March 7, 2024

In "A Tough Conversation," Dr. Osterholm and Chris Dall discuss the new CDC COVID isolation guidelines, a measles outbreak in Florida, and the latest news on avian influenza. Dr. Osterholm also provides an update on influenza and RSV cases in the U.S. and shares the latest "This Week in Public Health History" segment.




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Chris Dall: Hello and welcome to the Osterholm update, a podcast on COVID-19 and other infectious diseases with Doctor Michael Osterholm. Doctor 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, Doctor 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 Dahl, reporter for Cidrap news, and I'm your host for these conversations. Welcome back, everyone, to another episode of the Osterholm Update podcast and a busy episode. It will be, as there has been a lot of COVID related news since our last episode. Among the topics we'll be discussing on this March 7th episode of the podcast, after we examine the latest COVID-19 data from the United States and other parts of the world, is the recent COVID vaccine recommendation from the Advisory Committee on Immunization Practices. Another is the CDC's new COVID isolation guidelines, and the reaction we received from some of our listeners on today's episode. We're also going to spend some time discussing the measles outbreak in Florida and the actions of Florida's Surgeon general. We'll also provide an update on COVID-19 variants, look at the latest flu and RSV data, discuss some recent avian influenza news, and we'll bring you the latest installment of This Week in Public health history. But before we get started, we'll begin with Doctor Osterholm's opening comments and dedication.


Dr. Osterholm: Thanks, Chris, and welcome back to the podcast family to another edition of the update. As Chris noted, we have a lot of information to cover today, and some of it will be of, I think, real interest to you personally, but I think also we're going to talk about some big picture issues that, uh, if nothing else, I hopefully, uh, causes you to think about where we're at in this pandemic and what we can do about it. Uh, let me start out, as I always do, and, uh, thank you for your feedback, your input. Uh, this particular episode will illustrate just what kind of feedback we get and, uh, what it means to us. And I would also start out, uh, just with, I think one prerequisite that if it's never stated, if each and every opening of the podcast it should be, or at least it surely should be understood. And that is in the end. Uh, we're here to help provide you with the best information we have. Uh, you know, I promised you that from the very beginning in 2020 and have tried to live up to that. Uh, in some instances, that's not always been easy, because it didn't seem to always go with the general prevailing notion of the day. Uh, but I think time has handled our predictions and our comments well in the sense of how we could validate what we were concerned about or that we needed to address. So thank you again for being with us. Uh, and I also just want to again, thank the podcast team for all the work that they do to help me get ready for this.


Dr. Osterholm: And in terms of my dedication, I want to note that I'm really kind of speaking out of, uh, different parts of my brain. You might say one is very scientific and one is, uh, it's very least, uh, somewhat emotional. And I say that because today I really want to address the issue of measles cases in the public and what they represent in terms of where we're at in public health in this country and around the world. Unfortunately, it feels like the rise in measles cases that you've all heard about is matched with the rise in the coverage for the anti-vaccine movement. I'm sure many of you are like me and can barely bear to hear the disinformation about vaccine safety and efficacy being shared in the news, on social media, and even in our own social circles. There unfortunately continues to be a large platform for these who hold large megaphones to denounce vaccines, and even this past week to suggest that polio was not caused by a virus, but a toxin. So in an intentional effort to shine a light on the other direction, I'd like to dedicate today's podcast to caregivers who do make the choice to vaccinate their children and all the health care and public health professionals that promote and provide vaccines. You are my heroes. And note that we didn't say parents necessarily, although there are really an important part of the caregiver group, because we recognize there are children today who are living with relatives, who are living within social services related housing and oversight.


Dr. Osterholm: Um, all of you who have some impact on what happens to your children or grandchildren really are among these caregivers that we salute today. You are real heroes, and just know that there are more of you than you might think. Despite the outsized outrage and coverage, still, about 88% of American adults say the benefits of childhood vaccines for measles, mumps and rubella outweigh the risk. While this is surely good news when we actually look at coverage, though, we do have to acknowledge we have some big holes. For example, right here in our two metropolitan area counties, Hennepin and Ramsey, Hennepin being the where Minneapolis is located, and Ramsey, where the City of Saint Paul is. And if you look, we actually have three schools which have less than 25% of their kids vaccinated, 20 schools that have only 25 to 49% of their kids vaccinated, and 50 schools that have only 50 to 74% of their students fully vaccinated. These are really scary numbers in terms of the pockets of susceptible children that are out there. So thank you to you caregivers who trust and follow the science of vaccines and continue to push against this anti-vaccine world. I hope you share your reasons for vaccination with others who are reluctant to protect themselves and others by following vaccine recommendations, and thank you health care professionals who provide vaccines to patients and community members. You don't need me to tell you how many lives you've saved by doing so.


Dr. Osterholm: All of you have our deepest appreciation and this podcast is dedicated to you. Now, let me also add that moment of light today in Minneapolis, March 7th, I'm happy to report that the sun rises at 6:39 a.m., sunset at 609. That's 11 hours, 30 minutes, and 16 seconds of sunlight soon approaching the spring equinox when we'll be at. 12 hours. That's exciting. Right now we're gaining about three minutes and eight seconds of light every day, and will only be surpassed by the March 12th to March 23rd period, when it will be three minutes and nine seconds. One more second and then the increase will continue, but it'll be at a slightly slower rate. And of course, our dear, dear friends in the Occidental Belgian Beer House on Vulcan Lane and Auckland. Uh, today your sun rises at 7:11 a.m., your sun set at 751. Uh, you still have more light than dark. You have 12 hours and 39 minutes and 18 seconds of sunlight, but you are losing a bit at two minutes and 22 seconds a day. I also want to thank Roger and Jane, who sent me an email with a picture from the Occidental. Uh, it's amazing how many of the podcast listeners end up frequenting that place. Uh, as we've said before, we're going to have to get some menu item or some drink named after the CIDRAP for the Occidental. Thank you again, everyone, for joining us. And as Chris said, and I agree with, we have a lot to cover today.


Chris Dall: Let's start with the latest COVID data. Mike, what are you seeing on the domestic and international fronts?


