September 7, 2023

In "Time for a Mindset Change," Dr. Osterholm and Chris Dall discuss the rise in COVID activity in the U.S. and around the world, a recent study on COVID in white-tailed deer, and a survey on vaccine hesitancy in pet owners. Dr. Osterholm also provides an update on avian and human influenza and shares a moment of joy from one of our listeners. 

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Chris Dall: [00:00:07] Hello and welcome to the Osterholm Update, a podcast on COVID-19 and other infectious diseases with Dr. Michael Osterholm. Dr. Osterholm is an internationally recognized medical detective and director of the Center for Infectious Disease Research and Policy, or CIDRAP at the University of Minnesota. In this podcast, Dr. Osterholm draws on nearly 50 years of experience investigating infectious disease outbreaks to provide straight talk on the latest infectious disease and public health threats. I'm Chris Dall, reporter for CIDRAP News, and I'm your host for these conversations. Welcome back, everyone, to another episode of the Osterholm Update podcast as we flip the calendar and say goodbye to Summer and hello to the school year, we seem to be on the verge of another period of uncertainty. As Dr. Osterholm has pointed out in recent episodes, we are in a much better place now than we've been at any point over the past three years with respect to COVID-19. But will the increase we've seen in COVID-19 activity over the past month continue with kids now back in school? Is the BA.2.86 variant different enough from previous variants to pose a new challenge to our vaccines and treatments? These are some of the topics we're going to discuss on this September 7th episode of the podcast as we look at the international and national COVID trends and provide an update on SARS-CoV-2 variants, we'll also discuss a recent study on COVID infection in deer, provide updates on avian and human influenza. Look at a recent survey on vaccine hesitancy in pet owners. Answer an infectious disease query and share our latest moment of joy submission. But before we get started, as always, we'll begin with Dr. Osterholm's opening comments and dedication.


Dr. Osterholm: [00:01:49] Thank you, Chris. And welcome back to everyone, to another edition here of the podcast. In particular, I want to welcome all of our podcast family members. Thank you so much for staying with us, providing your feedback and your encouragement and hope today that we can provide you with information that you will find helpful. Also, we want to welcome any new podcast listeners who are exploring what we might have to offer you in the days ahead with regard to not only COVID, but a number of other infectious disease issues. I hope that you find what you're looking for. Before I go any further, though, I have to say this because I don't want anyone to worry you all, particularly in the podcast family, take such good care of me. I am sounding hoarse. It's only because of allergies. I've just gone through nearly a four days of 100 degree temperatures here in the Minneapolis Saint Paul area. And the pollen counts are incredible right now. So please, I'm fine. No COVID activity, no other illness. If you think my voice sounds off, it's because of the allergy issue. I'm looking forward to the days ahead when it cools down and the pollen counts drop precipitously. Today is going to be a, from my perspective, a challenging podcast. And I say that because we're covering lots of material and some of it's pretty complicated. But most of all, because I can't tell you with any certainty what's going to happen over the days ahead.


Dr. Osterholm: [00:03:18] You know, from the very beginning of this podcast, I have stated all my job is, is to call balls and strikes. How do I see them? Why do I see them? What are the data that support the way that I see them? And as you know, I've said time and time again with that, humility has to be a very, very prominent part of anyone's job right now with regard to predicting the future with COVID. But I will make some predictions today, clearly, and I'll give you the reasons why, and I'll also comment on what I think right now is unfortunately a disturbing, you might say, reemergence of some of the things that we saw in those first three years of the pandemic. Let me give you an example. Right now, we seem to be stuck in a narrative about is there going to be a national mandate for masking again as case numbers increase? And this has become a hot button issue on news media shows. I'm getting lots of emails and reporter questions about this issue and let me just make it clear we should not let that happen again. Do I believe we will ever mandate masking as we've talked about in this country? The answer is absolutely no. Does that mean that you as an individual cannot protect yourself more by using an N95 respirator, particularly if you're at increased risk for serious illness, hospitalizations and deaths? And we'll talk about that today.


Dr. Osterholm: [00:04:43] I want you to know that you still have that personal control to do what you want to do and how you want to do it. But please do not let particularly what I call the far right commentary trying to divide us again about will there be these mask mandates? Will my kids have to use a mask in schools, etcetera, etcetera? I just don't think that's ever going to be a reality. And I wish we could avoid that whole discussion because it really takes us nowhere except a big black hole. And so today we'll talk more about some of those issues that are emerging, too. But now having just mentioned schools, I have to tell you that today's dedication for this podcast is something near and dear to my heart. Every year, some of the most wonderful moments of my life occur on the first day of school when I get pictures of my grandkids as they're on their way off to the bus for that first day. And when I go back and look at those pictures over the years, it amazes me. How did they grow up so quickly? Amazing. And so today, our dedication is to those who are all part of our education process in this country.


Dr. Osterholm: [00:05:54] This includes not only the students, but also includes the teachers. When you think about the number of individuals in schools today in this country, it is such a critical and important part of our everyday lives. For example, if you look at public K-12 schools in the US, there are 49 million plus students in those schools. There's over 3.2 million teachers. If you look at US colleges and universities, there are 19 million students today in those institutions of higher learning. This podcast is dedicated to you. May you have a successful year in your educational pursuits. Education is one of those things that is such a well earned effort. You can never take your education away from you. They can take a lot of things away from you, but you can never take your education away from you. So today I salute the teachers. I look to the students and wish you the very best and to all the parents who for the very first time put their young child on a school bus. I recognize the trepidation that that must have been for you, because I went through that myself personally. But in addition, for all the parents who are supporting our educational process, thank you. And so this dedication is to you. Now, I'm going to have one more week here of talking about sunlight.


