June 15, 2023

In this episode, Dr. Osterholm and Chris Dall discuss national and international COVID trends, a study on metformin and long COVID incidence, and the use of N95 respirators for protection against wildfire smoke. Dr. Osterholm also answers a COVID query on booster doses and shares a moment of joy from one of our listeners.

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Chris Dall: [00:00:06] Hello and welcome to the Osterholm Update: COVID-19, a podcast on the COVID-19 pandemic with Dr. Michael Osterholm. Dr. Osterholm is an internationally recognized medical detective and director of the Center for Infectious Disease Research and Policy, or CIDRAP at the University of Minnesota. In this podcast, Dr. Osterholm will draw on more than 45 years of experience investigating infectious disease outbreaks to provide straight talk on the COVID-19 pandemic. I'm Chris Dahl, reporter for CIDRAP News, and I'm your host for these conversations. Welcome back, everyone, to another episode of the Osterholm Update podcast. It's June 15th. And later today, the FDA's vaccines and related Biological Products Advisory Committee, or VRBPAC, will be meeting to discuss what SARS-CoV-2 strains should be included in the next round of COVID-19 shots. That's among the topics we'll be discussing today in the podcast as we look at the international and national COVID-19 trends. We'll also discuss a new paper on country level predictors of COVID-19 mortality, some intriguing findings on a potential treatment for long COVID and whether N95 respirators can help protect people from wildfire smoke. We'll also share our first moments of Joy submission 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: [00:01:29] Thank you, Chris, and welcome back to everyone in the podcast Family. It's great to be with you again. I hope you've had a good two weeks since we last got together. And for anyone new today to the podcast, I hope that we're able to provide you with the kind of information you're looking for that's helpful to you, helps you understand where we might be in this pandemic and what the future may hold. It's a special podcast for me today because of the dedication. I'm dedicating this podcast today to Father's in honor of Father's Day coming up on Sunday. Now, this is a topic that is the best of times and the worst of times for me. And today I elect to focus on the best of times. As some of you know who've been following this podcast, I had a very challenged situation with my father, who was mentally ill, was an alcoholic and was a very violent man with everyone in the family. And I hardly would say that I learned any lessons about how to be a good father from him. At the same time, because of that situation, I was able, without really trying to find in my life surrogate fathers who played such an important role in who I wanted to be and learning how to be a good father for my own children and a grandfather for my grandchildren.


Dr. Osterholm: [00:02:49] And today, when I talk about fathers, I'm honoring everyone who is a father. Those who are stepfathers may not be related by blood, but they are surely related in many other ways. And even those who I call the surrogate fathers, those who are father and literally so many ways, but not by name or blood. And in that regard, today, I hope we all can reflect back. And for those of us who have had the wonderful, blessed experiences of knowing and loving fathers and having them reciprocate with that, that we celebrate that for those who have challenged situations with their fathers, you know, it's hopefully a time where you can reflect on that and maybe even reach out if it's at all possible knowing that it may not be. I've always thought to myself, there's never a bad time to do the right thing. And and today maybe that's the time to think about reaching out. And let me just close by saying of the things that I think are most important in my life. It's without question being a good father or a grandfather is that. And while I surely would tell you I could do better, I could be more attentive and more there. But I never forget for a moment the honor and gift that it is to be a father.


Dr. Osterholm: [00:04:08] And to those of you who would love to have your father sitting next to you right now but are not able to because they are gone, I most of all, really want to extend to you and this Father's Day, the best memories, those fond memories and enjoy them. So let me move on to the part of the podcast that either you love it or you don't, but I got to do it. You know that I can't help myself today, June 15th. I am very happy to report we're within a week of the summer solstice, a time of great light celebration today in Minneapolis. Sunrise is at 5:25 a.m. Sunset is 9:01 p.m., 15 hours, 35 minutes and 59 seconds of sunlight. If you factor in civil twilight, that light where you do not need artificial light to conduct outdoor activities actually runs today from 4:49 a.m. to 9:40 p.m.. A wonderful, wonderful time of the year. We are less than a minute from the longest day of the year here from sunlight standpoint this next week. Now i will have to say it's a bit challenged this week here. Sunlight is a rare gift in terms of at least direct sunlight, as we, like many other cities in the United States, have been impacted by the severe forest fire smoke problems that we're seeing around the country.


Dr. Osterholm: [00:05:31] And yesterday and today, we are seeing remarkably, remarkably smoky skies here in the Twin Cities. We'll talk more about that in a minute. Just to close out on the sunlight, reminding us all of our dear friends and colleagues at the Occidental Belgian Beer House in Auckland, that today your sunrise at 7:31, your sunset is at 5:10 p.m., nine hours and 38 minutes and 12 seconds. You're hitting your shortest, darkest day of the year. But that will soon change in the next week. And I know you'll be looking forward to getting back that sunlight. I just have to add one last sunlight piece of information. A number of years ago, I was fortunate enough to attend a meeting on HIV aids in Stockholm, Sweden on June 21st. And I'll never forget those long days there, and specifically how we were able to stay out late at night at the local beer garden. And enjoy the evening. Today in Stockholm, the sun rises at 3:30 a.m.. Sunset is at 10:08. That's 18 hours, 37 minutes and nine seconds. Remarkable. And if you look at civil twilight in Stockholm today, it begins at 1:59 a.m. and it goes until 11:40 p.m. And I remember those days very, very well. So to all those in Stockholm, enjoy your sun. So again, thank you for being with us and enjoy.


