May 18, 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 COVID Public Health Emergency of International Concern, and the potential for a surge in mpox cases in the coming months.

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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. Two weeks ago on this podcast, Dr. Osterholm and I discussed the expectation that the World Health Organization would declare an end to COVID-19 as a public health emergency of international concern at some point this year and what that would mean going forward. Lo and behold, the very next day the WHO made that declaration, noting that with declining trends in COVID-19 deaths, hospitalizations and ICU admissions and high levels of population immunity, it was time to transition to a long term management of the pandemic. Still, WHO Director-General Tedros Adhanom Ghebreyesus issued a word of warning that SARS-CoV-2 is here to stay and cannot be ignored.


Chris Dall: [00:01:25] The worst thing any country could do now is to use this news as reason to let down its guard, to dismantle the systems it is built, or to send the message to its people that COVID-19 is nothing to worry about, Tedros said. While this emergency committee will now cease its work, it has sent a clear message that countries must not cease theirs. How we move forward without letting our guard down and how we prepare for the next pandemic will be the focus of this May 18th episode of the Osterholm Update podcast. As we discuss the current COVID trends here in the US and around the world. In addition to sharing his thoughts on the W.H.O. declaration, Dr. Osterholm will also discuss an essay he co-wrote for the New York Times on the lessons learned from the public health response to COVID-19 and how they can be applied to the next infectious disease emergency. We'll also answer a COVID query about what the end of the national health emergency means for our daily lives and discuss the latest news on mpox. But before we get started, as always, we'll begin with Dr. Osterholm opening comments and dedication.


Dr. Osterholm: [00:02:25] Thank you, Chris. And welcome to all of you. Back to another edition of the update. In particular, I want to welcome back the podcast family. You know who you are. And we'll talk more about what that means in a moment. And again, I want to welcome those who might be tuning in for the very first time. I hope that we're able to provide you with the kind of information that you're looking for that can be helpful to you in trying to understand where we're at. If I could use an analogy today to describe where I feel like we're at and this is my feelings as much as it is my science based training, I'm in a major fog and I say that in the sense that in fog you usually don't have hurricanes or tornadoes. So I'm not worried about that, but I don't know what I can see and can't see. It's confusing. Typically with fog, you don't think of somehow dangerous weather occurring that could cause loss of life and limb. On the other hand, you also worry about in fog, airplanes may crash that otherwise wouldn't. Cars may be in auto accidents otherwise might not be. And so it's still a time of some challenge, but it's not what we've been seeing over the past three years. So today we're going to really get into that. I also have to say, because I have received so many inquiries about this, how I'm doing now that I'm literally at two months post my onset of COVID.


Dr. Osterholm: [00:03:50] Well, I wish I could tell you I was better. I actually have developed some of the classic symptoms of long COVID. I have very severe fatigue, something I'm not used to and any of my adult life. Some days it's a challenge to keep up even somewhat of a semblance of my normal activities. And in addition, I do from time to time, have moments of memory loss, which has been very disconcerting. It doesn't seem to last long term. It comes and goes. I have talked to a number of people who have had very similar long COVID symptoms who fortunately at four and five months post their onset, actually start to see complete resolution. So, you know, don't worry about me, I'm fine, I'm going to get through. Being somewhat tired is a challenge. But the bottom line is I'm making it through. Today's dedication reflects something that's happening in my life right now that is actually a wonderful, wonderful gift. I'm dedicating today's podcast to the graduates of high schools and colleges, universities around the country and celebrate what you have accomplished, particularly in a time of COVID the last three years. It has not been easy being a student in one of these settings for that matter, as I've dedicated in the past two, it's not been easy for teachers.


Dr. Osterholm: [00:05:16] Today, over 8 million individuals will be graduating from our high schools, from our associate degree programs, from bachelor's, master's or doctoral level programs, and our colleges, notably. Of those 8 million, 58% graduate from an institution of higher learning associate degree or higher. And this is a moment to celebrate the fact that we did make it through the pandemic. We still did provide the educational experience. While it may have been altered, it may have been challenged. We got people through. And for me in particular, this week is very meaningful. On Monday, I had the opportunity at commencement at the University of Minnesota School of Public Health to Hood, one of my PhD students, Corey Anderson. Corey is a member of our podcast team. Been incredibly important in helping to prepare for these podcasts, and Corey will now be staying with us at CIDRAP, working on chronic wasting Disease in particular as we go forward. And what an absolute gift it has been to have Corey as a student and now as a colleague. And then later in the podcast, I'm going to share with you some of my comments that I made in a commencement address yesterday at Case Western Reserve University in Cleveland. I was incredibly honored to be asked to give the commencement address for the all university commencement activity.


Dr. Osterholm: [00:06:40] And I think it really comes back to what it means to be a graduate today. And so for you, 8 million graduates or going into the world looking for jobs, looking for what you're going to do in life, I wish you the very, very best. And I can only say thank you for participating in that educational system, which will hopefully have prepared you to make the world a better place. We need you, your generation. And so I can't begin to put into words how much it means to me to be at a place like a commencement, like I was yesterday in Cleveland or on Monday in Minneapolis, and to see the future walk in front of me across that stage. What an amazing feeling it is to see that I have so much hope and faith in this generation, so much hope and faith and so congratulations. And we look forward to all the help that you can bring. Thank you. And I also want to say we will be covering a little bit later comments about the surveys that many of you have taken or emails that you have sent us about where we should be going with this podcast. What an amazing experience this is family. This is family and it was incredibly helpful and I'll get into that in much more detail.


