0:00

This week in virology,

0:02

the podcast about viruses,

0:04

the kind that make

0:06

you sick. From Micrope

0:08

TV, this is Twiv,

0:11

this week in virology.

0:13

Episode 1206, recorded

0:16

on April 3rd, 2025.

0:18

I'm Vincent Rackinello and

0:21

you're listening to the

0:23

podcast all about viruses.

0:26

Joining me today from

0:28

New York. Daniel Griffin.

0:31

Hello, everyone. It's a

0:33

nice bow tie. I like the

0:35

colors. It's my fungal bow tie.

0:38

Okay. Apparently the

0:40

WHO is sharing that we

0:42

are maybe neglecting fungal diseases,

0:44

surveillance, therapeutics, and the rest.

0:46

What do you think about

0:49

that? It's true, actually. Yeah,

0:51

I think fun, I think,

0:53

you know, I always find

0:56

this when Sarah and I

0:58

do the infectious puscasts. There's

1:00

always a shortage of articles

1:02

on fungal disease, so. I thought

1:05

mostly immunocompromised people get fungal

1:07

diseases. So it is

1:09

a problem in immunocompromise,

1:12

but also what we're

1:14

realizing is a lot

1:16

of what we've learned

1:18

about fungal disease, you

1:20

know, being uncommon, only

1:23

being in certain clusters.

1:25

Can you imagine? Is

1:27

not actually correct? Some

1:29

recent, recent studies where

1:31

they're looking at Coxi.

1:34

It's not bacteria, it's not

1:36

viruses, so. Yeah, but again, if you

1:38

don't look, guess what? You'll never get

1:40

a positive test. But can you treat

1:43

them? Well, that's the big thing is

1:45

you don't need to in most cases.

1:47

Recent guidance was hands in the pockets,

1:49

which I was talking about on rounds

1:51

today was my recommendation for. Hands in

1:54

the buckets. What does that mean? Take

1:56

money. No, just put your hands, keep

1:58

them in your pocket. don't mess.

2:01

I got it. Okay. Yeah. All

2:03

right. So let's jump right into

2:05

it. I am almost done with

2:07

John Greens. Everything is tuberculosis book

2:09

and so I have a quotation.

2:11

Biology has no moral compass. It

2:14

does not punish the evil and

2:16

reward the good. It doesn't even

2:18

know about evil and good. Stigma

2:20

is a way of saying you

2:22

deserve to have this happen, but

2:25

implied within the stigma is also.

2:27

And I don't deserve it. So

2:29

I don't need to worry about

2:31

it happening to me. So do

2:33

you like this book? You know,

2:35

I really do. And it is

2:38

funny, I was joking with my

2:40

wife and daughter about how when

2:42

my wife first met me, I

2:44

was much like John Green is

2:46

every conversation. I was like, well,

2:48

you know, this is really because

2:51

of tuberculosis. And did you know

2:53

he died of tuberculosis? And so

2:55

I said to me. And at

2:57

some point did that end. I'm

2:59

not aware of that. It's still

3:01

your favorite disease. And I was

3:04

like, oh my gosh. Yeah, no,

3:06

this is what I cut my

3:08

teeth on Vincent. My time in

3:10

medical school at Bellevue, I was

3:12

doing research on tuberculosis. And that's

3:15

what brought me out to Utah.

3:17

And so yeah, tuberculosis is still

3:19

one of my diseases that I

3:21

find most mysterious interesting. Well, this

3:23

guy does a lot of he's

3:25

on a book tour. He's all

3:28

over the place. Wow. Yeah, he's

3:30

a podcaster That's all I actually

3:32

got to know John Green is

3:34

he does these AP US history

3:36

podcast YouTube things Yeah, he's great

3:38

writer very engaging very good speaker

3:41

and actually the book is the

3:43

audio book is is narrated by

3:45

him. So it's worth the five

3:47

hours or for me at two

3:49

X the two and a half

3:52

hours So, all right, well, let's

3:54

jump into it because I think

3:56

like one of the one of

3:58

the things that I'm worried about,

4:00

this is why I put this

4:02

in here. is that we have

4:05

sort of lost 130 years. We've

4:07

gone back to this pre-coke, pre-passure,

4:09

you know, diseases are not caused

4:11

by germs, they're caused by, you

4:13

know, your constitution, your bad choices,

4:15

you know, sort of back to

4:18

blaming the patient instead of actually,

4:20

you know, realizing that a person

4:22

who gets sick is actually, is

4:24

a victim of this infection. We will

4:26

start off with measles where there has

4:29

been a lot of blaming of the

4:31

victims. You know, I really still upset

4:33

by when they talked about the child

4:35

dying. The fact that somebody who shall

4:37

not be named because they've been named

4:39

way too much actually said, you know,

4:41

there may have been an issue of

4:43

malnutrition. Well, I hope you hope you

4:46

said that to the parent when you

4:48

were talking to them because that is

4:50

not really the case in the US

4:52

with most of the people getting sick

4:54

with measles. The problem Daniel. have his

4:56

lies lies lies lies all the

4:58

time yeah it's just intolerable yeah

5:01

people are starting to call for

5:03

his resignation well I'm I'm glad

5:05

because you know I mean it's just

5:07

how many hundreds of people need need

5:09

to be sick before we say

5:11

this this was a mistake so

5:13

All right, so I'm going to

5:16

start off with the CDC buried

5:18

a measles forecast that stressed the

5:20

need for vaccinations. Leaders at the

5:22

Centers for Disease Control and Prevention

5:25

ordered staff this week, this past

5:27

week, not to release their experts

5:29

assessment that found the risk of

5:31

catching measles is high in areas

5:33

near outbreaks where vaccination rates are

5:36

lagging according to internal records reviewed

5:38

by pro-publica. In an aborted plan

5:40

to roll out the news, the

5:42

agency would have emphasized the importance

5:44

of vaccinating people against the highly

5:47

contagious and potentially deadly disease that

5:49

has spread to 19 states. And

5:51

so, you know, here we have

5:53

the CDC being muzzled. We have

5:55

experts, you know, doing what the

5:57

CDC has done for decades, trying.