Chris Dall: [00:07:02] So, Mike, let's start with the international and national COVID trends. The most recent updates from the W.H.O. and the CDC indicate that with the exception of a few hotspots, COVID-19 activity continues to trend downward. So what are you seeing in the latest data and what does the variant picture look like?


Dr. Osterholm: [00:07:21] Well, Chris, looking at the data, the assessment you just shared is correct on a global basis. The latest numbers from W.H.O. featured in their weekly COVID EPI report run up to June 4th. So about a week and a half prior to this recording. And so if you look in the 28 day period leading up to June 4th, in other words, May 8th to June 4th, there were a total of 1.7 million cases and 10,000 deaths reported worldwide. Now, again, I have to come back and qualify. The case numbers are, at best wild, wild estimates. We know that we are having major underreporting of the number of cases in our communities in terms of deaths. They, too, are underreported, but are a more reliable indication, I think, of what's happening with the pandemic. So in terms of official numbers, you can clearly see the downward trend continue, which matches with what we've been seeing throughout the first half of 2023. That said, even if you focus in a bit more and look at the regional data, you'll find that all six W.H.O. regions actually documented declines for both cases and deaths in the latest 28 day span. Again, with the caveat that I just shared, that these are official numbers and there are major gaps in reporting. You can see that compared to the previous 28 day period. Deaths declined 78% in the eastern Mediterranean region, 54% in Europe, 44% in the Americas and 35% in Southeast Asia. Finally, the Western Pacific region reported a 19% decrease in deaths, and Africa reported a 17% decline. So even on a regional basis, there's some real consistency with these declines.


Dr. Osterholm: [00:09:02] Now, with that being said, there are certain countries going against the trend. One that we've kept an eye on a fair bit is China. And although official data from the country is sparse, their CDC released data this past weekend indicating that the test positivity rate in Chinese hospitals stood at around 40% by the end of May, representing a five fold increase compared to the previous month. So this is basically confirmed the anecdotal but growing accounts of another surge in China. And to me it's another asterisks that could be added to the official numbers. I just got done sharing. In fact, this latest report, which was published by the Chinese CDC this past Sunday, was the first COVID update the agency had provided since the end of April. So basically a month and a half with no official data from China. Likewise, despite the dramatic rise in test positivity in health care settings, the Chinese CDC report claimed that the total number of severe infections nationwide throughout the entire month of May was below 2800, and the death toll was 164. Now, given that China is home to more than 1.4 billion people, I find it very hard to believe that these numbers are anywhere near accurate. I would say at this time there still is major underreporting in China. But I think the trend data are in fact real, that they are trending downward. And according to their sequencing efforts, the surge itself could be linked to the growing prevalence of variants. In other words, there's no indication that this is the byproduct of some novel variant, since, as we know, XBB has been the norm elsewhere, including here in the United States.


Dr. Osterholm: [00:10:45] In fact, shifting to the US, the latest variant data from the CDC signals that the XBB variant family, which is comprised of ten different circulating versions, currently accounts for around 99.9% of all cases in this country. So again, the situation in China, at least in terms of variants, is not unique. With that said, the situation in the US when it comes to activity does appear to be a bit different than China. In this country overall, we're basically seeing continued declines through 2023. Beginning in May, we saw the number of Americans housewives with COVID hit a new all time low, falling below the levels reached during previous lull in April 2022. And since that milestone, we've continued to drop to even further lows. In fact, as of June 3rd, there were 6600 Americans hospitalized with the virus. No doubt that's welcome news and I surely hope it continues. However, it would be helpful to know what impact the reduction in hospital screening and pre-admission testing for COVID is having on these numbers. Regardless, it is also reassuring to see that COVID deaths in this country have consistently declined through 2023 and are at the lowest levels reported since the start of the pandemic. Still, we must not forget that these deaths still are our brothers and our sisters, our mothers, our fathers, our grandparents. And this is still something that is a real challenge to addressing.


Chris Dall: [00:12:18] We've talked a lot on this podcast about individual risk factors for COVID-19 mortality, but there was a paper published last week in the journal Scientific Reports that aimed to identify country level predictors of COVID-19 mortality, looking at how things like demographics and socioeconomic and environmental factors may have played a role in increasing the risk of death from SARS-CoV-2 infection. Mike, what did you make of this paper? Does it shed any light on things that could have been done differently to mitigate the impact of COVID-19? And could it inform future efforts?


