TWiV 1374: 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 1374, recorded on November 12, 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. What's on your tie today, Daniel? It is Staph aureus, these little yellow coxci. Mm-hmm. Yeah, look at that. You probably can't see it. For you, it's like— I just see some yellow. I can't really see what it is. Well, it is an artist's rendition because they're not really yellow coxci. Of course. So, but all right, let's, let's jump in. So it was this last week we lost Patrick Stewart.

1:06I don't know if you were, were you a Star Trek fan, Vincent? The early, you know, the first phase, not the Patrick Stewart phase. But you know, I was in a, I was in a hotel in Berlin once and he was right there in the lobby. Oh, wow. I saw him in person. So I probably told you this before, William Shatner's daughter and I went to college together. No, I didn't know that. And he comes out to visit Boulder, Colorado and goes into like this, I think it was alfalfa's. Yeah, it was alfalfa's. It was like one of these health food, you know, granola type places. And they ask him for ID for his check.

1:42He's like, don't you recognize me? The lady says, should I? Yeah, right. No, that doesn't work always. People don't watch. Not everybody watches everything. Yeah. So, yeah. No, I was watching a Nathan Fielder show and he was interviewing, was doing this thing where a guy's like, oh, I'm trivia. I'm really great at trivia. He's like, oh, he's probably seen some of my shows. He's like, no, no. You've seen some shows? All right. Let's jump in with a quotation from Patrick Stewart. Jean-Luc Picard, right? And this is kind of a call to action. It is what you do from now on that will either move our civilization forward a few tiny steps or else begin to march us steadily backward.

2:28Do you think there are people who want to march us backward, Daniel? So there are people that do, right? And some of them for like personal gain. As long as all of society is going in one direction, they don't care. They care about their own personal gain. I mean some people actually have some really odd ideas, right? You know, the tin hat folks that seem to be in interesting positions of power. And then there actually, you know, there always are people that have some idea that it was so much better hundreds of years ago, you know. As if they lived and really know what was going on, right? Oh, hundreds of years ago, right?

3:05I mean, you know, life was bitter and short, right? Yes. It was one of our philosophers. We are living in a good time here in general compared to previous times, except maybe more recent times. It was a little friendlier than it is now in the U.S. But in terms of public health and medicine, it's a great time, right? Yeah, we have no need, no interest in moving back to the time when life was brutal and short. All right, but let's talk about a few things that are going on. And so some things that are in the news. Little C, big VDPV1. What is that? What are all those circulating vaccine-derived poliovirus one?

3:50That's right. In Syria. So Syrian Arab Republic launches coordinated public health response following poliovirus detection in Deir Azor. So we get this report out of Damascus. The Ministry of Health there is strengthening vaccination surveillance activities to protect children following the detection of the vaccine-derived polio virus 1 in two children aged between 16 and 13 months who developed paralysis. So this is paralytic polio from circulating vaccine-derived polio virus. So the ministry is supported by the WHO, UNICEF, and other partners, vaccination activities in affected areas, preparing further campaigns.

4:42When the families are being encouraged, check your child's vaccination records. Make sure that you're up to date. You know, this is what happens. The attenuated Sabin strains are being used. They revert. They circulate. And if you let vaccination coverage drop, you have cases of polio. Now, you know, so what are we going to do? Because not every country does 100 % immunization. Well, we have to get away from this attenuated vaccine and to something that's not infectious, of course. So that's the problem in that these vaccines cause a problem in themselves. Yeah, I think we've been pretty uniformly calling for a move to the injectable.

5:30Yes. Yeah. And all these arguments about, oh, money, money, and cold chain. No, I think we can do it. And so we really have to just do it. This is terrible. It has to be done because kids will keep getting – now, of course, I don't know how long it will be when after you switch to IPV, that all this circulating poliovirus goes away. That's the other question because you could switch to IPV and if you're not immunized, 5 % of your kids are not immunized, they are liable to get polio from this circulating virus. Yeah. Yeah. That's a real problem. Yeah. No. And so we've got to just keep vaccinating.

6:09That's the way we keep these little children from being paralyzed. Yeah. Yeah. All right. So measles, we're going to talk about measles a bunch, but America's measles problem has reached endemic level. So this is an article in the New York Times where we read that measles is once again endemic in the US, 26 years after it was declared eliminated. Now, right now, there's actually a meeting going on. And so when we record next time down in DC at the American Society of Tropical Medicine and Hygiene, we're going to hear basically, I think, that the United States has lost its official designation as a nation that has eliminated measles.

6:49I mean, the data is all there. So I don't see that they're going to reach any other conclusion. Yes, it's quite clear. It's circulating over a year. It's endemic. It's originating here. We've lost it. Yeah. Hundreds of cases each week. Yeah, this is terrible. But a little bit of good news, and this is an article that seems to be getting a little bit of press, and it's 501 Phase 1B Trial of Intratumoral Administration of the Seasonal Influenza Vaccine in Patients with Melanoma, published in the Journal of Immunotherapy for Cancer. So yeah, this is basically they're going to inject, or they did inject, the flu vaccine into tumors.

7:34Crazy idea. Well, what's up here? So for background, we actually know that in murine or mouse melanoma models, that if you actually inject the flu shot into the tumor, you see reduced tumor growth and actually sensitized resistant tumors to immune checkpoint blockade, right? So those are some of those immune checkpoint therapies. You inject the flu vaccine and now the tumors become more sensitized to those therapies. So this was a phase one trial, right? So preliminary, they're looking at safety, immune effects of this intratumor flu vaccine. So they've got 18 patients with melanoma. They're enrolled.