6:00

to make recommendation and here the staff

6:02

was ordered not to not to release

6:04

this information not to release. I went

6:06

to look at this article and someone

6:09

asked them why and they said oh

6:11

people already know this we don't need

6:13

to tell them. Isn't it

6:15

the most inane explanation you

6:17

ever heard? It's dishonest it's

6:19

it's disingenuous. Yes. Yeah. Yeah,

6:21

this is a time when

6:23

you remind people you talk

6:25

about vaccines, you enter into

6:27

as the CDC, that discussion

6:29

about the risk and benefit,

6:31

the tremendous. improved outcomes with

6:33

vaccination over getting the disease,

6:35

the immune amnesia, the 20%

6:37

ending up in the hospital,

6:39

the one in a thousand

6:41

children dying. Yeah, no, this is

6:44

when you enter that space and

6:46

you don't leave a vacuum for,

6:48

yeah, the anti-science snake oil salesmen,

6:50

you know, the people trying to

6:52

sell people stuff who are willing

6:54

to, willing to take that blood

6:56

money. And yeah, I mean, that's

6:58

not political. That's just the honest

7:00

science of what we're seeing here.

7:03

So. And how are we

7:05

doing? Not well. So we'll start

7:07

off with the, we are only

7:09

getting updates once a week from

7:12

the CDC. So this last update

7:14

was from March 28th. So that's,

7:16

you know, up until noon on

7:19

Thursday, we get the update on

7:21

Friday. As of March 27th at

7:23

noon, a total of 483 confirmed

7:26

measles cases in the United States

7:28

reported by 20 duristics. So measles

7:30

is all over the place. And

7:33

as I mentioned, we have of

7:35

those 483 confirmed 70 have ended

7:38

up hospitalized, not for quarantine purposes.

7:40

Just that was a straight out

7:42

lie. These are sick kids struggling

7:45

to breathe. And a quarter of

7:47

these folks are under five years

7:50

of age. These are tiny little

7:52

children that are in the hospital

7:54

because they are being preyed upon

7:57

by people that are willing to

7:59

lie. measles, cases by rash

8:01

onset, sort of showing what's

8:03

happened over time. You really

8:06

see we have this huge,

8:08

huge peak, and then David

8:10

can put this up where

8:12

people can actually look at

8:14

the map and see really

8:16

the big hotspot is Texas,

8:19

but we're seeing we're seeing

8:21

cases all around New Mexico,

8:23

California, up there in Washington,

8:25

Alaska, down the Southeast, Georgia,

8:27

Florida, Kentucky. Tennessee, Ohio, Michigan,

8:29

Minnesota, Pennsylvania, New Jersey, New York,

8:32

Vermont, all over the place. Even

8:34

Rhode Island's got... a number of

8:36

cases. So all over the country,

8:38

and you can actually compare this

8:40

to a map of percent vaccinated,

8:42

right? We really want a country

8:45

where 95% of folks are vaccinated.

8:47

Why do we do that? Because

8:49

yeah, your freedom ends at the

8:51

tip of my nose. It certainly

8:53

ends at the tip of my

8:55

child's nose, and it certainly ends

8:57

at the tip of every pregnant

9:00

woman's nose. Is that there are people

9:02

in this country who are either too

9:04

young? to be protected, their immune system

9:06

doesn't allow them to be protected,

9:09

or other circumstances. And yeah, we

9:11

live in a community where you

9:13

can make a choice that could

9:15

result in a child ending up

9:17

in the hospital, that could result

9:20

in a child dying, that could

9:22

result in a child either not

9:24

being born or being... deformed. So

9:26

yeah, that's why we have mandates

9:28

because we actually live in a

9:31

community and your decision, your quote

9:33

unquote freedom, can actually harm people

9:35

in your community. This is a

9:37

map here you have of vaccination

9:39

rates across the US. Really

9:42

interesting. Many states are below 95

9:44

percent. Yeah, there are actually very few

9:46

states that are 95 plus, right? So,

9:49

you know, one, two, three, four, five,

9:51

six, seven, eight, nine, only about 10.

9:53

New York is one of them. Yeah,

9:56

yeah. So we got this little, little

9:58

area here, like New York. Massachusetts,

10:00

Connecticut, Rhode Island, Jersey. Not

10:02

Jersey, unfortunately. No, not Jersey.

10:05

No, Jersey is 90 to

10:07

94.9. Yeah, not Jersey. Oh

10:09

my gosh, Vincent. You gotta,

10:12

don't leave the city. Stay

10:14

there. It's not safe. So,

10:16

no, and this is really,

10:19

this is a. crisis and

10:21

it's not being addressed by

10:23

someone who appreciates the crisis.

10:25

Now looking at the updates,

10:28

we get updates from Texas,

10:30

you know, over 400 of

10:32

these cases, right, are down

10:34

there, so 422 cases have

10:36

been identified in Texas just

10:39

since late January. Texas alone,

10:41

we have 42 patients requiring

10:43

hospitalization. New Mexico, we're up

10:45

to 48. And basically, as

10:47

we're seeing in all this

10:49

data, it's a disease of

10:51

the unvaccinated. But

10:53

it's not just us, our

10:56

friends in Canada, and they

10:58

are our friends in Canada,

11:00

just by what some people

11:02

say otherwise. between October 2024

11:04

to March 26, 2025, Ontario

11:06

has reported a total of

11:08

572 measles cases. So this

11:10

is associated with this outbreak

11:12

occurring in 13 public health

11:14

units and and that's just

11:17

Ontario. But if you look

11:19

around Canada actually is starting

11:21

to have a measles problem

11:23

as well. They have a

11:25

vaccination problem in Canada? You

11:27

know, all this unfortunately goes

11:29

hand in hand in hand.

11:32

We're going to have to put

11:34

some tariffs on those vaccinations then.

11:37

Well, maybe so that they can

11:39

stay there in Canada and they

11:41

can get vaccinated, but no, what

11:44

a disaster. Okay, and we do.

11:46

We'll leave in. We have to

11:49

successfully get that vaccine table recommendations

11:51

from NYPD. Yeah. To last

11:53

week's update, I put a link to

11:55

a picture image. People can click on,

11:57

so it should be in every week.

12:00

questions, talk to your doctor. We're going

12:02

to leave you that access so you

12:04

can help figure this out, like what

12:06

you need to do for your vaccination

12:08

status. All

12:10

right, oh my, bird flu, or what

12:12

were we going to call it last time?

12:14

The U flu, EWE flu, I was

12:16

working on these things, you know, that was

12:18

when it got in the female sheep. So

12:22

the EWE flu. But

12:24

cats test confirm H5N1

12:27

avian flu virus in recently

12:29

recalled raw food for cats.

