November 2, 2023


In this episode, Dr. Osterholm and Chris Dall discuss national and international COVID trends, the low uptake in the latest COVID vaccine, and share thoughts about which infectious agents have pandemic potential. Dr. Osterholm also answers an ID query about influenza vaccination and shares a moment of joy from one of our listeners.


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Chris Dall: 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 Dahl, reporter for CIDRAP news, and I'm your host for these conversations. Welcome back, everyone, to another episode of The Osterholm Update podcast. Although most COVID-19 markers in the United States have been on the decline for several weeks, putting at least a temporary pause on concerns about a fall surge of cases, recent data provided by the CDC to NBC news could raise a red flag for the coming winter. According to a CDC spokesperson, only 3.5% of the US population has received the updated COVID shot to date. The low uptake could be related in part to some early logistic and insurance issues that hindered the rollout and prevented people from getting the shot. But one expert thinks there's more to it.


Chris Dall: The logistic complications certainly were not helpful, but I think that the low uptake is more than that, Dr. Dan Barouch, director of the center for Virology and Vaccine Research at Beth Israel Deaconess Medical Center in Boston, told NBC. The low uptake reflects that most of the public is no longer concerned about COVID. If uptake of the updated shot doesn't pick up significantly, could we be in for another surge of COVID-19 cases, hospitalizations and deaths? That's one of the topics we're going to discuss on this November 2nd episode of the podcast, as we look at the international and national COVID trends. We'll also provide an update on the variant picture. Discuss the National Association of Allergy and Infectious Diseases list of viruses with pandemic potential. Look at the role that indoor air quality improvements could play in respiratory infectious disease transmission. Answer an ID query on the timing of flu shots and provide an update on human and avian influenza. We'll also bring you the latest installment of this Week in Public health history and share a moment of joy. But before we get started, as always, we'll begin with Dr. Osterholm's opening comments and dedication.


Michael Osterholm: Thank you, Chris, and welcome back to all of the podcast family. It's great to be with you again. Thank you so much for all that you do to help make this podcast possible. And for all of you who are listening to the podcast for the first time, I hope that we're able to provide you with the kind of information you're looking for. I think anyone would agree after listening to this podcast, there's not one message. There's not one type of information we cover. We tend to cover the waterfront, but I think that's what we all are in this world today. We're kind of those waterfront people. So again, thank you so, so much. Also, I hoped in today's podcast as we talk about the various topics and in particular get to the closing that this is also seen as a place when you leave it that there is some joy, there is some increased hope for where things are at or what's going on in the world. Thank you to those who got back to me regarding our dedication to the last podcast. That was a tough one, trying to understand pain and suffering worldwide and what that means. And of course, in particular when we talk about our children. So today I'm going to try to the best I can, at least give some sense of joy in the world with some of the topics that we're going to cover. To start out, however, the dedication in of itself is a tough one, and I want that to be made clear because it's also one that is truly a very, very important part of the entire experience, and it is one that we must never forget and hopefully often celebrate.


Michael Osterholm: I'm dedicating this to the health care workers of the world, without regard to where you're at or what you're doing, and it's important to understand that we have focused on health care workers often in this podcast series. We've had nine previous episodes dedicated to health care workers. Episode 15 way back when, on July 10th of 2020, we dedicated “A Coronavirus Forest Fire” to them. On episode 72, “A Surge in Optimism” on October 7th of 2021 dedicated that to the health care workers and a Thanksgiving mini episode on November 24th, 2021, as well as episode 121. “Thank you, Dr. Jenna” on December 29th, 2022, all dedicated to health care workers. Episode 12, “A Tale of Two Countries” on June 7th, 2020, was dedicated to the support staff of long term care facilities, including nurses, aides and orderlies. Episode 23, “COVID-19 and Mental Health” on September 10th of 2020 was dedicated to all mental health workers who today are just as important, if ever, as they were during the height of the pandemic. Episode 69, “A Whole New Ball Game” on September 6th, 2021 was dedicated to school nurses, and today they share and deserve that same dedication. Episode 86, “The Omicron Crisis” on January 13th, 2022 was dedicated to physician moms. As a father of a physician mom, I understand that one very, very well. And finally, episode 108, “Living with COVID” on July 8th, 2022, was dedicated to health care workers that have recently entered the field. All of these, all of these dedications were from our heart, and they were for a truly noble reason.