8:15And this is what happens. They give them a standard IM flu jab, right? So what you're normally used to, getting it in your shoulder, followed by two intratumor doses of flu cell vax quadrivalent unadjuvanted seasonal flu vaccine in a dose escalation. design. And then they're going to look at the tumors. And when they analyze these, so the pathological analysis revealed risk tumor infiltrating lymphocytes in 79 % of samples, tumor regression in almost 40 % with three complete pathologic responses, one of which was associated with germinal center formation. And they go ahead and they do profiling of the plasma cytokines.

9:02So you see significant elevation of IL-15, GM-CSF, CXCLN, CCL3, TNF-alpha, some decreases in IL-1 beta and IL-13. And then they do flow cytometry to look at non-classical monocytes, which increase. And the Th1-Treg ratio, actually, you have a 1.5-fold increase, right? So that's what you want. You want more of a Th1 and less of a Treg. And that's one of the tricks, right, of the immune evasion of the tumors is they actually can upregulate Tregs and get down your Th1. Here you get a shift there. 70 % reduction in the myeloid-derived suppressor cell, 65 % reduction in the exhausted CD4 T cells. Really pretty impressive, right?

9:59Just basically injecting the flu shot into a tumor. So is the idea here that they're getting two shots into the tumor and the normal IM shot, is that somehow collaborating to get the immune response into the tumor? Yeah, it's interesting, right? Because they're doing both. Like it would be nice to parse it out, right? But yeah, I think what they're trying to do is they're getting the normal flu shot, but then you're trying to get a targeted effect by giving it also into the tumor. I mean, is this just immune activation, like you get a polio vaccine and it prevents COVID kind of thing? You know, it's interesting, right?

10:40Because we had that other study, right? Where they gave people the COVID shots and actually it was allowing the immunotherapy to work better in their cancers. Yeah. So yeah, because the tumors have this ability, this immune evasion. And what we're trying to do is overcome that. And there's a really nice companion article by Ellie Dolgan in the Washington Post talking a little bit about what's going on here. But yeah, what you're trying to do is, you know, the immune system probably gets rid of many cancers over time until cancer is finally sort of, well, are selected to have this ability to do immune evasion.

11:15But if you could somehow undo that, it looks like we're actually getting immune response and targeting of the tumor. It's very interesting. although I don't know intratumoral is always tough right because not all tumors are accessible that's an issue like how do you get to some of these tumors right you're going to go down with the bronchoscope is it going to be close enough to the to the chest wall that you can go directly and with the needle without yeah and also melanoma typically you have many many tumors not just one right so I mean as long as they're on the surface right I mean that's one of the advantages of melanoma is that your primary will be right.

11:55If they're 20, I don't think you could do 20 of them. Sometimes they're in the back of the eye, right? Like Jimmy Carter had. Really, the best thing is to do systemic administration, right? And have the viruses home to the tumors. Yeah. But hey, they had a couple of people with complete... Complete responses, right? What does that mean? I don't know what complete responses is. Because they took them out surgically and they looked at them. That's how they know this. But what? Yeah. And remember, this is just phase one. This is very preliminary. So it's all interesting. But yeah, there's really a lot of work to do.

12:33There's phase two. There's phase three. I wonder how they got the idea to do this, right? Well, so I think it was from the mouse stuff. They were messing with mice. And if you do this in mice, if you inject the flu vaccine into mice, you actually see this positive impact. I see. All right. Well, dengue, another New York Times article, her death from dengue may signal that the disease is here to stay. It's here. I mean, it's now. We have autochthonous dengue in Florida. But here's the story. And I think it sometimes helps to put a human face on the story because just numbers. But here, Gay Small got dengue from mosquito bite, probably from one of her daily walks.

13:14You can sort of picture this person out for their daily walks. They get a mosquito bite. Don't think too much of it. She is so far the only fatality among hundreds of people in Florida who've been sickened with a dengue outbreak that scientists and public health officials are struggling to understand. The size of the outbreak, they say, indicates that dengue may be making a comeback in the continental United States at a level not seen for many decades. I think the dengue outbreaks will get worse over the coming years in the U.S. as Ira Longini, a biostatistician at University of Florida. In the continental United States, dengue cases are almost always traceable to mosquito bites from traveling.

13:49So it's especially foreboding, public health experts say that most of the current transmission in Florida is coming from mosquito bites locally. You guys did a bit of a deep dive on dengue on the last TWIV. And actually, a couple of things I'll say, because I think this is important. So we make a lot in dengue about this antibody-dependent enhancement, right? So the idea is you get one type of dengue, and then you get a second, different, you know, there's four different types of dengue, one, two, three, four. And the idea is maybe you get a dengue three, and then the antibodies, now you get dengue type two, and the antibodies actually allow the virus to get into cells it wouldn't get into otherwise, because the FCU-mediated endocytosis.

14:36But one of the things I want to point out, and I think this is really important for the fact that little kids go to Florida, they go to Disney, is a lot of the deaths. I would actually suggest that worldwide, the majority of the deaths we see in dengue are in little kids. And actually they can be the first time they get dengue. So there's antibody dependent enhancement is a huge problem like, you know, in older folks when they get a second. But, you know, particularly dengue type two in little kids, you go to places like Southeast Asia and their hospital's full. And even first time, a quarter of the travelers that end up sick enough to end up in the hospital, it's their first dengue.

