TWiV 1338: Clinical update with Dr. Daniel Griffin

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

0:10From Microbe TV, this is TWIV. This Week in Virology, episode 1338, recorded on July 9th, 2026. I'm Vincent Racaniello, and you're listening to the podcast all about viruses. Joining me today from New York, Daniel Griffin. Hello, everyone. I'm actually on dry land this time, Vincent. Yeah, no life jacket. I see you have a bow tie so we can say what's on your bow tie. I don't know. Are you able to zoom in? Can you get a good look at that? I can't zoom in, no. Okay. All right. Well, maybe David will zoom in. our YouTube watchers can see the little, it's Giardia. It's Giardia. Yeah, I just see dots.

1:05Well, let's start off. We got a few things to talk about today. That's not going to be too bad an episode, but lots of stuff is going on. It's always stuff to talk about. So I'm going to start off with a Mia Hamm quotation. Do you know who Mia Hamm is there, Vincent? Yeah, a soccer player, of course. Yeah, you know, I've been obsessed with the football, the beautiful game. And so she was, you know, has been always a role model for a lot of folks. And, you know, and she became a mom and she has all kinds of great, like, comments about things. So not only a fantastic football player, you know, also I guess it was, what was it, Pert Shampoo commercials or something may have made her more famous.

1:47and failure happens all the time. It happens every day in practice. What makes you better is how you react to it. I like that very much because, at least in science, you fail a lot. Yes. Do you fail a lot in medicine, Daniel? I think probably you do because it's not your fault either, right? I mean, hopefully I'm learning. Hopefully I get 30 years plus from the time I got my MD, and hopefully now I'm still learning, still learning. But if you lose a patient, it's not failure, really, is it? Usually not. Yeah, usually it's not. Unfortunately, you know, we do as much as we can. Maybe we don't do, you know, as great a job as we look back on and would like to have done.

2:34But, you know, we're not God. And so there's only so much we can do. That's right. And we're sort of, yeah, battling against the disease. So, all right. Well, we've got a bunch to talk about. And the first time is, you know, how long did this take, right? So news, and this is a little shocking, and I want just – we're going to go through this slowly and really point out what happened here. So Air Force trainee in San Antonio, Texas, died from flu, right? Young, healthy Air Force trainee died last month at Lackland Air Force Base in San Antonio from the flu. and this individual was 25 and they died on June 16th.

3:18Now, influenza swept the Air Force base in June one month. It only took one month after Defense Secretary Pete Hegseth made the flu shots voluntary rather than mandatory for American troops. Nearly 300 troops ended up sickened by influenza. I mean, it didn't take that long, right? It took a month for this change to result in the death of an American soldier. This is, of course, what happens in boot camp. You put a lot of people together who are, you introduce a virus and this happens. And that's why we immunize. And this just underscores why this decision by the secretary was just boneheaded. It was dumb.

4:05It was ignorant. and it should not have happened. I don't know why he has the power to do that and why he thought that this was all about medical freedom. Rather, it's about staying alive. Yeah, my understanding is they've basically reversed this. I mean, you know, a month later, we already have one person dead. It's just, you know, and the reason this has been mandatory is that, you know, sure, this is a young, healthy individual, But these people are going through training. Maybe they're not getting as much sleep. They're basically in a situation that puts them at risk for bad outcomes. So yeah, this was an ignorant decision.

4:47Fortunately, it's very quickly been overturned. But has he apologized? No. Yeah, that's kind of crazy, right? Like, where's the shame, you know? Nothing, nothing at all. Yeah, you made a decision and someone's dead. You should call up and basically say to that family, I screwed up. Yeah. And publicly say this was the wrong decision. But they will not because this is their thing, medical freedom. Yet this kid, 25 years old, a whole life ahead of him, dying for a useless reason. Yeah. He has many other reasons to die. He could fly a plane and crash, or he could be in combat. But no, he has to die of a vaccine-preventable disease.

