August 18, 2022

In "A High Plain Plateau," Dr. Osterholm and Chris Dall discuss the trajectory of the BA.5 wave in the US and around the world, the updated CDC COVID guidelines, and the latest data on long COVID. Dr. Osterholm also provides an update on the monkeypox outbreak and answers a query about polio.

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Chris Dall: [00:00:06] Hello and welcome to the Osterholm Update COVID-19, a podcast on the COVID-19 pandemic with Dr. Michael Osterholm. Dr. Osterholm is an internationally recognized medical detective and director of the Center for Infectious Disease Research and Policy, or CIDRAP at the University of Minnesota. In this podcast, Dr. Osterholm will draw on more than 45 years of experience investigating infectious disease outbreaks to provide straight talk on the COVID-19 pandemic. I'm Chris Dall, reporter for CIDRAP News, and I'm your host for these conversations. Welcome back, everyone, to another episode of the Osterholm Update podcast. As I often like to do in preparation for an episode, I took a look back this week at an old podcast script to remind myself of where we've been in this pandemic and how quickly things can change. On August 19th, 2021, little more than a month after the White House had essentially declared victory over COVID-19, we were in the midst of the Delta surge and new infections, hospitalizations, and deaths were rising across the country. All of a sudden, it seemed like the SARS-CoV-2 virus had changed the game, and we hadn't even heard of Omicron yet. It was a good reminder here in our third summer with COVID, because even though the virus has faded into the background for many, it has shown us several times that it has many tricks up its sleeve. Will the BA.5 Omicron variant be the last one? Today, on this August 18th episode of the podcast, we're going to talk about the trajectory of BA.5 here in the US and around the world and what it tells us about our future with COVID. We'll also talk about the CDC updated COVID-19 guidance, share the latest data on long COVID, update you on the latest developments in the monkeypox outbreak, and answer a listener question about the detection of polio in New York City wastewater samples. And we'll share a beautiful place mission from one of our listeners. But before we get started, as always, we'll begin with Dr. Osterholms's opening comments and dedication.


Michael Osterholm: [00:02:00] Thank you, Chris. And welcome to all of you to another episode of The Update. We welcome you back. For those who are part of the podcast family, if you're new to the podcast, welcome. We hope that we're able to provide you with the kind of information that you find useful that you can incorporate into your everyday life, or answer those really difficult questions that we all seem to have about where we're at in the pandemic, where we're going, and what it means. I will start out by saying today is part of a litany of ongoing declarations before I do the podcast to say, I think the more I know, the less I know. And today it won't be any different, I promise you. But at the same time, I hope we can give you a perspective as to how we're looking at things, what we're seeing, what it means to us, and how that, in turn may mean something to you in your life trying to deal with COVID. Let's just start out at the very beginning and say the vast majority of this world is done with COVID. They're ove it. It doesn't mean the job is over with them, doesn't mean that this virus is stopped, but they're over it. But at the same time, we have to put it into perspective. Where are we at? How is it different today than it was six months ago or a year ago? As Chris so very nicely illustrated with the point of where we were a year ago today. So I hope today's podcast will provide you some of that context. Also, I'm going to share with you today some of the more personal issues around the podcast and the messaging that we put out and what that means. And so as I wrap up today, I hope to share with you, I think, some observations about not just where we are in terms of the human head, but also we are in terms of the human heart. I have to start out as I do every podcast with a declaration of where we're at with sunlight. This is going to be more difficult, but I choose to look at the glass as half full, not half empty. Today, sunlight in Minneapolis, Saint Paul will be 13 hours, 55 minutes and 47 seconds. We're losing 2 minutes and 49 seconds of daylight every day this week. Now, that compares to just two weeks ago when we did the podcast of 14 hours and 33 minutes. So we've lost over almost 40 minutes of sunlight since that time. And it surely is less than we saw during the spring solstice on June 21st when we're at 15 hours and 36 minutes. But I think if nothing else, this pandemic has taught me appreciate what you have when you have it. Never take it for granted. And so I think 13 hours and 55 minutes of sunlight today is just wonderful. And I know it's going to get darker, but then I also know it's going to get lighter again. So I think that to me is the state of the art as I see it. And to all of our friends in the Southern Hemisphere, and we know we have a few. Thank you for listening. We hear from you. We know your days are getting longer and we're happy for you. Now, in terms of the dedication today, we we actually, believe it or not, we do put a lot of thought into these dedications as to how we might share with you the kind of information that is relevant to some parts of your life with regard to COVID. This particular one is very, very, very relevant to a group of COVID patients who have not been able, following their initial infection, to somehow put this disease in the rearview mirror. Namely, these are those of you who are suffering long-COVID. And today we dedicate this episode to you. We will discuss in more detail some of the new findings and some of the interesting issues that are coming up around COVID. But in the first instance, we never forget what you're experiencing, what you're suffering, and what this means every day for some of you just to get out of bed. And so we dedicate this to you. We want, more than anything to be there as your advocates, to help push forward wherever we can research and the clinical care for those who have COVID and what it means. So today, this is ones for you.


Chris Dall: [00:06:01] Mike, let's start with the international situation. If you take a look at new infection averages for many of the countries that have been hit by BA.5 wave, it appears that most seem to be on the back end of that wave. Are we through the worst of BA.5 and does there seem to be any variant ready to take its place?


