July 27, 2023

In "Perspective and Humility," Dr. Osterholm and Chris Dall discuss the state of the pandemic in the U.S. and internationally, a recent study on recombinant flu vaccines, and respiratory protection in healthcare settings. 

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Chris Dall: [00:00:07] Hello and welcome to the Osterholm Update, a podcast on COVID-19 and other infectious diseases 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 draws on nearly 50 years of experience investigating infectious disease outbreaks to provide straight talk on the latest infectious disease and public health threats. I'm Chris Dall, reporter for CIDRAP News, and I'm your host for these conversations. Welcome back, everyone, to another episode of the Osterholm Update podcast. In recent weeks, three newly published papers have shed new light on different ends of the COVID-19 disease spectrum. One of those papers explores the genetic underpinnings of why some people get asymptomatic COVID infections, while the two other papers look at the variants that might be associated with long COVID and the genetic factors that might make some people more susceptible to long COVID. Could the findings from these studies ultimately lead to the development of new vaccines and treatments that will further reduce the impact of this virus? That's one of the topics we're going to discuss on this July 27th episode of the podcast. After we take a look at the international and national COVID trends. We'll also discuss when the new COVID booster shots will be available and who will be eligible to receive them. Answer an infectious disease query on the use of respiratory protection in health care settings and talk about a recent study on recombinant flu vaccines. And we'll share our latest moment of joy submission. But before we get started, as always, we'll begin with Dr. Osterholm's opening comments and dedication.


Dr. Osterholm: [00:01:50] Thank you, Chris, and welcome back to all of the podcast family. It is a wonderful experience to have you with us. Thank you so much for your feedback, your input and your dedication to this effort. And again, as I say, each podcast recording, I also welcome anyone who might be coming to our podcast for the first time. Our effort here is to provide you with information that's helpful in understanding everyday life with COVID and what's happening with other infectious disease issues. And I hope that we can answer some questions for you that you find helpful. Today's podcast is going to be one about perspective. It's going to be about the combination of what we know and don't know and how we should approach where we're at in the COVID pandemic experience. But before I begin with that, I also want to address our dedication head on today, because this is one that is a combination of what I would call a perfect storm of events and information availability that we just can't ignore. As much as I'm focused in my world in infectious diseases, this is an area which does contribute to the impact that infectious diseases have, but also it goes to a much deeper issue, and that's about our very humanity. This week's dedication was chosen in light of a UN report that was released earlier this month on global hunger. According to the UN report, the number of people affected by hunger in 2021 rose by 46 million people from that number in 2020 and 150 million from 2019.


Dr. Osterholm: [00:03:30] Now, with more than 828 million individuals severely impacted by hunger, this is almost 10% of the world's population. Additionally, 2.3 billion people are almost 30% of the global population were moderately or severely food insecure in 2021. This includes 828 million people suffering from hunger and also those with limited or uncertain access to food. They are at risk of hunger. The number of people who could not afford a healthy diet rose 112 million from 2019, now at 3.1 billion people. The supply chain disruptions caused by the war in Ukraine and the increases in extreme weather events, as well as economic issues caused by inflation in much of the world, are all contributing to this rise in hunger and lack of access to healthy food. This may be one of the biggest public health challenges our world is facing and will continue to face in the years ahead. And with so many complex issues causing this crisis, there won't be a quick and simple fix. So to all of the 3.1 billion people lacking access to healthy food and the 2.3 billion people facing food insecurity, and the 828 million people experiencing hunger, in many cases severe hunger. We see you. You are not invisible to us. We see you. And it's in this light. I dedicate this podcast to all of those in policy positions, actually in agriculture, in shipment, in diplomacy, all of you who are working to try to help feed the world, we dedicate this podcast to you. And let me just add as a note, as a kid growing up in rural Iowa, I saw the moments in my mother's face when there wasn't enough food to go around for our entire family and she was the last one to eat.


Dr. Osterholm: [00:05:22] I will never forget what that looks like. I can't imagine today how many parents are realizing that their child is dying because of malnutrition and lack of food. So we must address this issue head on. There is no reason anyone in this world should die from malnutrition or lack of food. Just no reason. Now let me move on to the sunny side of life, which today is reminding me of the fact that the numbers of days of sunlight are decreasing rather quickly. Now, here in the northern hemisphere today, July 27th in Minneapolis-Saint Paul sunrise will be at 5:52 A.M., sunset at 8:45. That's 14 hours, 52 minutes, and 54 seconds of sunlight. We're losing sunlight at about 2 minutes, 11 seconds a day. Right now we are marching towards the fall, which is going to be coming soon. Even though with the temperatures we're experiencing today, it may seem as if that's not possible. Today, our colleagues in Auckland, particularly our dear, dear friends at the Occidental Belgian Beer House on Vulcan Lane, your sun rises at 7:24 A.M., your sun sets at 5:31 P.M. You're at 10 hours, 8 minutes ,and 48 seconds of sunlight. And I'm very happy to report that you're gaining 1 minute and 33 seconds a day, and that number is only going to keep getting larger.