15:12So do you think this lady had secondary dengue? So I guess what I'm saying is we don't know. Like people would think that, oh, she must have had another. And if you think, oh, I'm living in Florida, I got dengue, but there's only maybe one type of dengue, so I'm not so worried. But that's not true. About a quarter of the really severe cases, it's the first time. And a lot of the little kids, right? I mean, they haven't had multiple. It can be the first time you get dengue that you get sick enough that you end up in the hospital or die. It's unfortunate because a number of years ago, you wouldn't worry about walking around in Florida and getting dengue.

15:46But now you have to worry. Yeah. Yeah. You have to worry about measles. You have to worry about dengue. You have to worry about chikungunya. You're starting to have to worry about screw worm. Yeah. I mean, it's like you need to go see the travel doctor before you go to Florida these days. Yeah. And as mentioned, I think on the deep dive right now, there currently are no dengue vaccines licensed in the United States. So we're going to have to kind of rethink what to do about that if it becomes an endemic thing. And you're like, you're thinking about going to Florida on vacation. Is it OK? It's here.

16:18So these are autochthonous cases. It's endemic and it's probably going to spread because it's here. And with climate change, the mosquitoes range are going to move north. And so dengue will move north with it. Yeah. It's here. It's only going to get worse at this point. Okay. Bird flu. I really like this really nice – what is this, like a cartoon? Probably bio-render or something? Yeah. It's some kind of graphic. It's all drawn. There's no photographs. Yeah. Yeah. This was actually posted on X, formerly Twitter, right? And it's why H5N1 in mink is concerning. And they talk about the alpha-2 ,3-linked sialic acid, the alpha-2 ,6-linked sialic acid, and sort of showing the bird flu, the mink respiratory tract, which has both, and then the human with the A2 ,6-linked sialic acid.

17:20Yeah, this is interesting because even at the bottom they say, conceptual diagram for risk communication, receptor preference is only one factor in transmission. That's very good. I like that. I thought it was good. So we can, you know, people watching on YouTube can probably get a chance to say, hey, so watch on YouTube and you can actually see this really cool post. And I'll leave in a link, JP Weiland posted this on it. So minks are a concern and so are pigs, right? Because they are similar in that they have both kinds of receptors in the respiratory tract. Yes. Yeah. Yeah. So, yeah, we need to do something.

17:53I mean, you know, we're farming mink to send furs to China, right? I mean, I don't know what's going on here. I really think this should be discontinued. It's just, you know, it's another risk factor and we don't need it. And we really don't need to be doing it. I mean, look at the little, look at the mink. They're cute, little furry guys. Really, should you be raising these guys and skinning them and sending the furs? I mean, come on. It's horrible. I mean, you have to start – you have to restrict your animal torturing, okay? If you need it for food, that's one thing. But for a coat, you know, I just think that's wrong.

18:28Sorry. Yeah. So, yeah. So, yeah, there was a PETA person wrote in last week. He wrote in to Twiv and said, thank you for supporting not slaughtering animals for furs. And yeah, I mean, I have problems slaughtering them for food, but I understand that people need protein, right? Yeah, yeah. I mean, I was having cereal and I felt bad for the cows this morning because they have a miserable life. They get milked for four years and then they're slaughtered. Yeah, that's interesting. Yeah, that was a little bit of a discussion about, you know, and we kind of are touching on all these one health issues because they really are an issue with infectious disease.

19:10But yeah, apparently there are companies that own the milk cows and they lease them out for about three to four years and then they get milked. And at the end of their like milking time when they're basically in these areas, then they're then for meat. And so it doesn't – Yeah, it's just – I don't really like that. No. All right. Screwworm really is taking off, Vincent. Look at that. We're up to six fly track detections. already 41 cases for November, and we're recording on the 12th. So it really seems to be, you know, across the border and here in New Mexico. Now it's in Arizona. It continues to be an issue in Texas.

19:53What should we be doing to curb this, Daniel? Well, we had for decades had this really effective control program, right? And, you know, It required the release of all these irradiated mails. It required surveillance. It required cooperation with Mexico and countries in Central America down to the Daring Gap where we really maintain this wall. We really are going to have to up all those strategies because this is going to lead – not only is it horrible, but it's going to lead to billions of dollars of economic damages. I mean poor – I feel about the cattle industry in Texas. Like the last two years have just been a disaster with, you know.

20:41All right. Moving on to Ebola. This has become like the bad news, like, you know, but things are going to get better one day, right? So Ebola. So this is an article. This is actually CIDRAP covered this, and it's wider use of Ervibo vaccine urged as DR Congo Ebola outbreak nears 11 ,000 cases. We're actually going to talk about the fact that that's already dated, already passed, blew by 11 ,000 cases. So as we've been discussing, the total Ebola outbreak in the DRC continues onward, over 5 ,000 deaths, now over 11 ,000 cases. It's the outbreak, which began in May, is the second largest in history, and it's the fastest growing on record.

21:29Now, MSF is urging the WHO to lift restrictions, limiting the Ervibo to research use only, wanting to sort of extend that. There's a couple other vaccines. There's the Moderna mRNA vaccine. There's also another vaccine. So leave a link into that CIDRAP article. But for those of you watching on YouTube, it's just still – there's no plateau here. is just continuing along over 11 ,000. Well, when I checked the other day, it was 11 ,021. But if you look at the table, even more than 11 ,021 and 5 ,358 total confirmed deaths. Do you think we should expand the use of the Irvibo? We got to find out if it works.

22:15I think that's a huge problem. We don't even know if it works. So you think we should be doing the clinical trial as we are and making sure it works, right? Yeah. I think we have to find – this is an opportunity to find out if it works. Yeah, because it doesn't make sense to give it to many, many more people if it doesn't work, right? Well, we don't know if it works. That's – I mean it's hard because people are like, but we think it works. There's anecdotal evidence of cross-protect. Come on. This is not – we need to know because this will not be the last Bundabugio issue we have. Well, MSF, they're taking the humanitarian view, right?

