TWiV 1346: 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 1346, recorded on August 6th, 2026. Oh my God, all these sixes. I'm Vincent Racaniello. You're listening to the podcast all about viruses. Joining me today from New York, Daniel Griffin. Hello, everyone. And those are real books behind Daniel. They're not a fake background, right? Yeah, this is true. I could even... Yeah, a bunch of those, yeah, I was author on and stuff. And I think your tie is prions. So it's interesting, right? I've got a yellow and orange prion, but this is blue. So a blue background with like little coccidial and gram-negative rods.

1:00And so it's waterborne illness bowtie. Waterborne illness, which is appropriate for these days, right? Yes. We're going to talk a little bit about that. But let's jump in. And, you know, I was sitting with Barnaby, my son, yesterday. Like, what quote should we use? We went through like some Rick Riordan and a few others. And I actually settled on a Teddy Roosevelt quotation. I mean, Teddy was an interesting fellow, actually. I'll say like particularly like how he interacted with Panama was quite interesting. But anyway, this country will not be a good place for any of us to live in unless we make it a good place for all of us to live in.

1:40This is pretty relevant today, Daniel. It really is, right? You know, I mean, this is the kind of leadership you want. The idea that, you know, I am the president for everyone. I want to make sure everyone is safe, is able to pursue all those things that our government is supposed to protect and ensure, pursuit of happiness. So let's talk a little bit about a little bit of news, but then we're also going to get into more of the science. This is just, I think, straight news. Senate confirms Erica Schwartz as CDC director. People may have watched some of the interactions that went on during this process.

2:18But we read in CIDRAP, you can read in a lot of places, but here I'm going to link to CIDRAP. The Senate, Tuesday, August 5th, voted to confirm Erica Schwartz, MD, MPH, JD, as the director of the Centers for Disease Control and Prevention. The vote was 51 to 44 in favor of confirming Schwartz, who spent 24 years in the U.S. Public Health Service, commissioned a course, and served as deputy surgeon general in the first Trump administration. I was kind of bothered, I think, by this. The vote was pretty much along party lines with only one Senate Democrat, Tim McCain, voting in her favor. It's just terrible the way the appointment of the director of CDC has just become such a political thing.

3:02Yeah, it's a shame. She is very well qualified. However, during her hearing, she was very evasive. And if she really is going to do what she said, so at the end of this CIDRAP article, she says, the nation's health and well-being will take primacy. I will never compromise on that. So let's see. The first time she refuses to obey RFK, let's see if she gets fired. It's going to be – I hope she does well. I mean I really – I think we're all hoping – finally we have a proper CDC confirmed director. It seems recently that RFK Jr. has been walking back a few things. I'm not sure if he's as popular with his base as he used to be.

3:50He was on that – I think it was a CNN interview where he basically said, hey, people should get vaccinated. And then I think his Maha people are not so happy that sort of under him and Trump is more pesticides in the waters and in our foods. So, yeah, good luck, Dr. Schwartz. All right. We have a new report from the U.S. Government Accountability Office. Public health preparedness experts identified actions to improve surveillance for emerging disease threats. What GAO, so that's a government accountability office, what Gao found. So emerging infections are infections that are new, right? So it's COVID-19, something that sort of comes in or have existed but are reappearing in an area.

4:38So measles is the example there. And this is per the Department of Health and Human Services. So as the federal lead for public health, HHS partners with thousands of entities at all levels of government to conduct surveillance for emerging infectious disease, doing so through continuous data collection, analysis, and sharing of health data needed to plan for and respond to such threats. Experts on a roundtable GAO convened suggested a range of actions that the federal government could take to improve U.S. emerging infectious disease surveillance. GAO categorized experts' suggestions across four areas related to collaboration, data, methods, and communication.

5:21Now, four areas with examples of federal actions experts suggested to improve emerging infectious disease surveillance. So collaboration, I think that's straightforward. Increase coordination by creating a multisectional, multidisciplinary leadership group, right? So collaborative group. Data quality and infrastructure. So strengthen data quality by identifying, developing, and using standards for surveillance data. So give us the data. Surveillance methods. So optimize surveillance by evaluating effectiveness of surveillance systems and methods. Communication is huge. Improve awareness and perception of public health and surveillance by developing a communication strategy.

6:03And then basically a key theme and experts suggested actions for improvement was to unify efforts between animal and human health sectors. You can think of some people that are really on board with that, that one health approach in recognition that emerging diseases often affect both. For example, experts suggested that a multi-sectoral, multidisciplinary leadership group should be created to direct surveillance planning and activities across federal agencies, including those responsible for both human and animal health. Now, such a group could address a lack of centralized authority to direct cross-agency surveillance activity, leading to inconsistent collaboration that hinders the effectiveness of U.S.

6:47surveillance for emerging infectious diseases. You know, this sounds great. It's never going to happen in this administration. It really sounds great. You're like, obviously, this is really sort of common sense, straightforward. But yeah, is it going to happen? And, you know, in a lot of ways, as we're seeing now, who really wants to be like involved in this? and sort of the public light and how partisan health and how we respond to such things has become. This administration wants everyone sick. Well, we're going to talk about that because that's kind of interesting. So one of the big things that somebody has been pushing for decades is this whole connection between autism and MMR.

