January 26, 2023

In "Nowhere Land," Dr. Osterholm and Chris Dall discuss the state of the pandemic in the U.S. and around the world, the latest data on the XBB.1.5 subvariant, and a measles outbreak in Ohio. Dr. Osterholm also answers a COVID query about COVID deaths, provides an update on influenza and RSV, and comments on the new strain of antibiotic resistant gonorrhea that was recently detected in Massachusetts.

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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. With its COVID restrictions now dropped. Millions of people in China are headed home to towns and villages this week to celebrate the Lunar New Year. The celebration comes on the heels of a wave of SARS-CoV-2 infections that has affected roughly 80% of the country's population, according to China's chief epidemiologist. Some fear that Lunar New Year travel and gatherings could bring the virus into other parts of the country that are less vaccinated and spark another wave. Meanwhile, in the US and Europe, the post-holiday bump in COVID activity appears to be leveling off. On this January 26 episode of the podcast, we're going to talk about what's happening in China, the US and other parts of the world as we assess the state of a pandemic now entering its fourth year. We'll also provide you with an update on the XBB.1.5 sub variant. Answer a COVID query on whether COVID-19 deaths are being undercounted. Look at the latest flu and RSV data and discuss a measles outbreak in Ohio and detection of a resistant strain of gonorrhea in Massachusetts. We'll also share a beautiful place and poem 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: [00:01:53] Thank you, Chris. And welcome back to all of you who are part of the podcast family to another edition of this podcast. And for those of you who may be new today to this, I hope that we're able to provide you with the kind of information that you're looking for that's helpful, that's actionable, and if nothing else, at least hopefully it makes some sense. We have a lot to cover this week, even though some would say that the pandemic is on the wane. And we'll hopefully share with you new and emerging information about vaccines, about the risk of infection, etc. That is important. But I want to start out this podcast today with a dedication, and it will set the tone, I hope, for the remainder of the podcast. And that is, I am dedicating this episode to anyone with preexisting health conditions or older age that puts them at increased risk for serious illness, hospitalizations or deaths. Why? Why do I say this? Because today I think many of the people who are in those categories and I put myself in that category, I will soon be 70 years of age that we feel like our lives are almost seen as disposable. That in fact, the pandemic is over. It's gone. It's over with. We'll talk about that today and the case numbers. And I know a lot of people are feeling very discouraged by the narrative that COVID deaths are less significant and they occur in individuals who have other health conditions or who are just old.


Michael Osterholm: [00:03:13] Yes, we all agree we're all going to die. But, you know, as I sit here almost at 70 years of age, I've never been more active. Hopefully my work is as good as it's ever been. I know that the enjoyment of spending time with my grandchildren has never been more wonderful. And don't tell me it's 70 years of age. I'm an old man that therefore, if I die from COVID, it's expected. You know, I got a lot of years left in these pipes, and I want to be certain that I live them in the way that I know I can. And there are many of us who feel that way, many of us. And yet we feel that when we hear about, oh, there's only 460 deaths or 520 deaths, and they're all old people, you know, that That cut's very raw with me. And I know it hurts many of you. So you know, what this podcast today is dedicated to us is to those of us who basically are not done. And even if we do have underlying health conditions or age and we may be challenged, we've got a lot of life left. We've got a lot of grandkids to hug. And so today, this one's for you. And as you'll see, I think that this dedication ties nicely with the closing that I'm going to use today from one of our listeners. And we thank very much for a thoughtful submission. So that's the state of the art today.


Michael Osterholm: [00:04:35] You know what? None of us are going to go before our time. Or should we? And COVID, first of all, is not going to be what's going to take us. What do we have to do to make that a reality? Now, I also want to comment briefly on another really very serious and frankly, very, very troubling situation in terms of our health outcomes. And that is the gun related deaths that we see in this country and we've heard so much about, particularly in California in the last week and a half. This is a tragedy is so hard. Parents who find out suddenly that their son or daughter has been shot and killed or children finding that their parents are now lost. But I want to put this into perspective, too, because every one of these is a human life just as valuable as all the ones we talk about with COVID or anybody else here. And I think just to give you some sense of COVID and what it's doing, if you look today, these tragedies with these mass shootings are obvious. They're real. They viscerally hurt all of us. When you look at the events, though, we miss the vast majority of the pain and suffering that occurs with these gun related killings. When you look at the actual number of individuals impacted by mass shootings, which is makes headline news, it's a tragedy. If you look at the California three events that have happened, they surely have been topped in center in the news.


Michael Osterholm: [00:06:10] That's 20 individuals who have died. Tragic. No ands, ifs and buts about it. Tragic. When you look at the overwhelming impact of gun related events in 2020 last year, we could get good complete numbers. 45,222 people in this country died as a result of a gunshot. That includes 43% who died from murder, 54% who died from suicide, and 3% who died from unintentional shootings. Every day. As much as we see these tragic mass shootings, there are people being killed by the hour and we miss that. And that says a lot about what public health is about. That's what we're supposed to do is try to share the entire impact. And so I am moved by the massacres, but I never fail to be moved by the fact that just how many moms and dads and brothers and sisters, aunts and uncles will die today because of a gunshot, that they weren't part of a mass shooting. And when you try to put this into perspective, even, again, without minimizing in any way, shape or form the significance of these gun related events in this country. Think about the fact that it averages out about 124 deaths a day. Unimaginable. 124 deaths. When you look at COVID, right now, we're talking about 550 deaths a day. It also still gives you a sense that it does not minimize the absolute critical importance of gun related deaths. But it puts into perspective, COVID is not gone. It's not behind us, and it still is extracting a terrible price, just like guns are extracting.


Michael Osterholm: [00:08:00] So I just want to share this with you today as a perspective that it one surely points out the challenge we have with gun related deaths in this country. Number two, it just does give some sense of the importance of COVID this week. I don't know anybody talking about COVID deaths this week right now. And yet we hear about the deaths from guns, which is appropriate. But let's not forget about COVID. Now, I know that was all pretty heavy, so I'm happy to talk about lightning up. Today, I am very happy to report here in Minneapolis St. Paul we will have 9 hours and 33 minutes of sunlight. This is remarkable. We're gaining about 2 minutes and 20 seconds of sunlight a day. Sunrise today was at 739. Tonight it's at 512. If we look back to the winter solstice on December 21st, we've gained 47 minutes of light. Wow. Isn't that exciting? As we approach March, we see that the daylight goes up almost 3 minutes and 9 seconds a day. So hold on. It's coming. We're over the hump, I think. We got the light coming. Now, I do want to acknowledge our dear friends in Auckland again. Today, you'll have 14 hours and 7 minutes of sunlight. I do want to give a shout out to my friends at the Accidental Belgian Beer House and Balkan Lane in Auckland and say, Enjoy the sun and we're ready to get ours.


