December 15, 2022

In this episode, Dr. Osterholm and Chris Dall discuss China's new COVID mitigation strategy, a COVID query about KN95s, and the fifth phase of the pandemic that we have recently entered.


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Chris Dall: [00:00:00] Hi, everyone. As another holiday season arrives and this year comes to an end, we reflect on how the world of public health has been challenged this past year. We are thankful to have been able to provide you with this podcast for the last 12 months and with a new and improved recently launched website. Donations from listeners like you allow us to continue to be innovative and maintain a full time, seasoned editorial staff dedicated to producing the freely available news resources that you depend on. To support this podcast and our other news offerings, please visit Thank you and happy holidays. 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. While COVID-19 activity throughout the fall was fairly steady, the anticipated winter surge appears to have arrived. In the past week, the daily average of reported COVID-19 cases has risen by more than 50%. And while we know the cases aren't the most reliable measure, hospitalizations and deaths are also climbing. This upswing in COVID-19 adds to what has become a busy season for respiratory viruses. US hospitalizations for flu are at the highest point they've been at in more than a decade, and respiratory syncytial virus activity remains high, although it appears to have peaked. Amid the rise in COVID-19 and flu cases, officials in New York and Los Angeles have recommended that people mask up in indoor public spaces and crowded outdoor spaces. At the same time, COVID-19 is not presenting the same challenge as it did in December 2020 or 2021. Is this phase that we're in right now where SARS-CoV-2 seems to be battling out with other viruses, a new phase of the COVID-19 pandemic? That's what we'll be discussing on this December 15th episode of the podcast as we assess the current state of the COVID-19 pandemic. We'll also discuss the Chinese government's decision to ease up on its zero COVID policy, answer a COVID query about KN95 masks, and share a beautiful moment. And stay tuned at the end for a special holiday treat. But before we get started, as always, we'll begin with Dr. Osterholm's opening comments and dedication.


Michael Osterholm: [00:02:52] Well, thank you very much, Chris. And happy holidays to all of our listeners. To the podcast family, who we dearly, dearly appreciate welcome back. I hope that we're able to share with you the kind of information you're looking for today, particularly as we are in this uncertain world of COVID. For any new listeners, welcome on board. Again, the same applies. I hope we're able to provide you with the information you're looking for. I will start out right at the beginning in saying, I feel somewhere like I'm caught between Lewis's quote that if you don't know where you're going, any road will get you there. And Yogi Bear's, it's deja vu all over again. And I don't know quite where we fit between those two quotes, but I know it's somewhere in between the two of them. We are in a very challenging time in that we're tired, we're fatigued, we want to move on. This is the holiday season. We're ready for the holiday season. We feel confused about the information we're hearing and yet we hear that things are really bad. But what does that mean? And so today we're going to try to do our best to help in a sense, give perspective to that. And as I've said so many, many times, this virus continues to throw 210 mile an hour curveballs at us, and we will do our best to try to catch those and to give you a sense of what they mean. As you know, we put a great deal of importance to the dedications that we use in these podcasts. They reflect our listeners what you're looking at, looking for, what you feel, what you need, and frankly, what we feel and need here at CIDRAP. So this dedication was one that I've given some real time to and thought about and understood the time of the year and what's happening as well as, again, the virus throwing these curveballs at us. While many of us have CIDRAP and many of the listeners of this podcast, including our podcast family, have been looking forward to this holiday season and spending time with our loved ones, we surely have to understand that we have not yet entered into that post-pandemic world. I want to take this moment to recognize that this time of year can be challenging for many, including for some members of our podcast family. For the loved ones of the 6.65 million people who have died of COVID who are grieving that loss, especially the over 10.5 million children who lost a caregiver due to COVID, for many of whom this may be their first holiday season without their loved one. This can be a very tough time of the year. For those who are worried about their friends and family living in places that are still experiencing tragic unrest or war, to the refugees from those whose countries may be spending their first holiday season in a new place. And of course, to the people still living in those countries who fear for their safety every day. For those who are unable to travel to see their families due to concerns related to the pandemic or due to being infected themselves. And for those who are currently separated from their families due to pandemic related disagreement and conflict, including Rebecca, who we have mentioned in previous dedications, and the many others who have reached out sharing that they have too experienced similar conflicts within their families. We are dedicating this episode to all of you, recognizing that this holiday season may be especially challenging for you, and that even in moments of joy, you will be missing your loved ones dearly. This dedication is for you. Now on the good news scene, depending, of course, where you are in the world, I have to get back to my sunlight. I've been living for this particular moment for the last six months. And that is the fact that yes, I do want to celebrate today, December 15th, that in Auckland, New Zealand, my very favorite city outside of the United States, you will have 14 hours and 40 minutes and 34 seconds of sunlight. Sunrise at 5:55 a.m. this morning, sunset at 8:35 p.m.. You've added 23 seconds on to the daily sunlight over the last week. But when I only say 23 seconds, that should tell you something. You've just about ready to bottom out. With December 21st you all know in Auckland, that's your longest day of the year and it's the shortest day of the year for those of us here in North America. On December 21st in Minneapolis, we will have 8 hours and 46 minutes and 10 seconds of sunlight. That's it. But by June 21st, we'll have 15 hours, 36 minutes and 51 seconds of sunlight. The march begins. The days are getting brighter and brighter and brighter. And so even on the darkest days here in North America or wherever you are in the northern hemisphere, please do remember it's getting lighter and lighter and lighter. So shout out to all my dear friends at the Occidental Belgium Beer Huis on Vulcan Lane in Auckland. I hope you're outside tonight late at the bar and enjoy that sunlight. But as it gets to be brighter and brighter here, we'll shift some of that sunlight back to you as you've been doing for us. Thank you.


Chris Dall: [00:07:52] Mike, let's start our international roundup once again in China, where the government last week finally decided to scrap its zero COVID strategy in the wake of public protests. What do you think lies ahead for China? Though we'll likely never know exactly what's going on in that country, is it headed for a massive wave of infections?