Michael Osterholm: They were all about what you as health care workers have done. Now, the reason why we bring this back up again, there was a moment in the past several weeks that reminded all of us of the challenges of being a health care worker. The CDC published a report last week that discusses the challenges that health care workers have faced while working through the COVID-19 pandemic. Notably, the number of health care workers reported harassment at their job in 2022 is more than twice the number that reported harassment in 2018, just before the COVID pandemic began. This report goes on to show that these hostile work environments is strongly linked to poor mental health outcomes among health care workers, such as anxiety, depression and burnout. Concerningly, but perhaps predictably, just under half of the health care workers surveyed said that they would consider looking for a new job in 2022. Now, another point to make here, as we look at particularly emergency rooms and some clinical floors, is the level of physical attacks occurring on health care workers by patients often either mentally ill or on drugs, etcetera. And even there, from that standpoint, we don't think of going into health care to actually have to go into some kind of personal battle. To you health care workers, we so, so, so appreciate you all we do. And we will link the report from the CDC that I just noted on the website for the podcast. So you can go and take a look at it on your own. Now, in terms of the expected discussion of sunlight, I have to acknowledge that this week is a rather unusual week relative to sunlight.


Michael Osterholm: Light length and you'll say, why? Well, let me first of all, start out by saying In Minneapolis today, the sun will rise at 7:52 a.m. it will set at 6 p.m. that's ten hours, seven minutes and 21 seconds of sunlight. Now, this Saturday coming up, it will actually not rise until 7:55 a.m. And because Daylight Savings Time then goes into effect overnight, it won't actually get to that late again until next year. Even with the time period between November and when the sun set is, the latest is actually from December 30th to January 5th, where then it's at 751, so it doesn't quite make up the hour that we lose by turning our clocks back again here in the fall. So this Saturday is the single darkest day in terms of starting the day. I don't need to remind you that that means that the afternoons are going to get darker a lot faster. Now Auckland, our dear, dear colleagues in Auckland, they today are experiencing a rebirth of light with the sunrise at 6:15 a.m., sunset at 7:54 p.m. that's 13 hours, 38 minutes and 46 seconds. And our dear friends at the Occidental Belgium Beer House and Vulcan Lane. We hope that you're able to enjoy all that additional sunlight and just know as we know that we're not far away from that winter solstice. And then it turns around and we're going to be coming after your sunlight, but we're very happy to share it with you.


Chris Dall: Mike, let's start with a look at the international and national COVID data. As we always have to note, we are limited by the lack of data we have, particularly when it comes to the international picture. But given that caveat, what is the picture looking like at the moment?


Michael Osterholm: Well, honestly, Chris, that's a question I'm still trying to find a good answer to. Of course, the shrinking amount of data being made available, which you mentioned, really doesn't help. As an epidemiologist, if you want to disarm us, just take away our data. And that's unfortunately what's happening right now. But regardless, I've got to say that these are confusing times. And the reason I say that is because after almost four years with this virus, we still don't really understand some pretty key things. For example, what causes COVID activity to start increasing even when there isn't any new variants involved? Is it solely due to waning immunity in the human host, or is there something else? And what exactly determines when and where are these increases actually happen? To me, there's a whole laundry list of questions like these, which I don't think we have many good answers for. I surely don't, and as I've shared with you throughout this pandemic, when I don't know something, I'll just tell you I don't know. I'm trying to find out better answers, but I don't know. So don't get me wrong, there is a lot that we have learned the past several years, but with these bigger picture questions, we're still lacking. And I think that's important because these types of questions basically shed light on what our future might look like with COVID.


Michael Osterholm: So I think a lot of us are not only trying to understand where we are right now, but also trying to determine if this is actually just part of a new normal with COVID-19. And the reason I bring this up is because COVID hasn't simply gone away as much as we would all like it to. On top of that, there are certain people who really want to believe that COVID is now a predictable disease that follows the same pattern, such as seasonality. To me, there is simply absolutely no data supporting that. In fact, this is a seasonal type disease. In fact, when you break the year down into four quarters, in other words, first quarter January to March, quarter to April to June, 2:45, July to September, and quarter for October to December. And look at when each surge in the US occurred. You'll find that two happened in quarter 1st January to March, two happened in quarter two, April to June, four happened in quarter 3rd July to September, and one in quarter 4th October to December. So again, the only thing seasonal about COVID that I've seen so far is that transmission can occur in all four seasons, and even peaks in transmission. And the latest trends I've seen continue to support this reality. So what all is really happening? Well, globally, the overall number for cases and deaths has apparently decreased, at least according to the latest Who report published last Friday, October 27th.


Michael Osterholm: In that report, just over a half a million cases and 4700 deaths were reported worldwide during the 28 day period that spanned from September 20th 5th to October 22nd. So in terms of the sheer numbers, things don't appear to be at all bad. And for the most part, that's true again, relative to what we've seen throughout most of the pandemic. The overall numbers are a fraction of what they've been. This is great news. Regardless, digging into these W.H.O. numbers, there are still a couple of things that stand out to me. First is that there are far from representative, at least in terms of the overall global picture. In this latest report, just 40% of the world's countries reported any data on cases to W.H.O. Again, let me repeat that. Only 40% of the world's countries reported any data on cases to W.H.O., and just 16% of countries reported data on any deaths. So that's been a problem. And as more countries likely opt out of reporting data to show, it really makes it difficult to know if declines are real or if they're just an artifact of less reporting or a combination of both, but unclear to what degree otherwise. Looking more closely at the countries that had reported data, I've noticed that quite a few are back to seeing some recent increases in activity.


