TWiV 1294: Clinical update with Dr. Daniel Griffin

This Week in Virology, the podcast about viruses, the kind that make you sick. From Microbe TV, this is TWIV, This Week in Virology, episode 1294, recorded on February 5, 2026. I'm Vincent Bracaniello, and you're listening to the podcast all about viruses. Joining me today from New York, Daniel Griffin. Hello, everyone. What's on the bow tie, Daniel? Give me a clue. So let's see. One of the nicknames is Red Snappers. It's these little red bacilli. I've never heard Red Snapper before. Oh, really? Okay. You know, everything is about... Is that a clue? Oh, good. Sorry, I coughed up a little blood there. Tuberculosis. Yeah, it's not – it was a reference to the green book, Everything is Tuberculosis. I think when I mentioned it, I talked to my wife about when I went through a phase when I was just really obsessed with tuberculosis. She's like, yeah, that has not ended. So you like that book? It's actually – it's a good book. I mean he's an engaging writer. And I think it's a good book. It's worth – I would recommend it. It would be my pick of the day, my pick of the week. It's nonfiction, right? It is nonfiction, yeah. And it really just talks about the scourge and it really – it makes it personal, which I think he does a really good job. What is the name again? It's one of the Green brothers. It's Everything is Tuberculosis. He also wrote Turtles All the Way Down. John Green. John Green. Oh, my gosh. Okay, I will read it. Yeah, it's a quick, but it's really good. And yeah, let me do my quote, but then I'm going to talk a little bit about sort of a little aside on tuberculosis and why I was thinking about it apparently when I put on my tie this morning. But I'll start off with a quotation from Albert Einstein. I've quoted him before. He said a lot of stuff. And this one just sort of came up. I've been studying weather and one of the comments was, everything should be made as simple as possible, but not simpler. That's great. I love it. Yeah, and I think that's kind of what we aim to do is we want to make things understandable. We want to make it simple as possible, but not too simple, right? We don't want to lose the subtlety, the nuance. But yeah, so the reason I'm wearing this, I was doing an interview yesterday for USA Today about people maybe have been following what's been going on in the detention centers, the family detention centers across the country. I don't know, Vincent, have you followed that at all? Yes, yes, yes. So it's measles, tuberculosis, and just from an infectious disease standpoint, this is just – it's a disaster. I mean forget about the humanitarian aspect, you know, going to court appearances or going to like school drop-offs, grabbing mom and dad, grabbing the kids who are U.S. citizens. You know, Liam, that little kid with the bunny hat, you know, being like grabbed by the backpack by ICE and put on a bus. So these are people that have been in the country for a year or two. A lot of them are trying to go through the legal process and they take them to these centers. And, you know, it's winter respiratory season. We now have measles endemic in the US. We have problems with tuberculosis. And when you just read about the accounts of what's going on, I mean, a lot of these people are sick. They have limited access to medical care. I think it's ibuprofen is kind of the drug of choice or maybe the only drug that, you know. And sometimes when the kids get sick enough and finally do actually get seen, they realize they have measles, for instance. There was a pregnant woman who had latent tuberculosis brought in on one of the buses. So it's just really what a disaster. They won't let them be inspected. That's the thing. And Congress is now trying to push to get these facilities inspected because they're a horror show and they know it and they don't want people seeing it. That's scary, right? United States of America, we've got people, armed, masked people on the streets, not identifying themselves, dragging people away to these facilities that are run by these private contractors and not being allowed to inspect. I think it's like members of Congress. They won't let them see what's going on. I mean, oh my, what country do we live in? No, it's just unbelievable. And I don't understand the 30% of people that still support this. What are you thinking, folks? Yeah, it's just, well, I mean, I'll thank all the thousands of people, right, that tune in each week to us and support us and allow us to continue to basically inform you about what's going on. And, you know, as measles, we'll get back to that in a moment, but as measles becomes an issue in these facilities, as tuberculosis is an issue, as all the other infectious diseases. I mean, you can imagine having norovirus in a facility like this. Well, the thing is, it's just not the inmates. It's the people who work there. Then they go home and they bring it back and forth. Now, they're trying to spin this as dirty immigrants bringing, you know, measles here and TB. No, they're already here and it's circulating in the U.S. So another lie that they're promulgating among all their lies. Yeah, yeah. These are at-risk individuals put in situations. Well, all right. You guys on the Deep Dive TWIV always like to talk about the weather. Yes, we do. And this is the only time of the year that I like to talk. Well, I always watch the weather. People probably know I basically watch the wind. You know why we talk about the weather? Because we're human. Human beings like talking about the weather. That's what we do. And people complain about it. Tough. We're human beings. That's what makes it an approachable program. Well, I think that's also it makes it the realization that scientists are not these like evil, like, I don't know, antisocial individuals in some lab trying to plot the demise of human society. Yeah, we're human beings. We walk our dogs. We care about when it rains. They're not evil, but some of them are antisocial. No doubt about that. Yeah, some scientists are antisocial. We were talking about that yesterday and you weren't mentioned. But no, no, just as an aside. But anyway, let's talk about some really exciting – like, you know, in the United States, we have a history here. And actually, if you trace the roots, this was actually imported from Germany. And the whole idea of getting the animals to predict weather for us, it's really interesting. Germans came to Pennsylvania and we're now all down for this. And so we read Northeast Alabama sand mountain Sam predicts an early spring. Now, what's going on here? Now, on Groundhog Day, my