December 14, 2023

In "A Seasonless Virus," Dr. Osterholm and Chris Dall discuss the latest COVID-19 trends in the U.S. and around the world, provide an update on influenza and RSV activity, and review two recent studies on long COVID. Dr. Osterholm also answers a listener question on fomite transmission of SARS-CoV-2 and celebrates a recent event in public health history. 

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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 COVID-19 activity in the US has been relatively quiet for much of the fall, last week's update from the centers for Disease Control and Prevention is yet another reminder that SARS-CoV-2 is very much still with us. The CDC's two main severity indicators hospitalizations and deaths showed notable rises from the previous week. Test positivity and emergency department visits were up and JN.1 Omicron subvariant proportions jumped dramatically. What's behind the resurgence? That's one of the topics we're going to discuss on this December 14th episode of the podcast, as we look at the international and national COVID trends. We'll also look at the latest flu and RSV data, discuss a new study on long COVID, and answer an ID query about COVID transmission via surfaces. Examine some concerning news about antibiotic resistance in Ukraine and bring you the latest installment of This Week in Public Health History. But before we get started, as always, we'll begin with Dr. Osterholm's opening comments and dedication.


Michael Osterholm: Thanks, Chris, and welcome back to everyone to another edition of the podcast. In particular, I want to welcome back the podcast family. You know who you are, we know who you are, and we appreciate you very, very much. Uh, to anyone who might be listening for the first time or who hasn't listened for some time and has come back to catch up on some information we welcome you to, hopefully, we're able to provide you with the information that you're looking for with regard to this podcast occurring during the holiday season. Here we've been setting the stage, you might say, for how we think about the world as it is right now and all the challenges that are before us, uh, we've dedicated this podcast to those who may be lonely and alone during the holiday season. Uh, we've talked about all those who are doing community service and helping out in the community and what that means in terms of our everyday lives. So today, I don't really have a dedication as such. What I have is what I've been thinking, and I want to share that with you, because in a sense, that is in my dedication, my thoughts about what it is that we as a podcast family and those listening might want to think about during the next several weeks. First of all, this episode is coming out. As you know, in the midst of this busy and special time of the year when people have been and will be gathering to celebrate Hanukkah, Christmas, New Year's, Kwanzaa, etc. for so many of us, it's a gathering with loved ones that gives this season such meaning and warmth.


Michael Osterholm: I know for some of you, you are wondering how to gather safely with your people this month given the rise in COVID, RSV, and flu cases. Oh man, we thought we were done with this or wanted to be done with this. How do we now talk about this in a time when everyone else is pretty well done with it? Maybe others of you are getting together for the first time in quite a while, finally feeling more confident after another vaccine and negative test results. I'm also thinking about those of you who wish you were able to celebrate with your loved ones. Whether it's that you can't join in or someone else in your life who you want to be there with, you are just missing. I'm thinking about those today who work in essential services. They don't get a day off. They don't have a holiday. As such, there are those who work in health care or emergency services pilots, flight attendants, anyone else whose dedication to service means they have to work today instead of join in the festive traditions. And so those individuals too, we are thinking of you and thanking you for doing that. I'm also thinking of those who live so far away from your community, particularly if you're wishing you could get together with your children, parents, extended families or spouses but can't. That can be a lonely moment. And of course, I'm thinking of those who have lost someone this past year who will have to go through this holiday season without someone they love and miss dearly.


Michael Osterholm: I hope that those of you who are able to gather safely and comfortably with your loved ones, enjoy this special time of the year and give thanks for this time of connection and celebration. I know that I will, and I feel fortunate to have that opportunity. For those that don't, I'm thinking of you and I will provide more detailed information shortly about how I think in a world that has basically moved on from COVID, moved on from influenza and RSV, how might we want to get together this season in such a way that it doesn't interrupt the actual getting together and causing people to say, I'm not going to come or I'm going to come, but at the same time providing as much safety as we can for what is surely now again, another challenge with COVID for all of you. We're thinking of you. And now moving on to what is actually a special week in the year for us with regard to sunlight, this is a very special week because it signals a very special event today, December 14th in Minneapolis. We'll have eight hours, 48 minutes and 22 seconds of sunlight. And what is interesting about today being December 14th today is the earliest sunset of the year, started back on December 5th and has gone through today with the sun setting at 4:31 every afternoon. Starting tomorrow, sunset will actually be later and each and every day after that.


Michael Osterholm: Yes, with the winter solstice, we won't see the shortest day of the year until December 21st. What will happen is the days will start getting longer in the afternoon, and they'll get shorter and shorter in the morning, such that it's January 6th to the 10th, that the latest sunrise occurs at 7:50, and then on January 11th, the actual mornings get longer, the afternoons get longer. And just think of this in one month from now, we will actually have gained almost an hour of sunlight. On January 31st we'll have nine hours and. 44 minutes of sunlight. Quite a bit more than this eight hours and 48 minutes now. So if this is all confusing to you, don't worry. The thing you want to take home with this message is the days are going to start getting longer soon. Isn't that great? Now, for those of you who are in Auckland, our favorite city afar and spending time at the Belgian Beer house in Vulcan Lane, which, by the way, I might say there's a number of you who have. We love the pictures you sent us from the Occidental there today. The sun rise is at 5:55 a.m., sunset at 8:35 p.m. that's 14 hours, 39 minutes and 38 seconds of sunlight. Well, guys, enjoy it. It's going to start getting shorter for you. You'll still have a lot of sunlight for quite some time, but just know we are in the running now, and those of us in the northern hemisphere are just months away from enjoying these long, long, beautiful days.


Chris Dall: Mike, let's start with a look at the international and national COVID data. As I noted in the introduction, we're seeing rising COVID-19 activity here in the US, whether it's in the official indicators, wastewater data or anecdotally. So what do you make of this? And are we seeing similar increases in other parts of the world?


Michael Osterholm: Well, Chris, let me start with my own observations. You'll see in a moment as if I had a dollar for every time I said what I'm about to share with you. I could probably pay for a trip to the Occidental Belgian Beer House. Over the course of the past 7 to 10 days, I have become aware of a number of people who have COVID right now, almost more than at any point in the pandemic. This is remarkable, and what has been specifically interesting, if not challenging, is that many of these individuals have become infected for the very first time. These are people who avoided four years of virus out there, only now to come down with COVID. And in each instance, all of these people have been vaccinated and including the recent BAA vaccine dose. So the question is, what's happening? I don't know, there's surely something going on with this virus as it relates to the variant, and we'll talk more about that in a moment. And I think there's something also about host immunity that's playing a key role here, is that these people are now becoming infected, not just because of their behavior, because they're out and about in ways that they weren't before. The people I know who have become infected are people who are living their life today very similarly to how they did through the last four years. So it's really a challenge right now to understand what's happening.


