April 6, 2023

In this episode, Dr. Osterholm and Chris Dall discuss the state of the pandemic in the U.S. and around the world, the latest news on vaccines, and the current Marburg virus outbreaks in Africa. Dr. Osterholm also answers two COVID queries and shares a beautiful place from one of our listeners.

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Chris Dall: [00:00:06] Hello and welcome to the Osterholm Update: COVID-19, a podcast on the COVID-19 pandemic with Dr. Michael Osterholm. Dr. Osterholm is an internationally recognized medical detective and director of the Center for Infectious Disease Research and Policy, or CIDRAP at the University of Minnesota. In this podcast, Dr. Osterholm will draw on more than 45 years of experience investigating infectious disease outbreaks to provide straight talk on the COVID-19 pandemic. I'm Chris Dahl, reporter for CIDRAP News, and I'm your host for these conversations. Welcome back, everyone, to another episode of the Osterholm Update podcast. Throughout the three years that we've been doing this podcast, there have been several episodes where I've sounded notes of optimism in my introduction that we might be nearing the end of the COVID-19 pandemic. The first time was in the spring of 2021 when cases were dramatically declining amid the initial vaccine rollout. But that optimism has almost always been dashed by news of new SARS-CoV-2 variants and a subsequent rise in cases. It seems we're now once again in one of those moments of optimism, especially here in the United States, where cases, hospitalizations and deaths continue to decline. Is the light at the end of the tunnel finally here? That will be the focus of this April 6th episode of the Osterholm Update podcast as we discuss the current COVID trends here in the US and around the world. Dr. Osterholm will also talk about the latest news on COVID vaccines, address some of the wonderful and not so wonderful email that he's received since coming down with COVID. Answer some COVID queries about his infection and provide updates on the Marburg virus outbreak in Africa and the ongoing worldwide avian influenza outbreak. 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.


Dr. Michael Osterholm: [00:02:01] Thank you, Chris, and welcome back to all the podcast family. And for those who may be new to the podcast today, welcome. I hope that we're able to provide you the kind of information you're looking for. This opening is probably the hardest one I've had to do in the three years that I've been doing this podcast. By now, some of you know that I can be a little bit emotional from time to time. That anti-science mind I have up there, and I just want to share with you how much I absolutely appreciate the many, many, many emails and outreaches that so many of you have made to me about my COVID case. I cannot begin to put into words how important they have been. Literally, I have read every one of them, and I wish I could touch all of you out there and say thank you. I wish I could shake your hand or give you a hug. It just reminded me that in a world today that is so complicated, that is so angry and is sometimes so difficult, there is more good than there is bad. And I just hope that you know, that I know that. And the last two weeks have clearly reminded me of that. And so it's for this reason today that I actually dedicate this podcast to all of you who have been so kind to me over the course of the last several weeks inquiring about my illness, where I'm at, what's happening. Your kindness did not go unnoticed. And more importantly, please do know what impact it has had. I'm happy to report that I'm almost recovered, not completely yet.


Dr. Michael Osterholm: [00:03:40] I still have upper respiratory symptoms. I still have some real fatigue, as you know. I was likely exposed on March 10th, had onset on March 12th, and I'll get into that more today when we talk about recommendations about what to do, for example, with vaccines and even taking Paxlovid, which I did do, and addressed the issues that I think that all of us right now are facing about what happens if I get COVID today. And as much as I am going to talk about good news today with regard to the number of cases of serious illness, I know more people today and I can't believe I can say this. I don't want to say it. I know more people today who have COVID than I have at any time in the pandemic. It's just simply remarkable. So we're seeing lots of milder illness. We're seeing lots of transmission. And one of the things we'll talk about today, what does that mean? You know, I am so, so, so thankful that my illness was not any more severe than it was. And I will right up front say those were my five doses of vaccine and my ten days of Paxlovid. You know, I could have been a major statistic here in our business if I had not had those on board. So we'll talk about that today. Now, also in the good news world, which is actually a little bit difficult here in Minnesota right now, we still have not had a day above the mid 40 seconds for temperature. We still have snow on the ground here.


Dr. Michael Osterholm: [00:05:08] We're expecting temperatures tonight to be in the middle teens. So the fact of the matter is, is that it might be hard to talk about weather or whatever, but we are seeing the change and it is surely associated with our changing sunlight. Today in Minneapolis Saint Paul, the sun will rise at 6:44 will set at 7:46. That's 13 hours, two minutes and seven seconds of sunlight. We're gaining about three minutes and five seconds of sunlight a day. Boy, does that feel good. And we are promised by our colleagues in the Weather Service that by the end of the week and into early next week, we may actually hit the 70 degree mark here in Minneapolis, Saint Paul and watch all this snow melt for our colleagues in Auckland, in particular, for those at the Occidental Belgian beer house on Vulcan Lane today, you have 11 hours and 28 minutes of sunlight. Sunrise at 6:38, Sunset at 6:08. Unfortunately, you're losing two minutes and 17 seconds of sunlight a day. But I'm promising you we're sharing it with you. Now, I also just want to add that I've actually heard from some of you who now on your trips to Auckland are actually taking time to go visit the Occidental Beer house. Please do go visit. It's a place where if you weren't a friend before, you can become one when you're there. And I think that's a great thing. So again, I just want to thank you for your very, very kind, kind personal notes and know that I cherish each and every one of them.


Chris Dall: [00:06:40] Mike, Over the last few months, we've been talking about declining cases worldwide. But over the last week there's been a surge in cases in India that appears to be fueled by a new variant, XB 1.16. What can you tell us about this and are there any other parts of the world that are seeing increasing COVID activity?