Chris Dall: [00:06:51] So let's start where we always do with the international and national COVID trends. The most recent update from the WHO shows COVID-19 cases and deaths continuing to decline globally. While the most recent CDC update shows the second straight week of small upticks in emergency department visits and test positivity along with rising hospitalizations. The Who also added the EG.5 variant, which is steadily rising in the US to its list of variants under monitoring. So Mike, what's your assessment of the latest data?


Dr. Osterholm: [00:07:21] Well, Chris, before getting into this, I'd like to start out by first just providing some perspective that I think might be useful to anyone who's trying to stay up to date on where things are at with COVID. And what this perspective involves really is understanding and considering the broader overall context or big picture of what's existing today with COVID. More and more, I feel like one of the biggest challenges I'm having in terms of providing updates and information on COVID relates to finding the appropriate balance that exists when it comes to the risk presented by this virus. This all has to be based on a very real sense of humility. Let me just be really clear today that we are on the backside of the pandemic. Make no mistake about that. I do not see us going back to the days of 2020, 2021, 2022. At the same time, I can't say that we're done at all with this virus because we're not. And trying to understand how to share that perspective is really very important. I see people who want to be completely past the pandemic as if the virus no longer exists. I see people who will say anything to minimize this virus suggests that you don't care. Neither of these are true. What I will tell you right now is that it's all about humility and it's all about not getting too far ahead of your headlights. Anybody that today gives you information about what COVID will look like 2 or 3 months or more from now, be careful, because they also probably have a bridge to sell you.


Dr. Osterholm: [00:08:52] And I think that this is just where we have to understand we are at. On the one hand, I find it important to really emphasize that we no longer are living in these days of the pandemic where hospitals were literally overwhelmed with COVID patients and thousands and sometimes even tens of thousands of people were dying worldwide on a daily basis. As an example, if you look back to January 2021, you'll find that the number of COVID deaths reported worldwide in a single week exceeded 100,000. That's roughly 14,300 deaths a day for seven straight days. In fact, in just that one month of January 2021, there were actually three separate weeks where deaths were passed, 100,000. So more than 300,000 deaths in a span of just three weeks. How does that compare to now? Well, with a caveat that reporting systems are far from perfect. Global deaths basically fall within a range of 1000 to 2000 a week. And actually, if you were to go back from where we're at right now and add up weekly deaths until you reached a cumulative total of 300,000, you'd be counting back a total of 34 weeks, whereas almost two and a half years ago, it took just three weeks to reach that number. So things are much better now and I think we can all be very grateful for that. But at the same time, there is still a very real risk that this virus presents and that also shouldn't be discounted.


Dr. Osterholm: [00:10:19] So you can sort of get a sense of the nuance that's involved and is absolutely required. This leads me to a recent story I read that was published by CBS News this past Tuesday, titled US Sees Biggest Rise in COVID-19 Hospitalizations Since December. Whoa. Read that and you think we're back at it again. Well, don't get me wrong, it's not a bad article. In fact, it provides some pretty good overview of where things are right now in the US and on a factual basis. It's actually accurate. However, the one fact that's used for the headline, presumably because it helps grab the attention of a reader, involves the percent change of new hospital admissions with COVID from one week compared to the previous week based on the CDC data that this was pulled from, which compares numbers from the week of July 15th to the previous week. On July 8th, there was a 10% increase in new hospital admissions with COVID specifically throughout the week of July 8th, there were 6444 new patients admitted to the hospital with COVID across the US, again 6444. For the week of July 15th, there were 7109 new admissions compared to that 6444. Thus, there was a 10% rise from the previous week. Again, on a factual basis is correct. But is this a notable rise? Well, at this point, I don't think we can conclude that. One of the reasons I say that is because COVID hospitalizations in the US are now at the lowest levels we've seen since the start of the pandemic.


