June 9, 2022

In "COVID Meteorology," Dr. Osterholm and Chris Dall assess the state of the pandemic in the US and around the world, discuss the data on the Novavax vaccine, and provide updates on monkeypox and influenza. Dr. Osterholm also answers a COVID query on the original strain of SARS-CoV-2 and shares a Celebration of Life from one of our listeners.

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Chris Dall: [00:00:06] Hello and welcome to the Osterholm Update COVID-19, a podcast on the COVID-19 pandemic 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 will draw on more than 45 years of experience investigating infectious disease outbreaks to provide straight talk on the COVID-19 pandemic. I'm Chris Dall, reporter for CIDRAP News, and I'm your host for these conversations. Welcome back, everyone, to another episode of the Osterholm Update podcast. We are now into our third summer of the COVID-19 pandemic, and while we continue to see the type of ebb and flow of cases that we've by now gotten used to, figuring out what comes next with this virus remains tricky. Globally, new COVID-19 cases appear to be declining, and nationally, the wave that began in April appears to be slowing. But with new and more transmissible Omicron variants gaining a foothold in the US and other countries, we all know that could change in a matter of weeks. That will be the focus of our discussion on this June 9th episode of the podcast as we assess the state of the COVID-19 pandemic in the US and around the world and discuss what the future may hold. We'll also discuss an FDA advisory group's recommendation to authorize another COVID-19 vaccine and how that might impact the vaccination effort, talk about the latest data on Paxlovid rebound cases, and answer a COVID query about the original version of the coronavirus. We'll also provide you with an update on monkeypox and share a celebration of life from one of our listeners. But before we get started, as always, we'll begin with Dr. Osterholm's opening comments and dedication.


Michael Osterholm: [00:01:51] Thank you, Chris. And welcome back to all of you to another edition of The Update. I know that some of you last week were disappointed that we didn't do an update a week ago, but rather the last one was two weeks ago. Where we're at in the pandemic right now, we hope that this is sufficient information to keep you fully informed and at the same time giving our podcast team a bit of a break. But if at any time things change substantially in terms of the COVID risk or new information that we think you need to get in your hands, we will go back to the weekly format. Today, I want to take a moment and take a step back and it'll be really clear and compelling in the final closing song that I've chosen today is the fact that we're in a world right now with tremendous hurt and pain, and the pandemic has actually subsided quite a bit in many parts of the world, but there's still pain in the sense of knowing what to do or not to do. Where are we at? What's going on? And so I hope that today we can help bring some additional clarity to that. But as you've heard me say many, many times on this podcast, I often don't know. And I will say I don't know. And we'll give you our best shot at what we do know and where we see the trends developing. I also want to acknowledge today that the world of public health in itself is not just all about COVID. As serious as this has been in terms of a public health challenge, we clearly have many other issues around public health. Notably, monkeypox is happening right now. We see influenza resurging in the southern hemisphere. We're watching the challenges of trying to recoup from two years of almost lost public health activity around vaccines, around drug treatment for chronic infectious diseases. I go down the laundry list. And so today, I want to take a step back and acknowledge my colleagues in public health, a group that has been challenged immensely over the past two and a half years and that frankly, often were not appreciated for what they did to help get us through this pandemic. Rather, they were often scapegoated. It's also notable to share with you that in 2008 in this country, we had approximately 250,000 people working at city, county, and state health departments, as well as in the federal agencies. And that was, to my mind, the absolute basement of what needed to be in terms of public health activity in this country to assure our public's health. Well, today we're at less than 200,000 persons working in public health. People are stretched. People are tired. Now we're asking them to rev up again. And I think this issue with monkeypox is only going to continue to be a substantial challenge. But just catching up and all the public health actions that should have could have been taken throughout the rest of the pandemic had it not occurred. And so today I dedicate this podcast to you, the public health workforce. Thank you for all you do to make the world a better place for my kids and my grandkids. That means everything to me. Next, I want to cover a topic that actually I did cover early in the podcast and was challenged by some of our listeners as to providing far too much esoteric information that was unnecessary to understand the pandemic. I received an email recently from Rob, who lives in western Wisconsin, and I want to share this with you because actually in spirit, I am completely with Rob, but I'm sure for many of you, you'll hear this and just shut us out for the next few minutes. And that's okay, we will get to something you need and want later. But Rob wrote to me, "Dear Dr. Osterholm et al., I've been a big fan of your podcast for many months now, but every week one thing bugs me. It has to do with your sunlight feature. I live in western Wisconsin, not far from the Twin Cities, so I get it. The shorter winter days can be brutal, but the long summer days are glorious. When it comes to sunlight, more is better. And by focusing on sunrise and sunset times to calculate day lengths, words matter. You're undercounting daily sunlight. A day's dose of sunlight doesn't begin with the sunrise, nor does it end with sunset. Thanks to Earth's atmosphere, which scatters roughly 50% of the solar radiation that reaches it, Earth also receives sunlight before sunrise and after sunset. That extra sunlight is called twilight. How does one tally up twilight? By first making some definitions. I'll quote the National Weather Service, "Civil twilight begins in the morning or ends in the evening when the geometric center of the sun is six degrees below the horizon. Under these conditions, absent fog or other restrictions, the brightest stars and planets can be seen, the horizon and terrestrial objects can be discerned. And many cases artificial lighting is not needed. Nautical twilight begins in the morning or ends in the evening when the geometric center of the sun is 12 degrees below the horizon. In general, the term nautical twilight refers to sailors being able to take reliable readings via well known stars because the horizon is still visible, even under moonless conditions. But detailed activities are likely curtailed without artificial illumination. And finally, astronomical twilight begins in the morning or ends in the evening, when the geometric center of the sun is 18 degrees below the horizon. In astronomical twilight, sky illumination is so faint that most casual observers would regard the sky as fully dark, especially under urban or suburban light pollution. To me, civil twilight, when artificial lighting often is not needed, is simply too beautiful to not count as part of my daily sunlight, especially in the summer. To illustrate the data upgrade, I'll jump right to the big one 21st of June 2022, when, according to the Farmer's Almanac, adding civil twilight to the day length makes our solstice sunlight one hour and 9 minutes longer than our solstice day lenght. What's not to love about that? Rob." Well, Rob, let me just say, I am a huge fan of these terms, and I actually did use them early on. But again, the feedback we got is stick with the COVID related information and let's move on. So I did cut them short, but I'm with you. So thank you for your incredibly thoughtful email. And let me just say, here we are in June 9th today, the sunrise in Minneapolis, Saint Paul was at 5:26 a.m., sunset is 8:58 p.m. for 15 hours and 32 minutes and 41 seconds of sunlight. But in keeping in the spirit of what you just shared, in fact, last night I very carefully went out and looked to see if I could still see that sun light on the horizon. And at 10:10, almost one hour and 10 minutes beyond sunset, I could still see that. You're right. And I did soak that up. And because of the cloud cover that was interspersed on the horizon last night, it was incredibly beautiful. So, Rob, thanks. For all of you, we're getting close to that summer solstice where we will have maximum sunlight. To those in the southern hemisphere, bear with us. We're sharing it with you. And we're going to be asking you for a return on investment. In the meantime, Rob, I won't be covering every week the terms for all the different lighting issues because again, I'm sure the listeners don't necessarily appreciate what you and I do, but I wanted to tell you, you are right on the mark and some of the most beautiful times of the day occur before sunrise or after sunset.