Dr. Osterholm: [00:08:01] But before we go on, of course, and no podcast would be complete without this, although we did hear from you about what you might like to do in terms of refining this information, But I am extremely happy to report today that the sunlight in Minneapolis-Saint Paul is only getting brighter and longer. Today the sun rises at 5:41 a.m. Sunset is 8:39 p.m. That's 14 hours, 57 minutes and 33 seconds of sunlight. Compare that to December 21st when it was eight hours and 46 minutes and 10s of sunlight. Now, it's also, of course, only fitting that I acknowledge our dear colleagues at the Occidental Belgian Beer Garden on Vulcan Lane in Auckland. And I say that acknowledge I know that you're getting darker and darker there today. You have ten hours and six minutes and 19 seconds of sunlight with sunrise at 714, Sunset at 520. Yeah, you're losing the light. We'll share ours with you for now. Knowing, however, that it's just literally a little more than a month away, when we hit the summer solstice here, our days will start getting shorter and you'll be back on the rise. So welcome, everyone, to this week's podcast. And again, I want to thank all of you for your feedback to us and what you invest in this podcast. So thank you.


Chris Dall: [00:09:27] Mike, let's start with the international and national trends. What is the picture look like at the moment?


Dr. Osterholm: [00:09:34] Well, Chris, as I have shared in all my past podcasts, that level of humility of acknowledging that the five inches of caked mud on my crystal ball every morning make it more challenging to know what that means. But as I started out this podcast, I tried to give the sense that we're not into the level of hurricanes and tornadoes from an infectious disease perspective, but we're in a dense fog. And what I mean by that is our weather is still here, COVID COVID's still here, and it's confusing. But it is not threatening the population as it did three years ago. And I think that is a very, very important message here. I sit as someone with long COVID right now, and for me, it's hard to see, you know, the bright light of tomorrow in front of me. At the same time, as an epidemiologist who has spent his career understanding disease trends, I can tell you there's enough information to here to say, I think that the worst is definitely behind us. Now, let me make it really clear that at this point, the reported case numbers that we're getting from around the world for cases and deaths and that includes right here in the United States, is really a challenge. Most of the systems that have been in place are now dismantled. So anything that we say about what's happening around the world has to be qualified multiple times before one can actually really use it.


Dr. Osterholm: [00:11:06] For example, if you look at cases around the world, we know that there are major challenges right now with testing and reporting, including right here in the United States. So I put little stock in cases. Having said that, let me just give you the numbers so you at least have them officially knowing that they may mean very little on April 10th to the 16th in the world, we have 704,000 cases reported. The first week of May. We had 595,000 cases reported a substantial decrease. How many does that represent of the total infections that are out there? I don't know. Even if you take a look at deaths for April 10th to the 16th, there were 4610 such deaths reported to the W.H.O.. By May 1st to the seventh, that number had dropped to 3750. Basically, deaths as a lagging indicator are surely much better than what we see with cases. But it still is a real challenge. For example, if you look at it by the various regions of the world across the entirety of Who's African region, which is home to more than 1.2 billion people, There were only three COVID deaths reported throughout the first week of May. For comparison, the Americas are both North and South America, with a population size less than Africa's reported thousand hundred deaths that week, almost half of the global weekly total.


Dr. Osterholm: [00:12:38] And I would surely argue that many of the deaths that actually occurred in those regions were not ultimately reported. In fact, if you combine the total death tolls for both the Americas and Europe, you get a total of just under 3000 deaths reported in the week of May 1st through the seventh. That would mean that around four out of every five COVID deaths right now reported globally are from one of the two regions of the world of the Americas or Europe. And yet this is home to less than a quarter of the world's population. So what does this mean? Clearly, we are seeing a substantial reduction in deaths around the world. But how many actual deaths are occurring still is a huge challenge. You can actually think of all these data points that I'm sharing with you as pixels on their own. It may not look like much or it may be unclear, but the more pixels you have, the more clarity that comes with the big picture. Right now we've lost most of the pixels that we've had and we're not gaining them. In fact, we continue to lose them substantially. Now, if we look at what's happening in terms of what is being reported, the COVID activity, let me just say that over the past four weeks, globally, the declines have occurred in regions like the Middle East and countries that had been experiencing upticks.


Dr. Osterholm: [00:13:56] We don't see any countries right now in major surgery activity. If you look, there's been slight increases in two regions, Southeast Asia and the Western Pacific, largely due to some upswings in activity around a handful of countries in these places such as India, Indonesia, South Korea, Japan or Australia. The same thing is true in other countries. Even outside of these two regions. For example, the European region as a whole has reported slow but steady declines. However, in several countries like Bulgaria, Croatia, Finland and France, there have been some recent rises, but again, they're very small rises compared to what we've seen in the past. So if you think about it relative to a previous points in the pandemic, the activity is very low, including deaths at 3750. A week is the lowest since the pandemic began in 2020. Let me repeat that. The number of deaths that have been reported right now are lower than any time since the start of the pandemic. So what's the wild card here? Well, it's all about the variants. What's going to happen? What will happen? One with population based immunity. Right now, we're seeing that the various xbb offshoots jockeying for position against each other as the variant in charge xbb. 1.5 is still dominant globally, but has seen some slight declines.