Dr. Osterholm: [00:11:54] Since just this past January, when more than 41,000 Americans were hospitalized with COVID, the number has consistently dropped. In early May, they reached an all time new low of 8900 and even then continued to decline. By July, the number of Americans hospitalized with COVID stood at just over 5300. And even with the increases in the weeks following, current hospitalizations still stand at 5000. 600. So one of the challenges I've been seeing is this emphasis by so many on percent changes with less attention given to what actually do these changes mean In overall numbers, an increase of 100% could involve going from 50,000 to 100,000. We've been there at the same time. It could mean that you went from a total of 2 to 4. And I believe that these numbers were seen today reflect the very, very low numbers where increases percentage wise can surely be misunderstood. I don't say this to shrug off any possible signs of an uptick. Rather, I say it's because I've already heard comments from some of the talking heads out there in public health implying that this signals the start of a late summer surge. Let me be really clear. The data we have supporting wind surges occur typically revolves around the issue of a new variant emerging that is either more infectious or has more immune evasion. And at this point, we just don't see any variant on the horizon that matches up with this great increase in infectiousness or in the ability to evade immune protection.


Dr. Osterholm: [00:13:30] So it's not that something couldn't happen. It's not that we won't see that happen again, but I am yet convinced that we will not see these big spikes in cases that everyone is talking about. Now, as far as us numbers go, there are some signals of slight growth that we're monitoring. I already mentioned the slight rise in hospitalizations, otherwise test positivity has climbed from 4% to just over 6%. And wastewater data does show a small but fairly steady rise in northeastern, southern and western United States. So it's not time to throw caution to the wind. And for me, just remind everyone I pay no attention to case numbers anymore because we have so systematically dismantled our surveillance activities here in the United States for COVID. We can't interpret these numbers and compare them to anything in the past. But again, the levels we are reporting right now in hospitalization, serious illness deaths are low relative to what we've seen even six months ago. And fortunately, deaths in the US have continued to climb to an all time low during the week of June 24th, which is the latest week we have complete data for. There were 531 deaths reported, roughly about 76 a day. I can remember so very well when we had spikes of 120 to 140,000 deaths per week. Remember that 531 versus 120 to 140,000 a week. Big, big differences. Finally, in terms of the variant picture in this country, it is still largely a mixed bag of offshoots from the XBB family, with five different lineages, each currently estimated to have a prevalence between 10 and 15%.


Dr. Osterholm: [00:15:12] However, the only lineage among them that seems to have a fairly marked growth advantage is EG.5, which is a descendant of XBB 1.9.2. Throughout this past month and a half, EG.5 has gone from around 1% prevalence to 11.4%. So it hasn't separated itself from the rest of the pack yet, but it does seem to be gaining ground fairly consistently, even outside the US. EG.5 appears to be on the rise. According to the latest WHO report on COVID, its global prevalence has climbed since late May, and on July 19th the agency designated it as a variant under monitoring. Fortunately, there is no evidence at this point indicating that EG.5 five causes more severe disease or even immune evasion. And even with its apparent growth advantage, I'm not necessarily convinced at this point that it will actually drive up activity. But ultimately we'll have to wait and see. Otherwise, when it comes to the latest global activity with COVID, things continue to remain fairly cool overall throughout the world. For the most recent 28 day period running from June 19th to July 16th, there were a total of 836,000 cases and 4500 deaths reported with virtually every WHO region once again experiencing declines. Again, let me emphasize, I don't put a lot of stock in the total number of cases. I think the death numbers are a more reliable, yet not completely reliable indicator of what's happening.


Dr. Osterholm: [00:16:40] The only exception to this overall global trend was in the Western Pacific, which reported a 30% increase in deaths, going from roughly 1000 deaths in the previous 28 days to 1350. However, it appears that most of that increase might simply be the result of Australia addressing some reporting backlogs. So even that doesn't suggest that we're seeing unusual or increased activity in the Western Pacific. So overall, globally and even regionally, things remain fairly low. That said, there are those countries, for example, Japan and South Korea, where activity has climbed. So it's not like the virus has disappeared. And I. Can't explain, nor do I know anyone who can explain what's happening right now in Japan and South Korea. And on that note, it's kind of fitting that the latest WHO report dedicated a paragraph to this concept stating, and I quote. Please note although the public health emergency of international concern for COVID-19 was declared over on 5th of May 2023, COVID-19 remains a major threat. WHO continues to urge governments to maintain, not dismantle, their established COVID-19 infrastructure. It is crucial to sustain surveillance and reporting variant tracking, early clinical care provision, administration of vaccine boosters to high risk groups, improvements in ventilation and regular communication. This is all about perspective and humility. And all I can say is that right now, I think we have to welcome the fact that while the virus is still here, we're in the best place we've been in over three years.


Chris Dall: [00:18:21] So, Mike, even though we are on the back end of this pandemic, most people in our audience are now well beyond six months since their most recent booster shot, and they're likely eager for their next shot. So what is the latest on the next formulation of COVID boosters? When will they be available and who will be eligible to get them?


