February 9, 2023

In "Taking Long COVID Seriously," Dr. Osterholm and Chris Dall discuss the trajectory of the COVID-19 pandemic in the US and around the world, review the evidence on long COVID, and provide some perspective on H5N! avian influenza.

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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 COVID-19 cases declining in the United States and around the world. There's an increasing focus on how we move beyond the acute phase of the pandemic. Well, the World Health Organization recently said COVID-19 continues to constitute a public health emergency of international concern. The agency also said the pandemic is likely in a transition point to a new phase. Last week, the Biden administration announced it would end the public health and national emergencies for COVID-19 on May 11. And as we discussed in our last episode, the FDA's Vaccine Advisory Committee has begun a series of conversations about a possible shift to annual COVID shots. Is that simply an acknowledgment by public health and government officials that the public is done with the pandemic, or are we truly in a new phase? That's what we're going to be discussing on this February 9th episode of the podcast, as we assess the state of the COVID-19 pandemic in the US and around the world. We'll also discuss what came out of the recent Vaccine Advisory Committee meeting on COVID vaccines and what comes next. Continue a conversation on COVID deaths. Look at a paper on the mechanisms of long COVID and address a recent article on the threat of bird flu. We'll also share a beautiful place 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: [00:01:58] Thank you, Chris. And welcome back to all of you who are part of the podcast Family, a group that we dearly and deeply appreciate. I hope that we're able to provide you with information today that will be a reason for you to want to come back again. And for those who are on for the first time, I hope that the same is true, that we can provide you with the kind of information that you find helpful. Surely this podcast has a few different pieces to it in terms of the data versus sometimes the feelings where we might be going, where we have gone, what it means. So but the bottom line message is we're so very, very glad that you're with us. We feel very fortunate to have this opportunity to reach out to so many of you. And I just want to say on behalf of the entire podcast team, thank you. Thank you. Thank you. For those of you who reach out to us with emails, cards, letters, any number of different ways to share with us what you're experiencing with this podcast, what it means to you in terms of trying to deal with COVID on a day by day basis. And just the entire confusion that many of us are living in right now. What does it mean to live in a COVID world? Is it a post-COVID world? What does it mean? And today we're going to try our best to really address some of these very issues.


Michael Osterholm: [00:03:12] And I say that as someone personally who is trying to address that. So I'll share my journey with you and that of our team to better understand what it means today to be living in this time of COVID. Today's dedication reflects, obviously, the current events of the moment. The world suffers. Many people in this world suffer every day, and we don't want to somehow prioritize one suffering over another. That surely is not the intent here. You cannot help but be incredibly moved by what we've been seeing in Syria and Turkey With regard to the earthquake. It's estimated that today that over 11,000 people have died. And I just saw one potential estimate going forward that it could be as high as 20,000 people have died in the earthquake. We know that rescuers are doing everything they can. It is a challenge and challenging situation, and particularly in an area with earthquakes where there could be aftershocks that could also, again, even put the rescuers in jeopardy in terms of their safety. Our hearts go out to all of you who are suffering in that terrible, terrible earthquake area and for that matter, anyone who is suffering right now because of some adverse event politically, geologically, however, a hard time.


Michael Osterholm: [00:04:30] And for all those individuals who are suffering from the earthquake, we dedicate this podcast to you. And for all of you who are routine listeners to this podcast, you know that we couldn't have an episode without somehow addressing the issue of light. And I have to say, I get many wonderful emails about this, some of them very technical and well written and a real learning experience for me. I feel like I'm almost becoming more of an expert on global daylight nighttime. But today, on February 9th, I'm happy to report here in the Twin Cities of Minneapolis St. Paul, Minnesota, we are now seeing 10 hours and 9 minutes and 32 seconds of sunlight. Sunrise today is at 720 to sunset at 532. We're gaining almost 2 minutes and 47 seconds a day right now of sunlight. And it won't be long until we hit March 21st, when in fact, we will have maximum increase in sunlight as we hit that very, very important spring date. And on March 21st, we will see sunrise at 714 that day and sunset at 726, 12 hours and 12 minutes of sunlight and think that's just six weeks away. Now, I have to comment also on a part of the sunlight that was challenging, and that is with regard to our friends in Auckland.


Michael Osterholm: [00:05:50] Many of you know, if you've been listening that I have a very near and dear special spot in my heart for my colleagues and friends in Auckland. And from a standpoint of sunlight today, on February 9th, they all have 13 hours and 40 minutes and 20 seconds of sunlight and they're losing about 2 minutes and 6 seconds of sunlight a day. But my comment about them today that is really an expression of support is the fact that on Friday, January 27th, and then going into Saturday and the 28th, they received over ten inches of rain in a very short period of time and had major flooding throughout the city. Seeing the shot of the Auckland airport with four feet of water in it basically was shocking having been in that airport and can't even imagine what the entire area around must have been like to be flooded. I'm happy to report that the information I have on my dear colleagues at the Occidental Belgium beer garden on Vulcan Lane was that they did have some water, but not anything serious. And from that perspective we're happy for them. But again, meteorological events aren't something. But you can still count on that sun. It will rise and set on its schedule. And that one you can count on.


Chris Dall: [00:07:05] Mike, we've obviously been following China closely since it dropped its zero COVID policy in December, but it appears the surge of infections in the country is now on the decline, with the caveat that will never really know how bad the situation has been in China. Do you think the country has seen the worst of it for now?


Michael Osterholm: [00:07:24] Well, first of all, as you mentioned, Chris, it's really been quite difficult, if frankly not impossible to determine where exactly China stands with COVID, at least in a comprehensive manner, as we have shared with our audience here over the course of the past several months, we've had multiple contacts in China from both a business perspective, reporters, as well as academicians who have been feeding us information about the circumstances in China. And to say that they are dire is an understatement. Again, with the overall lack of real time data from many parts of the country, we're basically left with on the ground reports, as I said, various anecdotes and some estimates of what might be happening given what we've seen the virus do elsewhere. So it's a piecemeal system that many of us are relying on. And as I've said in the past, there have been those times where it felt more like a guessing game than it did some kind of scientific based evaluation. However, despite that reality, I don't think it's unreasonable to assume that many places in China have hit a peak and are now seeing activity decline. I, for example, am aware of several private sector companies in China who actually went for several weeks with doors closed, not because they were made to shut down because they had no workers. They were home sick. It was remarkable. And now they're back open up and running. I think this is an indication that for a number of areas in China, we've actually seen activity literally ripped through those areas and now is on the way down at this point.