7:31So once again, we learn that vaccination does not cause autism. So we have the article. I mean, how many times are we going to have to learn this? But we have to learn it again. This is robust. It's timely. The article, Association Between First MMR Vaccination Before Age Two Years and Childhood Autism in a U.S. EHR Cohort of 2.5 Million Children, was published in the Pediatric Infectious Disease Journal. And I like the fact they've got 2.5 million children right up front. So these are the results of a very large retrospective cohort study using the Cosmos electronic health record database that includes 2 ,560 ,035 U.S.

8:17children with linked birth parent data and follow-up through age eight years. So to minimize bias related to exposure timing and healthcare utilization, they performed pre-specified age-based landmark analysis evaluating the first MMR vaccination administered between 11.5 and 24 months, and then adjusted hazard ratios for autism were estimated. And I'm going to talk a little bit about what this landmark cohort analysis actually means. But so here's the deal is what they're going to do. So in the primary 11.5 to 24 months, this landmark cohort, and the landmark basically is the age, right? So you're saying in this particular age, you know, when they get their primary shot.

9:05Was the first MMR vaccination associated with autism? And the answer was no. The adjusted hazard ratio was 0.97, okay? Across all age-specific landmark cohorts. So now you start breaking it. You say, well, let's look at 11.5 to 18 months. Let's look at 18 months to 24. So you're sort of looking at the timing, all negative. So they do this negative control analysis. You basically get the null estimate. So the adjusted hazard ratio is basically one. You've got a confidence interval of 0.99 to 1.04. So really, when you went through looking at the different ages, no association between MMR vaccination before 24 months and childhood autism.

9:52And I think this is really key because there's this idea out there that seems to be growing as well. I just want to be safe. Maybe I'll wait. I want to point out here in 2.5 million children, you're basically saying it's not safe to wait. There's no safety issue with giving your child the MMR vaccination. There is a safety issue with leaving your child exposed to getting measles now that we're seeing thousands and thousands of cases of measles in our country. Yes, but they will find some reason to discount this. Well, I'm hoping they don't. I mean, this is really robust. It's clear. I think this is going to be out there in the mainstream media for people to see and discuss.

10:37And there's no connection. We have looked. There's no hiding. There's no obfuscation. Is that that fancy word? Yes. Okay. But, you know, this all started with one misguided physician, Andrew Wakefield, publishing bogus work. It has continued since then. In the 90s, this was published, wasting so much money and time. There's no connection. Can we move on, please? It's crazy. I mean, you're kind when you say misguided. I mean, this was not misguided. This was a malevolent, fraudulent, dishonest individual who was basically trying to use misinformation to make himself money. And he's done that. I mean this man has made millions.

11:20And I don't know how people like that sleep at night. But very clearly this was a strategy to try to get money. And in a court case, the data was fraudulent. The study was retracted. They just used that. Oh, it's big. the dark state or whatever, the deep state is doing all this stuff. But yeah. All right. I'm very excited about this. There was an NPR thing, podcast thing that my son Barnaby was listening to yesterday. And so now we have the article. I'm very excited this morning to read this article by Christina Jewett in the New York Times. It's New York Times. I'll be behind that paywall. So maybe she'll send it out as a free share.

12:01But FDA approves Moderna's mRNA flu vaccine. The approval of the vaccine called M. fluceva. Is that, we gotta be able to remember M. fluceva? I want the M. fluceva. Needed mRNA somewhere in the title, unfortunately. How are we gonna remember that? Do you remember what the name of the mRNA COVID vaccine is? I remember like SpikeVax and Comirnaty, but then there was like a better one, better than SpikeVax. I don't know what that one's called. Yeah, the modified ones. The next gen or something, like the next gen spike or something. And yeah, I don't, you know. And then the one by Novavax. Everyone calls it Novavax.

12:42You're like, oh, the Novavax avoid. I want the Novavax, not the Novavax avoid. It's M next spike. Yeah. At least there's a little M in there. I guess the little M Fluseva. I want the little M Fluseva. But anyway, so it's manufactured by Moderna. And, you know, this is amazing that this happened, right? because RFK Jr. has canceled 22 projects meant to develop vaccines with mRNA technology through the government's Biomedical Advanced Research and Development Authority. Initially, as we covered, the FDA refused to even review Moderna's application for approval earlier this year, but quickly reversed course after a public outcry.

13:22So yes, you know, public, we have some power if we get really upset and vocal. Now, it's interesting. The new vaccine is authorized for people aged 50 to 64. So I'm in there. The FDA issued an accelerated approval for adults 65 and over, which allows widespread use and can be converted to a full approval if the results of a follow-up study are deemed acceptable. So we'll probably basically see a lot of this. And this is based on a study that we discussed. I'll leave in a link. So there was an article discussing this study, and it was the article, Efficacy and Safety of an mRNA seasonal influenza vaccine in adults in the New England Journal of Medicine.