Dr. Osterholm: [00:18:43] Well, Chris, as you just said, I know this is something many of our listeners are eager to hear about. And I wish I had a clearer answer for everyone wondering if and when they will be eligible for to receive their next dose during the FDA's VRBPAC meeting in June. Pfizer explained that they'd be able to distribute an XBB1.5 monovalent vaccine by the end of July, but an XBB1.16 vaccine wouldn't be available for distribution until at least August, and other formulations wouldn't be ready until October. Fortunately, because the recommendation was for XBB1.5, we should be able to expect doses very, very soon. But we still don't have a good sense of who will be eligible to receive them when they become available. The CDC's ACIP, which makes these recommendations, has yet to come forward with who they are going to recommend to receive these boosters. I want to remind everyone that these boosters are not going to significantly reduce transmission on a population level. So the purpose of these vaccines is really to reduce severe illness, hospitalizations and deaths, particularly for those who have underlying health conditions or who are older. For this reason, there isn't widespread demand for booster doses among those who are not at high risk of severe COVID illness due to age or chronic health conditions. But seeing as there's very little risk to these additional doses, it is my hope that they will be available to anyone who wants them. We'll have to wait and see what the final recommendations will be and hopefully by the time of the next podcast, we will have that information for you.


Chris Dall: [00:20:14] As I mentioned in the introduction, three new papers have come out in recent weeks on the genetic underpinnings of asymptomatic COVID and long COVID. So, Mike, what did we learn from these papers? And do these findings give researchers potential avenues to explore for new vaccines and treatments?


Dr. Osterholm: [00:20:32] Well, Chris, as we've discussed before on this podcast, the issues of asymptomatic COVID and long COVID are both very complex, and no single study will give us all the answers. Each of these studies uncover another piece of the puzzle, but we still don't know what the overall picture looks like. What I mean by that is I don't see any road map here for new therapeutics or for information about better vaccines that come out of this these studies. But I do believe that these studies are giving us some hints about how the human immune response and infection with the virus are so interlinked. And eventually these may give us more information about therapeutics or even vaccines. That said, this is still very valuable and important information. I want to just provide a brief overview of these studies, all of which will be linked in the episode description. In particular, I'm going to link for you an article by Dr. Eric Topol on Groundtruth that really summarizes these studies as well as anyone could. And I urge you to go look at the link in the podcast website. The first of the three studies I want to discuss were published last week in Nature, and it analyzed data from nearly 30,000 participants for whom human leukocyte antigens or HLA genotyping were available.


Dr. Osterholm: [00:21:52] Over 1400 unvaccinated participants reported positive COVID-19 test results. The researcher Studies potential association between disease progression and five HLA loci and found a strong association between asymptomatic infection and the HLA-B*15:01 allele. Those with one copy of this allele had 2.5 times the odds of experiencing asymptomatic disease as those with no copies of the allele and those with two copies of the allele had 8.5 times the odds of asymptomatic disease as those with no copies of the allele. Researchers determined that t cell cross-reactivity associated with this allele likely explained the genetic protection against symptomatic illness, something that we surely must look at with regard to vaccines and immunity. The second study that I want to discuss is a preprint published earlier this month out of Finland that assessed genome wide significant associations for long COVID. Using data from 24 studies conducted in 16 countries, researchers found that there was a significant association between the FOXP4 locus and long COVID illness. Those in the study who had a single allele at a certain location on this loci were found to have 1.6 times the odds of developing long COVID as those who did not. The third study that I want to discuss is a preprint published two weeks ago out of the U.K., which also explored genetic risk factors for severe COVID and long COVID.


Dr. Osterholm: [00:23:23] This study, which had a much smaller number of cases and controls, did not find any loci with statistically significant associations with severe COVID or long COVID. That said, the researchers did identify 73 allele variants that might be associated with long COVID. So I want to make it clear that this study did not conclude that there was an evidence for genetic risk factors for long COVID. It simply did not have sufficient evidence to say that there was. More studies with larger sample size, like the preprint from Finland, will be needed to explore the possibility that these variants could increase the risk for long COVID. The bottom line is that this is just the beginning when it comes to this area of research. I hope that projects like this can continue to find funding in the months and years to come so we can continue to learn more about the genetic risk factors and protective factors associated with asymptomatic COVID, severe COVID and long COVID. As always, we will continue to update you as this research progresses and more information becomes available. Wish we had more answers from this work, but it surely is shining a light into what has otherwise been a very dark space.