Michael Osterholm: [00:08:12] Well, after more than two and a half years of doing this podcast, I got to say that I've certainly gained a better appreciation for just how much can change in the matter of only a week or two. And in this case, a lot that has changed with what's been happening in China. Now, in our last episode, we touched on the dilemma that China was facing, which really boiled down to either: A, doubling down on zero COVID and risking more public outrage or B, moving away from zero COVID and subsequently running the risk of a significant COVID wave. To me, there was no easy or good choice to be made. And as I've said in the past, zero COVID was not a viable long term solution for China. Never was. So change was going to come eventually. And that's why I've emphasized time and time again on this podcast, why it was so important for them to prepare for that change in order to limit the damage that can accompany a major surge in cases. Well, from what I've seen, a lot of the things that might have helped prepare them haven't happened. Regardless in the two weeks since the last podcast episode, it looks like they've opted to move away from zero COVID and that change has occurred relatively quickly. In a nutshell, what started out as several cities moving away from mass testing eventually turned into a fairly long list of changes that have been greenlighted at the national level. Some examples of these recent changes include cases that are asymptomatic or mild now being allowed to isolate at home, whereas before they were required to do so in a designated facility. Likewise, close contacts of cases are no longer required to quarantine in state-run facilities. Third, entry into certain places like supermarkets no longer require a recent negative test result. Forth, results from rapid at home antigen tests are valid in certain situations, whereas in the past only PCR testing was allowed. And finally, the national level contact tracing app, which used phone signals to determine if an individual was in a high risk area and eventually acted as a passport was reportedly being scrapped as of this past Monday. Now, obviously, many of these policies have been in place for almost three years, a stretch of time that might have almost made them feel like they were the norm. So it's been pretty remarkable to watch all this unfold in what's basically been a span of just a week and a half to two weeks. Otherwise, for the people living there, the Chinese public, I've got to imagine that the whole situation feels quite bizarre and maybe almost like something out of an old TV show, The Twilight Zone. Just to be clear, it is not like China has up and removed all COVID measures. For example, their international borders remain closed off to most of the outside world. Furthermore, certain Chinese cities and provinces in the country have their own apps for contact tracing, which could still be required for residents living in these places. In many areas, a negative test result is still a requirement for anyone who might want to visit a restaurant or certain office buildings. And at the time of this recording, there still is a nationwide policy in China that requires a recent negative test result via PCR, not antigen, PCR only to enter select locations like schools and nursing homes. So while they've certainly made some pretty significant changes in terms of their approach, several of which they've relied upon heavily in the pursuit of zero COVID, I just want to provide this additional perspective and fully expected over the next two weeks we'll even see more changes occurring such that the list that I just provided you of changes may actually grow substantially. Now, this being said, I really don't think any of these measures that remain in place, at least for the time being, will make a difference when it comes to controlling the spread of Omicron there. As we know, China is home to 1.4 billion residents, the vast majority of who have never been previously infected. And although a significant portion of the population have been vaccinated, with the latest estimates indicating that 91% have received at least two doses, we know how evasive Omicron is. Even right here in this country, we've seen Omicron spread to and from individuals with multiple doses of mRNA vaccines. So I have no doubt that the Chinese will experience a wave of cases, even with their vaccination status. And based on what I know, I know this is already happening. Just in the last two days, I've participated in several conference calls and one meeting in which individuals in China or experts about China have reported major outbreaks of illness in the larger cities, including Beijing, where the city has not shut down because they're mandated not to go into the public spaces. Too many people are sick to go into public places, so this is surely beginning to unfold. If you look at the official numbers being reported from China, it surely does not support the point that I just shared with you telling me that in fact their numbers are actually cooked, not real. In fact, the official counts make it seem like the situation is only improving. For example, at the time of our last episode two weeks ago, China's National Health Commission reported more than 38,000 local infections, whereas on this past Tuesday, the total was less than 7,500. These numbers simply do not jive. Well, on the one hand, there are some concerns that they are not completely transparent in terms of the numbers. Otherwise, it's clear that their pivot away from mass testing and the dismantling of numerous state run testing programs in general has meant that the true size and scale of the outbreak in China won't be really accurately depicted in official reports. Regardless, I think it's clear and compelling that China is dealing with a growing wave of cases. Again, as I pointed out, people on the ground in China are confirming that widespread infections are occurring and that the Chinese social media have actually provided additional validation that this is occurring. For example, on Monday, a spokesperson with Beijing's Municipal Health Commission said that the latest number of calls made to emergency services in the capital city was six times higher than their average, and visits to fever clinics had increased 16-fold in just the past five days. In a Washington Post story published on Monday, a surgeon at a hospital in Beijing was quoted as saying that health care facilities were already being overrun with patients, and at the hospital she works at more than half of the staff tested positive just in the past week. Meanwhile, US consulates in multiple Chinese cities, one of them, which is Wuhan, have provided notices that they'll only be offering emergency services for the time being as a response to the increasing number of COVID cases they're dealing with. And finally, a well known Chinese individual who previously served as editor in chief of one of the state-run national newspaper outlets, shared the following this past week: The speed of new infections is really astonishing, and I believe that what we are witnessing here must be one of the most violent virus transmission speeds in the world since the onset of the COVID pandemic. As published in Reuters on December 13th. So clearly the virus is spreading widely in China, and it will continue to do so. Otherwise, at this point, I think the biggest question is what will happen in terms of severe disease and deaths. Remember, we're talking about 1.4 billion people in China. As I mentioned earlier, more than nine in ten Chinese residents have received at least two doses of a vaccine. However, booster coverage has been quite a bit lower, with just 58% of the population having had one. In addition, much like we saw in Hong Kong, the gaps that China has in terms of vaccine coverage across its population are predominantly in older age groups who, as we know, are at the highest risk of severe outcomes. Right now, 40% of the 80 plus year olds there have yet to receive a third dose. And since China has elected to rely exclusively on their domestic vaccines, which have repeatedly been shown to be inferior to others, including the mRNA vaccines that we use here in the United States, that third dose is really, really important. And that being said, for many of the individuals who already received a third dose, a lot of time has passed since the needle went into their arm, so waning immunity is something that needs to be considered also. And although protection against severe disease and death has fortunately held up longer than the protection against infection, multiple studies have shown they can also start to decline over time. Well, if you look at the total number of doses administered in China throughout the past six months, so from June til now, it adds up to a total of just shy of 60 million. In other words, less than one half of a percent of China's population has received a dose of COVID vaccine in the past six months. Let me repeat that. In other words, less than one half of a percent of China's population has received a dose of COVID vaccine in the past six months. That is a very significant number. For comparison, if you go back another six months and look at the number of doses given between December 2021 and June 2022, it adds up to 770 million. Still, the largest share of those doses were administered fairly early on in the timespan, December to January of 2021-22, and due to the rolling out campaign that China had. So alongside the gaps that remain in their older age groups, China is relying on a less effective vaccine that many residents have last received six months or more or even a year ago. Again, it's a situation that doesn't bode well for their health care system. Do not forget that China has literally only one tenth of the number of ICU beds per population that we see here in the United States. And on that note, let me make just one final point. Now, obviously, I know it isn't possible to go back and change the past so I won't get into the could have, should have, and would have. It's too late for that. And given the circumstances, I can certainly see why they made the decisions to move away from zero COVID. They really had no choice. But what's baffled me maybe the most about this whole shift has been the 180 degree change in their messaging. For most of the past three months, they've likened the virus to an enemy that could only be controlled by an all out people's war. In fact, that same language was used in a speech by their leadership just within the last two months. Fast forward to now. The leading Chinese officials, including their vice premier who is overseeing the country's COVID response, are saying that measures are only being lifted because the virus is now evolved into becoming less deadly. Well, if that's really the case, then explain why the Omicron outbreak that happened in Hong Kong earlier this year led to the world's highest per capita death rate reported at any point in the pandemic. Again, Hong Kong had the highest per capita death rate reported in any point in the pandemic. They are the canary in the mine for what will happen with the rest of China. Now, obviously, I understand the political motivations that might inspire some sort of rationale for why this sudden change in approach is happening. But if I happen to be living in China and heard this, especially after three years of hearing the exact opposite, it's safe to say that my head would be spinning. At the end of the day, the virus is the virus. It is still deadly. And even if there is a slight reduction in severity compared to past variants like Alpha and Delta, the speed at which Omicron spreads can quickly overwhelm health systems and result in significant loss of life. So what's being done to protect health care systems in China? Do they have the medical infrastructure to handle the sudden surge in patients? Do they have enough staff who are trained to provide the appropriate care that is needed? Do they have stockpiles of antivirals like Paxlovid? The simple and honest answer is no, no and no. Ultimately, those are the things that can really shape the severity of this wave. Yes, the virus can play a big role. It's in the driver's seat. But how we choose to respond and the systems we have in place are also critical. So overall, Chris, I hope they understand that they're dealing with a version of this virus that's not at all that different from the one that devastated Hong Kong. Otherwise, I worry about what the weeks and months ahead might look like in China.


