TWiV 1340: 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 1340, recorded on July 16th, 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. How's the air out there, Daniel? Is it smoky? So it's really bad, actually. Yeah, there were some of the camps were asking me what to do, but there's a system. We're going to talk about this, actually. Okay. Yeah, it's bad. But here in New York, well, I haven't been out since this morning, but this morning, it's fine. Either that or I can't smell anything. I don't know.

0:52Yeah, no, it's a health issue. But let's jump in, And we're going to start off with a quotation, which I will share with our listeners. Vincent ran it through AI. Let's see what AI had to think about this. And so the quotation is, stupidity is the same as evil if you judge by the results. And that's Margaret Atwood from Surfacing. So what you were telling me, what did AI have to say? Well, I didn't quite understand it. It's a little obscure, right? But it basically means if a house burns down, it doesn't matter if it was because of evil or stupidity. In the end, it's a big problem, right? Yeah.

1:33So that's why she says it's the same as evil if you judge by the results. That's the judge by the results kind of got me. I think the quote could be better. But, yeah, you can't just say like, oh, I didn't do it on purpose. That doesn't help. It's still the house burned down or whatever the disaster might be. So I get it now. I'll let our listeners speculate about why this seemed appropriate. But OK. So I got this little news section right up front. And why did this catch my interest? Well, so we have this statement from Senator Mitch McConnell, right? And why do I care? Well, to my fellow Kentuckians, this is from the statement Mitch McConnell, when you elected me to a seventh term and made me our Commonwealth's longest serving senator.

2:23You did so trusting that I'd keep showing up to fight for you every day. And over the past several weeks, Elaine and I have appreciated both your well wishes, your honest questions about what was keeping me away from the Senate. You all know how folks of my generation often hesitate to share the vulnerability that comes with growing older. Even in the public eye, I feel that same instinct. I can't help it. But at the same time, so I think it's interesting, I've had more than my share of experience with physical vulnerabilities. Surviving childhood polio meant spending my entire life with mobility challenges.

2:56They haven't exactly gotten easier to manage with age. And last month, I took a fall, which landed me in the hospital. My doctors have confirmed that I didn't break any bones or suffer a concussion. I didn't have a heart attack or a stroke. I didn't have any tumors or hemorrhages, but I was briefly unconscious and was taken to the hospital. We're all receiving excellent care over the past several weeks, I've also had to deal with a mild case of pneumonia. I just wanted to ask you, Daniel, I know you want to talk about post-polio. Yeah. First of all, if it was nothing, why was in the hospital for several weeks?

3:30And is there such a thing as mild pneumonia? There's also a little bit of somehow he lost consciousness, but he didn't get a concussion, right? I mean, you get whacked hard enough in the head that you lose consciousness and not all of it makes sense. And this is like a question I think that got me in a lot of trouble at one point where I talked about illnesses in our elders are not something just to take in stride or to write off. I mean pneumonia in a person over the age of 65, which Mitch McConnell, is about a 10 % mortality, a one in 10 % chance of not surviving. So quote unquote mild case of pneumonia.

4:07I mean pneumonia is infection of the lungs. It has a mortality associated with it. So nothing's so mild when we get older. So this is just a little bit slimy, I think, still. I don't think he's being straightforward. Well, the reason I like this statement is it really – it brought post-polio syndrome into discussion. And so there was a CIDRAP discussion of post-polio syndrome. What is this? And I have to say post-polio syndrome – Vincent, you're probably steeped in this with your kind of world. But many providers, many individuals here in the US were not really familiar, are not familiar with post-polio syndrome.

4:49And I was actually – when I came through NYU School of Medicine, that august institution, no one had ever taught me actually about post-polio syndrome. And I didn't really become acquainted with it until I started practice in Colorado. And you saw some? I saw a lot of folks. It was a big, big outbreak there. Back during a time, sort of a dark time in the history of Colorado, we had a Klan governor, if you can imagine that. Fort Collins was the home of the AKK newspaper, you know. So, you know, so and so so Sidrapp has this nice discussion. So let me just share a bit of that, because I think this is really important, right?

5:28When when we're we're at risk or while we're starting to see these vaccine preventable illnesses come back into the US. So many people today know polio, which paralyzed up to 58000 Americans a year at its peak. Thanks to vaccination, the disease was eliminated in the United States in 1979 and throughout the Western Hemisphere in 1994. Today, wild polio virus circulates routinely only in Afghanistan and Pakistan. I like the comment, why are we distinguishing between wild type and vaccine-derived, right? Still paralyzing people with vaccine-derived polio. So there's still polio virus circulating.