Michael Osterholm: For example, while there was just 29 countries that consistently reported hospitalization data during the most recent 28 day period, a total of 16 more than half saw hospitalizations increased by 20% or more. Here are some examples. From August till now, Italy has gone from less than 800 hospitalizations at any one time to almost 3700. Canada went from less than 1500 to nearly 4000. The Netherlands has seen hospitalizations grow from less than 50 to 481. The Czech Republic went from ten hospitalizations to 475. And finally, Sweden saw hospitalizations climb from less than 150 to nearly 700. Hospitalizations are hard to miss. Therefore, I think these numbers give us the best sense of what's actually happening. Again, relative to the numbers reported in many of these places throughout the pandemic, the hospitalization totals I just shared with you are not at all as large as. They've been in the past, which is very, very good news. But still, these simultaneous increases across multiple countries are not comforting, especially since we don't necessarily know what's driving it. Again, it doesn't appear to be a new variant. In fact, the increases are largely reminiscent of what we saw in the US the past several months with activity. For whatever reason, starting to climb after half a year of declines.


Michael Osterholm: Of course, when that recent increase first began here in the US, we were at an all-time low in terms of hospitalizations and deaths, so that lower baseline helped keep things low. But going from 5000 hospitalizations to more than 16,000 hospitalizations in a couple of months’ time, and also less than 500 deaths a week to almost 1400 now, is definitely something I'd prefer to avoid, if at all possible. And that's what worries me. Chris is the long term our future with the virus. Are we going to just continue to see these periodic waves? If so, will it ever actually follow a seasonal pattern at this point? We really don't know. Now let me just add some context also to what's happening here in the United States and how we have to be very careful about how we look at reporting, as I just noted. If you look at the data that's available for the most recent deaths, as well as hospitalizations, we are at about 16,186 hospitalizations in a given week. If we look at the number of deaths, we're talking about 1339 per week. We tend to focus on nationwide trends a lot in this podcast, but I want to emphasize this. This does not necessarily mean that the trends in every state are aligning with what we are seeing occur on a national level. For example, although new hospital admissions have declined 12% over the past two weeks in the United States, 13 states actually saw an increase in daily hospitalizations during this time.


Michael Osterholm: Four states New Mexico, Colorado, Alaska and North Dakota saw increases over 20%. That said, I want to remind our listeners, as I often do in this podcast, that these somewhat large relative increases are partially a reflection of the low number of total cases, hospitalizations and deaths we are seeing right now. For example, in North Dakota, which had the greatest increase in daily hospitalizations over the past two weeks of 51%, they are currently seeing an average of nine new daily hospital admissions. This is very different than the situation where we were seeing similar relative increases back when our new daily hospitalization admission numbers in each state were in the hundreds and even thousands of 51% increase in this case reflects an increase from an average of six hospitalizations per day to nine. Of course, any rise in COVID activity is something to keep our eye on, particularly as our wastewater data is showing upward trends in the Midwest and South. But I hope this helps put into perspective for our listeners that even when we discuss regional or state level increases in COVID-19 activity, this is still nothing like what we were seeing during the regional surges back in 2020 and 2021.


Chris Dall: On the variant front, the CDC said last week that the Hsv1 Omicron Sub-variant is now the leading variant in the US. The CDC also said it's monitoring the J&J one variant. So, Mike, what do we know about these variants?


Michael Osterholm: Last episode was the first time we noted that this HV1 variant had surpassed the previously dominant EG.5, and CDC models predict that this shift will continue. I'll remind everyone that these two variants, both descended from XB 1.5 Omicron, which is what the updated vaccine was designed to target. Genomically, HV1 is similar to EG.5, but the reason it is growing in numbers is that it has a mutation that makes it better at binding to ourselves, more infectious this way. These changes I emphasized in the last episode concern me the most. The advantageous mutations the virus can gain over time while COVID circulation continues. We don't know enough right now to make any conclusions about what this divergent HV1 variant means for COVID trends in upcoming months, but we will continue to monitor early and severity indicators. Now remember, as I have stated time and time again on this podcast, I, as a matter of approaching variants, have always assumed all variants are innocent until proven guilty. If I had a nickel for every time I heard someone predict that this new emerging variant was suddenly going to bring us back to the days of Delta and Omicron, and I could take you all out for lunch. And of course, it didn't happen, but that doesn't mean it can't happen. And so this is why we try to keep our eye on it. Chris, you asked about the JN.1.


