Charlie writes:

Hello.  I am a Family Nurse Practitioner in TN working in primary and urgent care with a background in Emergency and Flight Medicine.   First I want to say that when I found TWIV my nerd heart was happy.  Second, I want you all to know that I have referred so many providers to the clinical updates concerning SARS COV 2 because of the “you aren’t sick enough for Paxlovid” comments.

    Ok. So on to my personal question.  We have a son that is 13 yrs old, 12 yrs post kidney transplant, not big enough for treatments other than Remdesivir (he is only 33Kg).  He had 3 original vaccines at 0,6 and 12 weeks then a booster 6 mo later ( we did this because of the adult semi recommendation of a 3 dose series and what I gathered from Dr Offit). My question is this, for Dr Offit and you all with bigger brains and letters behind your names, would you recommend the new bivalent for him?  He has not had natural SARS infection and He is an incredibly healthy (never gets even a cold).  Renal function is pretty good considering he had a large cellular rejection 7 years ago.  We have not kept him in a bubble but I do worry somewhat about if he does get SARS COV 2.

    Any thoughts?

    Thanks again. Especially for the clinical updates which kept us rural practice people up to date!


Paul Offit responded:

It’s hard to answer this question without knowing the child’s complete medical history. But I would say this. If the child is currently on an immune suppressive agent and it has been at least 2 months (preferably 4 months) since the last dose, it is reasonable to receive a booster dose heading into the winter season.

Walt writes:

At about 27 minutes into TWIV 934, Prof VRR asks “isn’t [protection against severe disease and death] what matters?”

And while, yes, of course that matters, the idea has been pushed that mucosal immunity could “block infections, transmission, achieve containment of the virus, reduce the toll of sickness, & help prevent #LongCovid”

(Quote from:

As you noted, the preprint you discussed offers no evidence for that indirect path to greatly-improved public health. But that’s different than saying it doesn’t matter

Topol is clear in distinguishing between his hopes and results, so I think it fair to evaluate them separately

So what do you think? Wouldn’t a vaccine that achieved those goals be worth pursuing from a public health perspective, versus a strictly medical or biological perspective?

TWiV seems to have sought out alternate viewpoints and even if that’s just an excuse for Dr R to be grumpy in his inimitable way. It’s what we come for. Keep up the great work

Bob writes:

By now I am sure you have a lot of emails about the latest Revisionist History podcast that questioned your take on the SARS-CoV-2 challenge trial. I like Malcom Gladwell’s work, but I feel this time he made a fundamental mistake. He got so close when he examined the motives of the WWII conscientious objectors. In those talks he acknowledged the ideals of men who would not kill, no matter what the cause. He then turns around and criticizes scientists unwilling to do harm to healthy patients, no matter what the cause. CO’s know that to serve the military means you will be asked to do violence, and while history may judge one war justified, most are not. The only way to avoid this moral peril is not to serve. Scientists know that agreeing to risk unbalanced harm to a patient because they or someone else believes it will do good insures they will eventually do harm for reasons that turn out to be wrong. There is always someone who believes an experiment will do good, and if you are willing to harm people for that belief alone, you end up with things like the Tuskegee Experiments or worse. This is why Scientists rely on Institutional Review Boards and ethicists before they ever ask a patient for informed consent. Yes, some people are exposed to risk, but there is supposed to be equipoise with the possible benefits to the patient. When I participated in the Moderna vaccine trial, I took a risk, but that risk was more than balanced by the probable benefits of the vaccine to me personally. Infecting someone with a known pathogen that routinely kills people is not balanced by any benefit to that patient. 

To me, this is just another case of people not understanding what science involves, in this case not understanding the ethics of science, and why it must be done so carefully and cautiously.

Keep up the good work at TWIV. You were right.