Michael Osterholm: [00:08:52] It's now been almost two months since they dropped most of the zero COVID restrictions that they previously relied on in China. And basically with such an extremely infectious version of the virus in Omicron and letting it loose in such a large, highly susceptible population meant there was simply unprecedented transmission. We have not seen this kind of transmission at any time in the pandemic, in anywhere in the world except in China. They were a tinderbox waiting for someone to throw a match. So given those conditions, I think it could have easily burn through different parts of China quite rapidly. And as the Chinese report the number of cases dropping in many regions, I think that's probably true. In fact, we saw a similar situation play out last year in Hong Kong when they experienced a record breaking Omicron wave with activity bubbling up for a bit before suddenly spiking straight up and then reaching a peak almost a month later. Now, obviously, comparing a city such as Hong Kong with an entire country, in this case, China isn't exactly apples to apples, but at the very least, it's something we've seen before. So I'd like to think that the situation is improving across China. Now, that's not saying they're in a good spot. I think their overall numbers are still very high, especially relative to what we've seen in previous points in the pandemic. For example, air Affinity, a health analytics firm based in the U.K., estimates that as of this past Tuesday, February 7th, daily deaths in China stood at about 27,000.


Michael Osterholm: [00:10:19] That's 27,000 deaths per day. Now, overall, that's actually down from the peak estimates of 35,000 deaths a day in late January. But again, reaching a peak still means that there's a recovery phase ahead. And I think that's what most parts of China are currently dealing with. One footnote, a paper published this week in The Lancet from a group of Chinese researchers suggested that at least through the end of December, there was no evidence of any new variants that we would be very concerned about if they were then to spread around the rest of the world and what they might do in terms of transmission, potential immune evasion, etc.. So that's good news. We still will have to wait and see how it looks in another month or two where they have, in this case, more weeks of experience with the widespread transmission. But at this point, at least, we have no evidence that new variants have emerged. So is the worst over in China? Well, in terms of this recent COVID surge, I certainly hope so. I can imagine that health care systems throughout the country have been under immense pressure, and that's obviously not sustainable. In fact, the same thing could be said for their funeral home workers who also have experienced the same kind of surge. Otherwise, as far as your question goes, Chris, I think the key words are for now. Yes, current declines are really very important, but what's ahead? To me, that is the challenge.


Chris Dall: [00:11:40] Can you give us a quick update on the rest of the world? Are there any hotspots we're seeing?


Michael Osterholm: [00:11:45] Well, you know, it's very interesting that as you think about COVID, over time, we are all influenced by having experienced some very, very bad days in COVID and then some better days and COVID. And as I've said time and time again, we all are living in a world of shifting baselines. Remember when 450 deaths a day would be considered absolutely horrible? But then that was in comparison. Then one day to 3300 deaths a day. And we thought, “my, what great success we have.” So as I share this international update with you, I'm kind of caught in this shifting baseline world, you know, what's happening, what does it mean and what's going to happen in the future. So as you know, we just got done talking about China and some of the challenges we've had in getting data. But honestly, even outside of China, I think we're dealing with similar issues, meaning the data or the official numbers just don't necessarily align with actually happening on the ground. We have major surveillance fatigue for all aspects of COVID infections in any country. Again, it's that iceberg effect I mentioned in the last episode where we're basically seeing the very tip and have to use that to try and interpret what we're actually doing with under the water level. Of course, one could argue that this has been true since the earliest days of the pandemic, and in doing so, they would at least be partially right.


Michael Osterholm: [00:13:06] But there has been a time when we made every effort to count as many cases as possible and to identify them in such a way that we could actually describe who's getting infected at what time and where and how. But with the ongoing rollback of PCR testing, increased emphasis on at home tests which go unreported, as you know, and general dismantling of different programs we use to monitor the virus is becoming more and more difficult to know what's going on, just not in the United States, but throughout the world. So with that in mind, let me just share the global numbers as a whole. In terms of cases internationally, we're seeing roughly 203,000 being reported on a daily basis. That's less than half the levels being reported a month ago, in this case early January. And when taken at face value, it's actually the lowest average documented number of cases since July 2020. But again, I take this one with a grain of salt. Otherwise, in terms of numbers that may be more meaningful, think about it. With the deaths, we're seeing 2100 being reported each day. At the same time, we know there's tremendous abnormalities with these numbers, too. Given that, obviously they don't align with what's happening in China. That said, in my best attempt to read between the lines and make sense of what's happening, I have to say I still think many parts of the world are in this ebb phase as to why that's the case.


Michael Osterholm: [00:14:28] I'm not 100% sure. For the time being, we haven't necessarily seen XBB.1.5 growth associated with obvious surges in activity. So that's good. But as always, it's a confusing time. Again, some of the numbers being reported in certain Scandinavian countries like Sweden have really kept my attention with cases more or less staying flat, but deaths basically at an all-time high. Now, what's the cause? Why is that happening? I'm not sure. Could it have something to do with testing levels? Maybe. Could it be related to reporting? Possibly. Who knows? But I'm hoping for some more clarity there in the days ahead. Not just in Scandinavia, but throughout and all over the world. Otherwise, there are some early signs and other bump in activity in the UK with both cases and hospitalizations on the rise. And that's something to keep an eye on as well. In summary, we could certainly be seeing this ebb phase. In other words, going off the high plains plateau to someplace we've not yet been to since the beginning of the pandemic. But I have to explain right now with clarity and declaration, my crystal ball is now caked with five inches of concrete, not five inches of mud.


Chris Dall: [00:15:41] Here in the US, conditions are improving across most of the country, with reported cases and hospitalizations, both falling by more than 20% nationally in the past two weeks, according to the New York Times. Mike, is it safe to say that the XBB.1.5 subvariant has not really been a game changer, at least in this country?