22:52They want to save lives. Yeah. And I understand. We do too, but we want to make sure that we are actually – because the issue in the DRC is not that, oh, we have unlimited resources and we're just not giving this to folks. One of the problems in the DRC is even the traditional methods of identifying and contract tracing, we don't have the resources and manpower. The United States has put restrictions on any of us who might want to go and help with then even being able to come back and work a job for 21 days. So I think that there's a lot of other things that we're not doing. We need to find out if this vaccine works.

23:30So see if we get some angry emails from the Doctors Without Borders. Well, you know, there's a now there's a Bundy Bougio vaccine about to come online. So that will be tested. Yeah, let's see if that works. They'll probably say, well, you should just use it. But you can't. You have to test it. You have to see if it works. You have to see about side effects, issues. Yeah. Yeah. Because people will quickly forget, right? And if there's problems, then after the fact, people weren't really dying and you gave them this horrible vaccine. Of course. Of course. You cannot win. All right. And measles, if you follow here in the US, our own epidemic, measles cases were up to 5 ,400.

24:11It was like an extra 350 just last week. And 10 deaths, right? So there must be more cases than we're seeing. That's true. So really, really horrible. Canada is actually doing better than we are, but I will include the article, Impact of a Large Measles Outbreak Associated with Transmission in the Americas and Canada's Loss of Measles Elimination Status, Descriptive Cohort Study, published in the BMJ. And I think this is really, you know, for all the folks that are like, oh, you know, there's no measles, you don't have to get vaccinated, I don't have to worry about it, it's not gonna be a problem here in New York.

24:51This is, I think, a story that bears telling a cautionary tale. So Canada attained measles elimination status in 1998 after the introduction of a second dose of measles containing vaccine, and a national catch up program for school aged children. So sort of similar to what we did here in the US, right? Added that second. High uptake of the two-dose schedule led to a marked decline in measles incidence. In the province of Ontario, more than 5 ,000 cases reported in 1991 compared with 101 cases reported between 2013 and 2023. In November 2025, the Pan American Health Organization determined that Canada lost its measles elimination status due to ongoing domestic transmission.

25:38So here we're going to learn about, read about an outbreak that began in October 2024 after exposure to measles at a wedding in New Brunswick, Canada, followed by secondary cases among attendees in the provinces of New Brunswick and Ontario. So a lot of, you know, I don't know if our listeners have noticed, but a lot of these stories are there was a wedding, there was a funeral, right? There are these big gatherings. Yeah, that's problematic always, right? Yeah. I'm going to have to rethink my Irish funeral prescriptions for my family. I don't really want all my family getting together after my death and then getting some horrible disease.

26:21We may have to – we'll do it on Zoom. Put that in there. But anyway. OK. So the article is a descriptive analysis of the cohort of measles outbreak cases reported to Ontario's public health surveillance system during the outbreak period, epidemiological week of 28, October 2024 to 6, October 2025. The outbreak consisted of Euripha's 2 ,377 cases over 49 weeks. So this is like that shampoo commercial on steroids, like that one person shows up and then we have 2 ,377 cases. So most of the cases, over 90 % occurred among members of historically under-vaccinated communities with limited spillover into the broader population.

27:07Among the 2 ,377 cases, three quarters were in individuals aged 19 years or younger. About 90 % were unvaccinated. 97 or 4 % had unknown vaccination status. The outbreak had 7 % of these folks ended up in the hospital. 2 % of the infections were during pregnancy. There was a case of, well, there were 10 congenital measles infections, one case of encephalitis, one infant died. And there's some figures where you can really see the cases over time. And you can actually see they have some maps where you can see the outbreak incidents per 100 ,000 population. You can also look at the vaccine coverage.

28:01It's interesting that it didn't really get into the general population, right? It was mainly in these under-vaccinated groups, which is not what happened here, right? Here, we do have under-vaccinated groups like the Amish and the Mennonites. But then we also have people who are deciding because of RFK Jr. not to vaccinate their kids. And that's amplifying the outbreak. Yeah. I mean, one of the nice things you can see in these figures of people watching on YouTube is there are these areas where the outbreak was, but they're surrounded by these areas of greater than 95 percent measles vaccination coverage.

28:39Yes. Yeah. They're doing a good job in Canada in the general population because they don't have RFK Jr. to tell people that they shouldn't get vaccinated. All right. So here is, this is in Politico. In America's measles epidemic, RFK Jr. is now on trial. This week, eight public health officials who advise an arm of the UN will consider whether the US can still keep its eliminated measles. For health secretary, RFK Jr., the longtime vaccine, he's not a skeptic, the longtime anti-vaccine person who's helped helmed America's response to the thousands of cases that erupted since last year, it will be a legacy-defining decision.

29:21This is what we talked about. The Pan American Health Organization's answer would seem obvious with measles ripping through Pennsylvania, New York in a state of emergency, and more than 7 ,000 infections reported nationwide since January 2025. So the officials will have to determine that a single chain of transmission has continued for at least one year to take away measles elimination status. If not, Kennedy will get more time as he attempts to show that his agency can curb the spread of measles. I'll leave in a link so people can read a little bit more about this. It's going to, we're going to lose it.

30:00Okay, forget it. I mean, whatever they decide, we've lost it. I mean, we're seeing hundreds of cases of measles here. By the way, there's a very interesting graph over at the Johns Hopkins measles tracker. I'm going to put it in the show notes now. I'm looking at this Canadian one, and I'm thinking, well, what does it look like in the U.S.? So here's what it looks like. I'm going to put it in this exact second here. Oh, this is great. You're going to see that it looks like the Ebola outbreak. It's just rising. Yeah, there is no plateau. It is. No. No. I mean, isn't that crazy? And then it's the worst it's been in many years.

