April 20, 2023

In this episode, Dr. Osterholm and Chris Dall discuss the state of the pandemic in the U.S. and around the world, the end of the Public Health Emergency in the U.S., and the recent FDA approval of an additional bivalent booster dose.

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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. On April 10th, President Joe Biden signed a bill from Congress immediately ending the COVID-19 national emergency, which has been in place since the spring of 2020. The end of the national emergency means the end of some blanket waivers for federal health programs that were intended to help health care providers at the height of the pandemic. The national emergency is different from the public health emergency, which enables the government to provide Americans with COVID-19 vaccines, treatments and tests at no charge. That remains in place until May 11th, when it will be officially terminated. But any way you look at it, the US government has decided that the pandemic is over. In the meantime, a new COVID-19 Subvariant XBB.1.16, also known as Arcturus, is now in 29 countries and appears to be behind a surge of cases in India. As Dr. Osterholm has said countless times, we may be done with the virus, but it isn't done with us. That will be the focus of this April 20th 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 FDA's recent announcements on the Bivalent vaccine and a Biden administration plan to accelerate development of new coronavirus vaccines and treatments. We'll also answer some COVID queries and 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. Osterholm: [00:02:08] Thanks, Chris. It's great to be back with all of you again to share an update on where we're at in this pandemic and for a bit of a reflection. And when I say reflection, first of all, let me say that I'm reminded of the song from the 1970s hit “Welcome Back, Kotter,” which as many of you know is a TV show about a group of high school students. And there was a line in the theme song for that that says, “welcome back, your dreams are your ticket out,” and it's sung by John Sebastian. And I think today that in many ways “welcome back, your dreams are your ticket out” is we're all dreaming about a day when this podcast won't exist that we don't have a need to have this podcast or at least to reflect on what's happening with the COVID world. And today I just want to share with you the fact that, yeah, we still have more to learn. We are still experiencing this virus, but surely in a very different way, and that if nothing else has come out of this pandemic, which has been so, so painful, has been the goodness of this podcast family. I have to say that for two reasons. One is I'm pretty much recovered from my COVID infection. Still a little bit of fatigue. But beyond that, I'm doing very, very well.


Dr. Osterholm: [00:03:27] And I want to thank all of you, all of you. I can't say that enough times. All of you who reached out through cards, emails, contacts with staff to find out how I was doing, it was remarkable. It was kindness in a way that I had never imagined could exist. And it's in that second part of this issue that I want to raise about this pandemic. And what's happened is the fact that if we've done nothing else on this podcast for the last three years, we have created a community of kindness and the podcast family gets that. They understand that. And for every bad email I get, which may have nothing to do with the podcast, we get so much very, very positive feedback, thoughtful feedback, not always just agreeing either, but in a very thoughtful and respectful way. And so today I just want to say that it means the world to us at CIDRAP, because we read every one of these notes that come in. We take them very seriously. We take them to heart. And they have been remarkable. So I want to thank you all so very, very much for what you do to create this in a sense, counter pandemic of kindness, which I think has been so very, very important.


Dr. Osterholm: [00:04:43] I'm also very happy today to share this dedication with you because it's one that I have heard from many of you about. And what it really reflects is all of our desires to stay fully vaccinated as much as we can relative to what dose is available of which vaccine. And as you heard on Tuesday, the FDA announced that, in fact, we are now going to have access to a second bivalent vaccine dose booster. And I'll talk more about that in a moment. But I think that for those of you who are more than six months out, you have been nervous about, wouldn't it be great to get that? As you know, I was refused a second bivalent dose here in Minnesota because it did not line up with the national recommendations. Unfortunately, seven weeks later I got COVID. I wish I had gotten it, but so we'll talk more about that. So this podcast is really dedicated to those struggling with the desire to get a second bivalent booster dose. Your time has come. I wish I'd been in time for me, but I surely will look forward to a booster dose in the future. So I want to dedicate this podcast to you. I also want to share a very special beginning of what will be an Indian story with this podcast. And that has to do with the sunlight today in Minneapolis.


Dr. Osterholm: [00:06:07] Sunrise is at 6:20, Sunset is at 8:04. That's 13 hours, 44 minutes and 29 seconds of sunlight. We're gaining about two minutes and 51 seconds of sunlight a day. Remarkable in the fact that we now have gained over five hours and 58 minutes of sunlight since the winter solstice on December 21st. It's going to get better. Hang on. But for our colleagues in Auckland, in particular, our very dear colleagues at the Occidental Belgian Beer Garden on Vulcan Lane in Auckland today, you will have 10 hours and 59 minutes of sunlight with sunrise at 6:50 and sunset at 5:49. Now I say there's a second part to this because as we get to the end of the podcast, you'll understand why there's something very special about the accidental we're going to talk about today. So thank you for being with us. I hope that we can provide some context to where we're at today. I will say we have more good news, generally speaking, than any kind of bad news. But as I've said time and time again. Again, this virus has a way of sneaking up on us and doing things we hadn't anticipated. And I'll try to share that perspective today and what we know and what we don't know about that.