5:29This is absurd. Yeah, yeah. All right. Now, this, right, sort of in response or contrary, or, you know, I'll say contrary to that. The FDA committee unanimously recommends its first vaccine since 2023. Oh, my gosh. So the FDA's top vaccine advisory committee voted unanimously to recommend Moderna's mRNA influenza vaccine. It's called M-Fluceva for adults 50 and over. This was its first time reviewing a new vaccine application since 2023. The vote by the, this is VIRBAC, right? So this is the Vaccines and Related Biological Products Advisory Committee. is a step towards what may be the first vaccine filed and approved under the second Trump administration.

6:18In February, the FDA, remember this, they declined to review Moderna's application for the mRNA flu vaccine, but then reversed its decision two weeks later after criticism. So here we have this. Now, yeah, now what's the science, right? I mean, that's, that's why we're here. This is, you know, this decision was based on science. It was based on the results of a phase three double-blind active control trial published in May in the New England Journal of Medicine in the article, Efficacy and Safety of an mRNA Seasonal Influenza Vaccine in Adults. So we're going to talk a little bit about this, and then I'm going to sort of like, you know, the straw man, like what's the criticism?

6:58What are they going to say? So in this study, robust study, 40 ,703 participants, we end up basically with half and half. So 20 ,350, get the mRNA vaccine. You've got 20 ,353. They get the standard comparator, right? They don't get saline. Basically, this is the deal. There's a flu shot that works. The question here is, is this one better? Median fall-up is 161 days. RT-PCR confirmed protocol-defined influenza-like illness was observed in 2 % of the folks that got the vaccine and 2.8 % of the folks that got the standard dose. So this is a relative vaccine efficacy of 26.6%. So it is non-inferior, it's superior, there's actually a higher level of superiority here.

7:54So it's 27 % better than the standard. Now, what about safety, right? Everyone's just, oh my gosh, safety, you never look at safety. We always look at safety. Solicited adverse reactions were more frequent with mRNA vaccine, the 10-10, than with the standard dose. So a lot of folks, most folks actually got injection site pain, so pain where they were injected. They got that reactogenicity, that fatigue, about 45 % versus 20%. We saw headaches, 38 % versus 18. And we saw that myalgia, 35 % versus 11. But most of the reactions, they were mild, they were moderate, they're transient. Now, there were about 2 % of these serious adverse events in both the mRNA group and in the standard comparator group.

8:43And there were three events in the mRNA felt to be actually vaccine-related, two in the standard one. And then if you actually go into the appendix, right? Because I just want to point out, we spend a lot of time, I spend a lot of time looking at adverse events. So you go to the appendix, you see these AESI, so adverse events of special interest assessed by the investigators related to study vaccination. We saw one case in the mRNA of platelets going down and myopericarditis. In the standard comparator group, we saw one case of the pericarditis and one event of Bell's palsy. Now, according to the education by the cardiac event education committee, no cases of acute myocarditis, myopericarditis, or pericarditis were identified in the mRNA-1010 group within the conservative 42-day risk window following vaccination.

9:38So sort of put all that together. Well, I think it's good that we have another option, right? And the thing is that it's not much better than the standard vaccine. And, you know, we've always criticized the standard vaccine. It's just an inactivated virus preparation, right? Yeah. And it's very old. It's many years old. It was developed in the 1930s. So this isn't much better. So we have to fundamentally change the flu vaccine if we're going to really get substantially better. Yeah. I mean, I think there's two aspects. So one is, yes, it's not as much better. We wanted it to be much better, right?

10:1727 % better, you know, 2 % versus 2.8. You know, absolute, about 1 % difference, right? Not that impressive. There is one good thing, is that this technology allows you to more closely match what's circulating, right? Because this is when you get a good match, 27 % better. When you don't get a good match with the standard, because you had to decide six months ahead of time, the mRNA vaccine is going to work. The other is not going to do very much. So that's the other side. Yeah. The other aspect is that this is easier to make, right? You don't need to grow virus and eggs. Yeah. and extracted and purified and all that.