Michael Osterholm: [00:15:59] Well, Chris is clear that we have not seen major surges in case activity, including severe illness, hospitalizations and deaths with XBB throughout the country. We are seeing some creeping up of cases that may reflect XBB activity, but at this point, it's fair to say it's surely not been a surge. So I wouldn't say in the US we're quiet. We're not. We're still really hung up in what I almost call this high plains plateau level of cases. Today we're going to be reporting out over 450 deaths. Again, we have been stuck in this 380 to 550 death range now for almost 12 months. That's remarkable. So as you mentioned, Chris, COVID numbers continue to decline across the country in terms of overall number of cases and hospitalizations, which is a good thing. Clearly, I don't really put a lot of faith in the case numbers, as you know. And hospitalizations are important. But at this point, it's also clear that the deaths are still staying up. So this is really a question we have to ask ourselves, why is this happening? I'm going to comment more on this, where we're going with COVID and at least what should we consider about how we're going to live with COVID going forward? In a latter question.


Michael Osterholm: [00:17:12] But, suffice it to say right now that we are still seeing XBB.1.5 subvariants emerging throughout the country, but not at explosive levels. And even if you look at the number of deaths, there's not a clear pattern in terms of geographic distribution. The five states by the actual incidence of deaths due to COVID in order, Virginia, Wyoming, Massachusetts, which by the way, has the second highest rate of vaccination in the country. Florida, Oregon and New Mexico. What's common about those? Nothing. And so I think it's clear that as a regional pattern, we have nothing right now that we can actually hang our hat on and say this is what's happening and we're just going to have to wait and see what the next step will be with this virus in terms of US based incidence. But for right now, it just unfortunately continues with these number of deaths to be in that high plains plateau.


Chris Dall: [00:18:10] On our last episode, we previewed the meaning of the FDA's Vaccines and Related Biological Products Advisory Committee. So one follow up on that. The news out of that meeting was that VRBPAC recommended that going forward, the Bivalent version of the COVID-19 vaccine should be used for the primary vaccine series and booster shots. But there is a lot of discussion and disagreement about a shift to annual COVID-19 vaccine shots and a regular system for gauging when vaccine composition changes are needed. So, Mike, this is an ongoing conversation, but what did you make of that meeting and this idea of trying to streamline when we get boosters?


Michael Osterholm: [00:18:46] Well, it's fair to say that we right now are in a period of uncertainty and discovery. What I mean by that is we're all trying to figure out how to best use the vaccines that we currently have. What can we do to protect the most number of people? So let me just start out by saying I applaud the FDA for approaching this issue. And also, let me be very clear. I am not a disinterested party here. As someone who's almost 70 years of age, who's now been six months, that he got his initial bivalent booster dose, I want another one now. I don't want to wait until next October. And I base that on the best science that I know in terms of protection against severe illness, hospitalizations and deaths. So what is behind this current effort by the FDA to incorporate COVID vaccination into seasonal flu schedules? And I can see what they want to do. They want to try to normalize how we use this vaccine on a routine schedule so people don't feel confused. But we're not there In order to actually use the vaccine in conjunction with flu, vaccination has to assume that there is a seasonality to this disease. And in fact, there is not. The reason we vaccinate when we do and how we do for influenza, we can pretty well predict that between end of November, early December to the early part of March is when flu season is likely to occur. Now, this year, we surely had a very early season compared to the last 20 years.


Michael Osterholm: [00:20:17] But generally speaking, we can time the vaccine to be given within weeks, no more than a few months before the season is upon us. Why is that important? Because we know with influenza vaccine you may lose up to 15% of the protection of that vaccine each month following its injection in you. And you don't want to be caught short because it was six or eight or ten months ago that you got vaccinated. So just think that's why we can do seasonal flu vaccine is because we can predict with some certainty what will happen. Well, now, if you look at what's happened with COVID and you look at surges in hospitalizations rather than just cases to minimize the potential impacts that testing availability had in these trends we've seen multiple times a year in various months. April 2020 July 2020 January 2021. September 2021, January 2020 to July 2022 and now January 2023, where we've actually seen increases in hospitalization, suggesting some kind of a surge. If you look at the idea of seasonality from just the standpoint of a northern to southern hemisphere issue, which of course should be the telltale indication that this is seasonal. I've been following closely the epidemiology of COVID in New South Wales, in Australia, Melbourne and Sydney for the last 12 weeks, and it's virtually been identical to the epidemiology of COVID in the northeastern part of the United States.


Michael Osterholm: [00:21:48] Is that seasonality? No, I don't think so. So the challenge we have to ask ourselves is do I want to get a COVID booster dose? Say, for example, in October, maybe even as early as September, and actually not have the next surge occur until April or May of the following year. So to me, that's just not going to work. Now, I don't have great options here, so I have to be somewhat timid about my comments because I wish I did. I would like to be in a position based on everything I know about the vaccine to get a bivalent dose or whatever vaccines we're going to use twice a year. I think the data can do support the fact that with the waning immunity you get with at least the neutralizing antibody that once every six months would be a real benefit. Now, I know that does not take into account the T-cell immunity, which may actually still be very, very important and not be dependent on being vaccinated more often. So will a two dose schedule be something that might be reality? I don't think so. I think that people will find this far too confusing to when do I get it? How do I get it? Every six months. But I think the biology tells us that's what we should be doing. On the other hand, I also recognize it's hard enough to get people in for one booster dose. Right now, only 40% of those who are 65 and older have gotten a booster dose, which we know can provide incredible protection against serious illness, hospitalizations and deaths.


Michael Osterholm: [00:23:17] Why have we had such a problem getting that other 60% to get their bivalent vaccine dose? So now, if I'm adding in two doses a year, you know, at some irregular interval in terms of what your health care might be, meaning it's not like a full flu vaccine does a type thing. What's going to happen? I don't know. But I think what we have to do is just be honest with the public. Don't try to make this into a seasonal disease when it's not that yet. Maybe it will get to be one day, maybe one day. This will just look like an. A Windsor, but it's not there yet. And we just need to tell the public. We don't know. We have to tell the public. Yeah. Maybe you would like two doses a year. And I know many people on this podcast listening are like me. They want their second dose because it's been six months or more. So I think at this point, I hope that the FDA is hearing this, that they're realizing they just can't go ahead and make this a seasonal vaccine approach just because they want to in terms of trying to minimize confusion with other vaccines like flu. But right now, if I wanted to get my maximum protection, I do believe I should get a dose every six months.