6:10People are still getting paralyzed. We're still putting, you know, oral polio, vaccine-derived polio back into the environment anyway. Yet the polio virus continues to harm nearly 300 ,000 Americans, right? 300 ,000 Americans in the form of post-polio syndrome. And I don't think people are familiar that there are hundreds of thousands of Americans still suffering from post-polio syndrome with an array of medical problems that occurred decades after the original infection. Now, no infectious virus has been covered from post-polio patients. The syndrome is thought to arise as a result of years, decades of additional stress work of the unparalyzed limbs.

6:51After years of health, you notice they spelled limbs wrong. They spelled it with a P. I think they were thinking limp and limbs. After years of health, 25 % to 40 % of polio survivors may suffer pain, renewed muscle weakness, fatigue, problem speaking, or swallowing. I just think that's like something to really point out because people think of, oh, it's polio, you get it, nothing happens, or you're that rare person. We quote these numbers, one in 2000, depending upon which type of polio we're talking about. This is huge. 25 to 40 % of people that survived polio will go on to develop post-polio syndrome.

7:33We have hundreds of thousands of people in the US still with that. That's why so many of these senior folks got so upset with RFK's attack on vaccines and the polio vaccine. But McConnell, the former Senate majority leader, has long had an unsteady gait, has fallen several times in recent years. He's often seen using a wheelchair to get around the Capitol. The United States, most polio survivors are in their 70s or 80s. The number of people with post-polio syndrome is declining as these folks age and pass away. Now, around the world, the burden of polio is much greater with estimates showing as high as 15 million to 20 million suffering with post-polio symptoms.

8:14So this is like, you know, people who've had polio when you look at the percent of people that have issues down the road. So we may be doing what we're doing now, but there still are all these people suffering. And if polio comes back, not only are you going to see the acute paralysis, but every time you have polio sweep through an area, you're going to have this, you know, quarter to a third or more folks end up with post-polio issues. I mean, polio continues, as you know. Now it's mainly vaccine-derived polio, but it's still polio. It paralyzes. So there will always be post-polio as long as there is polio.

8:50Yeah, yeah. It doesn't matter if it's vaccine-derived. It does not. It's interesting that they called it post-polio and not long polio. And it's interesting that they called it long COVID and not post-COVID, isn't it? Yeah, it is interesting, right? Yeah. Yeah. But this is basically a long polio. I think it's long polio. Yeah, I lump it together when I talk about people who have like long flu, long polio, you know, long chikungunya, long Ebola. I mean, you know, there is this, I think now hopefully well-recognized issue with multiple infectious diseases where you have an acute illness, you have a period of time afterwards, And then you have this – it can be years, years of ongoing issues.

9:38This is the clinical update, right? So air quality issues like you started to talk about, Vincent. It's totally relevant. Absolutely. You know, and it not only puts people in the hospital because of all the inflammatory issues, but people with underlying lung diseases. This puts them at risk. So right now, for those of you who are following this, those of you who are living in this, right now we're sitting in a period with really poor air quality. And there's a whole scale and basically based upon the amount of particulate matter in the environment and there's even an airnow.gov where you can look and see what's going on in my area.

10:16Now, today it got up into the 190s, which is really like the upper limit of unhealthy. 201 is when you move into very unhealthy. And there's all kinds of guidance about what to do when the air quality is this bad. And really interesting. It was like a few years back, right, when we had those really bad – again, it was similar. You had forest fires. You had unhealthy air. Maybe people at that point were a little more sensitive to the fact that they didn't want to harm themselves. their children. A number of the camps said, okay, we're not going to do outdoor activities today. Yeah. Today, the kids are all out there breathing in the smoke.

10:57I'm looking at this in New York City Air Quality Index. It's really very nice. It's going to go down tomorrow, and it's not going to be in the 190s. It's going to be like 60s. Yeah. So it's going to be back to moderate, and then hopefully we'll get back into the good air quality again going forward. But this is the result of forest fires, right? Exactly. Them Canadians. Well, aren't there some out west also in the U.S.? Actually, yeah. So there's a fire, pretty big fire out in Colorado. This is that time of year when we start having these fires. All right. And we finally got a health alert, cyclospora kiatinensis.