14:02So you get an extra 27 % efficacy compared to the standard flu shot. Now, the vaccine efficacy in that study was against RT-PCR confirmed protocol defined influenza-like illness caused by flu A or flu B from at least 14 days after vaccination through the end of the flu season. So pretty – this isn't like hospital or death or so sick you need to go to seek medical care. This is a pretty low bar. This is actually just like I got some symptoms and I tested positive. So preventing even like very mild disease. I know which flu shot I want, Vincent. Is this going to be available this season you think?

14:50They actually say it's going to be available in a few weeks. So Moderna is ready to pump it out. And that's one of the things they talked about is that one of the great things, right, about mRNA vaccines is you can get them out pretty darn quick, like the production time. You know, and this will be great in the future, right? Because they can always adjust, you know, the target if it turns out, hey, we picked the wrong. So you don't have to pick six months ahead of time which particular type of flu you're going to target. You can say, oh, wow, this is the one that's causing a problem. Within 60 days, you got the new one out.

15:22Yeah. I got a text from CVS yesterday and it said the new flu vaccine is here, but I can't imagine that this is it. Yeah, no, it's probably the new flu vaccine, like the new one this season. It must be the old version, the new version of the old version, right? If that's clear to everybody. Yeah, yeah. For you, it'll be like the high dose, one of the high dose ones. I can never get the high dose. It's always out of stock. Maybe this one will have good supply. I'd be curious. We'll give everyone an update. Well, there's just one dose of this, right? This mRNA vaccine. Yeah, that's it. I'll wait for it.

15:54All right. So let's talk about cyclospora kiatinensis. Not a virus. Is that something going on with cyclospora? Yeah, we just got a health alert a couple of months after the problem started. But unfortunately, to start off with a little bit of, you know, I mean, it's pretty crummy, all these people with explosive diarrhea, but two deaths linked to cyclosporiasis in Michigan. So I'll leave a link into an article in the New York Times. Health officials in Michigan reported two deaths linked to this outbreak. But the outbreak has now spread. There are cases reported in 47 states, you know, Hawaii, Montana, and New Mexico, right?

16:38We're not seeing – yeah, they're probably cases, but we just haven't seen them. And then they have this really nice map. I'll leave a link into it. This is in the Washington Post. CDC expands largest known cyclosporiasis outbreak to 15 states. It's the biggest one so far. And on this map, you can see where there are reported cases everywhere. And you can see this sort of the heartland where it's linked to shredded lettuce sourced by Hayler Farms de Mexico. But all these other pink states with reported cases, what is that linked to? Also shredded lettuce or something else or what? No. So there apparently are multiple sources.

17:16So it's not all just coming from Taylor Farms, Mexico, right? So you've got all these areas, you've got North Carolina, but we think there's another outbreak going on, right? So let's go through the... Well, additional cases that require further investigation. But then you can break it down. I mean, Michigan is giving us 12 ,218 cases. 193 have ended up in the hospital. So pretty bad. And then the two deaths, as we mentioned. North Carolina, 867 as of Tuesday, 33 folks in the hospital. Missouri has over 1 ,000 cases, right? So 1 ,095 cases. We've got the cases in New York, but I wanted to – I pasted in this article, you have hundreds of cases in New York.

18:25I guess I'll just pop that in, 553 reported cases in New York. It's still ongoing. They have a nice – I'll leave a link to the New York City government DOH. And you can see like we're still going along. We're still seeing cases. But we should leave a link. I'll pop in a link to our This Week in Parasitism podcast where we actually discuss review. We talk about an hour about cyclospore. It's amazing that we could do that, but there's so much to talk about there. But I was looking for a picture, and I found it. And it was in this article in Forbes. It's the water, not produce, likely driving cyclospora outbreaks by Judy Stone.

19:07And I do think this article needs a little bit of sort of thinking through. But do you like the picture of that dude just hanging out there in the field and there's water everywhere? Yeah, the picture is great, but I don't agree with the headline. Yeah, I think that there's a problem here. So let's talk about it. So we read here that we rely heavily on irrigation systems. So we're going to talk a little bit about what's going on here. So a 2023 irrigation and water management survey found that 45 % of all water used as irrigation came from surface water, right? So it isn't just coming up from a well, it's the stuff that is on the surface, it's in these canals.

19:47And this is important because the surface water that we're going to end up using to water the crops can be easily contaminated. and with this particular organism, it doesn't take many organisms to make you sick. Now, we're going to talk about this because as we're going to circle back to is they're going to talk as if this is something that's happening here in the US as though the crops are getting contaminated here in the US. But we're clearly seeing the majority of these issues are coming from something that's going on in Mexico. So this actually probably applies to Mexico as well. So US particularly, but also in Mexico, employer-provided housing for the people involved in the crops is generally crowded.

20:36There's often poor sanitation. The drinking water may come from springs or wells. And while the wells are monitored before people move in, they could potentially get contaminated down the road because there's no requirement to ever check them again. So they could get contaminated and then just – people could keep getting sick. And the idea here, right, is that the workers are out there in the fields. They're supposed to be given water and bathroom breaks, right, so they can go to a facility and the feces ends up hopefully in a sanitation system. But we hear that lots of complaints that they're really not being allowed adequate breaks.