Dr. Michael Osterholm: [00:07:01] Well, Chris, just like we've talked about so many times before, its another prescient reminder that this virus can change and in fact it continues to do so. This is those 210 mile an hour curve ball situations that have taught me so much about humility and realizing that Mother Nature has tricks up her sleeve that we have yet not completely understood. Remember Omicron first arrived on the scene around a year and a half ago. Since then, it's maintained its status as the dominant variant family, largely owing to its incredibly high infectivity and capacity to evade immune protection. For example, since February of 2022. In other words, through the past year, more than 98% of all SARS-CoV-2 sequences made publicly available have been Omicron. But as we know, there have been some different chapters or phases during that time with Omicron, each of which is marked by different sub variants. So to start, we saw bar one and then eventually came bar two and then bar four and then bar five. And with each of these, which were distinguished by the different mutations they had, we often ended up seeing some resurgence and activity in different parts of the world. However, since then, we really haven't seen an Omicron Sublineage drive activity up like it did in those previous time points. And that's fortunately been the case.


Dr. Michael Osterholm: [00:08:26] Despite the emergence of fairly worrisome sub variants like BA.2.75.2 or XBB. But as we know, circumstances can change. So it's important to keep an eye on what this virus is doing and what that might mean for us as we continue moving forward. With that in mind, there are some attention being paid to a newer sub variant known as XBB1.16, which is reportedly spreading in India and could be associated with some growing activity there. Just recently, the country reported their largest single day rise in case numbers throughout the past six months. Now, granted, the total number of cases reported was just over 3600, which clearly isn't all that much in a country with more than a billion people. But considering the overall lack of testing that's happening there and the fact that they are reporting just a couple hundred cases a day less than a month ago, it surely has earned our attention. Adding to that attention has been the simultaneous rise of cases identified as XBB.1.16. In fact, last that I know, almost 60% of all cases there have been ID'd as this sub variant. So there's a real possibility that it's playing a role in what's happening there. As it stands, the W.H.O. classifies XBB.1.16 as a variant under monitoring. And that's not only due to its overlap with rising activity, but also because of some possible changes that might possess that would distinguish it from other sub variants.


Dr. Michael Osterholm: [00:09:58] Notably, this is a sub variant that is very similar in structure to XBB.1.5, with the primary difference being an additional mutation in the 1.16 spike protein. More specifically, during a press conference was held on March 29th, Dr. Maria van Kerkhove, who serves as the agency's technical lead on COVID, noted that the lab studies have found that thanks to this mutation, XBB.1.16 could have increased infectivity and potentially even increased pathogenicity. So there are reasons to keep an eye on this one. Otherwise, it's worth pointing out that in total there are only around 800 sequences of XBB.1.6 that have been identified across 22 countries, with India now accounting for most of that total. So it's still too early to know exactly what impact, if any, this will have, especially in other parts of the world. And in other words, what's happening in India certainly could just be an outlier. Maybe it's just more a product of waning immunity rather than this new variant. Obviously, there are a lot of things to consider and it all gets complicated fairly quickly, but that's exactly why it's important to be keeping tabs on the virus and working to understand not only what it's doing, but also why that's the case.


Dr. Michael Osterholm: [00:11:13] Ultimately, I'd like to know why exactly India is seeing things take off. Same thing goes for other countries in South East Asia and the eastern Mediterranean like Indonesia, Iran, Kuwait, Libya and Qatar. Why there and why now? That's what I'd like to know. Let me add one last perspective to this. I am very concerned how capable we are of actually detecting what's going on with COVID in our communities around the world. We have largely dismantled most of the surveillance activities that would detect cases that would allow us to know how many hospitalized patients there are and even deaths. Last week, the United States accounted for almost 34% of all the deaths reported in the world. Africa had a single death reported. I know. And you know. That that is simply not the situation as much as we may still be missing deaths here. It just points out to the fact that the world is missing them. So it is a more challenging time right now to understand what's happening globally. We will do our best to stay on top of it and to try to discern when is something happening we're missing, when is something happening. And that's the extent of it. And oh, blessedly, when nothing's happening. And that's actually the story.


Chris Dall: [00:12:28] As I mentioned in the introduction here in the United States, all COVID markers continue to fall, including daily deaths, which have been a stubborn holdout. While we know the number of daily cases is likely much higher, it seems clear that fewer people are becoming severely ill. The hospitalization and death numbers are some of the lowest we've seen in a while. So, Mike, what's your sense of what's going on in the US?


Dr. Michael Osterholm: [00:12:51] Well, Chris, first of all, I think it can be framed in the concept of the best of times and the worst of times by the best of times. If you look at what's happening with deaths and hospitalizations, the two areas that we still can measure with some accuracy as to what's happening, we are really seeing the lowest levels of activity we've seen almost since the beginning of the pandemic. Right now, we're reporting about 1600 deaths a week in the United States. That comes out to about 230 a day, far below that number of 350 to 500 that we saw just a couple of months ago. Hospitalizations are down 5673, 6% decrease in the last 14 days. This is all very, very good news. And I think it helps us understand why we're seeing so many people in our communities back to living life as if the pandemic never existed. Now, there is a couple of caveats to this. And of course, we'll discuss this a bit more in a moment as I'm going to talk a little bit more about my own experience with COVID. But right now I am aware of more people who are infected right now with COVID than any time since the pandemic began. And, you know, I thought when I said that six months ago, that would be the it it would be the mountain peak.