Chris Dall: [00:09:29] So, Mike, you said about as much as there is to say about the COVID situation in China, which we have to assume is probably worse than Chinese officials are admitting. But could Lunar New Year travel and celebrations make the situation even worse than we believe it to be?


Michael Osterholm: [00:09:46] Well, Chris, let me start out by acknowledging the fact that China surely has been a frequent topic of discussion on this podcast. Anyone who's been listening to it knows that. But it's in part because of the fact that what is happening right now is something that I unfortunately anticipated because we understood the magnitude of the catastrophe that was unfolding there in that country. So at this point, there could be some listeners out there, though, who are sick and tired of hearing me talk about it. Now, obviously, I don't want to become a bore. But to me, the approach that they took with zero COVID was almost like waiting for a massive dam to burst. So in a sense, I feel almost like I have to keep sounding the alarm. And let's be honest, there is a part of me that's angry. It's feeling disbelief. It's feeling the sense of why did they not do more? They could have and they should have and they didn't. To me, that is a story that will haunt this pandemic forever. And of course, with what's been playing out there, which sadly was almost as expected, as you know, we basically are seeing the virus burn through China's population with ease. So suffice to say, China is in bad, bad, bad shape. In fact, there is no doubt that these are the darkest days of the pandemic for them. And remember, this is a country with a population of more than 1.4 billion people. That's almost 18% of the entire global population.


Michael Osterholm: [00:11:17] So I hope everyone understands the sheer size and scale of their outbreak and consider some of the challenges that China is probably encountering at this very moment. But on that note, let me just say that the official numbers being reported publicly are likely bogus. At most, they represent just the tip of the iceberg. And there are plenty of stories, pictures and accounts to prove that case. Still, without any systematic data, it's almost impossible to know exactly how big the problem is. As I mentioned in past episodes, many in the international community, including the W.H.O., have called for more transparency from China in terms of their numbers and the size of this outbreak. But so far, these requests have only really been met with numbers that don't align at all with reality. Not at all. As you'll recall, the official overall death toll reported during the first few weeks of the surge didn't even exceed 50, at least initially. Eventually, that number was adjusted upwards to almost 60,000 deaths for the first month following their pivot away from zero COVID. And finally, another 13,000 deaths were reported there last week. In other words, at the time of this recording, they've reported a total of around 73,000 deaths since early December or throughout the past month and a half. Now, clearly that is a major undercount, and I really don't think you need to be an epidemiologist to come to that conclusion. First of all, we already know that they use a very narrow definition for what counts as a COVID case.


Michael Osterholm: [00:12:49] And notably, these 73,000 deaths only account for patients who died in the hospital specifically of what they declare COVID virus. On top of that, there are reports that COVID is sometimes being omitted from death certificates, even in situations where it's likely it played the significant role, according to a story published in Reuters last week. Doctors at multiple hospitals in China have been instructed to try and avoid listing COVID under the death certificates. A separate article published by the Financial Times mentions the same thing. In addition, it describes the absolute confusion being felt by family members and friends of loved ones who become infected and die shortly thereafter, but have no mention of the virus as a cause of death or even a contributing factor. I know because I continue to have conversations with researchers in or around China, and specifically certain businessmen and women who are also in China right now who have shared with us just how bad things really are owing to these circumstances and all that confusion that exists. The W.H.O. and other health officials are now asking China for any data on excess deaths to possibly help monitor what's going on there. A little better. Of course, with excess deaths, you're looking at total deaths from all causes during a certain period of time and comparing it to previously documented levels with some adjustments for things like population growth or time of the year. So basically you could look at the total number of deaths in China during December and January and past years to get a sense for what's typical or expected.


Michael Osterholm: [00:14:25] For example, and this is hypothetical, say, from 2009 to 2019, an average one and one half million deaths were reported in December through January combined in China. Then we could fast forward to now, and if all of a sudden that number is four and one half million, not one and one half million, you would obviously be able to tell that something was going on. It's not a perfect metric, but it can be useful, especially when the health systems are being strained. Unfortunately, as of right now, there hasn't been any recent data on excess deaths shared by China. Otherwise, what they have shared, interestingly enough, are estimates that 80% of the country have been infected since early December. Now, to be honest, I'm not really sure how they exactly came upon that number, especially since it would mean that the virus would have had to infect 1.2 billion people in just over a month and a half. But even if you pretend it's accurate, you could expect a death toll of more than a million. And that's just the case. Even if you assume China is seeing the lowest fatality rate reported with this virus to date anywhere in the world. Otherwise, For what it's worth, a health analytics company from the UK estimates that the daily COVID deaths in China are now about 35,000, and the projected overall toll since December 1st is close to 884,000 deaths. Let me repeat that 884,000 deaths. Again, it's not completely clear to me where this company is getting their numbers from and just how valid they are.


Michael Osterholm: [00:15:55] But I'd imagine these higher estimates do align closer with reality that we're officially being reported out of China to date. Still, until more data is made available, it's basically a huge guessing game. So long story short, it's difficult to know what the Lunar New Year will bring. Of course, with this being a time where hundreds of millions of residents travel back to their hometowns in rural parts of China to visit family and friends, I think there will be circumstances where the virus will have much more opportunity to spread from urban centers to more rural areas. And for the most part, many of these rural areas don't really have adequate health care systems in place to effectively treat a sudden surge of cases. On top of that, it's estimated that these same rural areas are home to 40% of China's elderly population. So there's still great vulnerability. Otherwise, I think Ben Cowling, an epidemiologist and a close friend of mine in Hong Kong, summarized it well recently. He said in a recent story published by NBC News that for the next two or three weeks, we know the virus is going to find its way to every corner of the country. That means in the rural areas they're going to have lots of infections, most likely within a short space of time. And the impact may be greater because of the lack of resources. China is a public health disaster.


Chris Dall: [00:17:18] Mike, are there any other countries that you're keeping an eye on?


Michael Osterholm: [00:17:23] Well, to be honest, I think right now I'm spending most of my time basically just trying to understand what this virus is doing internationally as a whole. And as always, it's not exactly simple. And I do have to admit that when I wake up in the morning now and I'm confronted with those five inches of caked mud of my crystal ball that I think recently has gotten to be seven or eight inches. So let me do my best from that crystal ball perspective. Overall, as of this Wednesday, reported, cases globally stood at 345,000 cases a day. As each day passes, I think the number means less and less to me, to the point where I don't really even think about it. But for what it's worth, it is down 30% over the last two weeks. Otherwise, deaths have started to climb to almost 4500 a day, which is up 74% from an official standpoint. That's the highest it's been since last March. And as expected, the biggest contributor to this rise in deaths is China, which accounts for almost half the reported toll. But of course, as I just touched on, this official number to me is even meaningless. In fact, if some of the current projections being made about China are accurate, like the UK health analytics company or affinity estimating that more than 35,000 people in China are dying each day from COVID or officially reported global deaths from COVID would be as high as we have ever seen throughout this entire pandemic.