Dr. Osterholm: [00:15:24] Xspb 1.16 is rising. It went from 4% of cases last month to 9%. Now it's dominant in some areas such as Southeast Asia. At the same time, there are other variants under monitoring Xbb 1.90.1, 1.90.2. But the bottom line message, it is a mixed bag. I mentioned in the last podcast that there were a group of viral geneticists that proposed that there may be as high as a 30% chance that we could in the next year or two, two years see another omicron like Surge. I don't know how that's going to happen, but in fact we surely have to at least entertain that. Now, in terms of the United States, I can clearly say that we are on the back side of what has been the major pandemic activity. I can't comment really on case numbers. The fact that we have reported only 72,136 cases this past week, which I'm very careful to footnote number one is I've already given you all the reasons why this is surely not an accurate number. And number two, I always, always find myself almost as I get an electric shock when I talk about those cases. We got to never forget that our moms and dads, our brothers and our sisters, our cousins, our nephews, our nieces, they're our friends and our colleagues. And that we must never forget. But if you look at what we have for case numbers, we were at 480,000 cases late last December.


Dr. Osterholm: [00:16:58] This week was 72,136 cases. That's a substantial reduction. Now, could that all be an artifact of just lack of reporting? Well, I am absolutely certain that there are many more cases occurring in our communities than we're picking up. I have a number of friends and colleagues who have all been infected within the last 2 to 4 weeks. Some of them are now on their third infection, meaning that they've been reinfected twice. These are people who never got reported because they only tested positive by a lateral flow test, not by PCR. So where are we at right now? Well, there are four states reporting some increase in cases. North Dakota has 67% increase, Virginia 10%, Wyoming, 6%, and Pennsylvania 4%. Two of these states are very low population density states. So it really points out that there's just not major activity occurring here. Now, if you look at hospitalizations and deaths, and this is where there is a sobering moment here that you just can't write this off and say we're done right now. If you look at daily admissions to hospitals, we have about 12,500 people hospitalized on any given day with COVID, and that includes 6672in ICUs. So it's still a challenge. It has been declining, however, since January when hospitalizations were at 48,000.


Dr. Osterholm: [00:18:25] Remember, today we're at only 12,500. And if you look at of those, back in January, 6000 were in ICU as compared to the 6372 now. These, I think, are reliable numbers relative to overall case numbers that tell us, yep, numbers are way, way down in terms of deaths. The numbers are still very sobering, but they also offer us some good news. 840 individuals died this past week from COVID in the United States. Horrible. But that is the lowest it's been since the start of the pandemic. Think of that in three years. This is the lowest weekly number we've had. And in fact, this is the first week that the numbers are below 1000 since the early days of the pandemic. So all the trend data is really in the right direction, both for the world and for the United States. Now, that's going to leave some of us still questioning what do we do about protecting ourselves? And we'll talk more about that in a moment. But I think if there's anything that I can leave you with right now, I think we are on the backside of this pandemic. You know, what we call a pandemic is surely a very subjective kind of definition because it means different things to different people. But nobody can deny that. In fact, we are moving on and hopefully we are at the backside of this horrible, horrible event.


Chris Dall: [00:19:52] As I discussed in the introduction, the big news of the last few weeks is the Who's decision to declare an end to the COVID-19 pandemic as a public health emergency of international concern. Perhaps sooner than some had expected. Mike, were you surprised that the declaration came so soon? And do you think this was the right decision?


Dr. Osterholm: [00:20:11] Well, first of all, let me give you some perspective, which I think is really important to understand. What do we mean when we're talking about a public health emergency of international concern? There have actually been seven of these declared since the 2005 international health regulations went into place, which provided for the ability to declare such an event from occurring. The public health emergency of international concern is defined as an extraordinary event which is determined to constitute a public health risk to other states through the international spread of disease and to potentially require a coordinated international response. Notice there's no words there like pandemic. There's no words there about major outbreaks in countries, etcetera. So it's always been a little bit unclear what this was about other than the fact that it provides the secretary of the W.H.O. the ability to actually make recommendations for the world. Now, the very first recommendation that they made under the public health emergency of international concern with COVID was to say, don't close your borders. And yet we learned later of over a thousand border closings that occurred throughout the world. So it doesn't mean that countries will agree with what the recommendations are and act accordingly. So I never really understood what the actual real power of this particular declaration is relative to. Is this a pandemic? Is this a worldwide epidemic that's going to kill lots of people? If you look at previous public health emergency of international concern, the first that occurred after the 2005 regulations were written was actually the 2009 2010 H1N1 influenza pandemic. No one can deny that, in fact, was a major challenge. But if you look since that time is the ongoing 2014 polio declaration, which is still in place.


Dr. Osterholm: [00:22:12] The 2013 to 16 outbreak of Ebola in Western Africa, the 20 1516 Zika virus epidemic and the 2018 2020. Also another Ebola outbreak in Africa. So none of these really pose the same kind of pandemic potential that a highly infectious respiratory virus like influenza or a coronavirus could do. So when we look back at what really happened here, notice this does not mean that there was a pandemic. This was really an administrative declaration to say, now I, as the head of the W.H.O., can make these proclamations, can put certain things into place to make the administrative wheels of international health hopefully work better. But it wasn't about how many people were dying or how many people were sick. And I think this is an important point to make because a lot of people pinned this onto what was almost like a light switch on or off declarations on. We got a pandemic declarations off, no pandemic. And that's not the case here. Anyone who has listened to this podcast knows that from the very beginning, I made the point that a pandemic was something that people believed was a pandemic. So when you declare one or when you say one is over, it's really all about do people believe that there is a pandemic? Is it a problem? Is it a challenge? And so I think we took several months to learn that, yes, the extent to which we were seeing serious illness, hospitalizations and deaths made COVID-19 a pandemic, we all kind of were on the backside here saying, well, I don't know.