Michael Osterholm: [00:06:20] Well, Chris, let me say that when you look at the global picture as a whole, there are surely some real signs that we've reached a potential peak with this wave, at least in terms of infections. Right now, daily cases stand at about 813,000, down from just over a million a day reported just last week. Now, as you've heard me say time and time again, I don't put a lot of stock into case numbers, since they represent just a fraction of the true total number of cases in the community. And when you consider that the current number would still rank among the highest ever recorded prior to Omicron, despite rollbacks in testing and reporting, I don't necessarily equate this moment with success. I will acknowledge for every case we see today, the likelihood of having severe illness, hospitalizations and deaths has surely dropped. But it is far, far from gone. Remember, when we talk about peaks of cases, we're talking about something that represents more of a halfway point than a finish line. So from that perspective, even if this downward trend continues, we still have a long ways to go before we fully move past this BA.5 wave. With that being said, I'm always happy when the numbers are getting smaller as opposed to growing larger. And although there are some significant limitations when it comes to reported infections, as I've talked about so often, I think the similarity in trends we're seeing across multiple regions of the world support this notion that we have reached a peak with BA.5. Of course, South Africa offered us our first real world glimpse of this sub-variant when cases started taking off there this past April. In May, just about a month after the surge began, they reached a peak and things started coming down actually quite quickly. And at least up to this point, activity in the country appears to be relatively low. Although it is worth noting that South Africa's health department recently shifted from daily COVID reporting to weekly. So the numbers there aren't being updated as frequently as they have been in the past. Regardless, it wasn't long before we saw BA.5's impact outside of South Africa. Throughout late May and into early June, cases climbed in Europe, Southeast Asia, the Eastern Mediterranean and the Americas, for example, surges in countries like France, Germany, Italy and the U.K. took weekly cases in Europe from 900,000 to more than 3.3 million in the span of a month and a half. 3.3 million was their peak with BA.5. However, since reaching that peak in early July, their numbers have dropped, with last week's total at around one and a half million. Again, I add the caveat that reported cases surely do not represent all the activity in the community. But this pattern that I just talked about is similar to what we've seen in other regions that I just mentioned. In the eastern Mediterranean, weekly cases went from 17,000 in late May to 178,000 in mid-July, just over a month and a half later. Otherwise, as of last week, they reported 86,000 infections, again down from their high of 178,000. With the Americas and Southeast Asia, it's largely been the same story. Cases of BA.5 started taking off, then they climbed for a month and a half or two months. A peak was hit, and although activity remains elevated, the case numbers now appear to be coming down a bit. We will talk more about what's happening in the United States in just a moment. But as you know, it's not just about cases. Severe disease and even deaths from this virus is still a reality. And although the overall risk of these outcomes is lower than it was earlier in the pandemic, it is still claiming about 2,500 lives a day. Remember, for context, W.H.O. estimates a 290,000 to 650,000 people die from influenza each year. And while I recognize that depending on where you live, the flu season might be comprised of just several months. If you turn those annual estimates into a daily average, it comes out anywhere from 795 deaths a day during the milder flu season to 1,780 deaths a day during a more severe flu season. So even after two and a half years of this pandemic, we're still seeing COVID have a more significant impact in terms of mortality than even a severe flu season. Now, back in June, which was a time when BA.5 had yet to really make an impact on mortality at an international level, the average number of daily deaths from COVID reported across the world had dropped to almost 1,300. So clearly there's been a noticeable rise since that point. And as no surprise, the BA.5 surges in each of those regions I just discussed have played a role. In Europe, deaths grew from less than 3,000 a week to more than 6,200. The Americas climbed from 3,500 a week to almost 7,000. The eastern Mediterranean went from 60 weekly deaths in early June to more than 650 and Southeast Asia recently reported 800 deaths in a week, up from 250 in early June. So clearly the uptick in cases from BA.5 has resulted in more deaths. That being said, most of these regions appear to have hit a peak from this wave. Even when it comes to deaths. And while I don't at all want to minimize the consequences of BA.5, it's interesting to note how peak deaths from this wave compare to the surges driven by previous Omicron sub-variants. As I mentioned, Europe reached a peak of 6,200 weekly deaths with BA.5. However, at the height of their BA.1 surge earlier this year, weekly deaths in Europe surpassed 27,000. A four fold difference. In the Americas, weekly deaths from BA.5 approached 7,000. During BA.1, they reached 35,000, a five fold difference. In the eastern Mediterranean, the peak of 650 deaths in a week from BA.5 compared to more than 3,300 during BA.1, another five fold difference. Southeast Asia recently reported 800 deaths in a week from BA.5. And although it's unclear if that will actually end up being their latest peak, it remains well below the levels reached during the previous Omicron surge, when 8,800 deaths were reported. A ten fold difference. Note the shifting baselines here. Just how now, today, even though there is this reduction in cases, we now have concluded almost that the worst of the pandemic is over, when in fact had the same number of cases we're seeing today occurred a year ago, we would have thought, boy, are we ever in the soup. So let me just say that there is one region of the world I have yet to mention. This is the Western Pacific, and that's because BA.5 appears to be having a much more marked impact there. Remember, this is a region that's home to countries like Australia, New Zealand, Japan and South Korea. Their surge, which actually started quite a bit later than it did in other regions, took weekly cases from less than 800,000 in late June to nearly 3.4 million in early August. And while cases in the region seem to have reached a possible peak, deaths are still climbing. In fact, last week they reported a total of 3,200 deaths. Now, at this point, that's still much lower than they reported from BA.1 when weekly deaths approached 7,000. However, considering the lag time between cases and deaths and based on what we're seeing in places like Japan and South Korea, we could see the number of deaths still grow. And although I think it's highly unlikely that deaths in the region will reach the same level they did during BA.1, the two fold difference in deaths from BA.5 is a bit of an outlier compared to the other regions I just covered earlier. Why the difference? Again, as I mentioned last week, I'm not sure there's any simple, straightforward answer. Could it be influenced by their success in limiting transmission prior to Omicron? Absolutely. But there's probably much more to it than just that. Otherwise one country in the Western Pacific that I brought up time and time and time again, since they could really tip the scales is China. On Tuesday, they reported a total of 2,368 cases across 17 provinces, three municipalities and four autonomous regions. According to reports, a majority of these cases are from a handful of these places with more sporadic detections elsewhere, including a few in Beijing and Shanghai. You may have seen this past week the Shanghai made headlines after shoppers at an IKEA store tried to flee following the news of a surprise lockdown there because of a possible exposure to a single case. Each of these flare up poses a potential threat to their approach of zero COVID and continues to have a tremendous impact on supply chain stability. And finally, to get at the last part of your question, Chris. Let me just say that I'm still not certain what we'll see after BA.5. Obviously, the virus is still changing and is doing so quite rapidly with these offshoots of Omicron we keep seeing. Of course, one that seems to be hanging around is BA.2.75 and there's been a bit more data on it since I mentioned it in a past episode with some signs that it might be able to compete with BA.5. But at this point, it's still largely been limited to a handful of countries with no clear indication that it's capable of leading the next global surge. On the other hand, we have seen BA.4.6 another Omicron sub-variant also growing in some areas including right here in the US. But at this point I'm not sure what the next chapter will look like. I fear that it could very well make things worse again. But how much worse? We don't know. So welcome to COVID. Welcome to this ongoing, horrible, horrible companion that we seem to have to deal with day after day and with the idea that we all would like to put it in the rearview mirror.


Chris Dall: [00:16:23] So what about the current situation in the United States? Even though we know that daily reported case numbers are a significant undercount and thus not a good measure of what's going on, transmission remains high, but hospitalizations appear to be declining, deaths have hit a plateau. Acknowledging the shifting baselines that you talked about, Mike, have we seen the worst of BA.5 here in the U.S.?