11:40I mean, it's gotten to the point. It's embarrassing, right? We hear about this in the just mainstream media and the – what's the Twitter and that stuff? Like social stuff? What do they call that? Social media. Social media. And then like after the fact, like weeks go by and finally it's like, oh, hey, by the way, we should like let the doctors know. We should send out an alert. It's like, yeah, we already know, by the way, CDC. So I even looked at the CDC data. It's not really up to date, which is a little disappointing. But I'm going to leave in a link actually to the epidemiologist newsletter.

12:16That's by Caitlin Jettlina and Marissa Donnelly. I'm actually going to be doing a podcast with Caitlin Jettlina. Maybe I'll learn how to pronounce her name properly. But they have a nice newsletter. You know, it's a nice map, reported cyclosporiasis cases. You can see, and this matches up when you go to the Michigan Department of Health, 2 ,640 cases. We've got dozens of people hospitalized. Ohio and New York, we're competing to have the most number of cases. Ohio's at 661, New York 470. So if you go to New York City, we have like almost 400 of those cases just right in the city. We've got some on Long Island.

13:06But Michigan has a ton. Michigan has thousands. And those are confirmed cases, right? So this is a bit higher than last year, apparently three times higher. Yeah, so a lot higher in New York and much higher in Michigan. So this happens often, but this year it's worse than usual and we don't know why, right? Well, that's what we're figuring out. The smoking gun at this point is lettuce. And so how do people get it? Just a primer, we talked about this a little last time, is cyclospora chitinensis, only human beings, right? So you're getting this from an infected human being, feces, ends up on the hands, ends up on the vegetables or the fruits.

13:51It's not on the deep fried food, right? So you can keep eating your deep fried food. It's all good there. it's really usually not on frozen stuff because if you if you do that really aggressive freezing that they do or even if you freeze it for a long period of time you're gonna you're gonna kill the cyclospora but so it's gonna be fresh usually the the washed bag lettuce is what we're thinking in the past it was raspberries in the past it was basil in the past it was lettuce also so yeah that's probably what it is and we're just trying to pin down and there was a discussion about why is it taking so long, right?

14:23Because when it takes long, people keep getting infected. And so the issue is that there's still, you know, you start off with, you identify, hey, this is more than usual. It's worth investigating. And then you start talking to people about how might have you been exposed. And then you can do genetic analysis on the people. You know, at this point, it's pretty clear it's coming from some kind of a source. It isn't just sporadic and a little bit higher than normal. And then you can then start testing the different potential lettuces and other vegetables. Got it. All right. Legionella. I think we're doing a little bit better as of July 14th, 63 total cases.

15:05But you can see we had that peak 8, 9, 10 a day. And now it's been one case, one case. So the last positive was on the 13th, but this is updated the 14th. So we'll see what happens. So July 14th, just a few days ago for folks listening, New York City Health said 76 cooling towers on the Upper East Side had tested positive for Legionella. Now, what to say about that one? It's a molecular test, very sensitive. We don't know if this is living Legionella. We don't know if it's a high enough amount of Legionella that's getting everyone sick, but basically going ahead and everyone is cleaning those towers.

15:48There was a discussion. I was listening. I listened to the Brian Lehrer show on NPR, full disclosure there. And there was a New York City health person talking. They were a little evasive when someone said, hey, can I still go to New York City and go to the Guggenheim? And do I have to worry about getting Legionella walking around the streets? And they wouldn't answer the question. I'm going to answer the question. It's okay. You can go to the, you know, you're not going to be out there standing, breathing long enough. I mean, the idea is you've got these cooling towers, and then unfortunately, there's usually an intake to the building, and then you end up with enough of an exposure.

16:22But we don't really think that you're on your way to go to a museum, and somehow you pass through a neighborhood and get Legionnaire's disease. Just full disclosure on that. So what you're saying is you have to be in the building for a long period of time? Well, you really need an actual inoculum of this. It's probably not one bacteria. It's not like you walk through or your taxi or your bus goes through a neighborhood and you end up. So people don't need to avoid the Upper East Side of New York City. But we do need to do a better job. I mean, we keep having these outbreaks. People keep getting sick.