Dr. Osterholm: Well, Chris, it's good news. Uh, and in this business, I'll take whatever good news we can get knowing that, uh, six months from now, things may change a bit. And in the US, we've seen that firsthand throughout the past 4 to 5 months. We have reasons to be positive. Remember, we had a bump of activity that peaked last September and then subsequent increases from November into January. The good news is that the activity here has largely decreased since that early January peak. At the height of the peak, just over 30,000 Americans were in the hospital with COVID, up from less than 13,000 exactly two months prior. Again, remember in January, 30,000 Americans in the hospital with COVID. However, according to the latest CDC data that's available, which is for the week of February 24th, that number has dropped to around 15,500. So we're at 13,000, went up to 30,000. We're now back to 15,500. We've actually had seven consecutive weeks of declines, and we've actually had a 10% drop in hospitalizations just this past week. For the most part, this tracks with the wastewater data we're seeing, which has also declined since the start of the new year. That said, even with those declines, the national activity levels are still considered high and the South in particular is still reporting levels quite a bit higher than what we're seeing in other regions of the country.


Dr. Osterholm: At last, we're finally now seeing deaths start to decline. After reaching a peak in mid January of just over 2500, in a single week. Again, every time I talk about numbers like this, I want to remind all of us these were our grandpas and our grandmas, our moms and our dads, our brothers and our sisters. And even, unfortunately, some of our children. As of early February, which is the latest period we have data for weekly deaths have dropped below 1600. However, that still represents the 25th consecutive week where COVID deaths have exceeded 1000. And even with the declines, we have a ways to go before we see numbers like we saw last summer when weekly deaths sat at around 500. So we're on the right trajectory. We just need to keep maintaining that, and we're going to talk more about that in a moment, about how we can support that decreasing number of cases in this country. Now let me move to the international picture on a global basis. Reporting continues to be a challenge that's only getting worse. Again, according to the most recent COVID situation report that was put out by the W.H.O. on February 16th, more than two thirds of the world's countries, 68%, did not report even a single case of COVID to the agency. In the latest 28 day period from January 8th to February 4th, we clearly know that that means we're missing a fair amount of activity around the world.


Dr. Osterholm: Only 12% of countries consistently reported hospitalization data, and less than 1 in 5 countries, or 18%, reported even a single death. That being said, based on the data we do have available, most countries appear to be experiencing declines in activities for many of these places, including Canada, the US, a number of the European countries, Australia, New Zealand and others. These declines have followed recent periods of several months where activity was either increasing or notably high. At the same time. There are some exceptions to these declines, with recent increases in activity across parts of Latin America, including Argentina, Chile, Colombia, Ecuador and another distinct wave in Japan, the second highest that they've had in the entire pandemic. But I also want to add that it looks as if the cases have peaked in Japan and are coming down. And as I have said a number of times in previous podcasts, I just want you to take note of the increased cases that are occurring in the Southern Hemisphere, which is occurring during their summer months. This virus has clearly not become a seasonal virus as we think of with influenza and RSV. The recent upticks, as I just discussed, are the latest example of the reality we're facing when it comes to living with COVID ongoing ebbs and flows, with a rudimentary understanding of the factors at play, even with things like waning immunity and variants, which we surely know play a role, we still don't understand the when, where and why of these waves.


Dr. Osterholm: How does the virus variance in waning immunity interact? What does that mean? Why are we seeing an uptick in cases in South American countries this past month? It started literally, as I said, in their summer season, we know that the variant JN.1 Has established itself as the dominant variant, accounting for 90% of cases worldwide. What role has that had? Limited sequencing in South America makes it difficult to know if that's what's been driving their activity, based on when it became dominant in other parts of the world, such as North America and Europe. I wouldn't be surprised if JN.1 Has already been dominant for quite a while in these South American countries that are now seeing these increases. Some previous examples also suggest that JN.1 Dominance didn't always coincide with the rise in activity. What do we know about that? Surely not a clear cut situation. More than four years since the COVID's emergent, and is still an issue which requires us to be sufficiently humble because this virus is still largely doing things that we don't understand.


Chris Dall: So you just mentioned the dominance of the JN.1 Variant, which accounts for more than 92% of cases here in the United States. Mike, are there any other variants out there that appear primed to challenge JN.1


Dr. Osterholm: Well, Chris, the short answer really is no. Following my motto that emergent variants are innocent until proven guilty. The latest development on this front is the BA.2.87.1, which was detected outside of South Africa, notably in Southeast Asia. Listeners may remember that this variant appeared to originate from a single immunocompromised individual. We talked in previous episodes that the apparent containment of BA2.87.1 was a good sign. It had not spread like wildfire and expanded its reach. Its detection in a small number of samples from wastewater surveillance in Southeast Asia is not a reason to be greatly concerned now, but it could be an early indication that this variant will ultimately have some pretty notable legs. The longer BA2.87.1 lingers via community transmission, the more opportunity it will have to further mutate and become competitive. But at the end of the day, it is still too early to tell whether or not it will challenge JN.1, especially in the United States. Another possibility is that the JN.1 subvariants with certain mutations in its spike will start to account for a large proportion of infections. I don't have an update for JN.1.23, which we briefly discussed in the last episode, but I'm seeing reports of several other divergent lineages with unique mutational profiles, such as JN.1.13 And JN.1.18, which has already been designated by the CDC. Each of these semi newcomers will have a combination of advantages and disadvantages that culminate in immune escape versus ACE2 binding profiles, two central factors in variant assessment. It is unclear at this point whether the vaccine efficacy from an updated shot would continue to demonstrate moderate protection against this lineage, but I'd much rather be safe than sick. In fact, I got my spring dose of my XBB.1.5 vaccine as soon as I could this past week, which we will talk about more later in this episode. I wish I could give you more information to define just what role these variants will continue to play going into the future. All I know is just keep your seatbelt buckled.


Chris Dall: So let's discuss the latest recommendation from ACIP, which met last week and recommended that people ages 65 and older receive an additional dose of the current monovalent COVID vaccine. Mike, I don't think that recommendation came as any surprise since that is the main at risk group. But should it have been broader?