Chris Dall: [00:24:24] On our last episode, we also discussed a recent Washington Post article that suggested COVID deaths are being over counted in the US. Since then, the CDC's chief medical officer has written a response in the post titled “COVID Deaths Are Not Being Over Counted.” Mike, Is there anything you wanted to add to this conversation?


Michael Osterholm: [00:24:43] Well, I can say that I have personally looked into this issue extensively and have really tried to understand how deaths are counted, whether that occurs at the local level by the physician who signs a death certificate, how state health departments collect that information and move it on, how it's reviewed in terms of looking at causality versus just association. I think, again, the examples we used last time was, you know, if you're an automobile accident and you die from that, but you also happen to be COVID positive at the time, you know, that's not COVID. But I thought that the response that Dr. Deborah Houry provided to the Washington Post and as you noted, she is the chief medical officer of the CDC, was very thoughtful. And it really does lay out that accurate, transparent and accessible data is critical to understanding any illness, notably COVID, and that more than 1 million people have died from it. And how that definition of died from it was actually arrived at. So I'm very confident and comfortable with this. Now, I think that there are additional questions that come up because in fact, in articles that have appeared recent in New York Times questioning why do we see all these excess deaths that occur that have been actually labeled excess excess deaths that tend to occur around the time that the COVID surges occur, meaning they're not attributed to COVID, but yet they appear at the same time that the big surges occur. And in a future podcast, we'll address that. But I think for now, suffice it to say, despite conspiracy theories, despite people believing that somehow the books are being cooked for whatever reason, they're not. And what we must never forget, and this is a part of this podcast that I hope everyone listening never forgets, these numbers are actually real people. There are fathers and our mothers, our grandparents, our brothers and our sisters, our colleagues. These are real people. And every time I deal with all of these quote unquote numbers, I always am very uncomfortable with the fact that we sometimes gloss over that there are actually real people behind each one of these.


Chris Dall: [00:26:53] Mike, as you know, many of our listeners remain very concerned about long COVID. There's a paper that came out in late January in Nature Communications titled “Long COVID Major Findings, Mechanisms and Recommendations.” What did you learn from this paper and what can you tell our listeners about it?


Michael Osterholm: [00:27:09] Chris, it is so clear that long COVID is such an important part of this pandemic. Just from the cards of letters, the emails that we get from people who are suffering miserably with long COVID. We hear you. We understand this is real, but this is a real challenge for you. And frankly, it's my greatest fear because I have my full doses of vaccines on board that I can get. I have access to COVID. My biggest concern is not dying at 70 years of age. It's getting long COVID. And to me, that is something I know many people who listen to this podcast either are experiencing right now or they're concerned that they might experience it. So let me just say that this paper that you referred to actually authored by Hannah Davis, is the first author, but the senior author was my dear friend and colleague Eric Topol, who I believe is one of the most brilliant minds in the entire pandemic response. You might say I'm biased up front. I put that out there. But this is really an excellent review on long COVID, and we have linked it to the website, so you'll be able to go back and pull that off and read it yourself. Some cases a little bit technical. For some of you who are not medically trained, but I think you'll get a good sense of it. For listeners who are interested in this topic, I absolutely urge you to read this. It's incredibly detailed and it has a lot of good references where you can dig even deeper into the evidence for the sake of time.


Michael Osterholm: [00:28:37] I can't review everything that was covered in the paper, but I think there are three major takeaways I think we can highlight. One is that long COVID is complex variable in individuals and impacts multiple body systems. Second is that long COVID shares some similarities to other post-viral conditions. There's a great deal we can learn from findings in that space. Finally, we need to take long COVID patients seriously. And when you read this paper, you can come away understanding just how significant the illnesses are among these individuals. The paper, based on a series of other studies, have estimated there are at least 65 million individuals who have experiencing or are currently experiencing long COVID. At this point, researchers have identified more than 200 symptoms associated long COVID that impact a wide variety of body systems, including the immune circulatory, neurological, respiratory, gastrointestinal and reproductive organs. That's an amazing array. For a deeper dive on some of the cardiac complications associated with long COVID. We did cover an article in Nature Medicine and Episode 118 of our podcast back in November 2022 entitled “A Time to Be Thankful but Alert.” However, having cardiac complications is not rule out involvement of the other organ systems. A smaller study with this review found that up to 59% of the study participants of long COVID patients had evidence of single organ damage, while 27% displayed multi organ damage, including kidney, spleen, lungs, pancreas and liver. When you compare across body systems, the timeline for symptoms is variable. On average, neurological symptoms tend to have later onset weeks to months after infection and persist longer compared to other symptoms.


Michael Osterholm: [00:30:28] In contrast, respiratory and gastrointestinal symptoms are more likely to begin with acute infection and then resolve more quickly. My second major takeaway from this review is that there is a great deal we can learn about long COVID when considering the other viral onset illnesses. Long COVID is not the only condition that appears after infection with other pathogens. Other examples include Myalgic Encephalomyelitis, (ME), Chronic Fatigue syndrome (CFS), and Postural Orthostatic Tachycardia Syndrome or POTS. Each of these conditions result in significant impairment is incredibly variable by the individual and can involve multiple organ systems. There are numerous physiologic similarities between these syndromes and long COVID include mitochondrial dysfunction, neural inflammation and altered fatty acid metabolism. We also see reactivation of herpes viruses such as Epstein-Barr or varicella zoster, commonly known to cause mononucleosis and chickenpox. I think it's really important to make these connections with other syndromes for a few reasons. One is that we may be able to harmonize research efforts regarding neuro immune illnesses, why they occur and how to diagnose and treat them. Breakthroughs and understanding long COVID could be critical for patients long suffering with these other conditions. Another reason to consider these conditions alongside long COVID that they share symptoms and may be able to share therapies. While these viral onset illnesses do not have a cure, there are a number of medications and strategies that could help relieve symptoms that may prove effective for long COVID patients. As. Well, finally, I think this article emphasized the reality of long COVID and the need to take these patients seriously.