Dr. Osterholm: [00:23:55] When do you say it's no longer a pandemic? There's a thousand deaths a week in a country like ours, no longer a pandemic when it was at 4 or 5000 before that. And as a result, I don't believe that the lifting of the public health emergency of international concern fundamentally changes whether we call this a pandemic or not. That's going to be up to the public's decision. I don't feel in fear anymore. It doesn't concern me that I might get COVID as a result of exposure in public places. So I think it was time for them to move on because there was no real benefit to maintaining the declaration. And as you saw with the other public health emergency of international concern, such as the Ebola or such as the Zika. Those are all ones that got lifted when the case numbers dropped to what people believed was at that time no longer epidemic levels. And I think that's what we have here. So if you're looking for this to be the declaration saying, ha ha, we hit a certain threshold, you know, it's like the Dow Jones or something where we went below this level. That's not what this is about. And for all I know, this could be revisited if. We were to see another big surge, like I talked about a couple of minutes ago. Maybe the number of cases and the concerns would be such that they would go back and reissue this public health emergency of international concern. I don't know that. But for now, I think we're moving on and I'm not surprised.


Chris Dall: [00:25:29] That brings us to our query, which regards the end of both the international and national health emergency in the US, which ended on May 11th. Elizabeth wrote, As the emergencies are winding down, can you guide us through what all this means to us everyday people out here? Mike what can you tell Elizabeth?


Dr. Osterholm: [00:25:48] This is a great question, Elizabeth, and one that many of our listeners have been asking. And, of course, I obviously have a very personal view of this right now, given that I finally developed COVID three years into the pandemic and now are feeling these ongoing long COVID like symptoms. So that from that perspective, you know, I have a potentially biased view of where we're at. First, let me address what this means from a policy perspective, either withdrawing the public health emergency of international concern or the public health declaration here in the United States. If we focus on the United States, what will change now with the public health emergency being over is that certain Medicaid and Medicare waivers and flexibilities for health care providers will end. Hhs will no longer have the authority to require that all laboratory testing for COVID-19 be reported, which will only further affect our ability to calculate test positivity, results, hospitalization reporting requirements will change from daily required reporting to weekly required reporting. Perhaps one of the biggest challenges that will occur with the end of the public health emergency is the change in coverage for free COVID-19 tests. The requirement for private insurance companies to cover COVID-19 test without cost sharing for both rapid antigen and PCR tests ended at the end of the public health emergency. People with Medicare will continue to receive no cost rapid antigen test and PCR tests, but only when ordered by a physician or other health care provider. I am very concerned about this. Without the affordable and convenient access to COVID-19 tests, we should expect that fewer people will test when experiencing COVID symptoms or when exposed to COVID-19.


Dr. Osterholm: [00:27:34] And even among those who do take a test, we should expect that fewer will be able to take multiple tests and therefore may receive early false negative results that are never followed up by a positive test. In addition to the risk that these undetected cases pose in regards to the transmission of SARS-CoV-2, this lack of available and affordable testing may also reduce paxlovid treatment uptake and therefore increase the amount of severe disease that occurs. Paxlovid has been an incredibly effective tool for reducing severe illness, hospitalizations and deaths. But people can only take it when they know they're infected, i.e. have a positive test and for many there is no longer reliable and affordable way to determine if that is the case. Second, I just want to address that The end of the emergency means in regards to precautions we take every day getting COVID. Well, there are those who more than four months ago, five months ago, decided the pandemic was over. They're back into public places and spaces. I see almost no one wearing any kind of respiratory protection today in these public places. Now, for most individuals, there is grant you a much, much lower risk of serious illness, hospitalizations and deaths. Today, just based on the numbers I shared with you earlier. So they're feeling that this risk is commensurate to what they might see in a flu season or driving in their automobiles or whatever. And they're back.


Dr. Osterholm: [00:29:02] Now, that doesn't account for those of you who have not yet been infected. And I'm telling you, I wish I had not been infected. I really wish I hadn't been. I would be very glad to double down on any kind of respiratory protection that I needed to use to have kept me from getting infected the first time, given my more long COVID symptoms. But I think what's important here is to understand that we are going to likely see lots of infections in our community over the weeks ahead, not cases that are coming to medical detection, not cases that are severe illness or requiring hospitalization, but just based on what I'm seeing, second and third and fourth infections. So if you get those, you're home for a couple of days feeling ill and otherwise you're doing fine, then, you know, I have to acknowledge, yep, you can move on with your life. Just know that if you've been previously infected, there is no reason why you might not get infected again. We're seeing more and more of reinfect oceans occurring, likely with waning immunity following a previous infection and or vaccination with that infection. But if you're someone who is still is at increased risk for serious illness, hospitalizations and deaths, again, my first recommendation be certain that you're updated on your boosters. The data are clear and compelling. You can significantly reduce the likelihood of developing serious illness, being hospitalized or dying by being updated. And I hope that ultimately the FDA will continue to make this a permissive opportunity where anyone who wants to be vaccinated at least every six months can get that.


Dr. Osterholm: [00:30:43] For those that are at that point of saying, you know what, I'm at such high risk for serious illness, hospitalizations and deaths that I just don't feel comfortable even just being in that fully vaccinated status, then I think you should feel comfortable and confident that you can go ahead and wear your N95 respirators wherever you go. And I think that's something we have to just continue with. And I don't know at what point we'll be able to come back one day and say no need. For some who have now been spared influenza, have been spared other can respiratory pathogen infections, you may say this is something I'm going to do forever, at least in public places with crowds. So do not take the two recent declarations by W.H.O. and the US government that the pandemic is, in a sense over as the fact that you don't want to protect yourself if you are someone as serious risk for hospitalizations and deaths for many others, it's time to move on with your life. I get that. Stay tuned. If things change where we do see a substantial increase in serious illnesses because of a new variant, then we've got to be able to share those data with you instantaneously and we'll do that. But in summary, let me just say there is more good news in this message than there could ever be bad news. But for some of us, it doesn't mean that the news is all good yet and we can't forget that.


