January 25, 2024

In "A Period of Transition," Dr. Osterholm and Chris Dall discuss the latest COVID-19 trends in the U.S. and around the world, a recent study on long COVID, and the rise of measles cases in the United States. 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. Although illnesses from COVID-19, flu and respiratory syncytial virus remain high across the nation, the latest updates from the centers for Disease Control and Prevention showed some signs of an improving situation. The rapid increases observed in all three viruses in the run up to the holiday season have slowed. Hospitalizations for flu and COVID have ebbed, and emergency department visits in most age groups are down. There's still a lot of viral activity out there, and SARS-CoV-2 wastewater levels still remain very high across the nation, but the indicators are pointing in the right direction. On this January 25th episode of the podcast, we'll provide some more detail on what's going on as we dig into the latest data on COVID, flu and RSV. We'll also provide an update on the JN.1 Subvariant. Discuss the latest research and news on long COVID. Answer an ID query about California's new COVID-19 isolation policies. Examine the roots of some of the measles outbreaks we're seeing around the country, and look at efforts to define viruses with pandemic potential. We'll also 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 and all those who might be joining us for the first time. I hope we're able to provide you with the information that you're looking for. In terms of the podcast family, I just want to say again, thank you, thank you, thank you. Uh, the communications you share with us, whether it be letters, cards, emails are really invaluable in helping us understand what information you need and want. But in addition, just your support. Um, it has meant a lot to us to be able to understand how this podcast fits in your life and ours. We will soon be approaching the 150th podcast that we've done. If you had asked me when we were into our first couple of podcasts, would this ever go that long? I would have said, never in 100 years. Well, I've learned in the art of humility during the pandemic, don't make statements like that because you just don't know. And, uh, this time, as I've said, though in the past, I am convinced that the worst days of the pandemic are over. And even what we'll talk about today is what I call a time of transition. Now, I have something unusual here. In fact, the podcast team is not even aware of this. I actually have two dedications today and one of them is very timely.


Dr. Osterholm: But the first dedication is really all about what's happening with measles. A little later in this episode, we're going to talk about the measles outbreak that has popped up most recently in Philadelphia and a few other cities in the East Coast. We'll get into all the details of the outbreak, the current trends in vaccinations, why granular vaccination data matters. But for today's opening dedication, I want to shine a light on the parents whose children are too young to receive the MMR vaccine today. The recommendation for receiving the MMR vaccine is at 12 to 15 months of age, and the reason we don't give the MMR vaccine any sooner is because there is clearly some protective antibody that is shared with the mother and the unborn child, and that can persist for some months and earlier. Vaccination may actually result in lower levels of protection because of the interference of that preexisting antibody. At the same time, that preexisting antibody, particularly as it gets to months six through nine, is while there and may influence the vaccine response, doesn't necessarily protect you against getting measles. So it's important to know that this is a highly vulnerable period for these children. So I think it's really important to acknowledge the unique circumstances faced by parents, especially when their child is in child care, a high risk transmission setting.


Dr. Osterholm: I know when new parents hear these news stories about measles outbreaks, your mind goes to the health and safety of your precious children. I extend my compassion understanding to all of you who are doing endless research, talking with your health care professionals, and trying to navigate a scary situation where the vulnerability of your child is heightened. I know this hits home for one member of our own podcast team, was a child under one year of age, and is feeling a lot of fear and frustration around this issue. As a working parent, it is really daunting to put your baby in daycare in an environment where a child doesn't have the immune protection and they're surrounded by little vectors every day. She says that if she was in Philly right now, she would likely pull her infant from daycare for at least a few weeks, if not until her child is fully vaccinated. But having parents that work full time really doesn't make this feasible for most people. So to any of you, in the midst of this frustrating and scary situation, we understand your struggle and above all, we see the love you have for your children. We hope you and your families stay strong and stay healthy, and that so many children are vaccinated at age, that it greatly reduces the likelihood of an outbreak of measles in your community.


Dr. Osterholm: The second dedication today is very, very, very personal to me, someone who I've gotten to know very well, particularly through the course of the pandemic, who has been a voice of incredible reason and thoughtfulness, who's been a friend, uh, who has offered me a great deal of enlightened information and someone who I have believe is one of the kindest, most wonderful people that I've ever worked with, lays today in an intensive care bed in a local hospital. With COVID, this is very hard for me to even fathom as he and I have had so many discussions over the years about this issue and what it means now to think that here he is, he is fully vaccinated. He did get Paxlovid early, but he is in an intensive care unit today. So this podcast is also dedicated to you. Don, uh, thank you for everything you've done. And we all wish you a very, very speedy recovery as you and your family and your friends and colleagues understand the power of this virus. Now moving on to a more enlightened topic. One that again, for those who this is new. Nails on the chalkboard. Just, uh, shut down for about 30s here. But today in Minneapolis, I'm very happy to report to you that sunrise is at 7:40 a.m., sunset at 5:10 p.m..


Dr. Osterholm: That's nine hours, 30 minutes, and nine seconds of sunlight. As of today, we're gaining two minutes and 17 seconds of sunlight each day. Isn't that wonderful? It's coming. And to our dear friends in Auckland, particularly at the Occidental Belgian Beer House, I have to say that, uh, you are still seeing lots of sunlight. 14 hours and eight minutes and seven seconds with that. 627 sunrise. 837 sunset. But you are losing sun at about one minute and 44 seconds a day, but you've still got a lot left to work with. Enjoy it. And, uh, we look forward to sharing some of our sunlight with you this summer. And I also just want to add one thing. I think we should start a little campaign here with our dear friends at the Occidental. I have now heard from two other people this past week, totally independent parties who, on their trip to New Zealand because of this podcast and their familiarity with the Occidental, went there for dinner. I think if we get enough, uh CIDRAP uh, podcast people to go there, maybe we can actually get a CIDRAP burger on the menu there sometime. So so whoever goes there next, you can suggest to them and I'll keep that up. So again, um, we're looking forward to spending this time with you today. Lots of information to cover today. Thank you.