Michael Osterholm: But I can say for certain that there is clearly a lot of transmission occurring right now. And as you'll see in a moment, the data supports that that's happening even though it's limited. For example, if you look at recent wastewater data, which helps provide a sense of where things are at in terms of COVID activity, you'll find that nationally, levels are at the highest they've been in the entire year. And so now we've passed levels reported this past summer when activity increased from July into September. And we're literally approaching numbers that haven't been documented since last December, according to the latest data from CDC, which was updated December 2nd, there were 43 states sharing wastewater data, and of those, a total of 33 or 77% reported either high or very high levels of SARS-CoV-2. Included on this list are actually most of the Midwestern states and a handful of states in the South and the Northeastern United States. And that actually tracks with the regional trends which show that wastewater activity is highest in the Midwest, followed by the South. In fact, if you look at the latest levels reported in the Midwest, you can see that they've already even surpassed the region's peak reported last December, and haven't been this high since January of 2022, just several months after the initial record breaking wave of Omicron.


Michael Osterholm: Let me repeat this. If you look at the latest levels reported in the Midwest, you can see that they're already even surpassed the region's peak reported last December and haven't been this high since January of 2022, just several months after the major peak with record breaking waves of Omicron. Wow. So suffice it to say, that's a lot of COVID out there. Now, it's clear that we don't yet fully understand what the level of virus in wastewater means in terms of comparing it to previous levels. And what I mean by that is, could a variant actually cause more excretion of virus in the stool per number of people infected than another variant? We don't know that, but I can tell you there's a lot of activity if you look at the number of cases and deaths, that also gives you some sense of what's happening. Unfortunately, if you look at the growing number of hospitalizations and deaths, it does begin to support that. We may be seeing a substantial increase in cases over the country in the weeks ahead. The number of weekly deaths has been inching up, reaching almost 1300 as of mid-November, about 186 a day. And these deaths, as you know, are delayed in reporting. So I think that when we get 3 or 4 more weeks out, which you can compare the data for the wastewater from now with the actual deaths, which will be delayed, it may be substantially higher.


Michael Osterholm: And again, to put this number into context, the number of deaths now puts us at 13 consecutive weeks where deaths have exceeded 1000. If we go back to the dedication, I know that we're in the midst of another holiday season, and this is not the type of news that anyone wants to hear, I surely don't. But as we know, there are going to be a number of people traveling and gathering together these next couple of weeks, and many of them are likely have not had a dose of the latest updated XBB vaccine. In fact, I would say that that will be the case for most people, considering the estimates from the CDC show that just 17% of adults have received a dose, just 17%. Of adult. I want to reiterate a concern I expressed last episode, which remains a critical, critical issue. And that is just 31% of long-term care residents. Less than 1 in 3 have received an updated vaccine dose. On top of that, just 7% of the nursing home staff who are tasked with taking care of the 1.3 million total residents have received one. So to me, that's another major challenge. Now, let me be clear, as I just shared with you, we are surely seeing individuals who have been fully vaccinated, meaning all of the recommended vaccines, including the recent bar dose, doesn't mean that you won't get infected.


Michael Osterholm: But again, data have been forthcoming for recent months showing clearly that being vaccinated will in fact reduce the incidence of serious illness, hospitalizations and deaths. So I'm not trying to make the case that if you get vaccinated, you're home free. You're done. Okay, may not be the situation, but it surely has a lot to do with how sick you get and whether or not you're hospitalized or whether or not you become seriously ill and even die. So I just want to come back to that vaccine piece and make that loud and clear. And I'll have a comment more about getting together over the holidays in a moment. But let me just say that the US being challenged by COVID right now is not unique to other parts of the world. There's a whole laundry list of countries that could go through, including Austria, Belgium, Denmark, France, Italy, the Netherlands, Sweden, Finland and Canada, all of which are experiencing substantially elevated COVID activity. In some of these places, like Austria and Denmark, wastewater levels are among the highest they've ever seen in the entire pandemic. Otherwise, they've all reported very notable rises in hospitalizations, and I know we'll be covering this in more detail later, but we've been seeing some different reports in the media attributing these increases to the winter season and cold weather, basically framing it like it's part of some easy, straightforward and expected seasonal pattern.


Michael Osterholm: Well, you've heard me say this many times before, there's just no evidence to actually support that. The data that I look at that helps me conclude that seasonality is not yet part of this whole situation, is explaining what's happening right now in the southern hemisphere. This is their summer. They're in the thick of it. And yet countries like Australia and New Zealand, both are experiencing major increases in cases, despite the fact it is this summer season. So that can't account for the fact that it's winter summer kind of seasonality happening right now. I think it has much, much more to do with the variant that we'll talk more about in a moment. So right now, I'll tell you, as I've said many times in the past, I don't have all the answers myself. And that goes back to the whole humility piece. There's still a lot we don't know about this virus, and we should just say that if you had asked me six weeks ago, seven weeks ago, would we see this major increase? I would have said, I don't know, but I would have said if a new variant shows up that has certain characteristics, that surely could be the case. Well, that variant has showed up, frankly, between the virus, the different variants and the whole immunology piece. Meaning how well you're protected 6 to 8 months out after vaccine or after having had COVID.


Michael Osterholm: All of these may play into what's happening. And as I've said before, this is not rocket science. This is more complicated than that. So when you consider that after almost four years, we're still dealing with these constant ebbs and flows, it doesn't really matter how complicated it is, because at the end of the day, it's a problem and we should want to do something about it. So how do we get through the next few weeks with all of our family contacts not wanting to put mom or dad or grandpa and grandma in harm's way? Here's what I would say. First, get vaccinated. Everyone. Get your additional dose. Now, even if it doesn't stop transmission, it's an insurance policy against getting severely ill. Second of all, test, test and test. On the morning of getting together with any family members, friends, colleagues, whatever. Test yourself. And even though you have that little sniffle, you know it's not COVID. It could be. And I've had far too many reports to me of people whose only exposure they had to someone who was infected was being with them when they had the sniffles. However, the next day it wasn't just the sniffles. So if you're potentially at all, ill test. Even test if you're not to have more confidence, then finally masking.