Michael Osterholm: This variant, most recently is gaining international attention as an offshoot of BA 2.86, which we've discussed in the last couple of Osterholm Update episodes, JN.1 is yet another highly mutated variant with marked differences from the circulating Omicron. Without diving too far into the genetics, it harbors an additional viral entry and immune evasive mutations from its alarm raising ancestors. This fact is crucial to notice, since the most recent vaccine approved is not geared towards a unique viral profile. According to some mathematical models, with the relatively small amount of data we have from countries like India and France, JN.1 has a heightened probability of growth, especially if case numbers begin to rise before the winter holidays. I'm concerned this variant may sneak up on us and the present moment when testing, surveillance, and public health countermeasures are being dialed back. Also, I want to add that it's important to always remember this concept of waning immunity. Both B-cell and T-cell immunity. What does it mean if a previous infection or a vaccine dose gives you a protection with the antibody during those first days after vaccination or infection? That's great, but what does it mean long term? How well do the T cells kick in? What kind of long term memory do they provide? These are all questions we're trying to answer. At the same time, we're constantly seeing these new variants arrive.


Chris Dall: As I mentioned in the introduction, the uptake of the updated COVID-19 shot has been quite low to this point. I actually did a double take because I thought the 3.5% had to be a typo. How concerned are you about the low uptake?


Michael Osterholm: Well, Chris, the CDC's Advisory Committee on Immunization Practices, or ACIP, as you've heard me call it, released some very concerning findings from their work looking into the 2023-2024 vaccine. More specifically, they conducted a survey including 2700 people asking them whether or not they had already gotten the new shot and if they were planning to get it in the future. They also gathered information on basic demographics like age, gender, race, ethnicity, income and insurance status. Now to the concerning part. After one month of availability, about 15% of those aged 65 to 74 and about 20% of those 75 years and up received the updated COVID-19 vaccine. Considering what we know about the risks associated with these groups, specifically, 15 to 20% is just not sufficient coverage, especially if these individuals live in group settings like long term care facilities. Sadly, though, these upper age groups actually have the most vaccine coverage. According to the survey, receiving an updated COVID-19 vaccine was more frequently reported as age group increased, with income insurance status also contributing to the acceptance. But think of this. But children under the age of 18 reported to have the lowest coverage, just 2.1% across all children, received this vaccine in the month following its initial approval. I'm going to comment more about this when we discuss vaccines. All this is to say that the 2023 vaccine is our best line of defense against the current circulating variants, and the low coverage has me really worried. I can't say that any more strongly. That right now I urge everyone who is eligible to get the updated vaccine as soon as possible, but most specifically, those who are over age 65, those who have underlying health conditions that put them at increased risk for serious illness. I think all of these are opportunities to avoid a very, very unnecessary and potentially life threatening situation. Again, I come back to please avail yourself to this vaccine.


Chris Dall: Moving on to some other infectious disease items, the National Institute of Allergy and Infectious Diseases recently published a series of papers in the Journal of Infectious Diseases that lays out the viruses they think have high pandemic potential and the research gaps that need to be addressed. You disagree with some of their conclusions. How so?


Michael Osterholm: Well, Chris, you know, it's always difficult to disagree with your colleagues at the NIH, but I think that they just don't understand what it means to be an agent of pandemic potential. As I've shared on this podcast multiple times, and I discussed this when we talked about the new book that I'm writing and what I consider to be those infectious agents capable of causing a pandemic. Remember, a pandemic is a worldwide epidemic where virtually everyone has an equal opportunity to get infected. Some people, because of their health status, will actually end up having increased risk for serious disease. But everyone can get infected. That doesn't happen by just having a virus of regional importance, or having a virus that is transmitted by a mosquito. And while mosquitoes may move, they surely will not infect most people in most countries. And what happened with the NIH effort was a special October 19th supplement to the Journal of Infectious Diseases, and it contains nine articles intended as a summary of the National Institute of Allergy and Infectious Diseases hosted Pandemic Preparedness workshop that featured scientific experts on viral families of pandemic concern. What they did is they basically made any disease that could be a very serious disease, one of pandemic potential. Case in point Ebola. That is one of them now. And remember, our group has been doing the vaccine roadmaps for these diseases. Hendra, Nipah. Very dangerous diseases. But these are regional diseases based largely on animal reservoirs in certain regions of the world, and for which there is no evidence yet of respiratory transmission of the virus.


Michael Osterholm: Ebola is one that I still believe could become one day a respiratory transmitted virus, which then would move it into that category of pandemic potential until a virus gets its own wings and can rapidly transmit to others such that it then moves around the world quickly. That is what causes pandemics, not these ones of what I would call regional importance. And so I'm worried that we'll dilute out the importance of why we have to focus on influenza and coronaviruses, the only two virus groups right now that I think are capable of causing a pandemic. Don't get me wrong, I think these other viruses, whether it be Lassa fever, whether it be Rift Valley fever, whether it be Nipah viruses, all of these are important, but they're not going to cause pandemics. And so I think that we have misstated what the risk is for a pandemic virus. And I would hate to see us divert our attention away from coronaviruses and influenza. And at the same time, I don't want to diminish the importance of these other viruses, but let's get our understanding straight of what causes pandemics and when the NIH doesn't get it straight, that's a pretty big error. And I think that's exactly what happened here.