Michael Osterholm: [00:16:46] As I've said during the last couple of weeks, cases here in the United States have actually been quite stable across the large region of the country. We're what I call now in a high plateau situation where we're not seeing these big mountain peaks of cases, these big surges, and then these rapid drops taking us down into the valley of cases with very few giving people the sense that everything's over. Right now, what we're seeing is almost kind of a steady state picture of cases around the country. For example, if we look at any of the measures, case numbers, hospitalizations and deaths, they all are actually remarkably stable. At this point, as I've shared with you time and time again, I don't put a lot of stock in case numbers other than to say, boy, oh, boy, I know so many people infected with this virus. And in fact, I actually had my first what I believe to be substantial exposure to COVID this past week, when someone who I know well who was testing negative, who had no symptoms, actually developed some symptoms during the day when I was with them. And that night became more severely ill and tested positive the next day. I'm happy to report four days out, I'm still hanging in there quite well. As I've emphasized over the past months and you stated in your question, Chris, we can't judge the case numbers being reported as a measure of what's going on. So all I can say, there's just a tremendous amount of transmission. We can see that hospitalizations have dropped slightly 5% over the past two weeks, with nearly 42,000 people hospitalized with COVID-19 on any given day. Deaths have remained pretty steady over the past few weeks, with an average of just under 500 lives lost each day in the US. Again, let me put that number into perspective. That equates to about 182,000 deaths a year in this country. If we were to maintain what we've seen for the past 10 to 12 weeks. Why is that important? Well, it now makes it the fourth leading cause of death in this country. And I think had I shared with this audience three years ago that a new virus would come and even in its more quiet days be the number four cause of death in this country, people would have not really believed that to be the case. Now, another part of what is really very interesting and challenging from a scientific standpoint to explain is, unlike the previous surges that we've seen dating back to the first days of the pandemic, where those case numbers went up dramatically in certain geographic areas and came down quickly, remember how many of the talking heads predicted we would see a very hot southern sunbelt state epidemic again this summer? Well, that's just not been the case. If you look at right now what's happened with hospitalizations, the District of Columbia has currently 29 hospitalizations per 100,000 population. That is, in a sense, the outlier number. 36 of the states actually have between 8 to 14 hospitalizations per 100,000 stretched all across the country. If you look at deaths, Florida is leading in that at 0.33 deaths per 100,000 population. But if you look at 32 other states, it's between 0.24 and 0.11 deaths per 100,000 population, meaning that again is uniformly occurring throughout much of the country. So from that perspective, I don't really have any clue as to what's going to happen, except if BA.5 continues to be the dominant variant hopefully over time enough people will have been infected or vaccinated and case numbers will begin to come down. But I also know that this virus has surprises still up its sleeve and whether we'll see another peak. You know, everyone talks about seasonality and the peaks occurring with that. We don't know that to be the case at all. Could happen, but we don't know. So this is a stay tuned moment. And it's actually a complicated moment because for many, they just want an answer. Is it safe for me to go out into the public? Is it not? What is, what am I up against? And I keep coming back to the same old answer, you know what, 500 deaths a day. This is still a real challenge. So for you in particular, who are at increased risk for serious illness, hospitalization and deaths, number one, please get fully vaccinated with all the eligible vaccines you can. And my fully vaccinated definition is different than CDC. So if you're eligible for four doses, get them. If you're eligible for five doses, you're immune compromised, get it. If you are someone who is immunocompromised access Evusheld, the monoclonal you can take to protect you in advance of getting infected. Wear your N95 respirator when you're in public places. I do it. I have just taken it on a second nature. And you know what? I'm not embarrassed to be in a public setting where 29 other people don't have their N95 on but I do. You know, feel empowered to do that. That will help you get through this current BA.5 activity. So as far as giving you a sense of where we're at, we're in the quiet of the storm, whether this high plateau will continue for weeks or months, I don't know. What will come next? Will there be a sharp drop off and basically limited activity? I can only hope that to be the case, but I don't necessarily believe that will happen. Do I think we'll have new big surges of cases like we saw earlier this year with Omicron BA.1? I don't think so, but no one knows. And so, again, vaccinate, vaccinate, vaccinate, do whatever you can to help protect you against serious illness, hospitalizations and deaths. And I'll be commenting on that more in a moment also. So, Chris, national update, more of the same. What it means, I don't know. What I hope it means is that maybe this will be the last of the big surges for some time. But again, as you've heard me say so many times with those famous three words, I don't know.


Chris Dall: [00:22:56] Well, that leads nicely into the next question, Mike, which is about the updated COVID-19 guidance that was issued last week by the CDC. So among other things, the guidance says that people who are exposed to the virus no longer have to quarantine regardless of their vaccination status. It drops the six feet social distancing standard, and the guidance no longer requires schools and other institutions to regularly screen healthy individuals. Many have criticized this new guidance for putting more of the onus on individuals to assess their risk. What are your thoughts?