Dr. Osterholm: Well, first of all, Chris, I want to congratulate the ACIP for what I thought was a very exhaustive discussion and data analysis to come to the conclusion that they did about recommending this additional dose. And I think it's very clear that they are looking at this in the appropriate way, not as a seasonal virus vaccine approach, meaning that they've categorically rejected that in their discussions. And very similar to the comments I just made a moment ago about activity in the Southern hemisphere. There's still no evidence that this is a seasonal virus illness, but what they did then is basically set this up so that potentially six months from now, when we will, by the way, have a new vaccine, it will be updated before the fall of 2024, and at that time would allow those of us who just got a new vaccine dose to be able to get the new additional dose in the fall. As I noted earlier, I'm very happy to report that I received my updated vaccine on Saturday of this past week, and each day I get further out from that vaccination, I feel more confident that my immune system has been boosted again, and the likelihood of developing serious illness, hospitalization or death has been substantially reduced. But we do have a challenge with vaccine uptake right now is extremely low, with only 22% of Americans over 18 and more troubling, only 43% of adults over 65 receiving this monovalent COVID vaccine. With these numbers, there is no shortage of vaccines and no reason to be restrictive about administering the doses we have. I just don't see any reason to prevent the small percentage of Americans who want to get a dose of vaccine and protect themselves from doing so. This virus, as we all know, is unpredictable, and I hope that going forward, we can have permissive recommendations that allow those who want to remain protected year round to have that ability.


Chris Dall: And make a brief follow up, because I know a lot of our listeners are interested in knowing what vaccine you chose. Uh, for the recent booster shot. So can you talk about that? And does it really matter?


Dr. Osterholm: Well, first of all, let me just say that it all three of the current available vaccines should be used. So to me, the most important thing is getting to a pharmacy that has one, 2 or 3 of those different, uh, uh, types of vaccines. So that is the by far the most important thing. Uh, I think we're not in a position right now to say one vaccine over another. Uh, you'll go into social media and see where some are actually making claims about, uh, one particular vaccine, potentially having less side effects, etc.. But I think the bottom line message right now is get your dose of vaccine, particularly if you're over age 65 or your immune compromised. I think that's the important message.


Chris Dall: Now on to the CDC's COVID isolation guidelines, which we discussed on our last episode when they were still in the works. Now, as most of our listeners know, they are official and we've received some emails from our listeners that, for the most part, respectfully push back on your position. So, Mike, has your opinion changed at all now that these guidelines are official, and is there anything you want to say in response to some of the emails that you've gotten?


Dr. Osterholm: Well, Chris, let me just say that I don't remember a moment in the 151 episodes of this podcast that we've recorded over the course of the past four years, where I have tried to best understand this incredibly unique relationship that we have with our podcast family. At this point, I just want to thank all the listeners who have reached out to provide feedback, even though you may not agree with what I have to say. As I've said, this truly is a podcast. Family and families sometimes have disagreements and sometimes really challenging disagreements. That said, I want to reiterate and elaborate on a few points that I made in our last episode as they came up and the emails that we've received. First of all, let me just share a sense of some of the emails that we received back, and I welcome all of them, even if some of them sting and sting badly. You know, I have never pursued this podcast for any other reason than to help you understand what we understand about COVID and what it's doing to our lives. So here's an email that came from Faye. Uh, and I will read it as she wrote it, so that you get a sense of what challenges we might have to address in terms of sharing this information with you. She wrote, dear Doctor Osterholm and team, it is with a heavy and hurt heart that I write this email.


Dr. Osterholm: I've been part of the podcast family since episode one and have supported Cidrap financially. But after Doctor Osterholm's comments these past few weeks and hitting a fever pitch with the CDC announcement of the potential one day isolation and Doctor Ostrom's endorsement of that preposterous recommendation, I can no longer in good faith, be part of this family. I am so saddened that you are willing to make a mockery of public health and throw a 50 plus year career down the toilet just to beholden to the capitalist enterprise. You yourself say you're no longer following science, but rather what everyone is doing anyway, so it is pointless and useless to bother wasting my time listening to the podcast. Which makes me sad because for a good portion of the last four years, you have been a trusted voice of reason and nuance. Faye, I, uh, read your email multiple times and, uh, and all those that I received in a similar vein, let me just make a couple of general points. And this is not to be defensive or to defend our group. I want to be really clear that anything that is in the Osterholm Update, week to week to week is my responsibility. The team does an amazing job of helping to prepare the background information, but in the end, it's me that makes the choice of what gets said and how it gets said.


Dr. Osterholm: So if people have a problem, it's not with the team. The team is an amazing group of individuals who I am deeply in debt to. It's me. So let's focus on that. So I'll, I'll I'll be the, uh, point of the discussion here today. Second of all is that I have, from the very beginning of my career, challenged the norms in public health time and time again. But I always did it based on the science. And I think the time has been its own judge of what those different issues that I've taken on, even with COVID. Uh, it was very painful for me in the early days when January 20th of 2020, I wrote a piece on the CIDRAP site saying this was the next pandemic, COVID was it, get on with it. And by far the most, uh, voluminous amount of email I got that was quite negative was from my colleagues who thought that I was sensationalizing the situation and scaring people. Um, I can go down the laundry list of issues that we took on, uh, early on when masking, uh, was such a hot topic and so many people were proposing what could be done by just wearing a cloth mask or a bandana. And we came out very strongly against that, talking about how respiratory protection could be a critical part of reducing risk, but you had to have the type of respiratory protection.


Dr. Osterholm: So I think that over the period of, of the past four years, we've taken difficult positions, but we've always based them on the science. And so I want to be clear, we have not said we're no longer following the science. That's just simply isn't the case. And if, in fact, what I say, uh, means that my career is going down the toilet, I will never change what I say. I will base it on my best science and best experience. So as I approached this discussion, I just want everyone on the podcast to know that we do listen to you. We do hear you. We do take your information that you share with us very seriously and at the same time as with family, I hope that we can sometimes agree to disagree in a positive and supportive manner, and I will continue to do that. We need and want to hear your comment. So let me just go back to the issue of. What we're talking about. And it really should boil down to one simple thing. We're trying to prevent people from becoming infected with COVID, and specifically targeting those individuals who are most likely to have serious illness, require hospitalization, and ultimately die. To me, that has been my goal from the very beginning. It had nothing to do with politics. It had nothing to do with financial considerations, had nothing to do about agreeing with my friends or not agreeing.


Dr. Osterholm: I believe very strongly that one's record in a lifetime should always be about how did you follow the science and when the science wasn't completely clear on a given topic, how did you proceed? Let me just say that the CDC's updated respiratory virus guidance, I think, makes very good sense. And it is all about reducing the risk of serious illness, hospitalizations and deaths. And you say, well, how can that be the case? Well, there have been a lot of reactions from individuals who, by the very nature, have not reviewed the data or understood the background of why these recommendations make sense. Rather, they've reacted. And and I know some of you in the podcast family here have reacted to what appears to be a just a not following the science kind of picture. Well, let me just paint again an example of where it's not a nice clean. If you just do this, everything will be okay approach. As I pointed out in the last podcast, and as the CDC highlighted in their background document for addressing this new guidance, upwards of 50% of all the transmission that occurs with COVID is either from asymptomatic, infected individuals or people who are presymptomatic, meaning that in the earliest time period before they have their first symptoms. If today I could eliminate all transmission from those individuals who are experiencing illness, who get tested, who are positive, it would materially only impact the whole experience with COVID very, very little, because that 50% that are infected not knowing it or who are infected and then only later become symptomatic will continue to drive transmission.