21:16Also, there's like a rule. There's got to be like adequate number of toilets. So the whole idea is you've got to have one toilet and one hand-washing facility for every 20 workers. And these facilities have to be orifice within a quarter mile of each worker. So if you've got like explosive diarrhea from cyclospor, so let's think about this, and this is kind of how it comes together. Are you going to travel a quarter mile to go to that bathroom and then back? So it's a half a mile round trip to go to the bathroom. or are you going to just go pop a squat over by the side and maybe rinse out, you know, clean yourself in the irrigation canal.

21:54And now that irrigation stuff that you've contaminated is now going to be sprayed or distributed all over the crops. I just don't buy this, Daniel. I'm sorry. People are eating shredded lettuce at Taco Bell. They're not squatting or what did you call it? Well, so what happens is, so here we are in Mexico, right? Because that's where the lettuce is. Is that where this is, we're talking about here? This picture is supposed to be a guy in Mexico? Yeah, that's where this is going. So you're down in Mexico. Okay. And you're going to, you know, you're going to water your lettuce crop. And so you've got all these canals running around.

22:30You've got your people who are out there harvesting the lettuce for you. And those people, the toilet's like, you know, quarter mile, half a mile round trip away. And so when they've got diarrhea, because you have cyclospora, you're going to get diarrhea. You're just going to pop a squat there because you're not going to make it to and from the bathroom however many times a day with the diarrhea. You're saying these workers are contaminating the water and the water is contaminating the lettuce. But remember, it has to sit for 7 to 14 days and has to activate. Which it does, right? In the water?

22:59Well, no. So it just has to get the little oozes on it and they're sticky. And then one to two weeks of like it's sitting there, it goes through the sporulation process. Now it's infectious. So like right there, if you like put the bad right, you're not going to get sick. It needs that week or two. And that week or two is when it's being shipped to you in New York or Michigan. But the problem here is they're talking about OSHA mandates. This is Mexico. This is not OSHA. They don't mandate. Yeah, you're right on. That's the problem. Because this isn't, yeah, this isn't happening in the US. No. So I don't know.

23:34You're talking about the cuts to CDC and this and that. It has nothing to do with Mexico. I mean, I understand that it's endemic in Mexico. And yes, this could happen, but it has nothing to do with toilets. But they're blaming Trump and Doge and we hate Trump and Doge, right? No, I'm on board with you. I think there's problems with this story. I totally agree that the CDC has been decimated and emasculated in every word you can think, but I don't know what it has to do. And I don't even mention Mexico here. I don't know if you edited this article because it's very discontinuous. No, yeah. These are just sort of little excerpts.

24:09But you are right. This argument doesn't hold water. Can I say that? That was a little bit of a pun. You could. But yeah, there's a little bit of an issue here. I think it's like, oh, yes, and you get angry and all these cuts and they no longer check for anything. And CDC loses 3 ,000 employees and the food safety, they lose almost 1 ,000 employees and the FDA is cut by over 4 ,000 jobs. and then FoodNet is no longer surveilling for any of these things. This is coming from other countries where cyclospora is endemic. This is not happening in the U.S. because of us irrigating lettuce. That's my understanding.

24:50Maybe I'm wrong. No, no, you're right. You're right. And I think that's why it's good for us to have this discussion. So I was talking to some folks yesterday. I was like, listen, just buy locally sourced vegetables, locally sourced lettuce. Not so easy. It is hard, yeah. You know, we certainly try to find some locally sourced raspberries, right? I mean, now in the summer, it's a little easier. But once we get into the winter, everything is going to come from somewhere else. Yeah. Or washer lettuce, right? Well, we decided on TWIP that that didn't work. It's really hard because it's so sticky.

25:26We read the paper, yeah. Yeah, the oozes are so sticky. I mean, I was on a plane the other day and I didn't eat my salad because I didn't trust it. Not eating salad anymore. All right. Okay. So hopefully we've kind of shed some light. Yeah, this is like at least the thousands and thousands associated with, you know, Taylor Farms. That's coming from Mexico. So it doesn't have anything to do with what's going on here. Water, not produce is driving it. No. The water, if the water just sat there, it wouldn't drive it. It has to get on the lettuce. The lettuce is driving the outbreak. Yeah. I mean, this reminded me of this conversation I had repeatedly with Dixon, which was, you know, he's like, I don't understand how people are getting COVID from the wastewater.

26:05I'm like, they're not. They're not. The wastewater just tells you they have COVID and they're, but I don't understand how they're getting from the wastewater. I'm like, oh, Dixon, you're killing me. But anyway, all right, let's get into Ebola. Well, they don't get polio from wastewater either. True. It's an indicator. Yes, you are right. All right. And we're going to be talking about wastewater later. So don't worry. We won't let a good, well, for you guys, Saturday morning go by without a discussion of wastewater, but for us, Thursday night. So Ebola, there was an article in Science, and it was, did we miss the beginnings of the Ebola outbreak?

26:44I think the answer is yes. And we read here that the epidemic ignited in January, perhaps even earlier, and they actually mentioned where. The idea that it was a patient seeking care may have brought it to the city from a rural area. And then they go on to say, by the time health authorities in the distant capital Kinshasa recognized the disease as a type of Ebola, a widespread sprawling epidemic was already underway. They interviewed 97 people and looked for likely Ebola cases by identifying households with at least two deaths within 21 days and symptoms suggesting Ebola. They also reviewed photos, WhatsApp messages, doctor's notes, even biographies read at funerals that mentioned the deceased symptoms.