Chris Dall: [00:20:39] Are there any other countries that you're keeping an eye on?


Michael Osterholm: [00:20:44] Well, to be honest, Chris, I am. Or at least I try to keep tabs on what's happening in other parts of the world. And so there always seems to be certain countries or regions that draw my attention, depending on the situation, whether that happens to be a sudden rise in activity or the growth of some new subvariant. Now, I will admit on more than one occasion I've asked myself if it's still actually worth the time and effort it takes to monitor these trends. In fact, there have been many times where I've looked over the international picture and felt more confused than I was before. But regardless, I know it's important because it's a pandemic, which in of itself means that there's an international component to consider. And too, because there's a lot of great information or even early insight that can still be provided by these countries. That said, let me start out with some of the overall international numbers, since that might provide an important perspective on where things are at. So in terms of average daily cases, we're seeing just over 580,000 of this Tuesday. As always, I'm not really sure what case numbers mean. They clearly do not represent most of the infections occurring in our communities. Not a great representation of the actual virus levels that are out there. But from a big picture perspective, I think it's worth noting that this total has been consistently growing since early November, so the, say, past month and a half. And again, in that time case numbers have gone from 320,000 cases a day to this new number of 580,000 cases a day. Something's happening. Otherwise for about a month, which included most of November, global deaths remained fairly steady. At that time, they more or less hovered around 1,400 or 1,500 a day. Remember that high Plains plateau? Well, unfortunately, that number started climbing again when December rolled around and currently it sits just above 1,800 a day. So as I've said so many times, probably more than you'd ever care to hear, this pandemic is not over. And in fact, there are a number of countries and regions like Europe, Southeast Asia, the Western Pacific and the Americas that are once again seeing activity climb and in some cases substantial climb. That being said, there still really doesn't seem to be a single common denominator that's triggering this growth. Instead, it's kind of a mixed bag, depending on the country or region you're talking about. For example, some places in the western Pacific, including Japan and South Korea, have seen activity grow for the past two months. In Japan, cases have climbed from less than 26,000 a day in mid-October to 129,000 cases a day this week. At the same time, hospitalizations there have gone from less than 9,000, including just under 500 and ICUs to more than 28,000, including 1,200 in ICUs. And deaths in Japan have climbed from 50 a day in October to more than 200 now, making it their third deadliest wave since the start of the pandemic. And let me remind you, it is still rising. Meanwhile, other places in the region, like New Zealand, Australia and Hong Kong, have also been seeing increases. Yes, for each of these places there is no clear indication that this is the result of some new subvariant. Instead, most of the sequencing data shows that BA.5 has continued to account for a sizable portion of the cases. So why the second wave with BA.5? Again, much like we saw in Europe there is no simple, straightforward explanation and anyone that has one be careful because they have a bridge to sell you. At the same time, we are seeing some countries in Europe once again experience upticks. For example, just in the past month, France has seeing cases go from 21,000 a day to more than 60,000 a day, and both hospitalizations and deaths have increased. In fact, average daily deaths in France reached 92 on Tuesday, which is the highest it's been since July. Of course, we know that BQ.1 has been growing in France and became dominant there sometime in the past month or two. So it's tempting to say that this is being driven primarily by that subvariant. And who knows, maybe it is, but BQs journey in other European countries like Germany has been quite different and much more slow going. So it really is difficult to know what impact BQ.1.1 can or will have in various locations. Honestly, Chris, I think I'll leave it at that, since it should be quite obvious by now, I don't have any clear and compelling advice or specific answers as to why we're seeing increases in these different places. So I'll spare the listeners the pain of having to hear me speculate and simply say that regardless of what's causing these increases, the biggest takeaway is that these increases are continuing to happen around the world. This virus remains in the driver's seat and continues to do whatever it damn pleases. Our best means of interacting with this virus is to protect ourselves with bivalent vaccines, having drugs available at the time of onset of illness, and continuing to use good respiratory protection, i.e. N95 respirators. That's the best we can hope for right now.


Chris Dall: [00:25:50] Here in the US, the seven day average of COVID-19 cases is around 66,000, a 57% increase over last week, the number of hospital and ICU beds being taken up by COVID-19 are rising and daily deaths are climbing as well. So we are now up from that high plains plateau that we've been stuck on for several months. So, Mike, you just discussed the role that the variants may be playing or may not be playing in France. Is it any different here in the United States?