Dr. Michael Osterholm: [00:14:10] And we'd just continue to see the gradual reduction number of cases. Now, I'm a classic example of someone who has been fully vaccinated, who still got infected, even making real attempts not to get infected. So I think that we're in a position right now, as I said before, if we eventually got to a world where everyone got COVID, but it was a milder illness, nothing more than a head cold and the worst minor flu, wouldn't that be a victory if we eliminated the deaths, we eliminated the hospitalizations. If people who are immune compromised or older people didn't get seriously ill, that would be a great victory. So I think the question we have right now is where are we at on that path? Are we going that way or are we going to be living somewhat on borrowed virus, human immune time? And what I mean by that is, is I've just got done discussing the change in these Subvariants could we see a reemergence of a sub variant overlaid on waning immunity? What is going to happen over time is more and more people get further out from having had either infection or having been vaccinated. Now, if we got a lot of people infected now, that must mean we're seeing more and more immunity being reinforced. Meaning that, yeah, yep, you did get it. You weren't seriously ill, but now you have an immune boost.


Dr. Michael Osterholm: [00:15:34] This entire interaction really leaves us wondering where we're at. So all I can say is the really good news is the serious illnesses and hospitalizations, the deaths are coming down. In terms of number of cases, I have no idea what they are. And that's in large part to most people are not being detected by surveillance systems in this country. You know, I'll answer a question in a few minutes on that issue. I called the health department immediately here and talked to my counterparts there and let them know about my infection, my partner's infection and my colleagues. But they weren't officially reportable because they were only positive by a lateral flow test. You know, one of the rapid tests and, you know, there was no need for me to go in to be tested by PCR, which right now is only in very limited availability. So I know that in this country this is happening day in and day out where many, many people who have COVID, who even know they do per a rapid detection test, end up not getting reported. So I'm not going to keep track of those milder infection illnesses not reported. I'll continue to focus on hospitalizations and deaths. And right now, the good news is that's the best we've been looking in a long, long time.


Chris Dall: [00:16:49] So you just mentioned waning immunity. And that brings us to the latest vaccine news. There were reports this week from The Washington Post and The New York Times that the Food and Drug Administration could soon sign off on a second Omicron specific booster shot for certain at risk groups. That's likely to be welcome news for some people in those populations. Your thoughts?


Dr. Michael Osterholm: [00:17:10] Well, Chris, this is a real issue for me. As you know, I made an attempt six and a half months after receiving my first bivalent dose of vaccine to get a booster and was not allowed to do so because it had not yet been approved. And then four and a half weeks later, I get COVID. So I don't know to the extent that had I had that additional booster, what would have happened. But I actually believe that it would have likely given me more protection. But as I mentioned in the last episode, there is now some movement at the FDA considering permissive language about an additional booster shot. As you noted on Monday, The Washington Post and on Wednesday, The New York Times put out articles explaining that the FDA is expected to allow an additional bivalent booster for those 65 years of age and older or with weakened immune systems at least four months after their last dose. The CDC is also expected to endorse this move. The word allow is used strategically. This move is not a formal recommendation to get vaccinated. Rather, it's a permissive statement, meaning they will not tell anybody to get an additional booster. But those who qualify will not be denied if they seek out that additional vaccine dose. You're absolutely right, Chris.


Dr. Michael Osterholm: [00:18:24] That is a welcome move for some. I wish I had had that opportunity more than eight weeks ago. I am relieved that now following my infection, I will be able to receive an additional dose. 3 to 6 months from now when my immunity from my infection may begin to wane. So where are we at with this? Well, it was interesting that in the past week an article was published in Nature by a group of scientists from Washington University, and they have found from their work that vaccinating people against the original strain of the virus, i.e., the first one we encountered, and then boosting with a shot that targets a new variant, can elicit a broad antibody response capable of neutralizing a wide array of variants, including ones that have not yet emerged. The trick is to target a variant for the booster, so that is different from the original strain of the virus and that it triggers the maturation of new and diverse antibody producing cells. Well, this may be a very important finding. It's interesting to note, of course, I had had the original vaccine and I had the Bivalent vaccine, which is what the authors are suggesting would provide more protection. And in fact, in that case, I still got infected, but I did not get seriously ill.


Dr. Michael Osterholm: [00:19:40] I can't tell you for certain that that combination is what made that the case. But I'm an old man with underlying health conditions that could have surely made me an ideal candidate for the ICU, and I didn't get there. So I think this is a great news. It's a permissive language that I hope for those of us who have wanted these doses, we go get for those that are turned off by getting any more doses, you know, we're not going to be able to change your mind likely. But I think for right now, get them. One question that comes up again and again is, well, is it safe to do so? And again, the data that we have supports the relative safety of these vaccines. It's quite, quite, quite good. Is it 100%? Never worry about it. You know, having a sore arm or a potential other vaccine side effect? I can't say that. But overall, if you're concerned about taking those vaccines from a health impact standpoint, your concern should be about not getting it as opposed to getting it. We know that this vaccine can continue to reduce serious illness, hospitalizations and deaths. And I think that's the real message you're going to hear coming out of the FDA with their permissive language, not mandatory.


Chris Dall: [00:20:54] And Mike, what did you make of the Who's strategic advisory group of experts on immunization recommending last week that healthy children ages 6 to 17 be deemed low priority for COVID vaccination?