Michael Osterholm: You know, I hear from people all the time about how I don't concentrate enough these days on masking, and I'm trying to what I guess I would say is be practical. I have watched all around me over the past. Romance, not just here in the United States. Last week I was in London all week at meetings. I virtually saw no one wearing any kind of respiratory protection. Now, you know my lone voice out there saying, oh, well, you should wear your N95 to the family gathering. People would look at me and just say, no way, I'm not going to I understand that. I would say that if someone was at a high risk of becoming infected and having a serious outcome, then, you know, you might want to consider that even at a family event, to have them in an N95. But let's talk about reality. That's not likely to happen. So I would really count on vaccination, testing, avoiding events if you're ill, and I would always support N95 use in a family event like this, but know that the likelihood that's going to happen is pretty, pretty low. This is the challenge we have right now, but just know that there are going to be family events that are going to happen over the next few weeks, where there will be substantial transmission of COVID. All I can hope is that no one becomes seriously ill.


Chris Dall: Mike. Our colder weather and more indoor gatherings playing a role in the uptick we're seeing in the US. Or does it have something to do with the JN.1 Omicron subvariant, which, according to the CDC, jumped from 8.1% of US cases to 21.4% over the last two weeks.


Michael Osterholm: Chris, before we dive into the current variance situation, I just want to provide some context regarding my thoughts on the role of colder weather and seasonality here. I just shared with you my sense that what we're seeing globally with this new variant and the increase in cases is not related specifically to seasonality. Clearly, it could have some implications as it relates to travel and people getting together, being in tight spaces with lots of other people. I've said this before in this podcast and I'll say it again, but when looking at the data we have in the last four years, it's clear that the only way this virus could be considered seasonal is because, frankly, it occurs in all four seasons. This is not a virus that is following the types of trends that we see with RSV, influenza and other seasonal pathogens. We've seen surges in cases, hospitalizations and deaths occur throughout the pandemic, but they haven't been tied to winter season. They instead are a reflection of the emergence of new variants and waning population immunity after previous surges of infection and or vaccination. Let's take a look at eight major surges in cases that have occurred in the United States. The initial rise in cases in April 2020, the July 2020 surge, the January 2021 surge, the April 2021 surge, the August 2021 surge, the January 2022 surge, finally, the July 2022 surge, and finally the January 2023 surge. There are three things I want to point out about each of these surges. The first is that four of them were driven by the emergence of new variants in the United States - Alpha in April of 2021, Delta in August of 2022, Omicron in January of 2022, and XB 1.5 in January of 2023.


Michael Osterholm: The second thing I want to highlight is the fact that the majority of these surges did not occur during the winter months. Two occurred in the spring, three occurred in the summer, three occurred in the winter. It certainly does not make sense to call SARS-CoV-2 a winter seasonal virus, when a majority of the surges have not even occurred in the winter months. The third thing I want to call attention to is the timing between these surges. Many of these surges peaked about six months apart, which is around the time that many studies are suggesting that we see immunity from vaccines and natural infection begin to wane. All of these things together suggest to me that we do not have any real evidence yet to support the idea that this virus is behaving in a way similar to influenza or RSV, with any kind of predictable winter seasonality. Now, if we take a look at what's happening with the variants, I think that this is a very important consideration. What's unfolding today? Well, the rise of the JN.1 variant that you just mentioned, I talked about this in the last episode, that it would be interesting to see how quickly this variant is distinguished from its BA 2.86 parent lineage. And here we are seeing it two weeks later as a discernible portion of the CDC's variant tracker weighted estimates. The CDC also published an update of the JN.1 variant on December 8th, stating that the continued growth of this variant is due to higher transmissibility or better immune evasion, though I would not be surprised if it were both JN.1 has the golden ticket of spike mutations, which historically is tied to increased immune evasion and is likely linked to this variants higher effective reproductive number or i.e.greater transmission. But as cases look to be sharply rising JN.1 cannot be the only sole factor to blame, especially ahead of its dominance. JN.1 may be added to the barrage driven by the under-vaccinated population. Approximately 17% of adults have had the new vaccine dose, but in addition, behavior change is associated with these winter months, including large gatherings, increased indoor exposure, traveling, etc. likely plays a role too. I hate to sound pessimistic here, Chris, but I fear that the COVID landscape will continue on this trend for a time before it gets better, probably after JN.1 accounts for more than 50% of new cases. That being said, there is promising preprint lab data showing this fall's updated vaccine, which I've referred to as the BA dose, is comparable in neutralizing antibodies between currently circulating Omicron variants like HB.1 and JN.1. From this, we do have reason to believe that this vaccine works to prevent severe disease, hospitalizations and death, which was not previously expected. Ultimately, we never know what's around the corner in this field, but we must continue to make informed decisions to protect ourselves no matter what the variant we’re dealing with. All I can say is I hope one day we can find a vaccine that will address all variants or the variants themselves, meld into our evolutionary past, and we don't see them emerge as we are now seeing them regularly do.


Chris Dall: Are we seeing any changes in illness severity?


Michael Osterholm: Chris, this is truly $1 trillion question because I think we would all agree, and I've said this many times and often it confused people. So I want to be clear now and not confuse people. If everybody in the world got COVID, but it never was more severe than a common cold, that'd be a great victory. If no one got long COVID because of their COVID infection, that would be a great victory. So we don't have to eliminate COVID to actually have a great public health success. But we have to do is figure out what not only causes COVID to happen, but why do we see severe illness and can we prevent that? Because that too would be a very important goal. So it seems like the illnesses that we've been seeing recently are less severe given the total number of cases. But let me dive into the data to see if this is actually the situation. The best way to analyze changes in illness severity is to look at how severity indicators such as hospitalization, ICU admissions and deaths have changed over time. If we look at hospitalizations versus death numbers, we get some idea of just how much severe disease is occurring among those hospitalized and compare it to the past.