Chris Dall: [00:07:21] Mike, As we discussed in our last episode, India is seeing a surge in cases that appears to be fueled by the XBB.1.16 sub variant. But we're also seeing cases rise in other parts of Southeast Asia, including Vietnam. What can you tell us about this and what do we know about XBB.1.16.


Dr. Osterholm: [00:07:42] Well, first of all, let me just start out by acknowledging once again that this virus has never really made it easier or even possible to figure out what it's going to do, where it's going, what might be tomorrow. It's been one long lesson in humility, and I am the first to acknowledge that. And that's exactly the reason why I've generally avoided making confident claims about what our future with this virus will look like. At least in the past several years, as I've learned so much about variants and sub variants. Well, given we're at today in terms of disease surveillance data and the dismantling of so many of our disease surveillance programs around the world, it almost feels like an equally difficult task just to understand what the virus is doing right now. So this is not understanding the biology of the virus. It's understanding can we even count the cases that are occurring in our community and what kind of cases? So in other words, I no longer just have a crystal ball caked in mud, Chris. This mud is all over the place. So now with that out of the way, let me try to at least get at your question. Of course, you mentioned India and all signs point to them seeing a notable rise in cases. Around a month ago, they were reporting several hundred cases a day.


Dr. Osterholm: [00:08:54] Fast forward to this past Monday and the cases there are now over 9100. Now, clearly, this is an undercount. Remember, that's a population of 1.3 billion people. There's no question about the number of cases being missed. What we are seeing is the rising test positivity and a spike in wastewater data. Right now, we're running at about 30% of all people tested in India are positive, which of course is very hard to interpret. But it was of interest that the only higher levels that they experienced throughout the pandemic was during the height of the Delta surge, when they were at 36% positivity and during the Omicron surge at 30% positivity. So I'm not quite sure how to interpret this other than it may be a sampling issue because the number of hospitalized cases is substantial below the peaks we saw with both Delta and the Omicron waves that occurred there. Now, maybe there's just a lot more infection out there that's much milder and that's being picked up through this testing. But from that perspective, I'm not sure that we are going to see a major impact issue in India even with this increasing number of cases being reported. In terms of what does the XBB.1.16 mean, What is its role right now? Well, as a reminder, it's an offshoot of the XBB.1.5.


Dr. Osterholm: [00:10:14] It's distinguished from that XBB1.5 with two substitutions in the spike protein. The earliest known samples of the sub variant were documented in January just a few months ago. In our last episode, I mentioned that the W.H.O. designated as a variant under monitoring. This was largely done in response to the apparent growing number of cases throughout different parts of India. But I think the important message here is to say is, is that at this time, this is clearly not creating the kind of major surge that we've seen in the past. It really is one that is like with so many other previous variants causing some uptick in cases, but we just don't know how much. So what is the implications for this and the rest of the world? Well, we know we have a lot more immunity in the world, even if immunity only against serious illness, hospitalizations and deaths from having either been vaccinated, which is probably the minority for most countries in the world, but rather from having been previously infected. So while there is some lab based data indicating that XBB.1.16 could have increased immune evasion and potentially some advantage related to the capacity to replicate and grow, I think at this time we don't have any evidence that that is actually translating into major, major surges.


Dr. Osterholm: [00:11:34] Now, let me qualify that only in saying that if you look at other countries in the world, we are beginning to see increases in cases in a way that is still far, far too early to interpret what's happening. Let me just say on a global basis, just as a summary, if you look at deaths, which surely are at least one more standard measure of what's happening, from March 13th to 19th, there were about 5700 deaths reported globally. That's a month ago from April 10th to 16th. We had 2300 deaths reported globally, not even half that number. That surely is a good sign. When we look at Europe's numbers, it's of interest to note that that, too, is an area where we're seeing decreasing deaths. If we look at the eastern Mediterranean, this is one that's a little bit more difficult to ascertain. Here we have seen both case numbers and deaths go up. I've put much more reliability in the death numbers where from March 13th to 19th, in the eastern Mediterranean, there were 122 deaths recorded. And in the April 10th to 16th time period, it was 261. So more than twice the increase in numbers of deaths. If we look at the Western Pacific there, the numbers have dropped substantially. Deaths in March 13th and 19th was 852.