Dr. Osterholm: So when I look at how I'm going to protect those from serious illness, hospitalizations and deaths, whether or not we ever have clinical cases that we are talking about here in terms of identification and and the isolation procedures, it's not going to change. We need to have a major focus on how do we pursue getting those 65 years of age and older vaccinated and keep them vaccinated every six months? How do we assure that they will have rapid access to Paxlovid if they do become clinically ill? How do we talk about masking? I find it's so difficult when I hear people say over and over again, if we just mask, look what can happen. And yet they never define what masking is. And I see this time and time again, this problem. I mean, I talked about this in a previous podcast, but I actually surveyed some of my dear colleagues in the Harvard Training Hospitals of Boston who acknowledged that they're less than 20% of the procedures or activities that should have required an N95 respirator to be used were being used, and rather, they were using surgical masks.


Dr. Osterholm: So I think the priority here is that we are not going to materially change the risk of transmission with these recommendations. And you say, well, that just doesn't make any sense. Well, let me just get into the document from the CDC and share with you what we're up against. First of all, we have to recognize in public health, we are not living in the 2020, 2021 or 2022 time periods. Now, that doesn't mean that if you get seriously ill and die today, that's not important. And it was back then. It still is. But now we are in a transition phase. We really do have a very real difference in what's happening today than happened before. And what we need to be mindful of is how are we consistent with regard to all the other respiratory infectious diseases. So when you look at COVID, it still remains a greater cause of severe illness and death than other respiratory viruses. But the difference between these rates are much, much smaller now than earlier in the pandemic. So when we look at this issue, what are we doing with influenza? What are we doing with RSV and how are we responding to those? Over time, the rates of hospitalization for COVID-19 have decreased across all ages, but have remained higher among those age 65. Years of age and older relative to younger adults, children, and adolescents.


Dr. Osterholm: Among older children, rates have decreased and rates among children are now um, highest among those infants less than six months of age. As the end of December 2023, about 70% of hospitalizations were among people 65 years and older, and only 14% were among those aged 50 to 64. Why do I come back to these data? Because if you want to have the most juice for the squeeze, we should be highlighting and constantly emphasizing the need to get those 65 years of age and older vaccinated. And I don't see that effort anywhere in our community of any note. The fact that we still have the few number of people vaccinated who are in long term care is really a critical issue. So if you want to have the most return on the investment right now, we should be concentrating there. We should be making sure that people get Paxlovid, particularly in that age group. And that's just not happening. If you look at in the CDC research, they actually summarized the reported COVID deaths for 2023 to 2024 through February 17th. And in the United States, there were 32,949 deaths reported. Tragic. But if you look at the estimates for flu deaths and these are estimates because we don't have the same level of granularity and reporting there, they estimate anywhere from 17,000 to 50,000 deaths, a wide number have actually occurred among flu deaths during that same time, which is right in the same place that we're seeing COVID deaths.


Dr. Osterholm: If we really are so concerned about COVID, we should be having an entire national discussion about what do we do to increase flu vaccines, how do we, in fact, get those vaccines into those who are older? This is the kind of discussion, I think, which would be much, much more helpful. When we look at the increased immunity in the population and immunizations, it becomes clear we're missing out. As of this past February, as I pointed out, 22% of adults reported they had received an updated 2023 2024 vaccine, including only 42% of those people over age 65. Vaccine uptake varies geographically and by other demographics, and really shockingly, as of this same early February time period, only 40% of nursing home residents were up to date with their COVID vaccine, so we could greatly reduce those with COVID-19 associated hospitalizations if we would focus on getting vaccine to this group of high risk people and getting Paxlovid. Now, do I want to reduce transmission? Yes, I do, and if you look at the studies that and they're cited in the CDC document again, which is linked in our website, and you can see these nice charts and graphs that show what is the likely level of virus activity in someone who is infected, not even asymptomatically. But symptomatically you can see that the culturable virus actually peaks at about 2.5 days after onset and then drops rather quickly.


Dr. Osterholm: So that in fact, if you get out to day 4 or 5, six and seven, less than 20% of those people are positive by culture itself. Which means that, again, it's not just is it there, but what's the level of the virus there, which in many cases somebody can be infected but not very infectious. How many times have we had members of this podcast family be in households where someone was infected and they never got infected, even though they were around that person? You know, what was the level of infectiousness? And so I come back to this and say that at the margin, we're not going to take out a big risk pool of people transmitting to others with this kind of information. Now, grant you, I'd like to take out everything. But you know what? As I pointed out last time in the data, support this. If in fact, we can get people to test at all, we're going to get them to test if in fact they don't believe that they're in for ten days, then that will help us hopefully keep them out for those next few days, which is the highest period of infectiousness. Don't think of ten days as being a highly infectious time period. Rather, it is in fact those first couple of days.


Dr. Osterholm: That's what we need to get out. It's kind of the old 8020 rule. I think if we could get 20% of the people, uh, in those first couple of days, to not be out amongst the public who are wearing adequate respiratory protection, we could maybe eliminate 80% of the transmission from that group. So I think that's a very important point. And let me just add that also. We have looked carefully as a public health community at the Oregon Data. As you may recall, last summer they put in place this very same testing and isolation protocol, and they looked at the data in Oregon versus the US as a whole, but more specifically, the state of Washington nearby, which had not put into place any changes and the data were identical. There was no evidence of increased transmission, uh, in in Oregon. In addition, I think most people aren't aware of it. The Canadian provinces of Ontario, Quebec and British Columbia, as well as countries like Australia, Denmark, France, Norway have all put in place very similar recommendations for months and they too have not seen any evidence of increased risk of transmission. So I just want to lay out the fact that I would be the first to say, you know what? Everybody ought to stay home for ten days. Uh, we ought to have some way to know that you got to mandate testing.