16:53So we need better approach to this. Well, why do these water towers get contaminated? Are they open? Is that the problem? Well, so the Legionella bacteria will be in the water at a small amount, and then you end up with this warm weather. The bacteria proliferates. It's in there with the paramecium. And then it's going to be a natural cycle, right? It's going to cool down. The bacteria is not going to do as well. It's going to go down. I see. Yeah. So the water in these towers is pumped up. It's reservoir water, basically, from upstate New York, right? So you're saying that Legionella is already present in the reservoir water.

17:29That's the problem, yeah. And usually it's at a small amount, but then you get the right conditions. It multiplies. You start getting enough inoculum that people are getting sick. But why are there, if it's everywhere, why are there so, they're kind of isolated, right? We had the Harlem outbreak, I guess, last year. Now we have this. Why isn't it everywhere? Yeah, I think particular cooling towers, and this is an issue, you actually get fined for this, for like finding that your cooling tower has Legionella bacteria. You know, there are in place protocols for how you're supposed to clean these and how often you're supposed to clean these to prevent this from happening.

18:00that we should put some kind of a UV sterilizer in these and just... I like the idea. Yeah, somehow like prevent this from happening. Yeah. Yes. Someone asked me last night on the stream if we need a Legionella vaccine. What do you think? So I don't think we do. Yeah, it's one of those risk benefits. We don't see enough cases for it to warrant probably number needed to vaccinate. What would be the number? Here we have, what do we have in New York? 63 cases. Yeah, in a city of millions. Yeah. What would it be? And as we've seen, like a few people end up in the hospital, right? So we've had 12, you know, currently hospitalized, 40 discharge, right?

18:40So, you know, of the 63 cases that came to attention, a number ended up hospitalized. Nobody died. I think that's part of it too. And this is also a city, mainly a city thing? No, no. So we see it in other areas. basically all you need to do is get that legionella in some kind of a water system and then so people can inhale it, right? We talked about an ID Puscast. We have a couple of cases down in the Virgin Islands where people are hanging out in hot tubs. Somehow the hot tub, you know, had the – Wow. Yeah. So what about your little window air conditioner? They usually have some water in them.

19:16Is that a problem? Yeah, that could be a source, yeah. And sometimes we'll see that like end of the season when people just haven't been cleaning those and the water gets in there and you start – Yeah. Okay. All right. And moving on to screw worm, we're still seeing more cases. No fly trap detections yet. At some point, we're going to have to talk about fly traps, and I'll bring a visual because that's kind of a cool idea that we have these. But as we're seeing here, we're up to 37 cases. A couple of these have been in pets and dogs. So we're not really putting an end to this. So we'll have to see what happens with the millions of sterile irradiated males being released.

19:56But the big thing going on, this is really a huge problem, is Ebola. The Ebola outbreak in eastern Congo is now the fastest growing one in history. And if you look at DRC, over 2 ,000 cases. We're up to over 750 confirmed deaths. That's just in the DRC. We've also got the cases in Uganda. We have that one confirmed case in France. And what are we doing about it? University of Oxford has launched the first human trial of a vaccine against Bundabugio Ebola virus. Bundabugio. Say this again. There's a soft G. Bundabugio. Bundabugio. Bougio. Bougio. Bougio. Like think bourgeois. Bougio. Bougio. Okay.

20:44Bundabugio. I'm going to have to write in some new mnemonics here. Sorry. And call it the BD Ebola virus in the meantime. But when did Bugio? No, Bugio. Bugio. Bugio. Okay. All right. This is not going to turn into YouTube short, I hope. Okay. So they got a vaccine. Get a lot of views. Early stage trial. And it's known as the BD-EBOV. Now, that's actually what it's named. They don't mispronounce it like I do. And they're going to look at safety. They're going to look at immune response. But this is tiny, right? They're only going to vaccinate 50 healthy adults aged 18 to 55. So that's a phase one, right?

21:26Phase one, yeah. This is phase one. Yeah, you have to do this. You can't just put it in phase two. Yeah, so you got to start with this, phase one, see if you had an immune response, see if there's any safety issues, and then we can move on. Probably going to be a phase two slash three, the way they do that these days. And so TWIV 1339, right? Yeah, Dom Kysak. Yeah, we'll leave a link into that. He thinks that it's mainly infection control that limits these outbreaks. He doesn't believe that the vaccines do much good. I wonder if the vaccines help with just, you know, healthcare workers feeling comfortable going into these areas, feeling sort of that security, and then they're more comfortable, willing to help.