Michael Osterholm: [00:26:20] Well, Chris, for the few people on this podcast who are old enough to remember, Welcome Back, Kotter a TV show back in the 1970s and eighties, there was a theme song that went with that show. And one of the lines was welcome back, your dreams are your ticket out. And you know what? We've been dreaming about being out of the situation that we're in right now. But we're back. And I will try to do my best to help provide perspective. But I must honestly tell you, there are so many unknowns about what's happening. It's clear that COVID activity is increasing across the board. Cases, test positivity, hospitalizations, and deaths in the United States are all increasing. Compared to just two weeks ago reported cases which, as a reminder, can't be trusted as the true number of cases just talked about that are up 56%, test positivity, which is more reliable, is up 25%, hospitalizations are up 24% and deaths are up 48%. Let me add some context to that. Just several weeks ago, we were seeing about 230 to 240 deaths a day in this country. Today, we're at 473 deaths, up 65% in just the last couple of weeks. Looking at hospitalizations, we're now at almost 39,000 hospitalizations, up 22% from where we were just a week ago. And if we look at ICU bed use, we're now at 4,450 ICU bed patients, up more than 19% in just the last two weeks. So something's really happening. If you just look at the ten states with the highest death rates right now, they are New York, California, Michigan, North Carolina, Ohio, Pennsylvania, Texas, Washington, Tennessee, and Florida. There's no regionalization there. There's no hot spot in the country. This seems to be spread across the entire US. And while this may seem like a story we've heard before, this time it's different. We're entering a new phase of this COVID pandemic, and there's no telling exactly how it's going to play out. I don't know. We've got lots of human immunity that may at best be partial immunity, but we're seeing these viruses continuing to infect human. We're going to talk about phases of the COVID pandemic in a moment, and we'll dive deeper into what these phases might really mean and how we interpret them about what's happening in the future. Let me just quickly update us where we're at with the subvariants in the United States. The prevalence of BQ.1 and BQ.1.1, all Omicron subvariants, continue to increase now making up 67.9% of new cases. Two weeks ago we discussed the lack of consistent trends globally with BQ variants, so it's really tough to say if the subvariants are what are driving the surge in cases, hospitalizations and deaths, just as I pointed out, with the international data. At the same time, we're seeing the subvariants increase in prevalence. We also are experiencing waning immunity and this overwhelming lack of concern about COVID in the general public all surely can contribute to the increase in COVID activity. So you might have guessed my answer to your question about the BQ subvariants driving the surge is that I don't know, but what I do know is if history repeats itself, things are going to get worse before they get better. When we consider the increasing COVID hospitalizations, the ongoing RSV and influenza situations, and the overwhelmed hospitals struggling with the shortage of health care workers and fewer available beds, we're heading straight into the perfect storm. And all we can do is encourage people to get vaccinated, use respiratory protection, and please stay vigilant. So now we're in this new phase of the pandemic, and I don't know where this virus is going to take us or how we're going to respond with vaccination treatment or N95 respirator use. But that will be important in determining what that next phase looks like.


Chris Dall: [00:30:13] So before we get to that next phase of the pandemic, Mike, let's talk about flu and RSV activity in the country. Can you give our listeners an update on where things stand with flu and RSV and what you're seeing in the data?


Michael Osterholm: [00:30:28] Well, Chris, as I hope you and the listeners have concluded over the course of these podcasts, humility really should run the day in terms of how we approach these issues. And I've tried my best to live up to that standard. But I must tell you, the past couple of weeks have been very challenging for me, listening to so many experts in the media, on television, etc., talking about what's happening right now. And frankly, they really don't understand what they're talking about. And what I mean by that is they don't understand the historic perspective of what has happened with RSV and influenza in the past, along with COVID. They don't understand what's actually happening right now by flu seasons. You know, I come in at this with over 40 years of influenza vaccine season surveillance, having worked a lot in flu. And so let me try to share with you the perspective that I see. Make no mistake, RSV and influenza are real problems right now, but they're not the same problem that the media has portrayed. And that's important because I think it also speaks to what might happen over the next 3 to 6 weeks. So I'm looking forward and trying to understand the past in that regard, not trying to go back and win a bet about what happened in the past. So I will give you an update on where we're at today with flu and RSV. But I want to remind the listeners of the discussions we've had about these two viruses over the past few weeks. The high rates for hospitalization for influenza and RSV have certainly been a major challenge in the past few weeks and months. And it is true they are far higher than we would expect to see them in these particular weeks of the flu season. But I must emphasize, we are not seeing influenza necessarily at a higher rate than would be expected to be seen for an average flu season. It's just that the cases have occurred sooner. Remember, in influenza surveillance language, we talk about week, surveillance week. So week one is the first week in January. Week 52 is the last week in December. When people keep talking about we've not seen flu like this in 10 to 15 years, what they really mean is not the highest level of flu, but for a week 42 to 43 or 44, it's different. That doesn't mean that overall the case numbers are higher. And I think this has been a real challenge trying to get this message across. So, for example, if you look back on what happened in Australia, and I've talked about this before, people talk about it being a bad flu season, well, the same thing happened there that I think is happening here. The flu virus arrived early, weeks earlier than normally be expected. So if you looked at that surveillance week, yeah, it hadn't ever shown up at that level before. It looks bad, but when you compare it to what would be expected if it occurred just 5 to 8 weeks later during the normal flu season, we'd say, oh, you've got a normal flu season outbreak occurring. When we looked at Australia, we saw that it primarily hit kids. We saw that it was primarily H3N2 influenza, which is not typically what we see in kids. We usually see H1N1. H3N2 typically hits the older age population. And what Australia saw was a limited hit on the adult population, but again, heavy in the kids. So if you're a kid, it might be considered a bad flu year. But if you look at the total number of cases and you look at the actual overall deaths that occurred, it was an average flu season. Well, the same thing is happening here in the United States. I've said this several weeks ago. I stuck my neck out to say I thought that if this was going to be like Australia, case numbers would start to drop precipitously after this very steep incline of 3 to 4 weeks. Well, that's what's happening right now. If we look at influenza like illness surveillance, it has now dropping this past week and I think you're going to see even a bigger substantial drop when the new report comes out on Friday. When we look at what's happened is almost 80% of the viruses were isolated are H3N2, not H1N1. When we actually look at the overall percentage of nursing home infections that are occurring by using a surveillance system, the CDC has set up to look at nursing home infections, about 5% of nursing homes in this country have reported even a single case, which is, again, not high at all for what we'd expect to see. And I can continue to go through these data and just point out that yes, flu is not a good thing, but that it's really not any different than a normal flu season. And I think by the time we get done looking at the total number of cases for this flu season between now and, say, February, March, it's going to be seen as an average flu season. And that's an important point. If you if you finally look at this impact, if you look just three years ago, there were 199 deaths in kids due to flu in our flu season in the United States. Right now, we're at 21 deaths. Now, any deaths is a tragedy. It's horrible. I don't think the cumulative number of deaths this year even when the late reports come in are going to get anywhere close to what it was just a few years ago. So I just wanted to dispel this only from the standpoint of understanding for people that there is a real problem right now with our hospital beds and with the pediatric side, with RSV, we think we've seen a peak. This one may have been higher in terms of total number of cases than we would see in an average RSV season. But in a sense, it's not that different. It just occurred very early at the same time flu did. And already we're beginning to see RSV numbers come down. Now, one of the things that's being missed is that when we talk about how hospitals are overwhelmed and it is true, there are many pediatric intensive care units, there are a number of hospitals that are literally at the breaking point. So I don't want to minimize that. But remember, why is that happening? It's yes, in part due to the case numbers increasing, but it's also due to the fact that our health care systems do not have the robust capability to respond that they had even 5 to 10 years ago. And so that today, if we look at emergency rooms, they've become the care centers for mental health status, particularly for kids. We look at 30% of the hospital beds in this country are occupied by people who shouldn't be there. They should be in long term care or stepdown, but there are no beds for them in the community. And when you add all these things together, this makes for a health care system that is so fragile to even a slight increase in cases. We don't have nearly the health care workers we need. They just don't exist anymore, they've left the profession. So I want to point this out because it's really important to understand that, yes, we have to care for these patients and this is a real difficult, tragic situation. But if we look at the fact of what's really happening in terms of responding to what this may mean with COVID, I think it's going to be very different. So I think hospitalization rates will come down substantially for flu. And as we've seen with RSV, they've gone down now over the past several weeks substantially. I think we're going to see the same thing. But what's that telling us then? Well, remember, again, also how many people have attributed the RSV, flu to the mitigation strategies we took over the past two and a half to three years and therefore, creating this kind of immunity debt, whatever, where we're now more susceptible because people didn't get infected with these viruses before. Well, let me just remind people that with influenza on an average year, only 5 to 15% of people get infected anyway. And 15% is high. Kids at a higher rate. If you look at the last two years, that may be 20% of the population didn't get infected. That might have. That's not a big chunk of people that now suddenly explain this. Also, remember 2009, the H1N1 pandemic that started in Mexico in mid-February, spread around the world quickly by mid-March or early April. We saw a peak of cases in the United States in April dropped precipitously, the summer months were relatively quiet and then it took off in late August, the big peak of cases in late September, early October, long before a vaccine arrived and then dropped after that. Vaccine had no impact. We didn't mitigate. We didn't use masks, we didn't distance, we didn't shut down anything. And yet that next flu season, the 2009-10 season, we only saw H1N1. There was no H3N2, there was no influenza Bs. We saw no RSV. Something interacted there to make that happen. And so to explain now that while people are taking their masks off and before they had them on, that's why we're now seeing this just makes no sense. And finally, just out of logic, if the kind of masking that was going on in much of the public not using N95s, but procedure masks were so effective in reducing the transmission of RSV and influenza, then why did so many people get infected with COVID? Same size viruses, is there somehow selection occurring there that if you get to the procedure mask entrance, if you're RSV or influenza, you can't come in. But if you're COVID, you could. This was true for all age groups. So if in fact masks were that effective and I want to be really clear, I'm talking about inadequate masking, using procedure masks. If that was so effective and now leading us to this immunity debt and causing a big increase in cases, then why didn't it stop COVID from occurring? So I think to make a long story short, Chris, is that right now I think you're going to see influenza and RSV drop precipitously. But at the same time, I think we're going to see COVID take off. I don't know how much higher the case numbers will go, but it surely, I think, has got a ways to go yet. And that by itself will still be enough to challenge our health care system. It will cause us to raise questions about what kind of recommendations do we make, as you're seeing now in New York and LA, where they're recommending voluntary use of masking again, etc.. So don't be distracted by influenza and RSV as the cause for why everything's happening right now. It is important. They are critical. People have died, health care systems have been overrun. But the explanation that many of the experts are giving right now, just don't hold water and be prepared with the next shoe to drop over the next days to weeks, COVID is going to be the dominant and most concerning of all the viruses that we see in our community.