Michael Osterholm: [00:18:47] Remember that the all-time high for COVID deaths globally was around 14,700 a day in January 2021. That's less than half of what we're just estimating is occurring every day in China. That said, outside of China, things almost seem to be in an ebb like phase. For instance, in parts of the Western Pacific, things have been cooling down a bit after several months of very heightened activity in certain places. So this includes Japan, Hong Kong, South Korea, where activity started picking up this past October and November and continued on through the new year. So obviously, these declines are very good to see. But still, when you stop and think about the levels reached in some of these places, even in the third year of this pandemic, it's very sobering. For example, in Japan, this latest wave was actually their deadliest since the start of the pandemic. Average daily deaths in the country went from about 50 a day in late October to 426 a day on the week of January 18. So in other words, last week, for a comparison, their previous high was 294 a day last September during the initial BA five wave. So they went to 426 versus their previous high of 294.


Michael Osterholm: [00:20:04] And even though deaths are starting to decline in Japan, their latest average of over 370 deaths a day is still quite high. Otherwise, in Hong Kong, this latest wave surely wasn't their deadliest. But if you remember, their initial Macron surge last March led to the highest death rate we've seen anywhere in the world to date. Let me just emphasize that again, What we saw with the Macron surge in Hong Kong last March led to the highest death rates we've seen anywhere in the world to date in this pandemic. So comparing what's happening now versus what happened last March doesn't necessarily mean that the recent wave was insignificant. In fact, if you look deaths in Hong Kong, which went from about ten a day in November to almost 70 a day by mid-January, are notably high. For example, this latest peak, which was reached on January 14, was about 9.3 deaths per million population. To compare here in the United States, our initial Macron surge peaked at 7.6 deaths per million population. And remember, that was when more than 2600 Americans were dying each day. In other words, the US equivalent to what Hong Kong has been experiencing, would be like our country seeing daily deaths above 3000. Sobering. So again, this isn't over, Chris. And in fact, just this week, North Korea announced that they were imposing a five day lockdown in a number of areas within North Korea due to, quote, rising cases of an unspecified respiratory illness, unquote.


Michael Osterholm: [00:21:37] Even though there's no direct mention of COVID, I'm willing to bet that they're dealing with another significant surge there. Otherwise, beyond the Western Pacific, there aren't necessarily any hotspot regions I'm seeing. However, there are always seems to be some oddities or things that stick out. And so again, I've been following some of the Scandinavian countries like Sweden, where deaths from COVID have been on the rise. For example, deaths in Sweden went from 11 or 12 a day in November to 58 a day earlier this month. For context, these are the highest levels they've reported since January of 2021. At the same time, cases there haven't changed all that much. And I have yet to see any evidence that this is somehow linked to a new variant. So. If you can't tell, I still have plenty of unanswered questions floating around in my head. And we'll have to wait and see what the path ahead might look like. But it's very clear SARS-CoV-2 is not done with us yet, and we keep forgetting that. So as the old saying goes, what goes up must come down? I'd like to say the past three weeks have also demonstrated what goes down, unfortunately, can sometimes quickly come back up.


Chris Dall: [00:22:51] Here in the US, COVID-19 cases, test positivity and hospitalizations have started to decline after a significant uptick in early January. But we're still seeing approximately 500 people dying every day, nearly twice the amount of deaths we were seeing in June. We'll talk more about COVID-19 deaths in a moment. But Mike, what is your sense of what we're seeing right now in the US with COVID?


Michael Osterholm: [00:23:14] Well, Chris, let me just be real clear. I'm not sure. But this is what we do know. Almost all the COVID activities decreasing across almost the entire country compared to two weeks ago, reported cases are down 29%. But I don't know what that means. Test positivity is down 22% and hospitalizations are down 25%. These decreases are being seen in almost every state but five states and the District of Columbia there, they're experiencing increases in reported cases. These states include Alaska, Tennessee, Illinois, Kentucky and Missouri. Tennessee and Kentucky have far higher case rates in their population compared to other states. But interestingly, despite the increasing number of cases being reported in both of those states, both have seen their hospitalizations decline over the past two weeks and both are experiencing the same rate as the overall US. This could potentially be because hospitalizations are a lagging indicator, but these trends are surprising to me, considering most cases that are being reported are those who are test positive in a hospital system. So I don't know what it means, but let me add context. And our last episode, I provided context to the Variant XBB situation by explaining what happened with the alpha variant in 2020 into early 2021. Based on what happened in England, many, including myself, expected the variant to wreak havoc across the US. The variant did wreak havoc, but only in Minnesota and Michigan. Why not in Iowa? The Dakotas. Wisconsin. Illinois. Ohio. Indiana? We don't know. Two weeks ago, during our last episode, this was the context for the situation in the Northeast.


Michael Osterholm: [00:24:59] The Alpha context remains true, but now primarily for Kentucky and Tennessee. Tennessee have seen cases increase 73% over the past two weeks. Kentucky has seen a 50% increase in cases. What will this mean three weeks from now? We don't know. Why is XBB.1.5 seen in the Northeast not spread to much of the rest of the country in any meaningful way? We don't know. Over the past two weeks in this country, daily deaths have remained relatively stagnant, down about 7% compared to two weeks ago. Remember, that's at 542 deaths a day. That's among the highest numbers we've seen since last spring. But as you noted, Chris, losing more than 500 people every day adds up to more than 3500 Americans lost every week. I know I sound like a broken record, but we need to remember that this is not just a number. Every single one of these people is someone's child, somebody's mother, somebody's father, friend or neighbor. So please remember when you hear about lives lost every day because of COVID. It is so much more than a number. And to me, I continue to believe that this number of deaths is just unacceptable. So where are we at with COVID right now? I think the best words to express would be nowhere land. It feels like I'm looking all around and there's nothing telling me which direction we're heading and my muddy crystal ball isn't going to do me any favors either.


Michael Osterholm: [00:26:29] But just because we're in nowhere land still does not mean it's time to let our guard down. We are those people who are older, those people who have underlying health conditions. We don't want to be one of these 3500 people a week that are dying from COVID. And so this is a challenge. I don't know where we're going to be 90 days from now. I do know that I will surely like to be continuing to take every precaution I can not to get infected. But I don't know what'll happen. We'll actually be 1.5 take off in other parts of the country. Will it just basically melt away like it appears it's beginning to do in the northeast? We don't know. So stay tuned. Again, I remind people they can protect themselves. If you are among those who are at increased risk for serious illness. You can do a lot. Make sure you have a bivalent vaccine dose. Make sure that if you do go out into the public, you or you're in 95. I don't go anywhere in the public anymore without my M 95, and it feels just like it's just another piece of clothing. And then finally, if you do get sick, you have to get early and very important access to health care so that you might get treated with one of the antiviral drugs we have that can reduce the possibility of developing severe illness, hospitalizations or deaths.