Dr. Osterholm: [00:07:16] I know for some of you this is a very, very boring, if not almost nails on a chalkboard kind of moment. But it's me, you know, you got to put up with a little bit of me now and then. But I am willing to be open to other alternative kinds of markers of time and where we've been, where we're going in the future. If anyone has a light bulb moment idea about what might replace sunlight length as something that we comment on in each and every podcast, I welcome that. We really do welcome your input. And so think about it. If there's something else you think that we could help mark time place, person over time, let us know if otherwise we will continue for now with the light length episode here. Now, grant you, I do recognize that this is somewhat of a difficult situation as the days are getting darker in the northern hemisphere. To our listeners in the southern hemisphere, you got great hope. But today in Minneapolis, the sun will rise at 6:42 A.M. will set at 7:39 P.M. We have 12 hours, 57 minutes and 11 seconds of sunlight. We're losing a little over three minutes of sunlight a day. Now, to our dear, dear friends in the Occidental Belgian beer house on Vulcan Lane in Auckland, New Zealand. There today you have sunrise at 6:34 A.M., sunset at 6:04 P.M., 11 hours and 30 minutes and 35 seconds of sunlight.


Dr. Osterholm: [00:08:44] You're gaining about 2.5 minutes a day. That means it's just a few days, about 20 some days. And we will actually both experience the same light length of days. And so we at that point recognize you'll be getting the sunlight that we just had. Now, for some people, they would argue that all these 100 degree days we've had, we probably could experience a little less sunlight and that would be okay. Well, I also realized that while that surely has been a challenge and heat has been a major public health challenge with regard to people who do not have access to cooling locations, I think we all in the northern hemisphere will, when we get into the throes of winter, wish we had a little more sunlight, a little more heat. So again, that's our status today, but we're open to any suggestions about how to change this. And just so you know, I promise to be open minded. In fact, I'll even let Chris choose if something comes in that is between us and the sunlight, and I'll let him be the final arbiter. So with that, thank you again very much for being with us. And I hope you can put up with the scratchy voice of mine for the minutes ahead.


Chris Dall: [00:09:58] As we've discussed over the past month or so with the usual caveat that reported case numbers are fairly useless at this point. We continue to see a rise in COVID activity around the world. The latest update from the W.H.O. shows a 63% increase in reported cases worldwide and increases in hospitalizations in several countries. While the latest CDC updates show more increases in COVID hospitalizations and deaths, though both are low compared with previous periods in the pandemic. And anecdotally, it seems like a lot of people are getting COVID right now. As for the variants, EG.5 remains one of the dominant variants worldwide and here in the US, but all eyes are now on the highly mutated BA.2.86. Mike when you take all of this into account, increasing activity, new variants, are you seeing things any differently than you have in the previous episodes?


Dr. Osterholm: [00:10:51] Well, Chris, you know, I think at this point it's fair for me to say that I feel like I'm picking which wave in a hurricane to surf today. It seems it's a challenge any way you look at this. We are clearly in uncharted territory. There is no question about that. But let's just take a step back before I really dig into this information and say that I think we're also at a major turning point in the pandemic in that if you look at those first three years of the pandemic and you look at the seven different discernible peaks that we experienced, there wasn't that much time between when someone might have been vaccinated or infected and then experience the virus again or for the first time for those who are vaccinated, waning immunity was never really one of the biggest factors we worried about was getting vaccinated or have you previously been infected? But if you look at the past year, what we've actually experienced is what I had called that high plains plateau event where basically we didn't see peaks, but cases just continued to be reduced in number and reduced in number and reduced in number. And we got to the point where for many people, the last time they had a booster dose was more than a year ago or that they had previously been infected. And we're still trying to understand what it means to have immune protection as we know about coronaviruses, before we ever experience SARS-CoV-2, seasonal coronaviruses would come and go.


Dr. Osterholm: [00:12:20] Every several years. People would be at risk for getting exposed, getting infected because the immunity they'd had from a previous infection with another coronavirus basically waned. Now, these were the cold like viruses, clearly not SARS or MERS or SARS-CoV-2. But now what we're looking at is that same situation on top of these rapidly emerging variants and the changing capabilities that each of those variants have for causing infection, evading immune protection and even causing serious illness. And so I'm going to work through this today in a way that hopefully helps give you a sense of how I view these interacting factors of waning immunity and vaccination and clinical illness have on what is happening today. So let me just review for where we are at, Chris. There clearly is evident rise in activity, as you just noted. I find it actually very challenging to understand what's happening today when it's so clear and obvious that there's widespread transmission. And it seems most of us want to be in total denial of that. Look no further than the US Tennis Open right now in New York. It is clear that that is one major superspreading event of COVID, but no one will get tested among the players or coaches because they do not want to be removed from the potential to play. And yet we have them on the court sick. We have them reports of many, many individuals with this illness and it is clearly COVID.


Dr. Osterholm: [00:13:53] But the fact we're in denial, the media is hardly covered it. That to me is really a comment on the state of the art of where we're at with what people are accepting. So let me just be really clear. All the data right now is at best limited in terms of case numbers and defined infections as determined by testing and so forth. Because as we've talked about, we know that the systems to collect that information have largely been dismantled. But we have so many anecdotal accounts of infections and outbreaks among people, many that I know. So I think a part of me has a sense of almost a deja vu moment all over again. Let me be clear. The surges that we've seen in the past that three years of the primary pandemic activity is not going to return. I'm convinced of that. But we are now in this next stage of living with COVID in a way that it doesn't mean it's disappeared. But we're trying to come to what I would call a steady state kind of setting where basically, like other potential seasonal viruses, we live with COVID. Within that context, it doesn't shut us down. It doesn't cause hospitals to be overrun. It doesn't mean that we have to cancel many events. But where are we at with that? So I'll try to do my best to go back to the data and ultimately just take a look at what it's telling us. So what do the data show? Well, Chris, you've already provided a good overview of the lead up to the question.


Dr. Osterholm: [00:15:27] It's very helpful. And so to avoid sounding like a broken record, I'll just say that the general trend we've seen play out the past month or two has basically continued with COVID activity continuing to climb. That said, I think it's also worth pointing out that these increases are happening at a time when many of the systems that were established for COVID surveillance globally either have been or are currently being dismantled. So that really has been a significant challenge when it comes to interpreting the latest trends and understanding the actual scale of the recent uptick. To maybe put this into perspective, let me just share a couple of examples. First, according to the latest weekly COVID report that published by the W.H.O. on September 1st. In other words, last Friday, 61% of the world's countries did not report even a single case of COVID during a 28 day period that spanned from July 30th 1st to August 27th. Remember that 61% of the world's countries did not report a single case. And again, that trend has continually worsened throughout the past year. Likewise, in terms of COVID hospitalizations, just 15 of 234 countries, or only 6%, have reported any data regarding hospitalizations for deaths is a similar story with a significant underreporting across entire regions. Just look at Africa, a continent that's home to 1.2 billion people in the 28 day period from July 30th 1st to August 27th.