Michael Osterholm: If hospitalization and death trends run parallel to each other over time would indicate that the infections have maintained the same severity over time. But what we actually see when we look at a graph of weekly deaths and weekly new COVID hospital admissions, as it since early 2021, while new hospitalization rates and deaths follow the same trends, the rate of new hospitalizations is far higher than the deaths are, indicating that those who end up hospitalized today are recovering much more often than they did earlier in the pandemic. In addition, if we look closely at the proportion of patients hospitalized by ICU status or not admitted to ICUs, we're seeing that there is a big difference today, with many, many fewer people being admitted to an ICU for their intense care needs, and that is a very good sign. So while we surely are seeing cases severe enough to lead to hospitalization, they aren't severe enough to lead to the deaths that we saw through the first three years of the pandemic. This is promising news. It seems we're finally moving in the right direction in terms of disease severity. Although I want to reiterate, we should never celebrate the fact that we continue to lose so many lives every day.


Michael Osterholm: And let me just say that there are a couple options for explaining this less severe disease. First, I believe it has to do with an increase in population based immunity. Immunity that may not be protecting you against getting infected, but surely protecting you from severe illness. We're now four years into this pandemic, and there is both vaccine induced immunity and immunity from that previous infection. On the other hand, the decrease in severity could be due to the virus itself. We have seen different variants cause different surges, and it could be that the virus is just evolved to be less severe over time or and most likely it's both of these factors. It's increased population based immunity, and it's the emergence of variants that are not as likely to cause severe illness and hospitalizations resulting in deaths. Yes, we have seen a milder illness spectrum with cases, and that's surely a great thing. But when you're talking 1300, 1400 deaths each week, that still is, in my world, unacceptable. These are our moms and our dads, our grandpa and our grandmas, our brothers and our sisters, our sons and our daughters. Just unacceptable. So we can do better. But we surely are in a better place than we were three years ago.


Chris Dall: So, Mike, what about the two other respiratory viruses that we know are more seasonally driven RSV and flu? What are we seeing there?


Michael Osterholm: Well, Chris, we still are in the thick of this year's respiratory virus season other than COVID. Two states right now are currently experiencing very high levels of influenza activity, the same as reported in our last episode two weeks ago. 13 states in New York City are experiencing high activity, up from eight states in New York City two weeks ago. Eight states in the District of Columbia are experiencing moderate activity, down from nine states two weeks ago. 11 states are experiencing low activity, and 16 states are still experiencing minimal levels of influenza activity. So if you add those last two up 11 and 16, i.e. 27 states, more than half are experiencing very low levels or no increased level at all. So it's a real mixed bag right now. What's happening, particularly with influenza activity, at least in the United States. Influenza vaccination coverage in children this year is currently around 38%, which is down from 43% this time last year. That is a real challenge. Influenza vaccination rates are particularly low for black children at around 30%, down from 38% last year at this time, and coverage is also very low for children in rural areas compared to those living in suburban or urban areas, at less than 28% coverage. Now, why is this so important? Because kids on the one end of the age spectrum are those who are most likely to actually have severe illness, be hospitalized, and unfortunately die from influenza. So we want to target them much as we want to target those who are over age 65, and particularly those who are in long-term care facilities. If we look at what's happening in adults right now, vaccine coverage is currently similar to around 39% as we're seeing with kids, but varying from less than 28% to over 49% depending on which state you live in.


Michael Osterholm: Just as with the children, we're seeing lower influenza vaccine uptake among black adults, Native American adults, and adults living in rural areas. Older adults have had higher vaccination uptake this year than younger adults, with 66% of those 75 years of age and older vaccinated against influenza this season, compared to only 26% of adults between 18 and 29 years of age. Sadly, but not surprisingly, influenza vaccine coverage in adults is also lower for adults who are uninsured and who are living below the poverty line. We so desperately need to get our older age population, particularly the fact that almost 40% of those 75 years of age and older are not yet vaccinated. Additionally, we've already seen 12 pediatric influenza deaths this season. Though 12 may seem like a relatively small number, I have to say even one child lost to influenza is too many. When we had a vaccine that very well could have saved them from that outcome. We need to find a way to encourage parents. Of the 62% of children who have not received their annual flu vaccine to get their children vaccinated as soon as possible. Remember, of the deaths that we're seeing in kids in the United States, both last year and this year, over one half had no identified risk factor for having serious influenza, meaning this was not a child that had some underlying immune deficiency or other health condition. That would have given us a sense they're at increased risk for having a very bad flu episode should they get infected.


Michael Osterholm: So therefore, again, we have to treat all kids as if they are that potential child who could become seriously ill and die from their influenza. All that said, and though we are several weeks into this year's flu season in many parts of the country, I want to remind our listeners it is still not too late to get your vaccine if you haven't done so, and to encourage your friends and family to do the same. These vaccines are far from perfect, but they can go a long way in reducing the likelihood of severe disease, hospitalizations and deaths from influenza. Moving on to RSV, we now have seen two weeks in a row with slight declines in cases with cases during the week of December 2nd, the most recent data available, down about 5% from two weeks before. It's possible that fewer people were tested over the Thanksgiving holiday, which could be contributing to these lower case numbers, but I absolutely am convinced that RSV is on its way down. And within the next 3 to 6 weeks, we'll continue to see that happen. We'll need to watch this closely. With that in mind, I want to also remind anyone who is eligible. This includes pregnant individuals in weeks 32 to 36 of the pregnancy and adults over 60 years of age. So get your RSV vaccine as soon as possible, if you haven't already. Cases may be declining, but there are certainly still elevated and it is not too late to protect yourself against this disease.


Chris Dall: Mike, you mentioned long COVID earlier and our listeners are always interested in this topic. So there were two studies published this week in the journal JAMA Network Open. One was on long COVID in Veterans Affairs patients, and the other was on the financial pressures faced by families with someone who had had long COVID. So what do we learn from these studies?


Michael Osterholm: Well, Chris, first of all, let me just say that we're going to link both of these studies to the website so that you can go and take a look at the stories that CIDRAP did within additional links to other information on this. You know, as you've pointed out, we've discussed long COVID many times in this podcast, and it is really fascinating to see the studies come out in real time about a health condition that desperately needs continued resources and research. This study used patient information from the VA's extensive database, and while this data set comes with its inherent biases of male gender and older age, the study highlights some interesting findings and key areas where further work can be dedicated. Overall, the researchers found that the cumulative incidence of post COVID-19 condition or i.e. long COVID as we call it here, to be around 5% of their cohort. This group includes nearly 400,000 subjects who tested positive for SARS-CoV-2 in the first 16 months of the Omicron era, namely October 1st, 2021 to January 31st, 2023. And they all had clinically coded outcomes for long COVID in their records. Since there are a number of baseline characteristics included in the VA dataset, such as social, demographic, geographic and clinical data, the researchers were actually able to uncover some associated factors worth noting as well. Let me just say that this was actually a very, very well done paper. The strongest of these positive associations are age groups over 50. Here we saw an increasing risk basically with each decade of age. We also saw increased risk associated with female gender being overweight or obese, a diagnosis with COPD or asthma, an increased number of symptoms with acute infection and hospitalization within 30 days of infection.