Dr. Osterholm: [00:12:55] This most recent April 10th to 16th was 300. And then again we come back to Southeast Asia. Another in a sense, outlier in terms of the general trend here. In March 13th to 19th, there were 50 recorded deaths. And from April 10th to 16th, there were 225 deaths. And with Africa, the death numbers, I think are so low as to be really notably unreliable. Only nine deaths recorded from March 13th to 19th, with only two recorded all of April 10th to 16th. So to put this into perspective, none of those numbers that I just shared with you indicate big new spikes of cases. We're not in an Alpha, Delta, Omicron surge world, but we still are in a world where activity is occurring. And what we don't know is what is going to be the interface between these new variants and human immunity. At this point, I'm more optimistic than I've been at any time in the pandemic in terms of just the reduced numbers and we talk about the US data, I think that will become abundantly clear what I'm talking about. So, Chris, even with the looking at the new Sub-variant impact, we don't see anything globally that looks to be a major concern that we're now seeing the emergence of a major new surge in activity.


Chris Dall: [00:14:15] Here in the United States. XBB.1.16 accounts for 7.2% of new infections, according to the latest CDC data. But that is not yet affected COVID markers, which continue to fall. So that leads me to this question, Mike, is now the right time to end the COVID-19 national and public health emergencies?


Dr. Osterholm: [00:14:38] Chris, let me be clear. There is no right or wrong answer here. Too much of the US population, the pandemic is done. The public health emergency is over. It doesn't matter what you have in statute or in declarations, anything. The pandemic is over for many. Now, let me begin with adding some context before we get into more of the nitty gritty of what's happening in the US. We are today averaging about 190 deaths a day. Again, everyone knows they've heard this time and time again on this podcast. These are someone's father or mother, brother or sister, aunt or uncle, dear friend, and even painfully sometimes, our children who are dying. So I don't want to dismiss that. But this surely is not the same as when it was at 350 or 500 or 600 deaths a day, or when during the big surges, we saw as many as 3300 deaths a day. So we have a new shifting baseline. And that's important to understand. You know, life is a risk for death. All of us are going to die. Nobody gets out of this world alive, depending on what your religious beliefs are. And so I think the challenge we have today is how do we put these numbers into human context? Nobody has to be reminded on this podcast. If one of those numbers was your family member, your friend, your colleague, that is a painful acknowledgment of something that's happened to you. And I don't want to minimize that. But let's look at where we're at. There's never really going to be a right time, I think, to say that the pandemic is over, given that the vast majority of people already believe that to be the case.


Dr. Osterholm: [00:16:18] But in reality, we continue to see COVID activity in this country. We are clearly beyond the emergency phase of the pandemic. And we even have health care workers suggesting we need to change how we're looking at COVID within our hospitalized patients. And I'll talk more about that in a moment. With the president declaring the national emergency over on the 10th and public health emergency set to expire on the 11th. I worry about some implications. The end of the public health emergency surely is of concern if in fact there is no longer access to free test and treatment, particularly for those who no longer have health insurance. This is going to be a huge issue. Now, the White House did announce that, in fact, they are launching a new program, though they are actually going to stockpile drugs, vaccines and tests for those who cannot afford them who are uninsured and that that will carry into the future. Now, we've not seen the details of that plan, but the population will qualify for free care, includes more than 30 million adults without health insurance, though, as we know, that number could grow as the pandemic error protections expire and more people lose their Medicaid coverage. We already also know there is a separate preexisting federal program that will continue to provide free vaccinations for uninsured kids. So in that sense, we're going to be covered. We just need more details from the administration about what that means. Now, what actually is happening with cases in the United States, I no longer have any real confidence in surveillance data.


Dr. Osterholm: [00:17:51] We've talked about that many times. You know, I'm an example, even though I called in my case to my colleagues at the Minnesota Department of Health, I was never counted because I was only a lateral flow positive test result. That was it. So but what can we do today? And I think this is where wastewater surveillance is really, really important. This is where I'm getting much of my data to understand what's happening. If you look at Biobot Analytics, they are the leading private organization in the country supporting wastewater testing right now for COVID. They're in all 50 states and some provinces of Canada. They have over 700 sites in the United States representing over 100 million population. And in the 85 weeks of surveillance that they've done, they're only six weeks in that 85 weeks that are lower than the rates we're seeing right now. The level is the lowest right now that we've seen all year long. That is a good measure that is telling us that activity is decreasing. And I think that that's a very important number. So I will continue to stay laser focused on the data coming out of the wastewater surveillance program. I think that's one without bias. So, Chris, I think the public health emergency challenge will be met if the administration is able to provide vaccines, drugs and testing to those that can't afford it. For many of us who have health insurance, it will be covered under that rubric. And what's really important is that we have some understanding of what's happening with the virus in our communities.