Dr. Michael Osterholm: [00:21:08] Well, Chris, as you noted last week, the group responsible for putting out vaccine recommendations met to adjust the COVID-19 vaccine prioritization. Their changes reiterated the fact that those who are still at risk of serious disease need to be vaccinated and boosted. They define three priority groups for vaccination based on the risk of severe disease and death, as well as other factors like vaccine performance, community acceptance of the vaccine, as well as being cost effective. There are three priority groups high, medium and low. Are listed as follows in their roadmap. The high priority group includes older adults, younger adults with significant comorbidities like diabetes and heart disease, people with immune compromising conditions such as people living with HIV and transplant recipients and including children aged six months of age and older pregnant persons and frontline health care workers. In the medium priority group includes healthy adults, usually under the age of 50 to 60 without comorbid 80s and children and adolescents with comorbidities. And then finally, the low priority group includes healthy children and adolescents aged six months to 17 years. The W.H.O. group determined that vaccines and booster doses are safe for all age groups, but provided different recommendations for the three priority groups. They recommend that countries determine their own recommendations for the low priority group based on their own health priorities and other factors. For the medium priority group, they recommended the primary doses on the first booster, but nothing further because of low public health returns. Finally, for the high priority group, they recommended an additional booster either 6 or 12 months following the last dose based on age and immunocompromising conditions.


Dr. Michael Osterholm: [00:22:54] Let me also add that these recommendations are based on the idea that there is high population level immunity from both infection and vaccination, but that doesn't take into account waning immunity. As I've stated time and time again, I think this is going to be a big challenge is understanding what is the intersection between waning immunity, new variants and serious illness. So we're going to be kind of in a wait and see. I don't think that these recommendations are necessarily going to be welcomed by everyone. Some who want the vaccines who are not in the highest priority group are likely going to say, please, can't I get it? And from a public health standpoint, given the safety of these vaccines, I would continue to promote forever wants to get vaccinated at that six month interval. Please continue to allow them to be vaccinated. You know, why deny them that Now, if in fact, you'll say, well, we want data to show that that really is going to make a difference versus not vaccinating, you know, we could spend years trying to understand, okay, you're at this many months after your dose of vaccine. What happens to you? I think we have enough data right now from countries like the UK and Israel to show that, in fact, at six months we do see waning immunity relative to the prevention of serious illness, hospitalizations and death. So I think the W.H.O.


Dr. Michael Osterholm: [00:24:17] is surely trying to serve the world's stage, meaning that there are a lot of countries right now that have very, very major challenges with other public health issues and that therefore, they need to prioritize where this fits relative to that. I think in the United States, I come back to the fact that any COVID death is a real challenge. But if you look at the overall numbers, again, over 97% of the deaths are in those 50 years of age and older. If you look at the number of deaths in kids right now from COVID and I'm talking about individuals 12 years of age and younger, unfortunately, and this is a very hard thing to say, the risk of dying from being shot in a school or in a community or dying in a car accident are higher than COVID. And so you can understand why some are saying, well, it's not that important to get kids vaccinated. So I'll leave it at that. The one thing I want to leave all this with is that every time I read these kinds of deliberations and these recommendations, they just so quickly morph into numbers. And I just want to say time and time again, I personally know these are not just numbers. These are people these are somebody's grandfather, grandmother, father and mother, brother and sister, cousin, in some cases, even their children. And so, you know, we can't forget that part of it ever, no matter how much we talk about the numbers.


Chris Dall: [00:25:44] Now it's time for our COVID queries. This week, Mike, we received several questions regarding your COVID case. The first is from Larry, who wrote, I was quite surprised to hear you say that you did not get public testing after your at home test. I can only imagine that you must have had your reasons for not wanting to publicly report your COVID infection. Perhaps you will explain in a future podcast why you chose not to report your case of COVID-19 as well as those of your friends. I wish you full recovery and will continue to listen to your podcast. Thank you very much for all you and your staff do for public health. So let's take that one first, Mike.


Dr. Michael Osterholm: [00:26:17] Well, that is a very good question, actually. And it goes to the heart of a point I made earlier about detection of cases in our community. For the record, having announced that my infection on this podcast to many thousands and thousands of people, I think that was a pretty public recognition of what I was experiencing. And so in that regard, Larry, you're right, though I didn't have it formally reported. One of the first things I did is called my colleagues at the Minnesota Department of Health, and they're not only dear colleagues, but trusted friends and coworkers and shared with them the state epidemiologist of about the three infections. But you give it in a very important point to actually be considered an actual confirmed case reported as you would have to go and be tested by PCR with that result then being submitted to the health department. I was positive by a lateral flow test, as was Fern, as was the third person who was with me. And at this point, you know, it's difficult to get a PCR test. You know, I'm sick. Why do I need to go into the public just to confirm that? And the fact is, I don't have any faith in the numbers of reported cases to begin with, nor does any of my colleagues in public health.


Dr. Michael Osterholm: [00:27:28] We know there's major underreporting. So I think this is a real challenge going forward in terms of really understanding exactly who is infected and who's not in our community. And that's why we're going to be relying on a different part of the iceberg of cases, a smaller part that's floating above the water of serious illness, hospitalizations and deaths. So it is important for us to have good surveillance data. But given, you know, whether or not you get a case reported by PCR positivity or not, today, it's a vast, vast minority. Of all the people that I just talked about who I know are infected right now, I do not know one of them that accessed a testing facility to confirm their PCR status as opposed to just that they were lateral flow positive. So an important point, Larry. And you know, there's not much I do in my career where I sit at the University of Minnesota that in the past 48 years has not been a public venue issue. I think it's fair to say that I expect that just about anything that happens in my life one way or another, will become public information.


Chris Dall: [00:28:39] The second question is from Yvonne, who wrote, You mentioned that you took Paxlovid with your first infection. Did you take another course of Paxlovid with your second? And could you review the recommendations for Paxlovid for rebound COVID infections? And just to be clear, Mike, I think what Yvonne is asking is, did you take a second course of Paxlovid after you started feeling the rebound symptoms?