Dr. Osterholm: [00:12:53] Chris, let me be really clear upfront here as I answer this question, that it is very important that we try to understand lessons learned from this pandemic, not to point fingers, not to blame, but to in fact, better prepare us for the future so that what we might have learned from what happened here can be applied in a future pandemic response. So I welcome these kinds of analyzes. I think they're very important. My challenge is so often they're based on data or lack thereof to come up with some of their conclusions. So if you take the paper you just referenced, Chris by Paul Brown, Paul is at the University of the West Indies in Kingston, Jamaica. This was a study in which he looked at predictors of COVID-19 mortality. The problem was he used mortality data, which we know is notably unreliable for many countries in the world. And so to use that as your endpoint as a critical endpoint and it's not reliable. How can you relate anything else to it that would actually explain what happened or didn't happen? So I think this is where we have to be very, very careful. There was another effort done recently that received a fair amount of attention, and I have not commented on it before, but this was an article that appeared in the April 22nd issue of The Lancet assessing COVID-19 pandemic policies and behaviors and their economic and educational trade offs across US states from January 1st, 2020 to July 31st, 2022, an observational analysis.


Dr. Osterholm: [00:14:29] And this was a study that was actually conducted by researchers at the Council on Foreign Relations, a group that I'm a member and the Institute for Health Metrics and Evaluation, or I'm in Seattle, both very distinguished groups. The problem was that this was also an observational study that used ecological data. And you'll see in a minute what that is ecological data. The Lancet paper showed that preexisting conditions, the approaches to COVID-19 control and COVID-19 outcomes varied widely by state and region. And they argue that the policies and mandates implemented by states had an impact on COVID-19 infection rates. Well, we all want to believe that. But I must say that when you do modeling like this, there are many potential pitfalls, including the fact that you put far too much emphasis and acceptance on the data that you put in to come out with your answers, meaning that if inputs into your model are flawed or biased, the outcomes and inferences from your model will also be flawed and biased. The metrics or inputs used in these models are often a best estimate available, but many are prone to severe measurement biases. For example, when the authors assessed whether mask mandates worked, they used ecological estimates of mask use collected from self-reported mask use in a Facebook survey. While it's a creative source of data, it is not at all a representative sample of a population. Nor do we know what type of mask or respirator the people were using, or do we know how they used them? And there's a very large difference in the level of protection with someone who consistently uses an N95 respirator or someone who may use a surgical procedure mask.


Dr. Osterholm: [00:16:12] But nonetheless, these data are fed into a model and then used by some to say, see masks work. The problem is that many interpret the results and extrapolate far beyond what is appropriate. So from the standpoint of what happened during this time, that the model might look at would also raise several other issues. Remember, this was not really a pandemic. This was a wave of pandemic activity that changed dramatically from the first year to the second year to the third year. And interpreting what worked or what happened in any of those years could be very different than the previous year or the year after. And so from that perspective, let me just give you some examples. If you look at the issue with lockdowns, we have had many people do analyzes on did lockdowns make a difference or not? Well, first of all, I don't even know what a lockdown is really, because there's no one standard definition for it. But if you look at what happened with stay at home orders, which is one of the categories used in this modeling study, did the government in that state put forward a stay at home order? And Minnesota was a classic example. We did that and our governor issued that in March of 2020. But what was challenging was as much as we had a quote unquote stay at home order or a lockdown, they then reviewed who was considered an essential employee.


Dr. Osterholm: [00:17:38] Ultimately, 82% of the Minnesota workforce was deemed an essential employee. That's hardly a lockdown. And yet that's what it's called in the analysis. If you look at another example, pediatric cases, I think this has been an example of this at the extreme. Early in the pandemic, there was little evidence that, in fact, we were seeing any kind of major transmission or severe illnesses among those in the pediatric population and says such. Then they became the norm, that in fact, this was not a problem. But that's not true. A way to consider this changing risk over time is just to examine deaths due to COVID in children 17 and younger in the US. In the first three years of the pandemic, there were 1486 deaths recorded in this age group 199in 2020 609in 2021 and 678in 2022. 87% of the deaths in children 17 and younger occurred in the second two years of the pandemic. Well, what happened? Well, public health officials, educators and researchers greatly underestimated the evolving risk of infection with the eventual arrival of variants like Alpha, Delta and Omicron over the next two years. These variants were increasingly more infectious in kids and caused much more severe clinical illness. Most regions of the country saw increasingly larger surges of pediatric cases in May 2021, which is associated with the Alpha variant. September 20th, 21, Coinciding with the fall school opening and arrival of Delta and January 2022 associated the major surge of Omicron.