Chris Dall: [00:24:32] Mike, the New England Journal of Medicine just published a new paper by Dr. Ashish Jha and the Secretary of the Department of Health and Human Services, Xavier Becerra. And it's called Project Next-Gen Defeating SARS-CoV-2 and Preparing for the Next Pandemic. Now, Mike, you've been a little skeptical of Project Next-Gen. What did you think of what they had to say in this paper?


Dr. Osterholm: [00:24:55] Well, I hope everyone recognizes the fact that by the very emphasis that our center has placed on vaccine work around roadmaps and the need to get better vaccines, the sense that we have very much appreciated the the very good vaccine that we've had with the mRNA COVID vaccines, But they're not the great vaccines that we ultimately need. Will find my comments helpful and not somehow contradictory to the importance that I think that vaccine research should take. My concern has been is that having worked with these vaccine roadmaps, detailed plans that say, okay, you do this first, then you learn from that and then you can do to the next section, and then you go to the next thing you know, it's like assembling a car. You start with a very basic frame and build from there. You just can't suddenly throw every piece on it at this one spot on the assembly line. And what we've seen with these roadmaps is they're basically wonderful guides that take time to actually materialize. We've now had the roadmap for influenza vaccines available for several years, and with that, we've actually seen great work being done. But it's just beginning to scratch the surface of understanding what we need to do to get better influenza vaccines. Well, the same is true with coronavirus vaccines. It's not any different. And what I'm very concerned about is, is that we are taking an approach here. If we just throw a whole lot of money at something very quickly, we can have a magical result. And I think some of that comes from the misunderstanding that the mRNA vaccines came about because of a ten month program that was highly successful in getting vaccines out, when, in fact, mRNA vaccine technology had been in the research for more than 20 years.


Dr. Osterholm: [00:26:47] And it wasn't just suddenly a new discovery. As such, I look at this because when I look at the funding right now for influenza vaccines, the model that we have right now from NIH is based on what's called the CIVIC Project, which is eight different centers around the United States with expertise in various aspects of influenza, vaccine research and development and who are all collaborating together. They have averaged about $50 million a year invested in that over the past four years. And they're making progress. But, boy, what they could do with even more money there. And given the implications of an influenza pandemic, it seems to me to be so penny wise and pound foolish not to invest much more in those ongoing efforts. Well, now look at COVID. What the plan here with NextGen is, is to basically take $5 Million in 18 months and just flood the research world with it. I will promise you at the end of 18 months, we will not have any major new discovery, any more than the farmer who plants four times as many acres in April and May of corn in Iowa can harvest it one fourth the time because he planted more acres. It's still going to take the amount of time to mature that corn. And what I worry about is with this at the end of 18 months, with $5 billion just basically thrown out there, we will not see these major new advances. And people are then going to say, well, where's the next tranche of research support? And Congress is going to look at that regardless of what happens with the election and say, wait a minute, we just gave you $5 Million to do this work.


Dr. Osterholm: [00:28:30] Where's your magical new vaccine? And I think we have misled the public and many of our policymakers as to what can be done with that amount of money. Now, if you gave me $5 billion and allowed a billion a year to be spent for five years, I know that's not as fast. I know that's not what we'd like to have happen overnight. But it is the realistic way to advance these vaccines to new game changing vaccines. So I hope from these comments you see that I very much support vaccine research and development. But let's be realistic about what can be done. Again, to use an analogy, if you wanted to build a brand new Empire State Building and you set out unlimited funds, but I need it done in two months, it's not going to happen. And that's what we're doing right now. So, you know, we'll just have to follow this. I worry that in 18 months when we don't have new breakthrough technologies, we will be on the short end of the stick with regard to answering, okay, why do we why should we give you more money? And so I don't celebrate this approach. I think it's a mistake. I think that, you know, it'll surely get a lot of attention, but I think it's a mistake. And I don't think that the article in the New England Journal of Medicine provides any validation as to why it won't happen, as I just laid out.


Chris Dall: [00:29:50] Now it's time for our infectious disease or ID query, which this week is about the use of respiratory protection in health care settings. A listener wanted your opinion, Mike. On a recent paper in the Annals of Internal Medicine that argued that universal masking in health care settings is a strategy quote whose time has come and gone for now, unquote. So, Mike, this is a really timely question because and this has been a surprise to me. Most health care settings aren't requiring any kind of respiratory protection anymore. So do you agree with their argument?