Michael Osterholm: [00:32:16] Unfortunately, another similarity of long COVID with conditions like CFS and POTS is that patients can be brushed aside or told it's all in your head. One study included in the review noted that 80% of patients with POTS receive a diagnosis for a psychological condition before receiving a diagnosis. Only 37% continue to meet criteria for the psychological diagnoses once they have received the POTS diagnosis. This demonstrates that patients seeking help were fatigued, worried, experiencing pain. Like some of you listening to this podcast are aren't always receiving the type of care and attention that you need to get to the root cause of this issue. This review clearly demonstrates that long COVID involves very real changes to the body that can be seen with laboratory and imaging studies. However, the variability in each patient's manifestation of the illness makes it very difficult to provide strict diagnostic criteria that applies for everyone moving forward. I'm hoping to see additional research shine on diagnostics and therapies to better identify and treat long COVID. And certainly my greatest desire is to see a reduction in circulating virus so that fewer and fewer people end up experiencing COVID infection and long COVID in the first place. Even if you haven't had long COVID again, I urge you to take a look at this paper. I think it is a very, very important piece in the entire COVID pandemic, and it's one that is addressing a very critical and largely unmet need issue. Long COVID.


Chris Dall: [00:33:52] Because of the concern about long COVID. Some of our listeners were puzzled by a comment you made on Meet the Press recently and have asked for some clarification. You said to Meet the Press host, Chuck Todd. My goal is to see everyone get COVID twice a year in this country, but have it be nothing more than a common cold like illness. That would really be a victory. Mike, what did you mean by that?


Michael Osterholm: [00:34:14] Well, I have to admit that did elicit a fair number of responses to that comment. So I want to go into some depth here. And again, this addresses really the whole issue of how we should be talking about or looking at the pandemic. Well, first of all, let's be really clear. This virus is not going to go away. It is going to be interacting with humans forever. What we have to look at is what happens between us and the virus over time. And so what I was commenting on, my dream is that we see less and less severe illness over time. And even to the point of wouldn't it be wonderful if one day years off this evolves into a virus that causes nothing more than the common cold, and that while everyone may get it twice a year, it doesn't result in serious illness, hospitalizations and deaths and long COVID is not a part of it. Now, that would be an ideal goal, but that is something that is not going to happen in my lifetime. So what I was trying to get at is, is that that means in the meantime, we have to figure out how we're going to live with this virus. As I've been emphasizing for a number of months, I recognize as the world is over, this virus, even if the virus isn't over us. And so how do we look at this? What do we do about it? Again, I'm going to give you comments as a seven year old man.


Michael Osterholm: [00:35:35] So, if I comment about age and risk for COVID and what it might mean, I'm right in the center of it. I'm self-interested here and this is a very important point. So it doesn't look somehow there's age discrimination. If you want to understand what COVID is doing in the worst way is we have to look at deaths. Long COVID is important. Hospitalizations are important, but it's important we look at deaths. And I have to say that if you look at the provisional counts for coronavirus deaths in this country, they're based on a very specific set of data that comes into the national vital statistics system. I do believe that these are the best we can get and they do accurately reflect what's going on out there. So when we talked earlier in a previous question about how are we counting deaths, I think we're doing a good job. But what we have to understand is and if we focus on deaths as boy, would it be something we could eliminate them and then wouldn't it be something we could add on to by eliminating most hospitalizations? Why wouldn't that be something? What if we could actually eliminate the fact that we ever get long COVID, or we could eliminate the fact that we even get that seriously ill? Each one of those kind of a step towards the ideal. But if you look at what's happened with COVID from 2020 to today, and this is as of February 1st, the data from the death certificates collected nationwide, about 10.8% of all the deaths since this pandemic began have been attributed to COVID.


Michael Osterholm: [00:37:08] 10.8%, one out of every ten. Now, that number has changed. In 2020, it made up 11.7% of all deaths in 2021. At its worst, it was 13.3% of all deaths. And now in 2022, it was 7.5 and 2023 so far, which the data are obviously very limited. It's 5.4%. So we have seen the number of deaths with COVID compared to the overall total deaths drop precipitously over time. I think that's a big drop to go from 13 to 5. At least four deaths. That's huge. And if you also look at the issue of deaths in terms of time, you can see that there is a big, big difference by when we saw surges. For example, if we look at 2020 in May of that year when we were seeing in the United States, these outbreaks occur in places like New York and Detroit and Chicago, etc. About 20% of all the deaths in the country were associated with COVID. And then if we look, numbers started roaring back in November and December in the earliest stages of Alpha, and there we saw the number of deaths rise to 17.6% in November, of all deaths or with COVID. And by December 26.7%, all deaths in this country were due to COVID.


Michael Osterholm: [00:38:29] It peaked out at 28.2% in January of 2021 and then started going back down into single digits. And then along comes Delta. And when in August and September of 2021, it goes back up to 18.9%. For August, 20.9% of all deaths in this country were due to COVID again, Delta. Well, then it starts to come down again. And then all of a sudden we see what's happened with Omicron. Omicron takes off. And in January of 2022, 22.2% of all deaths were due to COVID. So we've had these kind of peaks and valleys that have occurred. Now, however, we're really in a much more steady state and if we look at the last six months. Which I want to share with you. We've been in single digits and they haven't moved much. They haven't changed much. For example, if you look at the current number of deaths in the last six months, just the last six months, we've had 2577 deaths for those 49 years of age or younger. For those 50 and older. There have been 68,135. Let me repeat these two numbers for 49 and under. In the last six months, 2577 deaths. For those 50 and older, 68,135 deaths. For a total of 70,712 deaths in the last six months, 96.4% of all the deaths in the last six months have been in people 50 years of age and older. Only 3.6% have been in those 49 and younger.