Chris Dall: [00:09:37] Mike, as I noted in the introduction, cases continue to decline overall on a global level, but as we know, that doesn't mean cases are declining everywhere. So what parts of the world are you keeping an eye on right now?


Michael Osterholm: [00:09:50] Well, Chris, you're exactly right. On a worldwide basis, COVID case and deaths are continuing their downward descent, which has been a fairly consistent pattern we've seen throughout the past several months. As a reminder, during the original Omicron surge in January, reported weekly cases surpassed 23 million and weekly deaths reached 77,000. Compare that to last week's numbers, where cases stood at around 3.1 million, not 23 million, and deaths were below 10,000, not 77,000. And you can see where the past four months have taken us. Now, for all of you who will challenge these numbers, saying they are incomplete, that they surely don't represent all the cases that have occurred, all the deaths that have occurred, I agree wholeheartedly. But I think that the trend data does tell us a real story. For context, considering the following, as of this Tuesday, the global death toll for last week, according to the World Health Organization's dashboard, stands at around 8,000. Now due to slight lags in reporting and the fact that it's somewhat early in the week, there's a chance that this toll could be slightly higher by the time you actually listen to this podcast. Nonetheless, a weekly death toll of around 8,000 or even 9,000 would be the lowest we've seen since the start of the pandemic. And to help put that into perspective, just compare it to some of the daily death tolls we've reported in the past. On January 24th, 2021, average daily deaths from COVID worldwide reached a record 14,800. In addition, from November 7th, 2020 to June 28th, 2021, or a span of 233 consecutive days, the average daily death toll never dropped below 8,000. So while I by no means want to minimize any one of these 8,000 COVID deaths reported last week, it's certainly preferable to those times when this virus was killing many more than 8,000 people on a daily basis. However, at the same time, I still think there's a lot of progress that can and should be made. And I'm also aware of just how quickly this virus could wipe away any progress that's been made to date. So despite the overall pattern of declines, I think it's important to keep monitoring those outliers that are seeing increases or facing notable challenges from the virus, since they might best provide insight on where we stand moving forward. Never forget, we are still in an incredible tug of war between our human immune system and the evolutionary pressures of this virus. And between the two, we are still not quite sure where one day's equilibrium might actually exist. So in order to better understand that, let me just briefly run through a few different examples of what's happening internationally. First, there's the ongoing situation in North Korea, which we've touched on the past several episodes, and we all know obtaining a clear understanding of what exactly is going on there is virtually impossible due to the overall lack of data and transparency. According to official reports there, this outbreak has resulted in 4.2 million cases countrywide and just 71 deaths, an unrealistically low death toll. Last week, Dr. Mike Ryan with the W.H.O. was asked about the situation in North Korea. He said the following and I quote, "It is very, very difficult to provide a proper analysis to the world when we don't have access to the necessary data," unquote. Despite the lack of data, he went on to say that he assumed the outbreak there was getting worse, not better. And I think Dr. Ryan's sobering assessment is right on the mark. In addition to North Korea, regular listeners to this podcast have also heard me talk about China fairly frequently over these past several months. Anybody who's had a supply chain challenge surely understands what I'm talking about. Of course, this past week has brought headlines of certain restrictions easing for some residents of Beijing and Shanghai for the first time in months. For example, indoor dining at restaurants in Beijing is no longer banned. However, make no mistake, this news doesn't signal the immediate end of the battle for either city. In fact, in Shanghai, more than half a million residents remain under movement restrictions, some of which have been expanded in recent days due to a small cluster of cases that has recently cropped up there. In addition, for city residents that are allowed to move a bit more freely, frequent PCR testing is the norm. And of course, the looming threat of COVID there isn't exclusive to just Beijing and Shanghai. For example, in just the past week, there's been a growing outbreak in the Inner Mongolian Autonomous Region of China, which reported a total of 49 local infections on Monday and 69 on Tuesday, prompting a lockdown in one of the cities located there. Meanwhile, it's been reported that a number of cities across the country are looking into initiatives that might improve vaccination rates, particularly among the elderly, including insurance packages for those worried about side effects, which has actually been identified as a big reason why elderly individuals in China haven't been vaccinated there. However, it remains to be seen how effective this will be for a country as a whole, where more than 33 million individuals age 60 and older are unvaccinated, and an additional 61 million have yet to receive a third dose, which is particularly important for the vaccines they are relying on. So China's vulnerabilities still remain. And to think that the challenge with COVID is done and over with in China would be silly. Otherwise, as a whole, we're doing our best to monitor what's happening in places that are seeing growth of the sub-variants BA.4 and BA.5. As mentioned in previous episodes, both of these sub-lineages of Omicron share some notable mutations which have been previously linked to heightened immune evasion. And now we're seeing BA.4 and BA.5 consistently outcompeting all of the other Omicron sub-lineages such as BA.2. Again, one of the earliest examples we have of BA.4 and BA.5's potential impact is from South Africa, which saw cases start growing in mid-April when these sub-lineages took over for BA.2. So for a country that saw a record high wave of infections late last year, that was brought about by the original Omicron sub-lineage BA.1, a fifth wave of cases less than six months later warrants a much closer look. In fact, a recent preprint looking at the prevalence of antibody in South Africa's population estimated that 98% of the residents in mid-March, so prior to BA.4 and BA.5, had previous exposure through either infection or vaccination. So something was going on. Well, ultimately, cases from the BA.4 and BA.5 surge there would go from 1,200 a day in April to a peak of 7,700 a day in May before dropping back down to below 2,000 as of this past Monday. And hospitalizations and deaths have so far remained at a fraction of the levels reached during the previous waves. So from a severe disease and death standpoint, that's at least reassuring. However, a growing body of data suggesting that BA.4 and BA.5 can readily evade protection against infection, particularly among unvaccinated individuals previously infected by BA.1 indicates that growth of these sub-lineages could prompt notable case increase in a number of different countries. Again, I come back to that issue of the battle between our human immune system and the virus and its ability to evolve. We don't know where this ultimately will take us. In fact, there's some evidence of that playing out in countries like Portugal and Switzerland. And we're seeing these sub-lineages grow in places like the UK and the US as well. So as always, we'll have to see what actually happens in the days ahead. Ideally, any waves we could see won't be followed by a significant amount of hospitalizations or deaths, as has so far been the case with South Africa. But it just goes to show how quickly this virus can adapt and overcome the protection against infection. That means that none of us can provide you with a definitive answer of what will next month or three months or six months from now look like.