22:06Yeah, I would think a healthcare worker should get a vaccine for sure, yeah. Yeah. That would make you feel better. We need to make sure, right, that they're effective. But what about EBO-PEP? So July 14th, the first participants were enrolled in a trial testing Gilead Sciences' experimental antiviral drug, Obeldesivir. It sounds familiar. As post-exposure prophylaxis, PEP for preventing disease. For the ongoing outbreak, the DRC, the trial called EBO-PEP is being conducted. in Ituri province, the epicenter of the outbreak. It's being run by the National Institute for Biomedical Research in Kinshasa and several humanitarian partners.

22:52So Vincent, is it fair to think of this as oral remdesivir? Very interesting question. So when you take these drugs, they are not the final drug that actually inhibits. It's a precursor. It has to be activated. And both obeldesivir and remdesivir, the final drug is an inhibitor of the RNA-dependent RNA polymerase. So that final drug is exactly the same. But the precursor is different. So remdesivir is given IV. It has a phosphoramidate prodrug, which means it has a little chemical structure that looks like a phosphate, but it's hidden because things with phosphates don't get into cells very well.

23:35So you have to hide it. And then when it gets in the cell, the cell takes off the hiding group. And now you have the first phosphate. You have to have three. Getting the first one on is rate limiting. It's very inefficient in cells. So that's really cool that remdesivir goes in already with that. That's a chemistry that was done years ago, and it's very revolutionary. Now, obeldesivir is not like that. It's got a protective group, but it doesn't look like a phosphate. It's removed in the stomach because that's orally taken, whereas remdesivir, it goes up in the liver. And this now has to get into cells without a phosphate and get phosphorylated inside the cell, which is less efficient.

24:17But that's why it's different because the pro-drug form is what we call it, is different for the two, but the actual drug is the same. Yeah. Interesting chemistry, right? It's amazing. Oh, the chemistry is fabulous. This chemistry of making a hidden phosphate is revolutionary. It's really great. So people thinking of going into chemistry, right? Think of it. This is cool stuff. Oh my gosh, chemistry. Last night on the live stream, I gave a mini lecture on monoclonal antibodies. And oh my gosh, the things that they can do, it is revolutionary. Yeah, it's amazing. All right. So this has a bunch of folks upset.

24:50So CDC is assessing travelers arriving in the United States who have recently been in DRC or Uganda, as well as neighboring South Sudan for symptoms of and possible exposure to Ebola. To reduce the risk of Ebola importation into the United States. CDC under Title 42 and the Department of Homeland Security under Title 49 are currently working together on a do not board process regard to the DRC. American citizens who are departing from the DRC may be subject to a do not board order. Americans are able to return to the United States 21 days after leaving the DRC. So you've been in the DRC, you've been in one of these areas, you got to go somewhere else for 21 days before we'll let you in the U.S.

25:36U.S. citizens. And this is despite us having Ebola treatment centers here in the U.S., which are very capable. Yeah. Yeah. All right. Measles. We're getting, you know, if you look at the Hopkins tracker, we're already past last year's. So we're up to 2 ,250. The CDC has 2 ,231. Last year was 2 ,242 confirmed. So, yeah, I mean, at this point, we are now past. And here we are. It's mid-July, right? We're recording in mid-July. And we already surpassed the over 2 ,000 cases that we saw last year in the United States. This is terrible.

26:20So, all right. So, moving on to our multicolored curves for COVID. What is going on with COVID? I even did a zoom in so we could see, like, what's been going on over the last few years. But then it's flat. It's flat, but there's a little blip there. Is there a blip? It's very tiny, but – well, someone wrote in and said there are cases of COVID throughout the country. Yeah, it's got to be a few. I mean, there are a few. Some areas, yeah. Not a lot, but so it'll be interesting to see what happens. I mean, this date is only to 7-4 to July 4th. There also are some issues, and a lot of people have commented about how reliable.

27:00Are we getting all the information that we historically got that went into this? So keep an eye on it. Also, I'm going to keep an eye and share if we start seeing cases in the hospitals, in the clinics, the urgent care. So you haven't seen any so far? No, it's been actually a little while. All right. Oh, did you see we can combine a polio story? the lady, the last lady in an iron lung from polio in the U.S. just died. I heard that. I heard that. She was in it since 1953. Wow. Yeah. And she died of COVID. Yeah. Isn't that terrible? It's really terrible. I mean, I don't know how they treated her, but it seems to me that she shouldn't have died, right?