Chris Dall: Let's start with the latest COVID data. Mike. As I noted in the introduction, it appears the wave of cases we've been seeing in the US is starting to decline a bit. But what is the overall picture here and around the world?


Dr. Osterholm: Well, just to start here in the US, Chris, let me just say that I agree with your assessment. I do feel quite confident that we have, in fact, reached a recent peak in activity and are now starting to see declines. And again, as we have shared in most recent podcasts, there is still a lot of COVID transmission in our communities. I actually had a physician this past week that informed me that he lived on COVID Avenue, based on how many people in his neighborhood were currently infected. So the good news is that while we are seeing lots of cases, the number is starting to drop. Now, remember, we have said over and over again that we have so dismantled our surveillance system in this country for testing for reported follow up that we don't know the actual number of cases. It's almost hearsay, anecdotal information, the data we do have, and I'll talk more about in a moment, are hospitalizations and deaths are were more solid in that regard. But as we've also talked about over the course of recent weeks, it's clear that for the number of infections we're seeing, the proportion of patients that end up having severe illness are hospitalized or die is a much, much lower percentage than it was earlier in the pandemic. To get an understanding of where we are at, let's look at hospitalizations.


Dr. Osterholm: The latest data from CDC shows that just under 33,000 Americans were admitted to a hospital with COVID the week of January 13th. That's down from 35,000 admissions the week of December 30th and 36,000 the week of January 6th. Again, remember, we're down to 33,000 now. And actually the decline breaks a streak of nine consecutive weeks in this country where hospitalizations were on the rise. So it's a welcome decline to say the least. Now, with that being said, I also think that 33,000 hospitalizations in a single week for COVID is still far, far too high, so there's still plenty of room for progress. Otherwise, alongside these, declines in hospitalizations were also seen. Wastewater activities start to drop off across all regions of the country. However, it is also important to note that even with these recent declines, the overall levels are still being considered very high, particularly in the southern and Midwestern regions of the US. So make no mistake, there's still a lot of virus out there. But at the very least, we're starting to see things come back down again and we'll hopefully continue to see improvements throughout the coming weeks and months. Otherwise, when it comes to deaths with COVID in this country, we're unfortunately still left waiting for any recent progress. Remember, deaths often are delayed several weeks up to a month from their occurrence until they're actually counted.


Dr. Osterholm: As of late, the deaths have continued to increase in the US, approaching nearly 1800 a week towards the end of December, more than 250 deaths a day. This marks 20 consecutive weeks where death tolls in the US have exceeded 1000. And as I just mentioned, because of the delays involved in obtaining death data, these numbers are still from December, so unfortunately it could still take several weeks to see some apparent declines matching up with the declines in cases as of now. We'll discuss influenza a little bit later in this episode. But let me give you, I think, a very important comparison right now. If you look at COVID, it is killing Americans at a rate almost three times higher than influenza. Yet we've seen influenza vaccine coverage this season approaching almost 50% among children and adults, while uptake of the latest dose for COVID sits at roughly 8% in children and 21% in adults. So clearly we have a significant challenge here. Otherwise, looking outside the US, there's been a real mixed bag of activity the past several months. I'll cover that more in another question, but trying to understand what's happening has only grown more complicated with JN.1 Arrival. Also coupled in with that is this constantly shrinking availability of data that actually makes any interpretation possible in the first place. So as I've mentioned in the past, any time I try to summarize the overall global picture, I almost feel like I'm trying to put together a thousand piece puzzle, even though 700 pieces are missing.


Dr. Osterholm: Maybe to reinforce that point, let me just share with you some data that was featured in the World Health Organization's latest monthly COVID report, which was published last Friday, January 19th. According to that report, basically just 1 in 5 of the world's countries reported even a single COVID death to the W.H.O. in the 28 day period between December 11th and January 7th. Likewise, less than 1 in 10 countries consistently reported data on hospitalizations. Anyway, from the data I've seen, I think a lot of places have been dealing with situations not unlike what unfolded here in the US. Basically, there has been a number of countries with recent surges in the last month or two, but now apparent signs of declines. For some of these places, the surges have been fairly substantial. Countries like Denmark and the Netherlands saw an all time. High in their wastewater levels, and hospitalizations in Denmark actually reached the highest level reported since early 2022, when they experienced the first Omicron surge. But recently, things have started to cool off a bit in these countries. The same thing is true in other places like Austria, France, Italy, Sweden, Singapore, Malaysia and beyond. That said, I'm still keeping tabs on some other countries that so far have not seen clear improvements and maybe serve as outliers.


Dr. Osterholm: In fact, one place that's really caught my attention is Canada. Our neighbors to the north up there, activity started increasing this past fall, climbed to relatively high levels by early November, and for whatever reason, has only remained at similar levels so far in the months that have followed. Now, why the plateau? Is that the JN.1 Effect something else? Again, I think it warrants some consideration. The truth is, we still don't have a great sense of how and why this virus does what it does. Still, I'm at least glad to see that many places, including the US, are no longer seeing a dramatic rise. In short, this again is all about humility. Why is what's happening happening? I don't know, but at this current time, all I can say is that is much virus transmission is occurring out there in the community. We are surely seeing a much lower rate of hospitalizations and deaths, which, while they're still too high and they're still the dons of the world, who are the people who are getting seriously ill? And they mean a lot to all of us. At least that number is lower now, given the amount of activity out there than it would have been earlier in the pandemic.