Chris Dall: [00:18:17] Back in March, we talked about the COVID situation in Ukraine following the Russian invasion and some of the countries that were housing Ukrainian refugees. Mike, do we have an update on COVID in Ukraine and some of its neighbors?


Michael Osterholm: [00:18:29] Well, first of all, Chris, let me make it very clear. No matter where you are in the world, war is hell, and that we can never forget the pain and suffering that occurs when one human inflicts intentional pain and suffering on someone else. And I just have to say that because I continue to watch, as all of us do here, the challenges that the war in Ukraine continues to pose. And also, make no mistake about it, war is an infectious disease's best tailwind. And while that's been the case for a whole range of diseases since the earliest days of war in our society, it is particularly prescient when it overlaps with pandemic diseases like COVID. Not only does war often foster conditions that are favorable to the transmission and impact of diseases, including large scale movement, crowded conditions, and an overall lack of access to vital health care resources. It also causes significant disruptions to so many public health programs and initiatives, including those that were established to monitor what's happening in the first place. So from that standpoint, the fog of war has also involved our understanding of what exactly has been going on in Ukraine with COVID. Of course, from the same time that the Russians invaded Ukraine on February 24th, Ukraine was experiencing their initial Omicron surge, with average daily cases reaching 20,000 to 30,000 per day. However, by early March, just a week later, average daily cases reported in the country fell to less than 5,000. And according to the official reports, they've continued to drop since. However, there's no doubt that this is an artifact of reporting and another one of the many challenges that the invasion has brought about for Ukraine. In fact, if you look at the W.H.O's website, Ukraine has reported cases and death totals for COVID on just six days since the beginning of May, almost a 40 day range. So really, there's no way for us to know exactly what's happening on the ground in Ukraine. Still, there's no doubt that this virus is having an impact there. And that impact has likely been exacerbated by the war, which for obvious reasons has become the top priority for the country. So in addition to the countless tragedies and atrocities that we're seeing as a result of this war, many Ukrainian residents are also living in settings where the resources and tools used against COVID are unavailable or inaccessible. For example, it's difficult to obtain appropriate medical care when buildings are destroyed or qualified health personnel aren't around. Even getting diagnosed can be a challenge. According to a report published in April on Relief Web, which is a service provided by the United Nations Office for the Coordination of Humanitarian Affairs, COVID lab capacity in certain Ukrainian cities with just 2 to 3% of the levels reported prior to the invasion. As a result, testing is very limited and is presumably being prioritized for only those most severe cases that happen to find access. And if that wasn't challenging enough, the process of reporting cases out isn't easy. In some places, a lack of infrastructure limits reporting to only that which can be done over the phone. And of course, that can only happen if there's a service or an available connection. So again, the reporting of COVID data there has been extremely fragmented. In addition, for those cases that might require hospitalization, the ability to get appropriate treatment or care is a significant challenge. As we have seen, many hospitals have been targeted and destroyed there and the ones still standing are filled with wounded soldiers and civilians. So severely ill COVID patients there might often be facing situations where it's a struggle to find a hospital, let alone a hospital bed. And of course, that still requires the staffing and resources to provide optimal care. In some situations, the medicine and supplies needed might not be available at all. As a result, a much higher proportion of cases there could be experiencing severe outcomes, and we wouldn't know it. And finally, the situations and settings that some Ukrainian citizens have not only been horrific from a humanitarian standpoint, but they're also conducive for COVID transmission. Any time you have hundreds or thousands of people forced into a confined area, such as shelters with high densities and limited ventilation, you can see how it wouldn't take long for a virus to find new hosts. And of course, self isolation in these instances is virtually impossible. As a result of the invasion, we've seen a massive displacement of Ukrainians looking for refuge. In fact, according to the UN refugee agency, more than 7.1 million people have been displaced by the war and nearly 16 million are believed to be in urgent need of humanitarian assistance and protection. Of the 7 million refugees that have left Ukraine, nearly two thirds have temporarily resettled in other European countries, including Germany, Poland and the Czech Republic. In many instances, refugees are being offered vaccines upon arrival, including vaccines against COVID. And to date, we haven't seen any evidence yet tying this migration to major COVID surges in neighboring countries. Interestingly enough, based on the epi curves from Poland and the Czech Republic, COVID cases have consistently been declining since the invasion began. So we are hopeful that this is good news about what's happening in those countries. Otherwise, although Germany did experience an increase in cases starting in early March, that coincided with the rapid rise of the BA.2 sub-lineage there and was increasing prior to the point where any arrivals from Ukraine might have had an impact. So suffice it to say, what's happening in Ukraine is really a situation filled with tragedy after tragedy after tragedy, and the impact of invasion there extends far beyond Ukrainian borders. So for many reasons, including the health and safety of Ukrainians and food security impacts on numerous low income countries that emerge because of the situation, I can only really hope for peace.


Chris Dall: [00:24:44] Here in the US, the nationwide surge in cases that began in the Northeast this spring appears to be slowing as cases and hospitalizations decline in northeastern states. Or it could just be shifting to other parts of the country. It's hard to say at this point. And of course, as we've noted for the past several weeks, the actual number of infections is likely much higher, as many positive rapid home tests are going unreported. So Mike, what's your read on what's going on and what we may see in the coming weeks and months?