10:54This one, maybe it's not easier, but it should be. It's better. It's cleaner preparation, right? It's not old technology. And as you said, you could change the vaccine more quickly as well. Yeah, yeah. Quicker response, right? So, all right. Now, this is another, I think this is, you know, really important, right? So we just talked about this healthy individual in their 20s dying of the flu. So, and I just want to point out that people do die of the flu. So here we have this published in the journal Pediatrics, right? And so it's the article Influenza Vaccine Effectiveness Against Pediatric Death in the United States, 2016-2025, right?

11:38So these investigators conduct a case cohort analysis comparing current season influenza vaccination status among reported influenza-associated pediatric deaths, kids that died from flu, with survey estimates of influenza vaccination coverage in pediatric age groups. Underlying medical conditions, current seasonal influenza vaccination, all this status was obtained from surveillance case reports. They estimated the vaccination odds ratio and the 95 % confidence intervals comparing influenza vaccination among children who died with vaccination coverage in comparison cohorts. So we're really asking about, you know, the ability of the influenza vaccine to prevent pediatric deaths.

12:25So here's what I want people to just take this number. From August 2016 through July 2015, you ready for this? over 1 ,000, 1 ,234 laboratory-confirmed influenza-associated pediatric deaths. These are kids six months to 17 years of age. Over 1 ,000 little kids died, right? We've talked before about the fact that these deaths are often in kids that before this seemed completely healthy. Now, of the 1 ,086 reported deaths with influenza vaccination information, where we We knew what was going. Only a quarter, 23 % of 530 children with underlying medical conditions and 13 % of 556 children without known conditions were fully vaccinated against influenza, right?

13:18So majority of these kids who died, not fully protected. Influenza vaccination coverage in survey cohorts was 49%. So they're going to give us a vaccine efficacy of 80 % overall, 77 % among children with underlying medical conditions, 87 % among children without known conditions. And this is efficacy for preventing death from the flu in children. So this is important. It means that most of the kids who die would have benefited from vaccination. Not all of them, but most of them. Yeah, we can't prevent all these deaths, but we could prevent a lot of these deaths. And it seems kind of crazy to me, right?

14:05Like no parent is going to drive around without putting their child in a child seat, right? We're not talking about over a thousand children dying from not being in a child seat. And no parent's going to drive around drunk with their kid in the car, right? Like there's all kinds of things we do to keep our children safe. this seems like one of the things that should clearly be in that list. I wonder why these kids who were vaccinated died anyway. That would be very interesting to try and understand, right? Yeah, because there were, as we saw, there was 23 % of the folks with underlying medical conditions, 13 % of the kids who are otherwise healthy, right?

14:45So you saw basically hundreds of kids, even vaccinated, still dying. So what would be interesting, to know if that's different from an older group, right? If the percentage is higher because they are young children or is it similar? I don't know the answer to that. And then what's the mechanism? Are they not responding? Were they responding incorrectly? I think it would be important to know because that way you could possibly fix it with maybe changing the vaccine. Yeah. Well, also responding, right? We've talked a lot about how a lot of times children don't get the antivirals or maybe they don't get them as promptly.

15:23And that needs to change. And I think part of it, you got to appreciate. And these kids, they can get sick really quick. So they can go from being fine to 48 hours later, not being alive. All right. So vaccination, early treatment, make smart decisions. All right. I called this next section, not a virus. So we got that email They're like, screw worm. Dr. Griffin, is that a virus? So, you know, every so often I'm just going to, you know, full disclosure, we're going to discuss stuff that's not viruses, right? This is clinical update. It doesn't say virus. Yeah, it's clinical update. Although it says TWIV, but it's clinical update.

15:58Yeah, so you get a few things. So one, screw worm, we saw another, you know, four cases this last week. So we're up to a total of 33 cases. And why do we care? What's the issue here? So now we're up to 33 total animal cases. It's across the border. It's in New Mexico and Texas. It's a huge problem in Mexico, which we care about as well. But we care here in the US. One is this is horrible, right? It's horrible for the animals that get infected and have gone through like sheep and goats and dogs and cattle. But the biggest issue, the biggest economic threat is to the beef market, right? This used to be over a billion dollars in costs annually from the devastation of having this in our country.