favorite day of the year, the folks in Alabama, do you know which animal they turn to to get their weather? An opossum. Sam, sand mountain Sam the opossum. Now, he is Alabama's beloved opossum. He did not see his shadow at a ceremony. on Monday, meaning an early spring could be on tap is how they worded. Now- What does early mean? Like two days? It pretty much means, you're going to realize as eight days go by, like this guy might, this might be the year he doesn't do so well. It really means from here on out, it's like we're right into spring. The winter's pretty much over, you know. But Puxatawney Phil, like he's the famous guy from the movie, right? He's the guy out there in Pennsylvania. He did see a shadow and he runs back inside predicting six more weeks of winter. Now, I have a couple of comments. Now, I sort of picture this, right, of them coming out of a burrow. It's a sunny day. They see their shadow. It frightens them. They go back in. But apparently I realize it's much more complicated. There are actually these animal whispers and they tell us what Phil is trying to tell us about. And so it really comes down to maybe Phil always gets it right, but the whisperers get it wrong because he doesn't actually – they don't let him sort of come out and zip back in. And also, very importantly, as people may notice, Phil is basically immortal. He's had like four wives over his immortal career. He never dies. Apparently there's some special scientific elixir, a secret concoction that he takes. But I have to say Phil is only right about 35% of the time. So the reason I watch what Phil has to say is usually he's wrong. Now, the interesting thing, and this is government money, well at work, the National Oceanic and Atmospheric Administration page keeps a table with the reliability of the different groundhogs. And I'll leave in a link because I know people are going to care about this. And really, the most accurate groundhog out there is Staten Island Chuck. Now, he's about 85% accurate at predicting. And of course, I went and looked. Staten Island Chuck says winter's over. It's all going to be great. There's a whole list of other apparently taxidermied groundhogs. There's Concord Charlie. Maybe he's a groundhog. Who knows? I'm not sure how we get his predictions. How do you tell what they're predicting if you've never seen them? Apparently, there are whisperers, as I mentioned, and the whisperers tell us. Now, it's all fake now. Now, it's all hooey. Except, as mentioned, our opossum in Alabama is 97% accurate to date. Look, the best thing is the farmer's almanac, right? Okay. All right. So, moving on to some real science. or some human investigative science. So I think this is really important because there's been a tremendous amount of misinformation, confusion. Listen to this. Farmer's Almanac predicted for 2026 winter a wild ride, cold with significant, consistent, and sometimes frigid, snow-filled conditions. That's exactly what we have. No need no stinking animal. You just need the Farmer's Almanac. All right. So I want to mention recommended childhood and adolescent immunization schedule United States 2026 policy statement published in Pediatrics. So what's going on here? We read that the 2026 recommended childhood and adolescent immunization schedule has been published by the American Academy of Pediatrics. The schedule is revised annually to reflect current recommendations for the use of vaccines licensed by the US FDA. At this time, the AAP, the American Academy of Pediatrics, no longer endorses the recommended childhood and adolescent immunization schedule from the CDC. And 12 national organizations representing more than a million clinicians, physicians, pharmacists, other pediatric healthcare professionals agree with the AAP immunization schedule. And there's a list in American Academy of Family Physicians, the American College of OBGYNs, the nurse midwives, the pharmacists, the Infectious Disease Society of America, National Association of Pediatric Nurse Practitioners, a number of people really endorse. This is the science-based, accurate schedule to follow if you really want to protect your children. Ignore the ACIP, ignore the CDC, forget it. They don't know what they're talking about anymore. Yeah. I mean, they're clearly in the pocket of big wellness, right? I mean, they'll say everyone else in the pocket of something. But yeah, pediatricians do not make money off vaccines. I know it was out in Colorado, we tried to, and we actually successfully, John Bender, I think, who did this, one of the family docs, basically got the state involved, and the states were really supplying access to the vaccines. Pediatricians were just helping facilitate that because I was in private practice in rural Colorado for a decade. You're not making money off vaccines. It's a gamble. You got to put the money up ahead of time, try to guess who's coming in. Yeah, we don't make money off. So that's just a lie. But these guys make a ton of money off big wellness, right, selling these nutraceuticals and fake stuff. The nice thing I like about this is the AAP in this publication has some links to some really nice user-friendly vaccine schedules. That's great. It's really nice. I mean, aren't they like really easy to look at, easy to interpret, easy to follow and evidence-based, right? Right at birth, RSV, hep B, one month you get your next hep B, two months you get the next hep B, and you follow it on out. But they're still recommending craziness, polio. Imagine that. Unlike the CDC, they actually don't want children dying and getting paralyzed. Where's polio on here? I don't see it. So the IPV. Oh, IPV. Okay. Six down. Two months, four months, six months, and four to six years. Yeah. So it's actually six to 23. You could get it anywhere in that window. That's what the bar means, right? Yeah. Anywhere in that window. Yeah. Nice. It's really good. Then they have adolescents 7 through 18 years of age too And for both flu So starting at six months flu every year for the rest of your life Yeah And I want to point that out You know my daughter a pediatric ICU nurse And she had this really unfortunate episode recently where it was a family of Irish twins. I don't know if people know what Irish twins are, but it's an 11-month-old and a one-month-old. So when you have two kids within the same year, we call them Irish twins. And the 11-month-old had such severe COVID that they ended up in the hospital on this BiPAP pressure support to basically help the baby breathe because oxygen just wasn't enough. So here's the baby, 11-month-old baby in the ICU. This is