September 21, 2023

In this episode, Dr. Osterholm and Chris Dall discuss the state of the pandemic in the U.S. and around the world as they reflect on infectious disease challenges of the past, present, and future. Dr. Osterholm also shares his thoughts on the CDC's new vaccine recommendations and answers an ID query about outdoor transmission of SARS-CoV-2.

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Chris Dall: 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 Dahl, reporter for CIDRAP News, and I'm your host for these conversations. Welcome back, everyone, to another episode of the Osterholm Update podcast. As anyone who listens to this podcast on a regular basis knows, our discussions of global and national COVID-19 data dating back to last winter have typically included the disclaimer that the reported case numbers are likely a vast undercount. Most countries are no longer reporting case numbers, and most people are testing positive at home if they're even bothering to test. But it's been a while since the disconnect between the official data and what we're seeing in the community has felt this large. Anecdotally, it certainly seems like a lot of people are getting COVID right now. Wastewater data appears to back that up. Hospitalizations and deaths, however, are still low when compared with the worst periods of the pandemic. But given how much COVID activity there is right now, should we be thinking about changing our behavior? Those are some of the topics we're going to discuss on the September 21st episode of the podcast as we look at the international and national COVID trends. We'll also provide an update on the variant picture, discuss the CDC's COVID booster recommendations and the data behind them. Answer an ID query on the risk of COVID infection in the outdoors, and talk about some of the infectious diseases that have challenged public health officials for decades. We're also going to debut a new segment. But before we get started, as always, we'll begin with Dr. Osterholm's opening comments and dedication.


Michael Osterholm: Thank you, Chris, and welcome back to all the podcast family members. It's great to be with you again. As I say so often on these podcasts, I hope that there comes a time when we don't need these podcasts from a standpoint of at least public health information. But I have a feeling that many of us will continue to have podcasts like discussions wherever we're at. So again, thank you. And as I also have said, each and every podcast, please provide us with your feedback. We find it to be very, very helpful in terms of what we cover, how we cover it, and what are the pressing issues for you on any one given day. Now, anyone who is new to the podcast, I hope that we're able to provide you with the kind of information you find useful that you can act upon in your own life. Trust me, these podcasts are more than just didactic exercises. We live and feel these very points that we raise with you in our own personal lives. And so from that standpoint, we will continue to do what I believe is just calling balls and strikes. Now, to me, today's podcast is one of those ones where it's one thing to say you're going to call balls and strikes, but it's really a challenge If no one knows where home plate is, how do you even know where to look for the pitch and how do you declare it? And I feel like that's where we're at today.


Michael Osterholm: I must say that this is a confusing time in the pandemic history of the last three plus years that I know of since those earliest days. And so today we'll surely share with you those same feelings about confusion, but also try to provide as much clarification as we can of where we think we're at, where we're going and what that means to you in your everyday lives. And I'm also very excited about the fact that we're adding a new segment into the podcast. These histories and public health moments that I think you'll find interesting and surely reflective if nothing else, because they remind us of where we've been in the world of public health and infectious diseases and where we're going now. In terms of the dedication today, it seemed very obvious to us that as we each as a podcast team member and I work with really incredible people on this podcast, starting right with Chris and all the support staff that helped me collect and put together this information. We all are feeling a sense of what is happening, what does this mean to our own personal lives? And we're asking that as much personally as we are professionally. From that perspective, we can understand how all of you are in a very similar position. What does this mean? I will say right now, and I'm very careful about things like this because I believe data are truly sacred. You know, information is power, and data are not just anecdotal stories.


Michael Osterholm: They're not one offs. Well, we're hurting for good data today on what the incidence of COVID is in our communities. But I can tell you, as someone in this business for the last 40 some years, this is as dynamic transmission time for COVID virus in our communities is almost any time. I know of more people infected right now, people who are believing at least this is their first episode of COVID. I know of a number of people who have had now second and third episodes for which actually the latter ones were more severe than the earlier ones. So it's not a matter of just saying I already had it once, it wasn't so bad. And we'll try to cover all that today. What's going on? So the dedication is to all of us who are struggling to understand how to take this information and put it into our everyday lives. We do know with widespread transmission is occurring, but fortunately, we're not seeing anywhere near the same number of hospitalizations and deaths we saw earlier in the pandemic. Having said that, I know of many people who have been down in bed 5 to 7 days with COVID, and we're still trying to understand what the long term implications might be with regard to long COVID. There's a paper that was just published this past week which suggests that long COVID can occur in those individuals on their second or third episode experience as opposed to their first one. So it's not even fair to say that I didn't get it the first time I got infected, so I'm not worried the second or third time.


Michael Osterholm: So from that perspective today, this dedication is to all of us who are still confused, who are still trying to live a life. That does not mean we're locked up and that we aren't seeing others. But how do we do that safely? So this is dedicated to all of us. Now, let me just say feedback wise, I heard from a whole lot of people and I was actually surprised about the sunlight length issue. You know, I proposed in the last podcast, we might want to drop that. Was that helpful? I know some of you, it's like nails on a chalkboard. You try really hard to skip over this as quickly as you can. You don't. Want to hear about the light. Well, I heard from a lot of you. You do. And it is something that is almost a mile marker in your lives is what's happening. Sunlight length, obviously, is an indirect measure of how you're going to live your life, whether you need snow boots on or you need extra fluids because of the heat. So today I will continue to use sunlight length as one of the hallmarks of this podcast. And for all of you who wrote in, Thank you, I heard you and as did the team. And for those that didn't want to hear about this anymore, again, nails on a chalkboard. I'm sorry, but we're at a very important time in sunlight length in that we are officially making the dip right now from that summer sun to that of the fall sun.