Michael Osterholm: [00:25:13] Well, let me begin the answer to this question by making a very important statement, which by now should probably be old news to our listeners. And that is it is very difficult to predict things about the future when your crystal ball that you use every day has five inches of caked mud on it. So I will try my best within that context to give you a sense of what we see happening and then what that might mean for the future. Right now, average daily reported US cases are hovering around 100,000 a day. But as you just shared, and we all know, the actual number of daily cases is much higher. I, for example, can continue to state for the past 7 to 10 days I know of more new infections with COVID than any time in a similar 7 to 10 day period since the pandemic began. Most of these have been confirmed by lateral flow tests at home or their EPI related cases, meaning someone brought it into the household and within 3 to 5 days many other members were infected. So we know we have lots of transmission out there. We know that we're missing those cases. This is why I've continued to keep my eyes focused on the next best indicator of what's happening. And that, of course, is hospitalizations and deaths. Right now, the CDC's Community Transmission Map that we've talked about the last couple of episodes is overwhelmingly red. This virus is definitely not going away. Two weeks ago also marked the takeover of BA 2.12.1 as the dominant sub-variant in the US. At that point, the CDC was not tracking separately BA.4 and BA.5 sub-variants that are now variants of concern. The CDC, as of this past week, is now separating the two in their prevalence data. BA.5 made up 8% of the newly reported cases last week and BA.4 made up 5% of the new cases. BA.2.12.1 continues to be a dominant strain, making up 62% of new cases. These variants are certainly something to keep an eye on in the coming weeks and months. I'm convinced, particularly with what we've seen in Europe, that we will see BA.4 and BA.5 becoming the dominant sub-variants within the next several weeks. Currently, the US is reporting 2.3 new daily hospitalizations per 100,000 and an average of 29,000 people hospitalized for COVID in a given day, or about nine per 100,000. This is 12% higher than two weeks ago. But if you take a step back and again look at the 29,000 figure for hospitalizations that we're talking about now, and compare that to what we just saw in January, where on January 28th we had 158,838 people hospitalized in the United States with COVID. Big difference between 158,000 and 29,000. If you look at the ICU bed numbers, they are slightly increased with 3,100 patients in ICUs on a daily basis for COVID in the US, 11% of the patients who are hospitalized with COVID are in the ICU, which has been consistent over the past month. And just again, let remind you in context, with the 3,100 patients in ICU now, how that compares with that same January 28th experience, when we had 26,249 individuals in ICU beds in this country, a big difference from 3,100 now. And if we look at daily deaths, they are staying relatively steady now at 326 lives lost on an average day, which is 2% lower than it was two weeks ago, but far below the peak on again January 28th of 3,280 deaths a day. So this is all good news. Clearly, we are seeing lots of transmission with a much less severe picture at hand. And the question will be, with viral evolution and waning immunity in humans, what does it look like for the future? So let me get to your question about my take on all this. As I said at the beginning, I don't know what's going to happen. I can tell you that this pandemic is not over, and trying to declare it as such would be a huge mistake. It's deja vu all over again for me. Remember a year ago right now, some of you on this podcast know I got hammered pretty hard when I said in mid-June that I thought that some of the darkest days of the pandemic could still be ahead of us because of the unknown impact of the variants. I still don't know what's going to happen over the next 6 to 12 months. What happens if Pi and Sigma show up, which are very different variants than even Omicron and ultimately have other characteristics for transmissibility and or ability to cause illness? Just don't know what's going to happen. So right now though, we are in a period of uncertainty with BA.4 and BA.5. And I really can't predict over the next six weeks how this is going to play out or how this could change the bigger picture. As we are following closely, the CDC wastewater surveillance data indicates that the presence of COVID in more than a third of monitored sites have doubled in recent weeks, but another third of sites have seen decreases of at least ten and up to 99%. There's no single story to be told about this virus in the US, which makes predicting the future of the unpredictable virus that much more difficult. As I told someone in an interview this past week, I'm starting to feel like a COVID meteorologist. I can give you an idea about the forecast for the next two or three days. Beyond that, I really can't tell you what's going to happen, and I feel very much the same way with this situation here.


Chris Dall: [00:31:02] We had some vaccine news this week as the FDA's Vaccines and Related Biological Products Advisory Committee recommended emergency use authorization for the COVID-19 vaccine from Novavax. Now, as of this recording, we're still waiting to hear whether the FDA accepts that recommendation. They typically do, but not always. So, Mike, what do we know about the Novavax vaccine, and if the FDA does go ahead and authorize it, do you see it having any impact on the US or global vaccination effort?