27:45Yeah. It's horrible. But she used to sleep in it. She would get out during the day and move around and do things. She would just sleep in it. But then when she got COVID, she was in it all the time. Yeah, it's tough. Well, a couple articles here to wrap us up. And these are our long or post-COVID papers, past papers. So the first one, the article, Long-Term Ocular Symptoms Following COVID-19 Linked to Immune Dysregulation, Dysautonomia, and Peripheral Neuropathy, published in Nature Communications. So a prospective cross-sectional study that examined persistent ocular symptoms, POS, emerging in non-hospitalized individuals after COVID-19, and they're going to use individuals without persistent ocular symptoms, without POS, post-recovery controls, using symptom quality of life data, clinical examinations, biofluid proteomics.

28:39They documented ocular symptoms persisting from three months to up to three years post-infections. POS, persistent ocular symptoms led to significant vision disability and was linked to clinical findings not detectable in routine exams but only with specialized tests. These folks ended up with near vision disturbances, strabismus, weakened autonomic pupillary reflexes, corneal neurodegeneration, chronic activation of ocular surface dendritic T cells. And they actually, they identify this particular proteomic profile. Really, really interesting stuff. So really finding some objective differences in these folks.

29:24And they actually come up with these diagnostic models, basically 77 % to 91 % accuracy and implicate chronic T-cell mediated neuroinflammation in the pathogenesis. All right. And this, I think, hits home for a lot of ideas about what's been going on. And this is this article, vagal cholinergic denervation of the gastric mucosa in long COVID-19 in vivo evidence of structural autonomic dysfunction, published in the International Journal of Infectious Diseases. Great figure here. So they conducted a case control study, including 12 patients with long COVID, eight control patients undergoing routine gastroscopy.

30:08So they're putting the scope down. Gastric mucosal biopsies were analyzed using immunohistochemistry with the panneuronal marker protein gene product 9.5, PGP 9.5, and vasoactive intestinal peptide as a marker of cholinergic fibers. Nerve fiber density was quantified in both fundus and antral samples. and hopefully we'll have for the people watching this on YouTube or hopefully for people, we'll leave a link to this. It's really striking to just look. Compared with controls, long COVID-19 patients exhibited a significant reduction in mucosal innervation density, 2.1 versus 3.9 in the fundus, about half, 1.9 versus 3.9 in the antrum, so again, about half.

30:57The reduction in cholinergic innervation was most pronounced in the fundus and also evident in the antrum. Gastric nerve density correlated with some of these parameters that they give us. But look at these figures. I mean, you can see - It's very striking, Daniel. Really striking. But is it a cause or a consequence? It's a good question. We don't know. Don't know. I mean, long COVID may have caused this. We don't know if this caused long COVID, right? Yeah. Yeah. We don't know. The gastric part, that's what they're looking at here. Yeah. Yeah. So really, really interesting stuff. All right. So I'm going to wrap us up there.

31:34No one is safe until everyone is safe. We're actually in the final month of our Foundation International Medical Relief of Children fundraiser. Again, doubling your donations, trying to get to that donation of$10 ,000, which really goes a long way in Uganda. So go to parasiteswithoutborders.com. Click on the Donate button. And yeah, for all the folks that have already stepped up, thank you so much for that support. It's time for your question for Daniel. Your questions for Daniel. You can send yours to Daniel at microbe.tv. David writes, interested in your thoughts on how the Legionella outbreak is being handled in New York City.

32:15They seem to be waiting on cultural results to release data about which buildings are responsible. PCR and whole genome sequencing would give a faster and more detailed view of the outbreak, matching strains from infected individuals to populations in cooling towers would rapidly pinpoint sources of concern. David sends a link to a Twitter post, an ex-post, by someone who says, New York City should be required to release the concentration detected via PCR and the culture results as they get reported. Then we'll be able to evaluate how effective the approach of listing any building with detectable Legionella via PCR is in terms of advancing the response and reduction of risk to the public.

32:59Yeah. I mean, David, these are good comments. So basically what they've done is they've tested all the cooling towers. If it's PCR positive, they say, get it clean. And the majority of them have been cleaned like within 48 hours, right? So it's been really, really good response. But you bring up some interesting things. So they're not waiting on cultural results to go ahead and clean the towers. So that's number one. Number two is the issue is that, you know, you point out a really interesting thing. Can you use genetics, right? Can you do the sequence, like, you know, folks that have been hospitalized, compare those sequences to the sequences we're getting, and then see if it looks like, hey, it's the same source that got these folks sick.