16:43So this, yeah, this is a threat to the beef market. It's also a threat to sheep and dogs and people, actually. Yeah. Although at the numbers we have so far, it's not yet. If it can be contained, do you know how, what are the efforts to contain this in the US? Do you know? So the biggest thing they're doing now is the irradiated flies, right? So that, But the female, the lady, the screwworm ladies, they only have sex once and then they get basically a plug. So if that sex is with an irradiated sterile male, that's kind of the end of it. It takes that lady screwworm out of the population. It's not going to produce offspring.

17:26So that's really – and that's been incredibly effective. That was incredibly effective. That pushed it all the way down to the Darien Gap. We had kind of a wall of irradiated mosquitoes. Because that's probably the most effective way of countering this. And that's what they're starting to do now. And a couple other, not viruses, Legionnaire's disease. I don't know, Vincent, have people been asking you about this? Yeah, it's really unusual. It's on the Upper East Side here in Manhattan. Right. Usually it's in, usually what is it, in Harlem? Usually it's in the Bronx. Yeah, it's either in Harlem or the Bronx.

18:01It's in, you know, not well-to-do neighborhoods. I don't know why maybe the water towers are better kept on the Upper East Side, but now it's there. Yeah, it's very interesting. Yeah, so I'll leave in an article to Jessica Nix's Upper East Side Legionnaire's outbreak source remains unknown. It's behind a paywall, so I'll give you a little summary here. So, yeah, that was a great sort of start, Vincent, because we're going to talk about how people get this and how people cannot get this. So the New York City officials have not identified the source yet, but we'll talk about what we think it is.

18:37Upper East Side, we've already had 28 people infected. 21 are hospitalized. That's probably an undercount, right? So many more people are probably infected, not hospitalized, not aware. there. So the smoking gun are these rooftop cooling towers. And the New York City Department of Health already has gotten samples from 87 % of roughly 150 of these rooftop cooling towers. They're doing PCRs. And they're basically racing to do the testing to figure out which ones need to be cleaned, which ones might be the source. And then they warn people, basically, if you feel like you've got the flu, you feel sick, contact a healthcare provider and let them sort of guide you through this.

19:24Not everyone needs a test. There can be some judgment about who needs testing. The testing is mainly a urine antigen test in the case. But yeah, that's the situation here. People breathe in water vapor. The water vapor has the Legionella bacteria in it. So you don't get Legionnaire's disease from someone else. You get it from breathing in that vapor. And a lot of times these cooling towers can be the source of that. And then, you know, it gets warm, right? It's been warm. And that warmth allows the bacteria to multiply. It's a perfect ideal conditions for more and more bacterial growth. Also, it's hot, so more people are inside breathing the contaminated moist air.

20:07And then they end up breathing it in. And the incubation is pretty quick. It could be two days. It could be up to seven days. It's pretty quick from exposure to getting sick. and the um the bacteria by the way grow inside of an amoeba which grows in the water yeah amoeba and paramecium it's not just swimming around it's it's in those yeah now are the towers always full of of legionella or are there times of the year when it's higher than others do we do surveys of water towers in new york to know yeah so it's it's higher during certain times. Like we usually see Legionella with a summer cycle.

20:44So we'll often see it early spring, summer, and then kind of into the fall. You don't see a lot of Legionella in the middle of the winter, particularly in the Northeast. There are some other areas of the country where you might see a few cases here and there. For instance, like Las Vegas has them kind of, you know, every couple months you're seeing them because of the different climate and the different way things work there. Recently were some issues in the tropics, right? Because in the tropics, You got that warm temperature. So that really is conducive for Legionella to grow. And then they have air conditioning, right?