all from COVID, struggling to breathe. And the parents ask, like, were we supposed to get our baby vaccinated? The pediatrician never mentioned that. It's just disheartening, right? I mean, at least have the conversation. I mean, I know the anti-vaxxers have gotten so rabid, a lot of providers are kind of scared to even bring this up. But you certainly don't want to be in that situation like my daughter was, having the conversation already after the first baby's in the ICU. And then they're saying, oh my gosh, you know, we have a one month at home. Like, what's going to happen to that baby? You know, and that baby is below the six months. The doctor should never be afraid. They're in control of all interactions in society. The doctors are always in control. They have the upper hand and they can say, let's talk about this vaccine. There's just no reason for them not to do that. Yeah. So, and here, really nice laid out. Starting at six months, every year you're getting that COVID shot, you're getting that flu shot. And as we'll continue to talk about, significant reductions, particularly in the kids, this high-risk group of ending up in the hospital struggling to breathe. So we should reduce the number of those little kids that end up in the pediatric ICU being taken care of by my daughter. I noticed they have two HPV doses recommended, three if you give them after age 15. So this is interesting. Nine years old, between nine and 12 years old, two doses. Very interesting. Good. I'm glad to hear that. Yeah. And we talked about the fact that growing evidence that maybe one is enough, but we'll see how that pans out. All right. And there's even a more complicated for clinicians, you know, catch-up vaccinations, certain medical indication vaccinations, a lot of detail, but really good evidence-based. And I cannot let this go without a mention. Herpes Zoster Vaccination and Incident Dementia in Canada, an analysis of natural experiments published in The Lancet Neurology. Now, this study design should ring some bells for you, Vincent, and our listeners. They included people born in Canada between January 1, 1930 and December 31, 1960, who were registered with one of the 1,434 primary care providers in the Canadian Primary Care Sentinel Surveillance Network. They compared patients born immediately before versus immediately after that magic day, January 1, 1946. This is that same, like, threshold for getting the vaccine. If you're a little too old, sorry, you missed the boat. I will mention, as an aside, in the UK, they've actually started vaccinating older folks based on some of this data. Good. Like, okay, maybe we shouldn't just leave you out in the cold, right? That's a thinking of Canada thing there. Now, they extracted data on 464,637 patients who were registered with a primary care provider. Ultimately, 232,124 patients born in Ontario included in the analysis. It's about a 50-50 split, 54% female, 45.8% male. It's going to matter. However, patients born immediately before versus immediately after the two eligibility thresholds for herpes zoster vaccination didn't differ in their health characteristics. So they were pretty much well matched. It was really just the issue is, you know, your probability of receiving herpes zoster vaccination because of the eligibility. Now, being born immediately before versus immediately after the eligibility date decreased the probability of receiving a new dementia diagnosis over a 5.5-year follow-up period. But I want to talk a little bit about the data. It's really the women again. It's really, I mean, there's a trend towards a non-statistical trend in the men, but it's really the women that are benefiting from the vaccine. Yeah, I guess in women, Zoster has more of an impact on inducing dementias, right? Yeah. That's what it is, essentially. Yeah, this has been pretty consistent, right, from all the studies we've talked about. All the studies are consistent, yeah. Yeah. All right, just a little bit of a worrisome update. You know, bird flu now in Europe from the European CDC, detection of avian flu antibodies in Dutch dairy cow. So H5N1 widely circulating, repeatedly detecting in mammals. So the Dutch public health authorities report that antibodies indicating past exposure have been identified in milk from a dairy cow in the Netherlands. That's interesting. So it has not been seen outside of U.S. cows so far, right? I think this might be one of the first detection in Europe. I mean, it's just antibodies. They don't have virus yet, but we'll see. Yeah. Yeah. And it's worry, right, you know, that it's in the dairy cow or the dairy cow was exposed. Yeah. Yeah. So just cirrogical testing. All right. Measles. You know, I feel like at some point we should do one of those like shorts where we talk about like how to diagnose measles because I was talking to one of my infectious disease colleagues today about the fact that, you know, everyone needs to start getting up to speed on how to recognize measles, right? We talked a little bit about this. The three Cs. So three days of cough, choriza, conjunctivitis, right? So cough, we all know what that is. Choriza is just this really inflamed nasal mucosa and then conjunctivitis, right? So these are kids who have a nonspecific viral illness except during the first days that the fevers can be really high, 104 degrees, 105 degrees, so really high fevers. They really are a little more miserable than most viral infections. and it's during the first three days that if you look in the mouth, do a proper physical exam, you can see these Copelic spots. Now, doctors lie because they'll always like, they'll see the measles rash and then they tell me they see the Copelic spots. The Copelic spots are gone by the time the rash appears. So, let's all be honest. You got to just, we've got to start looking in the mouths of these little kids looking for those. And it really is, you look inside the cheek and you see basically an area, it's red and you see what looks like little pieces of rice on the sides. So kids super miserable, red eyes, red nose, and you see the Coplex bots. It gives you a little warning because they're already contagious. Then after those three days, that's when you see the fever. I mean, that's when you see the rash. So 10 to 14 days of a prodrum after exposure so the kids can show up at those internment camps. those family detention centers where there are tens of thousands of people currently locked away. You know, they're miserable, they're sick, they've got a virus, they don't have a rash yet. You really got to look in the mouth so you can pick this up early before