Michael Osterholm: And of course, with that comes the autumnal solstice. And today in Minneapolis, on September 21st, sunrise will be at 6:58 a.m., sunset at 7:12 p.m. We have 12 hours, 13 minutes and 57 seconds of sunlight. We're losing about three minutes a day. And on September 24th, just a few days from now, we will actually hit that official first day of fall in that we will actually pass below the 12 hours of sunlight a day. We recognize that that means the dark days of winter are coming. Now, if you're in Auckland, our dear, dear colleagues and friends there are experiencing something very different. If you're at the Occidental Belgian beer house on Vulcan Lane today. There the sunrise is at 613 in the morning, sunset at 615. You're at 12 hours and two minutes of sunlight. You're gaining two minutes and 19 seconds a day, and you are now on the fast rise in sun over the next several weeks as you take the sunlight we had and now get to enjoy it for all of us. Yes, in the northern hemisphere, we're getting darker. Southern hemisphere are getting lighter. But in the end, one of the beauties and blessings of this podcast, we share our light with everyone. So whether you're in the Southern hemisphere or northern Hemisphere, your light is our light. Thank you.


Chris Dall: As I noted in the intro, there certainly seems to be a lot of people getting COVID right now. Some wastewater data models, in fact, have estimated that the US could be seeing as much viral activity as we were at the beginning of the pandemic and during the Delta wave. Officially, the latest CDC update shows an 8.7% increase in COVID hospitalizations and a 4.5% increase in deaths from the previous week, though the numbers are still low. While the latest update shows global deaths are down 50% over the past 28 days. So, Mike, is it safe to say that this is a virus that remains as transmissible as ever, but whose ability to cause severe illness and death is diminished? And do the new and emerging variants change that picture at all?


Michael Osterholm: Well, Chris, you've asked a really very important question and one that I wish I could answer succinctly, but I'm afraid it's going to take a bit of an explanation to get the sense of where we're at. We have multiple things happening at the same time. We've got issues with regard to the virus and its change over time. Mutations, the things that we worry about with new variants and sub variants. And we also have human immunity which is waning over time. And then you add into that the fact that over the past year we've had less transmission of the virus in our communities, so fewer people have actually been exposed to the virus and develop the immunity from that infection. And we've done very little vaccination. So as a population whole, we have in many cases a diminished protection from previous immunity events, vaccination or illness. And what does that mean going forward? So let me try to put that all into perspective. But I want to confirm one thing. I can tell you right now, that there is a lot of us, myself and my colleagues included, that are in the same boat trying to figure out what this all means for us, our family, our friends, of course, the public all are asking these questions. So let me just be clear. I don't have all the answers. I'll try to call balls and strikes, as I said, but it is clearly a challenge. Let me in trying to answer this, be really clear about the fact that there is that issue of transmission, widespread transmission, which I believe right now in many communities in this country is close to that of what we saw in the earliest days of Omicron and the severity of illness.


Michael Osterholm: Those are two very different things in the sense that, you know, the common cold can be widely spread in a community with very little morbidity and mortality. On the other hand, you can have few infections of something like meningitis that could only cause an X number of cases, but a much, much higher case fatality rate. What we're dealing with right now is widespread transmission and a lower impact of disease. Now, I'm going to come back to that because that doesn't mean it's absent. Not at all. Please don't get me wrong in the sense of saying don't worry about it. I think we have to. So at this point, trying to track what's happening is a challenge with regard to data. I've already talked about that in previous podcasts. I do not trust any of the numbers right now that are determining the number of cases reported in a community. We are surely seeing many examples of people who are infected epidemiologically, clearly linked to other cases, but not getting tested because right now we have a shortage of testing in many locations in this country. And then even if you are tested by a lateral flow test, one of the kind of over-the-counter tests does mean it's going to get reported.


Michael Osterholm: From my perspective, how I am then sharing with you this transmission issue is just the anecdotal information. And there's enough of it that it starts to become data in the sense that we know of. So many people are infected, so many second and third infections now occurring. So without having a good surveillance system in place, and that surely is true globally. I mean, when we talk about what's happening globally, I have no faith. And even some countries in terms of reporting serious illness and deaths, I still think in the United States the number of hospitalizations, serious illness and meaning ICU care and deaths is a relative measure of what's happening on the top of the iceberg versus what's below it, which is all infections, probably the best tracking information I think we have on the overall burden of infection is indirect information, but powerful indirect information. Of course, what I'm talking about is the wastewater data, which at this point clearly is the most reliable metric, I think, in terms of monitoring COVID transmission. And right now the amount of virus we're seeing across the US is still 3 to 4 times higher than it was three months ago. Supporting that this increase in cases is real. The amount of SARS-CoV-2 virus detected in each milliliter of sewage surveyed across the United States climbed from 165in June to 640 by the end of August.


Michael Osterholm: And notably, these increases were documented in all four regions of the country the Midwest, the Northeast, the South and the West. Let me be clear. I can't tell you exactly what it means to have 165 virus copies per milliliter of sewage assessed or 640 or whatever. But I think they're giving us a relative sense of activity in the community. Let me summarize this point in saying that without additional testing capacity and for that matter, even demand, it becomes a real challenge to understand what exactly the data from wastewater translates in terms of case numbers. But with the data we've had from previous points in the pandemic and when testing was more common, we found that two metrics, case numbers and wastewater activity do correlate with one another fairly consistently. So given that relationship, there has been some attempts to model the projected number of infections that might be occurring in the US, and according to what these models find and they're conducted by some people who have had great accuracy in correlating the wastewater data and cases in the past where we had better case data. So I do have some faith in these particular models. And what these models found was that there was roughly 720,000 new daily infections that occurred in the US in early September. Let me repeat that 720,000 new daily infections that occurred in the US in early September. Even now there may appear to be some drop off, although we have to be careful because we've had these ups and downs before where then the trajectory goes right back up.