Dr. Osterholm: Whatever. If I thought we were going to save lots of lives, the way we're going to do that is acknowledging this very high risk of asymptomatic transmission and meaning we have to protect those who are at highest risk of serious illness, hospitalizations and deaths. Please join us on that level. That's where we ought to be taking the positive energy and really trying to emphasize that we should be emphasizing that, as the CDC recommendations do, if you are infected, you test positive at least for five days. You know, wear a tight fitting mask. They say, I wish we'd get rid of that term and say they should be using N95 respirators. If you're going to go see Grandpa or Grandma or somebody at high risk test before you go again, the PCR test will in fact tell you if there's viral debris there, not necessarily if you're infectious, but if you are positive, then I would definitely not go. Those are all still there. Finally, what I find really difficult is how many hospitals and health care facilities in this country continue to have their workers or patients wear a surgical mask as a means of protection against either becoming infected or transmitting the virus? The CDC guidelines don't change that. They still emphasize the need in health care facilities to actually follow the entire ten day period. I wish they were much stronger on wearing N95 respirators versus wearing a surgical mask.


Dr. Osterholm: Uh, but the bottom line is that hasn't changed. So let me just conclude it by saying, you know, Fay, I heard you, uh, did it hurt? Yeah. You know, those emails hurt. I'm. I'm human. I'm like, all of you. Okay. Uh, I would never sell my science out. And I hope that over the course of my career, I have made protecting the public's health my number one, two and three priorities. Um, if, in fact, people feel this way. I'm sorry. I wish that weren't. The case is with family. As I've talked about, sometimes we can surely disagree, but I hope that we can also have a productive discussion about what can be done. I won't give up, and trying to reduce the risk of serious illness, hospitalizations and deaths with COVID, I've lost too many close friends. I've lost people who will mean something very special to me from COVID. I've been there with COVID with regard to my long COVID of four plus months. I know that. And so I just so I just make a pledge to all of you on this podcast. I'll keep putting this information forward. It may not be popular, it may not even necessarily seem as if it's helpful, but it will be based on the best science that we have. And what I've just shared with you is the best science.


Chris Dall: Let's turn now to measles. Over the last few weeks, nine measles cases linked to a school outbreak have been confirmed in Florida's Broward and Polk counties. And as we've discussed on the podcast, this is something we've seen in other parts of the country as vaccination rates drop. Florida is one of 11 states that have seen measles cases this year. And in fact, according to the CDC, there have now been 41 measles cases in the country this year, compared to 58 for all of last year. But the bigger news here is the reaction of Florida's surgeon general, who has contradicted medical guidance by telling parents it's up to them to decide whether unvaccinated children who have not yet had the disease should stay home. The normal recommendation is for those children to stay home for three weeks to contain the spread of the highly infectious disease. Mike, your thoughts?


Dr. Osterholm: Well, Chris, it's clear that as I noted in the introduction, measles is a very serious challenge for us right now in public health. And let me just remind our listeners of what measles is all about, because we've been blessed by not having been confronted with measles in any large way for many, many years because of our vaccine programs. But if you look at the data, it's actually a very scary disease. One out of five individuals who develop measles are hospitalized. One out of 20 will develop what can be a very serious pneumonia. One out of a thousand actually develop encephalitis where the virus actually infects the brain. 1 to 3 out of every thousand will die. It's a very real challenge for pregnant women and pretum delivery. And as well as another disease called subacute sclerosing panencephalitis. Big words, we call it SSP. Ssp is 100% fatal and occurs in about ten per 100,000 people who are infected with the measles virus, where the measles virus then causes this combination of viral infection immune response to result in this picture. So this is a serious disease. Do not take it lightly on top of it. It is highly, highly infectious. So what do I say about where we're at? Well we're seeing measles activity taking off around the country, as you noted, with 41 cases reported in the US so far in 2024.


Dr. Osterholm: Give it another couple of days and those numbers could be substantially higher. For context, we've had 58 cases reported in all of 2023. So although 41 cases may not seem like a lot, it is much more than we would typically expect to see with measles. The worst of this is in Florida, where you mentioned, Chris. Nine cases have been reported, most which are associated with an outbreak in an elementary school in Broward County. The amount of information coming out of Florida has been extremely limited by both the state and local health departments, by orders of the state health department, notably, the CDC guidelines for controlling the spread of measles state that unvaccinated children that may have been exposed to measles at school should quarantine at home for 21 days, which is the full incubation period for measles. However, as you just mentioned, Florida's Surgeon General Joseph Ladapo recently sent a letter stating that the decision to quarantine an unvaccinated child that has been exposed to measles should be left up to the parents. This is extremely, extremely concerning, particularly because I suspect that many parents who choose to ignore public health guidelines by not vaccinating their children will also choose to ignore the CDC guidelines to have their children quarantined following exposure.


Dr. Osterholm: This will clearly lead to many exposed and potentially infectious children attending school furthering the spread. Though many cases of measles are mild, as I just pointed out, there are some very serious consequences for this disease, and particularly for those under five years of age. Now, let me just also put into context the impact that vaccine has and how we have to still understand we can have challenges in our community. Remember, as I pointed out earlier, in Minnesota, in Hennepin and Ramsey counties, the Minneapolis-Saint Paul counties, we have over seven. We have 70 schools that have fewer than 50% of their children up to date on their childhood immunizations, including measles. Think of that. These are huge holes in our system of trying to vaccinate kids. In addition, let me just point out that measles vaccine is about 95 to 97% effective, meaning that that's the protection you can expect. That's that's amazing. That's very high. But let's just do the math. If in Minnesota and it's true for every state, we have an annual cohort of children who are born who then quickly fall into that process, time for getting their vaccines. In Minnesota, roughly 60,000 kids are born each year. Now, if 5% of those kids do not develop a protective response from the vaccine and the other 95% do, that's just great.


Dr. Osterholm: But if you look at the fact of that cohort over a five year period, that's 300,000 children, that means that 15,000 of those kids, 5% of that 300,000 cohort, will not have protection against measles from their vaccine. Now, the vaccine is still really good. It's protecting 95% of the population. But you can see how between the combination of not vaccinating children intentionally and even vaccinating your child, but yet being one of those 5% who don't develop protection from the vaccine, you can still have a problem. So. Parents, please. If in fact you think you're home free, there's a good chance you are. If your kids are vaccinated but you may not be, you have an interest in what happens in your school and in your community, because your child may actually be one of those that could still develop measles. So I look at this and I say to myself, wow, this is really, really important that the public understands one, the significance of this illness and what it can do to how infectious it is. And three, the fact that even those who have done everything right to get their child vaccinated still may end up becoming a measles infected family. So let me just reflect back on Florida, the surgeon General's statement that parents can continue to send exposed children to school.