33:42No, these are excellent. But I do think they're moving ahead pretty quickly. Another question somebody asked, why don't they just clean them all? Say every cleaning tower in New York City needs to be cleaned right now. So depending on the size of the building, depending on the size of the cleaning tower, we can be talking about thousands or tens of thousands of dollars per building. So there's a big – yeah, there can be a big cost. So we're talking about, what, 70, 80 buildings. Let's say it's 5 ,000. It's a lot of money. It's a lot of money. Well, so you're going to just – when you refill them, you're just going to put more Legionella back.

34:14Yeah, that's why we need a solution like the UV or some way to actually – Something like that, yeah. Yeah, I like that idea. All right. Christine writes, I'm a dedicated listener of both TWIV and TWIV Clinical Update. I've been a nurse for 40 years and returned to school to get my MPH from Tufts School of Medicine during the pandemic. I appreciate the depth with which you cover all topics, viruses, parasites, bacteria, and the like. I, too, share your concerns for the current direction of our nation's health and under this administration. I'll digress here to say I'm delighted to hear that Dr.

34:47Griffin's daughter is a teacher at Magruder. I hope she has found her people. There are many William and Mary grads who remain in the area, and the Virginia Education Association has robust membership in and around town. I live in Williamsburg and volunteer at a local community health clinic. We work with area school nurses to ensure that all students have access to age-appropriate vaccines, and we'll be holding two free vaccine clinics in August. If she would like more information, she may reach me at this email. While Virginia is now a measles outbreak location with 177 cases this week as compared to five for all of last year.

35:25Recently, you've been reporting that the COVID-19 summer wave is virtually non-existent. Sadly, I can report that it is alive and well in the historic triangle. Anecdotally, folks are posting photos of positive antigen tests on Facebook. This seems to correspond with a higher wastewater analysis for the week of 7-5 at the York River collection site. As reported by the Virginia Department of Health, though, nothing of significance has been reported from the Williamsburg collection site. I wonder if, given the hypothesis that a large majority of the population has a degree of hybrid immunity this many years in, the collective viral load from COVID cases is less and thus not reflective of the number of cases but the degree of severity.

36:08Also, I've not opted to get a six-month summer booster as it seems that we might not have an updated vaccine formulation until the fall. What are your thoughts about the efficacy of Nuvaxovid versus Pfizer or Moderna's latest mRNA formulation? I've been partial to Moderna. Thank you for reminding us that none of us are safe until all of us are safe. The same can be said about gun violence prevention and the current dismantling of protective policies that were enacted during the Biden administration. Perhaps you will consider including the uniquely American public health crisis of gun violence in a future discussion.

36:45It can spread like a virus in our communities. Yeah, no, Christine, thank you for your email. I guess I'll jump in the one question that you ask about comparing the efficacy of the vaccines. Nuvo, Nuvaxivit versus Pfizer versus Moderna. You know, there are some comparative, right, where Moderna's newer formulation looked like there was a little bit of improved efficacy compared to the original spike vax. But in general, these are effective. A lot of the issue could be a difference in reactogenicity. Sometimes it could be an issue of access. So people that maybe have had a lot of reactogenicity with the mRNAs are looking at the new vaxavid.

37:30But no, they're all very effective, very safe. and I think vaccines that should be part of our routine going forward. Kathy writes, thank you for all you do. I started listening to TWIV during the pandemic. I find it very interesting, educational, and often over my head. I have a question I have asked my GP, who referred me to an asthma and immunology doctor, who said he does not know, but suggested a possible approach. Sorry, this is so long, but here's the story. One, as far as I know, I never had chickenpox. As a child, I lived in a typical Michigan neighborhood, went to public school, the four kids next door had chickenpox, but I did not.

38:10I'm currently 62. Two in 97, when I was pregnant with my first child, my OB guy ran a titers test. She said, you never had chickenpox. She recommended I get the vaccine. After my pregnancy, after I gave birth, I got the vaccine. Two doses in 99, when I was pregnant, same OB ran the test and said, did you get the vaccine? And I said, yes. She said it must not have worked because the titers were negative. And she said I should do it again. So she didn't do it again because of work and having another baby. So I'm trying to figure out how to proceed as I am at the age where my doctors keep recommending I get shingles vaccine.