Chris Dall: The most recent CDC update shows the Omicron subvariant JN.1 Now makes up 86% of all US cases, up from 61% two weeks earlier and 20% on December 9th. So this variant is really taken over very quickly, but is there anything distinguishing it other than its immune evasiveness?


Dr. Osterholm: Well, let me begin by just saying that anyone who attempts to tell you they understand exactly what's happening right now with case occurrence throughout the world and JN.1 Be careful because they also probably have a bridge to sell you, because in fact, I don't think anyone can really fully interpret what's happened here. It is a mixed bag. JN.1 Has surely demonstrated its ability to rapidly outcompete other circulating Omicron variants, and I believe this is due to a number of factors, including its immune invasiveness. But as I just said, we do not have evidence to point to just one silver bullet issue here. Let me give you some examples of what we've been following closely around the world. This may help give you some sense of why it is confusing in terms of understanding what JN.1 Is doing. Let's take Singapore. JN.1 Accounted for nearly 50% of Singapore's cases starting around late November. Around that same time, there was a notable rise in the number of weekly COVID hospitalizations. So if you look there, you can clearly see what appears to be a kind of cause and effect like relationship, where hospitalizations jumped from several hundred a week to almost a thousand a week after the occurrence of JN.1, hitting about 50% of cases.


Dr. Osterholm: However, the situation in Italy has not been as clear cut. They experienced a fairly sharp increase in hospitalizations starting in early November, and it reached a peak in mid-December when the increase in hospitalizations began. Sequencing data suggests that JN.1 only accounted for less than 10% of all of Italy's cases by the time JN.1 accounted for more than 50% of Italy's cases, the hospitalization numbers had already peaked, and they continue to decline. So there you almost would think that JN.1 From a cause and effect standpoint was actually somehow better than what was happening before. Now let's take the Netherlands. Hospitalizations started increasing there in July and August before JN.1 Could have played any role. However, when JN.1 Surpassed that 50% prevalence level, they increased quite steeply the next several weeks, suggesting that JN.1's Dominance had driven previously high activity up even higher. But then you have Austria. It's not as clear cut like Italy. They saw hospitalizations climb, even though JN.1 Accounted for less than 1 in 5 cases by the time JN.1 Accounted for half of all of Austria's cases, hospitalizations were already peaked and had begun a rather marked decline. In the UK. We could be seeing signs of a JN.1 driven uptick from late November to late December.


Dr. Osterholm: Weekly hospitalizations doubled during that same time, JN.1 Prevalence grew from 18% to 75%. However, several weeks of those increases occurred even while JN.1 Accounted for less than half the cases. As a final example, here's Denmark, which they saw hospitalizations increase, while JN.1 Prevalence also grew. It looks very much like JN.1 Was largely responsible for the increase in cases. So overall, I think these data support rises in activity seemingly prompted by JN.1. But as I pointed out, there are clearly exceptions like Italy and Austria, so I don't know what it means. I can say here in the US, I do believe JN.1 Has played a role, but how it has played a role, what other of the variants may play a role? I don't know, but at this time it's fair to say, Chris, that on a global basis, the JN.1 Is important. We don't have any evidence that's causing more severe disease. I think we have clear evidence that's surely transmitting at a much higher rate than we've seen the previous Omicron derived variants. But what it means for the future with JN.1 None of us know.


Chris Dall: And what are you seeing, Mike, in the latest flu and RSV data?


Dr. Osterholm: You know, there are those times when I actually welcome the opportunity to provide good news and not be seen as bad news. Mike. Um, it's beginning to look like the worst of this respiratory virus season in the US is behind us. We're continuing to see RSV activity decline, with reported cases down 45% from two weeks ago and 52% from four weeks ago. Some of this dramatic decline in cases could be due to slight delays in reporting, but overall, it is clear that we're seeing a lot less transmission than we were a month ago. As for influenza, we have started to see a similar trend unfold over the past two weeks. Outpatient influenza like illness is down 5% from last week, and new hospitalizations have decreased for two weeks in a row. Influenza mortality appears to have peaked during the first week of January, when 1.3% of all the deaths in the US were caused by influenza, which is less than we saw in the peak of last year's influenza season, but still a bit higher than we saw during the peak of the 2019 2020 flu season. Eight states are currently experiencing very high levels of influenza activity, but that's down from 21 just two weeks ago. Four states are experiencing minimal activity, up from one just two weeks ago, and I'm very happy to report. And I have no idea why.


Dr. Osterholm: In Minnesota, influenza activity has remained at the minimal level throughout the entire influenza season. So far, we are the only state among the 50 states that have experienced this very, very quiet flu season. This Minnesota results is just another reminder that viruses can behave in very unpredictable ways, and we need to express humility in all the work that we do with them. Finally, I want to point out that this has ultimately been a very average influenza season in terms of the amount of activity and mortality that we've seen, and actually a slightly better than average year in terms of pediatric influenza mortality, which is currently lower than it was during the peaks of the three previous years, the 2018 to 2019, the 2019 to 2020, and the 2022 to 23 seasons. And let me be really clear here, as much as I have suggested here that this was a better flu season, still the number of deaths, the number of severe illnesses cannot be forgotten. Again, there are grandfathers, grandmothers, mothers, fathers, brothers, sisters. So I always want to add that note into these kinds of reports because it's so easy, so quickly to make everything a number when it's always been a human life. So despite this reduction in number of cases, we keep hearing from several talking heads in the media about another tripledemic.