Dr. Osterholm: You're going to clearly put many children who are not vaccinated or who just didn't develop protection at great risk. When we look at the potential for transmission of measles, we have to understand also today in our medical care system, many people have never seen measles before because it's been absent for so many years. We have this situation happen recently in Michigan, where an individual who had measles actually went to two different outpatient clinics and ultimately sat in an emergency room at a hospital for an extended period of time, no one realizing that the individual was suffering from measles. How many people were exposed in those outpatient clinics? How many people were exposed in that emergency room? And this is only going to continue to be a greater problem. So we need to put a strong focus on measles prevention at this point and not find ourselves months from now talking about hundreds and hundreds and hundreds of cases and a number of deaths. It would be a tragic failure if, in fact, we find that the only way we can move people to vaccinate their children is, in fact, if they experience serious illness or deaths in their community. Among kids who were not vaccinated or who were but still lack protection.


Chris Dall: And now for our ID query. And this week we've gotten several questions about measles. And these questions have come basically from listeners who are age 50 and older. And what they want to know is whether they are still protected from measles if they were vaccinated as a child.


Dr. Osterholm: Well, Chris, this is a great question. And it's one that many epidemiologists are very interested in in terms of how durable and how long does protection last, uh, with, uh, measles vaccine or measles infection, uh, when in fact you're not re-exposed to measles. And what I mean by that is, in fact, uh, in the days when measles was still around and it circulated, if I initially had protection because I got measles or I had been vaccinated, and then I got exposed again, we get what we call an antagonistic response, where basically your immune system is almost another dose of vaccine gets boosted. And when you have infection occurring in the community, that's obviously a cost to society because people get really sick. Uh, but it also provides an additional kind of protection in a way for those who have already had exposure, because now it just boosts your immune system. So let me try to take a stab at this. And the short answer to this question is that according to CDC guidelines, most of our listeners are probably protected against measles, either through vaccination or previous infection. But there are some exceptions I want to explain. First, let's start addressing those who are considered to be protected against measles. Anyone born before 1957 is considered immune from measles due to the exposure to the actual virus. I remember very well, as a young child actually having a classmate in, uh, early days of school actually dying from measles infection.


Dr. Osterholm: Uh, we had it. I had measles as a child. I didn't have the luxury of vaccine. So that's why anyone born before 1957 is pretty much considered immune from measles. Due to the natural exposure, preschool aged children are considered immune if they had received one dose of MMR vaccine, and school aged children are considered immune if they've received two doses of vaccine. Now, remember, I just covered the situation where measles vaccine has a level of protection of 95 to 97%, which over time can lead to an accumulation in our communities of a number of children who are not fully protected. So it's a general statement to say these individuals are considered immune and in most instances they are. It is clearly a bit more complicated for adults. Most adults are considered protected if they had just one dose of MMR vaccine, which most listeners of this podcast likely got during childhood. However, for adults at an increased risk of measles exposure, the CDC guidelines state that two doses are needed in order to be protected. Adults at an increased risk for measles exposure include students and institutions of higher education, health care workers, and international travelers. If you fall into one of these categories and or under the age of 39, you likely have already received two doses of measles vaccine and don't need an additional dose. If the ACIp stated. Recommending a second dose of measles vaccine for school age children in 1989, in some states, health care workers were required to receive two doses of MMR vaccine or provide evidence of existing immunity through previous infection.


Dr. Osterholm: So if you're a health care worker, you may have already received a second dose. If you haven't received a second dose of the MMR vaccine and believe you may be at increased risk of measles exposure, please talk to your health care provider. They can help confirm your risk of exposure and may be able to help confirm how many doses you have previously had. Finally, there is one other group that may need an additional dose of the MMR vaccine, and that is adults who receive the inactivated or killed measles vaccine between 1963 and 1967. If you believe you are part of this group, also talk to your health care provider if you receive the inactivated vaccines or if you're unable to find your vaccination records but believe you were vaccinated. During this time frame of 1963 to 1967, your provider will likely recommend an additional dose. I do want to note that the data we have on vaccine effectiveness for adults that received their measles vaccine over 50 years ago is somewhat limited, and most adults in the US are not exposed to measles on any routine basis. Though the data that we do have suggest immunity is lifelong. There is something we'll be watching closely as measles exposures become more and more common. I hope we don't see breakthrough infections among those who are vaccinated more than 50 years ago.


Chris Dall: Let's turn now to some other infectious disease items. Mike, what's the latest on flu and respiratory syncytial virus?


Dr. Osterholm: Well. The influenza and RSV seasons continue to wind down in the United States. Clearly good news during the week of February 24th, which is the most recent data available. The percentage of outpatient clinic visits for respiratory illnesses, the number of influenza hospitalizations, and the percentage of weekly deaths attributed to influenza all remained relatively steady compared to the weeks before, though we saw the total number of influenza cases peak in late December. The peak number of influenza B cases occurred later in the season, as often does with influenza. We have now seen two weeks of declining influenza B cases after an apparent peak in mid-February. Finally, I want to mention that although influenza like illness is down in the rest of the country, things are still picking up here in the Midwest with the percentage of outpatient visits for influenza like illness now up 6% from last week. Minnesota is the only state that has seemed to avoid much influenza activity this year. With our activity now back at minimal levels after three weeks of low levels of influenza activity in February. It is really unclear why Minnesota has largely avoided influenza this year, despite high levels of activity in surrounding states, and will continue to update you as the influenza season unfolds here in the Midwest and as it continues to decline in the rest of the country. As for RSV, activities continue to decline nationwide, with cases nearly five times lower than they were during the late December peak. Rsv vaccination uptake is very low in the US, with just 22% of adults over the age of 60 and 16% of pregnant women more than 32 weeks gestation vaccinated against RSV. We need to continue advocating for increased uptake of these vaccines to protect those vulnerable groups from serious illness, hospitalizations and deaths.


Chris Dall: Finally, in late February, Spanish scientists reported that for the first time, pathogenic H5N1 avian influenza had been detected on Antarctica's mainland. Now, Mike, this gets back to a conversation I believe we had on the last episode. This is scientifically noteworthy and interesting news, but is it anything the public should be concerned about?