Chris Dall: There was a report this past weekend on 60 minutes that looked at the role that better indoor air quality could have played in slowing the spread of COVID-19, the role it may play in slowing other respiratory infectious diseases in the future, and what some companies are doing to improve their indoor air. So, Mike, while most of our listeners know you are a proponent of improving indoor air quality, you had some concerns about some of the claims made in this piece. So for those listeners who saw the piece, or even for those who didn't, can you add some more context?


Michael Osterholm: Well, one of the problems we have today is that we really are lacking in good evidence as to what we need to do in air to reduce the risk of transmission, particularly airborne viruses, i.e. those with aerosols. In this piece in 60 minutes, based on reporting by Dr. Jon Lapook, an internist who I actually have tremendous respect for, and he tried to draw out from several colleagues what we need to do to diminish the risk of transmission in closed settings. One of the challenges of the past has been that we have had individuals who have made very specific statements with real certainty about how something operated, acted or protected, and they were wrong. And because of that, later on our credibility was challenged. And I think that's the example here. We have continued to hear people say, if we just improve air exchanges to 2 to 3 or 4 or 5 air exchanges per hour will be fine. You know, there is not a single lick of data from anyone that supports that to be true. And in part, it's because guidelines for new airborne infection isolation rooms, for example, which require 12 air changes per hour. Yet a health care worker entering into one of these airborne infection isolation rooms with TB or COVID still must wear a respirator. Why? Because they have to spend time in close proximity to the patient.


Michael Osterholm: That's near-range exposure, and it doesn't mean that there isn't air moving in that room, but it's not enough to overcome that direct exposure. For example, if you increase the air ventilation in a room but somebody smokes. You surely can clear the smoke out faster. But if I'm standing right next to them, I'm still picking up the virus in a very high level in terms of time and dose. And so one of the things we have to do is admit we have a lot more research to do on exactly what is it that we need to do to really reduce the risk of airborne pathogens in closed settings. And I still very strongly support increasing air exchanges as much as possible. But understand that that doesn't automatically mean that you're protected against infection. It's just like the discussion we had about outdoor air several episodes ago, when I talked about people closely packed together outdoors, standing together at a concert. There's actually transmission that occurs because of that between these people now, it was outdoor air. It surely disseminated the virus much more quickly than it were indoors, but it was still a close setting situation. So I would never have said if a company spends up to $1 million to increase the air circulation in their buildings and have up to 3 to 5 air exchanges per hour is going to greatly reduce the risk of transmission of an airborne disease in their workplace.


Michael Osterholm: I don't know, you can say that. I don't think you can. You know, we've had outbreaks in call centers as such. And now we didn't know exactly what the air exchanges were there. But even if you're packed close together, that is not completely capable of overcoming that with just increased air flow. So I think that was an important issue, is that we want to make sure that we're not telling people, yes, if you do this or you do that, you spend all this money on getting your number of air exchanges up by two to 4 to 6, you're going to suddenly stop disease transmission. That's just not the case. And so I hope that people do understand indoor air is very important. I am a very strong proponent of the best air exchange quality you can get, including using MERV filters, all the kinds of things we've talked about before. But you're never going to hear me promise to someone. You get five air exchanges, you use MERV filters. You're going to not have to worry about it. That's just the data. Just don't support that.


Chris Dall: That brings us to this week's query. On our last episode, you answered an ID query about when people should get their updated COVID shot. For this episode, we've gotten a lot of questions from listeners about the best timing for the flu shot. So when should you get your flu shot for the maximum protective effect? And does your answer reflect the flu activity that we're seeing in the US at the moment?


Michael Osterholm: Well, Chris, the timing of this question and what it means to me personally and professionally couldn't be better. I'm getting my flu shot later today, and as I've shared with the audience throughout the course of this fall, I've waited until I thought that there was some evidence that flu activity may be picking up. And of course, I want to give the vaccine time to work. So that's a good 7 to 10 days minimum. And so even if I get it today, I'm not going to have increased protection for some time. The important message to get out now is, I think that there is enough evidence that flu is starting to pick up some, that I definitely would urge you to go out and get yours too. So don't wait any longer. Go get it. We are seeing what I would call lower or minimal levels of flu activity in most states, but as I just mentioned, this is beginning to change quickly during the week ending on October 14th. We had just one state Alaska, with high levels of influenza activity, three with low influenza activity including Florida, Georgia, and New Mexico, and all the other states had minimal influenza activity. One week later, during the week of October 21st, we had one state, Alaska, with high influenza activity, two states and the District of Columbia with moderate influenza activity, six states and New York City with low influenza activity, and all others were with moderate influenza activity.