they get that rash and have already spread it to others. Then they get the rash, right? That goes on for maybe four days. And then, unfortunately, about 20% of these kids get so sick, particularly with trouble breathing, struggling to breathe, that they end up in the hospital. And then some of them will get, it's about one in a thousand will actually have the virus go into the brain. You'll get encephalitis. There's even a late stage, right? Six to eight years later, everything seemed fine. But now about the same rate actually in this age group of they get that subacute sclerosing panencephalitis, SSPE. And then I was surprised by this. I think a lot of docs just because this was a historical thing, the immune amnesia. A lot of docs had not heard about the immune amnesia and that really horrific. Like, so here's these kids and most of the kids as we're going to see, we're going to talk about the South Carolina measles outbreak are in this five to 11 years of age. They already sort of earned their immunity by seeing a bunch of things and they end up with this immune amnesia where you got like this 80% reduction in your B cell repertoire. So really now you've got to try to build up all that immunity again. So all right. So what is going on? South Carolina, we are in the midst of a major measles outbreak. This is really like blown by the numbers we saw in Texas. So total cases, 876. So it's really just, you know, rising exponentially the number of confirmed, These are confirmed cases. There's even more. You know, what's really good is that 800 of those are in unvaccinated individuals. Yeah. That's it. This could be stopped. Yeah, this is a result of not vaccinating the kids. I mean, RFK Jr. is directly responsible for this because he's not having vaccination go forward. I mean, somehow he should be liable for this because it's the right thing to do. Yeah. Someone told me last night on the live stream that if a physician doesn't immunize someone and they die of an infectious disease, as a consequence, they are liable. I think if you don't have the conversation, if you – yeah, if you just – yeah. So it's very difficult. Yeah. I mean he doesn't have a medical license, so he can't be held – it's really odd. Here you have this guy giving basically medical advice. He's using his platform to give medical. Practicing medicine without a license is ultimately what he's doing on a grand scale. Yeah. So, all right. So approaching 1,000 there. And you can see there's, you know, if you go to the Johns Hopkins tracker, you can see, you know, they're always a little bit behind, but you can see they've really got this big thing going on there in South Carolina. But you've also got cases in a number of other areas. Got some stuff going on in New Mexico, in Utah, Idaho, various spots throughout the country. Now, the CDC is kind of a little bit out of sync. I think, like everyone else, I'm losing trust in them at a sort of rapid speed. Here we see 876 cases confirmed by South Carolina. CDC says only 588 in the entire country, right? So that doesn't really quite. And look at this map. The vast majority are locally acquired. That means the virus is circulating in the U.S. There's just one here imported. And, you know, so if you're going to say all the immigrants are bringing it in, no, you're wrong. They're not. It's circulating in the U.S. because people are not getting vaccinated. Yeah, that was what the guy at the CDC, he's like, oh, yeah, this is just the cost of doing business. You know, you got people coming in from other, no, no. Elimination status is about this. It's about local spread of measles. Measles is spreading in the U.S. It's spreading in Mexico. It's spreading in Canada. Basically, the Americas are no longer measles free. We have measles here. Okay. All right. Flu, maybe things are getting a little bit better here, right? We're still at high levels. Look at that map. It's still like bright red, dark red in a lot of areas, but a few places are moving down into just moderate to low high. And if you look at the epidemic trend, it's likely declining in the Northeast, but it's still growing down in Florida, down in the South, up in the West. And what I worry about is this, we often see this second peak. And what happens is it starts to go down. And if it does not get below a certain threshold, it can rebound back up. And about 50% of the time, we talked about this last time we'll start and we're already starting to see a little bit of a rebound. We got that big holiday. I'm sure, you know, like during halftime, instead of watching Bad Bunny, people are going to be listening to our clinical update as they breathe in this air full of flu virus. So, and it's really worth a football game to get sick. I don't know. You could watch it, you know, or you could like me, it could somehow sign up for the the shift to work that day. And, you know, so we'll see what happens, but I'm a little worried. We're, we're still a little too high. It looks like we're starting to see a little bit of an uptick. We'll, we'll know in the next little bit. And unfortunately, as I point out, the data is always a little bit behind. It always takes a little bit of time for us to, to get the data from the, from the CDC. And yeah, the, we're over 50 children have already died this season from the flu. So not good. And remember, you can treat this even in kids. I think it's an under recognition. Use Tamiflu all the way down to six months of age. And we've definitely talked about the Zofluza, which is the Zofluza.com. You can get your $50 pill from that site. All right. RSV, still pretty high and actually growing in a lot of the country, right? This is throwing me. We're supposed to be on the way out of this. And now New York State is not reporting. Yeah, I was a little surprised by that. We don't get any data from. That's not good. We have a good Department of Health in this state. What's happening? Yeah, I don't know why. Apparently the data did not end up there at the CDC. So we're like Wyoming. Yeah it another one which is I don know anything about their health department Yeah but most of the country it actually growing Yeah or not changing which means it high Yeah. And there's just a few states where it's declining. Yeah. All right, COVID. Well, look what we have here. It's like it's at least in the Midwest, it's going up again. Yeah, the Midwest has a little bit of an uptick. The South has a little bit of an uptick. Oh, but also the South, yeah. What's that other one? Northeast is the dark blue note. We're like the only ones. The Northeast is really – Going down. And the