Dr. Osterholm: Well, Chris, this is a difficult question and one that, uh, has been, uh, really a thorn in my intellectual side for a long time. Uh, I have been very actively involved with H5n1 work around the world. And actually following the 1997 outbreak of H5n1 in Hong Kong. The first time we saw it spread into humans from infected chickens. We have followed this very closely. Uh, it was in 2003 that we saw for the first time, additional transmission of H5n1 beyond what happened in Hong Kong in 1997. And since that time, there have been 887 human cases confirmed. This was between 2003 and 2024. Now, during this time, the virus continued to change, and it was interesting because it was not a situation where H5n1 from infected avian species transmitted to humans all occurred in one place. For example, in 2005, 100 cases occurred. Uh, of those, 187 I talked about, 61 were in Vietnam. Then the following year, in 2006 or 114 and 56 occurred in Indonesia. Now, I've been to both those countries working on flu and can tell you there's no one reason why it showed up or then why it kind of went away. And in fact, the impact of H5n1 in Asian avian species and humans actually began to drop after that 2005, 2006 time. So it went from 100 cases in 2005, 114 and 2006, and by 2000, 12 and 13 it had dropped to 35 and 39 cases each year, respectively, in humans.


Dr. Osterholm: Then in 2015, wow. What happened? We had 145 cases in humans, of which 136 were among individuals from Egypt, particularly in the Nile River valley, and again associated with now newly infected bird species. But what's happened since then? This is 2015. Here we are nine years out. And if you look, in 2016, we had ten cases, 17 four cases, no cases in 18, one case in 19, one case in 21 case in 21, 7 in 22, and now 12 cases in 23. The risk of H5n1 infection in humans has dropped precipitously in the time period of 2015 to now. Well, what is that? What's that all about? Well, you know, I've covered this on a previous podcast, but I just want to remind listeners avian influenza is a form of the virus which primarily targets birds and continues to result in deadly outbreaks among wild and captive bird populations. And more recently, we've seen a number of documented cases in which animals outside of the typical class, including infections and mammals such as sea lions and seals have occurred. Now, in these animal species, almost in every instance, they are a animal species that has consumed either sick or dead birds, so that in that sense, we have a way for which we know that they are actually becoming infected. We saw a lot of attention this past week paid to the fact that we've now seen infection in bird species in Antarctica. This really isn't a surprise given that birds fly over ocean bodies all the time.


Dr. Osterholm: So yes, this is a concern to humans, but at the same time, both the W.H.O. and the CDC maintain that the risk for transmission to humans as low. And why do they say that? Because in fact, what we see is the virus is changing substantially, making it more adapted to certain mammal species, but less likely to get deep into the lungs of a human. And so we will continue to monitor this closely, even though there's a lot more bird activity, a lot more mammal activity. Again, as I just pointed out, we're seeing a greatly reduced human activity. Could this change? Yes it could. Uh, do we have any evidence? It is. No. The media has a history of raising concerns when reporting on H5n1 outbreaks, making it seem that it is going to be the next pandemic. Virus spillover from birds to other mammals and humans is inevitable, considering the high prevalence of virus and birds, but the virus just does not have the ability to bind to the predominant receptors in the human upper respiratory tract, meaning that the chances that avian influenza, as we now see it in H5, poses a major threat to humans is minimal. I'm not going to say that it will never happen in the future, but this is a very different H5n1 situation than we were dealing with back pre 2015. And in the end, time will tell.


Chris Dall: Now for this week in public health history. And Mike, this one is not only timely, but it really marks what we may someday see as the beginning of the anti-vaccine movement, at least here in the United States, but possibly around the world. What can you tell our listeners about it?


Dr. Osterholm: For this episode. In the Week in Public health history, we're covering an event, a catastrophic event, really, in public health research that has had lasting detrimental effects. And we're still feeling them today. On February 28th, 1998, The Lancet published Andrew Wakefield's and his colleagues article, which reported a link between children who had received the MMR vaccine and later developed autism. Where do I even begin? The authors painted a completely unfounded picture of cause and effect, which began by claiming that the multi virus vaccine weakened the immune system and allowed measles virus to replicate in the gut. They go on to hypothesize that the viral replication damaged the intestinal lining, and allowed unidentified proteins to migrate through the bloodstream, cross the blood brain barrier, and result in autism. First of all, this study was completely uncontrolled, meaning there was no comparison between subjects who did or did not receive the MMR vaccine. This is a large limitation in any study, and seems especially grim after learning the full story of this horrible situation. Secondly, there are only 12 subjects included, which is far too few to consider these findings remotely representative of a larger population. Many of the data used in the study come from parents as observation, which is subject to a number of forms of bias. It was ultimately revealed that Wakefield and colleagues received financial backing for this project from lawyers of these patients, who were searching for a reason that their child developed autism. If Wakefield published a study that showed a strong association between the vaccine and the children's autism, the parent would have grounds to seek a settlement. This paper violated a number of ethical standards upon which epidemiologic research is based. It was full of methodological areas, speculative conclusions, and behind it all was Wakefield's undisclosed financial interest.


Dr. Osterholm: The public often looks to peer reviewed research articles for sound scientific evidence to inform their decisions, but that trust crumbles when so-called scientists like Wakefield reject their ethical responsibility. The media reported on this issue at length, and by the time further studies could be performed to investigate and fully disprove the association, the damage in the public minds had already been done. In 2004, ten of the 13 authors went on to submit a partial retraction of the study's interpretation, saying there is insufficient data to support a causal link between MMR vaccine and autism, and the claim was only meant as a possibility. I do not understand how seemingly ethical researchers can fail to intervene before publishing this study, let alone wait six years to comment on the falsely founded fears they incited. What's worse is that Wakefield, now stripped of his medical degree, has never acknowledged the error of his work and continues to push his anti-vaccine agenda across the world while profiting substantially from exploiting vulnerable populations. The silent victims in all of this horrible behavior by medical scientists are the children who have and will suffer at the hands of vaccine preventable diseases like those included in the MMR vaccine. This vaccine series is supposed to be delivered by the time a child reaches two years old, leaving decisions completely in the hands of parents and their pediatricians. Non-medical vaccine exemptions are on the rise and have been increasing since the beginning of the COVID pandemic, which signals growing vaccine hesitancy among millennial aged parents who are coming of age as the Wakefield study and fallout were underway. Parents have the responsibility to protect their children from harm, and getting them vaccinated is a necessity, and I implore you to follow this guidance and have conversations with those who feel unsure.