Dr. Osterholm: [00:16:55] A total of four COVID deaths reported there. Only four in the eastern Mediterranean region, which has a population of 600 million, just 28 deaths were reported. And in Southeast Asia, just 54 deaths reported across a population of almost 700 million. Now, trust me, I would celebrate these numbers if I thought that they were all valid, that they really reflected the actual activity in our communities. They don't. So it's harder to celebrate these very, very low numbers. So I think it's safe to say that we're missing some really pretty big pieces of the overall picture simply due to these gaps in reporting. Finally, let me just end this introduction by saying that even the number of viral sequences that are collected and shared has dropped precipitously, going from more than 425,000in August of 2022 to just now, a year later, August of 2023, with less than 13,000 uploaded this past month. And of course, data are critical when it comes to tracking and monitoring variants. So ultimately, we're left with whatever data we do have available and have to interpret from that. And despite those gaps, it's been clear that the uptick in COVID activity across a number of places is very real. This includes countries like Canada, Italy, South Korea and the U.K. In South Korea, for example, weekly deaths went from less than 60in early July to more than 250. Now. In the U.K., deaths have risen from 55 a week in late July to 115 a week by mid-August.


Dr. Osterholm: [00:18:30] Now, in this case, I think deaths in those countries does reflect a relative tip of the iceberg of what's underneath it. So, in fact, I think we can use these numbers to give us some sense of what's happening. And as you know, the US has been no exception to this trend. Here we've seen hospitalizations climb for the past two months with the number of new weekly admissions going from an all time low of 6300in late June to over 17,000 the week of August 26th. Meanwhile, the number of patients in an ICU with COVID has climbed from less than 700 to just over thousand hundred. And finally, we've seen weekly deaths grow from a pandemic low of 469in early July to 641 the week of August 12th. And we know that the August 12th data are not yet complete. So the final reported deaths will be higher. Unfortunately, demographic data for these outcomes aren't always available, but from what I've seen, the highest burden continues to reported in the older age groups, particularly those over 75, with some increase in those 65 years of age and older. For example, the COVID-net data, which is collected from 13 states across the US, including Minnesota, indicates that nearly two thirds of hospitalized COVID patients are 65 years of age and older. Again, not necessarily surprising with what we know about age as a risk factor for severe outcomes. That said, there is also recent data showing that more young children, those 0 to 4 years of age, are being admitted with the virus accounting for 5% of COVID hospitalizations in those COVID-net states, up from less than 2% in early July.


Dr. Osterholm: [00:20:10] So what other data do we have that helps address this issue? Well, of course, we've seen the rises in wastewater activity, which has played out in all US regions since late June, with the latest national average now more than three times higher than it was when the uptick began. So it's safe to say that more virus is circulating. And again, that tracks with recent anecdotal accounts of increasing cases. I'm sure all of you already know the first lady, Jill Biden, tested positive this past Monday. This is the second time she's tested positive for the virus with her first infection last August, a little over a year ago. She's currently isolating with mild symptoms. We wish her the very best. Reports have noted that she was with President Biden on Monday prior to receiving the positive test. He was tested as of yesterday and at least public report it still is negative. President Biden is also just a year out from his previous infection in July of 2022. Apart from that, there have been several outbreaks that have prompted school closures in some states, notably Oklahoma and California. And I'm aware of a outbreaks occurring in schools now in at least 14 different states from information that we've collected. So you can see that this virus is still capable of causing disruptions otherwise, even with the recent rise in wastewater activity.


Dr. Osterholm: [00:21:29] I just want to point out that the latest levels currently sit at about half of what was reported during the peak this past December and even during the 2022 summer surge. That's not to say let your guard down since it's still high relative to where we were just several months ago. But it might provide some really important context along that same vein, we've recently seen all time lows in terms of hospitalizations and deaths in this country, which came as a result of six months of steady declines. Now, in no way do I want to minimize these recent increases which are very real and worth additional monitoring. These are our fathers, our mothers, our grandfathers, our grandmothers that are getting sick largely and having serious illness. But I think that one silver lining has been that the overall numbers remain at just a fraction of what they've been throughout the majority of the first three years of the pandemic. Again, let me reiterate, we are not going back to the pandemic experience of 2020 to 2022, I have no doubt about that at this point is illustrated when we just look at what happened last summer, in 2022, when nearly 38,000 Americans were hospitalized with COVID compared to 13,000 now. Likewise, weekly deaths last summer reached 3400, more than five times higher than they are right now. Again, I'm not shrugging off what's happening. I think it's a very, very significant public health situation.


Dr. Osterholm: [00:22:57] However, I think it's really important perspective, particularly as the headlines read, doubling and tripling of cases and so forth, to understand where we've been, where we're at and where we're going. So what does this all mean? Well, I think in a moment we're going to talk a bit about variants. And so I'll address what I think that part of the contribution is to our case numbers and where it means we're going forward in the future. But let me come back to what I think is really a combination of factors. It is waning immunity in humans where the protection against getting infected is wearing off, and particularly for those who are at increased risk of serious illness, even that protection against that is wearing off in a sense. So what we have to ask ourselves is this now what we can expect to see with COVID going forward? Is this something that we can expect year after year? Well, we had the model already of the cold causing coronaviruses. And I think that this is going to be somewhat like that. I do not yet see any evidence of seasonality, and therefore I keep raising that because I still am very concerned about the FDA's approach to making this an annual fall seasonal virus vaccine approach. I think that's just dead wrong. I think we need to be looking at boosters potentially every six months to keep up with the variants and to also deal with the waning human immunity.