Dr. Osterholm: [00:19:30] And I think right now wastewater is going to provide that to us. Although I will continue to track deaths, I think that will be a very important issue. One last piece. We can't stop advocating these vaccines. I worry that there will be kind of a Well, it's all done. No, for those on this podcast who want that second bivalent booster dose, you know you won't be a problem getting it. You'll be there probably this weekend. And we'll talk more about when these might become available. You'll be there, but for everyone else, we have to. To continue to emphasize, particularly those that are increased risk for serious illness, hospitalizations and deaths, older populations, people with immune compromising conditions or other health conditions there. We want to continue to push that. I've said it before, I'll say it again. Some people have misinterpreted what this comment means, but I could live very happily with COVID infecting all of us twice a year, but never, never more than a mild cold, even in those who have underlying health conditions. Wouldn't that be a great way to end this and just say, I can handle a sniffles for a couple of days? Nobody gets critically ill, nobody dies. That's where we may see this virus taking us more to. I never will get to a point where no one will die, but we surely can see a change right now in the number of people dying and just how much virus is in our community. This is great news.


Chris Dall: [00:21:02] Well, speaking of vaccines, we discussed this on our last episode before it was official, but the FDA has now officially authorized a second bivalent booster shot for people aged 65 and over and those with weakened immune systems. In addition, in its announcement, the FDA said that all COVID-19 shots given going forward will be the bivalent vaccines. Mike, what are your thoughts on these moves?


Dr. Osterholm: [00:21:28] Well, first of all, I give credit to the FDA for moving on this information and making these vaccines available. Later today, the ACIP, as part of the CDC Oversight and Recommendation group for vaccine use will actually take this up. And I'm quite certain that they will support fully a recommendation to make the vaccines available, much as the FDA has recommended. So I think that will be available as early as this weekend. This is great news. I have to say that much of the data that supports the fact that vaccine effectiveness wanes significantly in the 3 to 6 months following vaccinations is still a challenge. There have been several recent papers that have come out that I think are very important that really support this. And while some of my colleagues have come out saying there's no data yet to support this idea of additional booster doses, the Bivalent vaccine, I just simply do not believe that's true. There's a paper making its way through a review process right now from a group in Israel and in Boston. My friend Jeremy Foust is one of the coauthors on that. And in this paper where they looked at it, they came to the conclusion that their study did provide evidence for the benefit of a routine six month cadence for COVID-19 boosters, for high risk groups, and probably more frequently, even during the relatively lower COVID-19 prevalence time period.


Dr. Osterholm: [00:22:59] So there's one there was a second paper published in Eurosurveillance that came out earlier in February, a paper from Italy that actually looked at the same thing, and they concluded a second booster vaccination six months after the latest infection may be warranted. And then finally there was a paper I already discussed that was published on April 12th in the New England Journal of Medicine on the durability of Bivalent boosters against Omicron Subvariants. All of these point to the fact, yes, let people get vaccines every six months, potentially, maybe even sooner at four months. And this is really a permissive situation. We're not demanding that people get vaccinated. So no one can say somehow that in fact, they're being forced into more vaccines. But there are a number of us who want to get those additional doses. I will after I go through a period following my infection so that I maximize on my next immune hit. We'll look forward to getting my bivalent booster dose 4 to 6 months out from my infection. So I think at this point, Chris, it is really a done issue. I'm really pleased that it's a done issue that we can move on from that. And I just want to say that at this point, I know that there are some who are disappointed to see that those under 65 who are not immunocompromised are not eligible to receive an additional dose.


Dr. Osterholm: [00:24:26] There are a number of individuals in this group, and I've heard from you, and I think that you're going to see even that be reconsidered in the near term in terms of ultimately making it a permissible recommendation where people who are under age 65 can still get the vaccine. You know, 97% of the deaths in this country in the last eight months were in those who are 50 years of age and older. So there surely is still some in that younger age group in the 50 to 65 in particular, that would be warranted to do that. So and as the FDA stated in their press release, they would consider the possibility of future additional doses at an advisory committee meeting in June. So I think the bottom line is that this is a major step in the right direction. But since we are still years away from having better vaccines that provide more durable protection, the fight for access to additional bivalent doses is far from over. And we'll just continue to stay on top of it. You know that our group at CIDRAP has been very actively involved supporting this area of information and action, and we'll continue to do so.