Michael Osterholm: [00:31:31] Well, first of all, Chris, this is a very popular topic, as we've heard from many listeners that they've been waiting patiently for us to discuss the Novavax vaccine. And our response has always been when there's new and relevant information that we can share with you that will update us all, then we'll do that. Well, now we have some. The FDA's vaccine advisory committee, known as VRBPAC, met Tuesday to review Novavax's emergency use authorization application for their two doses of COVID-19 vaccine in adults 18 and older. As you noted, the committee voted yes that the benefits of the Novavax COVID vaccine outweigh the risks. While the FDA is not technically bound to the decision, as you noted, I'm convinced with the vote as it was taken, it's almost certain that the recommendation will be followed and the FDA will likely authorize emergency use of this vaccine very soon, even possibly by the time that this podcast is posted. For our discussion, I want to start with a brief overview of the vaccine. Novavax has developed a two dose SARS-CoV-2 vaccine called NVX-CoV2373. It is a recombinant nanoparticle protein-based vaccine with an adjuvant. That's pretty technical language. So let me explain what this means. The SARS-CoV-2 virus is covered with spike proteins that it uses to enter our cells and cause infection. This type of vaccine works by training the immune system like the other vaccines, to recognize and respond to these proteins on the virus. If our vaccinated person is exposed to SARS-CoV-2, the vaccine prevents the virus from entering our cells. It can also trigger an immune response to attack cells that do become infected before they have a chance to spread the infection. This type of vaccine is also used for HPV, hepatitis B, and some types of influenza. The adjuvant is a commonly used ingredient that increases the body's immune response to the vaccine. This platform is very promising. In protein based vaccines for other diseases, it can produce memory B cells and T cells. This can help the body recognize and respond to infection for potentially years into the future. Novavax has some potential logistical advantages over other COVID vaccines in that it does not require the super cold temperatures like the mRNA vaccines and can be kept in a much more typical refrigerator like environment. There are some potential advantages for people that have been hesitant to receive the newer mRNA vaccines. Protein based vaccines have been widely used since the 1970s. It's possible that the added option of the Novavax vaccine will help convince some people to be vaccinated that have been holding out so far. I'll comment on that more in a moment. There are three major questions I'd like to address with all vaccines. Are they safe? How long do they provide protection? And third, are they effective, especially against new variants? Well, I'll start with some of the safety data we have for Novavax. The primary issue raised is around myocarditis and pericarditis, something we've talked about with the mRNA vaccines. The clinical trial showed five cases of myocarditis in participants within 20 days of immunization, which is only slightly higher than that seen in the placebo group. The company did note that they will continue to monitor the issues of myocarditis and pericarditis after receiving an emergency authorization approval. Just like the mRNA vaccines, the data show that there is still a higher chance that someone would have a severe cardiac event as a result of COVID infection than from receiving any of these vaccines. We do not have the data to demonstrate the relative risk of myocarditis from mRNA vaccines versus Novavax at this point. But this will be a stay tuned moment. Regarding duration of protection, we only have information between three and five months post immunization. The safety profile and efficacy was stable over that amount of time, but we don't know what things will look like beyond that time period. It's also notable that the FDA made a very significant point that the data that was submitted by Novavax represents really two different vaccines, one that is originally produced by the company and for which studies were done, and then a second one that is now being produced by the Serum Institute of India for them for distribution. And so they didn't allow the information from the earlier vaccine to be used in considering the approval of this second vaccine type. So again, we don't have long term information because this more recent vaccine study didn't give us the weeks and months that we would like to have. But let me talk now about the effectiveness of the vaccine. Most of the phase three trial data from the UK took place when the Alpha variant or B.1.1.7 was the dominant strain. Their data showed vaccine effectiveness was 86% against symptomatic COVID illness. But again, we need to know over what time period it actually holds up at that level. Trials in South Africa, when the Beta variant B.1.351 was dominant, only demonstrated 55% efficacy. At this point, Novavax has not formally published data on the performance of the vaccine against Omicron in the population. Novavax representatives presented data at the VRBPAC meeting showing that the antibody response for their vaccine diminished slightly against Omicron but still showed some significant protection. This is promising, but antibody responses alone does not give us the full picture on how effective the vaccine will be in the real world and over time. It is promising in clinical trials to this point, the vaccine has proven obviously to be very effective against severe illness, hospitalizations and deaths. Novavax is yet to officially recommend a third booster dose, but that is currently being tested as well as the development of an Omicron specific protein for the vaccine. Preliminary data does indicate that a three dose series shows a better immune response. So my guess is like the mRNA vaccines, it will be recommended once the trial is completed and published. Chris, you asked about the national global impact for Novavax. Nationally, I'm not sure we'll see much of an impact. We're at a point in the pandemic where the United States and other high income countries are sitting on a very large supply of available vaccines. The issue we're dealing with now is how to increase immunization in a subpopulation that has chosen not to be vaccinated for numerous different reasons. There is some optimism that a small group of vaccine hesitant people will choose this protein based vaccine. This may provide a small bump for 22% of Americans without any doses of COVID-19 vaccine. But I doubt it will make a large difference. I believe that similar to a perspective shared at the VRBPAC meeting and stated as, I don't believe most people have a technology based hesitancy as much as they have an ideology based hesitancy. I think that's true, and I think that the Novavax vaccine will not be a game changer in that regard. From a global perspective, Novavax has already been approved by the World Health Organization, and the European Union. It is being used in a number of countries already, including India, South Africa, South Korea and the UK. Having vaccines with an improved safety profile and are effective and available across the globe is a very good thing. And the logistical benefits to Novavax are certainly beneficial in resource limited settings. The W.H.O. specifically noted the addition of the Novavax vaccine in our COVID-19 toolkit could make a significant impact in the 41 countries that currently have less than 10% of their populations vaccinated. I'm hopeful that this vaccine will provide some benefit globally. There's still a lot of questions to answer about Novavax. How will it perform in the long term against new variants? Will we need boosters? Should we mix and match Novavax with other COVID vaccines? Will it proves safe and effective for children? There's currently a trial ongoing for children and teens 12 to 17. We at CIDRAP will certainly be watching this closely along with any other information that comes out, and we'll share what we learn as it becomes available. In other vaccine news, VRBPAC is meeting again next week to discuss the emergency use authorization for both of the mRNA COVID vaccines in children under five years of age. We'll cover this in our episode in two weeks on June 23rd. As I've expressed before, it's been absolutely incredible to see how scientists and researchers have quickly and diligently developed vaccines, treatments and diagnostics for COVID-19. To those listening, thank you. Thank you. Thank you for your hard work and dedication. As we all know, however, this virus is still a very formidable foe.


Chris Dall: [00:40:31] A few weeks ago, we discussed the increasing reports of COVID patients who've seen a rebound of symptoms and tested positive several days after taking a course of the antiviral Paxlovid. Mike, do we have an update on these rebound cases?


Michael Osterholm: [00:40:46] Well, Chris, as we discussed a few weeks ago, Paxlovid is a five day oral antiviral treatment for non-hospitalized COVID patients with mild symptoms to reduce the risk of developing severe COVID. In clinical trials conducted by Pfizer, there was a nearly 90% reduction in hospitalizations and deaths among unvaccinated patients that took Paxlovid. On May 24th, the CDC released an official CDC health advisory regarding COVID-19 rebound after Paxlovid treatment. Rebound has been reported to occur between two and eight days after the initial recovery following the course of Paxlovid and is characterized by recurrence of COVID-19 symptoms or a new positive viral test after having tested negative. Interestingly, a brief return of symptoms may be part of the natural history of COVID-19 infection in some people completely independent of treatment with Paxlovid and regardless of vaccination status. Pfizer reported a rebound or relapse rate of only about 2% in its clinical studies. The CDC reports that people are experiencing COVID-19 rebound after treatment with Paxlovid have had a mild illness with no reports of severe disease. However, the case numbers surely seem to be much higher than a 2% rebound effect. So with this situation, there are really two main concerns. First is not that people with rebound infection may experience serious disease, but rather they could unknowingly transmit the virus to others in their rebound period. It is recommended that if someone develops symptoms or has a positive test after a course of treatment with Paxlovid, that they begin the isolation protocol all over again to keep them from infecting others. This is a very important point, and is really the second issue of concern. If I'm someone at low risk of experiencing serious illness and I take Paxlovid, and rather than recover within the 7 to 10 days I have a rebound, might then that mean I would be in isolation for an additional 7 to 10 days, making my course anywhere from 12 to 15 days of isolation as opposed to what we currently do. At this point, there is currently no evidence that additional treatment is needed with Paxlovid or other therapies and cases where COVID-19 rebound is suspected. Paxlovid continues to be recommended for early treatment of mild to moderate COVID among people at high risk for progression of severe disease. It does, however, add additional credence to not treating young, healthy individuals without risk factors for severe illness with the drug at the risk of extending their infectious period and isolation time. In addition, we clearly need studies to be conducted to try to understand why this rebound occurs. Some have suggested that because of the higher infectiousness and viral load with some of the more recent sub-variants such as BA.2.12.1 or BA.4 and BA.5, that five days of treatment is just inadequate and therefore we need to look at studies that might extend treatment to ten or more days, which would then allow the body's immune system, together with holding down the virus load of the possibility of a successful treatment course. So at this point, we just don't know. We don't know if we're going to see recommendations ultimately made to extend the treatment longer. But I do think that at this point, the rebound issue is real. It's one that we do need to understand and it may have implications for who we make recommendations for to be treated.