Chris Dall: [00:32:16] I want to circle back now to what the W.H.O. director general said about countries not ceasing their work, because it seems part of that work is looking back at how countries perform during the pandemic, what they could have done better and how that assessment can help them do better next time. In a May 11th essay for The New York Times, you and several members of the Biden-Harris transition COVID Advisory Board noted that the US has not done that yet, and you offered 13 lessons that should be integrated into planning for the next infectious disease outbreak. Mike, can you highlight some of those lessons for our listeners?


Dr. Osterholm: [00:32:51] Chris. I was very fortunate to write with my coauthors led by Ezekiel Emanuel, Luciana borio, Rick Bright, Jill Jim, and David Michaels, all members of the Biden-Harris Transition COVID Advisory Board. And what we tried to do is come away with lessons learned that we surely should be trying to understand even better now so that we might apply them in the future and where possible, begin to implement some of these recommendations. Now that surely can have a positive outcome on public health, whether there's a pandemic or not. Well, we tried to do is put this into the context of this very highly disruptive phase of the pandemic is over. And as of last Thursday, of course, ending the public health emergency, we acknowledge daily life has by and large returned to normal. There are surely still may be more people working from home than they were before the pandemic. But most Americans are back to traveling, eating out, going to the movies, theaters, sporting events, and largely without any kind of respiratory protection. So what we did is we laid out what we thought were still very, very important, valuable lessons that we need to understand and implement. The first one was human tolerance for lifestyle changes is limited. As we noted in here, by September 20th, 22, 30 months into the pandemic, 46% of Americans had returned to their pre-pandemic lives. According to one major news media survey. This was despite the fact on September 1st of 2022, an average of 90,000 new cases in more than 500 deaths were reported every day.


Dr. Osterholm: [00:34:34] Patients appears to have been even shorter during the 1918 influenza pandemic. If the next public health emergency occurs soon, patients may run out much sooner than the actual crisis itself. We need to recognize the limitations of human perseverance and prepare accordingly. Meaning, what kind of measures are we going to put into place? What kind of recommendations are we going to make? If no one abides by them, then why are we doing them? What we need to do is go back and relook at that. So human tolerance is critical. The second one is we know incentives can change behavior. Social norms can reinforce that anyone who's ever had a habit that they wanted to change, they know how hard it is to change that habit. But people do change with the right interventions, like higher taxes on cigarets or sugar sweetened beverages to reduce unhealthy behaviors. What we need to do is understand what are the incentives that could have provided for people to do things that made their lives safer and those around them, such as what kind of incentives could we use for vaccination to wear respiratory protection to get tested? And is that incentive, rather than just the heavy arm of government coming down on you? That I think we missed that opportunity. Our third point is trust is crucial. Public trust in government and health organizations can reduce cases and deaths.


Dr. Osterholm: [00:36:01] It's clear that the United States already sharply divided politically failed on this essential element of response. For example, in 2021, according to the Gallup poll, only 39% of Americans had a great deal or a fair amount of trust in the federal government to handle either domestic or international affairs. Now, think about that. When you're trying to make recommendations or what people can do to reduce their risk of infection or even if infected, getting seriously ill. So what we need to understand is what is it that will take people to a place where they will listen, they will process and they will follow through accordingly, such as vaccines. To this day, I find it so unfortunate as we look at the number of deaths occurring right now in people who just refuse to get vaccinated, was there something in the trust that they had in vaccines or in the government's recommendations for vaccines that could have been changed? We don't know. The fourth one was to prepare now, and I find this to be such a challenge because I see a race away from COVID preparedness. And what I mean by that is I think most people want to forget this pandemic ever happened. We're not spending the time following up. And so we have, I think, missed many lessons that we could have and should have learned. And that one first lesson is start preparing now, because it may take years before we're able to get more effective vaccines, before we're able to realize much more effective medicines, etcetera.


Dr. Osterholm: [00:37:40] The fifth one we emphasize is reliable. Real time data is vital. I can't tell you how many times I was so frustrated we were using data from the United Kingdom or Israel to understand how well our vaccines were working or not working because of the fragmented nature of which health data are collected in this country and shared accordingly. And so we went into a fair amount to talk about what we need to do to address that and to address why if other countries around the world can do it, why can't we do that? The sixth area was what we need to know to reduce the spread of airborne viruses like COVID. Well, this is going to be old hat news for most of you because you've heard me time and time again talk about the importance of adequate respiratory protection. The N95 not just a surgical mask or procedure mask, which is so common even in our hospitals today. And we talk about how we can really reduce viral transmission with that, how we could also look at our building codes and what we could do to increase ventilation in buildings, to reduce the likelihood that even if someone with the virus is in that building, you will be exposed to them and get infected.


Dr. Osterholm: [00:38:52] The seventh one was two. Vaccines reduce serious disease but unlikely to prevent transmission. New therapies are needed. Bottom line message We need better vaccines. The ones we have are good. They've saved millions of lives, but their durability is limited. And we know that in fact, they very well might not work against newer variants of the virus that might emerge. So we need to invest heavily into this as well as therapeutics in the next pandemic. If it takes 5 or 6 months to get a vaccine, what are we doing to treat people in the meantime? What if we had broad spectrum antivirals for both influenza and coronaviruses that could be immediately dispensed so that we could treat people much like we do bacterial infections? That is something we need to develop. Number eight, we need our responses tailored to local circumstances. I said it time and time again in my first op ed, I wrote about COVID in the Washington Post in April of 2020. I said, Don't apply the same standards of quote unquote, lockdowns, etcetera to rural America. At that time, you lost all credibility as a public health agency. If you shut down small towns for weeks and nobody ever showed up with COVID, you've got to be able to have the effective tool of rapidly responding. So in the earliest days, New York City was under fire. They needed to do certain things that wasn't necessarily what needed to be done in northern Minnesota.