Michael Osterholm: The most compelling finding, in my opinion, is that receiving a primary dose of vaccine was strongly associated with protecting you against a diagnosed with long COVID, and the association was further strengthened in the group that received at least one booster or updated dose. Retrospective observational studies like this one will come with some limitations, and researching long COVID carries additional challenges due to the variability in patient symptoms and accurate physician documentation. But nonetheless, the researchers were able to pull together a very large study to uncover important associations and further established long COVID risk factors in their population. Work like this lays the groundwork for finding even stronger evidence, such as a randomized controlled trial to assess the effect of COVID-19 vaccination to prevent or even treat long COVID. Now to report on that second study. This was published out of a group from the University of South Carolina and Montana State University, where they administered what is called the Panel Study of Income Dynamics Survey to almost 7000 families about their financial status before 2019 and during the pandemic 2021. In this study, more than a fourth of the households headed by an adult previously infected by SARS-CoV-2 reported persistent symptoms. The remaining 84% had no history of COVID-19. What was most telling here was that in those situations where individuals had long COVID, and particularly if they were the primary breadwinner in the family, the economic implications were substantial due to an inability to either work or increased health care costs. I don't think anyone really has thought about yet, not just the individual pain and suffering that one is experiencing with COVID.


Michael Osterholm: But what does this do to one's life, particularly from an economic standpoint? If they can't work, if they can't be a part of everyday life? And so these two papers are linked in the website for the podcast, and I urge you to go back and take a look at them. Let me just close on one last article that came out this week. That actually, to me, is also very important. This is from a friend and a colleague Ed Yong, in which he wrote in the New York Times this week in an article reporting on long COVID taught me to be a better journalist, and in this piece, he details his journey covering long COVID since March 2020. I encourage everyone to take a look at the article. It too is linked in our show notes. But in summary, he describes the weight of his platform when those afflicted with long COVID cannot bring attention to their own condition, either due to debilitating symptoms or disbelief from people around them. He writes and I quote, “Societal dismissal leads to scientific neglect, and a lack of research becomes fodder for further skepticism.” Ed could not be more on the mark, but I would suggest that the two studies I just noted contribute positively to the lacking body of scientific research in this topic. The bottom line is that long COVID, as we've always maintained at the Osterholm update, is a very real and life-halting condition that necessitates further data driven investigation. Without ongoing efforts like these studies, millions of people will continue to struggle without answers they need and they deserve and possibly could even get.


Chris Dall: That brings us to this week's ID query. And this week we heard from Paul, who wrote. The CDC continues to suggest frequent hand washing and sanitizing as a means of preventing COVID transmission. Yet there is simultaneous guidance that COVID is only transmitted through the air. To date, has there been any evidence of COVID infection via surfaces? If a person cannot be infected by touching doorknobs, handrails, packages, mail, etc., why the stress on frequent hand washing? Next, while this isn't a listener question, we wanted to address a comment we received on the social media site X, formerly Twitter, after our most recent episode. This person wrote, “@sed to follow @MOsterholm updates and decided to give this episode another chance. When Osterholm stated vaccines and tests were our greatest weapons against COVID, I'd heard enough knowing COVID is airborne without declaring masks a powerful weapon is negligent.” Now, Mike, you kind of addressed this a little bit earlier, but I'll note for our listeners that we often get comments like this from listeners who are upset that you haven't addressed an issue that's important to them. So what's your response to that? And then to the previous question from Paul.


Michael Osterholm: Well, let me take the listener's comments from social media first. Chris. We do our best on the podcast to cover what's important in public health and infectious diseases, and specifically around the issue of COVID. We only have about an hour every other week, so naturally we can't cover every topic, every episode. If you were a fly in the wall of our planning meetings, you would hear all about the different outbreaks and articles we review for each podcast, including those related to respiratory protection. There's a lot on the chopping block. Please don't ever interpret a topic being left off for one week as us thinking it's unimportant. I would dare say that probably no one has covered the issue of respiratory protection more over the course of the pandemic than our group here at CIDRAP and with this update. But at the point that I was making in the previous episode was, again, in a world where masking is becoming a very unusual, if not almost nonexistent technique, I can say till I'm blue in the face, use your mask. However, what I was trying to cover on that episode of the podcast, and as I did earlier today in this podcast, is in a world where masking is not going to be used. What else can you do? Now, again, as I said today, I'm a very, very strong supporter of adequate masking. And what I mean by adequate, I don't mean just putting anything over your face. You need a tight fitting N95 respirator, maybe a KN94, but even there, there are still more compromise than I would like to have in terms of protection.


Michael Osterholm: So I'm sorry that this listener thought that based on that one comment, that I think he was going to leave and thought that I was negligent, he obviously hasn't listened to the body of information that we've shared over time, and how important we do believe respiratory protection is, but also we're realists. If people are not wearing a any kind of respiratory protection, and I would urge everyone to just take one quick look outside, take one quick look in a private setting, take one quick look in a large public space. Tell me how many people are wearing a mask right now, and I can tell them till I'm blue in the face to do it. In some ways I feel like it's almost as if I'm denying reality. If I don't say, well. So if you're not going to use a mask, what else can you do? And again, that's where I think the issue of vaccination and testing become very important. So I'm sorry that this person didn't find that answer satisfactory before, but it's reality.


Michael Osterholm: Now, in terms of the question about handwashing, You know, let me just take a step back and say that as someone who has been working actively in infectious disease prevention and control for 50 years now. We always have those situations where the information we have supports strongly. This is the way a virus is transmitted or the bacteria, but not exclusively. And one of the questions that's come up time and time again is a virus that can be airborne - can it be also transmitted via contact or touch? And let me just be really clear, there is no question that the vast majority, the large preponderance of transmission of SARS-CoV-2, is about respiratory transmission. Now, could there be some examples of contamination on a surface, hand contact, then a contact to an eye which would be most likely where that virus could enter? It surely could happen. There was actually a study done by a colleague, Vincent Munster, the chief of virus ecology at the NIAID of the NIH. He published a paper with some of his colleagues in 2021, using hamsters to model different routes of exposure and their impact on severity of disease. And what Vincent and colleagues found was that the aerosol exposure of these guinea pigs resulted in deposits of virus much deeper in the lungs. However, the animals also became infected through contaminated surfaces. For this type of exposure, initial viral replication took place in the nose and typically resulted in much less severe illness. Now, this is a controlled animal study, so we can't make 1 to 1 comparisons with human transmission in the real world. However, I do think it provides some information to understand that the virus may be capable of infecting us through multiple routes. But however, don't forget respiratory transmission is the real driver. So what does this mean? Should I be trying to sanitize all my packages and all my surfaces? No. I would tell you to use good hand hygiene.