Chris Dall: [00:27:49] Well, Mike, you just mentioned the XBB.1.5 variant, so let's get a little bit more into that. The most recent variant monitoring data from the CDC shows XBB.1.5 accounts for nearly half of new cases in the US, while data from Europe show it's only in the single digits in European countries, this seems to be a different trend than we've seen with other variants, which typically spread widely in Europe before they arrived here in the US. So what's going on with XBB.1.5?


Michael Osterholm: [00:28:18] Well, as I noted in my previous answer, I don't know. But this is what I do know. If we look back at the emergence of new variants and understand how they spread across the world, we realize that the alpha variant emerged in Europe. We know that the beta gamma variants emerged in South America or parts of Africa. We know that the Delta variant emerged in India and we know that the Omicron variant emerged in Southern Africa. Clearly the situation we're seeing now is very different, where it appears that a new sub variant, not a full new variant. Some would say it is a new sub variant. XBB.1.5 emerged here in the United States. We know that XBB and its precursors actually were around before XBB.1.5 arrived because we actually had a major increase in cases in Singapore earlier this fall with XB. Again, that which was before XBB.1.5. So if you look at this, Chris and I just laid out other variants have originated elsewhere in the world and spread across Europe prior to their widespread arrival in the US. However, this time things are different. XBB Which I think did probably emerge in the northeastern part of the United States, has provided us with a very unique experience.


Michael Osterholm: [00:29:41] In the past, we've had an idea of how a new variant was going to spread across the country and the type of surge we might be able to expect based on what other countries had seen. Of course, I add my caveat in about the alpha and what happened in the United States this time around, Chris. We don't know what's going to happen. We'll XBB just finally melt away, too. Will we see other areas of the country start to note big increases? It surely hasn't caused a major surge of cases in the Northeast as we're now beginning to see the percentage of persons infected. The XBB dropping somewhat there and case numbers are dropping. So does that mean that this was just going to be a transient event and we're done? Well, let me just share from that perspective what we might think about with XBB.1.5. As you noted, it makes up 49.1% of the new US cases as it continues to gain traction. We've seen interesting regional trends. It still remains dominant, though only in the northeastern part of the country. When it first rose to dominance in these regions, we saw reported cases and hospitalizations rise as well.


Michael Osterholm: [00:30:52] With this in mind, I want to draw attention to the large increases in reported cases we've seen in Kentucky and Tennessee over the past two weeks with ZB 1.5 rising in prevalence in the southeastern region, which contains both Tennessee and Kentucky. This may be an indication of what is to come with XBB.1.5 if it makes its way out of that region. I am concerned about what might happen with XBB.1.5 if it continues to outcompete BQ 1.1, which is still the dominant variant in the remainder of the regions of the country. However, the lack of large surges or viral flurries, as well as the slow pace of spread across the country, could be an indication that this variant is even less likely to cause serious illness and continue to spread than we once thought. As far as what is going to happen in Europe and other countries, it's really hard to know, especially because we have yet to see this sub variant story play out across the remainder of the US. This is one of those movies that's going to have a surprise ending, I'm certain, and we can only hope that doesn't end up setting us up for a sequel.


Chris Dall: [00:32:01] Mike, today, the FDA's vaccines and related Biological Products Advisory Committee VRBPAC is meeting to vote on whether to recommend an annual COVID shot for the majority of people and periodically update the vaccine in a way that would mirror how flu shots are updated. Your thoughts on what VRBPAC may and or should do?


Michael Osterholm: [00:32:22] Well, let me start out with a little bit of wisdom, not from me, from some of my heroes of wisdom. Lewis Carroll once said, “If you don't know where you're going, any road will get you there.” And Yogi Berra followed up and said, “If you come to a fork in the road, take it.” To me, I think that's where we're at right now with this issue on vaccines. You know that there's been this great debate about how well is the bivalent vaccine working? Does it produce enough antibody compared to the monovalent vaccine? That was the source of some discussion in our last podcast. I, for one, believe the data were emerging at the time to say that the bivalent vaccine dose does work better. And just in the last day we've had two additional studies, one from the CDC, another one from a colleagues in North Carolina published the New England Journal of Medicine, which really do support that the bivalent vaccine is working better than the monovalent vaccine. But there are some realities. The first reality is we do not know what a correlative protection is. A protection is something you measure in someone's blood to say, okay, I've got this much antibody, you've got something there that we can tie to. If you have this level, you're protected against infection. If you don't have it, you're not. That's the real challenge. We know that these vaccines surely make neutralizing antibody against the spike protein in such a way as is very important early on after you get your dose of vaccine.


Michael Osterholm: [00:33:50] We've also seen differences in what the actual antibody levels look like and then how much protection is provided over the next 3 to 6 months. And for me, I have found trying to debate or discuss even what does it mean in terms of antibody and T cells and so forth among vaccinees, a bit like arguing about how many angels can dance on the head of a pin. We don't know what they mean. And part of the challenge we've had with these debates has been arguing about that when in fact the only thing that really mattered did they actually prevent people from becoming infected or seriously ill? And the study that I just noted out of North Carolina shows that, in fact, the bivalent vaccines do do that. The study out of CDC supports the same thing. The one thing that's troubling to me is at least in the North Carolina study, they demonstrated that by 14 to 18 days out, you started seeing waning immunity. And while there surely was protection even into the 90 day period, it's not clear how long that protection lasts. And I think as much as we've shied away from wanting to compare this to flu vaccine in an approach like we use with flu, that's pretty much what the FDA is really hitting on here with their VRBPAC meeting that will take place later today is should we make this more like flu where we give a dose once a year? Well, there's a challenge with that, and I don't think it's really been understood.


Michael Osterholm: [00:35:18] If you look at influenza, we target vaccine to seasonal disease occurrence, meaning we tell you to get vaccinated in October, November or December, not before. Why? Because you have waning immunity with the vaccine. But if you know that the flu season is typically going to be December, January, February, you can time it in such a way as to try to have the most protection from your vaccine, even if, again, with flu. We don't understand what a call to protection is, but we know that you can surely reduce the likelihood of severe illness, hospitalizations and deaths by having whatever immune protection you get from the vaccine closer to the dose of the vaccine. As you can. Well, I think we're on the same boat with this one. I think that ultimately it's going to be a very similar situation. But the difference is we don't have a seasonal with this disease yet. We don't. It's year round. So do I get my March vaccine for April, May, June? Do I get my January vaccine for February, March, April? We don't have any information to share.