12:32

The New York State Department

12:34

of Agriculture and Markets on

12:36

March 28th warned consumers about

12:39

the risk of H5N1 avian

12:41

flu from savage cat raw

12:43

chicken cat food. It's just

12:45

like the idea of savage

12:47

cat branded raw chicken cat

12:49

food. Okay, this is a

12:52

California -based company recalled earlier this

12:54

month following an investigation into

12:56

cats that had contracted H5N1

12:58

infections after eating this food.

13:00

And samples of the cat food

13:02

from one lot were collected by

13:04

the New York City Department of

13:07

Health, tested by Cornell University, and

13:09

were positive. Findings

13:11

were confirmed by the USDA.

13:16

All right, maybe a little bit of

13:18

good news with the flu, right? We're

13:20

still, know,

13:25

they still are saying influenza A

13:27

is at a high level. But

13:29

if you start to look around

13:31

the country, I am seeing lots

13:33

of green, green for minimal activity.

13:35

Yeah, not New York. We're still

13:38

high. So still, still keeping me

13:40

busy here in New York, but

13:42

most of the country is really

13:44

starting to look a lot better.

13:48

And if you look at ER visits

13:50

across the country, really those flu

13:52

visits are really coming down. So

13:54

starting to see some some lights light

13:56

at the end of the tunnel

13:58

there. And I'll

14:00

leave in links for what are

14:03

going to be the flu vaccine

14:05

compositions for next year. Also, good

14:07

news for RSV. We really are

14:10

coming out of the respiratory season.

14:12

RSV is still high in the

14:14

wastewater scan.org levels, but the ER

14:17

visits are really dropping down. We're

14:19

really seeing that activity improve. And

14:21

RSV is exciting, right? Because we

14:24

now have an RSV vaccine. And

14:26

so we got this nice article.

14:28

early impact of RSV vaccination in

14:31

older adults in England, published

14:33

in The Lancet. So in

14:35

England, the UK Joint Committee

14:37

on Vaccination and Immunization advised

14:40

an initial program for those

14:42

turning 75 years old with

14:44

a catch-up to age 79.

14:46

Pending further data on protection

14:49

of those who were older.

14:51

So September 1st, 2024, vaccination

14:53

of individuals age 75 to

14:56

79 years began in England

14:58

using the bivalent prefusion F

15:00

vaccine. So that's the abrisvo.

15:02

So that's the Pfizer vaccine.

15:05

They conducted an early assessment

15:07

of RSV vaccine programs impact

15:09

on RSV related hospitalization in

15:11

older adults. really impressive. I've

15:14

got this figure in here

15:16

where basically you're seeing what's

15:18

expected and then you've got

15:20

this this group that is

15:23

in this vaccinated group and

15:25

about a 30% reduction in

15:27

those age 70 to 79

15:30

eligible for the RSV vaccine

15:32

as far as hospitalizations for

15:34

RSV. It's a

15:36

really pretty impressive, right? It's an

15:38

interesting way they show the data,

15:40

right? Here's what we would have

15:43

seen or what, you know, following

15:45

the line for that group, and

15:47

then this really nice 30% drop in

15:49

the folks that got vaccinated. All

15:51

right. COVID? This is a

15:54

protein-based vaccine, right? This is, yeah,

15:56

okay. Which is really interesting, you know,

15:58

so it is this. bivalent prefusion

16:00

F by Pfizer, protein-based, not

16:02

MRNA, we'll get to talk

16:04

about that soon enough, but showing

16:07

this nice reduction. You know this

16:09

is more of a traditional

16:11

vaccine. There were those safety

16:13

signals that we've talked about, but

16:16

interesting enough, all those safety signals

16:18

were really in South Africa,

16:20

so I don't know what

16:22

was going on with the South

16:24

African part. But otherwise we're seeing

16:27

efficacy safety data. All

16:29

right, COVID. We are, you

16:31

know, blipped a little back

16:33

down to medium and actually

16:35

per the CDC wastewater, they

16:37

actually have us at low,

16:39

currently low. A percentage of

16:41

deaths across the country is

16:43

actually coming down. And I

16:45

love our multi-colored wastewater trend.

16:47

What do you think, Vincent?

16:50

Yeah, we had a blip last week.

16:52

You were all worried. What was it

16:54

the national? But I just think a bunch

16:56

of people flush their toilets at the same

16:59

time. I thought you were blaming spring break,

17:01

all your students. You were, you know, blaming

17:03

the students. Yeah. But now it's going down

17:05

again. Yep. So all those spring break

17:07

students come back from home and they

17:09

bring some COVID with them as

17:11

well as other stuff. Yeah. And

17:13

maybe, you know, on the spring

17:15

break, they're all close to each

17:17

other, they're breathing a lot, you

17:19

know, so. But yeah, no, that's

17:21

going in the right direction. And

17:24

actually, emergency department visits in the

17:26

US are also continuing to drop

17:28

across the country. So encouraging there.

17:30

But all right, let's talk about

17:32

COVID-active vaccination immunity. And I'm going

17:34

to start with just a little

17:36

bit of a story. Just give

17:38

people flavor of my day and my

17:40

conversations about vaccine. So I'm sitting in the

17:42

doctor's lounge at one of the hospital. and

17:45

actually it was this last weekend when I'm

17:47

incredibly busy and so you know it's like

17:49

on that show the pit where you sort

17:51

of reach the the end of your day

17:54

and you're getting a little kind of done

17:56

with things and there's this pulmonologist and I

17:58

think he just likes to torture me,

18:00

Vincent. You know, he makes sure

18:02

that in every conversation he throws

18:04

all like those keywords, lab leak,

18:06

you know, you know, vaccine issues,

18:08

biocarditis, you know, I don't even

18:10

know why people bother to get

18:12

vaccines anymore. And I'm just like,

18:14

you know, you're killing me. This

18:16

guy's an MD. He's just torturing

18:18

me. I'm pretty sure he's just

18:20

torturing me. So of course, I

18:22

say to him, listen, I'm not

18:24

sure what I did in a

18:26

past life to deserve this. Because

18:28

it always seems like when I sit

18:31

down, people come and go, but they always

18:33

leave the spot next to me open, so

18:35

this guy can sit down and torture

18:37

me. But why are we

18:39

doing this? Why do we

18:41

keep vaccinating? So let's talk

18:44

about this, this pre-print. And

18:46

this is pre-print, because, you

18:48

know, sort of hot off

18:50

the press, so to speak.

18:52

But this is a pre-print.