Chris Dall: [00:41:09] Well so that gets us into this next phase of the pandemic. What do you see it looking like over the next few months?


Michael Osterholm: [00:41:19] Well, Chris, as you know, I've used a lot of metaphors throughout this pandemic. I've referred to each of these unique periods of time as baseball innings or acts in a play. For people who continue to wonder what baseball inning we're in, I don't even think we're playing baseball anymore. I think it might have been curling or archery at this point. But I do want to provide a bit of an overview of what I've been calling phases and where we may be headed. Now, let me be really clear. This is my description of the pandemic. For those who disagree with it, I'm your problem. No one else has necessarily come forward suggesting this is how it is, but I think it is a framework for me that at least in my mind, I can organize where we've been, where we're at and where we're going. So let me break this down into what I see are five phases and there may be more coming ahead. Let me look at phase one, what I refer to as a house on fire. This is what started the pandemic and ran through to the end of 2020. We had to act fast on very little information on a novel virus. Travel bans and attempts to isolate and quarantine to stop spread became fruitless quickly. Even as we gained information, clumsily messaging and misinformation muddied the waters for everyone. We experienced significant challenges in surging health care and public health capacity and figuring out how to handle work and school remotely. Saying things were chaotic is a massive understatement. During this phase, the US experienced over 350,000 deaths and global lives lost topped 1.9 million. Again, this is through the end of 2020. Then we went into phase two at that point or what I've named vaccines and variants. It started really in January of 2021, although with some hints of this as early as late November of 2020, and it ran through the following November of 2021. Here we experienced a mixture of successes and challenges. We were getting vaccines into arms, vaccines that we had no idea would actually exist just one year before. And they seem to have substantial protection. We also saw our first major variant B117, also known as Alpha, take off in the UK and in other parts of the world. That was a seminal moment for me because once I realized that these variants were not just examples of rings in a tree, meaning they just mark the growth of the virus, but then in fact they were tied to infectivity, transmission, disease severity. Suddenly that meant, Oh my, what else could be ahead? We didn't see Alpha actually end up having a substantial impact in the United States, except for the areas of Michigan and Minnesota, which for reasons today, I still cannot explain why only those two areas got hit hard. But from January to April 2021, Alpha was responsible for more than 1 million deaths globally in only a four month period. As you know, I made statements during this time that I thought the darkest days of the pandemic were still ahead of us because of what the variants would do. And I got considerable flak for that. At that time cases, hospitalizations, and deaths were all decreasing in the US and vaccine was in its rollout phase. But unfortunately, by the end of the summer, again, a new variant evolved, Delta, and it arrived on the scene and we saw a major surge in activity. At the end of this phase in November 2021, the cumulative deaths in the United States topped 825,000, and global deaths approached 5.5 million. Remember, in the first phase was 350,000 deaths. So we added well over 500,000 deaths in the second phase. Then phase three came along. I call this the Age of Omicron. It brought an additional wave of challenges all amidst worsening pandemic fatigue and anger. Starting in December of 2021 and running through the spring of 2022, we saw the impact of a highly transmissible variant matched with waning immunity. While vaccines were proven to reduce severe hospitalizations and deaths, they were not considerably reducing transmission infection as we had once thought they would do, resulting in some of the highest case numbers in the entire pandemic. Especially after a brutal season of Delta, hospital and health care workers were beyond burned out, and unfortunately, things still weren't over. By the end of this phase in April of 2022, the United States had reached 996,000 total deaths, with a global death count now surpassing 6.2 million. And then along came phase four, or as I have called it, the high plains plateau. Case numbers, hospitalizations, and deaths maintained a steady rate, but far above what anyone could consider acceptable. While updated boosters and oral antiviral treatments were proving substantial benefits, there uptake was far below what we wanted to see. Global leaders and the public were grappling with whether the pandemic is over, while understanding that any collective will towards mitigation had long passed. If we end this phase on December 1st of this year, this places that almost 1.1 million total deaths in the United States and almost 6.7 million deaths globally. And now, I think starting with the past month, we are now in phase five for what I'm calling what the heck? I think it describes a massive amount of uncertainty we're facing, along with the population that's desperate for this pandemic to be over. We're experiencing another rise in COVID-19 hospitalizations nationally and globally. We're adding on the stress of an early onset season of respiratory viruses like RSV and influenza. Subvariants of Omicron are prolific across the world, but their ability to take off like some of the past phases remains uncertain. So like many times in the pandemic, we're in a wait and see mode. I do hope this overview provides a bit of grounding over where we've been and the resilience we've had at making it through all of these challenges. We will have more phases. Phase five will not be the last phase. What I don't know is what phase six will look like, and I won't know probably for a year or more after the pandemic is over that, well, I think is probably over now, because, again, this virus just continues to throw 210 mile an hour curveballs at us.