Michael Osterholm: [00:40:04] And, yet from a population standpoint, they make up a much larger size of the population. If you look at also just the issue of deaths in general, where they contribute for those less than 49 in the last six months, COVID has only made up 1.9% of all deaths under 49. During that same six month period. COVID's made up 5.1% of all deaths for those 50 years of age and older. So what this is really telling us is if we are going to try to bring down the number of deaths, we have got to concentrate on those 50 and older. And I'm not dismissing 49 and younger. I mean, look at there were 2577 deaths in the last six months of the year in those 49 years of age and younger. But they only made up 3.6% of the deaths that occurred through this entire last six months. Now, I think this is really important. Again, let me just inject in a sense of reality here and say these are going to our moms and our dads, our grandpas and our grandmas, our brothers and sisters and painfully even some of our kids. So I don't want to diminish that, please. But I think that what we have to look at right now is how do we make recommendations about what we're going to do with COVID and where do we try to, in a sense, find the low hanging fruit? In the last six months, 224 deaths have occurred in kids 0 to 17.


Michael Osterholm: [00:41:28] Tragic. They made up 1.5% of all the deaths that occurred in kids during that six month period. But that 224 is very different than the 13,003 deaths among those 65 to 74 and the 20,240 deaths among those 75 to 84 and the 27,536 deaths in those 85 and older. So I think what we need to do is have a discussion about how do we best implement public health programs. Someone would say, if you look at the deaths that are occurring in those under age 50, they're mirroring a lot of other life experiences with death. And we can't just count a death as a death as a death. And I'm guilty of that. I get on this podcast, I talk to the public, I say, “Oh, we have 457 deaths today.” I don't tell you who they really are. I don't tell you how we could target them to best eliminate that or at least reduce it. And so today, I think the message I want to get across is it's time to have a very, very hard discussion about how do we go live our lives, our people who are 32 years of age or 18 years of age out there, they're not masked. They're not wearing any respirators. They may not even have their booster dose of any kind. And they're living life. We have to allow them to understand what is their risk.


Michael Osterholm: [00:42:46] Now, do I worry that they might transmit the virus to grandpa and grandma? You bet I do. That's why I still use the protocol I have here, even with my own grandkids. I'm the testing and so forth. But I think it's time to have a frank discussion. And when people realize that 96.4% of the deaths due to COVID in this country are occurring in those 50 and older, we are doing a terrible job of trying to reduce that risk. When we see only 40% of those 65 years of age or older are vaccinated with the booster dose, what would it be like if everyone could be boosted and have access to COVID? I think we could take these numbers down substantially more. Now, that may change with the new variant arriving. I'm wide open to these 210 mile an hour curveballs, you know, and say, okay, game on. But I think for now we have to have this discussion and I hope this podcast does not at all intend to suggest that we only concentrate on those who are older. I'm biased. I'm in that group. But, you know, as Willie Sutton once said, why do you rob banks? Because that's where the money is. And I think that what we need to see in public health is how can we do the most to eliminate and reduce, if nothing else, these severe illness, hospitalizations and death.


Chris Dall: [00:43:58] Now it's time for our COVID query, which this week is not about COVID, but about avian influenza, specifically the H5N1 strain and the potential for it to cross over into humans. In an opinion piece for the New York Times, columnist Zeynep Tufekci wrote, quote, “As the world is just beginning to recover from the devastation of COVID-19, it is facing the possibility of a pandemic of a far more deadly pathogen,” unquote. She then went on to describe that potential for cross over into the human population and what might potentially be done about that problem. So listener Lee wrote to us, “I share the writer's concern about lessons incompletely learned from our collective experience with SARS-CoV-2. I am curious about your perspective on the threat posed by H5N1 avian influenza beyond the price of eggs and our preparedness or lack thereof, to tackle this and other emerging threats.” Your thoughts, Mike.


Michael Osterholm: [00:44:50] Well, Chris, this is a very interesting, what I would call generational issue. And I mean that in that there are some of us in this business who cut our teeth on H5N1 back in 1997 with Hong Kong and what happened there with an outbreak that occurred. This was really the first example of this virus emerging into humans with the potential for a person to person transmission. And remember, up until this time in 1997, we all focused on H one, H two and H three. And suddenly now this new avian strain comes forward. Let me just set the tone for my response to this, because it's one that, again, is all about experience and time. And having dealt with this since it first appeared in Hong Kong and throughout parts of Asia, we have been tracking it and the W.H.O. has done a good job, I think, of overall keeping track of case numbers. And if you look at the experience of what the virus has done in humans, remember, what's critical is not just the fact that the virus can infect humans from a bird and other animal species, but then humans transmit to other humans. That's what is the defining moment in creating an influenza pandemic, and that's transmission has to be sustained. Well, let me just kind of share some numbers again. Since the beginning of tracking for H5N1 in humans, which really started in the early 2000 time period after the Hong Kong experience. We are aware of 868 cases that have occurred in humans, of which 457 have died.


Michael Osterholm: [00:46:29] It's a bad disease. Let me just share with you what happened between 2003 and 2009. There were five countries that really took the brunt of this issue with H5N1. The leading country is Indonesia, with 162 cases, 134 deaths. The high case fatality rate, the next was Vietnam, with 112 cases and 57 deaths. Then after that was Egypt with 90 cases and 27 deaths. Then we saw China with 38 cases, 25 deaths, and Thailand finally with 25 cases and 17 deaths. I've had the opportunity to actually be in Vietnam, in in Thailand, working on H5N1 and have actually been to the home of where a case cluster started in Vietnam when the family who had fighting cocks actually had transmission occur from the chickens to their children and then transmit. And at the time, we were all very concerned that this was going to lead to the next pandemic as such. But we never saw it happen. It wasn't just because of control measures. It just did not sustain itself. Then if we look at 2010 to 14, remember, the data I just gave you is for 2003 to 2009. Then it became largely in Egypt. Focused case numbers dropped precipitously in Indonesia, they dropped in Vietnam and it was 120 cases in Egypt with 50 deaths. And then that's 2010, 2014. Then we go to 2015, 19 with 160 total cases, 48 deaths. And guess what? Egypt led the way with 149 of 160 human cases reported. Now, deaths were down, some with 43 deaths out of 149 cases. Grant you from that time, from 2015 to 2019, the numbers changed dramatically from 2020 to 2022.