Dr. Osterholm: [00:24:23] Now, some will say, well, that's crazy. Nobody's going to take a vaccine every six months. And that may be true. That is largely going to be true, in fact. But for those who are at increased risk, you at least give them another tool to help protect themselves. So if they get infected and they have a mild illness, so be it. A victory. What we don't want is a major defeat where they become infected, become seriously ill and die, particularly after having made it through the horrible part of the past three years. So you can still wear respiratory protection, i.e. an N95 appropriately worn. That's your choice. You can do that. You can get your booster when it comes out, which will be within just the next two weeks and do that and you can figure out if you want to test family members as such when you get together for family events, just to be sure someone's not bringing the virus in or at least reducing the likelihood they'd bring the virus in. These are all things that are still in our control. These are with us. No government, no public body is going to tell you you can or can't do that. And I think that's the message you want to get across. We're learning to live with COVID in all of its unfortunate scenarios that we can imagine. But right now, we have truly an increasing activity. But fortunately, it still is much, much lower than it was over much of the past three years.


Chris Dall: [00:25:47] So let's talk about those variants, Mike, particularly the BA.2.86 variant, which has been studied by a number of groups since our last episode. What are we learning about it?


Dr. Osterholm: [00:26:00] Well, the variants are the notable curveball that keep getting thrown into the mix here, and it is important to understand that there is more to them than just a big name change, a number change. What does it mean with their functionality? What does it mean in terms of evading immune protection? Can it cause more serious illness? But let me just address this most recent BA.2.86 variant that's gotten a lot of publicity. Any time someone says, Oh my, this thing has over 34 different mutations on the spike protein, it makes it seem as if this is going to be really, really bad. But as I pointed out in the last podcast and I've said many times over the years, remember that a variant must really be considered innocent until proven guilty. And in this case, I think that's what we're going to see happening here. As you noted, Chris, data are coming out in several online sources with reassuring news about the potential threat of BA.2.86. But it's important to note that these studies have not yet been peer reviewed and there may be some limitations to their interpretation, but I think on a whole they're well done and are important. The first findings come from Dr. Cao and colleagues at Peking University and suggests that the Antigenically unique variant is capable of evading previous infection and vaccine induced antibodies, but may be less permissible to target cells in the body. Next, the Merrell Lab of the Karolinska Institute in Stockholm found that the post-XBB samples did have some neutralizing capabilities and suggest the outlook is not as grim as once predicted. Finally, the Baruch Lab of Beth Israel Deaconess Medical Center offered their data, demonstrating that neutralizing antibody responses, though less reactive for BA to Omicron, were comparable or even higher than response to the variants currently or recently circulating.


Dr. Osterholm: [00:27:55] Based on their data, it appears as though previous and recent exposure to XBB sub variants increased neutralizing antibody titers. Moreover, these two preliminary conclusions appear to contradict early fears of the highly mutated variants immune evasion capabilities. Of course, we have a responsibility to stay vigilant and update new lab and epidemiologic data as they emerge and encourage listeners to do the same. But as I just said a moment ago, variants must be considered innocent until proven guilty. And I think that the whole trial of BA.2.86 must continue. But at this point I'm encouraged by that. Now, having said that, we are seeing case numbers increase as we just talked about why, and I think this is where the IG five is particularly a very important consideration and that in fact we may very well be seeing that as the reason for these increases, although at this point I want to be really clear, as accounting for only about 20% of the variants we're seeing yet and FL.1.5.1 together, the two variants count for about 32% of the variants we're seeing right now in human illness. So I can't give you the exact reason why we're seeing this case increase other than I think it's the combination of waning immunity and these variants that are causing this increase occurrence and that this is all the more reason why, based on what I just shared with you, you want to get your booster.


Chris Dall: [00:29:27] That brings us to this week's query. And we've had several listeners ask about whether the updated COVID-19 booster shot will be covered by Medicaid and or private insurance. Now, this is not our area of expertise, but a lot of listeners are interested and it certainly could affect uptake of the vaccine. So is there any information we can provide our listeners?


Dr. Osterholm: [00:29:49] Well, as you just said, Chris, this is something that many of our listeners are concerned about, especially now that the public health emergency is ended. So we have had lots of inquiries about this. While we don't know for certain whether all employers and health insurance companies will cover the full COVID booster, we do know that all Americans will be able to get the updated vaccines at no cost through the CDC's Bridge to Access program. The Bridge to Access program does provide free COVID-19 vaccinations for adults that are uninsured or for whose insurance does not cover the COVID booster. I hope this information eases the concerns of any listeners that are worried about the cost of their vaccination. I want to recognize that there are still other barriers that could prevent someone from accessing their booster dose, like access to a vaccination site or the ability to take time off from work if needed to get the vaccination. Still, this is a major step in the right direction to ensure that these vaccines are distributed in a fair and equitable way. At this point, I just want to do everything I can to encourage, particularly those who are at increased risk for serious illness, hospitalizations and deaths to get this booster as soon as possible. The current data showing only 42% of those over the age of 65 who have been eligible for the previous booster actually got that booster. I think that that is a sign that it could be even much lower going forward. And I think that that would be a real challenge.


Chris Dall: [00:31:20] One last question here on COVID-19 before we discuss some other infectious diseases. Last week, CIDRAP News covered a study on the spillover of COVID-19 from humans to White-tailed deer. Mike, what did we learn from this study?


Dr. Osterholm: [00:31:36] Well, this particular data are, in a sense, not new to us. We had a sense already that the spillover of SARS-CoV-2 from humans to whitetail deer or cervids was happening. But I think this is one of those moments when, again, humility becomes a very, very important ingredient in interpreting what's happening. You know, I think the the fact that I learned some time ago that the older I get, the more vulnerable I am to learning is really an important lesson to be learned. And that is really an exhibit here. This study, which was done by someone who actually I had helped mentor earlier in his days in his work with influenza at the Ohio State University. Andy Bowman, and who is truly a really talented researcher, is a very important piece of data. This study, built on previous knowledge that coronaviruses can transmit between humans and animals. We know that there are many animal species that are susceptible to COVID-19, and specifically, though, reservoirs and wildlife could pose an additional threat as their populations are difficult to control compared to captive or domesticated animals. White tailed deer especially are more and more commonly existing in urban areas and increasing contacts with humans. The recently published article represents a large scale epidemiologic effort to understand the infection patterns and evolution of SARS-CoV-2 in Ohio's white tailed deer population. The research team sampled over 1500 deer in almost every Ohio county, which is quite a feat, and found almost 25% seropositive indicating previous infection.