National, we're kind of pulling. But yeah, other than the Northeast, every other regional is starting to see that little second uptick. So we'll see where things – and then if we look, you sort of follow the epidemic trend, right? You can see California likely growing all through the south. A lot of the – most of the country, it's just sort of holding at kind of where it is. But we'll see over the next bit. But, you know, what can you do about this, right? And this circles us right back to vaccinations, right? And I think a lot of people – I had a conversation with a gentleman in the hospital, right? So he's in the hospital because he got COVID. Apparently, he's sick enough that he's in the hospital. So I'm asking him. I bring up vaccines. and I say, so, you know, flu shots, COVID shots, you tend to get those? He's like, oh, you know, no, I don't. I said, well, what happened? He goes, well, I got the flu shot this one year, had a bad reaction. I'm like, well, what happened? He goes, I didn't feel good the next day. I mean, you do realize you're in the hospital with COVID. Just sort of weigh those two. I didn't feel good. What an idiot. So, but yeah, so, you know, so do these, do these flu shots at work, right? I mean, do these COVID shots work? Do these vaccinations work? So, you know, we continue to encourage people to get yearly flu and yearly COVID shots. And why? Because data like this, estimated effectiveness of 2024-2025 COVID-19 vaccination against severe COVID-19 published in JAMA Network Open. So results of a multi-center test negative case control study conducted by the investigating respiratory viruses in the acutely ill network. They included adult patients 18 years and older hospitalized between September 1, 2024, to April 30, 2025 at 26 hospitals in 20 U.S. states. Pretty robust here. Case patients presented with COVID-19-like illness. Remember we used to say influenza-like illness? Now we say COVID-like illness. And a positive SARS-CoV-2 nucleic acid or antigen test result. controlled patients had the negative test, but similar presentations, like other things going on. And so what were the outcomes we're going to look at? So they've got a total of 8,493 patients, and about half of them are female. And they're going to actually do whole genome sequencing. So we're going to see that the KP311, we've got 22, let's see, 36.7% with the KP3, 23% with the XEC, 14% with the LP8.1. Vaccine effectiveness against COVID-19 associated hospitalization, 40%. So 40% reduction in ending up in the hospital. and protection was sustained through 90 to 179 days after vaccination. But it talked about the fact that it really is a yearly thing. It does wear off. Now, vaccination effectiveness was higher against the most severe outcomes. So ending up on a ventilator or dying, 79% effective. It was about 49% effective for the KP3, 34% for XEC, and 24% for LP8.1. I thought that was sort of interesting, sort of breaking it down by the different variants. Yeah, this is good. I always want to see this, right? But you can see the effect of the variant on, you know, protection. It's good. Yeah, it's actually interesting. I think that that's sort of helpful as we're trying to understand the chasing the variant game that we've got ourselves into. So, Daniel, if you see a patient with respiratory symptoms without testing, can you tell if it's flu or COVID? You can't. You really can't. That's like the take-home message. The only way you know is by doing a test. Okay. Yeah. No, and I think people say, like, I knew it wasn't. I'm like, how did you know it wasn't COVID? Well, all I had was this or all I had was that. That's BS. Yeah, you know, scratchy throat could be COVID. So, all right. And I want to wrap us off with late phase long COVID. We've got a few things here to talk about. So let's start off with the first one. Long COVID associated with SARS-CoV-2 reinfection among children and adolescents in the Omicron era, recover EHR, a retrospective cohort study published in The Lancet Infectious Diseases. So retrospective cohort study, used data from 40 children's hospitals and health institutions in the USA, participating in the Researching COVID to Enhance Recovery, the Recover Initiative. They included patients younger than 21 years at the time of cohort entry with documented SARS-CoV-2 infection after January 1st, 2022, who had at least one healthcare visit within 24 months to seven days before the first infection. The second SARS-CoV-2 infection was confirmed by positive PCR, antigen tests, or a diagnosis of COVID-19 that occurred at least 60 days after the first infection. The primary endpoint was clinician-documented diagnosis of PASC. Okay. So basically, to wrap this up, I'm going to go through the numbers here, but I'm going to say we're seeing post-acute sequelae with the first infection, and we're seeing basically double the risk if you get two infections, right? So basically, each time you get it, it's the same roll of the dice. So 407,300 eligible children and adolescents with a first infection episode. And then you have 58,417 with a second infection. In this database, the incident rate of PASC per million people per six months was 903. It's actually pretty high. So why aren't kids eligible for COVID vaccines? You know, why does FDR, RFK think they don't need it? Clearly they do. Yeah. I mean, so they are, well, I think this is sort of the challenge is disconnect. We go up to our recommendation, right? If you look at the AAP recommendations as opposed to the who knows what's going on in the CDC, I mean, we do know what's going on. You know, the recommendation based on the science is that you start vaccinating the kids at six months and you do it every year. And for the youngest kids, there still is the FDA approved Moderna vaccine. And that starts at six months. The Pfizer's vaccine, that's approved for ages five through 64. Novavax, 12 years and older. So if you've got like an adolescent, you're just like worried about the mRNA technology for whatever misinformation they've sold you, you could do that. It's a protein-based vaccine. It's traditional. It's just fine. But yeah, so here we're seeing, and then they get the second episode, and you end up with another crop of kids. And a nice comment article, Long COVID is Here to Stay, even in children, where it reviews this above study. And we read, these findings reinforce an urgent message that children and adolescents can develop long COVID, not only after an initial infection, but also after reinfection. Okay. Now, this one, I was a little disappointed, and this was the article, Early Administration of