Chris Dall: [00:25:38] The Biden administration last week also announced the launch of a $5 Billion plus program to develop the next generation of COVID-19 vaccines and treatments. According to media reports, it will take a similar approach to project Warp speed, which saw the federal government partnering with private companies to expedite development of vaccines and therapies. Mike, what do you make of this effort?


Dr. Osterholm: [00:26:02] Well, this is a surely a piece of good news relative to the recognition that we need to continue to invest in finding even better COVID-19 vaccines than we have now. Make no mistake, the vaccines that we do have now have saved millions of lives, literally millions of lives. And that's not just a very verbose statement. There are data that support that. And so these vaccines that we have now still must be used and continue to be part of our approach to dealing with COVID. But we know that we need better vaccines. We need ones that have greater durability, that have the ability to protect against new variants or sub variants, even ideally any new coronaviruses that may emerge. And that is not going to be easy. And we happen here at CIDRAP to be in the middle of that. As many of you know, we developed under the leadership of Dr. Chris Morris CIDRAP, the coronavirus vaccine roadmap, which was a year long process involving more than 50 experts who brought their very best to the table for that year's period. And we developed a plan that looked at what do we need to know, how will we learn it and what will be the timeframe. And so we put a very measurable objectives and goals together with time. Unfortunately, that means that it may be five, 6 to 7 years before we realize some of the outcomes of our research and development work that will give us these better vaccines.


Dr. Osterholm: [00:27:37] Now, today is a very interesting day for us with regard to the roadmap work that I just referred to that we're actually having a webinar later this morning that by the time many of you listen to this podcast will already happened and which we are detailing our work with a number of the world experts, and we have a representative from the White House who will be on the webinar detailing this new, what it's called next gen activity. Looking at the next 18 months of this $5 Billion funding. Now, I don't want to get into it too much because in fact the details are still sketchy. We need to hear more from the White House. My only caution with all of this is that there is no way in God's green earth that we are going to have major breakthroughs in 18 months, no matter how much money you put into this. It'd be like if you asked someone to rebuild the Empire State Building in two weeks, but they had unlimited budgets isn't going to happen. And so we have to commit ourselves to this long term research and development situation, knowing that it won't be this year or next year.


Dr. Osterholm: [00:28:52] You know, we would welcome that if it were to happen, but it's just not going to the roadmap that we developed really lays out many or many of the questions we have, including just something as simple as what is a correlative protection. If I'm measuring something in your blood, whether it's related to A, B cells or T cells or any of the other immune aspects of our immune system, what is it that I can measure that says, okay, you're now protected or you're not? Because by that very fact alone, what it does is it tells us we understand the reasons why we're being protected and what we can do to enhance that protection. So all I can say at this point is I'm very thankful that the administration is pursuing this. Please, please do not do not make this an 18 month initiative. You know, I think people think that Operation Warp Speed was an example of what you can be done in 18 months. Please understand that mRNA vaccines and chip adeno platform vaccine research was going on for literally years and years before this application and its use in the COVID pandemic response. We have a lot of work to do. And so the good news is this is a start. The caution is don't see this as 18 and out. I would hate one day to have the Congress come back and say, hey, look, you got your $5 billion.


Dr. Osterholm: [00:30:21] You know, you had your chance. You didn't get it done. And there's no more to be had. We have to help everyone understand this is a long term investment and something that will pay back in spades if we can develop these truly game changing vaccines. And this is not just for COVID, this is for influenza, too. As you know, our group did the influenza vaccine roadmap, the very similar process several years ago. We've actually put out a report just several weeks ago looking at progress over the last year. And we still have a lot of work to do that way. And needless to say, the next pandemic is going to happen. It's likely going to be influenza or coronaviruses. We just don't know when it's happening. And I can tell you the pandemic clock is definitely ticking. So any work we can do to get better vaccines that actually can also instill more public confidence will be really, really critical. So, Chris, we'll hear more at our webinar later this morning from the White House with their first official comments on what this project is all about. And we appreciate their participation. We surely appreciate their efforts to bring more to the table on research and development of game changing vaccines.


Chris Dall: [00:31:42] Now it's time for our COVID queries. This week we heard from Brooke, who wrote I got COVID for the first time right after Dr. Oh, did I still feel it? And I still am testing positive. Work wants me back. So I checked with the CDC. I did their COVID-19 Isolation and Exposure calculator and found the results a bit confusing. It's been more than ten days since I became symptomatic, but I still have mild to moderate symptoms and a positive test. Yet the calculator tells me I'm clear as of a few days ago. Do we know anything more about the relapse syndrome and infectivity at this point? What can you tell? Brooke. Mike.