Michael Osterholm: [00:23:30] Well, Chris, as I said in the last podcast, as this virus has evolved in the epidemiology of the disease has changed, it surely makes sense for CDC guidance to evolve as well. But I do have to say, based on the fact that significant parts of the previous CDC guidance, I thought were not based on good science in terms of what they were recommending, anything they can do to fix that by itself will be a positive thing. I'm not sure that's happened here. I know that the CDC is trying to meet people where they're at, and I think that's an important recognition. You can be a purist in terms of public health practice and say this, this and this must be done. But if people aren't going to do it, then what's the reality of success when in fact, you put out recommendations that people just won't adhere to? So I still support data driven recommendations, but I don't think that the science is driving a lot of what we're talking about. For example, first, the new guidance emphasized staying up to date with vaccination while acknowledging waning protection over time, an important acknowledgment. While this seems to be a step in the right direction, it actually does not change the definition of fully vaccinated. It just adds a layer of confusion. The CDC still considers someone with two primary doses as fully vaccinated, regardless of evidence supporting improved protection with third doses across the board and fourth doses in adults over 50. This is an outdated recommendation and does nothing to encourage more vaccination. This past Monday in "The Guardian," Eric Topol, a friend of many of us here on this podcast, wrote a wonderfully thoughtful commentary on just where we're at with the CDC recommendation. Eric wrote, "This not only ignores a large body of data, but gives the impression to many that a booster is unnecessary, which helps explain why the United States booster rate is pathetically low with 32% of the population. In stark contrast to most other 37 organizations for economic co-operation and development peer countries which where the rates there exceed 65%. The United States ranks below over 70 countries, including Panama, Rwanda, Sri Lanka, Uzbekistan, and Iran." And that's just data for one booster, the third shot. He goes on to say, "As we've progressed through the Omicron wave in itself variants, the need for a second booster becomes highly substantiated for people age 50 and older. Five different studies with varying age groups from 50 to 80 plus have shown markedly enhanced protection with less mortality for the people who've had four shots, i.e. two boosters compared with three shots. But the rate of second boosters in Americans age 50 to 64 years is only 11%, and for age 65 and older is only 26%. If the CDC was truly interested in protecting the vulnerable, it would have been engaged in an aggressive effort to get the life saving potential of a fourth shot out to the public and revise what fully vaccinated actually means is substantiated by ample data. All of this is consistent with CDC is unwillingness to stand strong on the imperative boosters, not fully endorsing them for adults until the end of November 2021." End of commentary quote. I think Eric said it very well. I feel very strongly in the same boat. Do I believe that these boosters are going to be protecting us forever? No. Do I believe we're going to be continuing to see waning immunity? Yes. Have I said over and over again we can't boost our way out of this pandemic? Yes. And I do acknowledge we don't have a grand plan for what vaccines might look like 6 to 12 months from now. And will we need to continue to boost like this? But in the meantime in the meantime, the data are there. They're compelling. Please get that third or fourth dose. As I've said before, as many as you're eligible for. Get it. Let me look at another issue with regard to the guidelines. They now make uniform recommendations for everyone, regardless of vaccination status, and it drops the recommended quarantine period after an exposure. The new recommendation is that people wear a mask for ten days and test on day five. If someone tests positive, the CDC recommends that they stay home for five days and wear a high quality mask until day ten. We've discussed the issues with this guidance in several previous episodes, especially considering the evidence now that 50% of people are still infectious after day five. Five days is just not long enough to actually be isolated and trying to prevent transmission to others. Now I understand that for many people trying to isolate for up to ten days is virtually impossible. Economically it can be a hardship to have to miss ten days of work when in fact every week your paycheck is the only thing keeping a roof over your head. I get that. But at the same time, the CDC needs to then acknowledge what is it that is based on science? What is it that's based on practice that is most likely to be adhered to? And what is it that ideally we would like to see happen? But we understand the reality is that it won't. So again, let's make it clear to people we do not have data supporting that up to five days post onset you actually are no longer infectious. It's clear that this can last up to ten days and you need to plan accordingly. I have questions come in all the time from various companies, businesses, organizations who want to bring people back to the office and they want to make certain that they're protecting their staff. But at the same time, they find that the ten day isolation, if you've been infected, is far too long. So they want to somehow shortcut that because CDC had originally done that. And as you know, I've shared with you in the past, I was part of those conversations back in November, December and January, where the recommendation was at the time to cut down to five days, the period where you would be isolated with five more days wearing an N95 respirator if you were a health care worker or other essential employee where you had to be at work. If we did not have health care workers to take care of sick patients, what would that mean? And so that unfortunately, that recommendation got extrapolated to the whole public as just go five days. So I think that that recommendation is still a real problem. Lastly, the recommendations do drop the six foot social distancing guideline. As you know, I have never supported that recommendation because there's no data to support it. If the virus were only spread by respiratory droplets it would make some sense. But we know that this virus can be airborne, in which case it can spread much further than six feet. Remember that old cigarette smoking example? If you can smell someone smoking in a room, even if it's 20 feet away, you're inhaling potentially aerosols if they were breathing out the virus. So I am pleased to see that CDC has removed the six foot issue, but wanting them to emphasize that it means it could actually be much further than that. It's not that somehow it no longer matters in terms of how close you are to someone. I'm also pleased to see that they have actually emphasized improved ventilation and that to me is one of the things that has been missing throughout much of this pandemic. So, Chris, yes, the CDC needs to update their recommendations because this virus has evolved. But in their attempt to meet the public where they are, which seems to be overwhelmingly done with the pandemic, I fear they may end up causing more harm than good with some of these relaxed recommendations. And we, again, we'll see with time.


Chris Dall: [00:31:19] So going back to the booster shot issue, Mike, earlier this week, the U.K. authorized Moderna's updated COVID-19 booster shot, which targets the original virus, plus the Omicron BA.1 variant. It's the first country to do so. So what do we know about the efficacy of this booster against other Omicron variants? And when can Americans expect updated booster shots?


Michael Osterholm: [00:31:41] Well, Chris, I'm going to tie in to this very thoughtful question a couple of additional points, because I think all of them relating to vaccine and are relevant to understanding what we can do. The promising news here is, is that the data you just cited from Moderna did show strong immune responses to both the original virus and the Omicron BA.1 variant. Well, this is a step towards our current vaccines, which only target the original strain. I'm not convinced that this will be the silver bullet that many are hoping for. There are a few reasons for this, but it can all be summed up in a statement that you've all heard me say dozens of times by now. We cannot boost our way out of this pandemic. Part of the reason for this is that by making the variant specific vaccines, we will always be a few steps behind this virus. BA.1 was dominant at the time that this vaccine was developed, but now, several months later, at the time of its approval, we've seen multiple variants become dominant since then. First BA.2 then BA.2.12.1, and now BA.4 and BA.5. And while the bivalent vaccine is more effective for all forms of the Omicron variant than the original vaccine, we're already seeing a greatly diminished antibody response with BA.4 and BA.5 compared to BA.1. In contrast to what has been approved by the U.K., the FDA has recommended that any new booster target, BA.4 and BA.5, not BA.1. But by the time this booster will be developed, actually manufactured and approved for use, it's likely that it will be in exactly the same situation with the new dominant variant, maybe even one that's unrelated to Omicron. My other concern with this, which I want to reemphasize from my previous comments, is that our booster uptake is already alarmingly low. I don't expect this to change with a new Omicron specific booster, regardless of how effective that booster is. As I have stated in so many previous episodes, this approach of frequent variant specific boosters is also very unsustainable for low and middle income countries, which are already struggling to vaccinate their populations with two doses. In addition, as I have shared time and time again, also, the idea of turning a vaccine into a vaccination remains a substantial challenge. The bottom line is that this vaccine may add some protection at an individual level, but I think it's unlikely it'll have a large impact on our population as a whole. I still strongly believe that we cannot boost our way out of this pandemic, whether it's the BA.1 sub-variant vaccine or the BA.4, BA.5. So I hope that these vaccines are taken for what they are, an added layer of protection for individuals, but not longer term solutions for the world. Let me just conclude also with one last point when it comes to turning vaccines into vaccinations. I think we have hit a perfect storm moment with regard to vaccines in this country. What am I talking about? Well, first of all, let me just take a step back and look at our current health care delivery system and our public health systems in this country. They are stretched beyond imagination. They are having a hard time just keeping up with routine, everyday activities because of what has happened over the course of the pandemic. Well, let's look at the vaccine landscape for right now. We are now in the process of offering annual flu shots, something which is very important in reducing the impact of influenza. We don't want to give them too early because we do have data today showing that there is waning immunity over time. So at the same time, trying to concentrate, getting everyone vaccinated for flu in September, October and November is a challenge in terms of trying to compress them there. So we've got the clinical and public health communities trying to deliver flu shots. Now we've got the increasing confusion around COVID. The new BA.4/BA.5 vaccine will not be recommended as a primary serious vaccine, but rather it's one that if you're starting vaccination for the first time, which I acknowledge, there are probably only very few. You start with the old vaccine. Now, if it's a booster, you can use this vaccine. So now you've got the confusion, wait which COVID vaccine do I get and which one do I deliver? Then you've got monkeypox. Now we see public health systems and health care in general struggling to try to get enough vaccine for people on top of it now, having to deliver the vaccine via the intradermal route, which we've already discussed, is a real challenge. And how do we actually add that on with no new resources, no new funding, no new staff people to do that? Oh, but by the way, did I tell you that we're also now looking carefully at how can we enhance polio vaccination in the United States? Because we know we have a number of children who, through the course of the pandemic, missed critical vaccine visits or were not vaccinated because their parents objected to them getting the vaccine. Now, we're trying to play catch up in that area as we will talk more in a moment about the polio situation. And then there are those kids that missed their shots during the pandemic, whether it be measles, mumps, rubella, pertussis, diphtheria, tetanus. All of these vaccines are critical to the safety of our children. So now add these up flu, COVID, monkeypox, polio, routine childhood immunizations and this all overlaid on the same infrastructure that we had before we had any of these issues. And that infrastructure is frayed at the edges right into, in some cases, the whole cloth. So I worry that the conversion of vaccines into vaccinations is going to be a huge challenge over the months ahead. And we have to understand that we have to boost our delivery system here. We have to provide the support to health care workers. We need more people. We need more resources. And if not, again, turning a vaccine into a vaccination would be the cruelest of all failures if we can't do that. So when I look at this issue right now in the United States with vaccines, it's complicated. It's not rocket science. It's more complicated than that. And I think this is a message we have to get across to our elected officials, to our organizations. We need to have special support right now for vaccinations, unlike I've ever seen in my public health career.