Michael Osterholm: But as of this past week it suggested that there may be as high as 600,000 new infections daily in this country. Now, if one just does the math on that, you can see we're talking 4 to 6 million people a week are becoming infected right now based on wastewater data. That's a pretty substantial impact. Now, if these estimates are accurate, then that would put us at levels similar to what we experienced during the initial COVID wave in the spring of 2020 and the Delta wave in 2021. As a disclaimer, and you've heard me say this many times, I am not a modeler myself and I haven't seen exactly what went into these particular models. Other than that, I know that in the past they've actually been fairly accurate. So I can't necessarily speak to the accuracy of these specific numbers. But looking at the wastewater data now and comparing it to levels reported during the previous waves, I certainly think that a case can be made for this comparison. In other words, it wouldn't surprise me if the activity we're seeing these past few weeks is similar to some of the waves in 2020 and 2021. Before I give you the information to distinguish why these are slightly different, I also just want to point out to you that as much as we talk about the activity in 2020, 2021, 2022, I've said over and over again, I don't believe we're going to go back to that time in terms of the actual public health impact, meaning infections turning into illnesses, turning into serious illnesses, turning into hospitalizations and turning into deaths.


Michael Osterholm: So keep in mind, what I'm talking about here now is transmission, not how many people become seriously ill, which is the big difference between then and now. And it is a big difference. So let me share with you some of the key features that I think distinguish the current events from the past. First is the fact that those past waves so the very first COVID waves in the spring of 2020 and the Delta surge in the summer of 2021 were largely driven by really high activity in one US region, As many of our listeners will recall, the first COVID wave in the spring of 2020 hit hardest in the northeastern part of the US, particularly New York and New Jersey. Of course there was activity elsewhere in other regions, but the bulk of what that wave was from the Northeast. Similarly with Delta, a majority of the activity took place in the South. Again, we know there was still activity happening elsewhere, but for whatever reasons, the southern states were disproportionately impacted and those outlier regions were even apparent in the wastewater data. Compare that to now, and there is no indication that any one single region is driving up the case numbers.


Michael Osterholm: Instead, all four US regions have shown signs of steady increases. These data just really point out that the risk of becoming infected in this latest recent wave is fairly uniform from a geographic perspective. Maybe that's a function of the residual variance of Omicron. I don't know. But my point is that unlike these earlier waves mentioned, the activity now is widespread across all US regions. Finally, the last point I want to make in terms of this comparison between where we're at now and where we were during the spring of 2020 or with Delta, is that the levels of severe outcomes, hospitalizations and deaths are still fortunately much lower now compared to then. Of course, there is still a risk of those things happening and they're very real. I never want to minimize them because surely today someone listening to this podcast could know a severe illness in their family or themselves in the days they. Head, including hospitalization and death and looking at the latest CDC data. There were more than 20,000 Americans newly admitted to a hospital with COVID the week of September 9th, the highest it's been since this past March. Current hospitalizations are now about 16,000, almost triple what was reported two months ago. And the weekly deaths have climbed from less than 500 to almost 900 as of late. So, again, this is not a benign disease. But even in recognizing that risk, there's still room to appreciate that severe outcomes are no longer as prevalent as they once were.


Michael Osterholm: For example, during the initial wave in 2020, there were more than 58,000 Americans hospitalized at one point. Deaths from that wave, which basically lasted a total of 12 weeks, ended up exceeding 119,000, equivalent to almost 10,000 deaths a week. With the Delta wave, which spanned from July to early November. In 2021, we saw hospitalizations in the US exceed 103,000 on a single day in total. Throughout the 18 week span that we experienced a delta wave, there were nearly 170,000 deaths reported. Again, the equivalent of roughly 9400 deaths a week for 18 consecutive weeks. And now, well, again, current hospitalizations set at about 16,000. And while I recognize deaths are a lagging indicator and can be expected to increase, they currently are below 900 a week. So overall, Chris, I would say that right now the virus is having no problem whatsoever finding host to infect or reinfect. Clearly, there's a lot of transmission that's happening and it's important to keep that in mind, especially if you or a loved one are at higher risk for severe outcomes. I'll actually talk more about that and what I'm doing in just a moment. At the same time, recognize that there are tools available to help reduce the risk of these severe outcomes, whether it's the vaccines or antivirals like Paxlovid. And last, I just want to acknowledge that hospitalizations and deaths aren't the only severe outcome.


Michael Osterholm: There is still, this acute phase of the disease can make you feel really rough, even if it doesn't require hospitalizations. I'm hearing of many people who are bedridden for 5 to 7 days minimum and feeling like they are going to die, although they were never at risk at that point of dying. So it's really important to know that there still is substantial morbidity associated with this disease. And then finally, of course, we're dealing with long COVID. We don't yet know what the impact will be. Other than that. I want to reemphasize a point I made earlier. There are now data clearly supporting that long COVID does occur oftentimes in the second or third episode of infection when it didn't occur in the first one. So I think this is an important point. Now, let me just say one last piece about what's driving this. Why is this happening? Well, I think there's two interacting factors. One is human immunity and how much is waning immunity? We know that the vaccine we have right now doesn't give great protection against getting infected or even transmitting the virus beyond possibly several weeks after the administration of the vaccine. But we do know that for at least 4 to 6 months, there is quite good protection against serious illness, hospitalizations and deaths. So we always want to be focused on the human immunity. You know, what is the variant doing to avoid the immunity we have? What is happening with vaccine related immunity? And does waning immunity mean that eventually one has no protection against this virus infection? Again, I don't think that's the case.


Michael Osterholm: I think human immunity does persist for some time and the variants are playing some critical role in avoiding or getting around that immunity. So let me just share a bit about the variants itself. Infection with EG.5 variant is becoming much more common. This followed then by the FL.1.5.1 terms you've probably heard, but basically saying these are the two common variants. We talked a little bit about BA.2.86 on the last episode as well, and since then have recorded a total of 14 sequenced cases in the US across ten states. Right now this particular variant does not appear to be driving the rise in infections, hospitalizations or deaths, even though it has all these mutations we've talked about. Again, this goes back to the point I made earlier. I always consider a variant innocent until proven guilty, and I think that BA.2.86 is exactly that. The fact that 2.86 has popped up globally and seemingly unconnected cases may suggest low levels of geographically widespread transmission, but we cannot be certain without more robust surveillance to understand that. I do want to talk about the most recent publication on the variant on this past. Monday, the G2P research group out of Japan published a brief correspondence in The Lancet describing their lab work characterizing the variance effective reproduction number.