Michael Osterholm: [00:48:28] There were a total of seven cases reported in the world from 2020 to 2022. Now, I do believe that clearly the pandemic has some impact on reporting, but we still are getting really good follow up in many locations. So if anything, the human risk has actually dropped relative to the number of humans getting infected. And we've seen the virus continue to change and some of the internal genes actually have changed in such a way that may mean that the virus is less likely to be able to transmit human to human. But at the same time, it is now in the animal species and a number of them, not just birds that are huge. You've heard me talk about on this very podcast. My challenge is in terms of understanding what this will do to our poultry production in the United States. And I have been convinced that this transmission in these large production areas where we have many, many, many, many millions of birds being produced that are in barns, that are in some cases five, ten miles away from the next barn, where we see large ventilation fans blowing air in and blowing air out of these buildings such that the virus can get in easily through either the screens that they have in the building, if it's in the air or from these fans, and then move to another building. So we've been very concerned about this. And yet in both the 2015 large outbreak where we lost 50 million birds in the United States and now this one in 2022, 23, where we've lost over 58 million birds, there hasn't been a single documented case of infection that was actually tied to illness.


Michael Osterholm: [00:50:09] We have one case this year in a worker from a prison who is helping to depopulate a barn, who, upon sampling his nose with a swab, was found to have H5N1 in his nose. But he had no symptoms. I think that was probably environmental contamination and is no is not real symptoms. So we've had these experiences like this. Now, what's happened is the story comes along in The New York Times this past week. I think there's a lack of understanding of what has happened with H5N1 over time and what it means. I think the sentence in the article that says the world needs to act now before H5N1 has any chance of becoming a devastating pandemic. Well, we've had that since 1997. That's not new. And we don't really have better preparedness and we don't know if this is going to happen. There are many of us who are challenging that. And because mink on a farm in Spain got infected this last fall, that made people think, “oh my gosh, now it's starting to spread.” Well, in fact, it has now spread to a number of different animal species, which we see besides avian. But we, again, don't see evidence of the fact that it's actually creating a greater risk for humans. Now, it could tomorrow. It could tomorrow. The recommendation, the New York Times piece.


Michael Osterholm: [00:51:23] I think we're a bit naive. For example, talking about vaccines, you know, think about what happened in 2009. We had an H1N1 virus that was circulating in the world, had been for some time. We had a vaccine for it. And then along comes a new H1N1. And look what it did. It knocked out the previous H1N1. We had to get a whole new vaccine because our previous vaccines didn't work at all. Now we don't know with age five and one until we cross protection. If I have a vaccine I make on today's strain, if it were to actually become a pandemic strain, would there be any cross protection or would be like 2009? We don't know that. And so I think surely we have to consider a stockpile, but we're talking about stockpiles right now of a few million doses of vaccine. This is not going to solve the world's problems with vaccine now. So from that perspective, I think this is important. We need to ask ourselves, what would we do if we had another pandemic? Remember, this pandemic we're in right now is not the big one. It is not. Think of two other alternatives. One. What if we had another COVID virus pandemic where instead of 1% or less case fatality rate with this high level of transmission, as we see with SARS-CoV-2, we actually have the anywhere from 15 to 35% case fatality rate, as we saw with SARS and MERS. Wouldn't that be a different picture? Or what if we had an influenza pandemic like 1918, where at that time we basically had less than one quarter of the population we have now and yet 100 million people died.


Michael Osterholm: [00:52:58] So, we do have to be better prepared. I don't want to minimize that, but it's not going to happen by basically just saying we need to get new H5N1 vaccine. I don't think anybody is going to actually do anything about that. And that's unfortunate that we don't have a system in place to quickly ramp up not only vaccines in general, but enough for the world. The other thing is animal vaccines. There are over 8 billion broilers in the United States. These are the chickens you use for chicken meat. There is no easy way to administer a vaccine to them, even though other countries use some vaccines. When we use vaccines in the United States right now, for example, a viral infection called Newcastle disease, these are vaccines that can either be literally put into the air or into the water of the birds. Well, that's not going to happen with an influenza vaccine. It would have to be changed often. It's not just as simple as saying go vaccinate all the birds. The bottom line message I want to say is, yeah, I follow H5N1 very, very closely. Do I think that we're on the cusp of a pandemic because of new recent changes? And my answer is no. Do I stay awake at night thinking about it? No. But do I think about it? I do. And I haven't stopped thinking about it since 1997. So let me offer an alternative view.


Michael Osterholm: [00:54:13] That is, yesterday, there was a very thoughtful piece authored by Helen Branswell. I think one of the best reporters in the business on Stat news. The title of the article is called “Tracking the Bird Flu: Experts see a familiar threat and a virus whose course is hard to predict.” And I think if you look, there's a lot of the old timers in this article who have been working with this virus literally for 26 years. And I think it was a much more realistic perspective here. So in responding back to you, Lee, let me just say that I don't think it's imminent at all. I don't think that the changes we've seen recently mean that we're going to have a human pandemic. It's one we have to keep watching carefully. We need to be talking about the potential for the pandemic. I don't want to minimize that, but I don't think that these changes in the last few months mean suddenly that we're now closer to a five in one pandemic. And I think if you read Helen BRANSWELL piece, you'll find a very similar tone taken by a number of the, what I would call more senior and experienced researchers in influenza. But let me just conclude by saying there will be more influenza pandemics in the future and we are not prepared for them. It may not at all be h five in one, but we still have an absolute need to get prepared for the next pandemic in a way that we're not now.


Chris Dall: [00:55:37] Mike, what can you tell us about our latest beautiful place submission?