Dr. Osterholm: But as I have said time and time again in this podcast, the data simply do not support this idea. A triple epidemic means that we're seeing all three of the viruses in epidemic levels, and that just hasn't happened. Rsv and influenza cases and deaths have been well within the range we'd expect them to be at this point in the respiratory virus season. That said, I think many individuals in health care felt like this was a triple demic because of the strain that these viruses are putting on our hospitals and health care system. If we look at the Twin Cities metropolitan area alone, for example, 97% of all adult ICU beds and 99% of adult medical surgical beds are currently in use as of this morning. Again, just 3% of adult ICU beds and 1% of adult medical surgical beds in the Twin Cities metropolitan area are currently not in use, and this is in a state that is still experiencing very little influenza activity relative to the rest of the country. We need to find a way to improve our health care system capacity, or we should expect to see many hospitals feeling as if they're being overridden with influenza, RSV or COVID cases in the years to come. Just because we have reduced much of the capacity within our system to respond to these respiratory pathogens.


Chris Dall: So let's take a look now at long COVID, which as we both know, is which as we both know, is of a high interest to our listeners. Last week there was a hearing on Capitol Hill on Long COVID, a hearing that was notable in this era for its bipartisan consensus on the need for more funding and research into the condition. Now, with that as a backdrop, there was also a new study published in the journal science last week that found significant changes in the blood of patients with long COVID. Mike, how significant is this study? And more broadly, do you think there needs to be a stronger federal focus on understanding and treating long COVID?


Dr. Osterholm: Chris, I'll start by talking about the study that you mentioned, which we will link in our episode description. And before I get into the details of that study, I want to remind everyone that long COVID is a very complex puzzle, and each new study only reviews a few pieces. We're still missing most of the pieces to our puzzle, and the ones that we do have still are a bit jumbled, but we're slowly getting closer to seeing the whole picture and finding some answers. And as someone who experienced for four months post an acute episode of COVID classic long COVID symptoms, I have a very personal interest in this issue. So please understand that if I appear to be energetic on this topic, it's because I know what some of these people are going through, and I've been one of the fortunate ones to recover. The study that you mentioned, Chris, involved an analysis of blood samples from 152 individuals, 113 with what was described as long COVID and 39 healthy controls, who did not have long COVID. Researchers assessed the levels over 6000 proteins in these blood samples to determine if there were any association between some of these proteins and long COVID at six months and 12 months following an acute infection. The researchers found increased markers of complement activation and thromboinflammation in individuals with long COVID compared to those without long COVID.


Dr. Osterholm: This means among individuals with long COVID, there was more activation of the part of the immune system that helps rid the body of microbes and damaged cells, and that there was inflammation in the cells that are responsible for clotting our blood. For those interested in a much more technical aspects of this, I would highly recommend reading Eric Topol's recent Substack post Lighting Up Long COVID, where he explains this in much more detail. We will link that post in our episode description also. With that in mind, I'd like to focus more on the significance of these findings and where this leaves us. These findings are important because they can inform future diagnostic tools as well as identify potential therapeutic targets for future long COVID treatments. Unfortunately, however, we are still left with far more questions than answers here. We don't know which long COVID symptoms can be explained by the presence of these markers in the blood. Research on other chronic conditions, including myalgic encephalomyelitis or chronic fatigue syndrome, another post-viral condition, have found similar results, but this has not yet led to any breakthrough cures or treatments, so I don't think we can expect this research alone to result in any dramatic advances in the very near future. The reality is that long COVID is really complicated, and it'll take a lot of well-designed studies, such as this one, before we can truly understand what is going on in the body and how to treat it.


Dr. Osterholm: This is why continuing to fund long COVID research is absolutely critical. We will not find answers without more research, and we cannot conduct research without funding. As you mentioned in your question, Chris, there was a Senate hearing last week in which the Committee on Health, education, Labor and Pensions listened to patients, medical experts and others share their experiences and insights on the issue of long COVID. A recent editorial in the Minneapolis Star Tribune by editorial writer Jill Burcum titled "Follow up, funding critical on Long COVID," covered some of the important moments and takeaways from this meeting. We were very fortunate to have Jill in our community writing these kinds of editorials as they are very informed, very targeted, and we believe incredibly helpful in helping to explain the kinds of issues like long COVID. We will link Jill's editorial in our episode description, and I encourage you to read it. And I must say, it was a great public health moment to see that there was bipartisan consensus on the need for increased funding and research in the areas of long COVID at that particular hearing. You don't hear about a lot of that happening in Washington, D.C. today. So I have to say, I was very relieved to see that the long COVID issue is being taken seriously by both Democrats and Republicans alike.


Dr. Osterholm: This means that we have no excuse for inaction here. There's a lot of talk about finding a new normal as we learn to live with COVID, and this new normal needs to involve better treatments to minimize the pain and suffering caused by long COVID. This begins with continuing to fund research in this area. And finally, I just want to remind all of our listeners who are currently struggling with long COVID that we see you, we are thinking about you, and we will continue to advocate for you and to keep you updated as much as research becomes available. Finally, I also want to add there was another article this week that we're linking in our podcast description that I think really deserves to be reviewed. This was an article that appeared in CIDRAP news and written by our medical reporter, Stephanie Soucheray. This article was published on Tuesday and was entitled "Does Paxlovid prevent Long COVID? Maybe, experts suggest." This is an important article because it helps lay out some of the confusion. Recently. Does Paxlovid use reduced long COVID or not? And I think that the data supports that it does. And some of the explanations why there are conflicting results are actually provided in this article. I urge you to take a look.