Neutralizing Monoclonal Antibodies and Post-Acute Sequelia of COVID-19, published in the International Journal of Infectious Diseases. So using national COVID-19 registries and healthcare claims data, this group conducted a retrospective cohort study, including all Singaporeans who were unvaccinated, partially vaccinated, or immunocompromised at the time of SARS-CoV-2 infection between July 2021 and December 2022. Individuals were stratified by receipt of monoclonal antibodies. Of 19,689 eligible hospitalized patients, 6.9% received early monoclonal antibody therapy. So sort of think about those numbers there. About 20,000 So we're dealing with about 1,400 of those folks getting monoclonals. Well, they say monoclonal antibody had no statistically significant impact on overall post-acute sequelae. The adjusted hazard ratio is trending in the wrong direction, 1.26, but a confidence interval of 0.98 to 1.63. They saw an increased risk of autoimmune disease, adjusted hazard ratio of 2.2. And it was particularly lupus and rheumatoid arthritis. and also an elevated risk of DVT. So they speculate what's going on. And, you know, we published a study on this as well, which they do reference, so I appreciate that, where, you know, we were hoping monoclonal antibodies not only keeping people out of the hospital, not only saving an incredible number of lives by reducing the risk of death by over 80%, but these people lived and what happened down the road. You know, we did not see in our study that there was a reduction in PASC, post-acute sequelae of COVID, consistent with this. But what's going on with these other things? Now, we didn't look specifically at these, but when they did and they saw these things, they said causal inferences cannot be drawn from this observational study. I feel like they listened to TWIV, right? Yep. Several biologically plausible mechanisms may explain the observed association. Neutralizing monoclonal antibodies, persistent circulation for weeks to months, prolonged antibody exposure may facilitate immune complex formation, FC receptor immediate immune activation, complement activation. Now, one of the things, and they go on and talk a bit about this, one of the things they talk about is maybe it has something to do with these extended half-lives of the monoclonals. And if you look closely at the data, I spent a lot of time digging through this article. This is not necessarily a class effect. The elevated risk was observed in the sotrovimab subgroup, which has a really long half-life. They didn't see it in the casiemdevimab or the tixagabamab-silgabamab. That's interesting. That's very interesting. Yeah. So it may have to do with this really long period of time of having these monoclonal antibodies in the system. So are we now going to back off these long-lasting monoclonals as a consequence of this, you think? Well, it's interesting because there are these camps, right, where people are like, I don't want a vaccine, you know, and then if I get sick, I don't want Paxlovid. I don't want that drug. I want the monoclonals, right? Because somebody got the monoclonals and sort of championed them. So it's interesting because you would look at this data and say, get the Paxlovid. Yeah. Yeah. Get the vaccine. Get the antivirals. Monoclonals are not really, you know, because they may keep you alive, but then you may end up with lupus or rheumatoid arthritis or a clot or something. So even an immunocompromised person, they should take, they're not going to be able to get vaccinated, right? So they should take Paxlovid. So they can get vaccinated. They may not have as robust a response, but they still, we still recommend. And you do have to juggle some of the drug-drug interactions. But, you know, you can do remdesivir. You can do Paxlovid. You can do antivirals. But this does, as we're seeing, presents a downside to the idea that we'll just use monoclonals. I remember studies in solid organ transplant recipients. They give three doses of vaccine, then they finally got some kind of an immune response. So maybe they need more. Yeah. So they may require more doses. All right. So I'm going to wrap us up with metformin. So sort of interesting. Interesting. We'll spend a little time on this to make sure we clarify it. So new review highlights growing evidence that diabetes drug metformin can prevent long COVID. So it seems interesting. So I read, multiple randomized clinical trials and analysis of electronic health records suggest that metformin, a widely available diabetes drug, may reduce the risk of developing long COVID when taken during or shortly after COVID-19, according to a literature review published in CID. So this review is written by Carolyn Bramante and David Boulware out at University of Minnesota. It was – they were commissioned to comment on a recent population-based cohort study. And I'm going to talk about that study first and then kind of pull it all together. So the article they're asked to write about, to comment on, is this article, Effective Metformin on the Risk of Post-Coronavirus Disease 2019 Condition Among Individuals with Overweight or Obese, a Population-Based Retrospective Cohort Study. is published in CID in September. And we did discuss this. It's a retrospective cohort study. They used this sequential target trial emulation framework. Adults had to be overweight or have obesity. And basically what they did, I think this is really important, you're going to end up getting metformin. And the dosing is a little bit tricky. And the reason it's tricky is that when we initially were trying to do the COVID out trial, right, that was the United Health Group supported study, you couldn't just put them on metformin. You had to really, you know, I mean, they're sick. They've got COVID, right? They don't feel well. They're nauseated. So you have to sort of do a really slow introduction. So you start off on day one. And I think if people are going to consider this, keep in mind what the doses are. 500 milligrams of the immediate release on day one 500 milligrams twice a day for four days starting on the second day Then you go to 500 milligrams in the morning 1 milligrams in the evening You do that for nine days. You dispense 36 tablets. So it's pretty complex. You could build this into your EHR if you want to. But when they did this in this trial looking at overweight and obese individuals, there was a reduction in the one-year risk for post-COVID conditions in the intention-to-treat analysis. Yeah, it's not huge, but it's there. Yeah, it's minus 12.58%. Were these people getting metformin for diabetes or obesity, or