27:26Everything pointed to widespread Ebola infections, they say. One transmission chain started with a 50-year-old woman identified only as A, who died on January 25th after vomiting blood. Her mother died six days later. Her husband fell ill but recovered. On 11 February, A's nephew died, bleeding profusely from facial orifices. He was buried the next day during a funeral attended by many people. The nephew's wife died a few days later, and then their child, several more people in the family passed away. Others fell ill but recovered. Really kind of pushing this back to January. I've heard January thrown about previously, and everyone said, oh, no, April, May, you know, but this, yeah, this is January.

28:15Yeah, yeah. Yeah, no, April, May was what? April was what I had heard initially, but this really pushes it back. All right, so, and maybe that's going to affect this next graph we're going to talk about. So CDC updates, they're up to, in the DRC, 3 ,874 confirmed cases, 1 ,751 confirmed deaths, so a really high fatality rate. And they say number of days since the first case. And they have us like in the first 100 days still. But go back to January, right? And so then we're like February, March, April, May, June, July. That puts us 6 times 30, 180. So maybe we're farther than the first 100. But they still have this exponential, you know, approaching 4 ,000.

29:04So not good. Measles. The number keeps going up, 2 ,370 per the Hopkins tracker. So basically an extra 50. And that's actually pretty similar to what we're seeing. Actually, you ready for this? The CDC has a higher number than Hopkins, 2 ,371. So they have an extra 53 cases just this last week of monitoring. Did you hear RFK on CNN? He said, yeah, we controlled all the measles outbreaks in the U.S. Yeah, just, you know. How do you know if RFK Jr. is lying? Do you know this? His lips are moving. Yeah, yeah, you got it. Okay. So. All right. So now we're going to move into, and I thought we would do this in real time.

29:50We're going to do this live. So I'm going to go while you and I are here and look at the CDC wastewater because they hadn't updated this. So I was like wondering what was going on. So everyone, you can follow the link as well. And basically, what are we seeing? A little bit of activity, right? Did you go as well, Vincent? Oh, I should go to the CDC site? Well, I'm going to copy and paste it in for you. But basically, when we zoom out, you know, we see this pattern where we keep having these spikes. And there's really, it looks like there's a little bit of a rise in the west. Like that's what we talked about last time.

30:29But it's plateaued though. Yeah, just a little bit. And it's still, I mean, it's plateauing down in the low zone. So let me just paste that right in for us here. So really pretty, not much activity. So they have some categories here for wastewater activity. for SARS-CoV-2, very low is up to two. What does this two mean? The amount of virus in wastewater. I don't know what these, do you know what these numbers are? Two and two to 3.4, et cetera. What does that mean? I don't actually. And there's a lot of places where if you look at the actual, like where are we getting the data at the state level, there's a lot of area with limited coverage, right?

31:15So we think there's moderate activity in Missouri, but we have limited data. We think that there's low activity in Mississippi, but we have limited data. So that's a part of the issue, and I think we'll keep mentioning that. But unfortunately, it looks like we have issues here where we may not have the data we want. But if we start seeing it on the ground, I'll make sure to talk about this. These numbers are missing something. How can they publish just numbers on a table without saying what they are? Yeah, they should have a nice, you know, basically explaining what the data actually really translates into as far as units, right?

31:56Because it's this. Yeah, it should be right there where the table is, not somewhere else. Yeah, yeah. I mean, they have these categories and they say, low, it's these numbers, but then what are the numbers? And then you have to go to this other place to understand. So, you know, and people have criticized that. Like they can sort of define very low and then just change the definition, keep you there. Yeah. All right. So - Are you seeing COVID cases now, Daniel? Not really. There was a case the other day where the test was positive, but it didn't make any sense because they had come from an outside hospital where it was negative.

32:26And they actually have to say they're visiting from Bangladesh. They repeated the test. It was negative. There were no symptoms. Didn't make any sense. So it was a false positive, just like the Taylor Farms. Okay. Okay. So this is an interesting one. And maybe it's going to relate to some other topics we'll talk about. But we have the article, Household Transmission of SARS-CoV-2 in Washington and Oregon, United States, 2022 to 2024, published in J-PIDS. So this group conducted a prospective observational household study in Oregon and Washington, USA, and during 2022 to 2024. So the participants completed enrollment weekly and follow-up symptom surveys and submitted sera and weekly nasal swabs.

33:11Swabs were tested for SARS-CoV-2 by PCR. A subset of positive specimens underwent whole genome sequencing. Sera was tested for the antibodies. So they identified 617 households with a distinct index case of which 90 % were symptomatic, 41 % were children. Thus, it's in the Journal of Pediatric Infectious Disease Society. The estimated secondary infection rate was 16%, right? And I think that's interesting because we've got this new prophylactic medicine. And in that study, secondary rates were 9%. So these are lower than the first year or two. Remember, it was like 50%. It's important to think about.