21:13So a couple of reports of stuff down there. Now, they're doing PCR. So you want to have no Legionnaires, no Legionella bacteria in these cooling towers. So if your molecular test positive, you got to bleach it. You got to dry it. You got to clean it all out. Now, if a patient has Legionella, how do you treat them? So you treat them with certain antibiotics. And it is important, certain antibiotics. So one, you want to identify, you know, and it's... We talk about the urine antigen test, but you can also send off sputum and sputum studies because the urine antigen test, as we've talked about, I think on Puscast, you're only detecting about 30 % of the cases.

21:49So it's not hardly sensitive. So... And you treat with the macrolides. You could treat with azithromycin. You could treat with doxycycline. You could treat with the fluoroquinolone like Levaquin or Cipro. Okay. Okay. All right. And so cyclospora, we got a parasite in the news. Well, we always have a parasite. Not a virus, right? Not a virus.

22:15So yes, I'm not going to talk about the fact that we often have a parasite in the news, but this is a parasite in the news, cyclospora outbreak. So, you know, outbreak of diarrhea causing parasite grows to more than a thousand cases. Cyclosporiasis outbreak in Michigan, It exceeds 1 ,000 cases. So yeah, as of today, Thursday, July 9th, when we're recording this, 1 ,251 cases out there in Michigan. And it really is sort of exploding. I like this. The explosion of the explosive diarrhea. So this is a parasite. You know, historically, we've had outbreaks from contaminated raspberries, basil, leafy greens.

22:58So some of the fast food restaurants preemptively, and I really applaud them for this, have said, okay, we're not going to be putting cilantro on things until we figure out if that's the source. We're not going to be putting lettuce on things. I think they're also like not putting guacamole. But come on, you could put the guacamole, you know. Charge extra. This is mainly from contaminated food then. That's usually, yeah. That's really how you get it. And the problem here is that this parasite is chlorine resistant. So the idea of using bleach and some of the other things, you really got to like wash it off.

23:33So soap and water. And what's the ultimate source of the contamination of the food? So it's people, right? This is only people. So some people have this and then, you know, it's a fecal oral. Maybe they're involved in the collection of the food. Maybe they're somehow involved in the food chain. They've got it. They're not washing their hands. They're, yeah, contaminating. Or maybe we're using, what is it, night soil, you know, so. And how do you treat it? Will it just go away on its own? So not necessarily. So some people, you know, a young, healthy person, this might go away, yeah, it might, you know, seven to nine weeks.

24:08Now, sometimes it can actually last quite a while, I have to say, so jokingly, seven to nine weeks. Immunocompromised people, they can get quite sick. You really should not die of this, right? It's something where you can rehydrate. And the history is interesting. This was first really identified as an issue in Nepal, and they treated it with Pactrum, with TMP sulfa. And that's very effective. That's really the number one treatment. There are some other options if that isn't working for you. All right. Ebola, things are not going well. The Ebola outbreak in the DRC has reached another grim milestone as greater than 500 people have now died.

24:47Um, only July 5th, healthcare workers in Etitu or on July 5th, healthcare workers in Etori issued a 24 hour notice of an impending strike saying that working conditions were too poor to continue. Um, to follow that along, yes, now they have actually gone on strike. So some of the healthcare workers in, uh, in Congo's Ebola outbreak have basically said now as we're getting up to almost 600 deaths, they're not getting paid. They feel like it's not safe. They're not getting the appropriate gear that can help them stay safe. They don't feel like they're treated fairly by authorities. So this is not great.

25:29And if you look at numbers, the CDC just went there. This is as of July 6th in the DRC, 1 ,708 confirmed cases, 580 confirmed deaths. 20 cases in Uganda, staying steady there with only one death. France is a confirmed case in France.

25:53Well, tomorrow on TWIV, we will have another Ebola expert, Tom Kysak from UTMB. So you'll want to hear that this weekend. Oh, that's fantastic. So all right, listen to us on Saturday and listen to that on Sunday. All right. And the measles cases keep going up. We're up to 2 ,184 on the Hopkins tracker and per the CDC, 2 ,170. So basically, I think August, we're going to pass last year's total. So we're now living in a country that has measles, where we see thousands of measles cases every year. So not great. But let's jump into COVID, Vincent. What do you think? We're looking at our multicolored lines.