Chris Dall: Now it's time for our ID query. We've received several emails about California's recent update to its COVID-19 isolation policies. In brief, the new California guidelines say that a person who tests for COVID and has no symptoms does not have to isolate, while people with mild symptoms whose symptoms have improved and have been fever free without medication for at least 24 hours can end isolation. In other words, they don't have to isolate for five days. So Judy wrote. Dear Doctor Osterholm, I was horrified to see California's Department of Health end COVID isolation. They say their aim is to protect the vulnerable. As a 65 year old physician with a primary immune deficiency. I've been so isolated in an effort to avoid infection, and this just feels like it makes me more isolated. Our tools are imperfect. Vaccination. Paxlovid. Masks. Thanks for all that you do. So, Mike, what are your thoughts on California's updated guidelines?


Dr. Osterholm: Well, Chris, this is again one of those areas where there is not a right answer. We have to understand, we're in a period of transition from the kinds of early pandemic related activities, like what was initially called lockdowns, etc., to where mandating that people get vaccinated or wear respiratory protection. And over the course of the past four years, we have seen a sea change in how people perceive the risk of COVID and what they're willing to do to try to reduce the transmission to others. And we have to acknowledge that we can't just say, do this, do that, do this, do that, when in fact, we know that very few people will do that. That's not going to help make the world a safer place for COVID. So I, too, am sensitive to how do we make that transition from a world of COVID to one more like what was a world of influenza? Now, I've already mentioned today that surely even now COVID is more severe in terms of its health impact than is influenza. But when we have increases in influenza, we rarely do any kind of community wide activities where we shut down major activities. We may, in fact take snow days at schools where for several days to try to dampen down the transmission, schools will be off. But generally speaking, you don't see people wearing any kind of masking. You don't see people avoiding large crowds or groups. You don't see people not traveling. You don't see people who are keeping their kids from school.


Dr. Osterholm: And so we are trying to find that transition period to where COVID becomes a part of our lives. But as Judy articulately just stated, this is a real challenge for people who fear their infection could kill them based on their existing risk factors. And I completely empathize with that. So let me just share with you what California did, as well as the state of Oregon, who did this earlier in the year. I believe that they are legitimately trying to find the next level of public health recommendations, as we go from the early days of the pandemic to what now is surely on the other side of the big hit of COVID cases. And as Judy just detailed, in fact, there have been changes and the recommendations of the California Department of Public Health. These changes, in part, were actually developed through a community wide process where talking to school teachers, talking to places where kids get together and what was being done, people weren't testing at all. We've had so many parents and said, they've said it to me. If my child has a mild respiratory illness, I'm going to test them for COVID because then he's out for ten days. And so that's counter to what we want to have happen. So, in short, what California has recommended for people who test positive stay home. If you've had COVID symptoms until you have not had a fever for 24 hours without using any fever reducing medication, are there data to support that? That doesn't mean there won't be transmission, no.


Dr. Osterholm: But is that better to recommend something that parents can do where in fact, otherwise they wouldn't do anything at all. They also talk about mask. When you're around people indoors for the ten days after you become sick, or test positive with no symptoms. That still is a lot better than anything we're doing right now. As I pointed out in the previous podcast, I had just been to the Minneapolis International Airport and seeing thousands of people, and I didn't see one person with any kind of respiratory protection on at all. The public's moved on. The third recommendation was avoid contact with people at higher risk for severe COVID-19 for ten days if you test positive. Again, that was a recommendation we had before. And let me just add, I'm not sure that this particular recommendation is being realized for most of the country, even though it's their people going into Long Tum care facilities or other areas where there may be people at increased risk for serious illness. And again, these recommendations do not relate to the hospital setting. So let me come back to that. They also recommend, if you test positive seek treatment. I can't say that loud enough in enough times because of, again, the ability for Paxlovid to reduce the potential serious illness, hospitalizations and deaths. And even I do believe long COVID. So if you look at those recommendations, I think that they make sense. And remember, we made a big recommendation change with Omicron.


Dr. Osterholm: Remember at the time we said you had to, uh, isolate for ten days following a positive? And then we realized when Omicron hit, there were so many health care workers, so many pharmacists, so many key people in our communities out that if they had to stay out ten days, we would have really had a crisis just staffing hospitals. And so CDC moved it to five days and said. Basically, where are your respirator those other five days? Now, the data doesn't support five days as such. Uh, what we have seen from the earlier variants of COVID, uh, about 70% of people are still infected and potentially infectious at five days. And that really doesn't reduce down to a much smaller number until about day ten. So at this point, is anyone really going to stay out for ten days if in fact they're have mild symptoms, if no symptoms at all? I don't think so. So I think that the California recommendation, in fact, is a compromise that actually may get more people to do that than do nothing at all, which in the end will actually still provide more protection to what's happening now in terms of the workplace settings there, that's a different issue. And the health care setting. And you've heard me say this so many times on this podcast, I think what hospitals are doing for respiratory protection in this country is an utter failure. If out in 90 fives, you cannot have good respiratory protection either for the health care worker or for the health care worker transmitting to the patient.