33:49So here, the estimated secondary infection rate was 16%, reflecting 203 secondary infections among 1 ,267 household contacts. Among household contacts, factors associated with secondary infection included low anti-nucleic capsid antibody titers, like doubled it. Residing with an index case who was symptomatic, that basically doubled it. Had viral detection greater than a week, doubling it again. Among 136 sequenced index secondary case pairs, 94 % shared lineage, right? So these were 94, 95 % of the time. These were from that person in the household. All right. And we have a study here. And I'm going to go study, we're going to talk a little bit about figures.

34:38And we're going to talk a little bit about virology, because I think there's a viral group here that a lot of our listeners may not be familiar with. And so this is an article published in Nature, right? So there's a ton of data here. There's like figures, and then there's supplementary figures. But this is a topic that I know we've covered several times, virus reactivation in acute and long COVID-19. So, you know, as our listeners are familiar with, there's this finding that during SARS-CoV-2 infection, you can get reactivation of chronic viruses such as Epstein-Barr virus, cytomegalovirus. Yet the full extent, temporal dynamics, and immunological impact of viral reactivation, well, I'm going to say remains, even after this remains, incompletely understood.

35:26So here these folks are going to do these multi-omic longitudinal investigations looking at 1 ,154 hospitalized patients with COVID-19 from the IMPAC cohort. So they actually go ahead and they identified significant reactivation of herpes viridae. I think we all know what that is. And then the anelo viridae during acute COVID-19. Racinello. The racinello? So the anello viridae? The racinello viridae? It's kind of similar. Racinello, man, it's different. Maybe that'll be how people remember. Anello means ring. Anello is ring in Italian. Okay. Because the DNA is circular. It's a single-stranded circular DNA genome.

36:15And is it negative? Could be either one. Oh, interesting. Okay. It doesn't matter because when it gets into the cell, it's copied and it's double-stranded. Okay. So interesting in this study, and we're going to walk through a few of the figures, but they found that reactivation correlated with disease severity, host immune effects, and clinical outcomes. And they highlight the prevalence of chronic viral reactivation during acute COVID-19 and long COVID. They say their findings challenge the prevailing view that chronic viral reactivation is primarily a consequence of immunosuppression, demonstrating that reactivations occur frequently in immunocompetent individuals during severe illness and in association with increased systemic inflammation.

37:03Additionally, they provide this sort of demonstration of persistence of viral reactivation in convalescence and report an association of anelloviridae with long COVID. The study provides immune, transcriptomic, and metabolic signatures of viral reactivation that they say could inform, and I agree, could inform future strategies to sort of predict what's going to happen, how to maybe treat COVID-19, how to maybe prevent or treat COVID. But let's walk through just a few of the figures. But this is open access. So everyone can actually look at this, but it's not exactly the easiest study to walk through.

37:44But figure two is pretty nice. You've got a number of these viruses, so CMV, EBV, HSV1, HSV2, the aneloviridae, and the enterovirus group together. They break them down into specifics. But then they look at which participants were positive for the viruses. And then they're going to basically also look at complications and comorbidity and the associations. So what do you think, looking at this, Vincent? Well, so it's quite clear that there are viruses reactivated in acute COVID. I just don't know what they mean because it could just be a consequence. It may not do anything, right? Yes, that's kind of the issue in this first figure.

38:34So, okay, so it sort of establishes that, okay, we're getting this activation, but what is going on? So the next thing they go through, well, I'm going to jump ahead to figure four. Again, these are all correlates, right? We have not established causality here. They're very good about saying that. The next is they look at the correlate between the reactivation of these viruses and inflammatory cytokines and cytokine, chemokine expression. And it's really nice. You can basically see, and they do a heat map positively associated with the virus, negatively associated with the virus. And there's a number of these inflammatory cytokines, and then they even follow them over time, that are positively associated with the virus reactivation, CMV, EBV, HSV-1, the aneloviridae.

39:26The aneloviridae don't get a lot of hits. It's really just IL-18 and CXCL-11. You get a lot of hits for CMV and HSV-1 and EBV. How do they associate a virus with a particular cytokine or chemokine? So you're really looking and you can break down people who have the reactivation and people who don't. I see. So not everyone has all the viruses reactivated. Yeah. And they look at different places too, right? So the EBV, they're looking nasal and they're looking in PBMC. So like 35 % of, you know, these people are having, you know, the different groups are having, we'll say, EBV reactivation. Where, you know, HSV, it's like 40%, 50%.

40:11But then you look at CMV and it's only around 10%, let's say. So then you can compare them to the 90 % or the 70 % and see if there's any kind of correlation. People who have it, people who don't, what's going on with the cytokines. And then what's probably the most interesting, I think, and this will be maybe something that gets some attention, is in figure six, they look at associations between these viral reactivation detections and long COVID. And they actually find a number of things that are positively associated with the virus. They find neutrophil, degranulation.

40:49I think there's still a lot. Yeah, there's still a lot to do here. but the title is telling associations. Yeah. So we don't know if this is a cause of long COVID or a consequence of it. It's important to look at it. I agree. But this kind of study, an observational study can't tell you that. Right. Yeah. And I think that's tough, right? Because a lot of people are out there using antivirals and it becomes this issue, like, are these reactivations causing long COVID? Or is there something about people that are developing long COVID that have these viral reactivations. And so, yep. I mean, it could very well be that you reactivate during acute COVID and these infections persist, right?