26:40I had to follow this new link and... Yeah, it's looking good. It's really flat. And that one line is still dropping. Yeah, look at that. I mean, the Northeast, it's never been that low in the Northeast like ever. No. It's very interesting. And we still have time before it would go up, if it's going to go up. You know, the graph that we have here, it looks like, I don't know, the second week in July, maybe it starts to go up. Yeah. So, yeah, we still have a little time. Yeah. So, I mean, you know, going back historically. Yeah, this is not. It's good that it's slow. Yeah. Right? Yeah. And we'll keep an eye.

27:17We'll let folks know. Well, so, you know, now that it isn't anything to worry about, do we need to worry about treatment? Well, the article, Nermitrelvir, ritonavir for the treatment of COVID-19 in children aged six years and older, was published in Pediatrics. So this is an ongoing phase 2-3 interventional open-label study evaluating Nermitrelvir, ritonavir, so Paxlovid, in pediatric participants with mild to moderate COVID-19 at risk for severe disease, right? So this is that first week. These are folks that are at high risk, twice daily, Paxlovid for five days. These are folks who are at least six years of age and at least 40 kilograms or 20 to less than 40 kilograms.

28:01They've got a second cohort they're looking at here. So they're going to end up with different doses, right, based upon their weight. What do they find? They find that Paxlovid was safe. It was well tolerated. As far as adverse events, they saw some loose stools. They saw some headaches. No discontinuations from treatment-related issues. No treatment-related serious adverse events were reported. No hospitalizations. And they did see robust reductions in the SARS-CoV-2 RNA from baseline to the end of treatment. All right, COVID late phase. We've got a couple articles here to talk about. So this first article, the article, Efficacy and Safety of Rivaroxaban, Ultracine, and Femotidine Liratidine with specialist supportive clinical care for fatigue in patients with post-COVID-19 condition in the UK, a multi-site, open-label, randomized controlled trial published in the Lancet Infectious Diseases.

29:06Can you tell us what these drugs are? Yeah, let's tell you this right away. So the first one, Revax, Revaroxaban, right? So these basically are direct oral anticoagulants, right? So it's sort of modern, think of it as modern rat poisoner, the modern warfarin. Colchicine, right? That's the gout medicine, right? And famotidine, loratidine, these are basically antihistamines, right? So the famotidine is the GI, loratidine is more of an allergy antihistamine. So these are medications that people have thought would hold to promise, right? So they go ahead and they're going to do this one to one to one to one, right?

29:49So you're going to get either one of these drugs or you're going to get no drugs. You're going to do this for 12 weeks. And then they're going to do this fatigue assessment scale and they're going to see how well you do. And I'm just going to cut to the chase. They find a statistically significant but unclear if it's clinically significant, basically 1.5 point change with colchicine and the antihistamines, not with the direct oral anticoagulant. And then when they stop, things kind of go away. So they don't really see much, much beyond that. So, you know, I'm not overwhelmed, right? This isn't like, oh, gosh, this is great.

30:31Yeah. So this is not going to solve the long COVID problem. It's really not. I mean, there were like tiny, tiny reductions. It didn't last once they stopped them. It was, you know, not necessarily clinically significant, but a statistician said, yeah, it is a little bit different. So, yeah, a little disappointing.

30:54All right, the article. And I think this goes more to sort of support the idea that there are post-acute sequelae. There are, you know, long tails to some of these infectious diseases. This whole idea that, oh, you get sick and now you should be fine. Stop complaining. Well, the article, Long-Term Sequally Associated with Severe West Nile Virus Disease in Maricopa County, Arizona, 2021, was published in Open Form Infectious Disease. So here we've got 159 patients with West Nile Virus Disease and 75 patients who mostly had COVID-19 and COCSI. So they're going to compare some other diseases here.