Dr. Osterholm: [00:19:26] We saw smaller but real increases in cases coinciding with children returning to school after summer and winter breaks in 2021, 22 and 2022 and 23. But I think the study that provided the clearest and most compelling answer to the risk of infection in children related to school attendance and the role that that played in terms of subsequent transmission in the community was an elaborate US cohort study of 166,170 households with adults and children using smart thermometers conducted from October 2019 to October 2022. The authors concluded that more than 70% of household transmission in homes with adults and children were from a pediatric index case. When schools reopened in the fall, 2020 children contributed more to household transmission when they were in school and less than during summer and winter breaks. This pattern was consistent for two consecutive years of the study. Well, then how do you measure schools closed or not closed? And I think that's the challenge that we have, is it wasn't about the school closures. It was about which virus was circulating in the community. Well, how do you bring that into your model? None of the models that I've seen so far even attempt to do that. And so what we have to understand is that this is a relationship between the virus and us. Some of the things the virus does, some of the things we do. But at the root cause, we are going to see that it's not just about what we did that make a difference.


Dr. Osterholm: [00:21:01] And even to the extent of looking at how did the cases of COVID present from a standpoint of serious illness over time. If you look at a study that was conducted by the CDC of hospitalized patients just recently published in clinical infectious diseases, they looked at cases or hospitalized between March 11th, 2021 and August 20th, 22. In 21 hospitals in 18 states. They had 9825 patients they followed. And what they did is they compared adult hospitalized during the early COVID variant periods with those hospitalized during the Omicron variant. They found compared to adults hospitalized during early COVID variant periods, those hospitalized during the Omicron variant were older, had multiple comorbidities and were more likely to be vaccinated and less likely to experience severe disease and death. Again, that changed throughout the entirety of the pandemic. So how could you factor that in through a measure of lockdown mask use? What the public policies were not saying that they weren't important. They were. But it's not that simple. And oftentimes I say to people, you know what, this is not rocket science. This is a lot more difficult. And I really believe that. So these papers that have come out, you know, I welcome them. I think they're a great points of discussion, but I challenge often how valid they are of what they're actually providing. I would just close here by sharing a quote from someone who I have found as a fascinating character in history, Sir Josiah Stamp. He lived from 1880 to 1941. He was an English industrialist, economist, civil servant, statistician, writer, banker.


Dr. Osterholm: [00:22:48] All kinds of things. And he was good at quotes. This is, to me, a one that really helps define this whole discussion. And he said the government are very keen on amassing statistics. They collect them, add them, raise them to the nth power and take the cube root and prepare wonderful diagrams. But you must never forget that every one of these figures comes from the first instance from the village watchman who just puts down what he damn pleases. And I think we have to be very careful here in analyzing these data. Just remember, lockdowns was Minnesota lockdown state or not? On paper, we were in practice. We weren't. A lot of other states were like that. School closings. What does it really matter? Well, in the earliest days, you could have closed schools, but it wouldn't be because school closures, reduced transmission because it wasn't really happening that much in kids anyway. Later on with schools were open. We saw lots of transmission, even though people wanted to believe it wasn't happening. I could go through the laundry list of that masking, etcetera. So I think to close it here, Chris, I'll just say we always welcome these discussions. I think these papers help us look more closely at what happened, but I've seen no one yet who's been able to fully explain how in this dance that we've had with this virus, who directed what, at what time, was it the virus or was it us? And how did that all work out?


Chris Dall: [00:24:09] Now to the latest research on long COVID. Last week, a team led by researchers at the University of Minnesota published findings from a Phase three trial that suggested early outpatient treatment with the diabetes drug metformin reduced incidence of long COVID by 41%. This seems like very promising news. What should our listeners know about this study, Mike?


Dr. Osterholm: [00:24:32] Well, I too think it's an important study. I wish I had known about it 3 or 4 months ago, and I want to congratulate the team that put this together. It was actually led by one of my colleagues, Carolyn Bramante, here at the University of Minnesota as part of the COVID out study. And it was really a very well done study. It was a randomized, quadruple blind, placebo controlled trial that occurred at six different locations in the United States. The participants in the study were adults aged 30 to 85, with a BMI greater than or equal to 25, or for Asian and Latino participants, a BMI greater equal to 23. We had COVID for fewer than seven days before starting the study. And who had previously not been infected with SARS-CoV-2. 55% of the participants were vaccinated with a primary series, and about 5% of the participants had received a booster dose. Participants in the study were randomly assigned to receive one of six possible combination of drugs metformin plus ivermectin, metformin, plus fluvoxamine, metformin plus placebo, ivermectin plus placebo or Fluvoxamine plus placebo. 663 participants received metformin and either a placebo, ivermectin or fluvoxamine and 660 did not receive metformin and instead received fluvoxamine alone, ivermectin alone or just placebo. To determine the effects of these drugs on long COVID incidence, participants were followed for up to 300 days after their acute infection. Researchers determined long COVID status of participants through participant reported long COVID diagnoses from a medical provider. Overall, 8.3% of the participants reported a long COVID diagnosis by day 308.3%. 78% of those diagnoses were made by a primary care provider and the rest by specialists, emergency room and urgent care doctors or other medical providers.