Dr. Osterholm: [00:33:23] Further, 163 returned to PCR positive result and 80 underwent whole genome sequencing to better understand crossover instances and the variant data. 71 of the 80 samples were identified as being the Delta variant, which the team further temporarily linked to human circulation patterns at the time the study was being done. They estimate that at a minimum of 12 human to deer transmission events occurred during this time, which also corresponds to the Ohio deer hunting season. Why this transmission occurred? How this transmission occurred is truly a mystery. Yet perhaps the most interesting finding of this study was that the virus appears to evolve at an increased rate in white tailed deer compared to humans, as evidenced by estimated genomic substitutions per site per year. Granted, this conclusion is based on projections generated by mathematical modeling, but the assertion holds water since the white tailed deer is an immunologically naive host with less background selection. To echo the interview with Andy Bowman by CIDRAP's Stephanie Soucheray, the most concerning aspect of these findings is that a range of divergent strains circulating in the wildlife reservoir could pose a unique threat to humans. This study surely raises additional questions surrounding the persistence of COVID-19 in white tailed deer populations and calls for additional research on virus evolution in this species as a threat to a crossover back to humans and what that would mean for human public health.


Chris Dall: [00:35:00] Now for a few questions about influenza. And we're going to start with avian influenza. For those of our listeners who regularly read CIDRAP News, you've probably noticed several reports in recent months about the detection of H5N1 avian flu in shelter cats in South Korea and in foxes and minks on Finnish fur farms. Mike, are these mammal infections any indication that H5N1 has made some kind of genetic leaps that could make it more capable of infecting people?


Dr. Osterholm: [00:35:32] Well, Chris, this is a question that is near and dear to my heart in that I've been working on influenza literally since 1997 when H5N1 first appeared in Hong Kong. And I have to say that, yes, this virus has made remarkable changes in its genetics during this time period. But the question that we all have to ask is, does that mean that there is an increased risk of transmission to humans and the potential for ongoing sustained transmission between people? Or is this, in fact genetic changes that actually makes that less likely to happen? And I think there has been so much misinformation provided to the public about this over the course of the past months, where it is almost been, you know, that other term that I absolutely deplore, which is the tripledemic, which I think is such a misleading and challenging concept because it just scares the hell out of people needlessly. Well, I think in many ways that's where we're at here. Now, that may come across to some as sounding like I'm dismissing the importance of H5N1. And let me just tell you that after 26 years of studying this so carefully, following it with great concern that I should be ever considered as someone who doesn't take H5N1 seriously, I do. I take it very seriously. But let me take you on a journey. I think that helps you understand a little bit about what's happening with H5N1. As I noted, the virus was actually first discovered in birds in Hong Kong in 1996.


Dr. Osterholm: [00:37:14] And then there was the cluster of cases that occurred in 1997. And it was assumed at that time in these 20 some cases that, oh, my, this was the beginning of the next pandemic, that this avian influenza virus was going to cross over into humans and now be the cause of that pandemic. Now, I think that it's important to note that we've learned a lot about influenza since that time, and particularly about the virology of the virus. But let me just lay out the course of this. In 2003. Human cases returned to Southeast Asia after the elimination of the virus out of the markets in Hong Kong in 1997. And during that time period, I was actually in those countries working on influenza in the birds. I've actually been to the homes of individuals who died in that family from H5N1. And we all at that time continued to be concerned about the fact that this was just gearing up to become the next pandemic virus. Then in 2010 to 2014, those next four years, we saw the epidemiology change substantially. And now what was happening was, in fact, Egypt had become ground zero with 120 cases, 50 deaths within Cambodia with 47 cases, 30 deaths. And it was during this time period that I was on the National Science Advisory Board for Biosecurity. And in 2012, we were presented with data from some really very established influenza researchers suggesting that H5N1 was literally one mutation away from becoming the next influenza pandemic virus, and there was grave concerns about what was happening with H5N1.


Dr. Osterholm: [00:39:10] But as time went on, nothing more happened other than Egypt continued to be the hottest spot in the world for H5N1. 160 cases occurred during 20 1519, of which 48 died. Of those 160 cases, 149 cases and 43 deaths were in Egypt, specifically along the Nile River Valley, where we saw ongoing sustained spillover from birds to humans. And then in 2020, in Shirley coincides with the pandemic, but also coincides with the emergence now of a new clade of H5N1. And this is H5N1 clade 2.30.4, 0.4 B, and this emerged in 2020. And what happened during that time? Well, from 2020 to 2023, basically, we had 11 cases documented in humans at a time when we were looking for a lot of viruses, particularly SARS-CoV-2, but other influenza viruses. Of those 11, only three died. So think about this now from 2022, 2023, and compared to what we experienced over the previous decade and a half. This is remarkable. So from that you could argue, well, things look better for humans. But it was at that time that then we saw this big increase in 2020 with the virus spilling over now into many different animal species. And it was with that spillover that people all assumed that that meant that the risk was going to be increased for humans. Well, if you look at the virus, there's actually reasons why that is not the case. And in fact, both the World Health Organization and CDC did risk assessment analyzes of this virus for its ability to infect humans and be sustained in the human population with humans transmitting to other humans.