41:29And they can be part of the symptomatology of long COVID, but we just don't know that. We don't have the data to say that. Yeah, we don't know yet. We are, I mean, I'm glad people keep looking, right? Because there's people out there suffering. And so we need to - By the way, we will do this paper on TWIV tomorrow, deep dive. Oh, fantastic. I'm excited. I'll look forward to that. All right. No one is safe until everyone is safe. We are now in August through October. We are doing our American Society of Tropical Medicine and Hygiene fundraiser. And this is a special one. So what we have decided to do, and people know that Dixon DesPommiers, who I talked about earlier, close friend of all of us, a founder of Parasites Without Borders, frequent participant on our podcast.

42:14He passed away. And we are working with the American Society of Tropical Medicine and Hygiene to create a Dixon-Depamier annual talk for the next five years. And it's going to have to do with global health and parasitology and things like that. So we're actually trying to raise$100 ,000 so that we can go ahead and work with ASTMNH to create that annual lecture series. We'll be announcing it, hopefully, fingers crossed, all of them. I will be announcing it this fall at the annual ASTMNH meeting. And we're hoping, so this is a big one, we're hoping to get up to that maximum donation of$100 ,000 for that lecture series in memory of Dixon.

43:03Yeah, it should be fun. Yeah, I think that this is something that I think he would really be special and really appropriate for all he's done. And he liked that meeting a lot, so it's perfect. It's time for your questions for Daniel. You can send yours to danielatmicrobe.tv. John writes, if more efficient refrigeration and transport had preceded the polio vaccine, might we be or have been reading of polio outbreaks from imported lettuce? I don't think we were importing produce on any scale back even in the 70s. Thoughts? This is a good question, Vincent. So if somebody in, let's say someone in Mexico, right, has polio replication going on their GI tract, and they do what I talked about, right?

43:52They go and they squat over there in the canal, and then we spray it all over the lettuce, and then we bring it into this country. What do you think? Like, would the virus stay on the lettuce? Would it survive? I know of no case of polio other than person-to-person transmission, right? It's exceedingly stable. The virus is exceedingly stable. There's no question that it would remain infectious on lettuce. but there's no, in the heyday of polio, there's no foodborne polio. And I understand the lettuce didn't come from long distances back then, but there would be lettuce grown in the U.S. and workers might contaminate it.

44:46So I don't think it would happen, no. Yeah. I mean, it is interesting. Yeah. I mean, you could think it's such a hearty virus. Why couldn't that happen? But But yeah, back when you had it in the U.S., I don't think we, yeah, as I mentioned, we didn't describe these food-borne polio outbreaks. No, it was always, you know, fecal oral contamination, right? Yeah. With people transmitting it by hands. You know, there were lots of investigations of the route of transmission. People suspect that flies at some point, right? Flies would land on feces and pick it up. But no, nothing except suspected person to person.

45:25So I don't think so, but it's an interesting idea. Yeah. Marianne writes, I thank you for providing clinical updates every week. I'm concerned about a September bridal shower luncheon menu, which includes fresh, uncooked vegetable salads. The wedding is two weeks after the shower, and I wouldn't want anyone to become sick from cyclosporiasis. Pariasis. Seems like Nassau County is reporting just 17 cases. Should I throw a caution to the wind or ask the restaurant to provide a cooked alternative? Daniel, what is an uncooked vegetable salad? I don't even understand what that is. Yeah, I think that's just basically a salad.

46:04You don't cook the tomatoes. You don't cook the lettuce. You don't cook the radishes, whatever the shredded carrots you put in there. Yeah, this is a little bit of a challenge, I think I talked about locally sourced your vegetables. Now, here in Nassau County, Long Island, we have a lot of local produce. We have a farmer's market here every weekend. What about that? What about locally sourced salad ingredients? That would be great. I would agree. You get it locally and then you're good. Okay, downrise. Daniel and Vincent, this message is in response to 1342. Daniel makes a statement that cyclospora can be washed off fresh produce.

46:50This is not a scientifically sound recommendation. Washing is generally a poor way to remove any contamination from any fresh produce. Washing has at most a one or maybe two log reduction. There's also some evidence that parasites like cyclospora are more difficult to remove than bacterial or viral contaminants. We don't know the median infectious dose for cyclospora, but it's unlikely that washing will significantly reduce the risk, even given a moderate level of contamination. Expert opinion is also that washing pre-washed leafy greens is not recommended. He provides a link for that. Yeah, we'll pause there.

47:27Hopefully we've talked about, you know, the sticky oozes and how hard this is. But yeah, I mean, we agree with you, Don. This is not easy to get that stuff off. My wife goes through this ritual where she like washes the lettuce and then she spins it and then she dries it off. And yeah, but as mentioned, it's really sticky. It's hard to get the oozes off there once they're stuck on. But Don says that washing is a poor way to remove any contamination. I think you have to wash your produce because they have dirt on it for God's sake, right? Yeah, it has dirt. And as mentioned, you say, oh, a log reduction with each washing.