Michael Osterholm: This value generally refers to the number of people in a population that can be infected by a primary case at a given time and is used here to explain the potential impact of this variant. They found that BA.2.86 infectivity may be lower than other omicron variants, but its immune evasion capabilities were significantly higher. In other words, the virus had difficulty actually infecting cells, but antibodies generated from previously rolled out vaccines and three types of monoclonal antibodies were completely ineffective at neutralization. Although this is just one study with a relatively small sample size, these findings do give me pause. Maybe this particular variant will go from innocent to guilty. I don't know. However, assessing the big picture depends on a combination of lab and epidemiologic data to better understand the real world implications of this variant. And we'll be watching more carefully as more information comes out. Grant you some of that information is going to be fragmented or in some cases we just won't have it. As frustrating and as frightening as the waiting game may be to listeners and myself alike, it really is too early to make any definitive predictions about BA.2.86 and its many mutations. In the meantime, all I can say is please get your additional dose of vaccine that's now available since preclinical data from both Moderna and Pfizer demonstrates protection against this highly mutated variant and others like it, which are currently circulating. Specifically the issue with both EG.5 and FL.1.5.1.


Chris Dall: So given all that information you just laid out, Mike, are you changing your behavior based on what you're seeing right now?


Michael Osterholm: Cross, I I'm changing my behavior and I surely am recommending that to those close to me. One of the challenges that I've had is I'm now waiting for my third appointment that I've made to get my vaccine dose. The first two I had scheduled only to receive a message hours before I was to get the vaccine at a local pharmacy here that, in fact, they ran out of vaccine. They didn't have enough. The rollout surely has been challenging. I know of many people who have been waiting to get this dose of vaccine who actually have visits scheduled to receive it, only to learn that, oh, never mind, we don't really have it. So that's one thing that will impact my overall behavior going forward. If I get that dose of vaccine and then wait ten days to two weeks for it really to kick in, I'm going to feel very different than I feel right now. In the meantime, I actually am using my N95 in any settings with additional people nearby. I'm minimizing my contacts in public settings. All my presentations or meetings are in Zoom. I just have been through COVID.


Michael Osterholm: As many of you know, I had lingering COVID for four months. I don't want to go through that again. And so I am counting on this new vaccine dose to be very important in protecting me against any type of serious illness and even having a real impact on my risk for developing another lingering or long COVID event. So I think this is a temporary measure. No one is telling people you're going to be locked up for a days ahead. But for those who are at increased risk of serious illness and we've talked about these groups many, many times right now, avoid, if you can, the kind of risk exposure, whether it be family, friends, whoever, until you can get that dose of vaccine and then give yourself 10 to 14 days for that to kick in and you will truly, truly increase your protection against this infection in such a way that you probably can go back into the public settings, feel comfortable having dinner parties at your home again or wherever you want to go. That's where I'm at right now.


Chris Dall: So speaking of that booster shot, as most of our listeners are well aware, the FDA last week approved the updated COVID booster shots from Pfizer and Moderna, and the CDC followed that with a recommendation for everyone six months and older to get the updated vaccine based on the deliberations of its vaccine advisory committee. Mike, I think some people were a little surprised at how broad that recommendation was. What are your thoughts?


Michael Osterholm: Well, let me just begin by saying I strongly support that recommendation and I will give you the information why I do. And I know there have been some very vocal colleagues out there not supporting it. And I don't believe that they've really accounted for what the risk of this infection is. And I'll specifically give you some data around kids and why I think it is very, very important to vaccinate children as well as these particular high risk individuals. Let me make it really clear. There are those who are at increased risk for serious illness, hospitalizations and deaths, and we can identify them. But there's others that also still have from an age category standpoint, some real risk. And I'll explain to you in a moment why. Again, I support the CDC recommendations, but let me just start out by saying I've been waiting to cover the news of this particular vaccine dose being available for almost a year. And so I'm relieved that I'm able to get my updated vaccine, hopefully this week. And as the podcast family knows by now, I urge everyone who is eligible to get the vaccine, get it now more than ever, we need these vaccines. And I was thrilled that the recommendation was as broad as it was. And I'm particularly relieved that children over six months were eligible because of a number of daycare outbreaks we're seeing right now are able to get the vaccine.


Michael Osterholm: I can understand why people may have been surprised by the broad recommendation, but I think it makes a lot of sense when you consider some of the main points that were brought up during the ACIP meeting. We have vaccines that have been shown to reduce the risk of serious illness and death in every age group. And this virus is causing serious illness and death in all age groups, regardless of being at high risk or not. More than half of the COVID deaths in children occur in those without any preexisting risk factors. Think about that one half of all the children who have died 6 to 23 months of age have occurred in kids that had no underlying risk factor. While we see this percentage drop with age 32% of 2 to 4 year olds, 24% of 5 to 11 year olds and 22% of 12 to 17 year olds do not have an underlying risk factor. But let me just put the numbers into context with kids again, and this is what's often missed in the discussion. If you look at the course of the pandemic in kids 0 to 17 years of age, in 2020, 199 children in that age group died 199. This is when we did many of the studies saying this was not a big problem virus for kids in schools, etc. And it was really the variants at the time were not having the same impact on kids, both in terms of transmission or serious illness that we later saw.


Michael Osterholm: And unfortunately, the data from 2020 were often used to justify how we handle schools in 2021, 2022 and even 2023. Well, what happened in 21? We went from 199 deaths in 2020 to 612 deaths in 2021 in the same age group. And in 2022, the third year of the pandemic, we went to 748 deaths occurred in this age group. Now, fortunately, in 2023, this current year, we're at 133 deaths in kids. However, we're again beginning to see serious illness increasing in young kids. In early August, about 2% of the hospitalized cases in this country were in kids 17 and younger. Within a few short weeks, that got up to 6%, which, by the way, the number of hospitalizations itself was growing. So 6% is a much bigger piece of the pie. But let me put this into context. Influenza, a disease that I've spent the better part of my career dealing with and have to say it is a very significant public health challenge. But let's just take a look at the recommendation and the case numbers for influenza of you all know influenza vaccines are recommended for all children six months of age and older. Recommended, not just available. Well, if you look at the 2019, 2020 data for influenza deaths in this country for kids, we had 199 such deaths.