Chris Dall: [00:44:24] That brings us to this week's COVID query, which is from Sarah and Christopher, who have a question about the original version of the coronavirus that emerged from Wuhan, China, back in late 2019. They wrote, "Is the original COVID virus or even some of the earlier variants even in existence anymore? And if not, can it ever reappear?" Mike, this is a great question.


Michael Osterholm: [00:44:46] Chris, this is a great question, but let me be clear in my discussions with what I consider to be among the very best coronavirus experts in the world, there isn't a clear and compelling answer. Remember my comment I made earlier about the issue of human immunity versus viral evolution? What we still don't really understand yet is what the dynamics are between this tug of war and now we throw in the animal population that are infected. So let me just share what I do know and where I think this may give us information about what we might expect in the future. The first thing I want to note is that the Omicron and its sub-variants currently account for 99.9% of sequenced samples in the US. So whatever other variants are circulating, they are circulating at very, very low levels. Out of our 18,000 samples sequenced in the US from May 16th to May 30th, just three were Delta and 69 were other, which may include the original strain. This is similar to what other countries are seeing as well. This is because more transmissible variants tend to outcompete the less transmissible variants, viral evolution. This is why Delta became dominant over the original strain of the virus, and then Omicron later became dominant over Delta. This means that it is unlikely for a previously dominant variant to become the dominant variant again unless we see a new variant or sub-variant emerge from that strain that is more transmissible than Omicron. This is what occurred with the emergence of Omicron when Delta was dominant, the original strain of the SARS-CoV-2 evolved, despite the fact that it was circulating at very low levels, and then the new variant quickly outcompeted Delta. This is not what's happening with Omicron sub-variants as those evolved from the Omicron variant itself, not the original strain. So how can the original strain or another variant like Delta circulate at such low levels without being outcompeted entirely? Well, this is somewhat of a variant calculus problem with several interacting variables that we don't fully understand. I'll briefly discuss two of them. The first is that a previously dominant strain of the virus could be lingering in an immunocompromised person that is chronically infected. They could potentially transmit the older strain of the virus to others. But since it's not as transmissible as the other circulating strains, it would not account for a significant proportion of cases. The second factor is the possibility that previously dominant strains are still circulating in animal populations and are likely spilling back into humans as a result of the close contact with animals. But again, unless there was significant changes in that strain, it's unlikely that it too would compete against the more infectious strains we see now. There are many other factors involved in the variant calculus problem, and we don't know the extent to which they're all contributing to this. But this is concerning because these previously dominant strains have the ability to evolve again when they're circulating at low levels and then become dominant as a new variant. This is what happened with Omicron. It is impossible to say with 100% certainty whether this will occur again or if Omicron sub-variants will account for most of our future variants of concern. But we must acknowledge that this circulation of previously dominant strains in humans and animals could and likely will lead to the emergence of new variants. As you've heard me say multiple times on this podcast, my concern is what will Pi or Sigma or the new variants look like after Omicron? Will they be more infectious? Will they be able to evade immune protection? So this is the challenge we have. I'm not nearly as concerned about the previous dominant variants unless they are, of course, residing in an immune compromised host or an animal population. So for right now, as the data shows us, it's about Omicron, Omicron and Omicron.


Chris Dall: [00:48:45] Mike, moving on to other infectious disease news, what is the latest on the monkeypox outbreak?


Michael Osterholm: [00:48:52] Not surprisingly, monkeypox cases have now continued to increase in the last few weeks. As of Tuesday, there have been over 1,088 cases reported from 29 countries, most of them in Europe. This is likely an undercount, as some countries have already identified cases that have not had any close contact with other known cases, meaning there is something going on undetected in terms of transmission occurring in these various areas. Last Friday, the CDC released a report in the Morbidity and Mortality Weekly Report with details regarding the first 17 monkeypox cases identified in the US. Of these 17 cases, 16 occurred in men who have had sex with men. This is similar to what's being reported out of Europe, where most but not all cases are occurring in men who've had sex with men, which I will talk about more in a moment. 14 of the 17 US cases also reported recent international travel prior to the onset of their symptoms. Many of these symptoms are consistent with what we would expect to see with monkeypox. All but one of the men had a rash across their body. Many reported fatigue, chills, swollen lymph nodes, all common for monkeypox. The one unusual aspect of their symptoms is that for 18 of these 17 men, their rash started in the genital or anal-genital area and then spread to the rest of the body. This is not consistent with past monkeypox cases, where the rash most often started in the patient's face. As I said before, a vast majority of reported cases have been in men who have had sex with men. Contact tracing has revealed that cases are largely occurring within extended sexual networks. It is possible that due to the higher prevalence of HIV in this group, that they may be more likely to seek sexual health care, which could lead to a higher proportion of cases in this group being reported. But based on the numbers that we're seeing is also clear that there is much more transmission occurring within this group than with any other demographic. It is very difficult to talk about health issues that occur in certain populations without seemingly imparting blame or exacerbating health inequalities. It is critical that we avoid stigmatizing messages. With that in mind, we still need to clearly communicate with groups of people who are most at risk of contracting the infection so that they can take the right precautions and seek treatment as soon as possible, if possibly infected. Ignoring the fact that so many cases are occurring in men who have sex with men, including multiple partners and anonymous partners, would mean that we're not providing that individual with the kind of adequate information they need to both respond to their personal level of risk and their personal health concerns. That said, I do still want to emphasize that anyone can get monkeypox, and not everyone who has been diagnosed with monkeypox in this outbreak is a man who has had sex with men. Health care providers should be alert for patients with monkeypox symptoms, regardless of gender and sexual orientation. In a recent CIDRAP news article, risk communication expert Peter Sandman pointed out that one group that has been missing from reports regarding monkeypox risk is people who have sex with men that have sex with men. In other words, women that have sex with bisexual men. Sex workers and health care workers of all sexual orientations and genders are also at increased risk of developing monkeypox. Peter also expressed concern over many organizations describing monkeypox as mild. Though the risk of dying from monkeypox is low, particularly this West African strain, the rash can be very painful and result in long term scarring. Fortunately, there have been no reported fatalities to date with this monkeypox outbreak, but there have been some hospitalizations and cases that require prescription painkillers. Though the disease may have had a low mortality rate, again, with this particular strain of the virus, we need to be clear about the fact that this is something that people do not want to be infected with and should make an effort to avoid. Finally, I want to address one other major concern with this outbreak. There are at least two known strains of monkeypox currently circulating in the US. Most of the US cases are the same strain that have been circulating in Europe, but there are a few cases of a different strain here. Both strains were seen in the US last year, so it is likely that some transmission was occurring in the last several months and went undetected, either due to individuals not seeking medical care or being misdiagnosed. With increased awareness among both health care providers and the general public, we will hopefully see less of an undetected transmission going forward, but it is definitely a concern and could limit the effectiveness of mitigation strategies like contact tracing or specifically targeting vaccines that we have that can be used to protect contacts of cases. That said, even with improved awareness, there are still other limitations to using contact tracing as a strategy here. Many individuals who have been infected with monkeypox, have reported having anonymous sex within a few weeks prior to the onset of symptoms. Only 28% of the first 87 people infected with monkeypox in the UK were able to provide contact tracers with the names of their sexual partners and as a result, their partners could not be contacted. This is exactly why we need to make it clear who is most at risk men who have sex with men, specifically those with multiple anonymous sex partners so that they can take the precautions necessary to protect themselves and be prepared for the event that they need to contact their partners or their partners may need to contact them. We can do this in a way that is respectful and minimizes the risk of exacerbating the existing stigmas that impact this group. This will be essential in reducing the transmission of this virus and eventually stopping the outbreak. There are two additional issues, though, that we need to confront with this outbreak. One, what are we going to do about all the citizens of those countries in Central Africa who for the past 40 years have not had access to a smallpox vaccine that in a sense, rendered them protected against the sylvatic or wild life cycle of this virus. This has got to be a very high priority issue because unless we're able to reduce transmission in Central Africa, which we should be doing for the very sake of the African population, but also its for the fact that it will mean we will see ongoing sparks of monkeypox flying out of Central Africa consistently causing very similar situations like this to occur in the days, weeks, and months ahead. We need an international response where vaccination of African residents is surely a priority. And last, I just keep coming back to this issue of that sylvatic cycle that I just talked about, a cycle of virus in wild animals. Well, I worry very much that with the number of cases we're seeing around the world right now, that someone will have contact with one or more rodent pets or in some wildlife areas, somehow a contact with a rodent that could become infected with this virus. Once that happens, if that particular rodent should escape from the ownership of the individual or wherever it's at, get into the wild, we could begin seeing an entire new sylvatic cycle of this virus in other parts of the world. Remember, it was in 1899, the ships from China brought over the first rats with plague infected fleas that ultimately ended up seeding plague in the United States. And today, the remnants of that, including the large plague outbreaks we've seen in prairie dogs in North and South Dakota, is an example of what can happen if we seed this virus into wildlife and to whole new areas. So we have got to make certain that anyone who is infected with monkeypox does not have contact with gerbils, with pet rats, with any other kind of rodents, prairie dogs that could result in the establishment of a sylvatic cycle in the area in which that exposure occurs.