they were just given it as part of this trial? That's always been an exclusion. So these people have to not be getting metformin. and they have to not have gotten metformin in the prior year. So that was one of the exclusions. And so this sort of builds on it. And I think it's, you know, it's probably worth looking at the article, Preventing Long COVID with Metformin, that this was published in CID. And they have a really nice chart where they sort of break down, like, what are the different trials, right? So the COVID out randomized control trial did not have low-risk adults. You had to have either standard or high-risk adults. there was, well, this EHR analysis. And actually, I will also point out there was ACTIV-6 RCT. And the ACTIV-6 RCT is when they said, let's also include, you know, the lower risk, non-obese individuals. And that was the one where it really didn't quite reach statistical significance at huge confidence intervals. Maybe there was a reduction. The COVID-out RCT, You did see a statistically significant reduction. So basically putting all this together, the metformin may have a reduction, may be associated with a reduction in progressing on to long COVID. The data is more compelling in people who are overweight, higher risk. You do have to follow this dosing because otherwise people are vomiting it up, people are not doing well. And the other, which the authors really, I think, make an honest point about, is none of the trials have looked at treating long COVID with metformin. We really haven't seen much success. This is really a particular way of trying to prevent long COVID by treating acutely. Isn't metformin used to treat obese people for diabetes? It is. It is. And so maybe that's the effect we're seeing because diabetes and obesity are complications for COVID, right? Long COVID even as well. Yeah. And they do reference a study where there was a 93% reduction in, they say viral load, but what we really mean is the RNA copy numbers with this acute treatment. So they're suggesting that maybe there's an antiviral and anti-inflammatory. We don't know. We don't really know. Well, because obesity is an inflammatory disease. And so So on top of COVID, maybe that's why you get long COVID and this is somehow dampening that. I don't know what the mechanism is. Do you? Yeah. No, it's a good, yeah. But I just want to share that. Okay. Yeah. So, all right. So no one is safe until everyone is safe. Vincent, we finished the Micro TV fundraiser and it was successful. Very good. Glad to hear it. Yeah. So we'll be supporting. Thanks everyone for your support. It's wonderful. Look forward to making more science for you. All right. So what are we moving on to? Floating doctors, right? February through April. So now February through April, we're going to be doing floating doctors. So go to parasiteswithoutborders.com, and we will match your donations. And if you're as generous as folks were, we'll get up to that maximum donation of $20,000 for floating doctors. It's time for your questions for Daniel. You can send yours to Daniel at microbe.tv. Mary writes, I am writing to request a science-based approach to measles exposure in a clinic. I am a pediatrician working in a busy multidisciplinary neighborhood health center. We had a patient in clinic later diagnosed with measles. About one week later, a staff member vaccinated developed a mild case confirmed by the health department. Our administration is requesting all staff have an IgG titer drawn. Anyone with a low titer is sent home for three weeks. Is titer indicative of actual immunity? People sent home are not quarantined. What is the science-based approach to dealing with an outbreak? What would you do at your clinic? Yeah, so that's clever. Curious, the idea of doing titers on people and then trying to use that to separate. I mean, there's a couple sort of like, so what's the science? What do we know? So if an individual gets their vaccines, right, they still could get, as you saw, measles. But one is they're very unlikely to spread it onward. So you've reduced that by 400 fold by getting vaccinated. We introduced that second dose to reduce the risk even more. So really, it's the getting one or two doses of vaccine. So one thing is, you know, working in a pediatrician's office, probably want to make sure everyone's had their two doses. Now, it is interesting. In healthcare, you know, particularly when you go to certain hospitals, they will draw your titers. And if it's below a certain threshold, you will be revaccinated. And I don't know how solid the science is, the correlation between whatever that titer threshold is and whatever outcome they're really looking at, right? Because we're talking about the fact that if you're vaccinated, you know, you're not likely to get a severe case. You're not going to get that immune amnesia. You're not going to end up in the hospital. And really, the reason we added that second dose is to just reduce the onward transmission more. It wasn't that people were getting sick with just one shot of the MMR. So, you know, unfortunately, the science-based approach to dealing with these outbreaks, one of the things I talked about, we're going to be seeing more and more measles. Kids are going to be coming into these clinics. You got to start doing that oral exam because you want to pick it up before they have that rash. And it is tough. Busy, multidisciplinary health clinic. It's tough because you got so many different things pulling for your time. And then, yeah, when there's a situation like this, the big thing is just to make sure people are vaccinated. There is that. We talked about 10 to 14 day incubation period. So if you've got an unvaccinated staff member who's been exposed, one bad idea to be in such an environment without the protection of vaccine. I'm not sure I would really divide things out based upon serum levels. I would vaccinate them, right? Yeah, everyone needs to be vaccinated. And if you're going to work, two doses would make a lot of sense. If there's a case, just vaccinate everybody. Yeah. And, you know, with COVID, some people quit. Okay, if they're going to quit, let them quit. But this is a healthcare situation. You can't be fooling around. I think that's the challenge here because, you know, if you decide, oh, my freedom, I want to be unvaccinated, that's not fair to the little kids. No. No, there's no freedom with this. You got to be vaccinated. It's so baloney, this medical freedom crap. Do you stop at a red light? Do you go through a stop sign? Do you not buckle your seatbelt? Do you not smoke inside? Give me a break. Do you come