Dr. Osterholm: [00:40:24] And we've got to have more of that flexibility and be able to deal with that. The ninth one was schools should not be interrupted or placed online except in rare circumstances. The school issue to me was one of our greatest failures. And what I mean by that, it was a failure to understand what was going on. We did not need to shut schools down for the entirety of the pandemic. What we needed to do, however, though, was look at what kind of transmission was occurring. And if you look, you'll see the majority of deaths occurred in kids in the last two years of the pandemic. Not at all in the first part of the pandemic. Many researchers interpreted the relative lack of serious illness in kids in that first year, as that's what's happened in the rest of the pandemic. Well, no, it wasn't true. As Alpha showed up, as Delta showed up, as Omicron showed up, the risk to kids and the serious illnesses they were suffering went up accordingly. And what we should have been able to do is judge how much activity is in our schools, what is happening, and then guide our school openings and closings by that. The 10th one was one that I think a number of you on this podcast can identify with is social isolation is harmful and increased mortality. We have to understand it's not just taking care of our bodies.


Dr. Osterholm: [00:41:46] It's taking care of our souls. It's taking care of everything that we live for as humans. And we didn't. Much of the physical distancing led to depressions. It led to real challenges. And it's not that there's an easy answer about what to do about this, but we have to address this. We have to ask ourselves, how can we deal with this kind of isolation? What could we have done to minimize that? And at this point, I see very little attention being paid to that as we go forward. The 11th one we had was we need vaccines, access and paid sick leave. When people wanted to get vaccine, they should not have found it so difficult to have to travel on busses through 2 or 3 stops to drive long distances to get vaccines. And then if they were ill or they had family members ill, they were taken care of. They needed to have paid sick leave, keep infected people out of the workplace, keep people caring for sick people in the position where they could continue to do that because the paid sick leave. Our 12th one was indifference can kill. For most of the 20th century, life became much safer as risk of deaths in car crashes and workplaces and from diseases declined. But clearly, COVID upended that narrative in the 21st century. Even so, people seem to have become normalized to COVID, though it was the third leading cause of death in the United States in 2020 and 2021, and the fourth leading cause of death last year.


Dr. Osterholm: [00:43:21] We seem to tolerate 200,000 or more COVID deaths a year. More deaths than strokes and diabetes in about five times the number from breast cancer. We really worry that this indifference may be related to the fact that more than three quarters of the COVID deaths have been among older people, minorities and those with obesity and disabilities. This is just simply unacceptable. We must address this. And finally, our last point. COVID will not be the last pandemic to strike the United States, and the next one could be worse. This is a huge issue. Right now I'm writing a new book on what lessons we should have learned from the pandemic. And there are many. There are many. And we can't turn away from this. This is not to lay blame. This is not to point fingers. This is to say, what could we have learned from this would make it better for the future. And I fear that we're avoiding that very situation. So in summary, Chris, this was a big list and it surely covers a lot of information, but I think it's a realistic list and it's one that for those of us who are still thinking about what the next pandemic might look like, we must keep our nose to the grindstone and keep working on these issues day after day after day.


Chris Dall: [00:44:45] Now for an update on mpox, which we haven't discussed in a while. On May 11th, the W.H.O. declared an end to the public health emergency of international concern for mpox, noting that cases have dropped 90% over the last three months compared with the previous three months. But earlier in the month, officials in Chicago sounded the alarm about a cluster of cases in the city since the middle of April. And just this week, the CDC warned providers about a possible resurgence of cases connected to summer festivals and gatherings. So, Mike, our listeners heard a lot from us about Mpox when the outbreak first began last summer, but not so much in recent months. What's going on with Mpox and what are you concerned about?


Dr. Osterholm: [00:45:24] Well, as you mentioned in your question, Chris, the mpox public health, emergency of international concern ended on May 11th, nearly ten months after the emergency was declared on January 23rd, 2022. There have now been over 87,000 reported cases of mpox associated with the outbreak. Nearly 31,000 of those have been in the US. The number of daily mpox cases peaked in the US in August at 460 per day and has declined significantly since then. But mpoxdidn't simply disappear. Over the last several months, this reduction in cases from 460 per day to up to three per day can mostly be attributed to three things immunity in the high risk groups acquired through actual infection, immunity at high risk groups acquired through vaccination and changes in behavior at risk groups all played a role throughout this outbreak of vast majority of cases have occurred in men who have had sex with multiple male partners in a short period of time. I mention this not because I'm here to judge or stigmatize anyone in this group, but from a public health activity standpoint. It's absolutely crucial that we identify who are those at at risk groups so they themselves know and the medical community can know who it is that they should be in particular concerned about in terms of screening. Let me just mention that some speculated that we would see a significant rise in cases in women, in heterosexual men as the outbreak progressed. But as of right now, this has not occurred on any large scale. As I just said, cases in this group have declined significantly over the past several months, largely due to behavioral changes, which meant mostly reduction of anonymous and one time sex partners and the immunity acquired through natural infection and vaccination.