Dr. Osterholm: [00:26:29] As you mentioned in your question, Chris, the researchers found that metformin reduced the incidence of long COVID diagnoses by a medical provider by 41%, with 6.3% of participants who received metformin having been diagnosed with long COVID by day 300, compared to 10.4% of the participants who did not receive metformin. The effects of metformin did not change significantly after adjusting for vaccination status or any of the other medications used in the study. Metformin also had similar effects on reducing long COVID incidence, regardless of which variant was dominant at the time of a participants COVID infection. Though metformin treatment had a greater impact when initiated within the first three days of symptom onset, it still had some effect if initiated between days 4 to 7. I want to briefly mention two limitations in the study, which the authors did point out. The first is that the study excluded adults with healthy or underweight BMI and adults under 30. So it's yet really still unknown if these results are generalizable to these populations, as I would be surprised if they're not. The second limitation I want to mention is that a long COVID diagnosis by a medical professional is in no way a perfect way to measure the incidence of long COVID. There is no perfect way to measure the incidence of this long COVID condition. It's very likely that some of these diagnoses were missed diagnoses and just as likely that some of the participants had long COVID but never reached a medical diagnosis due to an inability to seek medical care or a misdiagnosis by a provider. Despite these limitations, I think these results are very promising.


Dr. Osterholm: [00:28:10] It's exciting to hear about any treatment that can reduce long COVID incidence, especially when the treatment is as affordable, accessible and safe as metformin. I hope that this brings some hope to our listeners that continue to fear the possibility of one day being infected and getting long COVID again. Remember that using Paxlovid by itself is a means of reducing the incidence of long COVID once you become infected. Adding in metformin will be another important tool. And let me just add here, as I've received many inquiries from this very kind, kind, kind family of how I'm doing, and it's been a long road. As you now know, I became infected in mid-March and have suffered from a long COVID symptom of fatigue like syndrome. I found that I started to get better and then I pushed myself a couple of days of more extreme exercise. And by day three, I was back down again. And so I'm being much more careful about what kind of exercising I do, trying to modify my need to get out and get going at the way I used to. But it is really frustrating and all I can say is I wish I had taken metformin back when I became infected. And just to be clear on this, since metformin has not yet been approved. For use with COVID and long COVID. Do please talk to your physician because of course it can be used off label. And but the safety of the drug is such that I don't think you'd find any clinician today that would not want you to take that if, in fact, you had developed COVID.


Chris Dall: [00:29:50] As I mentioned in my introduction, the FDA's Virb PAC will be meeting today to discuss the makeup of the COVID-19 vaccines for the 2023 2024 vaccination campaign. Advisors a few weeks ago recommended that vaccine makers switch to a monovalent vaccine that contains an XB lineage. So, Mike, do you expect a similar recommendation from Virbac?


Dr. Osterholm: [00:30:14] Yes, Chris, I think this is exactly what we're going to see come out of this meeting today. And let me remind everyone, even before they meet today and review the meeting materials which were made available earlier this week, both the Ecdc, the European CDC and EMA, the European Medicines Agency on June 6th put forward an approval for basically a Monovalent vaccine. So we'll be following in line with what the Europeans have already done. Let me just add that the materials that are being provided today for the meeting, detailed considerations such as effectiveness, virus surveillance, antigenic characterization of variants and manufacturing, amongst others. Ultimately, they explain that the Sublineages account for more than 95% of the circulating virus variants and thus a Monovalent XBB lineage vaccine would be the best recommendation. With all that being said, it's looking more and more like we can expect the same recommendation from VRBPAC. As you mentioned in your question, this is the same recommendation the W.H.O. made a couple of weeks ago. And as I noted, both Ecdc and EMA have also done so. But I do want to add that just because there are recommendations made by Who and the FDA Technical Advisory Committee, it does not mean that FDA has to follow this recommendation. Typically it does, and I can't imagine that they're not going to follow this recommendation here. So we'll have to wait and see when these boosters will be approved and available. Hopefully it will be well before the early winter months.


Chris Dall: [00:31:56] And that brings us to a query that we received about booster shots. Andrea wrote. My question is about COVID boosters. I'm vaccinated and twice boosted last in September of 2022. Since it sounds like I would be eligible for another booster at this time, I wonder if I should get it right now or perhaps wait until the fall when cases might be higher in my community due to more indoor gatherings. Mike what can you tell Andrea?