18:54

evaluating the effectiveness of 2024,

18:56

2025, seasonal MRNA, 123, vaccination

18:58

against COVID-19 associated hospitalizations and

19:00

medically attended COVID-19 among adults

19:03

aged greater than or equal to

19:05

18 years in the United

19:07

States. posted on Med archive,

19:09

right? So this is the

19:11

Madonna vaccine, and this is

19:14

looking at this season, looking

19:16

all the way across the

19:18

board. So this study evaluated

19:20

the effectiveness of Madonna's updated

19:22

MRNA-1-273 vaccine. This is one

19:24

targeting the K-P-2 variant, compared

19:26

to those who didn't receive

19:29

a. COVID-19 vaccine this fall.

19:31

And we'll talk a little

19:33

bit more about that. So

19:35

really, just to give everyone

19:37

context right up front, you know,

19:39

people have been vaccinated in the

19:42

past, maybe they've had COVID in

19:44

the past. This is really just,

19:46

did you get an updated shot

19:48

this fall or not? And what

19:51

they're looking at COVID-19 associated with

19:53

COVID-19 among adults 18 and up

19:55

during the 24-25 season. So

19:57

the data was extracted from

19:59

link. administrative health

20:01

claims, electronic health

20:04

records. It's where they

20:06

get vaccinations from 23rd August

20:08

2024 through 24 December 24.

20:10

They conducted a retrospective matched

20:12

cohort study with propensity score

20:14

waiting to adjust for differences

20:16

between groups to assess vaccine

20:19

effectiveness against COVID-19 outcomes. So

20:21

pretty robust study. Overall they've

20:23

got 465,073. MRNA 123, MRNA

20:25

1273, K-RNA 1-2, vaccine recipients,

20:27

so folks that got updated

20:29

mandarin shots in the fall,

20:31

they're matched one and one

20:33

to, they say, unexposed adults,

20:35

so unexposed to vaccines. So

20:38

they're matching one to folks

20:40

that got vaccine versus folks

20:42

that did not. a vaccine

20:45

dose in the fall. The

20:47

mean age was 63, with

20:49

more than half of the

20:51

population being 65 years and

20:54

older. So really that that

20:56

group were really trying to

20:58

target here. Approximately 70% of

21:00

the adults had an underlying

21:03

medical condition, making them high

21:05

risk for severe outcome.

21:08

30% did not. The

21:10

vaccine efficacy was 52.8%

21:12

against COVID-19 over a

21:15

median follow-up of 57

21:17

days. So about two

21:20

months. vaccine demonstrated significant

21:22

incremental effectiveness in preventing

21:25

hospitalization with COVID-19 and

21:27

medically attended COVID-19 in

21:29

adults during this season. So

21:32

just as I sort of

21:34

pointed out, maybe we'll have

21:36

this cumulative incidents figure for

21:38

folks to look out. This

21:40

is COVID-19 hospitalization. You clearly

21:42

see a separation with hospitalizations

21:44

occurring much more often, well

21:46

twice as often, right, 50%

21:48

reduction in folks that did

21:50

not get versus did get

21:52

the vaccine. So as I

21:54

mentioned, most individuals in this

21:57

study had gotten some kind

21:59

of vaccine. in the past. So this

22:01

is really just looking at people

22:03

that are staying up to date

22:05

with their with their boosters I will

22:07

call it. And this is a very small

22:09

difference though really. Well let's yeah

22:11

let's let's talk about this right

22:13

so that that is kind of

22:16

thing. So what numbers are we

22:18

talking about? So you know how

22:20

many folks and we're looking at

22:22

October 1st to March 22? How

22:24

many people with COVID-19 ended up

22:26

you know? seeing a doc, right?

22:28

So we'll talk about COVID-19 outpatient

22:30

visits. So about two to three

22:32

million. So if you can reduce

22:34

the two to three million

22:36

by 40%, right, that's kind of

22:39

the way the numbers here, you're

22:41

basically looking at a 1.5 million

22:43

dollar, you know, million reduction

22:46

in COVID-19 outpatient visits. And

22:48

then if you look at

22:50

COVID-19 hospitalizations, it's in the

22:53

sort of two to 400,000.

22:55

So sort of split the

22:58

difference, say 300,000. You're

23:00

talking about, you know,

23:03

avoiding 150,000 COVID-19 hospitalizations

23:05

if people get a booster shot

23:07

in the fall. So this is good

23:09

reason to four people, what is

23:11

it, 65 and over? Most of the

23:14

people in the study, I think that's

23:16

important where, you know, the majority of,

23:18

so mean age was 63, but more

23:20

than half of this population was 65

23:22

and over. So it's really this issue.

23:24

If you're at risk of getting sick

23:26

enough that you're going to end up

23:29

going to end up getting hospitalized, you

23:31

know, you can actually reduce that with

23:33

just getting a shot. And this is

23:35

on top of it. This is getting

23:37

a booster. So you get a booster,

23:39

we might reduce the COVID-19 outpatient visits

23:41

by a million. we might reduce those

23:44

COVID-19 hospitalizations by one

23:46

or 200,000. But what I also

23:48

put in here, I want to sort of

23:50

compare this to, you know, this whole, you

23:52

know, thing about, you know, why my father

23:54

getting vaccines, I always return with, like, do

23:57

you get the flu shot? What about the

23:59

flu shot? And I think it's interesting,

24:01

we had a really bad flu season

24:03

this year. And we had not great

24:06

uptake when it came to flu shots.

24:08

So COVID, right, it's kind of this

24:10

year-round, it's got this double peak, and

24:12

here we're just talking about this winter

24:15

peak, right? So our summer peak was

24:17

worse, right, as we talked about. Now,

24:19

flu, we just have this winter peak,

24:22

but how many flu illnesses, how many

24:24

flu medical visits? Flew medical visits actually

24:27

dwarfing, right. to 34 million. It's

24:29

almost 10 times as many

24:31

medically attended flu visits as

24:33

we had COVID outpatient visits.

24:35

As far as hospitalizations for

24:38

flu, 560 to 1.2 million, just in

24:40

this winter season. And then flu deaths,

24:42

you know, pretty wide-arraged because we're

24:44

not really sure where that's going

24:46

to follow it. But this was

24:48

a pretty high. We're probably 60,

24:51

70,000 flu deaths this winter when

24:53

we get final numbers. And that

24:55

overlaps with the COVID deaths, right?

24:57

Or less. Yeah, so it's really interesting.