Dr. Osterholm: [00:47:17] My concern now is that the cases have declined and the public health emergency of international concern is over. That a combination of waning immunity from either previous infection or vaccination and return to previous behaviors will fuel an increase in cases in the coming weeks or months. There's already evidence that this may be occurring, as you mentioned in your question, Chris. Public health officials are currently investigating a cluster of 14 cases in Chicago. One thing that is particularly alarming about that cluster is that ten of the infected individuals were fully vaccinated earlier in the year. None of these cases resulted in hospitalization, which may be a sign that the vaccine was still effective in reducing the severity of the illness. But it clearly was not enough to stop people from getting and spreading mpox. 11 of the infected individuals identify as men who have had sex with men, and the sexual orientation of the three individuals is unknown. Let me be really clear here. The breakthrough infections we've seen have all occurred among those who were previously vaccinated. I'm not aware of any cases yet in those who are previously infected actually having a second infection. This may say something about how well we can expect this vaccine to work going forward. Maybe we will be expecting to see ongoing breakthroughs occurring, unlike with what we saw with smallpox vaccines where that didn't occur.


Dr. Osterholm: [00:48:42] The fact that we are seeing clusters of cases continue to occur in this at risk group, even among individuals that are fully vaccinated, is very concerning. We need to make it clear, especially to those at high risk of contracting impacts at the end of the public health emergency is not the end of impacts and not a time to abandon safer sex practices, to reduce the risk of contracting the virus as well as other sexually transmitted infections. We also need to emphasize that it's not too late for the 63% of at risk individuals that have not yet received any doses of vaccine to be vaccinated. Let me repeat that 63% of at risk individuals have not yet received any doses of the vaccine, and 14% of the at risk individuals have only received one dose of the vaccine not yet being fully vaccinated. So vaccination may be just as critical now as it was last summer as we see potential immunity waning among vaccinated individuals in these networks. Now is not the time to put impacts in our rearview mirror. Now is the time for advocacy. Now is the time for us to have straight talk about what's happening, what needs to be done, and how we can protect individuals from this infection. We need to continue promoting the public health tools that were effective in reducing the number of daily cases occurring last summer. Or we can expect to see a similar rise in cases occur again this year.


Chris Dall: [00:50:12] Finally, we asked our listeners last episode to share their thoughts about what this podcast should look going forward. Mike We've gotten quite a response so far. What can you tell our listeners?


Dr. Osterholm: [00:50:23] Well, Chris, I hope I can get through this one. Okay. This is going to be a challenge, as you noted. We've received an incredible amount of feedback from you, our dedicated listeners, and specifically our podcast family. We're still trying to comb through more than 1000 responses that we received. And I just also want to note that we're still taking in information. So if you've not yet filled out one of the surveys, please do so. It's at our center's website for the podcast. It's easy to do and we really appreciate it. And every one of these is read. Every one of these is is summarized and used to help inform us about what to do. And as you probably noticed, nothing has changed with this week's podcast. And that's because we're still carefully going through every response to make sure we get this right going forward. But I wanted to give you our initial impressions of the responses. My first one is how are we so fortunate to have you in our lives? You know, I've said this time and time again, and I mean it from the bottom of my heart. I think I get a lot more out of this podcast from you than you might get from me. I can tell you that all of the CIDRAP team feels it's very, very special relationship with you and your support. Your ongoing input has been so important to us. What we did find from the survey to date is the majority of you want us to keep the every other week frequency with many of you do, wanting us to go back to the every week layout.


Dr. Osterholm: [00:51:52] 70% of listeners want other current public health news to be incorporated. More 60% want to hear more about other public health controversies and topics, and 50% want to hear more about my experiences with historic infectious disease outbreaks. There are also more than 800 thoughtfully written responses to the other questions in the survey, including what you'd like to hear less of and other feedback to the podcast team, as well as hundreds of additional emails. By the way, for all of you who had a comment on the light issue. We heard you and it was interesting rather than saying to stop it, you wanted me to give other cities of light length in the podcast. So we're looking at that. Let me just say that the number of you who have responded is such a beautiful thing. This is my beautiful place and I just want to thank you so much for this. You have given us the gift of a lifetime, which for every reason makes us just want to do these podcasts and do these podcasts and do these podcasts. It really is a gift. It's a privilege. And we never forget that. And I can speak on behalf of all of the CIDRAP team to say that. So as we continue to go through these responses, we're going to look at how we can change this podcast to be more effective, to be more meaningful to you. And trust me, we take your input very, very seriously. Thank you.


Chris Dall: [00:53:18] And gesture reinforce Mike's message. Please keep the input coming if you haven't yet. You can either email us at or you can fill out the survey that will once again be on the podcast page. Mike, what are your take home messages for today?


Dr. Osterholm: [00:53:34] Well, Chris, as always, I have three messages here that I hope came through in our discussions today. First, is declaring the pandemic over right now is related to what data we have. And data, by the way, which does look very favorable. But we all know that for some of us, the pandemic isn't over yet. If you are so concerned about serious illness, hospitalizations and deaths and so, please, we need to keep that in mind. And that means being updated on your vaccine booster dose. That means respiratory protection in public places where you might be exposed. The second thing is, on the 13 part plan and priorities that we laid out today, we have to understand how critical these issues are. And otherwise, we are at our own peril for future pandemics. As I mentioned, I'm writing another book right now with my coauthor, Mark Olshaker, on what the next big pandemic might look like and what we will regret having not done from potential lessons learned with this pandemic to have put in place better preparedness. And so we'll continue to do that, push on it. But it's amazing how people just want to move on from tragedy. And finally, I just want to thank everyone who has provided feedback to us. It has been so meaningful to us. And we continue to ask you to to keep that feedback coming, your ideas, your thoughts. And I promise you we will take it all in. As I said, everyone has read multiple times and we want this to be your podcast that we actually can be just a part of. So thank you for that.