Dr. Osterholm: [00:32:22] First of all, Andrew, this is a great question and one that we all are asking ourselves here at CIDRAP. And surely our family members and friends are asking us also. So I may sound like a broken record in answering it. As always, I recommend that if you're eligible to get a booster, get it. We know that these vaccines are really good at keeping people out of the hospital and preventing death, at least for a period of time. But we also know that these vaccines are not great and immunity does wane somewhat quickly over the next 3 to 6 months. In our last episode, we discussed the data from the Vision Network study and the results published by the CDC. This study found that the Bivalent vaccine effectiveness dropped from 62% to 24%, six months after a booster dose in adults without immunocompromising conditions. And those numbers were even lower in adults with immunocompromising conditions. Remember, these were numbers about protecting you against hospitalization. So having received a booster eight months ago, your immunity is surely waning. This virus is unpredictable and we don't know how cases will trend. It is best to be as protected as possible and not be wishing you had gotten it earlier when it is too late. As I just discussed with the FDA advisory committee happening today, I anticipate we will have a better idea of who will be eligible for the new composition vaccine in the coming weeks.


Dr. Osterholm: [00:33:47] And I think that we'll have an additional booster dose available within six months from now. So if you get a vaccine now, you'll be able also to get the other one when you're again eligible. And I say that with confidence, I'm sure they will not be a shortage. As it stands, remember, only 17% of the US population has received a bivalent booster dose. 43% of adults over 65 have received one, and only 20.5% of adults over 18 have received one. With numbers this low. I'm sure that when you are eligible and looking for another dose, you won't have to look hard to find one. That's unfortunate. All this is to say that if you're eligible for a vaccine, get it come six months from now when the new monovalent vaccine that is likely to be recommended by FDA later today becomes available. I'll be recommending that one as well. Please keep getting your boosters. They're the best tool you have right now. And if even if you've been infected at least four months after that infection into six months afterwards, get another booster. Hybrid immunity. The combination of vaccine based immunity and infection itself can give you some of the best protection for second or third episodes. And so, Andrea, I hope this answers your question. Thanks again for asking.


Chris Dall: [00:35:07] So this next item isn't directly about an infectious disease, but it is about a public health issue. And it involves one of our favorite topics N95 respirators. Last week, as many of you know and may have experienced, New York and other parts of the East Coast dealt with several days of dangerous air quality caused by wildfires in Canada. That prompted many people in those areas to break out their N95 respirators. Mike, this is an issue we could be dealing with more and more in coming years. As you noted earlier, we're experiencing it this very week here in the Twin Cities. We experienced it last summer. Californians deal with it every year. So our N95 respirators, an effective form of protection if you have to be outside when the air is affected by wildfire smoke.


Dr. Osterholm: [00:35:53] Well, Chris, another great question and one that, again, a lot of people are asking and unfortunately, it's affecting more and more of our listeners. Let me just remind everyone that wildfire smoke can pose a significant health risk, usually for those with health conditions that affect the lungs. But the air quality we've recently seen in places like New York, Philadelphia and now even Minneapolis was bad enough that almost everyone will experience health effects to some extent, even those who are otherwise healthy. The good news is there are things you can do to protect yourself against wildfire smoke. The first is to stay indoors if you're able. Even though, yes, the air around you may have more smoke, the penetration into homes is much less than it is outdoors. When you're indoors, use an air filter or purifier if you have one. Remember the Corsi boxes that we've talked about in many previous episodes. This can include also using your central air conditioning if you have it with the appropriate filters. But let me go to the heart of this issue, because to me, I find it quite ironic that we see public health leaders around the country, including the CDC, urging people to use N95 respirators as the ultimate protection, particularly if they have to go outdoors. What is smoke? It's an aerosol. We've talked about that many times in this very podcast. So we are now strongly urging people because of aerosol related exposure, to be sure, and use a well-fitted N95 respirator. And yet we couldn't get people to say that with COVID, which was also an aerosol. And so I think from that standpoint, this is a bit of a challenge.


Dr. Osterholm: [00:37:31] So if you do go outside, please wear your N95 respirator. This is not guaranteed that you won't inhale a small amount of smoke, especially if you're N95 is not perfectly fitted, but it's certainly reduced the amount of harmful particles you inhale. These respirators can block at least 95%. We call it PM 2.5 particulate matter, that kind found in wildfire smoke. Cloth masks, bandanas, surgical masks. Procedure masks are not effective at all in blocking particles of this size, and they do not fit tightly enough to be effective. The N95 block similar sized particles as n95s. Remember, they lack the tight fit in some instances. That makes the N95 so effective. So remember, if you can smell the smoke through your respirator, you're still inhaling smoke. And remember, if you're in a room with someone who is infected with SARS-CoV-2, even though you wouldn't smell it, you too could become infected. So that's why we want you to be using your N95. The bottom line is you can stay indoors with air conditioning and or an air purifier. That is the best way to stay safe. I realize there are many people who don't have access to air conditioning or an air purifier, and that is a challenge. I will say that there have been a number of public health agencies distributing N95 respirators over the course of the past two weeks. If you can't afford one, please check with your local public health agency to see if there may be a way that you can obtain one in Kn95s will go a long way in protecting your lungs and thus your life.


Chris Dall: [00:39:10] A bit of housekeeping here. After our last episode, a listener had a question about some discrepancies between the COVID numbers we used and the CDC numbers. So in the interest of transparency, we wanted to take this moment to talk about the sources we use for our data and why.