Dr. Osterholm: [00:41:11] The CDC published their risk assessment analysis this past July, and they concluded that looking at the current clade of H5N1, that it continues to be mostly an animal health issue. Human infections with H5N1 bird flu are rare, and these viruses are not well adapted for spreading among people, as they do not currently have the ability to infect the human upper respiratory tract. Most past human infections have occurred following close unprotected contact with sick or dead birds. In addition, the World Health Organization did their own risk assessment and they too came up with a very, very similar conclusion that in fact there was limited risk at this time to humans, that because of the unique changes in the virus and what that meant. And so here you have two organizations who have looked carefully at this risk and almost counterintuitively have come out and said this isn't as big a risk today as it was before, and it's because this new Clade virus has changed. Well, what is that all about? Well, if one looks at barriers that have been identified that inhibit avian influenza, a virus infection in humans, there are multiple for example, virus hemagglutinin receptor site binding specificity has changed, meaning that this new clade actually has less ability to bind at the hemagglutinin receptor. There's an increased high hemagglutinin th fusion level in humans that also limits the transmission of these avian viruses to humans.


Dr. Osterholm: [00:42:51] There's increased efficacy of the virus polymerase in human cells, which is different than in animals, where we actually see more resistance. There's even the length of the neuraminidase stalk, which is different in humans than it is in animal species and specific other host factors. In the past several weeks, there have been two really important studies published one from Suminski and colleagues in Germany, which actually showed that there is a protein that is called Mxa, which actually is an intrinsic host barrier for avian flu viruses to infect humans. And this is not present in many of the other mammal species out there that would in fact, they too could get infected then. Then a second paper by Pinto and colleagues from Glasgow showed that a specific protein bt N3A3 actually is also an inhibitory part of the human immune response and a specifically restricts avian influenza viruses from infecting humans. And so it's a very different situation today because the virus, which while it is able to infect more of the mammal population and particularly scavenger mammals, mammals that are eating other dead birds, whatever from H5N1, can then become infected. So it's not even respiratory transmission. And notably the one animal species that to me has always been the sentinel animal species for human infection is swine. Swine to have these same characteristics. And we have not had a single case reported of H5N1 over recent years in swine. So when you add this all up, I think actually H5N1 surely is a challenge to bird and other scavenger mammal populations across the world.


Dr. Osterholm: [00:44:51] And I would never, ever take my eye off of this with regard to human transmission and what that might mean. But right now, I think actually the world is probably safer against H5N1 human related transmission and ongoing transmission between humans than it has been probably in the last 25 years. But does that sound like what the media is covering today? Not at all. There is no context here like I just shared with you of what's happening in terms of case numbers, what's happening in terms of the virus changes. These articles I just mentioned, and I have a real concern about this now, you know, I am not personal in my work. Science is science. Facts are facts. You know, be where they may. And so I've never taken too personal warfare as a way of trying to address something. But I think we have to call out some of our literary journalists, commentators, etcetera, for how they have hyped this without context. And one particular columnist who I think has really done it more than anyone else and I think in an irresponsible way, quite honestly, is Zeynep Tufekci. She is a sociologist by training and an opinion writer in The New York Times, and she's written two pieces in recent months that actually address this issue. One published in February 3rd of 2023 and even deadlier pandemic could soon be here. And then a more recent one in which she addressed the issue of H5N1 in cats, particularly in Poland.


Dr. Osterholm: [00:46:29] Cats with bird Flu. The Threat Grows, published in August 31st. None of the contexts that I just shared with you is in any of these articles, and there's a very limited number of interviews done with people who have done the kind of work that I just talked about. No mention of the CDC or W.H.O. risk assessments, no mention about these intrinsic protection issues of humans against the current version of the clade virus that we're looking at. And even to the point of saying, well, we've got to do more with influenza vaccines, which is obviously something we'd all like to have, But it's naive to think we're going to stop an emerging pandemic just by having some influenza vaccine around. As you've heard me say time and time again, these are viruses with wings. Once they take off, they're gone. Remember the H1N1 pandemic that emerged in Mexico in 2009? By the time we confirmed it existed, it was already in 127 different countries. And so the idea that vaccines could work and yet if you read her pieces, it's just we're not doing enough to get good vaccines. And so I point this out to you because I worry that much of public policy today is being directed by social media, you know, cable news and unfortunately, even The New York Times. You know, I'm currently writing a book on lessons learned from this pandemic or lessons we should have learned with my coauthor, Mark Olshaker.


Dr. Osterholm: [00:48:00] And in there, I have an entire chapter on communication and what the issues are around communication. And there are many when it comes to responding to a pandemic. But one of the lines that I have in the book is, is that some of the very best articles covering the pandemic were published in The New York Times, and some of the very worst articles covering the pandemic were published in The New York Times. And while this is not a COVID pandemic related set of articles, it reflects exactly what I think about the worst of the reporting is not balanced, it's not comprehensive. And it leaves people to think, Oh my God, we're on the edge of an H5N1 human pandemic. We are seeing animal deaths associated with this virus unlike any time in history. But this is a long way from saying that means that we're going to basically have an H5N1 situation from this clade in humans. And I hope that that more people will take the time to explore, investigate, understand, for example, the risk assessments at W.H.O. and CDC did or that matter, even talk to other experts who can comment on these intrinsic factors. I just related to you that actually protect us against avian influenza virus that are not found in other animal species. So I hope this had some context at this point. I know it sounds counterintuitive. I feel safer right now with H5N1 in humans than I have ever since the first days of. Dealing with it in Hong Kong in 1997.


Chris Dall: [00:49:45] Well, what about human influenza? Have we started to see any uptick in flu activity in the Northern hemisphere yet? And does the flu season in the southern hemisphere tell us anything about what our flu season is going to be like this year?


Dr. Osterholm: [00:49:59] Well, Chris, I'm happy to report that influenza activity across the globe is relatively low with activity decreasing in the southern hemisphere after their recent peaks here in the US. We still haven't seen much flu activity, which is typical for this time of year. As of week 34 of the flu, 20 2223 influenza season. Remember weeks are Week one is the first week of January of that year. Week 52 is the last week of December of a given year. At this point, there are now six states experiencing low activity. And Georgia is the only state experiencing moderate activity during this last week of August. There were 33,251 clinical laboratory specimens submitted for influenza and only 266 or 0.8% of them came back positive. 170 for Influenza A and 96 for influenza B. As far as the rest of the northern hemisphere, activity also remains very low, which is again, very typical between influenza seasons. Most of the southern hemisphere is on the back end of peaks that occurred within the last month with some parts of South East Asia still experiencing elevated influenza activity. The Southern Hemisphere's flu season typically occurs between April and September, and while not always a perfect representation, can provide a preview for what is coming in the northern hemisphere. For example, last year, based on the southern hemisphere season, we expected to see increased levels of flu activity early.