Michael Osterholm: [00:36:24] That allows us to understand that and what's happening here right now and what FDA is proposing, which I understand where they're going from, is that the new plan would basically have the type of virus determined in June, meaning what's this variant that's currently most likely to cause illness and then have the manufacturers make that vaccine and start administering it in August, just as we've seen our seasonal flu vaccines. Now, there have been many of us who have been very critical of that August rollout for flu vaccines and say, no, no, no, put them later into the fall. So even if we do that with the COVID vaccines, does that mean that's when we're going to see this increased occurrence of cases? Remember, we've been averaging 400 and some deaths a week dating way back to March with Omicron. When was the season to have given that vaccine? What should it have been in March? Well, if it only last. A few months. What does that mean? What this all comes to is we are basically trying to describe the elephant all blindfolded and all of us having a different part of it. We don't know what to do for certain. I do believe that boosters will be important. I think they'll be important from a neutralizing antibody standpoint. I'm not sure what they'll do in terms of protection relative to T cells.


Michael Osterholm: [00:37:46] It may be that, in fact, our T cell responses are not going to be as dependent on getting another dose of vaccine. So the point that I just want to make today here is you're going to see people who are going to take very specific positions, yes or no. And I got to tell you, there is no yes or no here. I don't know what to do. I, again, was critical of the FDA when they approved the Bivalent vaccine and did not have any serologic data, only in the sense it would be nice to know it would appear that the vaccine, the new one, was similar to the old one and antibody production. After all I just said about how we don't know what that means. They didn't do that, but I think it was the right decision. They did, as we're now beginning to see the data come forward. And for those critics of Bivalent vaccine doses, I think you're just dead wrong. You're wrong and it's good. But I don't know what the next decision is going to be. Maybe we'll find we have to give doses twice a year. Well, that's not going to happen. You say we don't have the resources. People won't do it. I don't know. But what I really want to emphasize is we're in an uncharted territories, just like I said, about Lewis Carroll and Yogi Berra.


Michael Osterholm: [00:38:58] And we're going to have to be open to new information that comes out. You know, I find myself, if I'm behind by a day in new breaking information, I'm way behind and we'll learn more. So today, when the FDA in its VRBPAC committee makes a decision about what approach to take with COVID vaccines for the future, it's one of those things you got to take some approach. I don't know what the right one will be. I do believe that vaccines will be needed continually for some time to come. I just don't know how to handle it with the seasons. I don't know when best to get it. What happens if we see a new variant emerge that suddenly causes a big surge when we tell people, Wait a minute, don't wait for your booster, come in and get this now. I don't know what we're going to do. So the bottom line is, Chris, I really support that. We have to increase vaccine uptake. I support the fact that FDA is addressing this. But let's not pretend we have more data than we do and just know that we're in uncharted territories, that doing nothing would be wrong. Doing something will get you in trouble. I can only hope that it's good trouble and that what we're doing will protect more human lives.


Chris Dall: [00:40:13] And now it's time for our COVID query. This week, we received a number of questions about an article published in the Washington Post by Dr. Leana Wen, who spoke with infectious disease experts who told her they believed the number of deaths being attributed to COVID-19 is far greater than the actual number of people dying from COVID-19. So, Mike, our listeners want to know if A, you agree with that assertion. And B, if you could clarify the current criteria for death from COVID versus death with COVID.


Michael Osterholm: [00:40:44] Well, Chris, this is really a very important question and a very complicated one. This is an issue of defining whether someone has died from COVID or with COVID. And it is one of the questions we've had since the earliest days of the pandemic. But before I address this, let me just give you an example for which you can think about as we talk about this issue. Imagine, I live in an area I would have said California before, but now with all the rain, I'm not sure that that holds. But I live in an area with dense woods, lots of dead brush in the woods. My house is right in the middle of. It's beautiful. The same area has been in a four year drought. Extremely dry, brittle. And, you know, on top of it, it has very, very high winds right now, 60 to 70 mile an hour winds. And I'm living there every day just doing okay. The wind is surely not helpful, but I'm doing just fine. And then somebody comes along and throws a match into that woods. Before I know it, my house burned down. Now, was that match important? You sure bet it was. Even though there was the high winds, there was the low humidity, there was the drought. There was a dense brush, all which made it more likely that my house would burn down if somebody threw a match there. But that's not what that's not what burnt my house down.


Michael Osterholm: [00:42:09] Well, in many ways, what we're talking about here are underlying health conditions that surely enhance the likelihood that someone may, in fact, die if they get COVID. But in the end, was COVID the event that did it? Was COVID the inciting factor, the match that made it happen? And if it's not, then in fact that means then that COVID would not be part of what we would consider the cause of death or related deaths. So let me just start kind of in a primer 101 on death and how we talk about it here in this country from a public health perspective. In order to understand this issue, I think it's important to take a step back and explain exactly how death certificates work and how causes of death are listed. This is something when I was a state epidemiologist, we dealt with often trying to understand, you know, what was actually happening in our communities. Part one of the death certificate in this country lists the underlying cause of death, starting with the immediate cause of death on the first line and the chain of conditions that directly led to the death below it. For example, a COVID patients death certificate may list acute respiratory distress syndrome on the first line of Part one as the immediate cause of death, followed by pneumonia, followed by COVID-19, as the patient would not have had acute respiratory distress syndrome if not having pneumonia and they would not have had pneumonia if they had not been infected with COVID-19.


Michael Osterholm: [00:43:43] Part two of the death certificate lists all the other causes that may have contributed to their death, but did not directly cause it. This is where we may see things like obesity, heart disease, lung cancer, and other factors that may have contributed to death, but it did not directly cause it. In other words, had a person not gotten COVID-19, that condition would by itself not have killed them. Just like the low humidity, the high winds, the dense brush and the forest never burnt the house down. And so what we have to do is parse that out to understand when is it cause and effect and when is it just an association? I'll talk more about this in a moment. A vast majority of COVID deaths are those in which COVID-19 is clearly the underlying cause of death. Again, this is the cause related to the immediate cause of death listed in the first part of the death certificate. In 2020, this was the case for over 90% of COVID deaths in 2022. Looking at data through September, this was the cause of only 80% of COVID deaths in individuals under 65 and 77% of COVID deaths in individuals 65 years of age and older. So again, about 80% of the COVID deaths that occurred in 2022 were instances in which COVID was considered the main underlying cause of death.