30:41They have other years on the graph, but this is just going up. Wow. And the thing is, 97 % of the cases in the U.S. are unvaccinated. Yeah. I don't know what more evidence you need besides the fact that the MMR is completely safe to get vaccinated. All right. So let's move into our next section. Four medical societies and panel led by UM-SOM expert back one set of flu, RSV, and COVID-19 vaccine recommendations. So what is this? So the four national medical societies have endorsed vaccine recommendations for flu, RSV, and COVID-19 that really aligns with the other societies, the American Academy of Allergy, Asthma, and Immunology, the American Thoracic Society, the American College of Chest Physicians, the Society of Critical Care Medicine.

31:42They didn't create new recommendations. They really jumped on board with the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the IDSA, the Infectious Disease Society of America. So here they are. And, you know, take notes. Actually, maybe we can have these up. We can do screenshots. So what are the recommendations of all our professional societies, of all these professional societies? So what about the flu shot? Everyone six months and older should get a flu shot. Just repeat that. Everyone six months. So if your child is one-year-old, two-year-old, four-year-old, 12-year-old, 23-year-old, if you're 59 or 75, everyone should get at least one flu shot a year.

32:31For those 65 and older, right, get the high-dose adjuvanted or recombinant, the special vaccines recommended for the older adults. If one of those isn't available, go ahead and just get your standard flu shot rather than wait. And don't worry about egg allergies. It's not a thing. You can get any of the flu vaccines. And most adults should get vaccinated, well, September, October. If you haven't gotten your vaccine yet, you're getting a little late because we've got a lot of flu activity. So get going on that. So that's the flu. Everyone's getting their flu shots. What about RSV? So all adults 75 and older should get an RSV vaccine, so should adults aged 50 to 75 who are at higher risk.

33:18Pregnant folks should get an RSV vaccine late in pregnancy, so that 32 to 36 weeks. And babies, this is important, I'm going to reiterate this. If you are born when you're about to enter into an RSV season, so babies younger than eight months whose mothers did not get the RSV vaccine during pregnancy should get it protective antibody shot before or during their first RSV season. A lot of these babies, they're getting shots in the hospital. So there's no like wait till six months. Like if you're born, your baby should be protected either with mom's vaccine during 32 to 36 weeks or the babies getting the passive antibodies.

34:01And we'll talk a little bit more about those. This should have a dramatic effect on reducing RSV. RSV is one and done so far, right? So far, except, yeah, so for the adults, it's one and done. But for the pregnant folks, right, you can get a vaccine with each pregnancy. And for the babies, you can actually, those who still remain at risk can get a second monoclonal antibody shot the next season. All right, So everyone's getting their flu shots. All the babies should be getting protected for RSV and the folks 75 and older and the high-risk people 50 and up. COVID-19, all adults should get a COVID-19 vaccine.

34:45All adults, right? So that's 18 and up, right? 18 and up. We're recommending everyone get your flu shot. COVID. Get your COVID shot and your flu shot. Yeah. Flu too, yeah. But we're talking about COVID, right? Get your COVID shot. Oh, look at this. Adults should get two doses, 65, two doses. Yeah. That's very interesting. Did you get two doses this year? I'm not 65 and older. Okay. But, you know, it's actually interesting, right? Because we're saying everyone's 65 and older. But what we've seen, and we keep talking about the data, is you get like this six-month antibody protection, and then that goes away.

35:23The T-cell stuff is a little more durable, so that's great. But that's part of what we base this on. You get this six-month reduction. So, yeah, adults. What's the timing? What months for the Northeast, you know, the Northern Hemisphere, what months are the best? Yeah. So, basically, you want to kind of keep an eye. So, you should have already gotten your COVID vaccine if you haven't get it now. So, let's say October is not a bad time to do it. And then about six months from now, you're going to get it. So, you can sort of do the math. Let's see, October, November, December, January, February, March.

35:54Time for get another one in April. And you don't have to wait. Like, you'll say, oh, but I got an April. girl, I'm waiting till I hit exactly six months. It's fine. You can hit it in October. It's fine. Okay. COVID-19 vaccination is recommended during pregnancy. I've talked about the data over and over again. It is much safer to get that COVID-19 shot than to lose your baby, than to get sick and have your baby have problems, right? Keeps you at 18-fold increased risk of ending up in the hospital with COVID if you're pregnant. COVID's not great when you're pregnant, and it's not great for your baby when you're pregnant.

36:25So get that COVID vaccine. And all children, six to 23 months old, should be vaccinated and older and teens at higher risk. So this is great. This is very clear, simple. And folks, it does contradict what RFK Jr. says, but ignore him because he doesn't know what he's talking about. Yep. Yep. All right. As mentioned, we're starting to get a bit of flu activity. So the map is no longer green. We actually have high activity in Louisiana and down there in South Carolina. And we're starting to pick up into moderate on the West Coast, Texas, Florida. So flu season is here. And you can really see that the epidemic trend for the CDC starting to climb.

37:15And unfortunately, we're already up to three little children have died of flu already. You know, the total last year, over 200 children died of flu last year. So this is like a call for action for people to get those flu shots for their kids. Because remember, half of those kids were completely fine. You think, oh, it's a normal, healthy kid. My child's not at risk. I'm not too worried. Half of those over 200 kids were completely healthy until they got the flu and died. So get those flu shots. And then remember, if you get the flu, we have treatment. If you've been exposed, we have post-exposure prophylaxis.