Dr. Osterholm: [00:51:27] That dropped off quickly and then thus turned into an average flu season. And that's exactly what happened. It's not only helpful as a preview for the trends in activity, but also the strains we might expect to see circulate this past season. The Southern Hemisphere saw a few different strains circulating both Influenza A and B. Australia experienced similar proportions of influenza A and B viruses. Influenza A, H1N1. The pandemic strain and Influenza B were predominant in New Zealand, South America, Central America and Middle Africa. South and Eastern Africa saw mostly influenza. H3N2, Southern and Southeast Asia detected both Influenza A pandemic strain and a H3N2. With all this being said, I expect to probably see H1N1 activity in the northern hemisphere. But as I pointed out, we're really not seeing any major activity yet. And that is expected with this lack of activity in mind. Please don't rush out to get your flu shot any time soon. We will continue to update you on any flu activity and let you know when it's a reasonable time to get vaccinated. Remember that influenza vaccination protection drops off month after month after month from when you receive the vaccine. You don't want to be 4 or 5 months out from having been vaccinated when the flu season really starts. But for now, it's just too early to get vaccinated.


Chris Dall: [00:52:54] And finally, an addendum to our conversation last episode on attitudes toward vaccination among American parents. A recent survey from the sampling firm YouGov found that vaccine skepticism has now spread to pet owners. Mike The results from this survey are a little concerning, given that our pets are vulnerable to many vaccine preventable diseases. And while part of me wanted to laugh when I first heard these results, this could have serious consequences.


Dr. Osterholm: [00:53:23] Christmas is a very important point. We live today so closely with our domestic pets and dogs and cats in particular are really a gift in a lifetime for so many people. But when they become infected with certain infectious agents, they can also become literally life threatening experiences. And so for us, it's our job to do what we do for pets is what we do for humans to try to protect them from becoming infected with things like rabies. And then also at the same time eliminating that risk of them transmitting something to us. So I think these results are very concerning. The survey specifically focused on the rabies vaccine, which is recommended for all dogs. 22% of the 2200 respondents believe that the vaccine is ineffective and has risks that outweigh the benefits. 30% believe that the vaccine is unnecessary. Only 37% believe that the vaccine is unsafe and can cause cognitive issues such as canine autism, which does not actually even exist. 53% of the survey respondents believe at least one of these three claims. Unsurprisingly, this distrust of canine rabies vaccine is likely to lead to vaccine refusals. 48% of the survey respondents believe that canine vaccination for rabies is an individual choice, and 11% reported their dogs were not vaccinated against rabies. This is very concerning as rabies is nearly 100% fatal for unvaccinated dogs as well as humans. Rabies is extremely rare in the United States, but if we were to see rabies vaccination rates fall below 70%, it is very possible we could lose the herd protection that keeps pets and people safe.


Dr. Osterholm: [00:55:14] This is especially alarming in that it's likely that those who are unwilling to get their dogs vaccinated for rabies may also be more hesitant to receive the vaccine themselves in the event that they are bitten or scratched by a rabid animal. Most Americans are not vaccinated for rabies, as vaccination is typically only recommended for those with high risk of occupational exposure or as post-exposure prophylaxis following a bite or scratch from a wild animal. Rabies vaccines are nearly 100% effective for both animals and humans if given in a timely manner. There has only been one documented case of an individual dying due to rabies, despite receiving the recommended doses of rabies vaccine following exposure. All I can say is I believe that this rise in canine vaccine hesitancy will carry out also for other animal species, particularly cats. And I believe that they too can play an important role in infectious disease transmission to humans. I will never forget, quite honestly, as a young boy, us having a cat in a small Iowa farm town that had never been vaccinated, that actually developed rabies. And as a result of that, my mother had to go through rabies shots because at the time she had been caring for this sick cat and was scratched or bitten. Fortunately, she had rabies vaccine at the time. I wish we had vaccinated the cat. So I can only say, Chris, that the spillover, I believe from human anti-vaccine efforts is real in our domestic pet populations. And I think it's a huge, huge challenge.


Chris Dall: [00:56:49] Now for some more upbeat news in our latest moment of Joy submission. Mike, who did we hear from this week?


Dr. Osterholm: [00:56:58] Well, again, I just want to thank everyone who continues to submit these moments of joy. They really, truly mean a great deal to us. And we do hear from podcast listeners who too, find real value in these. So this one's from Amy and she wrote. Hi, Dr. Osterholm. First, let me say how happy I am that you're feeling better. Well, thank you very much, Amy. I wish I had my voice back today. I hope you're having a wonderful summer filled with family and friends. Many of my moments of joy come while gardening. I think you'll relate when I tell you that I'm landscaping my yard with native plants. I remember you saying that you restored land you own as well. Gardening brings joy to my life in many ways. Working in the garden is a form of meditation for me. I've seen so many insects I never knew existed. I also feel great pleasure seeing all the different bird species who find food, shelter and nesting material in my gardens. Joy also comes in forming connections with the human community. Working on my front gardens is a chance for a friendly hello to people walking past. I've built friendships with people who wanted to learn more about my gardens so they could plant their own. And I once saw a woman's face light up with joy when a monarch butterfly flew from my flowers to circle around the infant in the stroller she was pushing.


Dr. Osterholm: [00:58:18] You know how it feels when you're out in nature and have an unexpected close encounter with wildlife that leaves you in awe that the earth just honored you with a gift. That's the look she had on her face. And it happened right here in a suburban neighborhood. I don't think she even knew. I witnessed her moment of joy, so I didn't spoil it by calling it out. I simply appreciated the joy that welled up within me, knowing that my hard work had helped bring such a gift to a neighbor. In honor of that moment, I've including a picture I took of monarchs in my yard, as well as a link to the pictures on my website. Many thank to you and the podcast family. I wish for many moments of joy for all of you as well. Amy. Amy, thank you. The pictures you sent are wonderful and we will post those on the website here for the podcast. And thank you. I can very much relate to your point of what it feels like to be in the outdoors environment with these plants, with these insects, with these animals, the bird species. I'm still in awe after all these years of seeing the hummingbirds as they go from flower to flower. They just are remarkable, remarkable survivors. How they do that, I don't know. But it's remarkable. Thank you, Amy.