Chris Dall: [00:47:32] Now for our COVID query segment. Here's an email we received from Carol, who wrote "You discussed N95 masks on your last podcast. In past podcasts, you've included KN95s as well. I've noticed more recently that you have not mentioned them. What are your thoughts on KN95 masks at this point? Are N95s the best option?"


Michael Osterholm: [00:47:54] Thank you for your very thoughtful question, Carol. This is a really important issue, and I know that it's a question that a lot of other listeners also have. KN95s certainly provide better respiratory protection than surgical or cloth masks, but compared to N95s, they have several limitations. The filter used in KN95s is very similar to the filter material used in N95s, which is the main reason that they are more effective than cloth or surgical masks, which are not made with this type of filter. Remember, these filters have a charge in them so that as the virus comes through this, more open spaces of the respirator so that you can still breathe, it traps the virus. So that it allows basically breathability at the same time trapping material coming in. Other cloth masks just don't have that capability. Unfortunately, the filter is just one component of what makes a respiratory protective mask effective. The other really important component is the fit. KN95s generally have ear loops which do not provide nearly as good a fit as N95, which have head straps. In addition, I must add that if you're a man with a beard for which many people have, there's really little opportunity to really get tight fit with your N95. And so therefore you have to understand, unless you decide to shave, you will always be challenged in having an effective respiratory protective device use. The fit can be improved for KN95s by clipping those ear loops together. However, it will still not be as good as a fit as if you would see with an N95 and unfortunately without proper N95 fit testing, there is no great way to check to see how well your respiratory protection mask really fits. If your glasses fog up while wearing any respiratory protection device, this is a good sign that your mask does not fit. But a lack of glasses fogging does not guarantee that it does fit. If your mask collapses and expands when you inhale and exhale, this could be a good sign that it's fitting properly, but you'll not necessarily see this with all well fitted respirators. Additionally, these respirators are designed to block viral particles, as I just mentioned, but not gases or vapors. So being able to smell something while wearing a mask is also not necessarily a sign that your mask is not fitting properly. Finally, there are now a lot of different KN95s counterfeits in the market. And according to our respiratory protection expert here at CIDRAP, Dr. Lisa Brosseau, there is no simple way to determine which are real and which are fake. The bottom line is, if an N95 is accessible to you, then it's best to use that over a KN95. However, if a KN95 is all that is available to, you know that you can improve the fit by clipping the ear loops together behind your head. And that assuming it's a real KN95, it is significantly a better choice than a surgical mask or cloth mask and better than no respiratory protection at all. And let me just conclude here on how we in public health have been messaged about masking. Frankly, I think this will be ultimately viewed as one of the lowest points of our performance in this entire pandemic. We continue to talk about masks in a generic term. I've used it in this explanation here, but I also try to make it very clear what we're talking about. N95 respirators must be seen as the minimum to best protect you from inhaling this virus. I go to hospitals around the country and I see people still wearing procedure masks, which these big gaps on the side. Remember, procedure masks were meant to protect you from getting a fluid, any kind of material onto you, but it is never meant to stop air coming in, out, or around. I've actually been in two institutions recently where in both cases I actually was violating their masking policy by wearing an N95. And in one of the situations I was actually told me I needed to take my N95 off to put on a procedure mask, and I, of course, said, no way. And they didn't make me do that. But I know of many circumstances where that's happened. I think public health has failed miserably, along with the clinical community on helping people understand why N95 respirators are so important for respiratory transmitted viruses like influenza and COVID. And until we improve on that education and messaging, I fear that we will continue to see people doing what they think is the best thing they can do to protect themselves. Yet it's inadequate. Again, the minimum standard should be an N95 respirator and recognizing that for many kids that will be impractical because they can't wear them. In that case, I don't have a great alternative for you, but at least for now, we shouldn't make what is convenient the answer. We must continue to use the science we have to say this is what is necessary.


Chris Dall: [00:52:48] Instead of a beautiful place submission this week. Mike, I understand that you have a beautiful moment that you would like to share with us.