Michael Osterholm: Yes. The common cold virus now is transmitted much more on the hands. And so for that reason alone, you know, I still strongly support hand washing. But I would not. I would not recommend to anyone that they wipe down their groceries or any other aspect of their life, to try to minimize what we're seeing in terms of transmission. And let me just conclude with an example of another infectious agent and how it's transmitted, and how it often surprises people to find out its primary mode of transmission. And that's norovirus. Many of us recognize norovirus is causing that diarrheal illness of several days duration with vomiting, diarrhea. It surely can be a very nasty bug to get. When I was at the Minnesota Department of Health, our group in the area of foodborne disease did a tremendous amount of research on the transmission of norovirus in the community, and we found many, many outbreaks of which respiratory transmission was the key and primary mode of transmission, I think. Wait a minute. This is an interrogation, you know, fecal oral. And in fact that can happen. But the actual respiratory component was very substantial. And so when I see some of my colleagues out there using norovirus to say, well, this is all a fecal oral transmitted virus, it's simply not. And it just points out the example of how you can have major respiratory transmission for an infection and still have another route.


Chris Dall: Now turning to some other infectious disease news. And this is an item of interest to me because it's a topic that I cover. There have been several reports over the past few months regarding concerning levels of antibiotic resistance in Ukraine linked to the ongoing conflict in that country, but not necessarily limited to Ukraine. What can you tell our listeners about this?


Michael Osterholm: Well, Chris, we have continued to cover the issue of antimicrobial resistance because it is a very, very major public health challenge. And another one of the listeners who responded to our podcast took me to task a couple of weeks ago because in the title of the description of the podcast, talked about a slow moving tsunami, and he assumed I was referring to COVID as being the slow moving tsunami and was not happy with our use of that, when in fact it was about what much as I'm doing right now. I also covered antimicrobial resistance on that podcast, and I referred to it as a slow moving tsunami. And he hadn't listened to the podcast, but he commented anyway, only to find out that if he'd listened to the podcast, that's what it referred to. Was that around antimicrobial resistance? Well, in this case, I can't ignore the fact that antimicrobial resistance will continue to be one of the greatest public health challenges of the next 20 to 30 years, bar none. The situation you described in Ukraine, Chris, is really a tragic situation. Reports have been coming in from public health institutions in Ukraine, saying that patients and hospitals there have concerningly high rates of antimicrobial resistance or Amr infections. Now remember, an Amr infection means that whatever caused the infection, like a bacteria or even a virus, is not responding to all or some of the antimicrobial agents being used. This makes infections very hard to treat, sometimes impossible, and it surely increases the risk of disease spread, severe illness and death.


Michael Osterholm: The latest survey from the center for Public Health of Ukraine sampled 353 patients from three regional hospitals and found that 14% of those surveyed had gotten an infection while in the hospital. And of those cases, there was a high rate of Amr. 60% had an infection with an organism resistant to carbapenems, which is a class of antibiotics that is very important in treating severe bacterial infections. Those numbers are obviously much higher than any of us would ever hope to see. And unfortunately, the issue has been going on in Ukraine for a while. Studies and case reports from the country have detected increasing numbers of Amr infections since February of 2022, which is when the Russian invasion began. These cases have been seen beyond Ukraine's borders, too, particularly in countries where Ukrainian refugees have fled. In fact, health care networks throughout Europe now consider prior hospitalization in Ukraine to be a risk factor for colonization with multi-drug resistant organisms. And once these antimicrobial resistant organisms arrive in a health care facility, they really are very difficult to get rid of, requiring extensive infection prevention and outbreak control measures. Of course, those measures are difficult to implement in Ukrainian hospital. That is part of a strained health care system in a country experiencing such horrible conflict. And if you're asking where are these Amr infections come from in the first place? The answer is from some of the same poor conditions.


Michael Osterholm: The Center for Public Health of Ukraine found hospitals there to have inadequate implementation of infection prevention measures, including hand washing, and not enough tools to test for antibiotic susceptibility. They're seeing an increase of patients with traumatic wounds, experiencing a shortage of supplies and medicine, and a depletion of the health care workforce. This can all lead to faster spread of the emerging pathogens and over-prescription of antibiotics, the use of expired drugs, and a dependence on non-optimal therapeutics. So you can see how these poor conditions both contribute to the problem and prevent the problem from being properly addressed. Of course, this isn't just a Ukraine issue. A rise in Amr infections is likely to occur anywhere in the world where there's armed conflict or civil unrest, leading to the destruction of the health care infrastructure and a shortage of desperately needed medical supplies. My mind, of course, goes to the conflict occurring in the Middle East among the daily tragedies occurring there, and there are long tum consequences. Or apply this to any of the more than 110 armed conflicts going on in the world today. Humanitarian crises result in public health crises. There's really an urgent need here to invest in surveillance, hospital resources and international plans to deal with the spread of antimicrobial resistance. A bug anywhere in the world can be everywhere in the world tomorrow. And when they're antimicrobial resistant, that makes it all the more challenging.


Chris Dall: And now it's time for this week in public health history. And this week I understand we are marking some fairly recent history.


Michael Osterholm: Well, Chris, I think it's fair to say over the past four years, I think we've gained about 25 to 30 years of history. A lot has happened this week. We have an event from recent history, although I think it will be one that people will look back on in the future as a top accomplishment in public health. Three years ago today, on December 14th, 2020, health care workers in the United States began receiving the first COVID-19 vaccine. Sandra Lindsay, a critical care nurse in New York, was the first recipient outside of the clinical trials to receive an mRNA COVID vaccine in the US. The Brits claim the first ever community inoculation with the Pfizer BioNTech vaccine six days earlier, given to 90 year old Margaret Keenan. This would be the beginning of the largest vaccination campaign in history. The vaccine itself was developed in record breaking time due to a significant outpouring of public and private funding, as well as decades of preexisting research on mRNA vaccine technology. But a vaccine sitting in a vial doesn't offer any protection. In the first month, over 13.7 million doses were administered in the United States.