24:59

Yeah, right. So we're starting to

25:01

see, you know, and this becomes

25:03

this issue. We have what, 18,

25:05

20% of folks got their flu

25:08

shots. So really a lot of

25:10

this, you know, you say, oh,

25:12

but the flu shots only 40,

25:14

50% effective. Well, if you can

25:16

take that 20, 30 million and

25:18

drop it in half, if you

25:20

can take that half a million

25:22

to a million hospital, drop them

25:24

in half. You know, you're talking

25:26

about. about tens of thousands of

25:29

people not dying of flu. Okay.

25:31

So I'm encouraging people to get

25:33

vaccines. Okay. But which vaccines?

25:35

And this is a bit

25:37

of an hour. Our listeners

25:39

may have also heard this

25:41

week that the US FDA

25:43

missed the deadline for a

25:45

decision on Novavax's COVID-19 vaccine.

25:47

This is the traditional. This is

25:49

maybe not so excited about

25:51

MRNA or you had some

25:53

reactogenicity or side effects. So

25:55

this was that, this has

25:57

been that protein traditional choice.

26:00

The U.S. FDA missed its

26:02

deadline for making a decision

26:04

on Novavaxis COVID-19 vaccine. Senior

26:06

leaders of the FDA said

26:08

the company's application needed more

26:10

data. and was unlikely to

26:12

be approved soon. The company,

26:15

however, said it had responded

26:17

to all the FDA's information

26:19

requests as of April 1st.

26:21

It believes its application is

26:23

ready for approval. So the

26:26

vaccine has been under emergency

26:28

use since 2022, and it's

26:30

basically waiting for them to get

26:32

full approval. The one issue, and this

26:34

is a big issue, is that the

26:36

Novavax... stocks that are currently out there,

26:39

they're going to expire the end of

26:41

this month. So if there isn't some

26:43

movement here, people that say, oh, I

26:45

don't want to get the protection of

26:47

a COVID vaccine, you know, we may,

26:50

you know, again, we were told, oh,

26:52

don't worry, we're not going to prevent

26:54

people from accessing vaccines. We're about to

26:56

lose access to this vaccine, unless the

26:58

FDA, which is under the HHS, does

27:00

something about this. Okay,

27:03

and I will leave the CDC

27:05

COVID-19 vaccine recommendations up, and they

27:07

still, just to a few, we

27:09

are recommending, and this is a

27:11

public health across the board, children

27:13

age six to four years, they

27:16

should get that initial series, and

27:18

then a yearly shot. folks age

27:20

5 to 64, that's one dose

27:22

a year, folks 65 years and

27:24

older or folks that have issues

27:26

with their immune system, then it's

27:28

a twice a year, right? So

27:30

it's get a shot in the

27:32

fall, six months later you get

27:34

a shot. So for a lot

27:37

of folks to keep that 40-50%

27:39

reduction in medically attended COVID and

27:41

hospitalizations, you know, probably getting about

27:44

time for that second shot of

27:46

this year. All

27:49

right and moving on to

27:51

COVID early viral phase.

27:53

So more on Metform

27:55

and Vincent. Well, go

27:57

away. So the art.

28:00

metformin alleviates inflammatory response and severity

28:02

rate of COVID-19 infection in elderly

28:04

individuals published in scientific reports. And

28:06

so I think this is one

28:08

of those studies where you really

28:10

need to look closely to see

28:12

what they actually found before you

28:14

just sort of jump on the

28:16

headline. So I remember the last

28:18

time you you reported on a

28:20

met-formin study you said the differences

28:22

were very small and you wanted

28:24

to see more data. Exactly. And

28:26

so we had talked about the

28:28

COVID out study that some of my

28:30

colleagues had done. And this is this

28:32

sort of complicated, you get a cute

28:35

COVID and you do this. graded ratcheup

28:37

of metformin during the acute phase,

28:39

and there were four different arms,

28:41

and the people that got metformin

28:44

compared to the metformin control group

28:46

seemed to have, you know, less

28:48

issues and less long COVID, but

28:50

they didn't necessarily have less issues

28:52

and less long COVID than the

28:55

other control group, so it was

28:57

sort of muddied water. But it

28:59

is this whole issue. Is there

29:01

some sort of anti-inflammatory effective metform?

29:03

And so people are still looking

29:06

at it. And here, the

29:08

study between 1st March and

29:10

2nd of July 2022, a

29:12

total of 649, 657 cases

29:15

of COVID-19 infection were reported

29:17

in Shanghai. Most were infected

29:20

with the BA2.2 variants of

29:22

these. over 600,000. 413 were

29:24

diabetic and we used this

29:27

study to analyze the putative

29:29

link between metform and treatment

29:31

and the severity of COVID-19

29:34

infection. So these results are

29:36

from this retrospective cohort study

29:38

where they they include 5,215

29:41

patients aged between 18 and

29:43

102, admitted to the north

29:45

campus of this particular hospital

29:47

affiliated with Shanghai University. School

29:49

of Medicine. They analyzed whether

29:52

there was a difference in

29:54

a number of parameters in

29:56

type 2 diabetics that had

29:58

been on Metform. prior

30:01

to infection for let's say three months

30:03

or longer, right? So this is

30:05

not starting them. This is looking at

30:07

folks have been on metformin for

30:09

at least three months versus folks that

30:11

are not being treated with metformin. So

30:13

they're going to look at some outcomes. They're going

30:15

to look at risk of ICU admission, development

30:17

of pneumonia, length of hospital stay,

30:19

and they're also going to

30:21

look at levels of IO6, CRP,

30:23

ferritin, lymphocytes, CD4 accounts. They're

30:25

also going to look at CT

30:28

values and they tell us,

30:30

but we're going to go into,

30:32

they tell us there were

30:34

no differences in age, sex, BMI,

30:36

comorbidities, number of vaccines, kidney

30:38

function, etc. So they do start

30:40

off with this this table,

30:42

right? This is the table where

30:44

you look at the total

30:46

number, you look at the 121

30:48

that have been on metformin for the

30:50

last three months, those not on metformin. You

30:53

know, they don't like statistically separate,

30:55

but there are a few differences

30:57

that I noticed. For instance, the

30:59

non metformin group, the A1C is

31:01

almost a full point higher, sort

31:03

of, you know, not exactly matched,

31:05

but not reaching statistical difference. But

31:08

then again, you're only dealing with

31:10

121 and 292. A few other

31:12

things, but just just to sort

31:14

of, you know, a little bit

31:16

of an issue there. Now, this

31:19

is the these are the numbers

31:21

that jump out. So in the

31:23

IC group, so the folks that

31:25

the proportion of patients not receiving

31:27

metformin was 92 .5%, which is quite

31:29

a bit different than the 69

31:31

.2 of patients not admitted to

31:33

the ICU. In the

31:35

pneumonia groups, these are

31:37

people with evidence of air

31:39

space disease, not receiving

31:42

metformin 78 .6 higher than

31:44

the 67 .2 in the

31:46

non pneumonia group. Compared to

31:48

patients receiving no treatment with

31:50

metformin, those receiving metformin

31:52

had a shorter hospital stay.

