, I understand they're all pretty similar in terms of protection, but is there any reason I should get one over the other? They've gotten mRNA vaccines before. They don't have reactogenicity issues. Yeah. So in that case, you could really go with

51:24any of these options, right? So you mentioned you laid them all out. So we've got Pfizer, Pfizer, we've got the Moderna SpikeVax, and then the Moderna Mnex Spike, which when they did head-to-head with the SpikeVax, was 25% better at preventing clinically identified COVID-19. It's the RB, the RG, receptor binding domain, RBG only, right? Isn't that correct with the- RBD. RBD. RBD, what? Ruth Bader Ginsburg, no, the receptor binding domain, RBD.

52:03And then the Nuvaxavid is, it's your protein-based. So some people prefer that, but no, I mean, if you look at all the efficacy data, it's pretty similar. I did mention the one comparison between the SpikeVax and the Mnex Spike. And Bob writes, I've been thinking of concept of vaccine hesitancy and how it might be overcome. Childhood vaccines are protective devices for our children. I remember when my child was born in 1982, we could not bring him home from the hospital unless we had a

52:34federally approved car seat properly installed in the vehicle. And the nurse checked the car in car seat before we could put the baby in it. Our families had never heard of this, and we were thought to be overprotective when we would not let our child ride in a car without a car seat. Ten years later, when there were many more young children in our families, it seemed everyone with children had the car seat and booster seats and seat belts. I live in California, and here seat belts are part of the culture. I'm not sure how the rest of the country feels about the importance of car seats

53:04and seat belts. But here, I think it would be helpful to talk to a vaccine-hesitant parent to think about vaccines like a car seat or a seat belt. You may feel you're a good driver, but as everyone else. You don't get in an accident every time you drive, but you know it can happen. Your child may not be exposed to viruses. Vaccines prevent every day, but it can happen. Just a thought. All right. Maybe Paul Offit will listen to this and hear your letter. Paul Offit always says that. He's always saying, what's this choice? You don't have a choice about

53:37seat belts. Why do you think you need a choice about vaccines? So he's bought into it. Yeah. Yeah. No, I remember the early days. I remember like, it's always the uncle. There's always some uncle who's like, I want to be thrown clear. I don't want the seat belt. It's going to bruise my chest. I'm like, no, really? You don't want to be thrown through a windshield. You do not want to be thrown through a windshield. You don't want to get measles. You don't want your kid to get measles. You don't want your kid to get these horrible vaccine-preventable diseases. And the vaccines are safe. They're effective. Don't let people lie to you about them.

54:07So being thrown clear is like getting measles naturally instead of being vaccinated. It's the same mentality. It's the same mentality. I'm going to be thrown through the windshield. And then hopefully six to 10 years, I don't end up dying of encephalitis. You want your child to be thrown clear. And if they survive that, then you got to worry that six to 10 years, it's going to destroy their brain. It's horrible. That's TWIV Weekly Clinical Update with Dr. Daniel Griffin. Thank you, Daniel.

54:39Thank you. And everyone, be safe.