Chris Dall: [00:55:22] So, Mike, I understand there's no closing song or poem today, but perhaps some words of wisdom for our graduates this year.


Dr. Osterholm: [00:55:31] I had the incredible good fortune yesterday to give the commencement address at Case Western Reserve University in Cleveland, one of our distinguished universities in this country. Now, you can argue there's something wrong at that place that they invited me to come and do this. But it was an amazing experience. And again, being around the students, being around the faculty just did my heart so good. It was the very best of times. And what I did in this commencement address is try to share with the students certain lessons that I had learned and learned from someone very, very special. Regular listeners in this podcast know that I experienced a love story for the ages as a young boy. It's a story about a magical, if not miraculous relationship that shaped my life beyond anything I'll ever be able to share with you. I was born in the small northeast Iowa farm town. The oldest would be six kids. As many of you know, my father, a photographer at the local newspaper, was an alcoholic and deeply emotionally troubled man who had a primary way of expressing his fierce internal anger with the world. It was through his fists and his mental intimidation without regard to our age or gender. And as I indicated to the students, I know that there were many in that room yesterday that went through the same thing, but that I may have had a very different experience because I was adopted spiritually at an early age by the wife of the owner of the newspaper where my father worked.


Dr. Osterholm: [00:57:07] She went by her family name, Nana. And to make a long story short, after many thousands of hours of discussions, letters written even though we both live in the small same town, notes from her. One of the worst days of my life occurred when she died in 1980 at the age of 72. I miss her dearly even today, some 43 years later. But she left a legacy for me, which I will never be able to repay. And what I tried to do is share with the students lessons I learned from Nana. And so I want to share with you today in part what I shared with the graduates. And I'm taking a very specific part of my commencement address. And it's all about the issue of class. What is class? And I tried to impart upon the graduates these few life lessons that could be learned that will carry them through for all their lives. So let me share with you the actual words that I used in that commencement address yesterday in which I specifically addressed the issue of class. Finally, let me say a few words about class. It's that ability to never forget who you are or what is most important in life, in particular for some of you being a health care provider. The life and death status of our loved ones may be in your hands.


Dr. Osterholm: [00:58:29] But never forget that class is the status you earn when your achievement allows you to go to the head of the line and you don't think twice about standing in the back of the line because others were there first. Nana taught me that class comes in many different packages and under many different circumstances. When I asked her once to better describe class to me, she replied, You'll know it when you see it. She was right. An experience several years ago provided me with such an example. I was given an endowed lecture at one of the largest teaching hospitals on the East Coast. The Chief of medicine at this prestigious institution is an internationally recognized expert in his area of medical specialty and was in charge of the day's activities. The only way I can describe him is to say he is a brilliant clinician and a wonderful gentleman. As we walked the halls, fellow physicians, nurses, security guards, nurses, aides and even station clerks addressed him by his name Jack or an affectionate doc. This lack of formality might be viewed by some as a lack of respect for someone of such stature. Nothing could be further from the truth. Jack seemed to know every one of them by their first name and address them as if he were talking to a dear friend or a neighbor. The deep admiration and respect for the chief was obvious.


Dr. Osterholm: [00:59:44] After my lecture in the hospital's auditorium, Jack and I were taking the back roads to get to his office. It seemed like an endless maze of hallways. Suddenly, in a relatively out of the way hallway near the lab, we encountered an older gentleman who appeared to be lost and distraught. Jack asked him if he could help. The older gentleman seemed almost surprised someone in a white doctor's coat would ask. He blurted out in a painful acknowledgment that his granddaughter had just been admitted to the pediatric intensive care unit and he was trying to get there. He was desperately lost. Jack looked at me and his eyes told me just to follow him. He asked the grandfather if he minded taking some stairs to save time. He replied, Anything to get to my granddaughter. After more hallways and two flights of stairs, we were in front of the intensive care unit. Jack put his hand out to the man and said, Please know the staff of this unit are remarkable. Your granddaughter is getting the best care possible. The grandfather got huge tears in his eyes, grabbed Jack's outreached hand with both of his and held it for a moment. I'll never forget that silent but heartfelt gratitude. Obviously, the grandfather had no way of knowing that the physician whose hand he held was a prestigious and powerful individual in his field of medicine. But then that was not the jack that I saw standing there either.


Dr. Osterholm: [01:01:00] As we walked away, making another attempt to get to his office and continuing our previous discussion, I realized again that Nana was right. I would know class when I saw it, and I was in the presence of real class. And I hope that all of you can relate to this sense of class, why it's so important, and what it means in our lives. And I hope that the students thinking about this goofy commencement speaker they had might one day also realize just the importance of living in the world and living it with class. As I've said many, many times, if you live your life with class, you never need doubt what you do. So thank you again for being with us. I hope that we were able to provide you with some useful and helpful information. Thanks again for participating as part of this family. We look forward to talking to you in two weeks. And again, we're going to keep working on this podcast. As they would say in the movies, we're going to get this right. We're going to get this right. So thank you so much and be kind. Be kind in the next two weeks. Have class. And don't forget that these cases still occur. They're not numbers. They're our family, our friends, our colleagues. We must never forget that. Thank you so much for your kindness and your class. Thank you.


Chris Dall: [01:02:30] Thanks for listening to this week's episode of the Osterholm Update. If you're enjoying the podcast, please subscribe rate and review and be sure to keep up with the latest COVID-19 news by visiting our website This podcast is supported in part by you, our listeners. If you would like to donate, please go to The Osterholm Update is produced by Cory Anderson, Meredith Arpey, Elise Holmes, Sydney Redepenning and Angela Ulrich