31:55

12 .1 versus 14

31:57

.5. Big confidence. intervals,

32:00

right? Plus or minus

32:02

5.9, plus or minus

32:04

8.2. Now in patients,

32:06

60 years of age

32:08

or older, those receiving

32:10

treatment had significantly lower

32:12

levels of IL6 and

32:15

significantly higher levels of

32:17

lymphocytes compared with those

32:19

not receiving treatment. But it's

32:21

really interesting and David can

32:23

have our figures up for

32:25

people. these differences are really

32:27

seen in folks over 60

32:29

but I have to say

32:32

like you can look at

32:34

these with me Vincent kind

32:36

of requires a statistician to tell

32:38

us they're different right yeah for

32:40

sure yeah they have big as

32:42

you said they have big plus

32:45

minuses yeah big plus minuses

32:47

lots of overlap so these

32:49

these graphs these are inflammatory

32:52

and immune markers exactly

32:54

right They're very close. Yeah,

32:56

I mean, statistically, there's

32:58

a statistical difference. I'm not sure

33:00

how much of a, you know,

33:03

well, clinically, right, because they're

33:05

sort of suggesting that there's this

33:07

correlate here. But it's really, we're

33:09

not, we're not seeing it unless

33:11

you're over 60, so that becomes

33:13

an interesting issue. But there are

33:15

a number of. of limitations here,

33:17

right? So maybe there's something here for folks

33:19

over 60, but not under 60, right? It

33:22

tends to be the folks that are asking

33:24

me all the time about Metform and the

33:26

folks under 60. We also don't know what

33:28

dose of Metformin they were on. And there is

33:30

a difference between a diabetic that you

33:32

can manage with Metformin versus a diabetic

33:35

who has an A1C of 8.6 and

33:37

is on insulin, right? And I'm not

33:39

sure it's the metformin and that's the

33:41

difference. It might be the difference that

33:43

allows you to manage them with an

33:46

oral bed. med versus insulin. We also

33:48

don't know what really happened exactly with

33:50

steroids or antiviral drugs. So we're not

33:52

sure if the patients on Medformin or

33:55

not were receiving the same other medicines,

33:57

you know, also other medicines that might

33:59

not. be helpful. There may have

34:01

been some differences there, but you

34:04

know I have to say this

34:06

is it's another interesting study. It's

34:08

still very much basic science. It

34:10

does build on animal experiments that

34:13

that show them Metformin might inhibit

34:15

the NLRP3 and flamism activation, you

34:17

know, and that's based on a

34:19

mouse model. So interesting stuff, but

34:22

I just I think it may

34:24

have gotten a little too much

34:26

excitement. These are people who are

34:28

already taking it for diabetes, right?

34:31

Yeah. If you wanted to treat

34:33

you with Metforma, you have to

34:35

do a proper clinical trial, right?

34:37

Yeah. This is not a clinical

34:40

trial, is an observational real-world study,

34:42

right? So you'd have to do

34:44

dumb dosing, first of all, because

34:46

you may not, as you said,

34:49

you don't need the same doses

34:51

for diabetes as you do for

34:53

COVID. So you're not ready to

34:55

say, here, here, here's a script

34:58

for Metforma. Yeah, and I think

35:00

that's what is happening is people

35:02

are, you know, they've got some

35:04

sort of connect the dots, COVID,

35:07

Metformin, you know, and there was

35:09

that one study, but you know,

35:11

it's not just putting them on

35:13

Metformin, it's a particular dose escalation.

35:16

Yeah, so. I think if you're

35:18

on it for diabetes, maybe you'll

35:20

do a little better if you

35:22

get COVID, but you know, having

35:25

diabetes makes COVID worse. So, yeah.

35:27

I don't know, it's a wash

35:29

probably. And having a milder case

35:31

of diabetes that you can manage

35:34

with metformin, you may have better

35:36

outcome than people with, you know,

35:38

A1C that are higher, requiring insulin

35:40

injections, more advanced diabetes. So, and

35:43

that's what I worry about. Is

35:45

this a correlation? Like, yeah, people

35:47

who, you know, yeah. Because people

35:49

who don't have diabetes and are

35:52

not a metformin at all, they

35:54

do the best. So all right,

35:56

so number one still recommended Paxilovid,

35:58

sort of interesting updated guidelines that

36:01

are being bandied about locally, is

36:03

trying to use this more in

36:05

the hospital instead of Rem Desabir.

36:07

But this was the article, and

36:10

this directly relates to probably why

36:12

this is being discussed. is cost-effectiveness

36:14

analysis of neurometralver, bratonovir for high-risk

36:16

individuals with COVID-19, a modeling study

36:19

published in Open Form Infectious Disease.