Dr. Osterholm: [00:32:18] This is an absolutely great question, Brooke. Thank you for asking it. And I want to start off by saying that you are not alone in being confused by the CDC isolation guidelines and isolation exposure calculator. For context, the CDC s current guidelines state that individuals with no symptoms or mild symptoms can end isolation on day six of their infection and wear a well-fitted mask when around others through day ten of their infection as long as they are fever free for at least 24 hours without the use of fever reducing medications. The CDC then recommends that those who have had moderate illness, including shortness of breath and difficulty breathing, isolate through day ten and those who are hospitalized or immunocompromised isolate through day ten and contact their health care providers regarding ending isolation. However, the CDC isolation exposure calculator does not even ask about severity of symptoms if you are hospitalized or if you are immunocompromised. And as a result can give advice that conflicts with CDC's own recommendations. Assuming your symptoms were mild, you aren't immunocompromised and weren't hospitalized due to your infection. Then, according to the CDC guidelines, you could have ended your isolation on day six of your infection as long as you were fever free for at least 24 hours. But as listeners of this podcast know, I have been critical of these guidelines that there's a lot of evidence to suggest that about 50% of infected individuals are still infectious on day six. This is not mentioned anywhere in the CDC guidelines. Now, let me just give some historic perspective here. It was in late November of 2022 that I actually contacted senior leadership at the White House and at CDC and said, look at Omicron is coming.


Dr. Osterholm: [00:34:07] It's going to be a real challenge with so many people who will be out sick or infected at the very same time. And how are we going to maintain our hospitals? How are we going to maintain the very critical infrastructure that we need every day just to basically make sure that people don't die from any other kinds of health conditions? Well, at that point, the data that we had said that, as I just pointed out, you may be infectious up to ten days with 50% of infected individuals still infectious on day six. At that point, we got into making policies that were not really based on science. When I made the recommendation to go to day five for someone who was mildly ill, who would be willing to wear an N95 respirator the entire time, and they were cohorted in hospitals working with other COVID-19 cases. That was really just a short term kind of triage recommendation to get through what were the course of. Weeks later, we saw that recommendation being stretched and stretched and stretched and stretched such that we now have this kind of what I guess I would call isolation conundrum. What do you do? So to me, I think the data is still support the fact that, you know, for you to be feeling confident, you're not transmitting to others. Even with milder illness, you may be infectious, not just infected and infectious for up to ten days when in that ten day period will you not be infectious anymore? Well, it's not even clear with rebounds like I had that that means you're still infectious again or you weren't.


Dr. Osterholm: [00:35:51] You weren't in. You are now. You know, when we look at the standard PCR tests or the lateral flow test, they're not really telling you whether or not you have live viable virus. They're they're telling you that you basically have the antigens that we're trying to pick up in these tests. And we know that with viral infections, you make lots of viral debris, extra pieces of material and that people may be picked up positive for weeks after their infection, even though they are no longer infectious. So the bottom line message here is, I think that this calculator is an attempt to make people feel more comfortable with what they're doing. I continue to say that up to ten days after your infection you may be infectious and that we just have to deal with that. Now it's interesting. There's a group of health care workers in this country that have just published a paper recently saying, skip all of this. We don't do this for flu. We never ask people to stay away from others, to wear an N95 respirator, etcetera. If you have influenza and that actually they're right. They are right about that. We haven't looked at that. But my answer is, rather than say because that's the case, skip any kind of respiratory precautions with COVID-19 and you can go back to work any time you want. I think we need to take a step back and look at all respiratory infections.


Dr. Osterholm: [00:37:14] We surely have done a poor job in this country looking no further than our health care settings and the number of studies now coming out showing widespread infection in health care workers in in the health care setting, which may actually have been acquired in the community, but then brought into the hospital or acquired in the hospital. So I think that at this point, I don't have a magic answer that's going to make you feel comfortable other than to say this is what I did. I basically isolated for ten days, may have been overkill in that the fact that I might have only been infectious for day 6 or 7, I don't know. But that I think are the best data we have. And if you're not going to use viral isolation data as opposed to these other tests, you're never really going to know if somebody's got virus or that they're blowing out into the environment or not. So I hope this is helpful to you, Brooke, because I know it's confusing. By the time you hear this, you've now had so many days since your infection that I'm sure you're back to work or doing whatever it is you want. And for all those that are struggling right now with this, this is my best advice, not necessarily what you wanted to hear, because I know that many of you who are feeling better at day 4 or 5 just say I'm moving on. And again, I understand that. But if you're putting others at risk for exposure, that's a real challenge.