Dr. Osterholm: [00:39:27] Well, I want to thank the listener who brought this to our attention. We welcome these kinds of questions, points of information and and in some cases, just challenges to what we've said or how we said it. And this is really important one. The listener was absolutely correct. The numbers that we reported for weekly deaths were slightly different from the numbers that the CDC provided. I don't have a great answer as to why that is, but I can tell you where I got the numbers and why the death numbers we used in our last episode came from Oxford's Our World in Data Dashboard. Previously, this dashboard used data from Johns Hopkins, and now it uses data from the W.H.O.. We use this dashboard rather than the CDC numbers, as it has international data in addition to data on the US, making it easy to visually compare COVID trends across different countries. Again, this still doesn't answer the question as to why these numbers were slightly different. So I know that this answer may seem insufficient, but I still felt it was important to address for the sake of honesty and transparency. I do believe that one explanation could be that the delay in getting numbers to W.H.O. from CDC means that we may have slightly more current numbers at CDC, which could be higher or lower than those same eventual numbers that make their way to W.H.O.. But we will continue to track this. And if there was any marked discrepancy, we'll tell you, of course, that that's the case. Otherwise, I think these are both good approximates of what's actually happening in our communities, at least in terms of deaths.


Chris Dall: [00:41:02] Now for our first moment of joy, which is replacing our Beautiful Places segment. Mike, who did we hear from this week?


Dr. Osterholm: [00:41:11] Well, let me begin with by saying that this was a very, very moving piece that was shared with us by a loving mother, someone who did not want her name used. And I understand why. And I think I look at all the turmoil in the world that we see right now and we're seeing what's happening with social political issues here in this country. And I hope all of us take this to heart. So let me share with you from a loving mother her moment of joy. My teenage child came out as transgender just before the pandemic. And I don't think I have to say how vulnerable my husband and I can feel these days in terms of our child's safety and welfare. My little bit of joy is that despite the pandemic and online learning, my child was able to meet a group of new friends freshman year at high school that embraced and accepted and enjoy my child 100% as he is. My child is vulnerable in a way I could never have imagined. But he has friends. He has very good friends. And like I see both you and Chris and this podcast family is my friends. During the podcast, my child has a space of kindness, acceptance and appreciation. This is more than a little bit of joy. This is a world of joy. Thank you for allowing me the space to share. Kindness goes a long way and I'm so grateful for all the kindness that is in this world. A loving mother. How could you not understand how special this is? Thank you so much for sharing this. I wish you and your child, your husband, the very, very best and the love that you have shared in this moment of joy is remarkable. Your child is so fortunate to have you and your husband as their parent.


Chris Dall: [00:42:52] Just a reminder to our listeners that we would love to hear about your moment of joy even as we move past the pandemic. We know that we live in challenging times. Finding the thing that brightens your day, even if just for a moment, is so important for our mental health. So what is the thing that brings you a little bit of joy? It can be a place, a person, a pet, a piece of art, a memory or whatever you want it to be. But you can share it with us at OsterholmUpdate@umn.edu. And we look forward to hearing about these moments of joy. And now I'd like to take a moment for a little bit of business before we wrap up this episode of the podcast. This podcast family has been so important to us over the last three years, and we hope that you have come to appreciate all the timely information, support and positivity we've been able to provide you through the Osterholm Update. With that, we'd like to take a moment to remind you all of how critical it is to have access to the type of high quality, authoritative and unbiased scientific information that you get from this podcast and from CIDRAP. Please help us continue to provide the coverage and voice you have come to expect from us regarding the latest infectious disease threats. By supporting the team you trust, respect and depend on any amount of financial support is extremely appreciated and will ensure that we can continue to offer this podcast going forward. Your support means more to us than you'll ever know. To contribute to this podcast and everything we do here at CIDRAP, please visit cidrap.umn.edu/support to make it easier for you. We'll put that link on the podcast page. We so appreciate your support, trust and continued partnership. Anything you'd like to add? Mike?


Dr. Osterholm: [00:44:34] Well, first of all, I just want to thank everyone who already has supported our efforts here and how much that means to us. The members of our news team and the podcast team do provide an amazing service for which no one in the research world or the granting world in a sense, necessarily wants to pay for. Yet we believe having this unbiased, just in time comprehensive information is very important. I'm terrible at asking for money, so I am relegated to the bench on this one because it's just not in my nature. But please know that it does mean a great deal to us and allows us to continue to do this kind of work for all of you. So anything you can do to help us is much, much appreciated. But I never want anyone to ever feel like they have to provide any support to benefit from what we can offer you. That is a promise I made to you when this podcast started, and I will keep that. This is not about who can pay for what This is about. How can we just make this work? And we thank you so, so much for that. Thank you.


Chris Dall: [00:45:43] Okay. So back to our regularly scheduled programing. Mike, what are your take home messages for today?