Michael Osterholm: To date, almost 677 million doses have been administered in the US and 5.5 billion doses across the globe. This is an incredible feat and involves the work of so many people, from the scientists developing vaccines to health care workers administering them, to the people managing logistics, transportation and storage. It was and continues to be a tremendous collective effort. But for anyone following this podcast, we know the work isn't done. While 81% of the US population has received at least one dose of a COVID vaccine, around only 20% report having received the most recently updated version. Over half of the vaccinated adults who have not gotten the most recent vaccine dose cite not being worried about getting COVID-19 as their reason. Well, as we've addressed in this episode, SARS-CoV-2 is still active, causing illness, hospitalizations and deaths. So let's celebrate how far we've come while still reminding our friends, family, and community that these vaccines, while not perfect, are good. Really good. They're one of the best tools we have to fight back against this virus.


Chris Dall: And now we'd like to take a moment for a little bit of business before we wrap up this episode of the podcast. This podcast family has been so important to us over the last three and a half years, and we hope that you have come to appreciate all the timely information, support and positivity that we've been able to provide you through the Osterholm update. With that, we'd like to take a moment to remind all of you how critical it is to have access to the type of high quality, authoritative, and unbiased scientific information that you get from this podcast and from CIDRAP. And we provide that information without any advertising, which is a rarity these days with podcasts. That's why we're asking for your help as we near the end of the year, please help us continue to provide updates and perspectives on COVID-19 and other infectious disease threats by supporting the team you trust, respect and depend on. Any amount of financial support is extremely appreciated and will ensure we can continue to offer this podcast going forward. Your support means more to us than you'll ever know. To contribute to this podcast and everything we do here at CIDRAP, please visit to make it easier for you. We'll put that link in the podcast page. We so appreciate your support, trust and continued partnership. Anything you'd like to add, Mike?


Michael Osterholm: Well, first of all, Chris, I too am very grateful for the podcast family, for those listening to this podcast and all of those who use the CIDRAP materials for making decisions about their everyday lives. We have tried very hard to provide unbiased, scientific based information and we will continue to do that. Do we always get it right? Not necessarily. I can tell you though, we always try to be as truthful as we can, and when we don't know, we say that and we do know. We try to tell you how we know that. Now, in terms of asking for support, this is something I'm terrible at. Okay. I acknowledge that this is something that is not in my nature, but as someone who has to run a center where we have the wonderful group of employees we do, that just doesn't happen by chance. And so I want to emphasize that your support does mean everything to what we do and how we do it. None of this goes into my pocket at all. The support we get through the podcast and you as listeners, all goes to support our amazing staff here at CIDRAP and the research that they produce for this podcast and for all the activities we're involved with. So please know how much we appreciate your support, how important it is to us, and the fact that I ask you something that has always been a challenge, but at the same time, please know how much I do understand the criticality of our support from you and what it allows us to do. And all I can say is, thank you from the bottom of our heart for your support.


Chris Dall: Mike, what are your take home messages for today?


Michael Osterholm: You know, Chris, I've thought about this. I think we should have a lottery of some kind or a pool where people can actually guess after a certain part of the podcast where they can send in and say, okay, what do I think is going to be the three most important points? What did I cover today? And I think hopefully the first one is something that is self-evident and that is that there are no easy answers as to what's happening right now. I don't understand what the interface is between this new variant, overall immunity and why we're seeing this major uptick in activity in our communities. But I can say even without the easy answer, one is that we are going to be getting together for the holidays and for those that are fortunate enough to be able to do so, what do we do to protect ourselves and protect those that we love? And I come back to the issue of testing, particularly if you have any signs or symptoms, even mild sniffles, and getting vaccinated, now is the time to get vaccinated for, you know, the next several weeks going forward. Now, I would say yes for those who will be upset if I don't mention respiratory protection, I do ill. But the reality is most people are not going to use that. And so I've got to give them the best I can and that is the testing and the vaccination. But if you have someone who's at increased risk of serious illness, hospitalizations and deaths, they may, in a crowded family or public setting, find comfort in using an N95 respirator.


Michael Osterholm: At the same time, I don't want to sit here and say, if you don't use that, you shouldn't get together because people are going to do that. So that's first. Second of all, this new JN.1 variant is bad news. It's just bad news. I don't know what's going to happen in terms of cases with regard to the emergence of this variant, but stay tuned. It is a challenge. And finally, if I could say there's one take home point that I didn't cover, but hopefully is reflected throughout the entirety of this podcast. This is a time to be kind. There is so much out there right now that is so painful. It is so sad. It is so challenging. Be kind. Be kind to those who most need it, to those who are lonely, to those who have no one, and just reach out each day. Do something that is way beyond your comfort level, just to reach out to someone and be kind. And I can tell you there will be no greater gift you will experience back than feeling the kind of satisfaction and the kind of goodness that if you are kind to people and as busy as we are, and as much as the world is shaking us up and down, keeping us a bit discombobulated, there's one North Star that will never fail you. And that is when you are kind. Everything else will get better.


Chris Dall: Mike, since this is our last episode before Christmas, we have a special holiday closing and I'll let you introduce that to our listeners. But before that, I'd like to note that we will have a shorter episode coming out on December 28th. And until then, happy holidays.


Michael Osterholm: Well thank you. Chris. You are one of those Christmas presents under my tree every day of the year. Thank you. Working with you is a privilege, and I know that there are many podcast listeners that love your voice over mine and what you have to say. So I feel honored to be partnered with you here in this situation. The closing this week is one of remembrance, one of celebration, and one that will forever touch my heart. You may recall, for those who have been long-term listeners of the podcast back in December of 2020, that first horrible year, I closed the podcast with a recording of reading The Polar Express to my grandchildren, my five grandchildren, and it was done over zoom. We recorded it and played it well. First of all, for all of you who are familiar with Polar Express, I need say no more. You understand how powerful and beautiful that particular book is. Uh, for those that haven't, I urge you, I don't care whether you're 15 or you're 105. Go read it wherever you can read it. It's an amazing book. This book was written by Chris Van Allsburg and his partner, Lisa Van Allsburg, who plays a very key role in supporting Chris in his work. I have read The Polar Express to my children ever since it was published in the 1980s. I read it to him every Christmas, and they kindly allowed me to do that as they turned into adults. And now, of course, it's with my grandchildren.