Chris Dall: [00:38:19] As you mentioned in your dedication, Mike, long-COVID remains a significant issue for an untold number of people who have been affected by this virus with many more questions than answers. But there have been some recent studies. So what are those studies telling us about long-COVID? Are they clearing up the picture at all?


Michael Osterholm: [00:38:38] Chris, as you so well know, we've covered long-COVID in a number of previous episodes. And each time I hope that by the next time we cover it that we'll have more and better information for our listeners. Unfortunately, that never seems to be the case. As you mentioned in your question, there have been some recent studies that have added a few new pieces to the long-COVID puzzle, but the overall picture is still very unclear. Let's start by discussing a study published a few weeks ago in "The Lancet." The study followed over 76,000 participants from March 2020 through August 2021. Participants who tested positive for COVID-19 were matched to controls by age, gender and time. Both groups were repeatedly assessed for 23 symptoms associated with long-COVID over time. The study found that about 21% of the COVID-19 patients had symptoms of long-COVID 3 to 5 months out after their infection. This compared with just 9% of the controls during the same time period. So 21% versus 9%. It's not surprising that we would see some controls with long-COVID symptoms, since many of these symptoms, like general tiredness or muscle pain, are very nonspecific. Accounting for the prevalence of symptoms in their control group, the researchers concluded that about 13% of COVID patients had symptoms up to 3 to 5 months after their acute infection that could be attributed specifically to long-COVID. Now, there are a few limitations to this study, one being the the study was conducted entirely pre-Omicron. If the study were conducted today, looking at data in 2022, it is possible we would see different results. The study did not ask participants about neurologic symptoms, including brain fog, which has been a commonly reported symptom in other studies. The study also looked only at data from patients in the Netherlands. The sample is not reflective of the global population. Still, despite these limitations, this study offers a lot of insight as to what percentage of our population experienced long-COIVD with previous strains of the virus. So what are we seeing with Omicron? Early reports suggest that a lower percentage of Omicron patients are experiencing long-COVID compared to previous variants. The UK data published in June found rates of long-COVID were 24 to 50% lower in Omicron patients compared to Delta. This is really promising news, but I want to add some context to this. Let's say that in a hypothetical community, long-COVID occurred in about 10% of people who were infected with the Delta variant, but only 5% of people were infected with the Omicron variant. But since Omicron is much more transmissible, remember that four times as many people in that community might have been infected with Omicron than they were with Delta. This means that we would have twice as many people experiencing long-COVID as a result of the Omicron infection than a Delta infection. I raised this very same concern in December 2021 about hospital capacity during the Omicron surge. Many were celebrating the fact that we saw a smaller number of patients experience severe disease without considering that, because there were so many more cases occurring that hospitals were struggling just as much, if not more, with Omicron than any other wave that they had seen. So just because the rate of long COVID in Omicron patients is lower does not mean that the absolute number is lower. I also want to touch briefly on a piece that was published earlier this week in "The Atlantic" titled "It's Not Just Long COVID" by my friends and colleagues Hank Belfour and William Hoffman from the University of Minnesota. The authors emphasize a very important point that often gets left out of the discussion of Long-COVID. Sars-CoV-2 is not the only virus that causes this post illness syndrome. Many infectious diseases have similar post acute infection syndromes. Infections such as Lyme disease and infectious mononucleosis caused by the Epstein-Barr virus can also cause similar chronic symptoms in a small percentage of patients. Ebola virus disease can cause long term eye problem, and polio, which we will discuss later in this episode, results in post-polio syndrome for about 25 to 40% of the patients. Unfortunately, we don't know a lot about most of these post acute infection syndromes. A study published a few months ago in "Nature," which we will link to in the episode description, highlights a few of the leading hypotheses of the mechanisms of these conditions. But there is still a lot more that we don't know about the subject than we do know. The review also emphasizes one important point, these syndromes are difficult to study. There are a lot of reasons for it. One is the post acute infection syndromes are difficult to define. We have discussed this in previous episodes about Long-COVID. A lot of the symptoms for most of these syndromes are nonspecific and subjective, like fatigue and brain fog. Two study participants could be experienced in the exact same levels of exhaustion or memory loss. And despite the researchers best efforts to clarify these terms, they may still have different answers to the questions. Are you experiencing fatigue? Are you experiencing brain fog? These symptoms may also be diagnosed as something else and then overlooked as opposed to acute infection syndrome. The review mentions Myalgic Encephalomyelitis or what's known as ME/CFS, which is thought to be triggered by an infection in up to 75% of patients. But some studies may view that as a separate diagnosis and therefore not mention those patients as having a post infection syndrome. And it's not just ME/CFS. Infections, including COVID-19, are heavily linked to autonomic nervous system conditions like POTS. But some studies may not consider these patients as having long COVID since they have another diagnosis, even though COVID or a different infection likely played a role in the developing the condition. All of these factors also make it difficult to compare results from one study to another, which makes it difficult for reviews on this topic to come to any clear conclusions. I think it's important that we recognize the similarities between long-COVID and these other syndromes. Not to say it isn't important because it happens with lots of other diseases too. In fact, that is all the more reason why it is very important. Patients suffering from these symptoms deserve answers, whether their symptoms were triggered by COVID or another infection. Finally, I want to discuss a study released this past week which looked at blood abnormalities in people with Long-COVID by comparing them to controls who had fully recovered from their COVID infections. There are two major findings from this study that I want to briefly discuss. The first is that cortisol levels of people with long-COVID were about half of those of people who did not have long-COVID. This makes sense considering that some common long-COVID symptoms like muscle weakness and fatigue are also symptoms of low cortisol levels. The study participants had normal levels of the hormone that controls cortisol production, so the cause of their low cortisol is still unclear. It's also unclear if using steroids, which are often used to treat low cortisol, would be effective in treating long-COVID symptoms. But early research suggests that that does not offer patients much relief. The other finding of the study that I want to touch on is that about 20 to 30% of the long-COVID patients had what has been described as exhausted T cells a year after their COVID infection. The T cell response was consistent with Epstein-Barr virus reactivation, though researchers believe that other pathogens, such as other herpes viruses, could also be involved. Though the study had some limitations, including having a sample size only 99 long-COVID patients, this is a great starting point for future research on causes and potential treatments for long-COVID. We cannot expect a single study to tell us everything about the cause and cure for a condition as complex as long-COVID. So we need to recognize the importance of these findings, even though they don't give us any definitive answers. The bottom line is that there is still so much that we don't know about long-COVID. We have a long road ahead of ourselves in finding these answers. I hope that by the next time we cover this topic, we have at least a few more pieces put together in this long-COVID and other post-acute infection syndrome puzzle. For now, I want to reiterate to our listeners who are struggling with long-COVID and any post acute infection syndrome that we hear you. We recognize what you're going through. We see you. And we will continue to advocate for more research to be done on this issue. You deserve more answers.