Dr. Michael Osterholm: [00:29:01] Thanks, Chris and Yvonne. Thank you. That, too, is a very, very good question. Let me be clear. I had a single infection. I was likely exposed on the evening of March 10th. I became clinically ill late afternoon on March 12th, and then I started Paxlovid on March 13th when I actually tested positive by lateral flow for COVID. It had upper respiratory symptoms, severe fatigue, something I'm not used to being an old English Channel swimmer. You know, I never could have imagined walking across the layout of my home would make me severely fatigued after five days on Paxlovid, which was then that following Friday, I actually thought I had turned the corner. Things were looking good. Then the following Monday, I really had a rebound and I was more severely ill than I was in the first week of infection and literally, you know, didn't want to get out of bed. Major upper respiratory, which you can still hear. I have some yet. And at that point, based on the discussion I had with a number of my esteemed colleagues in COVID, all, by the way, who they themselves had had previous infections and had had rebounds, ended up taking Paxlovid for an additional five days. Now, let me make it really clear Paxlovid does not cause the rebounds as such. There have been several studies now that show that in fact rebounds occur just as frequently or close to as frequently among those who don't take Paxlovid as those that do.


Dr. Michael Osterholm: [00:30:41] So when I hear physicians saying, Oh, you don't want to take Paxlovid, you'll just have a rebound. Please understand that's not true. That is not true. But I do think it raises the question, should this have been a ten day course to begin with as opposed to a five day course? So I did take my additional five days of Paxlovid and began to feel much better again by the end of the third or fourth day of that second five days. I'm now more than three weeks out with my infection and I'm still feeling it, but I'm surely doing much better. Let me make one really important point here is that there has not been a formal recommendation for a second five days of Paxlovid. But again, I find it somewhat disingenuous if I don't tell you that I would recommend that because all of my colleagues who are in COVID work who know a hell of a lot about this topic, all have taken the second five days. I hope your doctor will agree with that. If you become infected, and particularly for those who are at higher risk for serious illness, which we just talked about, you in particular, please avail yourself to paxlovid. And particularly for ten days, it could mean all the difference between being more seriously ill and not.


Chris Dall: [00:32:02] And finally, Mike, several listeners wanted to know if you'll be changing your protocols for indoor gatherings after your infection.


Dr. Michael Osterholm: [00:32:11] Well, you know, this is a moment of both intellectual and emotional honesty with this group. You know, somehow I feel like you're maybe all my therapists and I need to come clean. You know, I never wanted to get COVID. You know that. And I've struggled with that issue feeling like I failed and realizing how many of you have gone through those same emotional feelings of trying so hard not to get infected? And then you did. And so I don't recommend anyone still get infected if they can avoid it. I think that's important. But I would also say, though, that now I have this somewhat almost survivor guilt where I did make it. I did not get hospitalized. I was not seriously ill. And for the next 1 to 2 months, minimum, I likely have a very high level of immunity against getting reinfected. We have very, very little data supporting that. Anyone within the first months after being infected get infected again. And so the challenge I have right now is I feel like I just got to just get out of jail card that I'm feeling guilty about. And I don't know how else to say it. And I know that I've talked to people who some of you who are listening today who have been through the same thing. So for the next two months, I do not worry that I will put other people at risk for getting infected if I am out and about without an N95 respirator on if I'm in living a life as normal. But I think I'm going to have a real emotional debate with myself, which I hope I don't lose to myself about what to do two months from now. Now, I would argue that it would not be a good advice to recommend another booster dose at that point, because from an immunity standpoint, we have more and more data supporting that 3 to 6 months after your infection.


Dr. Michael Osterholm: [00:34:06] If you get vaccinated again, you may really boost your immune status. So what do I do from two months, say, to six months? Do I go back to wearing my N95? How do I do the in-house testing? You know, we've continued to use that protocol. And again, I will tell you, I did not get infected in my home with someone coming to visit me or my partner who I live with in a way that would have said, well, you know, if you had just followed your protocol, you could have not gotten infected. I still think I probably got infected in an elevator ride of 27 seconds. So the point being is, will I continue to advocate that testing program? And I will if we're having multiple guests here, that they might be at risk of transmitting from one of them not knowing they're infected to someone else who might be here. I wouldn't worry about myself, but I would worry that that would happen to them. And so Fernand and I will make certain that people still remain tested and that they have no symptoms to make sure that if we have events here, that we continue to protect that. So come and ask me in two months what I'm going to do, and I welcome your feedback. I welcome that. You know, I, I don't have all the answers on this. And I'm now living the personal side of this in a way that I didn't have to live for three years. But so right now, I don't consider myself done and over. But at least I have this respite right now. And frankly, it comes with a lot of guilt.


Chris Dall: [00:35:41] So, Mike, you talked in your opening comments about the many wonderful emails that you've received from our listeners and we you received them to your personal email address. We got them at the Osterholm update at EDU email address. But you've also received some not so kind messages from people. What did you want to say about that?


Dr. Michael Osterholm: [00:36:01] You know, these emails have been a reality throughout the past three years for me. I recognize they're there. I know that that happens and I've had to move on. For those that have been threatening to me or to my family members, obviously those have raised by far the greatest anxiety and concern. But I think we as a group listening to this podcast generally fit into one big family of people who care. People who aren't angry at each other in a way that causes them to use almost irrational, angry language. But I think it's important for people to know what's out there. And I'm just going to share a couple emails with you that I got. One of them you'll get a bleep on because it was not the best language. But I think it's important to point out what we're up against. So here's one from Ron that came in and said, “Hey, Osterholm, you ********, how much did you sell your soul for? This ain't over yet. WWG1WGA.” For those of you who may not know what that closing means, it's a popular QAnon slogan is “Where we go one, we go all.” And I don't know how we respond to people like this in the sense of I'm sure didn't get to email him back. But in our communities, you know, here we are trying to help everyone live their lives free of COVID, free of serious illness, hospitalizations and deaths. And then you see this. And in particular, I wanted to share the second one because it goes to the heart, I think, of what many of you are thinking. This came from Tracy Orvis, and it said that “Can't you see how ironic that someone who has been shot up and boosted five times and never leaves home and then gets sick from COVID is?