Michael Osterholm: So, to summarize, the amount of activity we're seeing in the US is still low, but it appears to be starting to increase. So I think, you know, you still have some time, but I would say now is the time to go get it and have maximal impact. I think it's noteworthy that a majority of the subtyped influenza infections this season have been the H1N1 pandemic zero nine strain. This is good news in that the vaccine strains that are in the vaccine appear to be providing good cover. They're well matched. And so I think that this is the time to get it. And let me add one more thing, Chris. We've been talking about respiratory syncytial virus for some time, RSV. And we are now seeing cases rising rapidly with weekly detections of RSV during the week ending in October 21st over double what they were four weeks prior to that. For all of our listeners who are eligible to receive the RSV vaccine, I urge you to do so as soon as possible. It will last longer. It doesn't have the same issues as influenza vaccine with more immediate waning immunity, so now's the time to get it. As far as I'm concerned, all three vaccines should be on board right now COVID, RSV and influenza, and hopefully you can make it through an entire winter season without a serious illness hospitalization, unfortunately, even a death due to one of these viruses.


Chris Dall: And what's the latest on avian influenza? As we've discussed in past episodes, the virus continues to spread among birds and certain mammals. But you have said that you have not seen to date any data that suggests the virus has made genetic leaps to be more transmissible in people. Do you still stand by that or have you seen anything different?


Michael Osterholm: Not only have I not seen anything different, Chris, but just this past week again, the CDC came out with a new updated assessment of the H5N1 situation, and they continue to determine that the risk is low for human infection with this virus. And I agree wholeheartedly with it. This is not the same H5N1 that we saw back in 1997, in Hong Kong, or for that matter, in Southeast Asia in the early 2000 time period, or the Nile River Valley area in the 2010 to 15 time period. This virus does not infect humans nearly as well. Now it is raising hell on a number of mammal species as well as avian species, and so I don't want to diminish its impact, but just know that that's a big difference between infecting these animals and infecting humans. And so we always must keep our eyes wide open for whatever flu could throw at us. And it could happen overnight. But I don't see that happening right now with H5N1. We're watching it closely. There is no reason at this point to think that that's going to happen. As devastating as it has been to the poultry industry in a number of different countries around the world, I just don't think that we have a real challenge in our hands now. Tomorrow we could see a brand new flu strain come out of nowhere. H7 you know, another one. Remember H2N2 the virus that caused a pandemic back in 1957 and then disappeared. In 1968, a new influenza virus emerged. And yet we've not seen H2H2 literally since that time. Think of all the people born since 1968 that are on the face of the earth, who have had no previous exposure or experience with H2N2. There's one that could show up tomorrow. And so I do worry about influenza viruses. I think about them all the time, but it's not this H5N1. This continues to get so much media coverage and notoriety as it's just one step away from killing all us humans. That's just simply not the case.


Chris Dall: Now for this week in Public Health history. This week, we're celebrating the anniversary of a book that exposed the appalling and unsanitary conditions in the meat industry and ultimately led to the creation of the Food and Drug Administration. Mike, what can you tell us about this groundbreaking book?


Michael Osterholm: Well, first of all, Chris, I love this segment, and I've heard from a number of our listeners who like it too. So anyway, thank you. We're going to continue to do it. So just as you said this Friday, November 4th, marks the 117th anniversary of the publication of Upton Sinclair's revolutionary exposé novel The Jungle. This happens to be one of my favorites. As somebody who has spent many, many years working in foodborne disease issues. This book rang true in so many ways. For those of you who may be unfamiliar, or has it just been a while since reading it in high school English. The jungle follows a family of Lithuanian immigrants who come to Chicago in search of a better life, but are instead met with incredible hardships as a result of the gruesome meatpacking industry. Apart from the heart wrenching tales of Jurgis and his family, this book played a key role in garnering support for food safety policy reform. Sinclair is often referred to as a muckraker who were investigative journalists who took their aim at corruption in business and government during Americans Progressive ERA. Although a fictional story, the derelict and dangerous conditions suffered by workers in the jungle were true, no surprise that readers were absolutely shocked by the description of backbreaking labor and a lack of transparency surrounding the food they were putting on the table feeding their children.


Michael Osterholm: I want to read a couple of lines from the book, but I will give listeners a fair warning that it may be upsetting. If you want to skip ahead just a little bit, go ahead. If you don't want to hear this quote. There would be meat that had tumbled out onto the floor in the dirt and sawdust, where the workers had trampled and spit uncounted billions of consumption germs. And another for it was the custom, as they found whatever meat was so spoiled that it could not be used for anything else either can it, or else chop it up into sausage just makes your stomach churn, doesn't it? Public response to the jungle eventually led to the passing of the 1906 Pure Food and Drug Act, which prohibited companies from selling misbranded or adulterated food products. Later, the US Food and Drug Administration or the FDA was formed, the country's first consumer protection agency. Food safety is an incredibly important aspect of public health, and Upton Sinclair's book likely led to a massive reduction in foodborne morbidity and mortality for the time it was written and beyond. Sinclair was more than a literary crusader. He also happened to be a citizen of Duluth, Minnesota for several years, so he can surely claim him at least a bit.