Chris Dall: [00:47:31] Now on to the monkeypox outbreak, which has now surpassed 35,000 cases globally. Last week, the Biden administration and the FDA announced a plan to begin allowing intradermal injections of the JYNNEOS vaccine, which will stretch the limited supply of that vaccine in the US. Mike, what do you make of this strategy?


Michael Osterholm: [00:47:50] As you mentioned, Chris, there are now over 35,000 global cases of monkeypox in the current outbreak, with over 12,000 of which have been in the US. Vaccine distribution continues to be a major challenge and I fear the steps taken last week by public health officials may only make matters worse, not better. The FDA issued an emergency use authorization last Tuesday, August 9th, that allows providers to administer the JYNNEOS vaccine intradermally instead of intramuscularly. Intradermal administration requires a much smaller dose than intramuscular administration, so it is expected that this approach will greatly increase the number of people who will be able to be vaccinated with the limited supply. Now, let me just first add before I even discuss how well that vaccine may work under ideal conditions in that setting, with the idea that it is very difficult to actually administer through an intradermal route any vaccine. And most health care workers are not trained in this regard. Let me just as a background remind everyone, there really are four ways to deliver a antigen or a vaccine, a antibiotic, a drug using a needle. There, one is it can be intramuscular deep into the muscle. Two, it can be subcutaneous meaning in the fat layer between the skin, the derma and the muscle. Then there is IV, of course, which is directly into the to the vein, and then there is intradermal, which is just at that very top layer of the skin you have in such a way that you get to these immune cells of that layer. If you go a little too deep, you get into the subcutaneous. If you get too far up, you actually have leakage of the vaccine out of the actual injection site. So this is not simple. This is tough. And again, I just talked about all the challenges that public health and the medical community has today with the vaccination programs. And now we're adding in this challenging intradermal approach. So I think that this is an area that we we really haven't looked at. And when I hear administration officials say that this is a game changer, it may be in theory, but I think in practice we got a hell of a problem on our hands. In our editorial in "Science" several weeks ago, Bruce Gellin and I suggested we explore this approach of intradermal use. Unfortunately, many of embrace the idea before we gotten a chance to fully explore the data which are very limited and how effective this whole approach will be. Many have criticized this approach due to lack of safety and efficacy data, including the vaccine manufacturer Bavarian Nordic. In fact, earlier this week, the Washington Post did a story detailing the criticism that has come forward about trying to move this intradermal program forward in the manner in which it's being done. Now the federal government has distributed about 600,000 doses of the JYNNEOS vaccine so far and will be distributing 441,000 remaining doses in the coming weeks. With this new dose sparing approach as they project, those 441,000 doses are now almost 2 million doses. While this does allow us to vaccinate the 1.7 million men who have sex with men that are at most at risk for contracting monkeypox in a much shorter time period, it means very little if we can't even guarantee that these vaccines are effective with this intradermal approach. In addition to my concerns about embracing this new approach, I'm also concerned about how these doses are being allocated. In Washington, D.C., health officials announced several days ago that they have expanded eligibility for monkeypox vaccine to include anyone with multiple partners in a short period of time, not just men who have sex with men. While this may seem like a good attempt to reduce stigma and allow a greater portion of the population to be protected, my fear is that it is ultimately going to make vaccine harder to access for the groups that need it. Most men who have sex with multiple male partners in a short period of time. DC Health officials cited a drop in demand for the vaccine as part of their reasoning in making this decision, along with concerns that individuals may not be choosing to get vaccinated because they don't want to answer questions about their sexual orientation. We need to advocate for and work with leaders in the LGBT community to ensure that all those at risk are choosing to be vaccinated and that they continue to be prioritized in the vaccine distribution efforts before we expand eligibility to most of the population. Also, we're seeing racial equity issues with the vaccine distribution. For example, in North Carolina, black people make up 21% of the population, but 70% of the diagnosed monkeypox cases. Yet they've only received 22% of the state's monkeypox vaccine doses to date. Similar patterns are emerging in other states that have released data on this. It's crucial that we advocate for racial equity in our vaccine distribution or else we can expect to see the disparity in case numbers get even worse. One last comment I want to make about monkeypox. As you know, over the course of the past several episodes, I've commented about how do we actually do risk communication in this situation such that it does not stigmatize men who have sex with men, but surely details specifically who's at risk, why they're at risk, and what that means to try to protect them. And this past week, there have been two really very, very thoughtful and I think very enlightening pieces that have been written about this. One is from Professor James Downs, who is at the Gettysburg College. And Professor Downs is one of the most articulate and thoughtful voices, both during the COVID pandemic, but also now with monkeypox an acknowledged gay individual who speaks with great authority and thoughtfulness. And his article, "Asking Gay Men to be Careful Isn't Homophobia" published in "The Atlantic" this past week and the second article from "BuzzFeed News" entitled "Let's Be Clear: The Monkeypox Outbreak Is Being Driven Mostly by Sex." Also, again, is a very thoughtful approach to how do we deal with not stigmatizing a population, but at the same time being very targeted, very open and willing to communicate very specific information that can, in fact, help us minimize the risk of this virus transmission. We have provided links for both of these articles on the podcast website and I urge you to consider reading them. Expect that the monkeypox situation will continue to worsen over the days ahead. And at this point, of course, the good news remains that there have been very, very few deaths around the world associated with this. But the bad news is that it's spreading. It's a very painful, really a truly, very difficult illness to have. And so we have our hands full in trying to address it at this time.