Chris Dall: [00:59:36] Just a reminder to our listeners that we would love to hear about your moment of joy. Even as we move past the pandemic. We know that we live in challenging times and finding the thing that brightens your day, even if just for a moment, is so important for our mental health. So what is the thing that you look to for a little bit of joy? It can be a place, a person, a pet, a piece of art, a memory or whatever you want it to be. You can share it with us at Mike, what are your take home messages for today?


Dr. Osterholm: [01:00:07] Chris, The first one is really, I think, the most important point that I could possibly make in any podcast is that, A, we're not done with COVID, but it is B in a very different place than it has been in the three previous years. And I think this represents a moment for us to have a mindset change, to say, okay, yes, it's coming back, what does this mean? Do you ignore it completely like they do at the US tennis tournament? Do you close schools when you have 35% of your students out sick? What do you do? Again. I already made the point we're not going to go back to mandatory masking of any kind, which actually wasn't all that common to begin with, even though many people assert it was. We're not going to be in a place where people are going to be restricted. But if you want to avoid serious illness, hospitalizations and deaths, you can do some things to protect yourself. Not counting on the public to do it. Get vaccinated, get that booster dose when it comes out, and make certain that you wear an N95 protection in public places where you might be at risk for transmission to you. So I think that's the number one spot. Number two is, you know, I covered the issue today on influenza and H5N1, and it surely was not meant to be a personal attack on anyone. But we got to start calling people out who are sometimes seen as credible voices when in fact, they are sharing a lot of misinformation or disinformation.


Dr. Osterholm: [01:01:45] And, you know, we got enough to worry about in this world. We don't need more things to worry about that are not really challenges. And we don't want to diminish those things that we really need to worry about. And I think sometimes they get so tied into personalities and and, you know, I trust him or I trust her or whatever, and it shall in the end be about data. I hope no one ever trusts me if I don't provide you the data you need. The data. That's what I hope to shared with you today on that. The third one that I want to share with you is, is that this ongoing issue about vaccines is real. And I think the piece that I just shared with you on domestic animal vaccination is really very important. We sometimes forget about the safety valve that those vaccines provide us as humans so that we can be in close and safe contact with our domestic pets all the time. And for where we have vaccines, particularly for dogs and cats, they have played an amazingly important role in keeping us safe and living our lives with those very, very special animals. So I worry if we're going to start seeing decreasing vaccination rates in those animals for these infectious agents, we're going to have a lot more human suffering coming down the pike.


Chris Dall: [01:03:06] And Mike, what is your closing song for this episode?


Dr. Osterholm: [01:03:10] Well, as you may recall, which now seems like eons ago when I opened this podcast, I talked about going back to school and our children and the system that supports them in that education and how valuable that education is. The one thing no one can ever take from you. Your education. So in keeping with that same theme today, we want to share with you a song from Into the Woods, one that I think is so, so appropriate for this moment. You may recall Into the Woods is a 1987 musical with music and lyrics by Stephen Sondheim and a book by James Lapine. The musical intertwines the plots of several brothers Grimm fairy tales exploring the consequences of the characters, wishes and quests. The main characters are taken from Little Red Riding Hood, Jack and the Beanstalk, Rapunzel, Cinderella and several others. The music is tied together by a story involving a childless baker and his wife and their quest to begin a family. Their interactions with a witch who has been placed a curse on them and their interactions with other storybook characters during their journey. One of the songs in this beautiful musical play entitled Children Will Listen, was part of Act 2 in the Prologue. And I think after you listen to these words today, you will agree how it fits so well with the dedication today.


Dr. Osterholm: [01:04:36] So here it is. The children will listen from into the woods. How do you say to your child in the night, nothing's all black, but then nothing's all white. How do you say it will all all be all right when you know that it might not be true? What do you do? Careful the things you say. Children will listen. Careful. The things you do. Children will see and learn. Children may not obey, but children will listen. Children will look to you for which way to turn, to learn what, To be careful before you say. Listen to me. Children will listen. Careful. The wish you make. Wishes are children. Careful. The path you take. Wishes come true. Not free. Careful. The spell you cast not just on children. Sometimes the spell may last past what you can see and turn against you. Careful. The tale you tell that is the spell Children will listen. How do you say to a child who's in a flight? Don't slip away and I won't hold so tight. What can you say? That no matter how slight, won't be misunderstood? What do you leave to your child when you're dead or whatever you put in its head? Things that your mother and father have said, which were left to them, to.


Dr. Osterholm: [01:05:55] Careful what you say. Children will listen. Careful. You do it too. Children will see and learn. Oh, guide them, then step away. Children will listen. Tamper with what is true and children will turn. It's just to be free. Careful before you say. Listen to me. Children will listen. Thank you very much for being with us again today. We I hope we provided you with the kind of information you're finding useful and helpful. An interesting time, to say the least. And I hope in two weeks from now I'll have my voice back and you won't have to deal with this gravelly sounding whatever it is. But thank you so much for being with us. And again, I can't say it enough times. It means more to me literally every day of my life. But kindness, kindness is such an important part of what we need in this world right now. There's so much turmoil, there's so much pain, there's so much suffering, but one act of kindness every day when magnified by the next person who does it? Who does it then? Who does it? Who then who does it? That will make the world a better place for you and for others. Be kind. Thank you very much.


Chris Dall: [01:07:15] Thanks for listening to the latest episode of the Osterholm Update. If you enjoy the podcast, please subscribe rate and review wherever you get your podcasts and be sure to keep up with the latest infectious disease news by visiting our website This podcast is supported in part by you, our listeners. To contribute, please visit The Osterholm Update is produced by Sydney Redepenning, Elise Holmes, Cory Anderson, Angela Ulrich and Meredith Arpey