37:53So check in, check in with your provider. All right, going to hammer a little bit on RSV because we're actually starting to get some activity, right? We're starting to get some activity down in Florida. And remember, what are our options for RSV, right? So there's the vaccine and there's the monoclonal. So we're going to talk about both of those. So who gets those monoclonals? Monoclonals for the little kids. We've got two choices. We've got Bifortis or Nersevamab and Enflonzia, Enflonzia, Closorovimab. What a horrible, they got to work on that naming, Enflosia. Yeah. So remember, these are those wonderful monoclonals, right?

38:36You know, like the Regeneron or the Bamlanivimab and all that stuff that you guys remember from COVID. So here, neonates and infants born during or entering the first RSV season, everybody, they can get the Bayfortis. And the Enflosia, this is actually very similar, except if you look at the FDA, I'm going to leave in links to the package inserts. It doesn't talk in the package insert about that second season, right? So with the nersevimab, children up to 24 months of age who remain vulnerable to severe RSV disease through their second RSV season can get another shot. It's a higher dose that second based on your weight.

39:19So it says here that Bafortis and Enflonzy are both monoclonals. Is that correct? That is correct. Yeah. And then it says that Enflonzy is a fusion inhibitor. I mean, it's a F-protein-directed monoclonal, therefore it inhibits fusion, right? Exactly, yeah. Okay, got it. Yeah. All right, and then we've got three choices on the vaccines, right? So remember, the little kids get passive vaccination, right? They get monoclonals, but adults can get active vaccination. So they can get GSKs, RexV, right? And that's FDA approved for individuals 60 years of age and older or 18 to 59 at increased risk, not approved for the pregnant women.

40:05You got to have to go to Pfizer's Brisvaux for that. Very similar approval, but Pfizer's Brisvaux is actually going to be the one that pregnant individuals can get 32 to 36 weeks. And then we have Moderna's M. Resvia. This is approved 60 years of age or older, 18 to 59 at increased risk. And how well does that mRNA vaccine work? Well, we just hot off the press. Right after Veterans Day, we have the article, Effectiveness of the mRNA-1345 Vaccine Against Respiratory Syncitional Virus in U.S. Veterans, published in JAMA Network Open. A total of 74 ,926 vaccinated veterans were matched to 286 ,425 controls.

40:53We end up with 60 % against documented RSV infection, 60 % vaccine effectiveness against ER department or urgent care encounters, and 81.8%, so about 82 % reduction in RSV-associated hospitalizations. I don't understand this first number, 60 % against infection. I don't think that it's blocking infection, is it? So it's interesting. This is – so they should say – I don't know how we word this better because this has become sort of a sticking point. So let's say you – I don't feel so great. You go see the doctor. They do a test and they say, oh, yeah, you know, you don't feel great. You're positive for RSV or let's say you're positive for flu.

41:39So we would call that an infection. But infection is kind of broader. Like let's say you just screened people and people were exposed and they got a positive test. That would be an asymptomatic infection. So what they should really call this, because the way they're doing this trial, these are documented symptomatic RSV infections. Because vaccines really protect us against disease, right? They're not great if you just screen everyone. You're going to get a little bit of replication. I think that what they're looking at, symptomatic disease here. Yeah. And they're calling that infection. So what they're doing is 60 % effective at preventing symptomatic disease.

42:18That's what it should be. Symptomatic RSV infections. Got it. Yeah. And I think maybe we should, yeah, we should kind of hammer that home because that comes up. And the biggest things that vaccines do, what do vaccines actually do? They prevent disease. The whole idea that somehow, as soon as the virus gets onto the mucosa and starts to replicate, it can't block that initial replication. And people would say, well, that's infection, asymptomatic infection, abortive infection. We use all these terms. So what vaccines do is they prevent disease. I love that CDC campaign before the current administration got involved, where it was like, you know, they turned the wild into mild.

43:02Yes, exactly. And that was great. That's what vaccines do. They turn wild into mild. All right. COVID. It's pretty solid. It's just trucking along. It's going to head right into a winter surge. Plenty around to spread. Well, this will be the next thing. It'll be Thanksgiving, right, in the United States? Everyone's going to get together for Turkey Day? Yeah, it'll have another spike probably. Yeah, yeah. So this peak here is probably never going to go to baseline as it has in previous years. It's probably going to stay at this plateau and then boom, it's going to go up again. It's just going to peak out.

43:40So what can you do about this? So a couple of things, right? I think we got to keep repeating these because we're coming up. We're, well, we're two weeks away from Turkey Day as we're recording this. People are going to be getting together. People are going to be traveling. So remember all the things. Like you get on an airplane. There's people in that airplane that are breathing out the SARS-CoV-2, right? Remember that Noah Kahn song, there's COVID on the planes. Yeah, there are people sick with COVID on the planes and they're breathing out the SARS-CoV-2. So you can think about that, like, you know, as my daughter, you know, scolds her boyfriend about like, you know, you could still wear a mask.

44:15Like they may not be cool anymore, but they still work because being sick is not cool. The other thing is post-exposure prophylaxis, right? So we've got the Zocova, the encitralivir. And then if you get sick, we have treatment. We have early antiviral therapy. And oh my gosh, did anyone mention vaccines? I know they're not cool either, but you could reduce your risk dramatically of getting COVID-19, getting the disease, and the severity of it if you get that vaccine. And if you don't like the mRNA vaccines, we've got a protein base. So we've got options. All right. What about little kids, right?