Dr. Osterholm: [00:30:25] Well, Chris, before I get into my opinion on this argument, which is a very important one, I want to voice a concern that I've had with this paper as a whole in many just like it. And this really goes to the heart of editors who themselves do not understand what they're publishing. Like so many other studies and opinion pieces, the authors fail to define what they consider to be masking. Is it surgical mask or is it an N95? Is it fit tested if it's an N95? None of these questions were addressed at any point in the paper, So to some extent it's difficult to comment on this because my opinion on universal masking in health care settings depends on what types of respiratory protection that we're talking about. As I have said many, many times, most masking requirements in health care settings during the pandemic were focused on surgical masks. In some cases, mask policies have required health care workers and patients to take off their n95s and instead wear a surgical mask provided by the hospital or health care facility. I experienced that multiple times going into hospitals. These types of policies provided little to any benefit at all to health care workers or the patients due to the lack of effectiveness we see with surgical masks. So phasing out these policies won't have any impact at all on the amount of COVID or any other respiratory virus transmission in these settings. To me, what has happened with respiratory protection in health care facilities around the world actually is what I consider to be public health and infection control malpractice.


Dr. Osterholm: [00:31:56] And I know that sounds strong, but I believe that to be the case. So when we look at this issue right now of whether to wear a mask or not, you know, we're arguing about how many angels can dance on the head of a pin if you're not going to use adequate protection. And, you know, the arrow biologist and the industrial hygienist and even NIOSH, all these groups have come back time and time again talking about the critical importance of actually using in 95 respirator quality protection in these settings. Now, let me now address the issue, though. When should it be used? And one of the challenges that we're having is really understanding how much transmission of respiratory pathogens occurs in hospitals themselves, meaning not the community. I come in with disease X, but why I'm there, I get COVID. We had so many examples of that happening where people who had been in the hospital 7 to 10 days already for another condition developed COVID, whether in the hospital. We see it with influenza, we see it with RSV. And so what we haven't done is taken a serious look at what are the modes of transmission relative to caregivers, patients and the public and health care facilities. And remember, you know, why are we worried about health care facilities? Because they're sick people there. There are people already compromised. And should we be placing these people in places where the health care workers who are responsible for their well-being are putting them at risk because they themselves won't address the issue of respiratory pathogens they bring in from the community? And it somehow as if I'm a health care worker, I walk in the door, you know, suddenly I have a halo above my head and I don't transmit any infectious diseases.


Dr. Osterholm: [00:33:47] Well, you know, I so, so dearly support and care about what happens with health care workers. They have been, as we know, throughout this pandemic, the incredible gift to society. But they also have a responsibility not to put their patients at increased risk for infection. So I think we've really missed an opportunity in this pandemic to change the way we think about respiratory protection in health care settings. Universal masking with well-fitted N95 respirators, not surgical masks, would protect so many patients and health care workers, not just from COVID, but from any number of respiratory illnesses, including RSV and influenza. I understand health care workers find the use of these respirators difficult and challenging. And all I can say is that at this time, I hope that there is much more research done in terms of developing new N95 quality respirators that are actually much more consumer friendly. They don't give you that feeling of of tightness or that, you know, it rubs your face, etcetera. All those things. So at this point, yeah, I think that it's not time to give up on respiratory protection and health care setting. At the same time, I would say that we have a lot of work to do to even begin to get health care workers and the medical and public health communities to understand what we really mean when we talk about respiratory protection.


Chris Dall: [00:35:15] Now to some other infectious disease news. Last week, researchers from the University of Pittsburgh published a paper showing that while both the recombinant flu vaccine and the standard dose flu vaccine provide low to modest protection against influenza hospitalization, the recombinant vaccine provides better protection overall. Mike, what is the significance of these findings?


Dr. Osterholm: [00:35:38] Well, let me begin by just commenting on the fact that the research group that published this paper really are among the nation's leaders in this work. And I really congratulate them. And they're doing the kind of work that is sequential in nature, meaning growing the information we know to the next level, then to the next level, to the next level to get us better flu vaccines. So I have nothing but the highest compliments for this particular group. But to talk about the study, we first need to review the multiple types of influenza vaccines that are available. There are a number of different vaccines designed against influenza that target certain populations, and they vary in technology. Flu vaccines are available and recommended to everyone six months or older. However, not all the vaccines are appropriate for all populations. For example, the live attenuated vaccines are not recommended for those who are pregnant or immunocompromised or those who are under two years of age. One of the primary targets for influenza vaccination is older adults. The CDC estimates that 70 to 85% of influenza related deaths occur in those 65 years of age and older. Therefore, certain vaccines are made with this population in mind. These vaccines typically contain higher doses of antigen or an adjuvant, a chemical that increases the body's immune response. This brings me back to the study you mentioned, Chris. Researchers from the University of Pittsburgh compared two types of influenza vaccines, the standard dose vaccine and a recombinant vaccine. Recombinant vaccines are made synthetically and deliver genetic instructions in the body to help produce antigens that fight the influenza virus. Recombinant vaccines, as newer vaccines, have the ability to produce higher amounts of antigen and stronger immune responses and therefore are recommended over the standard dose vaccines for older adults.