Dr. Michael Osterholm: [00:37:56] Stop the nonsense and come clean. I would think you would be terrified of dropping dead of a heart attack or a stroke from your stupid shot than catching COVID. You are a joke.” And for a number of you out there, you have experienced very similar comments as you have promoted your best approach for living with and more importantly, preventing COVID transmission. And, you know, I would only come back to Tracy and say, no, Tracy, it is absolutely a blessing that I had five doses on board and that I wore my N95 as I did. And more specifically, I also had access to Paxlovid. I very easily, as an older man, 70 years of age, underlying health conditions could have been in an ICU bed somewhere and ultimately even been one of those death statistics. So do not for a moment think that this is about you screwed up with all the doses of vaccine and with a drug on board. We know clearly from studies that, in fact, the doses of vaccine and the ability to access treatment substantially lowers the likelihood of becoming seriously ill and dying. So for all of you out there, please, when you can get vaccinated again, do it. Make sure you have access to Paxlovid. And again, hopefully those people around you and you yourself will do what you can to keep from getting infected. But if you do count on those doses of vaccine and count on treatment as what's going to make your infection an inconvenience, some cases, not something you would really want, but it's not going to be that life threatening situation. And Tracy, that is why all of the people listening to this podcast who adhere to that, they are not a joke. Trust me, they are not.


Chris Dall: [00:39:55] Now to some other infectious disease news. In the last few weeks, both Tanzania and Equatorial Guinea have reported outbreaks of Marburg virus. Mike, what can you tell our listeners about Marburg and how concerning are these outbreaks?


Dr. Michael Osterholm: [00:40:10] Well, this is going to be a little bit of an answer about demographics and one about viruses. First of all, let me just start out. The Marburg virus is a rare filovirus similar to Ebola virus. And it causes what we call a hemorrhagic fever. Previous outbreaks of Marburg viruses have seen case fatality rates ranging from 23 to 90%, making even a few cases a really major concern. The virus is rare with only a few cases reported most years, so it is surely somewhat of a surprise. We're seeing two outbreaks at the same time, but the epidemiologic data do not support that. These outbreaks are related. Let me be really clear also that Filoviruses, like Ebola or Marburg, are actually spread by body fluid contact. You know, the pandemic causing viruses are the ones I've affectionately labeled as virus with wings. These are the ones that are respiratory transmitted, aerosols, etcetera. Here you actually have to have physical contact with the body or body fluids of an infected individual. And so that is a very different mode of transmission in terms of how dynamic it can be. In Tanzania right now, eight people have been known to be infected with the virus, five of whom have died for a 63% case fatality rate. The outbreak is not over, but seems to be largely under control with all the cases occurring in a single district and just two individuals currently quarantined due to the virus.


Dr. Michael Osterholm: [00:41:40] On the other hand, in Equatorial Guinea, there have been 13 cases of Marburg associated with this outbreak, nine which have resulted in deaths or a 69% case fatality rate. While 13 cases may not seem like many. This is likely an undercount. And as the cases have occurred in three provinces, they are nearly 100 miles apart, suggesting that additional unreported transmission is occurring between people. Additionally, four of the cases have occurred in Bata, a coastal city and economic hub, with approximately 500,000 residents. So additional transmission of the virus, including to other countries, is possible. There are 825 current identified contacts who are being investigated, but as more cases are reported, we can expect that number to grow. Now, what I think is really an important context is to take a step back and remember, first of all, that all the filoviruses come from wildlife reservoir, likely infected animals, bats that surely are infected, where then they humans have contact with those animals either as bushmeat. However, that's where the virus comes from. Up until 20 to 30 years ago, Africa was largely a rural continent. There was very little urbanization of Africa. In 1990, even all the African continent had about 500 million people. Today, there are about 1.3 billion people.


Dr. Michael Osterholm: [00:43:12] The median age in Africa today is 19.7 years. And what has happened has been a major urbanization of Africa. So that what used to be all rural, where if an outbreak of a viral infection started in some rural location, the likelihood that it would spread far distances to many other people quickly just wasn't a reality. Now, today, that has changed. Remember what happened in 2014in Western Africa, in Guinea, Liberia and Sierra Leone. Between 2014 and 2016, we saw over 28,618 cases of Ebola. Of which 11,310 died. Why did that happen like that? Because it became an urbanized disease in these countries where people were packed together, body fluid sharing occurs, and the likelihood for a very rapid increase in cases is there. So while we have had a historic perspective with Ebola up until 2014 of small outbreaks, ten, 15 larger ones, 250, 300. Then you saw what happened. And so today, what our concern is with the Marburg virus, are we going to see a potential deja vu all over again? And could we have an urbanized Marburg virus outbreak occur, which could drive the case numbers into the hundreds and thousands as opposed to what we see here? So this is the challenge. So if you hear about Marburg cases, 13 cases, ten cases, that doesn't seem large and surely shouldn't be an international crisis. But in fact, what it could do in Africa could be very different in a matter of days to weeks. One more footnote. This is a virus, again, that's transmitted via body fluid contact. This is not a virus that's going to cause a pandemic. And therefore, it's not likely that we'll see any activity in the United States or other high income countries. Surely there may be a traveler that comes here, but the likelihood of seeing even a small outbreak in a high or middle income country where health care and infection control is much improved is not going to be a problem. So but we do have to stay focused on what could happen in Africa. And this surely could be a major, major challenge.