Dr. Osterholm: And we see this happen over and over again with individuals who are hospitalized in house for ten or more days, and then they get their COVID, which was clearly acquired in the health care setting. And what does that all mean? So I think that at this point in this transition, nothing will be perfect. Nothing. And if I was someone at increased risk for serious illness, you know, my age, I'm surely there, but not in the same way that someone who might be immune compromised, have a compromised lung functions, etc. and that. Judy, I understand what you're saying, but I do think that this is an attempt to carve out a more effective response that people will actually follow. Then if you kept the current recommendations of ten days out, etc.. So I know this will not be satisfying to many people. Uh, this is one of those areas where nothing will be satisfying. Um, I wish I could say that in the wisdom of Solomon, we could cut the baby in two and have two whole wonderfully healthy babies. We can't. You can't cut the baby in two at all. And that's the challenge we have right now of trying to find how do we both protect those who are at risk of serious illness and hospitalizations, and how do we acknowledge the kind of sense of society today? The pandemic is over. We're done. Don't tell us what the hell to do.


Chris Dall: And now to some other infectious disease news. Our audience has likely been hearing about the measles outbreaks reported over the past weeks in Philadelphia. There have also been outbreaks reported in Washington, D.C., Delaware and New Jersey. Now, we've been seeing small measles outbreaks in different parts of the country over the last few years, typically linked to pockets of unvaccinated children. And it should be noted that opposition to the MMR vaccines among certain groups predates COVID. But, Mike, do you worry that it's going to accelerate with the broader pushback against vaccines? And if so, what are the implications?


Dr. Osterholm: Well before I discuss what's happening here in the United States, which is, as you've laid out, a really critical issue, let me just point out, we are just part of a global crisis right now with childhood immunizations and particularly with measles. Earlier this week, we published another article in CIDRAP News, which we will link here in this particular episode, uh, looking at measles activity expanding rapidly in Europe. And the W.H.O. actually put out a warning saying that there's been an alarming resurgence of the measles virus across the European continent, adding that over 42,000 cases were reported last year, compared with 941 cases in 2022. They even went on to say that the spread of measles has accelerated so much in recent months, killing five children across Europe and putting more than 21,000 children in the hospital. Britain is now experiencing its biggest outbreak of measles since the early 1990s, and the clock is ticking to vaccinate kids before we see more deaths. So in a sense, this is a tragedy unfolding around the world, and we're part of that. Why is that important? Well, because surely we want to protect our kids here. We want to protect them globally. But as long as there is widespread measles transmission around the world, we're just like a submarine with screen doors. It's going to leak in from around the world.


Dr. Osterholm: So the world is only as safe as the entire world is. If there's a hot spot for measles in the world with transportation, travel, and movement of people today, we will spread it. So I think this is an important context to understand. So to talk about this country, though, it's always alarming to hear about these measles cases and outbreaks as you've laid out. And I think there's definitely a potential for vaccine opposition to continue increasing with really, really serious repercussions. Let's start by just diving into this Philadelphia outbreak. Reports indicate that the first recorded case was in a child who was admitted to the Children's Hospital of Philadelphia with an unknown infection, which was later determined to be measles. While admitted the child infected three additional individuals who were there for other health care concerns. One of the other hospitalized cases was a child who had yet to receive MMR vaccine, in contradiction to the Public Health department's quarantine rules that say individuals exposed to measles should isolate. This child was sent to a daycare where four additional cases became infected. The Philadelphia Health Department has reported that unfortunately, none of the people diagnosed with measles had been vaccinated. Now, all this is taking place in Philadelphia, where 93% of eligible children are vaccinated against measles.


Dr. Osterholm: However, to achieve what we call herd immunity to measles in a population, we need at least 95% of the population to be vaccinated. And while Philadelphia's percentage doesn't seem that far off, it's not that simple. While a city or a state's overall vaccination rates may be high, it's important to look at the smaller community rates rather than averages over a large area. Aggregate vaccination data is likely to hide that certain pockets of a community, either based on geography or other social characteristics, may have concerning low level vaccination rates. In these pockets, cases can spread rapidly in neighborhoods, schools, or community gatherings. For example, here in Minnesota, 89% of eligible children have received the MMR vaccine. Our health department publishes a report that shows that the percentage of attendees at each registered child care facility that have received each vaccine. Scrolling through, I saw a concerning the low vaccination rates as some of these centers, some with as low as 20% MMR vaccination coverage. Some centers reported more than 50% of children receiving non-medical exemptions for the MMR vaccine. It is a sobering reminder that there are a lot of vulnerable children out there who would be unprotected if exposed to this deadly virus. And just remember, even if you are a parent who is vaccinated, your child protection is not absolute.


Dr. Osterholm: We estimate that the measles vaccine, which is considered highly effective, is effective 94 to 96% of the time. But for every 100 children that get vaccinated, that means 4 to 6 could still be susceptible to being infected by measles. And it takes the collective good of all people to get vaccinated, to hold down that chance that I will ever be exposed to the measles virus, even if I were to end up becoming a vaccine failure, uh, based on my immunity. So it's important that we get as many children vaccinated as possible. And it's not just the MMR vaccine that's facing increasing opposition and decreasing coverage. It's really any type of vaccine, period. Let's talk about some contributing factors. There has been, of course, a rise in vaccine misinformation. Unfortunately, so many people have misconceptions about the contents and the effects of vaccines that have absolutely no scientific. Basis. But once people are scared, it's difficult to convince them that the evidence shows that the vaccines are safe and save lives. And then during the COVID pandemic, especially the early days, people were scared to go to a doctor's office, which meant many children fell behind or completely missed. Critical vaccine series. Now we're seeing how politicized vaccines have become. That's another ding to the vaccine acceptance in the US.