48:05So, you know, you have to kind of do it, you know, a couple of times. You rinse it off and you rinse it off again and the salad thinner. So if everyone stopped washing their lettuce, don't you think we'd have an increase in foodborne illness? Yeah, I suspect so. All right. Daniel also talks about person to person spread. When a person is infected with cyclospora, sheds osis, they have they're not immediately infectious. They require two weeks in the environment to mature and become infectious. We don't know why, but we do know this is the case. And we clarified that on the TWIP, right? Yeah, yeah.

48:36We talked about the fact that when it comes out, not infectious, it takes this one to two weeks before it actually becomes infectious. So yeah, the idea that someone's going to use the bathroom and prepare your food, no, it's going to take a period of time. finally daniel mentions the possibility of multiple outbreaks please note the fda is definitely investigating multiple cyclospora outbreaks there had been six outbreaks investigated by fda this year one has been closed with no cause identified gives a link for that a new one was just announced and only one of these outbreaks has a cause been linked epidemiologically to iceberg lettuce now this is great stuff don so appreciate you so don is chair of the department of Food Science at Rutgers.

49:17So Don knows what he's talking about. He totally knows what he's talking about. He's right on with all these comments. Connie writes, thanks once again for all that you do to keep us up to date. I just listened to the most recent episode in an answer to an email question. You mentioned that if you had measles after receiving the polio vaccine, it would be wise to get vaccinated again. I'm 77. Can't remember how old I was when I had measles. I do clearly remember getting the polio vaccine, shot and then sugar cube, but it may have been before I got measles. Is there any reason to worry about this?

49:52I imagine there are thousands and thousands of people around my age in the same boat. Yeah, no, this used to not be a problem. But thanks to some folks, this is becoming a problem because we've got older folks. You know, they may have gotten their vaccine, then they got polio. We're not sure how well that vaccine is protecting you now because of the potential immune amnesia that you could have gotten. So, yeah, I think there's a lot of folks that are just going to get another MMR just to be on the safe side now that we're seeing thousands of cases of measles. So I'm in this boat. So I was born in 53.

50:27I definitely had measles. Right. And I got polio vaccine twice. I got it in 55 and then I got it in 62. So I probably got measles in the 50s. So I'm probably okay because I got the vaccine again in the 60s. But there was a time when there was zero measles in the U.S. and this was not an issue. And thanks to people running public health in this country, it's now an issue. Yeah. Sorry, I think I misspoke. So yeah, it's the polio vaccine that people might need to get done. If they had measles, all right, you're protected there. But yeah, maybe the measles, now you're not immune to polio. We have to worry about that.

51:07Of course, I worked in a polio lab for many, many decades, so I got immunized many times inadvertently, so I'm not worried. All right, Ellen writes, many decades ago, I was diagnosed with Giardia, and I was told it would never leave my digestive system, so I would have to be careful to hand wash carefully for the rest of my life in order not to spread it. Is the same true for Cyclosporidia? Yeah. So the first, that's not true. So yeah, if you get Giardia, you can be treated. You can clear the Giardia. You could go get tested, see if you still have Giardia. And lo and behold, you'll find out that you don't.

51:48And the cyclospores. Yeah. So some people can have cyclospore infection for like a month or two, symptomatic for a month or two. Some folks can actually have it for longer and be asymptomatic. There's this asymptomatic carrier state. But no, you can treat cyclospora. You can clear cyclospora. And we mentioned it on our podcast this week in Parasitism and the Deep Dive. TMP sulfa, so your Bactrim, your SEPTRA are kind of the front line, and there's some alternatives as well. Have you seen any cases of cyclospora? I hate to share if I have or not because it might be a mystery case coming up on Twitch.

52:26Okay. although an id doc might not it could be dealt with by other physicians as that's hopefully true but i think some of the challenges right if you're going to do over in parasite you have to know it has to be with the acid fast aid uh you know got to know to do a molecular test so sometimes folks you know end up coming our way or they end up at the hospital yeah all right uh alan's next question around the same time there was an article published entitled new york a tropical paradise saying the workers in kitchens of many restaurants in New York City have chronic parasitic infections. In that case, it's amazing how few parasitic infections are reported.

53:05Is this true, Daniel, that most of the workers have parasite infections? Well, so there are a number of workers in New York City who actually have parasitic infections, but this actually, maybe the cyclospore is a good way for people to learn about this. A lot of the parasites, it's very hard for a parasite to go right from one person to another. Like the cyclospore, it needs that one to two week. Let's say you have the giant intestinal roundworm. That's going to, again, got to get in the soil, got to have a period of time. Very few parasites that you can just direct person to person. So what kinds of parasites would be in the intestines of food workers in New York City?

53:42So you might have Ascaris. That's probably pretty common. But again, that's the giant intestinal roundworm. That's going to need to be in the soil. You might have some Giardia. That's potential, but it usually takes a little more of an inoculum than you would see. Maybe strongoloides, probably 10 % from certain areas of the world will have that in the intestines. How about tenia solium? Yeah, you're going to see that, right? In some parts, Central, South America, you're going to see a number of folks with that. Those are tapeworms, right? Yeah. That's TWIV Weekly Clinical Update with Dr. Daniel Griffin.

54:19Thank you, Daniel. Oh, thank you. And everyone be safe.