36:21

This is where they really look

36:23

and they say, okay, I understand

36:25

charging over $1,000 for a scriptive

36:28

paxilovid when we had such a

36:30

high rate of hospitalization and make

36:32

it actually cost-effective. So that's a

36:34

study out of Europe. Number two,

36:37

Remdesivir, remember, first week, not hypoxic,

36:39

that's three days, once you get

36:41

into the hypoxemia, moving into that

36:43

inflammatory phase, and we're talking about

36:46

five days, Malnupiravir, some settings, convalescid

36:48

plasma. And week two, the early

36:50

inflammatory phase, the bad week when

36:52

people really feel rotten, steroids in

36:55

some context, anti-quigulation, pulmonary support, and

36:57

then as we've talked, rem desvere,

36:59

if you're still within the first

37:01

10 days, or it looks like

37:04

some folks that are requiring high-flowed

37:06

nasal cannula, even more severe pulmonary

37:08

support, once the steroids have been

37:10

started, there may also be a

37:13

role of concominate rem desvere. All

37:15

right, COVID, late phase past

37:18

long COVID. I've got a

37:20

just a few things here

37:22

to wrap us up. So

37:24

briefly, we have a pre-print

37:27

from the Recovery Consortium. And

37:29

I did hear that some

37:31

of the recover funding, long

37:33

COVID funding, may have been

37:35

restored. So we'll keep an

37:38

eye on that. But we

37:40

have the publication pre-print. re-infection

37:42

with, I guess we'll call

37:44

it a posting, we have

37:46

the posted pre-print, re-infection with

37:49

SARS-Covey II in the Amacron

37:51

era is associated with increased

37:53

risk of post-acute sequelae of

37:55

SARS-2 infection, a recover EHR

37:58

cohort study. Now here we

38:00

get the results from a

38:02

retrospective cohort study using data

38:04

from the recover consortium. comprising

38:06

40. children's hospitals and health

38:09

institutions in US between January

38:11

2022 and October 2023, a

38:13

total of 465,717 individuals. Under

38:15

21, so we're talking about

38:17

kids, adolescents here, the mean

38:20

age was 8.7, about half

38:22

of them are male, compared

38:24

to first infection, a second

38:26

infection was associated with a

38:28

significantly increased risk of an

38:31

overall past. diagnosis more than

38:33

doubled so a relative risk

38:35

of 2.08 with many specific

38:37

conditions including myocarditis that relative

38:40

risk went up almost fourfold.

38:42

Changes in taste and smell

38:44

went up almost threefold. Thrombo

38:46

phlebitis, thromboembalism, increased more than

38:48

twofold, heart disease, twofold increase,

38:51

acute kidney injury, twofold increase,

38:53

fluid electrolyte, generalized pain, arrhythmias,

38:55

abnormal liver, the board. So

38:57

this circles me back to

38:59

that, what did I do

39:02

in a past life colleague

39:04

who always wants to know,

39:06

why would anyone get a

39:08

COVID-19 vaccine, particularly a child?

39:10

Well, there's a really nice

39:13

figure here because everyone is

39:15

all focused on, I hear

39:17

about this, you know, one

39:19

in, however many thousand, they

39:22

get a few hours of

39:24

myocardial inflammation and then it

39:26

resolves. Well, here you can

39:28

see what happens when you

39:30

are unprotected. and get a

39:33

COVID infection. And right now,

39:35

our kids are getting these

39:37

infections once or twice a

39:39

year. So here, myocarditis almost

39:41

quadruples and all these other.

39:44

So really important that, yeah,

39:46

if there was no COVID-19,

39:48

we wouldn't need to vaccinate,

39:50

but this is really trying

39:53

to make a safer choice.

39:55

Oh, Daniel, just let it

39:57

rip. Jay, but. the

39:59

chariot great barrington

40:01

declaration let it rip

40:03

through the kids we don't knowing

40:06

anything about this you

40:08

know that that is really the crazy

40:10

thing to this day even even

40:12

when people write about things and they

40:14

say I think maybe we overdid

40:16

it with COVID and the mandates and

40:18

all this and they keep saying

40:20

like oh but you know it really

40:22

wasn't as as big an issue

40:24

in kids we lost over a thousand

40:26

children who died from acute COVID

40:28

the first one to two weeks thousands

40:30

of children ended up with the

40:33

inflammatory syndrome after COVID tens of thousands

40:35

of children ended up hospitalized so

40:37

the only thing that you know

40:39

makes COVID mild in children

40:41

is comparing it to

40:43

adults but hundreds of children should

40:45

not die from an infectious disease

40:47

in the current you know time

40:49

period you know all these children

40:51

you know it's about one percent

40:53

of them are not better two

40:55

to three weeks later they're still

40:57

suffering they're missing school they're having

40:59

problems yeah it's not just deaths

41:01

with acute COVID which is unacceptable

41:03

it's not thousands of people hospitalized

41:06

which is unacceptable and it's all

41:08

these kids who are not better

41:10

months after that acute infection and

41:12

he's rewarded with the head of

41:14

NIH good job Senate is that

41:16

really a reward

41:18

Vincent it's just a punishment

41:21

for the rest of us yeah

41:23

it is a punishment for us

41:25

so all right well we do

41:27

have our friends up in Canada

41:29

so Canadian researchers led by McMaster

41:31

University she has an interesting track

41:33

record McMaster what are they famous

41:35

for Vincent why do we know

41:37

the name McMaster what did they

41:39

do up there no maybe

41:41

our e -mailers can remind us

41:44

I think they may have

41:46

done stuff that so McMaster

41:48

University they have developed the

41:50

country's first comprehensive guidelines for

41:52

diagnosing managing and treating post

41:54

-COVID -19 condition or long COVID

41:56

and they have this plain

41:58

language recommendation section. I'm

42:00

going to say it's worth reviewing

42:03

for clinicians, but also patients. And

42:05

they have these nice sections, right?

42:07

So they have prevention of PCC,

42:09

post-covid conditions, and a whole bunch

42:12

where they go through recommendation strength

42:14

and what are the recommendations. So,

42:16

interesting of prevention of post-covid conditions,

42:19

they're actually recommending using Paxilovid for

42:21

prevention of long COVID, and they're

42:23

giving this a recommendation strength conditional.

42:26

another of other prevention recommendations. They

42:28

are talking about testing identification and

42:30

diagnosis of post-covid conditions. They've

42:33

got a number and also

42:35

in there as we've discussed

42:37

that 10-minute standing test, that

42:40

NASA modified lean test, and

42:42

that also has a recommendation

42:44

strength of conditional. They give

42:47

recommendations here for pharmacological and

42:49

non-pharmacological clinical interventions, so talking

42:51

about antihistamines and folks with

42:54

that MCAS type presentation, talking

42:56

about other therapeutics for people

42:58

with pots and autonomic dysfunction.

43:01

They even talk about where

43:03

and when you might think

43:05

about movement and exercise therapies.

43:07

And they make a really

43:09

nice point of basically saying

43:11

we're talking about these people

43:13

without post-exertional malaise because post-exertional

43:16

malaise is a situation where

43:18

these approaches can actually make

43:20

things worse. They talk about

43:22

melatonin, good sleep habits, and

43:24

a number of other do's

43:26

and don'ts with good graded

43:28

exercise. So I'll leave in a link

43:30

for folks to take a look at that. And

43:32

I will wrap us up with no

43:35

one is safe until everyone is

43:37

safe. You know, thank you for

43:39

all the people that have stepped

43:41

up and sent donations our way

43:43

during our floating doctors fundraiser, which

43:45

we're in the middle of February,

43:47

March, and April. Our plan is

43:49

to double those to a maximum

43:51

donation of $20,000 to help floating

43:53

doctors continue to do the great

43:55

work that they're doing down in

43:57

Panama. It's time for

43:59

your question. for Daniel. You can send

44:01

yours to Daniel at microbe. TV.