Dr. Osterholm: And there's also the fact that because vaccines work so well, people who have never dealt with large scale circulation of certain diseases like measles don't realize how serious they were pre vaccine development. I can't believe we have to ask ourselves how we can get people to understand the importance of vaccines without having to see a kid be hospitalized or die from a preventable illness. Whatever the reason may be, we can see the vaccination coverage is down and that puts a lot of people at risk. It's so important you get yourself and your family vaccinated, and if you and your children are fully vaccinated for MMR, the good news is that you will be protected against infection at a very high level. Not perfect, but a very high level. And if you know people with young children, talk to them about vaccination. Some people may be completely off the deep end in terms of anti-vax views, but there are many who fall along the spectrum of hesitancy, and it may just take a conversation where someone listens to and validates their concerns. And to those working in health care and public health, don't give up. This fight is absolutely worth fighting, even if it's just so that one child doesn't have to suffer and even potentially die.


Chris Dall: Finally, both the National Institutes of Health and the World Health Organization have been working to define viruses and pathogens with pandemic potential and provide some guidance on where vaccine research and funding should be focused. Mike, what do you make of these efforts?


Dr. Osterholm: Not much. Uh, that may sound very strident, uh, given that this is the W.H.O. and the NIH, but I think it's actually, at this point, uh, unfortunate that they have decided to approach the issue of future preparedness in a similar way. Let me start out by clarifying why I have a problem with what they're doing and what it means. As you just stated, they're looking for pathogens with pandemic potential and how to fast forward the research on vaccines and drugs for these diseases. But they've missed the boat. The only two viruses right now that have a pandemic potential are both respiratory transmitted viruses, influenza and coronaviruses. That's it. Uh, in my new book coming out later this year, The Big One, I cover that in detail and I talk about those viruses as viruses with wings, meaning that they literally can infect everyone in the world, and the viruses will move in such a way that that will happen. Now, the viruses that they're focusing on right now are ones that surely have the ability to cause serious illness in a regional level. These include viruses like Ebola, Zika, Lassa fever, all these ones that are really important but important at a regional level. You may recall back in 2014 over 2015 or early 2016, when we had the large outbreak of Ebola in Western Africa.


Dr. Osterholm: You know, that was an incredible tragedy. But we never were at risk for widespread transmission in high income countries around the world. It was a virus that was transmitted via body fluid contact, not by a respiratory route. Now, should it one day ever become a virus that's transmitted via the respiratory route, then that's a whole different picture. Ironically, of all the diseases that the NIH and the W.H.O. have identified, they left the two off that are the ones that are likely to cause the next pandemic, influenza and coronavirus, because they're not part of this process, which today we need to focus heavily in this area. That's what we have to prepare for. Now you can say, well, you don't understand, Mike, how important these are. Let me tell you. We have lived front and center with these other viruses. Starting in 2016, CIDRAP was, along with the Wellcome Trust and with who developed detailed vaccine roadmaps, blueprints for how to get better vaccines for these diseases and have involved many, many international experts. We actually have developed roadmaps for Ebola, Marburg, Nipah, Lassa, Zika and influenza and coronaviruses. And so you can't say that we don't think these aren't important. They're very important, but they're missing the focus of influenza and coronaviruses.


Dr. Osterholm: And to say that these other viruses I just mentioned have pandemic potential is absolutely, 100% scientifically wrong. And when you look at the October 2023 supplement that came out in the Journal of Infectious Diseases by the NIH entitled Pandemic Preparedness The NIAID Prototype Pathogen Approach to Accelerate Medical Countermeasures, Vaccine and Monoclonal Antibodies. That was wrong. These are not viruses with pandemic potential, and why they did not include influenza and coronaviruses as the ones that really need to have the focus. So, you know, this may turn out that some people will not be happy with me saying this, but they're just wrong. We should continue to stay laser focused on influenza and coronavirus vaccines, on all the countermeasures that we need for treatment, etc. more than these other ones. Not to say that these other ones aren't important and they need to be prioritized, but don't call them pandemic potential agents. They're not. You just basically invalidate your expertise to me when you actually say that. So I hope that we can get people to continue to stay laser focused on influenza and coronaviruses, because they're very likely to be the infectious agents of the next pandemic, not these other ones, which will continue to occur and need to be addressed.


Chris Dall: And now it's time for this week in public health history. Mike, I understand we're focusing today on smallpox.


Dr. Osterholm: Chris, I have to tell you, I love these public health history segments. So to the podcast team that put them together. Uh, thank you. And for all of you who write in and ask us about this. So today is one that, uh, clearly could be one of those questions that would appear in a game show, uh, that if you knew the answer to it, you'd be the only one in the audience that would. Chris, this episode of the Public Health History is one we're highlighting two events centered around the same deadly disease as you noted, smallpox. First, I want to talk about the first ever medical article published in America, and it was titled A Brief Rule to Guide the Common People of New England How to Order Themselves and theirs in the Smallpox or measles. Now, let me just ask the audience. First of all, take a guess when this was written, the first publication. Well, if you can believe it, this publication first circulated on January 21st, 1677, almost 100 years before the Declaration of Independence was adopted. These early European settlers brought smallpox with them to North America, where it further spread to native indigenous populations and continued its path of destruction for generations. The case fatality rate of smallpox is estimated to be between 20 and 60%, and millions of children and adults died of the insidious disease. So we can assume this pamphlet signifies very early public health efforts to prevent and manage the infectious disease. That being said, the guidance came along before the discovery of the actual disease etiology and thus includes some heavily outdated recommendations like bloodletting, drinking warm beer and cordials, variolation, which was the practice of actually taking pus from a smallpox lesion and putting that on the skin of another individual, not letting them inhale it, which is the way that, in fact, smallpox is really transmitted, was actually also used at this time, and it was used in limited settings until the end of the 1700s.