Michael Osterholm: Now, this was really before COVID took off because many of these were occurring in that January, February, March time period of that season of 20 1920. So you got the impact then in 2020 and 2021 season that that winter overlapping those two years, there was only a single death reported. And we've talked about this many times before, this viral interference that really eliminated most of the influenza activity. So that number really isn't one you can use. And for that matter, 20, 21, 20, 22 winter only 49 deaths. And I say only I can't imagine as a parent any one of these deaths being in my family. But now, as the viral interference likely disappeared, people got back to everyday normal living as such in 2022 and 2023. 174 deaths occurred almost back to that 2019-20 number. These are kids that we talk about all the time in terms of trying to eliminate their risk of serious illness. Well, look at what I've just shared with you and the COVID numbers far, far, far is more extensive in terms of the horrible impact it has than does influenza. And I don't hear anybody complaining about the influenza vaccine recommendation for kids. I don't hear about it. So I can't understand how you could not support also recommending these vaccines for kids when you can't identify who all the high risk kids are. And you look at the numbers of cases that are turning into deaths in this age group.


Michael Osterholm: So I find that the arguments that we shouldn't be pushing vaccine in this age group is just dead wrong. Unfortunately, dead is the operative word. Now, do I really strongly support emphasis on those highest risk groups? Absolutely. You know, that should be the lowest hanging fruit protection we can get. But I think it's fair to say all of us should be protected against serious illness, hospitalizations and death. I'm sure there are going to be plenty of questions about timing of these vaccines based on prior infection and also concerns about how the efficacy of these doses will wane. I don't have all the answers, and it's hard to know what will happen in the months to come. But I can tell you the best thing you can do right now is get a dose If you're eligible and you haven't had COVID in the past three months, if you have had it in the past three months, I would get it as soon as you hit that three month anniversary of your infection. Let me again sound like a broken record and say that these vaccines are the best defense we have right now, particularly against serious illness, hospitalizations and deaths. They are not perfect, but they are what we have for the time being. So please, please, please get this vaccine. If you're eligible, most everyone should be eligible.


Chris Dall: That brings us to this week's query. This week, we received an email from Michelle who wrote, “After being very COVID cautious since the pandemic first began, my partner and I were infected for the first time in mid-July. We keep up to date with our booster shots and we're ten months out from our most recent shot. When we got sick. Now that updated booster shots will be available. We're unsure as to the best timing for our next shot. We're both in our 50s and if we can avoid it, don't want a repeat of this summer next year. If we rely on the natural immunity from our recent infections, when should we plan to get boosted in order to get protected until fall of 2024? Since I assume we won't be able to be eligible to get another booster until then, Unfortunately, we believe we were infected outdoors, something we once felt safe doing. Are the recent variants even outside just more transmissible than before?” So, Mike, I'm going to assume that you would tell them to get their vaccine now, but let's drill down on that last part. Outdoor infection.


Michael Osterholm: Thanks, Chris. I think you really focused it quite well. There are really two issues here. They can get their new dose of vaccine right now. They don't have to wait until the fall of 2024. So I would urge them to do that immediately. But let's drill down on the last part. Outdoor infection. This is one that has been somewhat controversial because it originally was tied into George Floyd here in the Twin Cities in the early days of the pandemic because we didn't see a lot of transmission occurring with all these crowds outside. And people assumed that, in fact, it was just because the outdoor air dilution and the air moving and no one was in a place to get a sufficient infectious dose. And then shortly thereafter, there was transmission that occurred at the Republican National Convention indoors. And people somehow equated this to, politically it was okay to do what they did with George Floyd, but it was not okay with the Republican convention. That was not the point at all. It was one was indoor air, one was outdoor air. And how people were dispersed. So this is an issue that listeners have raised over and over again about how many people can be together and gravitate towards outdoor gatherings to reduce their risk of getting COVID. I want to be very clear that gatherings outdoor is opposed to indoor does greatly reduce the possibility of SARS-CoV-2 transmission. But the key word here is reduces the possibility of transmission, not eliminates any possibility of transmission. This is because the risk of transmission is not a black and white issue. We're able to say there is a risk or there isn't a risk.


Michael Osterholm: It's all about the infectious dose and how long you're exposed to get that infectious dose inhaled. And if you have an indoor air situation, we know that air circulation and how air moves inside a room and the number of people in that room can mean that you can have a lot of people exposed in a relatively short period of time because the virus, in a sense, concentrates there. It's not being removed nearly quickly enough. With outdoor air, you basically have some air movement that's removing that from in an individual who is infected and their immediate area from those people who are in that immediate area. But again, it is not absolute. A couple of examples. I happen to have a dear friend who was infected recently and his only exposure and can be well documented was in fact working an outdoor race over a period of some hours where he was in the outdoor environment, never indoors, not with anyone before or after who was infected, but working that outdoor area where he basically handed out waters, metals, all kinds of things like that, but never was that close to any one individual during that entire time. And clearly in the incubation period that we would expect to see for the exposure from that event, he got infected. Again, not indoors. I know of concerts that have occurred where individuals were standing next to each other, didn't know each other at an outdoor venue for hours in which a whole group of people standing in a given area got infected. Again, someone was in that area, obviously standing there too, who was infected and their exhaled air wasn't moving sufficiently such that it didn't mean that over time, it wasn't an exposure that occurred that resulted in infection.