Chris Dall: [00:57:15] And are there any other infectious disease threats that you're keeping an eye on at the moment?


Michael Osterholm: [00:57:20] Well, you know, it used to be that line that you always sleep with one eye open when you're an infectious disease epidemiologist. You now need four or five extra eyes based on all that is happening with infectious diseases. One disease that we're very concerned about is influenza, both in terms of human cases now in the southern hemisphere and avian influenza here in the US. Let's talk first about the increased influenza cases in the southern hemisphere, specifically in Australia. Australia's flu season usually runs from April and ends in October. So it's not entirely surprising we're seeing more influenza transmission there. That said, surveillance from hospitals, labs and public health departments have identified a far sharper increase in cases than we might expect at this time of year. This is notable because this is now the exception to what we've seen throughout the pandemic, where other respiratory viruses were severely suppressed, at least from a seasonal standpoint. Something's changing. We have no reason to believe that these cases are any more severe than normal. Influenza A is the dominant strain here, with H1N1 being commonly reported in children and H3N2 commonly reported in adults. That said, the number of cases alone could prove to be challenging as the country is still struggling with high numbers of COVID hospitalizations. We can expect an increase in influenza transmission to worsen the existing healthcare and supply chain issues in the country, especially given the incredibly low rates of flu vaccination. As of May 24th, just 24% of Australian adults and 9% of Australian children have received their seasonal influenza vaccine. We all know that the protection from these vaccines may be limited, but nonetheless they still play a role in minimizing the amount of severe illness, hospitalizations, and deaths and the economic and societal disruptions caused by seasonal flu. This will be an especially critical issue in Australia this year as they struggle to fight COVID and influenza at the same time. I also want to briefly mention the H5N1 avian influenza transmission that we've been seeing here in the US. We talked about avian influenza a few months ago in Episode 98, which was released on April 7th. I explained in that episode that there's still a lot that we don't know about avian influenza and the likelihood of bird to human transmission and subsequent human to human transmission and the impact that that could have on our society. There is still a lot that remains unknown, but I'll give you an update as to where we're currently at with the disease in the US. Fortunately, it appears to be in remission. H5N1 avian influenza has been detected now in over 1,300 wild birds in at least 41 states. Literally a tip of the iceberg kind of finding meaning that there were many, many wild birds that died from this virus that were never, ever documented. Outbreaks have occurred in poultry farms in at least 36 states, resulting in the deaths of nearly 38 million birds. There's been one reported human case of H5N1 in a poultry worker that was responsible for culling the birds with avian influenza. There are only symptoms where fatigue and they recovered within a few days. No known human to human transmission has occurred. So what does this mean? Well, the immediate threat of avian influenza to humans remains low, but we still don't know how this virus will evolve in the future and what it will mean for birds or for humans.


Chris Dall: [01:00:46] Mike, we have a celebration of life from one of our listeners this week commemorating just one of the more than 1 million US lives that we've lost during this pandemic. What can you tell us about this individual?