Chris Dall: [00:38:41] Then we received a non-covid query from a listener who wanted to get your thoughts on a cluster of creutzfeld-jakob disease cases in Western Michigan and possible links to chronic wasting disease.


Dr. Osterholm: [00:38:54] Thank you for that very interesting question. It's one of great interest to us because we are doing so much work right now in chronic wasting disease. And we are very concerned that the prions in white tailed deer and other cervids may very well one day infect humans as a result of consumption of the venison or the meat from that deer. When we look at how we're ever going to pick up a cluster of cases, that will give us an indication that such transmission may have occurred, we likely what we saw in Europe back in the 1980s and 1990s, you may recall, with bovine spongiform encephalopathy, another prion disease that was actually transmitted ultimately from cattle to humans. The big outbreak of BSE in cattle occurred in the mid 1980s, as were the outbreak of variant CJD, or in this case caused by BSE, didn't really show up for almost another 8 to 10 years later. And so we're constantly in surveillance right now for human cases with any cognitive dysfunction that could in fact suggest that it is not just Creutzfeld-Jakob disease, a condition that occurs in about one per million population throughout the country, but one that actually is due to the prion from consuming contaminated meat.


Dr. Osterholm: [00:40:23] Now, one of the issues with this particular cluster that was apparent right up front, these were all people in their 70s, older individuals, which is very typically what you see with Creutzfeld-Jakob disease is prion related condition. This is one that is often genetic related. It's not related to transmission of any kind of prion between people. As I mentioned, it has an overall rate of about one per million population. So in a state like Minnesota, for example, with 5 million people, we would expect to see on average at least five cases of Creutzfeld-Jakob disease annually. Now you have these clusters in Michigan where there were four cases, as you pointed out, of which several of them actually were deer hunters or consumed deer meat. And so that surely was a challenge that this could be. I'm unfortunately for these individuals, they've experienced this fatal condition. But in talking to the investigators, including our colleagues at Case Western Reserve University, that actually is the one single human testing lab in the country for human prion related diseases, that these were, in fact Creutzfeld-Jakob disease situations and not chronic wasting disease. My big concern is going to be one day when I hear about a cluster of three individuals who are in their 30s in some area in the country knowing that, oh my God, that is almost a guarantee.


Dr. Osterholm: [00:41:55] It's not going to be Creutzfeldt-Jakob disease, but rather it will be related to the prion activity of consuming deer meat. I hope that day never comes, but I'm very concerned that it might. We have initial data right now from the US Department of Agriculture, which we wish they would provide more clarity to it, suggesting that there may actually have been transmission from cervids or whitetail deer to feral pigs, swine in one or more southern states in the United States. That by itself is a real concern. And the data we have right now shows that the CWD prion in whitetail deer now can readily infect humanized mice, mice that whose immune systems have been made more to look like humans. And that by itself is also very concerning. So this is a stay tuned moment. And this is why we urge everyone who is a deer hunter, particularly in areas where CWD is known to exist in the deer, Please test your animal before you consume it. That's going to be a very, very important way for you to protect yourself and your family.


Chris Dall: [00:43:09] Mike, what can you tell us about our latest beautiful place submission?


Dr. Osterholm: [00:43:15] Well, this one is very, very, very special to me. And I hinted at it in the introduction when I talked about how we'd combine that with the accidental Belgian beer house. I received an email this past week from Jim and he sent along a very beautiful picture and he stated, We stopped off for lunch at the Occidental Belgian Beer Garden in Auckland. Our waiter knows Dr. Oh well, and says he was given a nickname by Dr. Oh. Please accept my deep gratitude for the last three years and guiding me through COVID. Jim. Well, thank you, Jim, for that wonderful picture of the Occidental. It's on our website for the podcast. Please go take a look at it. And I always love connecting with the group down there. They're very, very special people. I've had some wonderfully special times there and I think it goes with that whole discussion we had earlier about kindness. Every time I've ever been in that bar, it has been a very kind situation with lots of entertainment and fun and people just caring about people. So, Jim, I'm so glad that you went and had a wonderful time. Great picture. And any of you who might be in New Zealand stop off there, you know, I have no investment in the bar. Okay. So there's nothing in it for me other than the fact that I will never forget the wonderful times I've had there and look forward to the wonderful times I will have in the future. Fernand I will definitely be going back to New Zealand and we will definitely be stopping at the Occidental. So thank you, Jim, for this beautiful place.