Michael Osterholm: And here they are now, three years later, from the time I did that first reading for them during the pandemic. And what we've done is taken the original reading that we posted back in December of 2020, and it's now posted again here. I also want to say that one of the great gifts of this position, getting to know people through the contact of the podcast. And several years ago, uh, Lisa and Chris Van Allsburg reached out to me after listening to the podcast and particularly the Polar Express version that I cited. And the following Christmas, Chris very kindly signed a book for each one of my grandchildren with a kind of a little drawing on it with their name. And, uh, I was able to give them that for Christmas. Uh, and I could never thank Chris and Lisa enough for having allowed that to happen. Uh, these are heirlooms in our family now, these are truly gifts that my grandchildren will now have to give their grandchildren. It'll be remarkable. So I hope you enjoy it. The message is powerful. Listen to the message. Just believe and listen. And I leave you today with a great thanks in my heart for all of you being out there, for who you are, for what you do, how you support us, how you are. Provide us with really very important feedback. You make us better. We're better because of you. And I never forget that. And we're kinder because of you. Happy holidays. Thank you. Be kind.


Grandchildren: Grandpa, can you read us the Polar Express?


Michael Osterholm: The Polar Express, written and illustrated by Chris Van Allsburg.


Michael Osterholm: On Christmas Eve many years ago, I lay quietly in my bed. I did not rustle the sheets. I breathed slowly and silently. I was listening for a sound, a sound a friend had told me I'd never hear. The ringing bells of Santa's sleigh. There is no Santa. My friend had insisted, but I knew he was wrong. Late that night. I did hear sounds, though not of ringing bells. From outside came the sound of hissing steam and squeaking metal. I looked through my window and saw a train standing perfectly still in front of my house. It was wrapped in an apron of steam. Snowflakes fell lightly around it. A conductor stood at the open door of one of the cars. He took a large pocket watch from his vest, then looked up at my window. I put on my slippers and robe. I tiptoed downstairs and out the door. All aboard! The conductor cried out. I ran up to him. Well, he said, are you coming? Where? I asked. Why? To the North Pole, of course, was his answer. This is the Polar Express. I took his outstretched hand and he pulled me aboard. The train was filled with other children, all in their pajamas and nightgowns.


Michael Osterholm: We sang Christmas carols and ate candies with nougat centers as white as snow. We drank hot cocoa as thick and rich as melted chocolate bars. Outside, the lights of towns and villages flickered in the distance as the Polar Express raced northward. Soon there was no more lights to be seen. We traveled through cold, dark forests where lean wolves roamed, and white tailed rabbits hid from our train as it thundered through the quiet wilderness. We climbed mountains so high it seemed as if we would scrape the moon. But the polar express never slowed down. Faster and faster we ran along, rolling over peaks and through valleys like a car on a roller coaster. The mountains turned into hills, the hills to snow covered plains. We crossed a barren desert of ice. The great polar ice cap. Lights appeared in the distance. They looked like the lights of a strange ocean liner sailing on a frozen sea. There, said the conductor, is the North Pole. The North Pole. It was a huge city, standing alone at the top of the world. Filled with factories where every Christmas toy was made. At first we saw no elves.


Michael Osterholm: They are gathering at the center of the city, the conductor told us. That is where Santa will give the first gift of Christmas. Who receives the first gift? We all asked? The conductor answered, he will choose one of you. Look! Shouted one of the children, the elves. Outside we saw hundreds of elves. As our train drew closer to the center of the North Pole, we slowed to a crawl. So crowded were the streets with Santa's helpers. When the Polar Express could go no further, we stopped and the conductor led us outside. We press through the crowd to the edge of a large open circle in front of us to Santa's sleigh. The reindeer were excited. They pranced and paced, ringing the silver sleigh bells that hung from their harness. It was a magical sound, like nothing I'd ever heard. Across the circle, the elves moved apart and Santa Claus appeared. The elves cheered wildly. He marched over to us and pointed to me, said, let's have this fellow here. He jumped into a sleigh. The conductor handed me up. I sat on Santa's knee and he asked, now, what would you like for Christmas? I knew that I could have any gift I could imagine, but the thing that I wanted most for Christmas was not inside Santa's giant bag.


Michael Osterholm: What I wanted more than anything was one silver bell from Santa's sleigh. When I asked, Santa smiled. Then he gave me a hug and told an elf to cut a bell from a reindeers harness. The elf tossed it up to Santa. He stood holding the bell high above him and called out, oh, the first gift of Christmas! A clock struck midnight. The elves roared their approval. Santa handed the belt to me and I put it in my bathrobe pocket. The conductor helped me down from the sleigh. Santa shouted out the reindeers names and cracked his whip. His team charged forward and climbed into the air. Santa circled once above us, then disappeared into the cold, dark polar sky. As soon as we were back inside the Polar Express, the other children asked to see the bell. I reached into my pocket. But the only thing I felt was a hole. I have lost the silver bell from Santa Claus's sleigh. Let's hurry outside and look for it, one of the children said. But the train gave a sudden lurch and started moving. We were on our way home. It broke my heart to lose the bell. When the train reached my house, I sadly left the other children.


Michael Osterholm: I stood at my doorway and waved goodbye. The conductor said something from the moving train, but I couldn't hear him. What? I yelled out. He cupped his hands around his mouth. Merry Christmas, he shouted. The Polar Express let out a loud blast from its whistle and sped away. On Christmas morning, my little sister Sarah and I opened our presents when it looked as if everything had been unwrapped. Sarah found one last small box behind the tree. It had my name on it. Inside was the silver bell. There was a note. Found this on the seat of my sleigh. Fix that hole in your pocket. Signed, Mr. C. I shook the bell. It made the most beautiful sound my sister and I had ever heard. But my mother said, oh, that's too bad. Yes, said my father, it's broken. When I'd shaken the bell, my parents had not heard a sound. At one time, most of my friends could hear the bell. But as years passed, it fell silent for all of them. Even Sarah found one Christmas that she could no longer hear its sweet sound. Though I've grown old, the bell still rings for me, as it does for all who truly believe. The End.


Grandchildren: Merry Christmas grandpa!


Chris Dall: Thanks for listening to the latest episode of the Osterholm update. If you enjoyed 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, Clare Stoddart, and Leah Moat.


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