Michael Osterholm: [00:55:42] Well, the next beautiful place comes from a very interesting place, Staten Island, New York City. And this is from Gail. Gail, thank you so much. This is a beautiful, beautiful submission. And it's on our website, along with the pictures that will be described here in the actual beautiful place. And Gail wrote to us and said, I live in Staten Island in New York City. When New York City became the US COVID-19 epicenter, we were plunged into a scary unknown. We lived near one of the two hospitals on the island, and the ambulances ran day and night. It was awful hearing the sirens because it meant someone was in a bad way. Throughout the pandemic, I could measure the rises in severe illness by the frequency of ambulances passing our house. During these times, my refuge was the Snug Harbor Cultural Center here in Staten Island, opened in 1833. Sailor Snug Harbor was originally a home for retired merchant seamen. This complex, with its centerpiece of beautiful 19th century Greek revival buildings, was saved and landmarked in the 1970s and is now part of a city run art center. I'm an artist and have a studio in a former dormitory for the sailors. There are expansive lawns, large trees, ponds, fountains, gardens, a glass house. The past is present here. The buildings are grand, but old. The wear is apparent. They are not pristine. The effects of time passing are visible. Things change seasons in years past. At the outset of the pandemic, our studio building was temporarily shut down, but the grounds were kept open. I started taking early morning walks there with my dog. I would think of the old sailors walking the same paths I now walked. Now, almost 200 years later, across time, their place of refuge was also mine. My snug harbor. My beautiful place. Thank you. Gil, that was simply beautiful. And I know all the audience will very much enjoy seeing the pictures. And thank you. Thank you so much.


Chris Dall: [00:57:46] 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 provides some peace and comfort in challenging times. Please email us at Osterholm. Update at UMKC. Edu. Mike We've covered a lot today, but what are your take home messages?


Michael Osterholm: [00:58:09] Well, actually, I have a number of them, but I'll stick with the three so that people sense what I'm prioritizing. Number one is the fact that it's clear we're still in this holding pattern with COVID. As long as we continue to see those deaths in the 400 plus range, day after day after day after day after day, we are not in the best place we should be. So from that perspective, I would say that we have to look at what can we do to minimize the impact of this pandemic that continues even in a world that thinks it's over with. Again, I remind people, you know, those deaths are clearly, as I described today, among the older population. But when I think about it, we make incredible efforts in this country to respond to and hopefully prevent lung cancer, but at the very least, treat it and as a leading cause of death each day from cancer in this country, we average about 350 deaths a day with lung cancer. We would never say that's acceptable. That's done. We're over and we're talking about 450 deaths a day with COVID and largely a similar population. So I think it's important to understand that we have to do more and we have to recognize we need to target our efforts before we kind of just hit the entire country with everyone saying this is what we need to do. Today, I think we have to target how we reduce these numbers of serious illness, hospitalizations and deaths. So that's number one. Number two, we still have to work out this vaccine issue. I actually believe that we should have access to vaccines at least every six months, particularly for those of us who are older.


Michael Osterholm: [00:59:48] You know, maybe the data will change over time to say, oh, you don't need it that much. But I think that's the case now. We need to target the younger age population for frequent vaccines. Probably not unless we see changes. The numbers are continuing to drop in terms of serious illness, hospitalization and deaths for those under age 50. And we need to acknowledge that and we need to try to explain how do we live in this bifurcated world of increased risk among those who are immune compromised, those who are older? What do we do? And I do want to include the immune compromised in the under 50 age group. That's very important. They're still vulnerable. So that's number two is we've got to work on the issue of vaccines and how we're going to prioritize having them be most effective in our communities. Number three, I'm not sure at all that H5N1 is coming around the corner to get us. I think it's a very challenging time right now to understand what's happening with the virus. Surely there are changes occurring. But if you've been working with this virus, like some of us have, you've seen this same movie over and over again since 1997, trying to understand why it is, in fact not causing a pandemic is a very important question, because that may define what for the future is the risk that we're dealing with. Stay tuned. We'll keep you posted on that. But at this point, to say that an H5N1 pandemic is imminent just is not the case.


Chris Dall: [01:01:15] And do you have a closing song or poem for us today?


Michael Osterholm: [01:01:19] I do. And it's one that I was motivated to bring this forward. Hearing it sung on the Grammys. If any of you watched that award show, it was a very emotional moment. And this was a song by the late Christine McVie, who was a member of Fleetwood Mac. And it's a song that has meant a great deal to me over the years. And in part because listening to her explanation of what it was all about, the song was first appeared in the band's 1977 album Rumors, and released on the B-side of the Single Dreams. The song is Songbird. She wrote it in a half an hour around midnight one night, but didn't have anyone around to record it to ensure she did not forget the chord structure in the melody. She remained awake for the entire night. The next day she went and met with a producer at the Sausalito Record Plant, and at that point they recorded it. Now the ambiguity of Songbird captures really what I think is the essence of selflessness, of love for someone or oneself and what it means. And I think this song is very fitting for the time. So here it is. Sung by Christine McVie. Songbird. For you. There will be no more crying for you. The sun will be shining. And I feel that when I'm with you, it's all right. I know it's right to you. I'll give the world to you. I'll never be cold. Because I feel that when I'm with you, it's all right.


Michael Osterholm: [01:02:51] I know it's right. And the songbirds are singing like they know the score. And I love you. I love you. I love you like never before. And I wish you all the love in the world. But most of all, I wish it from myself. And the songbirds keep singing like they know the score. And I love you. I love you. I love you like never before. Like never before. Like never before. Christine McVie, Songbird. Thank you so much for being with us again this week. I hope that we are able to provide you with some information that is helpful, maybe even challenging, which will cause some conversations to occur. We sincerely welcome your feedback. I appreciate it very, very much. And while we can't respond to each and every email or card or letter that we get, please note all of them are read and read by everyone. So this is really very important. So thank you so much. Remember, these are not all numbers. These are about people, real people. And in that regard, I just have to also remind us at this time, be kind. You know, it's one of those simple things to do sometimes. And yet we don't often do it when we could just look at the expression on someone's face who was not expecting a kind moment from anyone. And you provide that. Be kind. It's a wonderful feeling. So thank you very much. Be safe. Be kind.


Chris Dall: [01:04:27] 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 to donate. The Osterholm update is produced by Cory Anderson, Meredith Arpey, Elise Holmes, Sydney Redepenning, and Angela Ulrich.