Michael Osterholm: [00:45:04] And this was even higher in 2021 and 2020. Now let's talk about the other 20%, those individuals in which COVID-19 was not an underlying cause of death, but COVID-19 was still listed on their death certificate. I want to first address the false rumors that have circulated throughout the pandemic, suggesting that any time someone dies while infected with COVID-19, that COVID is listed as the contributing cause of death on their death certificate. No matter how unrelated the death is, though, somebody an automobile accident who dies, who happens to test positive for COVID, that's not the cause and effect of COVID is not listed as the cause of death. This has been a piece of misinformation that has been repeated often and often. So it's clear that we are not just labeling deaths as COVID related when they're not associated with that. It's just not true. And in fact, the CDC specifically states that providers should not include COVID-19, a death certificate if it did not cause or contribute to the person's death. So this idea that someone could die of something like a gunshot wound or a moderate motor vehicle accident and be counted as a COVID death is entirely, entirely unfounded and directly contradicts the CDC guideline in reporting COVID-19 and death certificates. But there also is a bit of gray area here that needs to be discussed.


Michael Osterholm: [00:46:27] And this is what Dr. Wynn's article in The Washington Post was really addressing, and that is this idea that for some individuals, underlying conditions who have COVID-19 listed as a contributing cause on their death certificate, they would have died regardless of being infected with the virus due to their underlying cause. So it does not make sense to count them as a COVID death. There are a number of reasons why I fully disagree with this line of reasoning. The first is that it's very rare for only one thing to lead to a person's death. There are usually several conditions and lifestyles that come to play, so it makes sense to count it as a COVID death, even if it was one of the many contributing causes. And of course, the idea that someone is already going to die due to an underlying condition is flawed. When we consider that this statement actually applies to everyone simply due to the fact that we are all human and we're all going to die someday. With that line of reasoning, one could argue that the only valid underlying cause of death to list on a death certificate would be birth. The question is not about if someone is going to die is about when and how, and if someone makes the judgment. Call that COVID-19 should be included as a contributing cause of the death. Then it's because COVID-19 played some role in when and how that person died, even if the death was primarily caused by a different condition.


Michael Osterholm: [00:47:51] If COVID-19 truly played no role, that would not have been included in the death certificate. We're actually learning more and more about these deaths, for example, certain acute coronary events. Now, today we have more data to support that they may be associated with that COVID infection and the THROMBI and the issue of the cardiac arrest due to that aspect of that infection. So whether COVID-19 takes 20 years, two years or two months off of someone's life, if a health care provider believes that it contributed, then it only makes sense to consider that person's death to be at least a COVID related death. To say otherwise is essentially suggesting we can expect patients with chronic illnesses to die suddenly and quickly when the reality is, is that people can and very often do live for many years with conditions like cancer, heart disease and dementia. Part of our goal in public health should be to improve the length and quality of life for individuals with these major chronic conditions, not to treat their lives as disposable. And if they were already ended, most people with these conditions are not minutes away from death. So if COVID-19 accelerated their deaths and that was therefore listed as a contributing cause, then there should be no reason to suggest this isn't a COVID death.


Michael Osterholm: [00:49:08] Again, because deaths can and very often do have multiple causes. Finally, I want to add one other piece that I continue to struggle with, and that is the fact that so many of our health care facilities in this country continue to allow the staff to wear surgical mask or procedure masks, and that is the extent to which they have respiratory protection. Why is that important? Because we know how effective those quote unquote, procedure masks actually are. And we continue to see a subgroup of patients who go into the hospital with a condition and 4 to 5 days later develop COVID. And they may actually get sick enough to die in the hospital from that condition. They say, well, they came in with cancer, but then they died seven days later and it was three days into their COVID infection that they acquired in the hospital. Now, how do you how do you deal with those? Because you could argue, well, when he came in or she came in, they didn't have COVID, so that wasn't the reason they were hospitalized. I think we have to take a much closer look at how many cases today of COVID infection are actually acquired in health care settings, which then could be a complicating factor with some other health condition for which you're actually being hospitalized. And I think this, too, will add to the fact that, again, COVID can be a very important collateral cause of death.


Chris Dall: [00:50:38] Now on to some other respiratory disease topics. What are you seeing in the latest flu and RSV data, Mike?


Michael Osterholm: [00:50:46] Well, Chris, quite honestly, flew in our sphere, continuing to play out exactly as I'd predicted Over the last several episodes. Flu hospitalizations would continue to drop dramatically with the hospitalization rate during the week ending on January 14. Over three fold lower than it was the week before and nearly 11 fold lower than the peak during the week ending on December 3rd. This has turned out to be, as I predicted, an early but otherwise completely ordinary flu year in terms of the amount of transmission and hospitalizations we experienced. This was not an example of a tripledemic, as I've said before. This is exactly what we saw in the southern hemisphere earlier in 2022, where they too experienced record high case numbers and hospitalizations early in the flu year for that particular week of surveillance, meaning that every year, as I pointed out before, we count our weeks of surveillance by week one, first week of January to week 52, last week of December. And yes, if you suddenly see influenza at week 42 in the northern Hemisphere, that's really early. You usually don't see it until late forties or early fifties into the next one, two and three weeks.


Michael Osterholm: [00:51:58] So all this was and I don't say all in a sense that it wasn't still a significant issue, but it was an early flu season that this appeared to be out of whack. But there is a very important lesson here that I fear we have not learned, and that is, is that the number of cases and hospitalizations, while within what we'd expect to see in a typical flu year, it doesn't mean that the impact was not significant. We saw health care systems across the country pushed to their breaking point, trying to keep up with an ordinary number of seasonal flu and RSV cases because of the staffing shortages, burnout and lack of available beds, beds that have actually been taken out of service for reimbursement reasons over the last 5 to 6 years. The influenza numbers haven't changed, but the capacity of our health care system has, and this is just one of the many lasting public health impacts of the pandemic that we will see for years to come that extend far beyond just COVID cases and deaths. We have got to address this issue.


Chris Dall: [00:53:05] We haven't talked a lot about measles on this podcast, Mike, but Columbus, Ohio is currently in the midst of a measles outbreak that started in November and is now affected 85 children. On top of that, the CDC recently released data showing that vaccination rates with the MMR vaccine and other state mandated childhood vaccines continue to decline among U.S. kindergartners in the 2021 2022 school year. Given that context, how concerned are you that we're going to see more of these types of preventable outbreaks?


Michael Osterholm: [00:53:39] Well, Chris, I'm very concerned about these types of outbreaks. And despite the fact that they are completely preventable, I do believe that we can expect to see more and more of these until we get our vaccination rates up. And that could be a real challenge to do that. According to the Morbidity Mortality Weekly report from the CDC that you just mentioned, the vaccination rates for MMR, measles, mumps, rubella, diphtheria, tetanus and pertussis, polio and varicella vaccines for the US kindergartners during the 2021 and 2022 school year were at around 93%. That's down from 94% during the 2020 and 2021 school year and 95% during the 2019 2020 school year. Only 0.2% of kindergartners had medical exemptions for vaccines, meaning that the rest of the unvaccinated children either had a non-medical exemption or no exemption at all. Now, these numbers may not seem like a lot. A 2% drop doesn't seem like, well, that should be a problem. But a 93% vaccination rate and although it may seem high when we compare it to the vaccination rates we're seeing for COVID, this is still a very significant issue. We live in a very connected world. So while these diseases are not common in the US, they can quickly spread from regions where they are endemic, causing a significant amount of illness and transmission. We saw this over the summer with polio and while there's only been one case of paralytic polio associated with polio found in the wastewater in New York, even one case is too many when we have the resources to avoid it.