31:29And they're going to do these standardized assessment tools. And they're going to do them 17 to 24 months after hospitalization. Now, what happens here? So among patients with West Nile virus, 40 % end up getting transferred to long-term care facilities. 83 % experienced ongoing symptoms, including fatigue, myalgia, arthralgia, pain, problems with sleep, memory, and concentration. overall 33 % reported disabilities, 55 % reported worse health than before the illness. So it turns out that long-term sequelae in patients hospitalized with West Nile virus were common up to two years after hospitalization.

32:13But they go on to say that it looks like there are similar common inflammatory or physiological pathways leading to the post-infectious sequelae and outcomes related to hospitalization. So, you know, sort of basically an awareness saying providers caring for patients with West Nile virus should make them aware that there can be a prolonged and possible incomplete recovery process. That's a lot. 40 % in long-term care facilities. It really is a lot. I mean, West Nile virus can be really bad stuff. You got to protect yourself from mosquitoes, folks. Yeah, not great. Wow. All right. Well, no one is safe until everyone is safe, particularly while there are mosquitoes in the world.

32:57I want everyone to pause the recording right here. Keep getting updates from Foundation International Medical Relief of Children in Uganda. Uganda has been doing a really good job so far with the Ebola outbreak, but that's because of the support that the people have there that they need. So we are in the middle of our May to July fundraiser, hoping to send a maximum donation of$10 ,000 to FIMRIC, particularly to help support the Beduda, Uganda site. So go to parasiteswithoutborders.com, click on the donate button. Even a small amount helps. It's time for your questions for Daniel. You can send yours to Daniel at microbe.tv.

33:38Mark writes regarding the doctor who said she is unable to give shingles vaccines in her office due to it being a Part D service. It's Medicare Part D, right? I am an internist. We give Shingrix in our office. Medicare pays for it. There's a program called TransactRx. They are a private vendor. Patients get the same coverage in my office that they would get in the pharmacy. Some insurance plans do not participate. so we check every patient beforehand and let them know what their copay will be as the website tells us in real time. It's very easy to use. We sign up for it and it allows us to give our patients vaccines.

34:18This is not a new program. The writer needs to have a talk with her office manager. So Mark, this is great. And hopefully our listeners. So TransactRx, this is really a great option. And hopefully more people hear about this, more people will be aware of this. And then more people will then have access to the wonderful dementia prevention vaccine. Yeah, spread the word, folks. We know you can do that. Susan writes, my then-teenaged son was temporarily put on a steroid that apparently tamped his immune system enough to cause him to get shingles. He was around 17 at the time. He's now 32. too. Should he request to get this shingles vaccine early or just wait until the recommended age of 50 plus?

35:08Thanks for all that you both do to keep us well-informed and educated during this dark time for public health. Yeah, so this is a slightly complicated question you ask, Susan. So, you know, if you had said, oh, my son is immunocompromised, he had shingles, what should we do, he's not 50 yet. You know, the vaccine is indicated for folks 50 and older. It's also indicated for folks 18 and older who are at increased risk because of immunodeficiency or immunosuppression. So it would really come down to the question, is he going to be on steroids again? Is his immune system going to be tamped down because of something like that?

35:47If this was sort of a one-time deal and that's behind you, you don't necessarily go ahead and get the vaccination. But yeah, if there's going to be immune issues again, the second indication is for the folks under 50 who are potentially at risk because of an issue with the immune system. So he got shingles, so he has latent virus in ganglia. Yeah. So he could, he could after 50 get it again. That's the idea, right? So he, yeah. So that would be his, you know, his risk would go up when he hits 50. So hit 50, go ahead and get your two vaccine doses as recommended. But unless he's going to be steroids again, this was sort of a one and done.

36:29He's back to a normal immune system. Yeah, the recommendation would wait until you're 50. Okay. Jeff writes, long-time listener to the podcast, reaching out because I am curious. I know there are a variety of viruses which cause viral hemorrhagic fever disease. Are there analogous pathogenic eukaryotic species which cause hemorrhagic fevers? If so, like what? And if not, why do these symptoms are present in viral infections? So is there anything other than viruses that cause hemorrhagic fevers? Yeah, I was thinking about this. So like eukaryotic infections would be like our helmets, right? Our worms, our fungi.