Dr. Osterholm: The method was moderately protective, although variolation sometimes resulted in unpredictable short and long term patient results, including them actually developing smallpox itself. Smallpox prevention efforts only became meaningfully successful following English physicians Edward Jenner's contribution to early vaccine research. Many listeners may be familiar with this story. Jenner observed that milkmaids who were previously infected with cowpox, a relative of the smallpox virus, displayed resistance to smallpox, and from there he began experiments to inoculate susceptible people with material from the cowpox pustules. Jenner's research laid the foundation for future scientific innovation, and his relentless promotion of immunization practices allowed the smallpox vaccine to become widely accepted globally, like preventing millions of smallpox deaths. Jenner passed away on January 26th, 1823, leaving behind a legacy of devotion to protecting the public's health. He was quoted as saying, I hope that someday the practice of producing cowpox in human beings will spread over the world. When that day comes, there will be no more smallpox. And he was right. The W.H.O. declared smallpox be eradicated in 1980 following large scale immunization campaigns and increased surveillance. This feat simply would not have been possible if not for the effective vaccine rooted in Doctor Jenner's work.


Chris Dall: So, Mike, what are your take home messages for today?


Dr. Osterholm: Well, Chris, as I've already shared in the podcast, this is a period of transition. We are moving from the heavy, heavy days of that early and mid-pandemic time period to one of kind of a post-pandemic time period where there still is a significant illness in our communities, but it's not the same as it was during those early three years. This is going to be a troubled time, because there won't be a perfect way to make that transition, where the recommendations will match up as exactly people think they should. Some will find them onerous, overbearing, and not at all compatible with everyday life. On the other hand, there will be those that say, look, you're putting me at risk to die by not doing more to reduce transmission in our communities. So in this period of transition, I keep coming back to vaccine. Getting your vaccine dose for COVID right now can go a long, long ways to keeping you from serious illness, hospitalizations and deaths. So that is part of this. And just know that we won't get it perfectly right each and every day. In trying to make that transition from what we recommended in 2020 and 2021 to what we're recommending today, and that'll change even more by the time we get to 2028. The second point is COVID is still here. It's not done with us. Again, as I pointed out, we're seeing three times as many deaths in the US right now from COVID than we do flu. It's still a challenge, but it's not the challenge that we once had where it would have been literally many, many times higher death rates from COVID than from flu.


Dr. Osterholm: Now, will this change again in terms of what happens with the next variant? It could, I don't know. Uh, I've already laid out for you in this podcast today the confusion about what does the JN.1 variant mean in terms of cases in your community? When is it really a cause and effect for a big increase in cases? When is it not? So this is a challenge. And finally, when we talked about measles today, I just can't emphasize enough the challenges we have ahead of us with childhood immunizations and vaccine acceptance. This is huge. And I could see us basically, uh, going backwards in ways I could never have imagined in vaccine preventable disease prevention in this country and for that matter, the world. So we have got a lot of work to do to understand why people are resisting vaccinations. What does it mean? How do we most effectively accomplish getting individuals vaccinated? And just like the mother of the child who is not old enough yet to get his measles shot, but in fact is in child daycare, I can only imagine what that feels like, and so I cannot emphasize enough how important it is that we keep laser focused on understanding how vaccines are researched and developed, but also equally, how do we convince people to convert a vaccine into a vaccination?


Chris Dall: And what is our closing song for this episode?


Dr. Osterholm: Well, today we actually have a listener input that I thought was very, very helpful. This comes from Michelle. This song really is all about where are we at and where are we going and what we need to do to keep focused on getting to where we're going. This song, When I'm Weary, is in the album Come Tomorrow, which was the ninth studio album by the Dave Matthews Band. It was released on June 8th of 2018, and it was one that, unlike almost all the other songs on the album, had not been released before the album was actually produced. And this song really speaks to us about where we're at today and where we're going and what we need to continue to remember. So here it is by the Dave Matthews Band when I'm weary. When I'm weary. When I'm tired. You remind me to keep on trying. There will be dark, dark days. More coming. Just as sure as this sweet earth beneath my feet. It don't matter. Come tomorrow. Together we must face what lies ahead. When you're weary. When you're tired. Please remember to keep on going. Dave Matthews band. Thank you again for joining us. I hope that we've been able to provide you with information that you find useful. Uh, I have a feeling, particularly as we talk about the transition time for public health recommendations, this will be unsettling and unsatisfactory to a number of you.


Dr. Osterholm: And we're all working hard to try to find out what that right answer really is. And it's not just an esoteric issue, it's about human lives. So I surely take that very seriously. I want to give a shout out to my dear friend Don. I hope that you're doing better today. Um, and, uh, COVID has been cruel to so many of us. I never forget that. For all of you who have experienced its cruelty, my heart is with you today. Thanks again for joining. We look forward to all of your input. Please share that with us. Uh, that makes us better. I want to thank the podcast team who helps put this together. Without them, it wouldn't happen. And I also just want to remind all of you right now is a great time. A great time to be kind. Uh, the world is a troubled place. Uh, and while none of us can change that world, we can begin to change parts of that world. And just wherever we're at, however we can be. Be kind. So thank you. Be safe. Talk to you in a couple of weeks. 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 CIDRAP.umn.edu. This podcast is supported in part by you, our listeners. If you would like to donate, please go to CIDRAP.umn.edu/support. The Osterholm Update is produced by Sydney Redepenning, Elise Holmes, Cory Anderson, Angela Ulrich, Meredith Arpey, Clare Stoddart, and Leah Moat.