to work drunk? Margaret writes, thank you for all you do and for keeping the light on in the darkening night. What organization has the best chance of providing medical care for Liam Conejo Ramos and other children in detention? Who should I call and email besides my elected officials? Yeah, so this is tough, right? So Liam's that little kid with the cool hat, you know, who we talked about a little bit earlier. Yeah, I mean, I think everyone, right? I leave in our notes, I think, a link up above to how to reach out to your local representatives. This is a disaster what's going on. And I think that's – we really need to stop doing this. We can't be having these little kids, U.S. citizens, being taken to these basically internment camps. I mean the last time we interned this number of people was the Japanese internment camp. So this is really horrible. So in our show notes, we'll leave a link and reach out to your local representatives. Let them know this is unacceptable. Yeah, before more. Is there anybody else that they could reach out to? I mean, you're not allowed in these facilities. That's the problem, right? Yeah, I don't know if there's anyone you can really reach out to, right? Because these places are basically, they're dark. Even members of Congress can't even see what's going on. Really limited access to medical care. So we really need to change. So I have this www.house.gov forward slash representatives forward slash find-your-representative. Go there, reach out. I mean, this is the United States of America. This is not what should be going on. This is horrible. And yeah, it would be great. Oh, reach out to this organization, the providers. Well, no, they're not even letting the healthcare people into these places. The disdain of this administration for public health is showing now, and it's causing problems. It's just the beginning of the tip of this iceberg. Judith writes, I recently traveled abroad and having learned from your podcast that so flusa could be taken to prevent flu exposure. I asked my doctor for a prescription, which he readily provided. I'm vaccinated, but I also was last year when I contracted flu in London. So I was very worried about it happening again. The good news is that using my Medicare drug insurance, I only paid $25 for it at my neighborhood Upper West Side New York City pharmacy. Also good news, I took the single pill dose two days after traveling and didn't get sick. I wore a quality mask in the airport, on the plane, and around people. Thank you for the important service you provide with your podcast. My pleasure. El writes, a few years ago when I was in my 40s, I acquired HPV for the first time and was having trouble clearing it. After more than 18 months of monitoring, including a colposcopy, my immune system still wasn't clearing it. My Jain couldn't prescribe Gardasil because I was too old. Only approved up to age 25 back then. So having prescribing privileges, I prescribed the vaccine series for myself, paid out of pocket and gave it to myself according to the schedule. And I got rid of HPV right away and I've never had it again. So yes, in my case, it was curative. Thank you for all your work for medical science. Yeah, this is great. I mean, you know, there was a deep dive on TWIV discussing this, the fact that, yeah, that getting HPV vaccine after infection can still be curative. So we need to get this approved for all ages. Yeah. Or just start using it off-label like this, which is fine. And Laura writes, we hope 2026 is off to a good start for you. I continue to benefit greatly from your clinical updates and appreciate every week's information. Thought you might be interested to know that San Francisco currently has an outbreak of tuberculosis associated with a private high school in the city. This high school has a boarding school component for international students. The school has three active cases of TB identified since November 2025 and 50 cases of latent TB. The entire school is under remote learning this week. beginning on February 9th. Hybrid learning will commence and all students must complete TB testing to be allowed back on campus later the month. At our hospital, we admitted one of the students who is immunocompromised and has active TB with liver involvement. This is not the index patient. My question is, once a patient with active TB undergoes treatment, when is it safe for them to leave isolation? Thanks again for your valuable updates. All the best from Laura and Kip, two PharmDs in San Francisco. All right. So this is an interesting issue. So tuberculosis. You know, how do you get tuberculosis? It's by breathing in, right? So someone has tuberculosis, they're coughing, singing, doing whatever they're doing. They're creating these droplet nuclei which are then in the air and we can breathe them in. You know, measles and tuberculosis suffered from this issue. When we moved away from the bad air miasma to germ theory, it was, you know, nothing can spread through the air. There's no such thing as bad air. Well, if you walk into a room where someone's been coughing up a lung and it's full of TB, that is bad air, but it's not miasma bad air. It's bad air full of pathogens. Now, the interesting thing is children under the age of 12 seem unable to produce those droplet nuclei and spread it to others. So the contagion is occurring from adults. That's one issue. Age is an issue. So a lot of times when we want to diagnose it in kids, you really can't get it from a sputum. We'll actually put a tube down and we'll do a gastric lavage, first AM gastric lavage to do it. Now, the general rule, someone's been diagnosed with tuberculosis, we want them on treatment for a minimum of two weeks. And then we want them to be smear negative. So you cough up and you don't see any tuberculosis, any red snappers under the microscope. med snappers on your tie there you go so once a kid is treated they're not going to transmit right so usually they're not transmitting anyway it's usually anyway right yeah it's usually some adult and so the adults that and and you know each county has their own rules like you know we'll sort of and it'll go back to like so let's say i'm taking care of a patient doesn't matter where the hospital is it matters where the patient will return to so if it's nasa or suffolk or new york City, we'll reach out to Department of Health. They have specific roles, but that's basically the sciences. Two weeks of being on effective therapy and then smear negative. Got it. That's TWIV Weekly Clinical Update with Dr. Daniel Griffin. Thank you, Daniel. Thank you, and everyone be safe.