Michael Osterholm: [00:52:56] Chris, this is an oldie but goodie, and it's one that I've used before on the podcast, and I actually had a number of people comment to me about how they would like to hear this again this year. This is a stretch for me because it's very personal. And so I went back and forth quite a bit and whether I really wanted to do this one or not. But here it is. I'll give it my best shot and hopefully it means to you what it means to me. I'm going to share with you it is one that I shared in Episode 83 on December 22nd of 2021, entitled "On Viral Time." And it's about a story that I am involved with. So let me tell you about that story. Some of you know who have read my book or who have heard me talk about this in previous podcast, I'm the oldest of six kids. I was born and raised in a small town in Iowa. I was born to a family where my father who was a photographer at the local newspaper was a seriously troubled man from a mental health standpoint and from his alcoholism. He was an extremely violent man. I spent a better part of my childhood as the oldest of six kids trying to protect my siblings and my mom from him. In October of my senior year of high school, I came home from a football game that night we had won. I actually even got to play and I found my mother on the kitchen floor. My father had beaten her within an inch of her life. I'd never, ever done anything to him other than just in a defensive posture, trying to cover myself when his fist would get thrown. He had a terrible habit of when he got drunk, he'd come upstairs when I was sleeping and I'd wake up to him pounding on my head. I always hated nighttime like that. This particular October was it. I could do it no more. I found my father in the house and literally physically threw him out of the house. I told him he was never welcome back again. He left town a day later, and our family never saw him again. From that October to that Christmas, it was tough. Financially, my father was largely the sole breadwinner, even though he drank away a lot of his weekly paycheck. My mother worked as a nursing assistant at a long term care facility at nights just to try to make the budget meet. But between October and Christmas, that particular December, it was tough, very tough. I remember two of my sibs who, because of the size of their feet, didn't have any snow boots to wear. My mother couldn't afford to buy new boots. She sent my sibs to school with red socks over their feet in the snow with rubber bands to keep them up. That was hard. That was really hard. Christmas came, and the week before Christmas we had no tree. We were just trying to have enough food in the table. And obviously it was a tough time, a very tough time emotionally in ways that I can't even begin to explain. But some of you I know understand exactly what I'm talking about. You've been there. You felt that. You know that pain. But as some of you know, I was also very blessed to be adopted in a way by the wife of the owner of the newspaper where my father worked. Nana, her family name and who I dedicated my book to in 2017 was a renaissance person in every way, including being multilingual. She's the one that got me into this business because it was her that provided me with copies of The New Yorker, the magazine that included articles by Bertrand Roget on the Annals of Medicine, the medical whodunit stories. After I read those stories, I knew what I wanted to do. I wanted to be a medical detective. Nana was such an incredible force in my life and to the extent the life of my family. Three days before Christmas, a letter arrived. It was to my mother, and I knew it came from Nana. It was her typewriter, even though it was not signed. All it said inside was Merry Christmas in the envelope, and it had $50 in it. The most important $50 I will ever know in my lifetime. My two sibs got boots that day. We bought the last Christmas tree at the local grocery store. It was pretty scraggly one, but it was beautiful. And we each got very cheap but absolutely incredibly meaningful presents. And Christmas took a complete turn on that one letter. But it still is very troubling to me. I was still pained by all that was happening. Angry at my father for what he had done to us and how he had done it. And then on Christmas Eve afternoon, another letter came. This one from Nana, too. But she signed this one. And it was to me. The letter talked about the future and how Christmas would not have to be like this again. And now is the time to know that. And she included in the letter a passage that was from the yet unpublished MacKinlay Kantor book "I Love You, Irene." MacKinlay Kantor was well known as Iowa's poet laureate and someone that Nana has struck up a letter writing relationship with that was actually very special. The passage that Nana shared with me from Kantor's book was all about his relationship with Irene, his wife, and a very difficult experience they were going through. In the book, he wrote the following, and Nana shared this with me. "My child, you will see many strange things. You'll watch holly berries wither and freeze while the nettles are pressed tenderly. The good deer will starve in icy thickets when the rat grows partly amid his corn. You'll see the inspired creator neglect it and his smug imitators extolled. Heroic nord and presumptuous coward foetid richly. These you will observe. The shyster shall dwell long in luxury. The diligent and dependable will fall early. And on the dole, a kindly nation may shiver in terror of the iron harshness adopted by its neighbors. Bright universe eclipsed. Black tarned gilded by a permanent sun. You see your future so. And yet in their season the candles will be lighted again. The cone smell pungent. Then may sing with the tongues and the throats of angels amid the saintliest frost. There is time now for consideration of the noblest fairytale of all, if one be willing to believe. God rest ye Mary in the midnight clear." Thank you, Nana. Thank you, MacKinlay Kantor. Those words made that Christmas all the more special. And they're words that every Christmas since then I have read, reread, read and reread and remember and never forget. That now, without regard to what your religious beliefs are, without regard to your social, political or economic status, it's now time for consideration. If one be willing to believe. Thank you, Nana. Happy holidays to all of you.


Chris Dall: [00:59:27] And just a reminder to our listeners that we love your beautiful place submissions, so please keep sending them. If you want to tell us about the beautiful place that has helped get you through the pandemic or just provide some peace and comfort in challenging times, please email us at Mike, what are your take home messages for today?


Michael Osterholm: [00:59:49] Well, Chris, I love being creative and trying to find new ways to express things, but you know, sometimes it's just the old reliable words are all you have. Number one, we're not done with COVID. That has clearly been a primary finding of all the podcasts in recent weeks. Number two, the tripledemic as the media has called it is likely not going to continue in the way that we think. I think influenza and RSV will begin to drop precipitously in terms of case numbers. But on the other hand, I think it's very clear that we're going to see COVID do more damage. How much, when, where, and how? I'm not sure. And finally, boy, three years is a long time. But now is not the time to give up. This virus continues to kill 450 to 480 people a day, more than 100 more than die each day from lung cancer in this country. We can't accept that. The way to address it, clear and compelling, get vaccinated, Get that bivalent vaccine dose. Get your influenza vaccine. Number two avail yourself to treatment, if you do become infected. Paxlovid can be a lifesaver. And finally, just remember that to avoid infection to begin with, using an N95 respirator in public places and places you might get exposed can be a lifesaver. So it's not done. It's going to change a bit in the days ahead, and there's a lot we can do about it.


Chris Dall: [01:01:21] Since this is our last episode before Christmas, the special holiday treat that I mentioned earlier is going to replace our closing song this week. It's a recording of Dr. Osterholm reading "The Polar Express" with his grandchildren. So, Mike, before we get to it, and as we close out this episode of the podcast, can you talk about why this book is so special to you?