44:04

We only have three today

44:06

because everyone's sending questions

44:08

about measles vaccinations.

44:10

Go look at the charts and see

44:12

if your question is answered. And if

44:14

it's not, then write us, okay? Okay.

44:16

All right, Brad writes. I was born at

44:19

59, my wife and 60, had measles

44:21

as a child. My wife did not.

44:23

She was brought up Latin America. Unclear,

44:25

she received any measles vaccine.

44:28

because we were both after

44:30

the 57 cutoff day where the

44:32

CDC considers people immune and before

44:35

68 when the more effective vaccine

44:37

became available. We would both be

44:39

candidates, however I receive infleximab, so

44:42

I can't get an attenuated vaccine,

44:44

but I did have measles as a child,

44:46

so that's good. But my wife, I think

44:49

she should get an MMR vaccine, but is

44:51

there a meaningful chance that

44:53

my wife could infect me if

44:55

she receives the measles vaccine? This

44:57

is actually a, Brad, Christina, this

44:59

is a good question here. So

45:02

we have not seen that a

45:04

person gets the measles vaccine and

45:06

then they spread it to someone

45:08

else. It is attenuated to the

45:11

point where if your wife went

45:13

ahead, she got the MMR vaccine,

45:15

which the scenario you're describing makes

45:18

sense, then there would not be

45:20

a meaningful chance that you would

45:22

end up getting infected.

45:24

Deborah rights. I have a question

45:27

about measles vaccination. I'm

45:29

sure I'm not the only person to whom

45:31

this may be relevant. I'm one

45:33

of many people born in the early 60s

45:35

who may have received the weaker

45:37

measles vaccine and are now 65

45:39

or older. So my understanding is I should

45:41

get a booster now. Okay, as you might or

45:43

might not be aware, chronic lymphocytic

45:45

leukemia is the most common

45:47

chronic blood cancer in this age group.

45:50

Many of us are at the beginning stages

45:52

of our cancer. cancer I

45:54

am at diagnosis we are told to

45:56

not get any attenuated vaccines due to

45:59

the hit or immune system will

46:01

take. I am not talking about cancer

46:03

treatment, just from the natural often slow

46:05

progression of the disease. However, note the

46:08

luckiest among us will never need treatment

46:10

and will dive something else like another

46:12

cancer to which we will be susceptible or

46:14

to infection. So my question is, for those

46:16

of us who are not yet having symptoms

46:19

and are on watch and wait for CLL

46:21

and not needing cancer treatment for it

46:23

yet, is there a situation? Some of them

46:25

must might... have with low CL numbers in

46:27

our blood and not that much else abnormal,

46:29

that we can safely still get the measles

46:32

vaccine as a booster. Better to get it

46:34

now when my immune system is still relatively

46:36

healthy than to wait until measles is

46:38

in my community and I'd have to

46:40

isolate for the rest of my life.

46:42

Never get on a plane or have

46:44

a vacation or fly to see my

46:46

grown children and future grandkids. How much

46:48

risk would there be to getting the vaccine

46:50

AASAP? Is there any guidance from infectious

46:53

disease about what to measure? to see

46:55

if my immune system is healthy enough.

46:57

Yeah so Deborah this is a this

46:59

is a great question and this is

47:01

one of those where I'll talk a

47:04

little bit about it but the ultimate

47:06

punchline is going to be talk to

47:08

you either your CLL doctor or better

47:10

yet I'm going to recommend talk to

47:13

an infectious disease doctor about this. Yeah

47:15

so CLL very familiar with this actually

47:17

published a paper with Konti Rai on

47:20

this a number of years back and

47:22

CLL can impact your immune system but

47:24

as you point out there's a whole

47:26

gradation of CLL most people die

47:28

with CLL not from CLL and

47:31

so you know this black and

47:33

white you have CLL you can't

47:35

get a replication competent vaccine, it's

47:37

not that black and white. You

47:39

can actually look at the degree,

47:41

the severity of the CLL. I

47:43

remember there's actually a contri-staging system,

47:45

which has been supplanted in recent

47:47

years. But you can actually look

47:50

at the CL severity, and I

47:52

would actually recommend going, seeing an

47:54

infectious disease doctor, having them kind

47:56

of look and help guide you through

47:58

this. Because yeah, the CL is. you know,

48:00

potentially going to progress. We are changing

48:02

our world here in the US to

48:04

one where we're seeing measles all over

48:07

the place. And so if there is

48:09

still a window here, when it might

48:11

be safe to get that MMR, now

48:13

is probably the time to have that

48:15

discussion. And Susan has a question

48:17

about Zika. May 30th, my pregnant

48:20

daughter-in-law will be vacationing in Bermuda

48:22

for a few days. She'll be

48:24

27 weeks. Do you know of Zika.

48:27

or other infections that could impact

48:29

our pregnancy or concern in Bermuda.

48:31

I don't see information on the

48:33

CDC's side, but with the ongoing

48:36

attempts to weaken CDC, I didn't

48:38

expect it to have current

48:40

information. Yeah, so, you know, this

48:42

is one of those issues where,

48:45

yeah, the CDC has historically been

48:47

pretty good. Right now, I don't

48:49

believe there's any evidence of ongoing,

48:52

like, significant Zika activity in Bermuda.

48:54

But let's see, May 30th, she's

48:57

going to be vacationing. Yeah, I

48:59

hear your concerns, and this is

49:01

I think shared by a lot

49:04

of us, like will we still

49:06

be able to go to that

49:08

CDC site in 30 and

49:11

check and see if

49:13

there's any travel advisories

49:15

or is the information

49:17

just not going to be

49:19

there? I would reach out. you

49:21

know, to your doctor, there still

49:23

are some commercial sites out there

49:25

that are trying to keep track

49:28

of things. The Travex and some

49:30

of the other travel providers, you

49:32

might be able to get a

49:34

little bit more information as you

49:36

get closer to that May 30th. As

49:38

of now, Bermuda is Zika free.

49:41

Yeah. That's Twive Weekly Clinical

49:43

Update with Dr. Daniel Griffin.

49:45

Thank you Daniel. Oh, thank

49:47

you. And in these tough times,

49:50

everyone, be safe.