Chris Dall: [00:55:03] That brings us to our COVID query segment, which this week is about another infectious disease and one that I think most Americans thought we dealt with long ago, polio. Today's question comes from Albert, who asked if you could comment on a CIDRAP news article from last week about the detection of polio in wastewater samples in New York City. Mike, what should our listeners, especially those who live in the greater New York City area, know about this?


Michael Osterholm: [00:55:30] Chris, I think the overarching theme here is that there is no rest for the weary in public health. Just because COVID and monkeypox are taking center stage doesn't mean we can stop working in other areas with public health significance. That's certainly the case with polio. In mid-July, the New York State Health Department reported a case of paralytic polio in an unvaccinated young adult in Rockland County, just north of New York City. Since then, the Health Department has detected polio virus in wastewater in Rockland County, neighboring Orange County, and in New York City. What this tells us is that polio is being transmitted in these communities and is going relatively undetected. It seems unusual that a disease of such public health significance could be transmitted in a community without significant hospitalizations or deaths. However, it's important to know that most cases of poliomyelitis are either asymptomatic or appear similar to influenza, meaning few people are likely to be tested for the infection. Approximately 1 to 2% of polio virus cases will result in severe disease, including paralysis. However, longer term, we have a more concerning picture. Post-polio syndrome, one of the most acute infection syndromes I discussed earlier in this episode, occurs anywhere from 15 to 40 years after initial infection and affects 25 to 40% of polio survivors. Symptoms of post-polio syndrome include muscle weakness, fatigue and joint pain. So even while we may not see a considerable number of severe polio cases right now in the coming decades, people with undetected infections may just begin to show symptoms. What is most concerning here is that two of these counties in New York have very low vaccination rates for polio. While the national average for children fully vaccinated for polio is about 93%, Rockland and Orange counties have rates just below 60%. Specific zip codes in those counties have rates closer to 30%. We don't have a cure for polio or a way to reverse paralysis. Our best option is to prevent it using vaccines. Globally, we have two primary types of polio vaccines. One is an inactivated or killed version of the polio virus that is injected, and another that is a mixture of multiple weakened strains of polio viruses giving as an oral dose. The US has exclusively used the inactivated injectable version of this vaccine since the year 2000. Other parts of the world use the weakened oral version of the vaccine for a few reasons. One is that it's considerably cheaper, both the product itself, as well as the lack of syringes and other tools needed alongside the vaccine. Another is that any trained volunteer can administer the oral vaccine while a licensed health provider is required to perform the injection. Oral polio vaccines have greatly expanded access to immune protection around the world, but also come with more risks. Because the virus is not inactivated, recently immunized children may pass along weakened strains of the virus in their waste. In areas without robust sanitation and hygiene measures, some people in the community can become infected with the virus, and over time it can become strong enough to start causing illness, even paralysis. This is what we know as vaccine-derived polio, and it's what has resulted in the most recent case in New York. So Albert and all the other listeners in the New York metro area, the takeaway is really important for everyone of all ages to have received the full series of your polio vaccination. For those concerned about getting vaccine-derived in the United States from your immunization, there is no need to worry as we exclusively use the inactivated form here. My heart goes out to the parents right now with infants who are too young to be fully vaccinated. I hope you're able to be as up to date with your vaccine schedule as possible and make sure you have an appointment as soon as your little one is eligible. If you're older than a younger child and not vaccinated, it's is never too late to get your first dose of polio vaccine.


Chris Dall: [00:59:46] Mike, I understand we have a beautiful place to mission this week from a place that's near and dear to your heart.


Michael Osterholm: [00:59:53] Well, Chris is not just near and dear to my heart, but actually one of two submitters on this particular beautiful place is also very near and dear to all of us. But before I highlight the beautiful place submission, let me just give you some background. I think most of you all know if you're in a routine listening to this podcast, I'm from Iowa. I'm very proud of that. And one of the great things that happens in Iowa is what we call RAGBRAI. RAGBRAI is an acronym and registered trademark for the Register's annual Great Bicycle Ride Across Iowa. Of course, the Register being the famous Des Moines Register newspaper, this is a non competitive bicycle ride organized by the Des Moines Register that goes from one end of the state, the west to the east, and it draws recreational riders from across the United States and many foreign countries. First held in 1973, RAGBRAI is the largest bike touring event in the world. Riders begin at a community in Iowa's western border and ride to the community on the eastern border, stopping in towns across the state. The ride is one week long ending on the last Saturday of July of each year after beginning on the previous Sunday. The earliest possible starting dates on July 19th and the latest is July 25th. RAGBRAI holds an annual lottery that selects about 8,500 weeklong riders. The lottery is held beginning November 15th of the previous year and until April 1st with random computer selections determining the participants. Additionally, passes on a first come first serve basis are made available for about 1,500 day riders. The average distance for a RAGBRAI ride is about 467 miles. Eight host communities are selected each year, one each from the beginning and end points, and then the other six serving as overnight stops from Sunday through Friday. I'm happy to say that my home community of Waukon, Iowa, which I'm very proud to be a son of Waukon, has actually served as one of these host cities. And then this past year's RAGBRAI actually was a point where riders rode through to get to Lancing, Iowa on the Mississippi River. One of the great moments in the RAGBRAI ride is getting a picture of your bike tire landing in the Mississippi River in whatever host city is on the river. Well, we actually had two submissions this past week about RAGBRAI. The first one is from Laura who wrote, "Each year except for 2020 folks bicycle across the state of Iowa during the last week in July as part of RAGBRAI. But even if one doesn't do the larger ride, training on the nature trail scattered across Iowa is a beauty in itself. This summer, I've taken pictures of some of the succession of wildflowers along the edge of the Cedar Valley Nature Trail and the Herbert Hoover Trail." And she provided us with these beautiful pictures, which will be on our website. But then in addition, one of our own, one of CIDRAP's favorite people, also participated in RAGBRAI. And this was Meredith Arpey, who has given us permission to show her pictures. And she actually notes that she says, "Mike, I understand we have a beautiful place submission this week from a place that's near and dear to your heart. And she says a wise man once said, All roads lead to Waukon." Well, she then went on to say, "After reading Laura's beautiful piece, I cannot help but reminisce as well. I too, joined the more than 20,000 other people from around the world who think riding their bike for 462 miles across Iowa sounds like a fun way to spend seven days. And I have had the time of my life." So also we have pictures from Meredith, including pictures of my hometown of Waukon. So thank you very, very much for the opportunity to share the RAGBRAI experience if you don't know about it. Learn more. You may find that this is the calling that you've all had in your life to do something unusual and remarkable. I can tell you personally that the kind of emotional support, physical support, the connection between the communities and the riders is just simply remarkable. It is an experience that everyone will tell you is a once in a lifetime effort. So thank you very much to both of you for your beautiful places. And I hope you all enjoy the pictures that are on the website.