Dr. Osterholm: [00:45:50] Well, again, my three messages boil down to kind of a theme that we've had ongoing for the past several weeks. The COVID cases in the United States and for that matter, most of the world continue to trend in the right direction in terms of seriousness. This is a really a very important time to recognize that. Now, it doesn't mean that everyone's out of the risk picture, particularly if you're someone who has underlying health conditions that in fact can put you at greater risk for serious illness, hospitalizations and deaths. We've also said get vaccinated, use paxlovid and now metformin, and they will surely be very important. But we have to recognize what we're at. And unless we see some new variant emerge, I just don't see where we're ever going to go back, ever go back to where we were. And I'm not even sure how big surges will get. The second thing is that I have to say, I mean this from the bottom of my heart. COVID epidemiology is not rocket science. It's more difficult. It's complicated. And hopefully today the discussion of the paper is trying to understand what we know and don't know about why this pandemic did what it did and what we can learn from it so that we can be better prepared for the future. And in this regard, we do have that obligation. But we can't take simple answers. We can't use data that really aren't addressing the question that we're asking. And then finally, I just have to say, the boosters will be available later this fall, no doubt about it. But don't wait. If it's been more than six months since your last bivalent booster, get it now. Knowing that you'll be eligible about the time when the new Monovalent vaccine comes out. So I hope that everyone does that. Again, these are not bulletproof vaccines. They're not great vaccines, but they're really good. They're very good. And we want to do all we can to continue to drive those case numbers down, those serious illnesses down, and most importantly, the deaths. So those three points really summarize it.


Chris Dall: [00:48:06] Mikey said in our prep meeting that the song you chose for this episode is one of the greatest love songs of all time, which intrigued me. So what is the song?


Dr. Osterholm: [00:48:17] Well, I think this will probably surprise a few people, but it ties into my original dedication of this podcast and the fact that, you know, love is a very special thing when it happens between two people and it isn't always romantic love. It's also the love of family, love of fathers, the love of their children. And to me, one of the greatest love songs of all time ever written was written by the late Dan Fogelberg. You may recall Dan Fogelberg, who had a number of hits back in the 1980s 90s and into 2000. Unfortunately, Dan died in December of 2007 from prostate cancer. Dan was born in Peoria, Illinois. He was the youngest of three sons, born to Margaret, a classically trained pianist, and Laurence Fogelberg, a band director at Woodruff High School in Peoria, and then on at Pekin Community High School in Pekin and at Bradley University in Peoria. Dan had a very close relationship with his father, and in 1981, Fogelberg released the song Leader of the Band, which was written in inspired by his father. And so to me today, of all the loves that we can have, there is one that I do believe. Is of such importance and value and yet not often articulated. And that's the love that a child can have for their father. And so to me, this is the ultimate love song. Talking about that. So here it is.


Dr. Osterholm: [00:49:55] Leader of the Band by Dan Fogelberg. An only child alone. And while a cabinetmaker's son. His hands were meant for different work and his heart was known to none. He left his home and went his lone and solitary way. And he gave to me a gift I know I never can repay. A quiet man of music denied a simpler fate. He tried to be a soldier once, but his music wouldn't wait. He earned his love through discipline, a thundering velvet hand. His gentle means of sculpting souls took me years to understand. The leader of the band is tired and his eyes are growing old. But his blood runs through my instrument and his song is in my soul. My life has been a poor attempt to imitate the man. Oh, I'm just a living legacy to the leader of the band. My brother's lives were different, for they heard another call. One went to Chicago and the other to Saint Paul. And I'm in Colorado when I'm not in some hotel. Living out this life I chose and come to know so well. I thank you for the music and your stories of the road. I thank you for the freedom when it came my time to go. And I thank you for your kindness in the times when you got tough. And Papa, I don't think I said I love you and you're enough. The leader of the band is tired and his eyes are growing old.


Dr. Osterholm: [00:51:24] But his blood runs through my instrument and his song is in my soul. My life has been a poor attempt to imitate the man. I'm just a living legacy to the leader of the band. I am a living legacy to the leader of the band. What father would not want their son to share those lyrics about their love? Remarkable, huh? And thank you again for all of you joining us today. I hope that we're able to provide you with some useful information. And I want to particularly thank the podcast family for your wonderful concerns and and follow up with my own illness here. You have been more than kind. Really kind. Thank you. And please, if you're in one of the cities with the smoke, I hope that you're able to protect yourself from that, as we just discussed. And at a time when things are so difficult, when the world seems to be dark in so many ways, there was ever a time for us now to be kind, as we learned in our moment of joy, it's now. So I hope all of you are safe. Protect yourself as you need. Love your family. Love your father if at any way you can this weekend, even if it's a difficult relationship. Love your father and thank you for being with us. Be kind. Be safe. Thank you.


Chris Dall: [00:52:55] 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/support. The Osterholm Update is produced by Cory Anderson, Meredith Arpey, Elise Holmes, Sydney Redepenning, and Angela Ulrich.