Chris Dall: We also have a moment of joy submission from a listener in Wisconsin. Who did we hear from? Mike?


Michael Osterholm: Chris, we did receive a wonderful moment of joy from Nicole. She wrote hello to Dr. Osterholm, Crystal and the other team members bringing us these invaluable podcasts. Thank you for your work to keep the public informed about COVID. In December 2019, I was diagnosed with breast cancer at the age of 44. Two weeks after the diagnosis, I underwent a mastectomy and was finishing radiation treatment. When the pandemic was declared in March 2020. My husband and I have continued to be COVID cautious by avoiding people and wearing masks when entering buildings. So far I've avoided contracting COVID, but it has come with sacrificing our once busy social life. I wanted to share my moment of joy with you. Like many people who are suddenly housebound, when the pandemic was declared, my husband and I started a vegetable garden in our backyard during the spring of 2020. Our garden has grown each year and so has my love of the nature I share my life with. Simply paying attention to my tiny piece of the earth, mere steps away from my door has revealed a world of wonder. I think the source of much of my new found joy in the garden can be summarized in two words Bumble bees. Bumble bees are a constant presence in my life year round. I've marveled at queen bumble bees clumsily emerging from holes in our raised beds after a long winter hibernation, and hypnotically watched bumble bees fly in and out of the nests in our yard.


Michael Osterholm: Each fall, my heart melts, watching bumble bees fall asleep in our New England aster flowers, their petals closing around the pollen covered, fuzzy foragers. However, my most significant moment of joy was discovering a rusty patched bumblebee. As I walked by some of the native wildflowers we planted, I snapped a few photos and sent them to the Wisconsin DNR, who verified that it was indeed my federally endangered rusty patched bumblebee. Having that confirmation brought tears to my eyes. I feel so honored to have these extraordinary visitors. Nicole. Thank you Nicole. The bee issue is something I'll carry through in a few more minutes. I just want to say that it's wonderful that first of all, you appear to have recovered fully from your previous breast cancer episode and that you have found an even days of real trial and tribulation, ways to find happiness and joy. And all of us, all of us, more than I can ever say, are so happy. For those that find that type of joy in life. And we have included several pictures here that Nicole shared with us about her bumblebees. And they really are beautiful. So thank you. Thank you Nicole.


Chris Dall: Just a reminder to our listeners that if you have a moment of joy that you would like to share with us and the Osterholm Update listeners, you can share it with us at Mike, what are your take home messages for today?


Michael Osterholm: Well, Chris, I hope that everyone already knows the first one just by listening to this podcast. It is without question the most important thing you can do. Get all three of your vaccines if you're eligible for them, meaning COVID, influenza and RSV. Now is the time to be fully vaccinated going into this season, and I can't say it enough times that I've heard from too many people who regret not having been vaccinated, only to have suffered a very severe illness, or a family member even dying from one of these three infections without having been vaccinated. Number two, the variants continue to mystify me. Innocent until proven guilty. I don't know how this battle that's going on between our immune systems, our capability of fighting off new viruses that may have mutations that make them more likely to be transmitted or more likely to infect the cells. But this is an ongoing immunologic chess match with an opponent, a virus that we know is dangerous. So all I can say right now is, is that the variants are one of the things changing. We as humans aren't changing that quickly at all. And so we have to keep watching this carefully. I feel like we're in a pretty good place right now compared to where we were, and we'll continue to follow that closely and let you know if we think that's changing.


Michael Osterholm: Finally, it's all about the air that we breathe, as we discussed earlier in this podcast. It's not a simple issue. It's not just having a bit more air that can help, but it's also an indoor air. For example, the mixing that occurs, you know, how long are you very close to someone? If I'm sitting next to them at a table, you know, having five air exchanges in the room may do little to actually shield me from that person's virus. And so we have a lot more work to do in this area. And I think it's work that we can do now. I am all for improving air quality. If, you know, even if I don't have the data to say that five air exchanges per hour significantly reduces my risk of a certain infectious disease, I still am very strongly supportive of that. But we have to be careful as a public health community not to sell that to people as an absolute answer, meaning that yeah, you do this and spend hundreds of thousands to millions of dollars retrofitting your building, you're okay. We don't know that yet. And I think that that's an important consideration.


Chris Dall: And what's your closing song for this episode?