Michael Osterholm: [01:01:42] Well, Chris, this particular book is very meaningful to me and both from its message but also its historic perspective. Anyone who is familiar with "The Polar Express" knows it's all about believing and being able to hear the bell. And in a time like now, believing sometimes is very difficult to do. But this book gives us all the reason why. It's also very special to me, because I, for reasons I can't explain, I realized very early when this book was first published, how important it was to me personally and how it might be important to my family. So in 1985, I read this book to my kids, and as they grew up, we continue that tradition each and every Christmas. And then I had the beautiful gift of having five incredible grandkids over the course of the last 13 years. And so we continued this entire experience with my grandkids and kids. And so today, 37 years later, we're preparing to read "The Polar Express" again for this Christmas. And it's to the point now where my grandkids can actively participate. They love to read it with me. And they have certain lines that they love to accentuate in terms of the reading. And another thing that happened was when my son was nine years old in his class here in the Twin Cities, he had to write a piece for his class on a book and what it meant to him and why this particular book was meaningful. And he did. And their mother, Peg, who was very kind in keeping a copy of that and framing it for me to see all these years later. And I asked my son if I could share this with you, because I think it's really all about the Christmas spirit and Christmas gift. So this is what my nine year old son read and handed it in for his assignment on a book, "The Polar Express" by Ryan Osterholm. "Ever since I was a little child, I remember reading a book with my father every Christmas Eve. This book is "The Polar Express." This book is so special to me because it means more to me than just a book. It symbolizes a strong relationship between my father and me. Christmas is not just a time to receive gifts. It is a time to be with your family and be giving. Reading this book every year helps me hear the bell and makes you remember what Christmas is all about." So today we share with you again "Polar Express." I must also add that another benefit of "The Polar Express" experience for me was the fact that I have now gotten to know and have a wonderful relationship with Chris Van Allsburg and his wife, Lisa. And Chris inscribed in a copy of the book for each of my grandchildren specifically addressed to them about "The Polar Express." And so this will be a lifelong gift that we will be able to continue to pass down. And I hope that all of you, all of you in this season can understand and appreciate the feelings of this. If you have not read "The Polar Express." Go get it. It's an incredible book. And most of all, thank you for being with us as we approach this holiday at a time when there's still lots of confusion and concern and real challenges. It's been a gift to be with you. I never take for granted how important it means to be part of this podcast family. It's a gift for which I will never, ever adequately be able to share how much it means. So thank you. Thank you to you, Chris. Thanks to the podcast team for all you've done. Please everyone, with these next couple of weeks, be careful, but also never miss an opportunity to be kind. Thank you very much. And as I started out in the dedication, we remember all those who are hurting, all those who will have tough days ahead. You're in our thoughts. Yes, you are definitely in our thoughts.


Grandchildren of Michael Osterholm: [01:05:30] Grandpa, can you read us "The Polar Express?"


Michael Osterholm: [01:05:34] "The Polar Express." Written and illustrated by Chris Van Allsburg. "On Christmas Eve many years ago, I lay quietly in my bed. I did not rustle the sheets. I breathed slowly and silently. I was listening for a sound. A sound a friend had told me I'd never hear, the ringing bells of Santa's sleigh. There is no Santa, my friend had insisted. But I knew he was wrong. Late that night I did hear sounds, though not of ringing bells. From outside came the sound of hissing steam and squeaking metal. I looked through my window and saw a train standing perfectly still in front of my house. It was wrapped in an apron of steam. Snowflakes fell lightly around it. A conductor stood at the open door of one of the cars. He took a large pocket watch from his vest, then looked up at my window. I put on my slippers and robe. I tiptoed downstairs and out the door. All aboard, the conductor cried out. I ran up to him. Well, he said are you coming? Where? I asked. Why? To the North Pole, of course, was his answer. This is the Polar Express. I took his outstretched hand and he pulled me aboard. The train was filled with other children. All in their pajamas and nightgowns. We sang Christmas carols and ate candies with nougat centers as white as snow. We drank hot cocoa, as thick and rich as melted chocolate bars. Outside the lights of towns and villages flickered in the distance as the Polar Express raced northward. Soon, there was no more lights to be seen. We traveled through cold, dark forests where lean wolves roamed and white tailed rabbits hid from our train as it thundered through the quiet wilderness. We climbed mountains so high it seemed as if we would scrape the moon. But the Polar Express never slowed down. Faster and faster, we ran along. Rolling over peaks and through valleys, like a car on a roller coaster. The mountains turned into hills. The hills to snow covered plains. We crossed a barren desert of ice. The great polar ice cap. Lights appeared in the distance. They looked like the lights of a strange ocean liner sailing on a frozen sea. There, said the conductor, is the North Pole. The North Pole. It was a huge city standing alone at the top of the world. Filled with factories where every Christmas toy was made. At first we saw no elves. They're gathering at the center of the city. The conductor told us. That is where Santa will give the first gift of Christmas. Who receives the first gift? We all asked. The conductor answered. He will choose one of you. Look! Shouted one of the children, the elves! Outside, we saw hundreds of elves. As our train drew closer to the center of the North Pole, we slowed to a crawl. So crowded were the streets with Santa's helpers. When the Polar Express could go no further, we stopped and the conductor led us outside. We pressed through the crowd to the edge of a large open circle in front of us to Santa's sleigh. The reindeer were excited. They pranced and paced, ringing the silver sleigh bells that hung from their harness. It was a magical sound, like nothing I'd ever heard. Across the circle, the elves moved apart and Santa Claus appeared. The elves cheered wildly. He marched over to us and pointed to me, said, Let's have this fellow here. He jumped into his sleigh. The conductor handed me up. I sat on Santa's knee and he asked, Now, what would you like for Christmas? I knew that I could have any gift I could imagine, but the thing that I wanted most for Christmas was not inside Santa's giant bag. What I wanted more than anything was one silver bell from Santa's sleigh. When I asked Santa smiled, then he gave me a hug and told an elf to cut a bell from a reindeer's harness. The elf tossed it up to Santa. He stood holding the bell high above him and called out, Ah, the first gift of Christmas. A clock struck midnight as the elves roared their approval. Santa handed the bell to me and I put it in my bathrobe pocket. The conductor helped me down from the sleigh. Santa shouted out the reindeers' names and cracked his whip. His team charged forward and climbed into the air. Santa circled once above us, then disappeared into the cold, dark polar sky. As soon as we were back inside the Polar Express, the other children asked to see the bell. I reached into my pocket. But the only thing I felt was a hole. I had lost the silver bell from Santa Claus' sleigh. Let's hurry outside and look for it, one of the children said. But the train gave a sudden lurch and started moving. We were on our way home. It broke my heart to lose the bell. When the train reached my house, I sadly left the other children. I stood at my doorway and waved goodbye. The conductor said something from the moving train, but I couldn't hear him. What? I yelled out. He cupped his hands around his mouth. Merry Christmas! He shouted. The Polar Express let out a loud blast from its whistle and sped away. On Christmas morning, my little sister Sarah and I opened our presents when it looked as if everything had been unwrapped. Sarah found one last small box behind the tree. It had my name on it. Inside with the silver bell. There was a note. Found this on the seat of my sleigh, fix that hole in your pocket. Signed, Mr. C. I shook the bell. It made the most beautiful sound my sister and I had ever heard. But my mother said, Oh, that's too bad. Yes, said my father, it's broken. When I'd shaken the bell, my parents had not heard the sound. At one time, most of my friends could hear the bell. But as years passed, it fell silent for all of them. Even Sarah found one Christmas that she could no longer hear it's sweet sound. Though I've grown old, the bell still rings for me as it does for all who truly believe. The end."


Grandchildren of Michael Osterholm: [01:12:36] Merry Christmas, Grandpa!


Chris Dall: [01:12:46] 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 This podcast is supported in part by you, our listeners. If you would like to donate, please go to The Osterholm Update is produced by Cory Anderson, Meredith Arpey, Elise Holmes, Sydney Redepenning, and Angela Ulrich.