Chris Dall: [01:04:17] Just a reminder to our listeners that if you want to tell us about the beautiful place that has helped get you through the pandemic or share a celebration of life for a loved one friend, neighbor or coworker who died during the pandemic, please email us at Mike, what are your take home messages for today?


Michael Osterholm: [01:04:37] Well, Chris, as you know, I always try to distill down each podcast into three messages that I think really highlight what we tried to share with you today. The first one is we're on the high plane plateau of COVID in the United States. We're not seeing the big mountain peaks and the valleys anymore. It's on this very high level plateau where we are now seeing the number of deaths in this country making COVID the number four cause of death. And yet it happens day after day after day after day. And we're trying to understand what this means. How do we adjust to this? How do we live our lives? And as I pointed out in the podcast, it's a challenge. But in fact, we have to understand where we're at. We're on the high plane plateau. The second point is we don't know what is next, but we do know that get as many doses of this vaccine as you possibly can, because even with waning immunity over time, it still can provide you with increased protection against serious illness, hospitalizations and deaths. I can't say this with any more resolve to try to respond to this virus, get vaccinated. And then finally, I think that having the discussion today of COVID, monkeypox, polio, all these things really illustrates the fact that we have to expect the unexpected. Now, unexpected doesn't always have to be quite as big a surprise as one might think. If we use our creative imagination, we could have and should have seen that, in fact, monkeypox was going to become an increasingly major problem in Central Africa, as the number of people born who were not vaccinated against smallpox increased year after year after year over the last 40 years. We shouldn't be surprised by seeing the challenge of converting vaccines into vaccinations in polio as well as the other diseases. So we need to prepare for the unexpected, but let's prepare with as much creative imagination as we can so we don't get caught surprised. Those are the three, I think, important take home message of the day.


Chris Dall: [01:06:47] And do you have a closing song for us today?


Michael Osterholm: [01:06:50] Thanks. I do. But before I do that, I want to share an experience I had this week, which I, I think is illustrative of why I do this little thing at the end here. I'm a scientist. I'm an epidemiologist. And people wonder what the devil you doing out there talking about this other stuff? And I actually received an email this week from someone. It was written in in I would have to say, a constructive tone. It was surely not disrespectful, but it was somebody from the science world who suggested that I was, in a sense, wasting part of his time by listening to the podcast. And he did compliment parts of it, but he didn't understand why we had to do this kind of touchy feely stuff. I think his exact words were, Why do you have to appeal to the emotional side of all the issues? And then not but a few hours later I got another email and it was from someone who had never written before, and they just wanted to tell me that they had come to a place in their life with COVID, whereby having listened to the podcast and having been challenged to do one act of kindness every day, something they had never thought about before, let alone ever tried to do, how much difference that made in their lives in trying to deal with COVID. And in itself, it was, as they described it, in the infectiousness of kindness. And I thought to myself, now, if I listen to these two, you know what? What do I do here? You know, how do I meet the needs of those who don't want a moment of any of these other discussions? Just stick with the facts, man. And those who actually do find, as we at CIDRAP do, and I do personally for certain how to get through this pandemic is in part about things like kindness and understanding and empathy. And I have decided that for those that find that part of the podcast difficult, I'm sorry, but, you know, it's me. This is. This is me. I'm going to do it. And if that means you don't listen to the podcast, I'm sorry. I understand. I wish you would reconsider. But for those of you that can find the strength and the beauty of the kindness, of the outreach moments, they will never stop. I hope you know that. You know, it's just who we are, who I am. And it will continue. And today's song is in keeping with that very spirit. This is one that I've actually used before in "Episode 98: A Stay Tuned Moment" back in April 7th. But after the discussion today that I just had with you, in looking over all the possible songs and poems and lyrics, I came back to this one time and time again. This is the song "Somewhere" referred to as "Somewhere There's a Place Out There for Us," or simply "There's a Place for Us" from the 1957 Broadway musical "West Side Story" that was made into films in 1961 and 2021. I think all of you know, the music is composed by Leonard Bernstein with lyrics by Stephen Sondheim and takes a phrase from the slow movement of Beethoven's "Emperor Piano Concerto," which forms the start of the melody. And it also has a longer phrase from the main theme of Tchaikovsky's "Swan Lake." It's a song that when you listen carefully to the words, I think it tells the story of our moment. It tells the story of who we are and what we are. So today, "Somewhere," Leonard Bernstein. Stephen Sondheim. "There's a place for us. Somewhere, a place for us. Peace and quiet and open air. Wait for us somewhere. There's a time for us. Someday, a time for us. Time together with time to spare. Time to learn. Time to care. Someday, somewhere. We'll find a new way of living. We'll find a way of forgiving. Somewhere. Somewhere. There's a place for us. A time and a place for us. Hold my hand and we're halfway there. Hold my hand and I'll take you there. Somehow. Someday. Somewhere." Leonard Bernstein and Stephen Sondheim. And I believe those words so very, very much. We just got to keep holding our hands. We're going to get through this. And God knows which 210 mile an hour ball is going to come at us next. But we will. Thank you so much again for being with us. Thank you for all of you who provide us with such wonderful feedback, constructive feedback. Thank you for for your support and thank you for sharing your kindness. We must not ever forget how important that is for all of us and frankly, how wonderful the surprise look is on people who are of recipient of that kindness. Now is the time to do that. Be safe. Don't give up life. We don't have to. We just have to figure out how can we take those moments when we might be at risk and what we can do to protect ourselves? The vaccines and the respirators right now are key. Most of all, we are going to get through this. Just take our hand somewhere. Somehow we'll get through. So thank you so very, very much. Thanks to podcast crew again, this could never happen this podcast without the incredible people who work on it at CIDRAP. I thank you personally for all you do. Chris, thank you and have a great week. We'll see you in two weeks. And be safe. Be kind. Thank you.


Chris Dall: [01:12:48] Thanks for listening to this week's episode of the Osterholm Update. If you're enjoying the podcast, please subscribe, rate, and review, and be sure to keep up with the latest COVID-19 news by visiting our website This podcast is supported in part by you, our listeners. If you would like to donate, please go to The Osterholm Update is produced by Cory Anderson, Meredith Arpey, Elise Holmes, Sydney Redepenning, and Angela Ulrich.