Dr. Osterholm: [00:37:28] The bottom line of this study is that recombinant vaccine showed only modest improvements against hospitalization for influenza compared to the standard dose vaccine. But truly, the numbers were not very impressive. The most relative benefit for the recombinant vaccines was for women, younger adults and those without high risk conditions. Recombinant vaccines do offer some benefit from a manufacturing standpoint, as they do not require eggs for development and can be produced more quickly. However, regarding improved protection against symptoms, hospitalizations and deaths from influenza, especially for older adults, recombinant vaccines alone, unfortunately, are not a silver bullet. My biggest concern that we're not making substantial enough progress to develop effective vaccines against seasonal and pandemic influenza. I noted this earlier in a previous question, and this is something that CIDRAP is committed to addressing. Our Influenza Vaccine Roadmap initiative includes a roadmap to produce more effective influenza vaccines, as well as a funding dashboard and a landscape of the novel vaccine candidates. Again, I come back and say that the support that the NIH has had for this project called CIVIC, for these eight vaccine centers, including the group here, really is a critical, critical aspect of this ongoing influenza research. I can tell you when we get to the next big influenza pandemic, if we haven't been moved by why we need better influenza vaccines for seasonal flu, we will be reminded in a pandemic, Why have we not done more to support research like the kind that we're talking about here, where incremental increases in knowledge and effectiveness are really critical and how we build on the backbone of those findings like this one to get us hopefully to even much better flu vaccines.


Chris Dall: [00:39:22] Now we come to one of my favorite moments of the podcast, our latest moment of Joy submission. Mike, who did we hear from this week?


Dr. Osterholm: [00:39:31] Thank you, Chris, for that introduction, because I feel exactly the same way. I love reading these. And I want to again, thank all the podcast family for sharing these moments of joy with us. You know, I wish we could use them all, but they mean so much to us and I hope with us sharing them with you, you can get a sense of this. As bad as this pandemic has been and as much as everyday life right now is so complicated, it's a wonderful, wonderful gift. Just to take a moment and to think about the joy in our life. And this is exactly that. This one is from Ann, and she wrote, “Dear CIDRAP team, I am overjoyed by the news I got on Monday and I wanted to share. My husband, a physician took a job three states away. Our plan was that he would fly back and forth on weekends for the contract term of two years, waiting out a non-compete clause with his former employer and then find a job back home again. Well, COVID hit six months in. The kids and I were stuck in one state and he a thousand miles away with airlines shutting down and him working nonstop in a hospital with so many sick people and too few N95s.


Dr. Osterholm: [00:40:43] It was truly terrifying. The whole medical system was turned upside down. And what was supposed to be a two year contract morphed into four years. But this week we finally got the call. He is now coming back home to a job in Minnesota. I'm so very grateful to have our family under one roof again and that we are all safe and healthy. Sending so much love to everyone who stood their post and provided health care during the pandemic and their families. Ann.” Ann, first of all, thank you again for this lovely, lovely note. Please extend our appreciation to your husband for his work as a physician on the front line and to all of your family for being there to support him during this very difficult time. I could not be happier for you, and I look forward to hearing from you in the future as to what it's like to have him home. Thank you.


Chris Dall: [00:41:37] Just a reminder to our listeners that we would love to hear about your moment of joy even as we move past the pandemic. As Mike said, we live in challenging times and 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 you look to for a little bit of joy? It can be a place, a person, a pet, a piece of art, a memory. Maybe just some great news you just got. It can be whatever you want it to be. And you can share it with us and the rest of the podcast Family at OsterholmUpdate@umn.edu. Mike, what are your take home messages for today?


Dr. Osterholm: [00:42:13] Well, Chris, I hope the most important one that I can share with you today is that with all the information that we're being hit with about what's happening with COVID, that we take away one very important conclusion, and that is we are on the other side of the pandemic. I'm convinced of that. I don't see us ever returning to those days of 2020, 2021, 2022. Now, in that regard, my second point is still unclear, though. What will be the next chapter for COVID in the world? I would urge all of you right now to be careful of experts who tell you exactly how it's going to look, including the issue of disease seasonality. You know, if they go beyond 1 or 2 months in their predictions, it is virtually beginning to feel like pixie dust. So two months out, that's it. But I think at this point, even with the small numbers we're seeing, even if we double or triple them, they are not at all the same level of activity that we saw back in those earlier days. And finally, my third point is get your COVID, RSV and influenza vaccines when they become available. This is an important point. And while I didn't mention it earlier in the podcast, I myself am going to get my COVID vaccine as soon as possible. Then I'm going to get my RSV vaccine after that. And I will wait to see what the flu season looks like. And as soon as I see an uptick in that activity, I will get my flu vaccine. And I think that that gives me the best shot at preventing all three of these infections, or at least with COVID reducing the likelihood that I might have a severe illness or again, more long term COVID complications.