44:57We talked about the recommendations. We actually recommend COVID shots for the little kids. And why do we do that? Well, because little kids get sick, little kids end up in the hospital, little kids die, little kids end up with long COVID. Not great. So the article, the magnitude and durability of immune response to the SARS-CoV-2 vaccination among children was published in J-PIDS. The objective of the study was to assess children's SARS-CoV-2 specific immune responses post second vaccine dose, and to compare immune responses between unvaccinated children and children vaccinated with two or three vaccine doses.

45:30Three observational cohorts of children's age three to 14 were followed longitudinally from December 2021 to October 2023 in Montreal, Canada. Two had scheduled serology assessments before their second dose at one, six, and 12 months post-second dose. And we're going to look at Binding antibody units. BAUs. What are BAUs? I think this is good. So this is a WHO standardized way of comparing antibody levels lab to lab. So for some of the clinicians out there or actually some of the patients who maybe have AFib or they're on blood thinners, maybe remember Coumadin, rat poison, and we give it to people.

46:11We get a PT slash INR, and the INR is that standardization. So BAU is a standardization of these antibody binding levels. So controlling for recent infection, anti-spike IgG, antibody receptor body domains, RBD, IgG, and neutralizing titers against wild-type SARS-CoV-2 declined by six months post-vaccination. I think we talked a little bit about that six-month magic number. For example, average IgG anti-RBD was 1 ,374 BAU per ml one month after dose two, with an estimated decline of negative 856 at six months. Basically, we're going to look at some charts here. Basically, boom, it goes right back down.

46:54But encouraging, T-cell responses showed little evidence of decline over 12 months across all groups. And then we'll show some figures here. It really goes down in six months, doesn't it? Yeah, yeah. Wow. But the T-cell responses tend to be holding, so. All right. Well, no one is safe until everyone is safe. We're in our Vincent's favorite fundraiser of the year, the Micro TV fundraiser, where again, we're doubling your donations. We're sending out our maximum donation. And remember, we're doing this. We're raising all the money in two thirds of the time. So you got to jump on board. And people have been jumping on board.

47:37So thank you for everyone who's already started donating. I mean, this is the end of the year when you kind of look up and you see where you're sitting financially and you have an opportunity to support organizations and efforts that align with you. So if you want us to keep doing this, then, or if you just like what we're doing, either way, every small amount, every large amount, go to parasiteswithoutborders.com and click on that donate button. It's time for your questions for Daniel. You can send yours to Daniel at microbe.tv. Jen writes, as a 50-year-old, I'm now eligible for the pneumonia vaccine and the shingles vaccine.

48:13I'm wondering if there's any strategy to timing these out for maximum immune response protection. For additional context, I got my flu shot last week and still need to get this season's COVID shot as well. Should I space the COVID pneumonia and first shingles vaccine out? If so, how much time should I allow between them? I know the most important thing is that I get them, period. That said, I would appreciate guidance on timing. Yeah. So probably the time critical shots are COVID. And I don't see you mentioned flu here, but yeah, COVID and flu. I got my flu shot last week. Okay, great. So you already got your flu shot.

48:49So that's great. So you got your flu shot. You're covered there. Next on the docket, we got to get that COVID shot because solid levels and three weeks from now, we're going to be having a lot of COVID, I would predict. You can get the COVID pneumonia and your first shingles vaccine at the same time. There's then when do you get the next shingles shot? So the COVID is going to be one and done for now at 50. The pneumonia is one and done. It's a protein conjugate vaccine. So that's a PCV20 or 21 at this point. The shingles vaccine, it's going to be one shot. And then that next shot is one to three months later.

49:28I usually say three months later. Marco writes, I live in England and I just got COVID four weeks after vaccination, Pfizer, when antibodies should have been at their peak. I understand vaccines do not prevent infection, but the level of efficacy appears to be kind of low now. The latest data from the UK government states that incremental effectiveness of the autumn 2025 vaccines against hospitalization was highest in the period five to nine weeks post-vaccination at 47.6%. Isn't this rather low? Can I legitimately feel frustrated also given I paid 100 pounds,$130 to get my vaccine privately? Okay.

50:11Marco, you seem in your email, you've got all the information here. As you say, I understand vaccines do not prevent infection. So that's true. They turn wild into mild. So, you know, whatever sort of level of illness you experience, the COVID vaccine probably reduced the severity and the duration of that experience. Yeah, as, you know, as we talked about, those T cells tend to have a durability. So what you're doing is kind of topping things off with those antibody boosts, a little bit of a T cell boost as well. So 50 % reduction and ending up in the hospital. It's pretty solid stuff as we get these numbers down.

50:47So don't feel frustrated. This was money well spent. Kelly writes, thank you for the weekly clinical updates, which have been a lifesaver over the last six years. I'm very grateful to have such reliable medical information from people who are as outraged by the current U.S. administration's disinvestment in science as I am. My recently vaccinated husband, September, tested positive for COVID for the very first time last Friday, October 3rd, and started Paxlovid the same day. He tested negative October 7th and 9th and positive again on the 11th. I know this is just a typical second week for COVID, Paxlovid or not, but my husband is now questioning whether Paxlovid helped him.

51:31Where should I look for definitive data about how Paxlovid shortens the length and severity of COVID? Any data on how much shorter a post-Paxlovid second week COVID rebound tends to be? And I believe you've said that if you've taken Paxlovin and after any second week symptoms have passed, you can stop masking. Is that correct? He is comparing our 18-year-old son's three-day experience of COVID with his own 57-year-old self. He's prone to getting severe colds and has autoimmune issues. So I believe he's lucky to only feel like he had a mild cold this week. But how do I prove it? Thank you for making this world a better place.