37:10I can't think of any kind of a hemorrhagic fungal infection or hemorrhagic parasitic infection. I'm thinking it's certain viruses, right? So according to AI, some bacteria like Rickettsia and Leptospira can cause malaria can be associated with hemorrhagic fever. Did you know that? So actually, yeah, that's interesting. So yeah, and that would be eukaryotic. So I like that actually as a thing. And then some worms can cause hemorrhagic fever. Which worms? I'm curious about that. Let's see. This is actually a paper.

38:02Well, this is... Oh, interesting. So this one has...

38:11I don't know. This article is viruses, so I don't know which worms would be involved. It sent me to this article, but it's not worms. I mean, I know it's not popular, but I like AI. It's helpful for questions like this. Well, if you can go to the literature and confirm it, that's always good. And that's key. You got to do that next step so that you can ask these questions like, hey, and then you bring up, you're like, yeah, actually, oh, lepto, yeah, I didn't think about that. rickettsia yeah that's great not eukaryotic but not viral well then if they don't give you a reference what they did here you can ask them what's the reference for that and then you go look at it yeah and that's key otherwise they can hallucinate or just tell you what they think you want to hear so which i like that too but i just wanted to check brooklyn writes thank you for all you do we why have we not seen debt more deaths with this year's measles outbreak yeah so brooklyn it's about one in a thousand acute deaths, right?

39:11So we're 2 ,000. So, you know, one or two deaths is all we'd expect. So we're kind of doing okay there. Unfortunately, and this is the problem, is the risk of death is going to go up. It's going to be like threefold higher for all these individuals for the next two to three years. That's going to be very interesting to try to connect, you know, those deaths. So, you know, hopefully people are following these individuals that had measles over the next few years. There's also, you know, several years later, there's the neurological issue that can occur. So, you know, may not have been enough time.

39:47Hopefully these kids are getting good care so that we're, you know, I really do not want to see kids dying of measles in the United States. Yeah, we have not had any deaths in 2026, but we have over 2 ,000. It's just probably too close, right, statistically. Yeah, yeah. Mary writes,

40:33with COVID symptoms. There's one stop the medication and switch to Paxlovid. I understand that Zocova is used in Japan to treat COVID. What is the effectiveness of Paxlovid versus Zocova for treatment of COVID? Thanks for all that you do at TWIV for your dedication to the science. All right. So Mary, this is great because this brings us back to the science. So what was the FDA approval based upon? So there was this study, right, where you have the index patients. These are the folks that have COVID. And then you've got the household contacts. And what they do is they do the point of care, like they do the rapid test, they go ahead, they start people in ZOCOVA, but they also go ahead and they do PCR.

41:12So what ends up happening is some of the folks, actually a fair number, like double digit percent of the folks that get started in ZOCOVA end up having positive PCRs. So you're actually starting it on some of the people. So, you know, it's more effective at preventing COVID and people that don't have it, right? Like if you actually remove those people in the analysis, so intent to treat versus people who confirmed PCR, you don't have it. Does it prevent it? Right. 80 % prevention. That's great. But yeah, certain people had it. And then Zocova doesn't have the indication for treatment. So if you're using it for prevention, great.

41:51Go ahead. Take the N-Citrelvir, the Zocova. But if the patient actually gets diagnosed with COVID, then the recommendation is to treat with Paxilovid. So comparing effectiveness, Paxilovit versus Zokova for treatment. Here in the U.S., we have the compelling data that we've talked about repeatedly, randomized control trial, and then the post-analysis where Paxilovit is effective for treatment. Zokova doesn't have basically FDA-level data to get approval for that here in the U.S. That's TWIV Weekly Clinical Update with Dr. Daniel Griffin. Thank you, Daniel. Oh, thank you. And everyone be safe.