Michael Osterholm: [00:55:18] And the fact that it's likely that we will see more polio cases because we have this unrecognized chain of transmission we don't know how to break. And of course, as you mentioned, your question, Chris, this is what we're seeing right now in Ohio with 85 children infected with measles, 32 of whom have been hospitalized. 74 of the children infected with measles are unvaccinated. The rest are partially vaccinated or have unknown vaccination status. It's estimated that 95% of the people need to be vaccinated for measles in order to achieve a sense of herd immunity. And this is a perfect example of what can happen when vaccination rates fall below that number. And Ohio isn't the only state that has struggled with measles in recent years. Just last year, right here in Minnesota, we saw a rise in measles cases in unvaccinated children. An 11 month long outbreak in New York in 2018 2019 resulted in over 650 cases of measles. So why have vaccination rates fallen over the last few years, especially in light of the fact that there have been recent measles and polio cases in the US? Initially, this drop in vaccination rates was thought to be due to the result of people avoiding medical care during the pandemic due to COVID concerns.


Michael Osterholm: [00:56:34] While this certainly may still be the cause for some, this situation, I believe, is a reflection of the lost trust we're seeing in vaccines, health care providers and the medical system as a whole. More and more parents are seeing these vaccines as an effective at best and legally dangerous at worst. This could not be further from the truth. These vaccines MMR, Tdap, acellular pertussis, polio, varicella have been long long studied and we know that they have a very high level of safety and they are effective against preventing severe disease and death. And in cases where the vast majority of the population is vaccinated, protecting the population with herd immunity, we need to continue to emphasize the uptake of these vaccines and how important they are. These outbreaks only become more common in the years to come. Children will die. Even adults will begin to become infected and some die. So we have to figure out how to break through this disinformation. The social network world where this myths disinformation combination is common. And unfortunately, this is a challenge that we don't have a lot of answers yet for how to deal with.


Chris Dall: [00:57:51] And one last item here. I cover antimicrobial resistance and stewardship for CIDRAP News. And last week I wrote about two gonorrhea cases in Massachusetts with reduced susceptibility to the last remaining recommended antibiotic treatment for gonorrhea. These are only two cases. But Mike, should this be a warning sign for public health officials about the rising threat of antibiotic resistance?


Michael Osterholm: [00:58:13] Well, before I comment on this, I just want to share with the audience that Chris is actually one of our star reporters at CIDRAP News who specializes in the era of antimicrobial resistance. And if you don't read his work, you should. It's up every day. And it's some of the very, very best reporting in the country on COVID resistance. So, Chris, I should almost be asking the question and having you answer it, But let me just start out by providing some context here. Antimicrobial resistance is something that goes back to the earliest of all microbes. They have fought with each other for food and space. And to do that, they actually experience a whole series of mutations for which many which are fatal to the bacteria or the parasite or the virus even. But for some, it actually lends itself to better survival. So in fact, I put out a toxin or a chemical that kills the bacteria next to me because it destroys their cell wall. And now I have, Wow, look at me. I can survive and do just fine. That's the very essence of antimicrobial resistance, because it may be that that same chemical goes at the antibiotic that we're using to kill that bacteria, and it prevents that bacteria from being destroyed because of the actual chemical that it produces or any other aspect of what these mutations do. And to give you some sense of where we're heading with this.


Michael Osterholm: [00:59:40] Make no mistake, my grandparents and great grandparents grew up in a pre-antibiotic era. When a puncture wound in your arm, a sore throat, a scraped knee could all lead to death easily. And it did. I mean, think about this. In 1900, in this country, average life expectancy was 48 years. Today, even with COVID at 76 years, roughly every three days we've lived, we've gained a day, a life expectancy that goes all the way back to the caves. It took us from the caves to 1900 to get to 48 years. Now, much of those gains were made around public health, safe water, safe milk supply, safe food. It vaccines and antibiotics. Antibiotics played a key role. So imagine now going from a pre antibiotic era to an antibiotic era that I've been able to grow up in where I took for granted. Those very things I just talked about that could kill you. And just know that our younger generation, my grandkids, who is anybody listening to this podcast know they're everything to me. They're likely to grow up in a post-antibiotic era. That's challenging. Why? Because we keep seeing the use of antimicrobials that are now very high rate around the world, often indiscriminately without actually related specifically to the kind of treatment that should be delivered. And we are just giving these microbes every additional ecological advantage to mutate, to evolve, to change, and to become resistant.


Michael Osterholm: [01:01:20] The sobering note I wanted to mention was a report that was done in published in 2016, led by Sir Jim O'Neill, who is a famous UK financier, brilliant brilliance man in many ways, who led this incredible study done by the UK and Wellcome Trust, which they looked at antimicrobial resistance and project it. And the numbers are holding true that by 2050 worldwide, over 10 million people would die not from just an infectious disease, but an infectious disease that was so resistant to all the treatments we had. That's why they died. 10 million rejected age adjusted improvements in care. 8.2 million people will die from cancer. 1.5 would die from diabetes. More people will die from antimicrobial resistance. So this is a critical issue and one of the reasons why CIDRAP put so much time into this, we actually have an antibiotic stewardship program trying to lessen the use of antibiotics unnecessarily so that we don't continue to accelerate this resistance issue and that we try to save them for as long as we can to be most effective. And Chris, your reporting on that is remarkable. So what you just shared with me, though, was this these two cases of gonorrhea in Massachusetts that basically virtually are almost untreatable. This is one of many warning signs of the threat of antibiotic resistance. Another issue that has just so worsened during this pandemic because of our wholesale and often unsubstantiated reasons for using antimicrobial agents.