Chris Dall: [00:44:01] And Mike, what's the closing song that you've chosen for us this week?


Dr. Osterholm: [00:44:07] Well, you know, it's a challenge picking songs out after this many episodes, you know, after three plus years of this, of making sure I don't use the same one over and over again. You know, as I'm human, you know, there are certain songs I love to hear over and over again, but I don't want to become boring for you. But this song today really reflects back on the dedication and what we as a society have to consider and think about. This is one that I've used three previous times on June 24th, 2020, in Episode 13: What I Know and Don't Know About COVID-19, on March 18th, 2021, in Episode 48: A Mended Heart, and on March 24th, 2022, in Episode 96: A Familiar Uncertainty. This is a song that meant a great deal to me back when it was first issued in 1969. It's He Ain't Heavy, He's My brother. It's a ballad written by Bobby Scott and Bob Russell, originally recorded by Kelly Gordon in 1969. The song became a worldwide hit for The Hollies later that year and then also a year later, became a hit for Neil Diamond. It has since been recorded by many artists. Scott and Russell were introduced to each other by a common friend at a California nightclub. And although Russell was dying of lymphoma at the time and the pair only met three times, they managed to collaborate on this song. There is a lot of history behind. Where did this term come from? He ain't heavy. He's my brother. It goes way back to James Wells, the moderator of the United Free Church of Scotland, telling his story of a little girl carrying a big baby boy in his 1884 book, The Parables of Jesus.


Dr. Osterholm: [00:45:50] Seeing her struggling. Someone asked if she wasn't tired with the surprise. She replied, No, he's not heavy. He's my brother. The 1918 publication by Ralph Waldo Trent, also titled The Higher Powers of Mind and Spirit, relates the same story. The first editor of the Quantas magazine, Ralph Fulkerson, published a column in September 1924 carrying the title He Ain't Heavy. He's My Brother. The first use of that phrase exactly as it's rendered in the song title. And then finally, in the 1940s, the words adapted is He ain't Heavy Father, He's my brother. Were taken as a slogan for Boystown Children's Home by founder Father Edward Flanagan. According to the Boystown website, the phrase is used by Boystown was said to Father Flanagan in 1918 by one of the residents while carrying another up a flight of stairs. The boy being carried is said to have had polio and worn leg braces. So today I share with you what I can still consider. The Hollies recorded song as it was in June 1969 at EMI Studios, which now then became Abbey Road Studios. This song is a reflection of what we talked about in the dedication and world hunger and what we must do to help each other. And so here it is. He ain't heavy. He's my brother. The road is long with many a winding turn that leads us to who knows where, who knows where.


Dr. Osterholm: [00:47:16] But I'm strong. Strong enough to carry him. He ain't heavy. He's my brother. So on we go. His welfare is my concern. No burden is he to bear. We'll get there for I know he would not encumber me. He ain't heavy. He's my brother. If I'm laden at all, I'm laden with sadness that everyone's heart isn't filled with the gladness of love for one another. It's a long, long road for which there is no return. While we're on the way to there, why not share? And the load doesn't weigh me down at all. He ain't heavy. He's my brother. He's my brother. He ain't heavy. He's my brother. Well, thank you all for joining us again this week. It's a wonderful gift to be able to share these moments with you. Thank you for your feedback, your very thoughtful comments, your suggestions. We listen to all of them. And please keep in mind, as we just discussed, you know, what can I do to live a life where he ain't heavy? And also, again, celebrate what we can about COVID. Some people will find that as somehow minimizing what is still happening. The fact that people are dying, I'm not. I remember that every day. But I also have to at least consider where we've been and what we've come through. And for all the survivors, what has that meant? So be kind. Be kind. Today, it's gets tougher and tougher sometimes to be kind with what goes on in the world. Be safe. Thank you.


Chris Dall: [00:49:03] Thanks for listening to the latest episode of the Osterholm Update. If you enjoy the podcast, please subscribe rate and review wherever you get your podcasts and be sure to keep up with the latest infectious disease news by visiting our website cidrap.umn.edu. This podcast is supported in part by you, our listeners. To contribute, please visit cidrap.umn.edu/support. The Osterholm Update is produced by Sydney Redepenning, Elise Holmes, Cory Anderson, Angela Ulrich and Meredith Arpey.