Michael Osterholm: This is why I think we really need to be careful in our messaging about indoor and outdoor air. We reduce the risk, but we don't eliminate it. Encouraging outdoor gatherings can still play a significant role in reducing transmission in the community. A 2021 review article actually found that the risk of transmission was 19 times lower at outdoor gatherings compared to indoor gatherings. So this is still a very important thing we can do to reduce our chances of getting COVID. But again, even if the risk is 19 times lower, it is still not zero. And if you have someone by time and level of virus that they are excreting in an environment, you can see substantial outdoor transmission occurring. So I hope this provides you with some sense that, number one, first of all, please do go get your dose of vaccine now. Don't wait. Second of all is that outdoor air enhances increases. It surely supports more time near someone who is potentially infected, but it doesn't stop the transmission from occurring if the infectious dose is inhaled over time. I'm concerned that there are people who have a kind of a black and white line on this issue. If I'm outdoors, I'm perfectly safe. If I'm indoors, I may not be. Outdoor environments can still result in substantial transmission and we just have to be mindful it's all about the amount of time and the level of exposure you have. For the air of that individual.


Chris Dall: Now to some other infectious diseases. Mike, I was inspired to ask this question by the United Nations upcoming high level meeting on tuberculosis, which takes place tomorrow in New York. As the CIDRAP News reporter covering bacterial infections and antibiotic resistance, TB is part of my beat, but I did not know before coming to CIDRAP that TB though it was briefly overtaken by COVID is the leading infectious disease killer globally and has been for decades. And it's just one of many infectious diseases that most people probably think of as diseases of the past, yet are still major causes of severe illness and death around the world. We talk a lot about learning to live with COVID, but we live with a lot of infectious diseases. Why haven't we made more progress against some of these diseases?


Chris Dall: Chris, this question.


Michael Osterholm: Is really at the very heart, I think, of where we're at today in public health and infectious diseases. This is really an example of the more things change, the more they stay the same. You know, when I began my career in public health in 1975, almost 50 years ago, some of the infectious diseases of greatest concern were tuberculosis, polio and syphilis. And here we are today with treatments and prevention methods for all of these diseases, and yet they continue causing significant morbidity and mortality. Many people, especially in the United States, view these diseases as ones of the past. I hear discussions of reemergence of these forgotten diseases, but in reality they've continued on in the background and it's out of sight, out of mind for many. Just because we've stopped using iron lungs and have closed sanatoriums doesn't mean that these diseases have disappeared. To start, I'll provide some background on where we currently stand with polio, syphilis and tuberculosis. Let me start with polio, since we've spent some time on the podcast last fall discussing the case identified in New York and the positivity in wastewater samples, while the discussion of polio felt kind of out of left field for many people in the US. It's a sad reminder that our efforts to stop polio are still ongoing. The W.H.O., along with the Global Polio Eradication Initiative, sought to eradicate polio by the year 2000. 23 years ago. Here we are now with wild type polio cases having decreased by 99%, but we're still unable to cross the threshold of eradication.


Michael Osterholm: There was a recent report from the Independent Monitoring Board that evaluated the work of the Global Polio Eradication Initiative. The authors provided a sharp critique on the lack of progress, even stating that the rhetoric provided to stakeholders that were almost there is misleading. One of the authors quoted an article in Science saying that we're closer than ever to eradication, but that doesn't mean we're close. In 2022, there are almost 900 reported cases of polio worldwide. Now syphilis represents a different set of challenges. We are currently experiencing a significant increase in cases nationally and globally. This is really a mind boggling statistic I'm about to share with you. In 2021, the US reported over 177,000 cases, the highest reported incidence for syphilis since 1948. Before I was born. Most tragically, this is accompanied by a dramatic rise in congenital syphilis cases, leading to 220 stillbirths and infant deaths that year alone. Now, compounding the problem is the fact that the United States is facing a prolonged shortage of antibiotics. The preliminary treatment for syphilis, a type of penicillin, is experiencing a shortage that is projected to last until late 2024. Other antibiotics can be used, but this type of penicillin is the only recommended treatment for pregnant women. The drug is desperately needed to reduce the impact of congenital syphilis. Chris, you mentioned tuberculosis, also known as TB. The most recent report from the UN stated that 10.6 million people were diagnosed with TB in 2021 and over 1.6 million died from the disease for the first time in nearly two decades.


Michael Osterholm: These numbers are increasing. Multidrug resistant and extensively drug resistant infections present an increasing challenge against fighting tuberculosis. And as our listeners know, antibiotic resistance is a major area of work for our CIDRAP team. Treating drug resistant infections is incredibly complex, requiring significant resources and teams of experts. Amid the COVID-19 pandemic, we've seen a decline in access to this specialized care. The UN estimates only 1 in 3 patients globally with drug resistant TB receives care. Just 30 countries account for almost 90% of the TB infections. But cases still appear around the globe. Recently, CDC s Morbidity and Mortality Weekly report described an outbreak of multidrug resistant TB in Kansas. So we have to understand it can impact any community. Your question about the lack of progress against some of these diseases is complicated. There are some distinctions that make each of these pathogens unique, but there are common threads as well. Primarily around prevention, identification, treatment and social determinants of health. These challenges are going to feel eerily similar to the ones that we continue to face around the world with COVID-19. The first major challenge is prevention. We too often find ourselves playing a losing game of Whack-A-Mole, trying to handle outbreaks of these diseases, vaccination infection prevention measures, needle sharing programs and promoting safer sex practices are all very cost effective means of fighting these public health battles and result in far less pain and suffering.