Michael Osterholm: [01:03:00] This novel strain of gonorrhea that you mentioned showed reduced susceptibility and resistance to several antibiotics, including reduced susceptibility to ceftriaxone. This is particularly alarming because, as you mentioned in your question, Chris Ceftriaxone is the last remaining recommended antibiotic treatment for gonorrhea. Fortunately, the standard 500 milligram Intramuscular Ceftriaxone treatment was effective for the two identified cases. But this won't be the case for all future patients. We have to understand that these two cases were detected through public health surveillance and were not epidemiologically linked, meaning the patients did not know each other, have no contact with each other, which means that there's also certainly other cases of this strain circulating in the Massachusetts area. A similar strain has been detected in Asia and the United Kingdom. And since this antibiotic susceptibility testing is done at public health labs and not directly by health care providers, providers cannot be certain that ceftriaxone will work for their future patients At the time that is prescribed. For many, the treatment may still be effective. Again, it was for these two patients in Massachusetts, but for more and more patients, this treatment may be unsuccessful. Imagine untreatable gonorrhea. This could cause a number of long term health consequences, especially for individuals that are pregnant or who may become pregnant in the future. And of course, this issue is much, much bigger than just gonorrhea.


Michael Osterholm: [01:04:30] We are now seeing standard treatments become ineffective for more and more pathogens and increased antibiotic usage during the pandemic. And as I said, that is only accelerated with the pandemic. We have experienced a pre-antibiotic world full of illness and mortality. And I fear that we is just another sign that we're getting closer and closer to that post-antibiotic era that I talked about and all the consequences that will come with it. Finally, for any listeners who find this topic particularly interesting, I do want to remind everyone that CIDRAP has a podcast called Superbugs & You. That covers antimicrobial resistance, including stories from patients, physicians and researchers from around the world. Episode eight The Clap Claps Back resistant gonorrhea includes interviews of clinicians and drug developers discussing concerns and promising research related to antibiotic resistant gonorrhea. New episodes of Superbugs & You will be released in mid-February of this year on topics including Acinetobacter and Candida auris, the fungal disease that we are so concerned about. So, Chris, in short, this is a huge issue. It's another reason why CIDRAP has continued to put so much effort into this area. And we don't have the luxury of just concentrating on one disease like COVID. The single view of that one disease, all of this is happening at the same time and again for our loved ones. That's why we have to work on all of it together.


Chris Dall: [01:05:59] Mike, what are your take home messages for today?


Michael Osterholm: [01:06:04] Well, I feel like some people could probably fast forward through this because they seem to be repetitive over the course of recent episodes. One, when people ask me, what's this pandemic going to be like in 6 to 12 months, I say, Well, I'm not quite there. I can't tell you. Well, then they say, “Well, tell me about 90 days.” And my next reaction is, How about if I give you nine days and I'll try to stick with that one? I don't know what's going to happen. The XBB.1.5 we just talked about, will it play out in this country? Why are we seeing what we're seeing? I noted earlier that seasonality is not an issue with this virus infection. If you look at the recent epidemiology of COVID in New South Wales, that area around Sydney and Melbourne, it was identical as happened in New York at the same time. Is that seasonality? No. So we don't know what's going to happen. All I can say is we will continue to keep you updated and that you can still do so much to protect yourself even with that. Second point is, just understand we are on a vaccine journey. We're learning. When I describe for you what VRBPAC is doing and trying to find a way to use vaccines going forward, is it every year whatever we are learning? And don't be surprised if we have some starts and stops and that we end up changing recommendations based on new and important information. That's not being wrong.


Michael Osterholm: [01:07:31] That's not being wishy washy. It's saying as we get more information and how to better use these vaccines, we will in fact share that with you. Now, the challenge, of course, will be getting people to use the vaccines. And we know that that is real. And finally, I come back to that same point week after week after week. And this is particularly true for those that I dedicated this podcast to us, the people at increased risk because of age or underlying health conditions. Please, please be current on your booster. Get it. Number two, if you do become ill, make sure you get early care and make sure that if you are able to take packs of COVID, you take that. If not for other medical conditions or other drugs that are not quite as effective but still can be used, get treated quickly. And then finally, if you're in public places that in 95 respirator tightly fitted to your face can be a lifesaver. I don't go anywhere without mine in public spaces, and I've grown so accustomed to it. It's just like putting my glasses on. So again, if you do those three things, you can do so much to continue to live your life and yet be protected against those virus as we're trying to understand where it's going to take us next. So those three points don't know where we're going. Vaccines are journey and you can do a lot to protect yourself. To me, those are my take home messages.


Chris Dall: [01:09:01] Our listeners might be wondering what happened to our Beautiful Place segment this week? Well, today we're combining with our closing thanks to a listener who sent a picture of their beautiful place, along with a really lovely poem about one of our favorite topics. What can you tell us about it, Mike?


Michael Osterholm: [01:09:18] Well, let me provide the combined effort here that Bev from Green Valley, Arizona, shared with us. Bev, thank you so, so much. Your beautiful place is just that You wrote to us and you said Dr. Osterholm and staff, Happy Winter Solstice. This was sent to us in December. You said, “We so appreciate and respect the public health work you continue to do. We have listened to your podcast earlier from the beginning. They keep us informed and we're thankful for your honesty. And even though we are now residents of Arizona, we do like hearing about the light in our native state of Minnesota. That was very kind to share with us a picture of her area in Arizona, and it is absolutely stunningly beautiful. I hope you go to the website and take a look at the link to the picture. And then finally, she shared with us a poem that I think is absolutely wonderful for the time and in light of the light. So here it is from Stephanie Lehr, a poem suggested to us by Bev. May you find peace in the promise of the solstice night that each day forward is blessed with more light. That's the cycle of nature. Unbroken and true brings faith to your soul and well-being to you. Rejoice in the darkness, in the silence, find rest and may the days that follow be abundantly blessed. Stephanie Lare” Thank you Bev, for that wonderful, wonderful combined gift of the beautiful place and the poem. I can surely identify with that light. Trust me, I can. I want to thank all of the listeners today to the podcast family.


Michael Osterholm: [01:10:55] Thank you again. Your cards, your letters, your notes mean so much to us. We read them all. We listen to you. You help make us better. You help make us a lot better. And again, to all those that we dedicated this podcast to, we're with you. We're thinking of you. You are not disposable. Not at all. We realize we have a challenge ahead of us yet of trying to figure out where we're at. Is the glass half empty? Is the glass half full? Does the glass hold water? We don't know. And we're trying to find that out. But in the meantime, the one thing that we can do and must do. Be kind. It's a tough, tough time. Be kind. And for those that take the current time with COVID, as if just an insignificant event, when you don't feel bad about that for yourself. You don't have to. You want to protect yourself. At the same time, if you can participate in everything out there, if you want to go to a movie, you want to go to church and you where you're in 95, do it, feel empowered, get that vaccine. But in the end, also be kind. Right now, that is the one thing I think this whole world needs more than anything. So thank you for being with us again. We'll be back in two weeks. We look forward to sharing this time with you. Thank you so much. It means the world. Thank you.


Chris Dall: [01:12:21] 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 for donate. The Osterholm update is produced by Cory Anderson, Meredith Arpey. Elise Holmes, Sydney Redepenning, and Angela Ulrich