Chris Dall: [00:45:44] We also continue to receive reports about H5N1 avian flu being detected in mammals in several countries. In fact, earlier this week, there was a report out of Canada about a dog being infected. Mike, is this growing list of mammals who've been infected by H5N1? Any indication that it could potentially make it more likely to infect people?


Dr. Michael Osterholm: [00:46:05] Well, Chris, this is obviously making lots of news. And as we begin to see spring migration in North America of wild birds, we're going to see a lot of additional activity, particularly in poultry, as these wild birds and poultry mix in the migratory process. So stand ready for that. But as I've shared in the past, H5N1 has been something that some of us have been dealing with extensively since 1997, when it first emerged in the poultry markets of Hong Kong. And at that time saw human transmission of H5N1. We then saw over the course of the next few years limited activity in all of Asia. And then in 2003, that changed substantially with it, not only transmitting to domestic poultry and then to some humans, but in migratory birds moving around the world such that we begin to see more widespread transmission in Asia. Eventually, by the period of 2012 to 2015, seen major activity not just in Asia but also now in Africa. And throughout this time it has been a challenge for humans in that over 900 cases have occurred for which the case fatality rate has been over 50%. But we haven't seen is evidence of ongoing sustained transmission in humans, which is the key to a flu virus causing the next pandemic or becoming a problem in general in humans. So at this point, if you look at what we're seeing is actually almost the lowest number of cases of human H5N1 reported since the beginning of the 1997 episode with it.


Dr. Michael Osterholm: [00:47:48] Why is that yet? Why? Why are we seeing other mammals becoming infected? If you look at the genetic changes in the virus, it does not appear at this point that it is nearly as capable of infecting human upper respiratory tract cells and then causing that to be a classic flu infection that would result in that person then becoming infectious to other humans. And so from that perspective, I don't see at this point H5N1 necessarily being the highest risk virus. Surely I don't want to minimize it. It could change tomorrow. It could become the next pandemic. But I've been dealing with this virus now for all these years and just it has had its opportunities to do this and it hasn't. In contrast, one of the things that when, as I jokingly say, the band gets back together, there's a group of us who've been working on flu since the late 1990s, and as a group we were working closely together on influenza H5N1 in 2003, right up through, you know, 2012 when the whole debate emerged about gain of function work with flu viruses into more recent times. And our flu memory doesn't keep focusing back on our experience with H5N1, although, you know, if you're a domestic bird today, particularly in production area, it isn't good for you. You may be an aquatic mammal. It isn't good for you.


Dr. Michael Osterholm: [00:49:18] You may be a pelican in Peru and it isn't good for you. But we're not seeing that same thing with humans, where I think the human risk is today and I hope this never materializes. Is h two into now you say what's that? Well, for a few in this audience, you're old enough to remember that influenza viruses following the 1918 pandemic have actually followed a very similar course of their presence and then eventual absence pending a new virus emerging. And what I mean by that is in 1918, H1N1 became the prevalent virus, even though at the time we couldn't grow it. We subsequently did learn. And that virus was the seasonal flu virus until 1957, when in 1957, H2N2 emerged and H1N1 disappeared. And then in 1960 H3N2 appeared and eliminated H2N2. We don't know why this happens, but H2N2 disappeared. Remember that date? Okay, that's an important one. 1968. Now along comes H1N1 again in the late 1970s, which we have at this point surely determined was a H1N1 virus the Russians were working with and their vaccine programs and likely escaped from their program to now cause a co-circulation of H1N1 and H3N2, which happened until 2009 when a new H1N1 replaced the old one and that caused that pandemic. But the bottom line message here is that we have not seen h two into since the late 1960s.


Dr. Michael Osterholm: [00:50:57] Think of all the people in the world who have been born since the late 1960s. Would never have encountered this virus. Would have never had any residual immunity from an H2N2 infection. And I think that's the one that, to me raises the great challenge and among many of my colleagues. So I hope we never encounter an H2N2 pandemic. But it would not surprise me that is the next one we would see. And I'm hopeful that H5N1 will not become a serious human challenge. And I surely wish it wasn't so much of an animal challenge at this point either.


Chris Dall: [00:51:35] What can you tell us about our latest beautiful place submission?


Dr. Osterholm: [00:51:40] You know, I can never adequately explain how these beautiful place submissions. So move us to all of you who have submitted them. I wish we could use them all. And to those who have had the opportunity to view them, I hope they're as meaningful to you as they are to us. The beauty of these beautiful places is so hard to describe. In a word. You have to experience it. You have to feel it. You know, for the first time, you walk to the rim of the Grand Canyon. You can use whatever words the English language provides, but you'll never be able to adequately describe the feeling of that very moment. And I feel that way with these beautiful places. It's just remarkable. And today it is no different. This is one that is not only creative, but incredibly impactful in terms of telling the story of COVID.


Dr. Michael Osterholm: [00:52:36] This beautiful place is from Jane Ellen. And you have to see the pictures that are attached to the website here to really understand this. She wrote after following the Osterholm update. For some time now, I wanted to share this art project that I created during the coronavirus pandemic. It is a daily visual journal where I marked each death from COVID-19 with a one fourth inch mark of graphite on paper. It is intended to be a memorial for all of those who have died from this virus. The large image shows the first year of the pandemic and includes 459,381 marks. Year two and three are formatted to month so that the comparisons can be shown. Year two, there were 442,487 deaths and year three exhibits 210,956 deaths totaling 1,112,806 deaths. Starting on February 6th, 2020 and continuing through February 5th, 2023. My footnote this is of course for the US. I hope that Dr. Osterholm can see the images from this work, which I obviously have. It is an astounding project to see in person and easily understood once the observers realize that each mark represents one death. The first year image is 90in high and 110in wide and the second and third year images as shown, start with the month of February and continue through January. This work was shown locally in January 2023, just as I was ending my project. My data was from Johns Hopkins, as published in the New York Times Coronavirus Daily Report. I would love for others to see this project and hoping there might be some institution that might be interested. It is quiet and provokes much thought about the loss of our nation suffered during this time.