Michael Osterholm: [01:00:59] I so welcome these celebrations of life as part of this podcast series. When we started them, it was to help us all remember that so much of this pandemic has been reported in numbers and statistics when in fact each and every one of them was an individual, a father, a mother, a grandpa, grandma, a son, a daughter, a brother or sister, a friend, a colleague. Even people we didn't know but, we wish we had gotten to know. And so from my perspective, I don't want us to ever lose sight of this. And I hope that you will continue to share with us with your celebrations of life. This is no exception, this particular celebration, the first time I read it, it was hard for me to get through it. I can't say it any other way. If any of you know my personal history and my family's upbringing, you understand why I feel that way. So let me share with you what was lovingly shared with us by Martha about her mother, Jane. She writes, "Thank you for your podcast that continues to inform, enlighten and support us through this ongoing trial. In response to your request for submissions and remembrance of the death of a loved one due to COVID, I'd like to remember my mom, Jane. You are so right to remind us all that these are not just numbers. These are real people who loved and were loved and deserve to be remembered as such. My mother was 98 and growing frail. The lockdown in her assisted living accelerated her frail health as it did everyone living at these facilities. Luckily, my sister is an RN who took a job where our mom was living so she could be with her. My niece was a student nurse and able to take a job as a CNA to be near her Grammy as well. My sister and niece are my heroes because they risked getting COVID themselves at a time there weren't vaccines. They saw many residents succumb to loneliness and give up. So it wasn't just COVID that ended their lives but in the end, the isolation also took a toll. It was heartbreaking to witness. My mom raised five children and was a full time school teacher. She grew up on a farm during the Great Depression, was part of the greatest generation. As if she didn't already have enough on her plate, she cooked every meal from scratch, managed to get all the shopping done and grade papers in the evening. She was also married to an alcoholic and with a violent temper and did her best to shelter us from the worst of it. Mom was human, but she never felt like she did enough. Thankfully, I got to tell her before she died that she did more than any mom I could think of. And June Cleaver had nothing on her. I was able to tell her how grateful we were to have her for our mom. Her values, resilience, and work ethic made a lasting impact on us and helped to carry us on after she left this earth. Please, if any of you still have parents who are living, please let them know how much you love and appreciate everything they did for you. Thanks again to the team and my heart goes out to all who have lost a loved one. We are all part of your podcast family and it helps to know we are all in this together. God bless all of you. Love Martha." Martha, any words that I would say would be so inadequate to express the beauty and the love that you just shared in the celebration of life. I only wish I could have known your mom. Thank you so much for sharing this. And for all of you out there, please help us celebrate the lives of so many we've lost. But like Jane, who were special before and will be special forever. Please never forget the Janes of the world.


Chris Dall: [01:04:41] And if you would like to share a celebration of life of a loved one or friend, a neighbor or coworker who died during the pandemic, please email us at osterholmupdate@umn.edu And keep those beautiful places coming as well. Again, you can share those with us at osterholmupdate@umn.edu. And also to elaborate on something that Dr. Osterholm said earlier in the podcast, we will be going to an every other week schedule at this point. So after this June 9th episode of the podcast, the next episode you'll hear will be on June 23rd, and that will be our schedule for the foreseeable future. And as in the past, we will change and adjust if the situation calls for it. So Mike, what are your take home messages for today?


Michael Osterholm: [01:05:28] Well, Chris, my first point is one that I continue to hit home podcast after podcast and surely did today that we're still in a battle between our human immunity and the virus and whatever it will do. It continues to throw us curveballs, the variants continue to challenge us in understanding what's happening, but that in fact, we have to acknowledge we don't know what the next shoe to drop might be with this pandemic. We can hope that in fact it is only going to get better. But as I've said so many times, hope is not a strategy. The second point is the pandemic is really over in the minds and hearts of so many people in our society. And I understand why the data I shared today surely showed the best picture of disease in our communities that we've seen really almost since the beginning of the pandemic. That's great news, and we must not forget how good that feels. But the pandemic is not over yet. And as much as politicians may try to come up with a number to say, if we're under this many deaths, it's over with. We saw that a year ago. Right now, one year ago, we were in a place where everyone thought we were done. Independence from COVID is just a month away. We can celebrate on the 4th of July and look what happened. So I think we just have to continue to remember maybe it won't get any worse than this. I hope so, but it may again surprise us. Finally, the last thing I want to share with you is something that I'm about to address in a moment with the closing song. And that is if there was ever a time with all the pain and suffering we see in the world with war, with violence, if there was ever a time to be kind, be more kind, it's now. This is hard to address in a time when it seems as if violence and evil is all around us. But if maybe to me represents the most important time for us to be more kind. And I'll just leave it at that and share with you my closing thoughts with that regard.


Chris Dall: [01:07:33] And so, Mike, what is your closing song for today?


Michael Osterholm: [01:07:36] Well, this is one that I want to thank Anne for, a colleague of mine, a very dear colleague who suggested this. And it was from an artist that I would not normally have heard or followed. This is a song by Frank Turner. Frank is an English singer songwriter. It was released on the 4th of May in 2018. It's one that he wrote. It was recorded in 2017, and the title of the song is just what I shared with you in my closing comment, "Be More Kind." I think Frank Turner has nailed it. And if there were ever words to live by, live for and hope by and hope for, it's Frank Turner's "Be More Kind." Here it is. "History has been leaning on me lately. I can feel the future breathing down my neck and all of the things I thought were true when I was young and you were too turned out to be broken. And I don't know what comes next. In a world that has decided that it's going to lose its mind, be more kind my friends, try to be more kind. They started raising walls around the world now like hackles raised upon a cornered cat. On the borders in our heads between things that can and can't be said. We've stopped talking to each other and there's something wrong with that. So before you go out searching, don't decide what you will find. Be more kind of my friends. Try to be more kind. You should know you're not alone. And the trouble comes and trouble goes. How this ends, no one knows. So hold on tight, when the wind blows. The wind blew both of us to sand and sea. And where the dry land stands is hard to say. As the current drags us by the shore, we can no longer say for sure who's drowning or if they can be saved. But when you're out there floundering like a lighthouse, I will shine. Be more kind, my friends try to be more kind. Like a beacon reaching out to you and yours from me and mine. Be more kind, my friends. Try to be more kind. In a world that has decided that is going to lose its mind. Be more kind, my friends. Try to be more kind." There are no words that I can express that better share that sense of why now more than ever, we need to be kind. Well, thank you, everyone, for being with us. Hopefully this closing frames this entire episode of one of information and one of heartfelt feelings. Now is the time for us to be kind. The world is a difficult place. We all know that. COVID is giving us a breather right now, but that still means that almost 2,100 people a week are dying in this country from it. I wouldn't call that a breather yet in that regard. So thank you so much again for being with us. I want to thank the podcast team for all their efforts. Thank you, Chris. And please note, we read every note you send us. We learn a lot from you. So keep them coming. And in the meantime, thank you so much for being with us. Be kind.


Chris Dall: [01:11:05] Thanks for listening to this week's episode of the Osterholm update. If you're enjoying the podcast, please subscribe, rate, and review, and be sure to keep up with the latest COVID-19 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/donate-now. The Osterholm Update is produced by Sydney Redepenning, Cory Anderson, Angela Ulrich, and Meredith Arpey.