Michael Osterholm: Yet we're watching funding around the world reduced for these very activities. The second challenge is that much of the world has limited access to diagnosing, reporting and following up on identified cases. You can't do much about a disease if you aren't identifying it, but it takes significant resources, time and effort to do so. And those limited resources over the past three years have shifted to COVID-19. The UN's 2020 Global TB report describes that as many as 4 million people between 2020 and 2021 have likely fallen ill with TB and have gone absolutely unreported. We can't get a handle on transmission and we're not able to identify and follow up in cases. A third major challenge is accessing treatment. I've already mentioned that this has been a major hurdle for syphilis amid drug shortages. For TB, treatment is a costly process that involves months, if not years, of following a strict regimen of antibiotics. We have made some progress in developing protocols that involve oral rather than IV therapies, and that reduces the total time needed for treatment from two years to six months for some cases. But equity continues to be an issue in terms of access to care around the world, especially for drug resistant infections. And the final challenge I want to mention is that fighting these diseases is purely biological, but also socio economic. 30 years ago, the New York Times published a series on the reemergence of TB, which resulted in multiple well written letters to the editor from medical and public health experts.


Michael Osterholm: A title that resonated with me was Society, Not Science has Failed TB Victims. And it's true. Many of these, quote, forgotten diseases primarily impact low income countries and low resource settings. Much of the public health progress that has been made in high income countries and communities can be attributed to improved standards of living. These diseases really thrive in areas that have overcrowded housing and working conditions, poor sanitation and hygiene infrastructure and overall lack of access to health care. Improving water and sanitation infrastructure is critical to fighting polio in Afghanistan and Pakistan, not to mention many other health benefits that would result from these improvements. In 2023, accessing clean water should be a given. Yet 2 billion people around the world lack access to safe managed drinking water services, 1 in 3 globally. That's completely unacceptable. As you mentioned, Chris, the UN is hosting a high level meeting tomorrow, September 22nd on tuberculosis. The purpose of this meeting is to come together and create a comprehensive plan that can be implemented, monitored and evaluated by heads of state in member countries. This is many years in the making and I sincerely hope it can result in measurable change. Each of these diseases requires coordinated efforts to stop. I don't want the next generation of public health professionals to have to continue fighting these same battles that I thought would be won back in 1975.


Chris Dall: Now for our new segment this Week in Public Health History, which is an idea that was suggested to us by one of our listeners. Mike, what are we commemorating today?


Chris Dall: Well, Chris, this is.


Michael Osterholm: A topic area that's very near and dear to my heart and one that surely has shaped my career like few other diseases have. You know, when I think about my career and the time that I've spent working on any number of infectious diseases, I calculated only about 10% of it was ever spent on COVID. The last almost four years. Whereas since 1980, I've been involved with HIV Aids. And for those who had the opportunity to read my book, Deadliest Enemies Our War Against Killer Germs, some of you may recall me describing a meeting that I attended in June of 1981 at the CDC in a small conference room off the director's office, in which a small group of CDC professionals, myself and several people on phones, were discussing what was this new phenomenon we were seeing of Kaposi's sarcoma in gay men in new York and pneumocystis pneumonia in gay men in LA. That really was the first time that there had been a what was recognized as a meeting on what eventually became HIV aids. That disease has continued to haunt us, although with treatment where it is today for much of the high income countries, it is a very different picture and fortunately for that. But there are still many parts of the world that are suffering significantly from HIV. And as we see this debate right now in Congress about refunding PEPFAR, the very unique program that the US has put into place to help save millions of lives around the world from HIV by supplying effective drugs is up in the air.


Michael Osterholm: And I worry that we're going to see again a resurgence of HIV, serious illness and death if we don't deal with that specific issue. So for the first installment of this new segment you just talked about, we're highlighting two moments which occurred in the very early years of the Aids epidemic. On September 21st, 1981, dermatologist Marcus Conant opened the doors of the first Kaposi's Sarcoma Clinic at the University of California, San Francisco Medical Center. And on September 24th, 1982, the CDC used the phrase Aids for the first time in a weekly article and outlined the first case definition. At that time, CDC had received reports of 593 cases of Aids, and 41% of these individuals had died of the disease complications. Looking back on that window of uncertainty and fear is amazing to see how far medical science has come in terms of innovation and discovery. September 18th actually marks national HIV, Aids and Aging Awareness Day, which brings to light that many challenges faced by the aging population of those diagnosed with HIV aids, as well as stresses the importance of HIV prevention and treatment in older age groups.


Chris Dall: So, Mike, we just got done talking about the infectious diseases that we have not made progress against. But I'm old enough to remember the early days of Aids and Aids really being a death sentence. We have made a lot of progress against HIV Aids.


Chris Dall: Chris, we have.


Michael Osterholm: Made a lot of progress. And let me put that into context. One area that we wish we had made much more progress on was HIV vaccines. I think the challenge that we have faced and continue to face with finding effective HIV vaccines is real and will continue. And it would be the ideal to be able to vaccinate our way out of this situation. But we at the same time have developed very effective drug therapies, very effective, and have revolutionized what HIV aids was all about. A diagnosis of it was in back in the 1980s a death sentence in a sense. Today, that doesn't have to be the case. But what I worry about is just what I talked about with polio, syphilis and TB is the fact that it's not enough to have the tools. You've got to be able to use them. You've got to be able to afford them. You've got to be able to distribute them. You have to have a public that's willing to accept them and that's the challenge today. And I noted the PEPFAR funding, the program that President Bush started that has basically saved millions of lives in low income countries around the world by supplying effective HIV antiretroviral therapy. That program right now is basically being challenged and the resources for it. All of the gains that we made with that incredible technology could go out the window if we can't find a way to supply it to those who are at risk of infection or those who are currently infected. So this is the never ending battle of public health. You know, I look at it right now, even from the standpoint of our work at CIDRAP, I see funders, I see government agencies, I see a lot of institutions that in the past would have been on the forefront of helping to support the kinds of efforts that would be needed to reduce, if not completely control, these infectious diseases.