Dr. Michael Osterholm: [00:54:31] I believe it is a way that science and art can work together to understand the reality of the pandemic. Thank you for looking at the work. Sincerely, Jane. Ellen. Well, Jane Ellen, I am so moved by what you've created here, and I hope everyone does take a look at it. And it's also a reminder to me of the long journey that we've been on. I remember very well in January of 2021 being on Meet the Press in which I said I thought the darkest days of the pandemic were still ahead of us. And that was met with a lot of anger by a lot of people for being scary. Yet you remind us with this very work that you've done, that 41% of the deaths had occurred as of that time, i.e., 59% were yet to come. And this just reminds us of the long journey we've been on. And I know that you, Jane Ellen, would want everyone to remember that each one of these marks is not just a mark. It was a human soul. It was someone we loved. It was someone we cared for. And when you see all of those marks, it is really mind boggling what we've lost in this world. So I hope you do take time to go and look at the photographs. Jane, Ellen, thank you so, so much for sharing them with us and for what they represent. It is a beautiful place to remember these lives.


Chris Dall: [00:56:00] And just a reminder to our listeners that if you want to tell us about the beautiful place that has helped get you through the pandemic or share a celebration of life for a loved one friend, neighbor or coworker who died during the pandemic. Please email us at OsterholmUpdate@umn.edu. Mike, what are your take home messages for this episode?


Dr. Michael Osterholm: [00:56:19] My most important message I can share right now, at least from my own personal perspective, is thank you, thank you, and thank you. To this podcast family and for your support. I wish all of us could support each other the way you have supported me in the last couple of weeks with this infection, and I can't begin to put into words what that means. Just never forget that. I never forget just how important those connections are. It shouldn't take a deadly virus to make that happen, but for where it has and how it has. I thank you.


Dr. Michael Osterholm: [00:56:57] Second of all. I don't know where we're going. I don't know what's going to happen in India. Is that a harbinger of things to come? Are we going to see a gradual reduction in serious illness and hospitalizations around the world? I hope so. I don't know.


Dr. Michael Osterholm: [00:57:13] The third thing I'd leave you with. And I said this earlier, and in sharing some of the emails I did, I tried to provide maybe that sense of contrast. But I've never believed more than I do now that there is more good in this world than there is bad. And we must never forget that it is so easy to be inundated with the bad, whether it's on our TV screens. It's what people send us on social media, etcetera. Sometimes it happens right in our own families. But please never forget there is more good than there is bad.


Chris Dall: [00:57:51] And your closing song or poem for today.


Dr. Michael Osterholm: [00:57:55] Well, in trying to follow through on this theme of what the world is all about and what we can expect for the future, I've taken us back to a song that we've previously used three times on November 6th, 2020, in Episode 30: A New Dialogue. We used it on November 4th, 2021, in Episode 76: Vaccines in the World of Delta, and again finally on May 26th, 2022, in Episode 105: COVID-19, Monkeypox and Pediatric Hepatitis. Now, this song is one familiar to all of you, whether you've ever listened to this podcast or not. It's Tomorrow. It's a show tune from the musical Annie with Music by Charles Strouse and lyrics by Martin Charnin. It was first published in 1997. The number was originally written as Replay The Way We Live Now for the 1990 short film Replay with both music and lyrics by Strouse. And so here it is. Tomorrow, something we must always count on. The sun will come out tomorrow. Bet your bottom dollar that tomorrow there'll be sun. Just thinking about tomorrow. Clears away the cobwebs and the sorrow. Till there's none When I'm stuck a day that's gray and lonely. I just stick out my chin and grin. And say, oh, the sun will come out tomorrow. So you got to hang on till tomorrow. Come what may tomorrow. Tomorrow. I love you tomorrow. You're always a day away Tomorrow. So you got to hang on till tomorrow. Come what may. Tomorrow. Tomorrow. I love you tomorrow. You're always a day away. Thank you so much for being with us again this week. I hope the information was helpful and thank you for everything you do for us.


Dr. Michael Osterholm: [00:59:58] Hopefully these podcasts continue to give you the information you may need in a world that is not interested largely right now in talking about COVID. And we just appreciate you so much. And we never forget that those marks are more than just marks. There are souls, and that's something that every podcast only becomes more and more real, that we must never just become number crunchers. That would be the worst of all.


Dr. Michael Osterholm: [01:00:28] Thank you so much. Have a good, safe two weeks here. Be kind, Be kind. You know, really mess somebody up big time by wondering why were you so kind to them today? Do it. So thank you so much. Until next time. Thank you. Thank you. And be kind.


Chris Dall: [01:00:52] Thanks for listening to this week's episode of the Osterholm Update. If you're enjoying the podcast, please subscribe rate and review and be sure to keep up with the latest COVID-19 news by visiting our website cidrap.umn.edu This podcast is supported in part by you, our listeners. If you would like to donate, please go to cidrap.umn.edu/donate. The Osterholm Update is produced by Cory Anderson, Meredith Arpey, Elise Holmes, Sydney Redepenning and Angela Ulrich.