Chris Dall: And just a quick note for our listeners before we wrap up here. We are coming up on the fourth anniversary of the Osterholm update podcast, and we'll have some special segments over the next few episodes related to that anniversary. But if you have any questions for us about how the podcast gets made or any other question you can think of, please email us at Mike, what are your take home messages for today?


Dr. Osterholm: Well, Chris, thanks again for a great job. Let me just first of all say it's not one of my three takeaway points, but again, just reminding all the listeners we do very much welcome your feedback. We are surely informed by it. We learn from it. Uh, I am always in the learning mode and in fact there are many, many days when I think the older I get, the more vulnerable I am to learning. So please share those comments, those thoughts with us. And it's actually helpful if they can be constructive. Uh, if you can't do it that way, I still want to hear it. So I hope very much that, uh, uh, we can continue to hear from you and what you want or don't want from this podcast. As I've said to you on many occasions, the day that we realize that you don't want this or need this podcast anymore, you know, we don't want to clutter your life with, uh, with a podcast coming out every two weeks. So we we look forward to getting your, your guidance and feedback. Uh, the three points I'd bring home today, number one, and it's the most important one we can do. Do not take your eye off the prize. The prize is keeping people from developing serious illness, hospitalizations and deaths. And the way we're going to do that. And the most important way is getting people vaccinated up to speed. And that six month dose for those 65 years of age and older, and who have underlying health conditions for younger than 65, rapid access to Paxlovid is so important, the data are clear and compelling.


Dr. Osterholm: We can reduce the likelihood of serious illness, hospitalizations and death with very early use of Paxlovid reuse respirators. I'll come that back in a moment. If in fact, you are infected. Uh, and to protect others, use those for at least 5 to 10 days. And if you want to protect yourself and you're in public places and spaces, feel confident and comfortable to use your respirator. And if you're ill, stay home. Stay home. If we did those four things, we could see a substantial drop in the overall number of serious illnesses, hospitalizations and deaths. With this number two, encourage family and friends to be adequately vaccinated for measles. You know, if you're a parent, please, if you're a grandparent, an aunt or an uncle, if you can, knowing that, of course, you don't want to be accused of butting in where you shouldn't, but in fact, helping to share with parents or other caregivers why it is so important to get vaccinated. And my third point is I want to get rid of the Terme mask. I really have a hard time with masks because everyone lumps them together just as vehicles of transportation lump bicycles, tricycles and and jet planes. Because they all are vehicles of transportation. It's all about adequate protection, which is all about N95. So, you know, I just can't come back and say that enough times. It's really important that I don't hear people say, wear a mask, because in many instances that is so highly ineffective.


Chris Dall: And do you have a closing song for us today?


Dr. Osterholm: We know. I'm trying to keep with the theme of this podcast today and dealing with the tough information. You know, I wanted to find something that, uh, in my mind reflected our mutual sharing, our mutual kindness, our mutual need for each other. You know, it's us versus the virus. It shouldn't be us versus us. And, oh, by the way, the virus is a problem. And so I went back to my oldies but goodies as which I, uh, constantly do. And I picked a song and the words to that song that we've actually used four times before. I think this sets the record going five times on June 24th in 2020, an Episode 13: What I Know and Don't Know About COVID-19, on March 18th, 2021: A Mended Heart on March 25th, 2022, in Episode 96: A Familiar Uncertainty and aptly named today on July 28th, 2023, in Episode 136: Perspective and Humility. The song I've picked is He Ain't Heavy, He's My Brother. This is a ballad written by Bobby Scott and Bob Russell, originally recorded by Kelly Gordon in 1969. The song became a worldwide hit for The Hollies later that year, and also a hit for Neil Diamond in 1970. It's been recorded by many artists in subsequent years. The Hollies version was rereleased in 1988, and again was a major hit in the US. Uh, when you look back at the origin of this in his 1884 book The Parables of Jesus, James Wells, moderator of the United Free Church of Scotland, tells the story of a little girl carrying her big baby boy.


Dr. Osterholm: Seeing her struggling, someone asked if she wasn't tired. With surprise, she replied, no, he's not heavy, he's my brother. The first editor of the Kiwanis magazine wrote. Fulkerson published a column in September 1924 carrying the title He Ain't Heavy, He's My Brother. The first use of the phrase exactly as rendered in the song title in the 1940s, the words adapted as He ain't Heavy, father, He's My Brother was taken as a slogan for Boys Town Children's Home by founder Father Ed Flanagan. According to the Boys Town website, the phrase as used by Boys Town was said to be Father Flanagan in 1918 by one of the residents while carrying another up a set of stairs. The boy being carried is said to have had polio and wore leg braces. So today I'm very happy to revisit, reconsider and embrace the words to he ain't heavy, he's my brother. The road is long with many a winding turn that leads us to who knows where, who knows where. But I'm strong. Strong enough to carry him. He ain't heavy. He's my brother or my sister. So on we go. His welfare is my concern. No burden is he to bear. We'll get there, for I know he would not encumber me.


Dr. Osterholm: He ain't heavy. He's my brother and my sister. If I'm laden at all, I'm laden with sadness. That everyone's heart isn't filled with the gladness of love for one another. For it's a long, long road from which there is no return. While we're on the way to there, why not share? And the load doesn't weigh me down at all. He ain't heavy. He's my brother and my sister. He's my brother and my sister. He ain't heavy. He's my brother and my sister. Thank you very much for joining us again this week. I hope, uh, the discussion was helpful. If nothing else, I hope it provoked you to think about things and maybe a slightly different way. Uh, and, uh, again, I can't emphasize enough. I know we're all part of a family where we have our moments. Uh, and, uh, I understand that I'm human, too, and have those same moments. But again, if there's one word I hope we can continue to never forget, and that's kindness. Kindness right now is so desperately needed. This world is in a tough place. And, uh, you know, none of us can change it by ourselves. Or, you know, sometimes I wonder, even collections of humans, what we can do, but we can never, ever not be nice, be kind. I think that's such an important issue. So, uh. Thank you. Be safe. Be kind. Thank you.


Chris Dall: Thanks for listening to the latest episode of the Osterholm Update. If you enjoyed 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. If you would like to donate, please go to The Osterholm Update is produced by Sydney Redepenning, Elise Holmes, Cory Anderson, Angela Ulrich, Meredith Arpey, Clare Stoddart, and Leah Moat.