Michael Osterholm: All of that is basically waning. It just like the immunity to the virus wanes. The interest and the support for these efforts is waning. And I think you're going to see a number of major public health efforts in the next 3 to 5 years greatly diminished, if not virtually disappear, because we're over the pandemic. Now let's move on. Let's get on with other things. We're always going to have to deal with the top ten causes of death. There will always be ten of them. If we eliminate the current top ten, there will be ten new ones. And I can tell you that we never need to have the kind of picture of mortality in this world due to infectious diseases, when in fact we have the tools, the technologies and the ability in many cases to deal with it. But we don't. And I think that's the challenge we face today. And I applaud all of those who work so hard in the days of HIV aids in the early days to try to reduce the risk of transmission through outreach education long before the drugs arrived and how they handled that. And so today, it seems so fitting for us on our first occasion of using these public health moments to actually highlight both the incredible accomplishments and yet the significant challenges we face with HIV Aids.


Chris Dall: So stay tuned for more public health history moments in future episodes. And just a reminder to our listeners, we have not abandoned our Moments of Joy segment. So if you have a moment of joy that you would like to share with us and the Osterholm update listeners, you can share it with us at Mike, what are your take home messages for today?


Michael Osterholm: The first message is we are in a very confusing time with COVID. So if you're feeling confused, welcome to the crowd. Now, that doesn't mean it's acceptable, but it means that we're all trying to work through what does this increased transmission really all about? Why? What do I have to worry about in terms of not only getting infected, but what the serious outcomes could be if I do get infected? And so we will try to continue in this podcast to share with you what we think are the nuggets of information that you need to have to respond to this. And the first, second and third nugget is vaccine, vaccine, vaccines like real estate and location. Please anyone six months of age and older avail yourself to the new vaccine. It is, in fact one that will help reduce the risk of you having serious illness, hospitalizations and deaths, and also developing potential long COVID, at least for some months after receipt. I will have to go back and revisit how often those doses of vaccine to be given. But having protection from that vaccine right now could be the difference between a serious illness dying versus having a milder illness and being inconvenienced, but surely not at risk of something much, much worse.


Michael Osterholm: So that's number one. Number two, and our discussion today of TB, polio and syphilis were somewhat eye openers as to where we're at today. I think most professionals would not get it right If we're asked what number of cases of syphilis reported back in 1940 and what number are reported today, you know, that's shocking. So we really have to stay focused on a much, much larger agenda than just COVID, even though that's critical up front and important. But we have a lot of challenges, infectious diseases. The final thing I would emphasize today is the fact that we are going to need as a public health community to make the case why cutting public health activities now in response to what some would call kind of the COVID reaction is so penny wise and pound foolish, it is going to cost us so much more in the long run. And again, we don't want to see the top ten causes of death in this world littered with infectious diseases that could have been avoided and could have allowed us not to have to see early deaths or deaths that could have been completely prevented. That to me is is such a critical message.


Chris Dall: And your closing song for this episode?


Michael Osterholm: Well, as listeners to this podcast know, there's a lot of thought that goes into this and our DJ Crystal is always a very important voice in terms of choosing a song that matches up with the mood of the moment of the podcast itself. This time we've chosen one by a singer we've used in the past, but this is the first time we've used this song. American Tune is a song by the American singer songwriter Paul Simon, someone familiar, I'm sure, to almost everyone on this podcast. It was the third single from his third studio album, There Goes Rhymin’ Simon in 1973. The song reached number 35 on the Billboard Hot 100 in that year. Billboard describes it as a discourse on inner security while being far from home. Cashbox called it a gorgeous, haunting, highly lyrical track and said that the soft vocal performance is heightened by sweet string sections. Record world said that it should touch the hearts and ears of many Americans with a beautiful melody wrapped around meaningful lyrics. So today we salute Paul Simon and his song American Tune, and I think the lyrics surely apply to the moment we're in right now. American Tune. Many's the time I've been mistaken and many times confused. Yes. And I've often felt forsaken and certainly misused. Oh, but I'm all right. I'm all right. I'm just weary to my bones. Still, you don't expect to be bright and bon vivante.


Michael Osterholm: So far away from home. So far away from home. I don't know. A soul who's not been battered. I don't have a friend who feels at ease. I don't know. A dream that's not been shattered or driven to its knees. Oh, but it's all right. It's all right. Or lived so well so long. Still, when I think of the road we're traveling on. I wonder what went wrong. I can't help it. I wondered what's gone wrong. And I dreamed I was dying. And I dreamed I was dying. And I dreamed that at my soul rose unexpectedly. And looking back down at me smiled reassuringly. And I dreamed I was flying. And high above my eyes could clearly see the Statue of Liberty sailing away to sea. And I dreamed I was flying. Oh, we come on this ship they call the Mayflower. We come on the ship that sailed the moon. We've come in the age's most uncertain hour and sing an American tune. Oh, it's all right. It's all right. It's all right. It's all right. You can't be forever blessed still, tomorrow going to be another working day. And I'm trying to get some rest, that's all. I'm trying to get some rest. American Tune by Paul Simon. So thank you again so much for being with us today. I hope that the information we shared was helpful.


Michael Osterholm: I will be the first to say that I wish I had more definitive information I could share with you that could give you that absolute compass reading. Don't have it. Interesting times. Again, let me emphasize we're not going back to the first three years of the pandemic, but we are experiencing something that had not necessarily been anticipated or clearly at least described to the public that was going to happen. We are in interesting times. I also want to just acknowledge that even though this is not the same kind of picture we saw three years ago, the deaths were still seeing. The hospitalizations we're seeing are still real challenges we can never, ever forget. These are not numbers. These are real people. There are mothers or fathers, our brothers, our sisters, our grandparents, friends and colleagues. And that means that it continues to touch us even though we wish it would go away. Thank you for listening. As I say, each week and I try very hard to live that life. Be kind, be kind. Right now it's a crazy world. It's a tough world. But our kindness surely can begin. The pandemic of kindness we've talked about so often through this pandemic. So thank you. Have a good, safe week and we look forward to talking to you in a couple of weeks. Thank you.


Chris Dall: 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 CIDRAP.Edu. This podcast is supported in part by you, our listeners. If you would like to donate, please go to CIDRAP.Edu/support. The Osterholm update is produced by Sydney Redepenning Elise Holmes, Cory Anderson, Angela Ulrich, Meredith Arpey and Clare Stoddart.