Chris Dall: [00:44:55] 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. And also please keep those queries coming. And as you heard today, they don't have to be about COVID. Whether you want to know about flu or Marburg virus or Ebola or antibiotic resistance. We are game to try and answer your questions. And again, the email is OsterholmUpdate@umn.edu. Mike, what are your take home messages for today?


Dr. Osterholm: [00:45:32] Well, first of all, let me just follow up on what you just said. We do welcome your feedback. And if you have a topic areas that you think that we could or should cover, whether they're about COVID or not, you know, we can be helpful. We sure want to be. So we look forward to hearing from you on that regard. My take home message is today really focus in three areas again. Number one, we need to celebrate the fact we are not in an Alpha, Delta, or Omicron surge right now on a worldwide or national basis. But we have to remember, we're not out of the woods yet. And this is all about those shifting baselines, you know, whether it's 190 deaths a day or whether it's 400 deaths a day, whatever. This is still a challenge for us. And so we we need to keep that in mind. And as we move through our daily routines, we ourselves know are we likely to be at increased risk for serious illness, hospitalizations or deaths due to COVID? And if we are, what can we do about it? And today we are so happy to be able to report to you. Yep. Another dose of vaccine is on its way for many of you, but not all of you. But we still will go ahead and continue to push for FDA to actually provide a broader recommendation for many of you to get the vaccine that can't yet get it.


Dr. Osterholm: [00:47:02] And that then leads me to my number two point, please. If you are eligible for the bivalent booster dose, get it. I know I'm going to get mine as soon as I've had some period of time after my infection. I'm going to boost my immune system again. And so I urge you all to get that, that as the papers I talked about today are demonstrating, clearly, we are seeing the fact that there is better protection against serious illness, hospitalizations and deaths with these booster doses. And then finally, we need to make certain that the 30 million Americans who are going to lose their insurance because of the change in the public health emergency declaration still have access to vaccines, testing and treatment after the public health emergency is over. It's critical that we make certain that they can still have access and that we encourage them to get access. For many of us again who have insurance, we will be covered as part of a benefits package. But so we will continue here at CIDRAP to monitor it and to push very hard for the assurance of coverage for those people who otherwise would not have access.


Chris Dall: [00:48:20] And Mike, do you have a closing song or a poem for us today?


Dr. Osterholm: [00:48:25] Well, Chris, that's like asking, is it going to snow in Minnesota in January? I hope so. Um, today I'm going to come back with a good old oldie but goldie and this one really is an oldie and a boldie. Both. This song has been used once before. On January 27th of 2022 in Episode 80: Vaccines, Variants, and Long COVID. And this really was one that Chris and I picked out together, reflecting on where we're at this moment here at CIDRAP and what I've been through with Fern over the course of the past few weeks. Again, I cannot begin to adequately express my deepest appreciation to the kindness, the thoughtfulness, the well-wishes that so many shared with me as it related to my infection. And so I've picked a song that in a sense goes to the quote unquote, heart of that very issue. It is Heart of Gold by Neil Young. It's a song that was on his fourth album, Harvest. It's Young's only number one single in Canada. It reached number one in the national single charts there for the first time in April 8th, 1972. And to me, this really speaks to where I feel so, so, so appreciative of all the hearts of gold out there that I have found throughout this podcast history, but more specifically very recently. So here it is. Heart of Gold by Neil Young. I want to live. I want to give. I've been a miner for a heart of gold. It's these expressions I never give. They keep me searching for a heart of gold.


Dr. Osterholm: [00:50:16] And I'm getting old. Keep me searching for a heart of gold. And I'm getting old. I've been to Hollywood. I've been to Redwood. I crossed the ocean for a heart of gold. I've been in my mind is such a fine line that keeps me searching for a heart of gold. And I'm getting old. Keeps me searching for a heart of gold. And I'm getting old. Keep me searching for a heart of gold. You keep me searching. I'm growing old. Keep me searching for a heart of gold. I've been a miner for a heart of gold. And I can tell you, I found the mother lode and so many of you with that heart of gold. Thank you. Thank you. Thank you. I want to thank the podcast team. You know, we have an amazing group here, and I know so many of you are very kind and giving me your compliments about this podcast, but know that they really must and should be shared with the entire team. They're the ones that keep me upright and keep me going and provide often these very insightful comments that some of you think or at least are insightful actually didn't come from me. They came from them. So thank you so, so much. And be safe. Be safe out there. And most of all, be kind. This world right now needs kindness more than it's ever needed it. It's a challenging world, but we can take it on with our pandemic of kindness. Thank you. Thank you so much.


Chris Dall: [00:51:51] 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.