52:11All right. This is a great email, Kelly. So first off, you know, the tests are great for making the diagnosis. So once your husband tests positive, you don't need to keep testing, right? So he's got COVID, you did the right thing, took Paxlovid. There are over 200 studies on Paxlovid, right, showing, you know, in the vaccinated, the unvaccinated, et cetera, et cetera. So there's a lot out there. But of course, you know, if you go on like the social media, they'll find like the one study from Canada, you know, sometime where, you know, it failed to reach statistical significance, which in their world means it doesn't work, but that's not true.

52:48So Paxlova, it shortens the length and severity. The biggest thing it does though, is the wild into mild effect is as we just in the email up above, about a 50 % reduction in that second week, which is when people end up in the hospital of ending up in the hospital during that second week. So you may never win this one. Oh, but he had a mild cold. Of course it worked. Right? It's so funny, right? The positivity is meaningless. It's the symptoms. Yeah. Stop testing. I mean, we still, as I think we were mentioning with the numbers, I mean, I've got folks in the hospital with COVID that I saw today on oxygen.

53:28Yeah. COVID's still a big thing. So he's like, oh, I still had a little bit of cold. I don't know if the Paxilovid helped. Wesley writes, how exciting to see you covered the Bundy Buggio articles in your late August podcast. You and Dr. Racaniello's look at the intervention represents what was a busy number of days working to get these American citizens to care during a point where the outbreak was only being announced. These two articles represent care of an entire family unit the U.S. government assisted retrieval from a very insecure location. This work involved hours of investigator training for U.S.

54:05and German care teams, overnight shipments, and diplomatic actions to allow importation, colleagues hand-delivering remdesivir prior to takeoff, and in-flight consented infusion of products after days of coaching supportive care strategies to the patient and family. As the ID physician filing the EIND paperwork, I would be remiss to not say I would do it again in a heartbeat to make sure the patient and our care team have the best available tools to move the outcome needle in the best direction possible in an austere setting. This was only made possible with the help from our Aero Medical Team, FDA, ASPR, BARDA, and NETEC SMEs, backstopping me in the excellent care of our Berlin colleagues.

54:52We are additionally grateful that our Berlin colleagues asked deeper questions and so closely followed the safety by showing the viral kinetics in the father, while the mom and children had extremely high-risk contact exposures that left us compelled to offer PEP as an option as the EIND treatment plan allowed for either. These interventions are actively being studied now in the Partners Adaptive trial in DRC. The U.S. government has made MBP available to the trial as well as compassionate use treatment courses to the MOH of DRC. This mission set is one the Department of State has supported since the 2014 outbreak, and just prior to this event, we had just completed the Hantavirus repatriation.

55:37Thank you again for covering these two articles, and I hope the background information reassures you that there are clinical care teams working with virologists and other experts to be aggressive in supporting patients we are charged with caring for even at 30 ,000 feet. I enjoy tuning in as my days permit. Wes, who is an advisor, Tropical Medicine Infectious Diseases Bureau of Medical Services in the U.S. Department of State. No, Wes, this is great. This is a great letter, right? And yeah, Wes, hello. Thanks for writing into us. Yeah, what a fantastic story. Lisa writes, Dr. Griffin, I'm a longtime listener and I appreciate your straight talk when good information is hard to find.

56:23I also appreciate that you communicate when the scientific community does not know things yet, meaning the trials and investigations to get the information have not yet been done. My family has gotten every COVID vaccine. The kids were first in line when the vaccine was approved for their ages. We've gotten all annual boosters. One of my kids tolerates the shots okay. Low-grade fever and pain, but not too much worse than the flu shot. My other kid is another story. She gets a high fever, high enough to cause nausea and vomiting. That's difficult to manage, even when alternating Motrin and Tylenol.

56:57She misses multiple days of school. She's turning 10 in the fall, too young for Novavax. Her pediatrician has told me we don't have the science yet to know firmly how often kids need COVID boosters. she recommends every other year, but admits that is a non-scientific recommendation. I'm debating whether to get my child with a bad reaction to the COVID shot this year or skip it. To be clear, the rest of the family would still get it. Are there any studies that would provide better info about kids in COVID vaccine frequency? Is there data to support an annual COVID booster for kids rather than every few years?

57:32Since the uptake for the COVID shot in kids is low, I suspect it may be a long time before that work is done. If ever, thank you for your thoughts. Lisa, your timing on writing in is perfect, right? Because I just discussed that article where we saw that the antibody levels go up. By six months, they're back down. But the T cell protection actually endures. So this is kind of a tough challenge, right? It's, you know, sort of the risk benefit. It sounds like your one child is really pretty sick, nausea, vomiting, high fever. Yeah, and unfortunately not old enough for the Novavax option. So, you know, at least we shared the data.

58:15The antibodies only give you about that six months, but the T cells may give you a little more durability. So hopefully that information helps you and your pediatrician navigate this. But remember, Daniel, this kid is 10, right? Yeah. It's not recommended to get a vaccine at all. All adults should get an updated vaccine every year, and that's 18 and up. And then children, 6 to 23 months. So the 10-year-old is outside the recommended range by all these societies who we believe in, right? Yeah, no, I mean, as they say, so their children recommendations is 6 to 23, older children and teens at risk.

58:53So, yeah, if you're following the guidance, you may actually, you know, fall on the side of foregoing the vaccination. Yeah, she's turning 10 in the fall. So she doesn't need it. Yeah. That's TWIV Weekly Clinical Update with Dr. Daniel Griffin. Thank you, Daniel. Thank you. And everyone be safe.