38:47And I have to explain this story. First GP said everyone has a chickenpox, so just get the vaccine. I no longer see that doctor. My current GP consulted an ID doc who said due to my sluggish response to the chickenpox vaccine back in 98, he suggested we check my overall immune capacity to rule out an immunoglobulin deficiency. So I had my IgG levels tested and you can see those, Daniel, there. The immunologist suggested I get Pneumovax 23 and test my IgG after the vaccine. I have not yet done this. My understanding is a person with low IgG is typically sick often. I'm not a sick person. I get a cold once a year and I did have mild COVID, but I'm not sick.

39:33My question is, would you recommend a specialist to go see to help me figure out the following? My understanding is I do not need the shingles vaccine if I had not had chickenpox. My understanding is also that the shingle vaccine does not protect me from chickenpox. Should I get the chickenpox vaccine again, since it appears I don't have immunity and there are less children receiving the vaccine? My research also says I can get chickenpox from someone who has shingles. If I get chickenpox vaccine, do I need to get the shingles vaccine because the chickenpox is a infectious virus? If I get the chickenpox vaccine, should I have my titers tested?

40:08These were all my original questions. I'm not against vaccines, but I don't want to get one that's not necessary or that will do nothing for me. Oh, Kathy, this is great. I mean, this is like one of the reasons like I went into medicine. I love things like this. So, okay. So going back a little to the different immunoglobulin subclasses. So yeah, the way you figure out what's going on here is sure there are ranges, you can check stuff. But what you really want to do is what the immunologist suggested is you do a challenge, right? So you get the Pneumovax 23 vaccine and you're going to do the IgG levels before and then 30 days after the vaccine.

40:46So that's going to tell us about your ability to respond. Now, what are we going to do with that information? I'm not really sure at this point because we're going to sort of move forward. So you'll get that information. You'll see if there's an issue there. It sounds to me like you're absolutely fine. So I'm not sure we're going to really do much with that information other than kind of move forward to try to figure out what's going on. So here's your questions. One, my understanding, I do not need the shingles vaccine if I have not had chickenpox. So that's true. If you'd never had chickenpox, you don't really need a shingles vaccine to prevent shingles.

41:14But if you've never had chickenpox and you're potentially vulnerable to chickenpox, ideally you want to be protected. It sounds like you already went ahead and got the chickenpox vaccine. You may not have gotten the antibody levels, but you know, you hopefully got some kind of a cellular response. So you're going to fall into this category like so many young people these days. To get chickenpox vaccine when they're younger, their risk of going on to get shingles is incredibly low to the point now where we really have not started to routinely suggest it. So yeah, so I mean, at the end of the day, I'm not sure you need the shingles vaccine.

41:51I'm not sure you need any more chickenpox vaccines. Probably could just go on with life. All right. And Quetzalcoatl writes from a cool and rainy Scotland, I was listening to the recent clinical update at 1338 and heard of Long West Nile and wondered if there was long polio other than paralysis. So this is great. So appropriate. Does long polio exist? And what are the symptoms? Every search and resource I find comes back with the obvious paralytic issues. Are there any papers on this? First world countries tracking of chronic conditions was poor before elimination of polio. and places with polio now tend to have poorer follow-up.

42:37Yeah. So we can talk a little bit about this. I mean, this is as we talked early on, sort of appropriate with this email, is this incredibly high, 25 to 40 % of folks that get polio, years go by and they're going to end up with post-polio syndrome with all those lists of different things, gait issues, weakness, falls. Sometimes it can even be breathing issues, right? They could start ending up having a higher incidence of pulmonary infections. You jump in, Vincent. This is your bread and butter. I am not aware of any non-paralytic long polio. Okay. So this is an acute infection. Well, so is SARS-CoV-2.

43:17Yep. And there are many undiagnosed polio infections. You know, you can have abortive polio. You can have nonspecific flu-like symptoms. and most of these people recover. But we don't know if there are some people who have a continuing issue, but it's never tied in with polio because they were never diagnosed with polio. Yeah, I think that's a good point. It's really theoretically destruction of the nerves, the fatigue, the brain fog, the other things that we hear about. I don't really see that in post-polio. Yeah. So I think that, I mean, the major concern is there's still ongoing polio And so there will still be post-polio.

44:00This happens many years later, right? 20 to 40 years later. So it's bad. That's TWIV Weekly Clinical Update with Dr. Daniel Griffin. Thank you, Daniel. Oh, thank you. And everyone be safe.