Michael Osterholm: Well, Chris, this is one that is very near and dear to my heart and is actually two songs on evolution, you might say, in one's life. I think almost all of us are familiar with Winnie the Pooh and the wonderful story of the Hundred Acre Wood. Someone who I have very much appreciated over the years is a singer songwriter. Kenny Loggins actually wrote a song when he was 17 years old about House at Pooh Corner. Many of you heard that song. It's a beautiful song, and it really serves as an allegory for the loss of innocence and nostalgia in childhood. As that 17 year old high school senior. He wrote it that very way. Well, as you know, that song went on and became very famous. It's interesting that Loggins actually did an interview with a reporter from The Tennessean some years ago, and he talks about how this song came about and how it was inspired and what he was going through at the time. And it turned out he didn't realize that he couldn't write a song like that, because, of course, the rights were already owned by the record company, and in this case, the characters around Milne's book were owned by Disney. He sold the song the Nitty Gritty Dirt Band, recorded it and started to play it, and they had to stop because of legal issues with regard to Disney.


Michael Osterholm: And it so happened. Loggins was on a date that night with a young lady in which he mentioned to her the challenges he had just had as a 17 year old, with his song no longer being able to be used because of the rights with Disney. And he said, I'm really bummed out because of this. And the young lady said to him, well, it was a Disney lawyers. And he said, yes. And she said, let me talk to daddy about that. He did not know that he was dating the daughter of the CEO of the Disney Corporation at the time. Well, fast forward now. Kenny Loggins has now had four children, very successful individual who had basically taken this initial high school aged mind, wrote this song and then reflected back on it all these years later. And he rerecorded this song back in 1994, and it was part of an album called Return to Pooh Corner. And in this song he added new lyrics, and it was about really coming back to his roots and what that meant. And so I want to share this song with you tonight with the new lyrics at the very end, and then I'll comment on them in just a moment. But now Kenny Loggins returned to Pooh Corner.


Michael Osterholm: Christopher Robin and I walked along under branches lit up by the moon, posing our questions to Al and Eeyore as our days disappeared all too soon. But I've wandered much further today than I should, and I can't seem to find my way back to the wood. So help me if you can. I've got to get back to the house at Pooh Corner by one. You'd be surprised there's so much to be done. Count all the bees in the hive. Chase all the clouds from the sky back to the days of Christopher Robin and Pooh. Winnie the Pooh doesn't know what to do. Got a honey jar stuck on his nose. He came to me asking help and advice. And from here no one knows where he goes. So I sent him to ask of the owl if he's there, how to loosen the jar from the nose of a bear. Help me if you can. I've got to get back to the house at Pooh Corner by one. You'd be surprised. There's so much to be done. Count all the bees in the hive. Chase all the clouds from the sky back to the days of Christopher Robin and Pooh. It's hard to explain how a few precious things seem to follow throughout all our lives. After all said and done, I was watching my son sleeping there with my bear by his side.


Michael Osterholm: So I tucked him in, kissed him, and as I was going, I swear, the old bear whispered, boy, welcome home. Believe me if you can. I'm finally back to the house at Pooh Corner by one. What do you know? There's so much to be done. Count all the bees in the hive. Chase all the clouds from the sky. Back to the days of Christopher Robin. Back to the days of Christopher Robin. Back to the days of Pooh. Kenny Loggins. That verse he describes with his bear basically there in the bed with his young boy. And the bear looked up at him and told him, welcome home. You know, we all have that potential to remember to go back. And at times when things get tough, sometimes it's going back to our bears. It's going back to those things that for whatever reason, we abandoned, we moved on. We grew out of whatever. But in the end, they still have great meaning. I hope all of you can go back and have a discussion in the days ahead with your bears, whatever they may be. And I hope it can bring that kind of experience back again, of what it must be like to want to return to Pooh Corner.


Michael Osterholm: So thank you all very much for being with us this podcast. We realize you have lots of opportunities to get your information from a number of different sources, so we sure appreciate you being with us. I want to thank the podcast team again for all the work that they do. Chris, thank you so much. This podcast wouldn't be possible without them. I also want to emphasize again that while, yes, the cases are nowhere like they were back in the 2020-21-22 time period, people are still dying. Thousand hundred people every week. And I think that that's the kind of situation where it sometimes is easy to get back into the numbers and only the numbers, and I would just leave us all today reminding ourselves every one of those numbers I talked about is somebody's mother or father, grandfather, grandmother, brother, sister, unfortunately even son and daughters. That really is something we can't forget. And I want to come back one last time to our health care workers. Thank you for what you do. Thank you for what you put up with. Thank you for bringing the best out of all of us in terms of helping, saving and caring. So be well. We'll be back in two weeks and I look forward to talking to you then. Thank you so much.


Chris Dall: 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 This podcast is supported in part by you, our listeners. If you would like to donate, please go to The Osterholm Update is produced by Sydney Redepenning, Elise Holmes, Cory Anderson, Angela Ulrich, Meredith Arpey, and Clare Stoddard.