September 1, 2022

In "A Reason for Hope," Dr. Osterholm and Chris Dall discuss the state of the pandemic in the U.S. and around the world, the trajectory of the monkeypox outbreak, and why we should remain hopeful for the future, even in the face of COVID.

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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 we near the end of our third COVID summer, it's time once again to take stock of where we are in this pandemic and where we might be going. While cases have been slightly declining here in the United States and elsewhere over the last two weeks, we remain on the high plane plateau that Dr. Osterholm talked about in our last episode. And with many K-12 and college students either back in school or headed back, we could see case numbers start to rise again. At the same time, updated COVID-19 booster shots could be ready to go as soon as next week. But will there be enough people interested in getting those shots to make a difference? And will there be enough money to mount the type of vaccine outreach efforts that are needed to increase booster uptake? These are some of the issues we'll be discussing on this September 1st episode of the podcast. We'll also talk about the latest data on Paxlovid, give you an update on the monkeypox outbreak, and answer a COVID query that asks some really difficult questions about the future of the COVID-19 pandemic. And we'll share a beautiful place submission from one of our listeners. But before we get started, as always, we'll begin with Dr. Osterholm's opening comments and dedication.


Michael Osterholm: [00:01:50] Thanks, Chris. And welcome back to all of you to another episode of the podcast update. To all of you, part of the podcast family, I welcome you back. I also want to thank you very much for the many emails and letters we received in the past two weeks since our last podcast recording with great questions, wonderful ideas, and most of all, just really very thoughtful support for what we're doing. For those of you who may be new to the podcast, we welcome you and we hope that we're able to provide you with the kind of information that you find useful, both from a professional and even a personal standpoint. Today, we will share with you that we still are in the midst of what I would consider a global pandemic of COVID-19. Many people want to move on beyond it. I know that we don't have distinct definitions that will be a very lights on, lights off kind of decision. But I think what we share with you today, we are in this stage of the pandemic where in some ways we have many more questions than we had even 6 to 12 months ago. What does this mean? Well, what constitutes the pandemic and what's the impact? Today we will really address the issue of the biology of the virus. We'll address the policies and we'll also address a sense of perspective. Where are we? What's happening? What do we need to do to protect our own lives, that of our loved ones? And can we go back into the everyday world that we once knew and loved back in 2019? We'll try to share a sense of all of that with you today. A lot to cover. We'll do our best. Before we begin, though, as we routinely do we have a dedication and throughout the course of this podcast, I can always dedicate it to those of us who have suffered immeasurably because of the pandemic, lost loved ones, and how we remember those loved ones, how it's impacted our own lives. Again, I regret that I have to say this and I can say it with some certainty, I actually know more people today in my life family, friends and colleagues who have COVID than at any other time in the pandemic. This has been almost the eighth consecutive week that I've said this, and each week I see only more and more. A number of these cases were part of events where a large number of people got infected. And today, we'll try to put those case numbers into perspective. What do they mean? Is a case really as important today as it was two years ago in terms of what their serious outcome might be like? So we'll cover that today. But one of the things in terms of dedication, we try to think about those areas of the world, those individuals who are suffering or who surely are their lives compromised because of this pandemic. One of the areas that I think that we have forgotten, which is a terribly unfortunate thing for us to do, is the resonances of some of the diseases that we've had in recent years and what they've done to society and how those who have suffered from those diseases are doing today. And I want to take a step back to a time when we were at CIDRAP, very involved with the discussion and the work on Zika, that mosquito borne disease that all ended up turning out to be also sexually transmitted. It's one that had been seen for many decades in parts of the world where there seemed to be little or any human illness associated with the infection. And then, of course, we saw in 2015 and 16 that change where we not only saw infections in individuals, often with mild or asymptomatic infections, but the consequences were dramatic. One of the real challenges we experienced with Zika was women who were pregnant, who were infected during that time with the Zika virus and what that meant for their unborn child. If we take a step back and we all know the case reporting for any disease, particularly in many parts of the world, is quite incomplete. But in 2015 and 16, we saw the case numbers of reported cases of Zika go from 78,850 in the Americas to in 2016, 651,000, a dramatic increase in cases. And during this time, we saw that 5 to 14% of pregnant women infected with Zika gave birth to a child with congenital Zika syndrome. 4 to 6% of these births were children with microcephaly, a very distinct and very apparent result of the infection with Zika virus. Today, these children are now approaching 6 to 7 years of age. And at this time, we hear very little about what's being done to provide the kind of medical and social support to these families with these children, particularly with microcephaly. And this is just one example of what's happening around the world. We'll talk more about that in today's podcast of the forgotten, the people who because another crisis came along, their crisis no longer was a crisis, nor was it worthy of the kind of public health action that had other crisis is not occurred, these would still be front and center. So today I dedicate this podcast, a podcast on COVID to the families, and particularly to the children who have suffered immeasurably from the large outbreak of Zika that we saw in the Western Hemisphere in 2015 and 16. Cases still continue. We still have confirmed cases in the Americas, not nearly as many as we saw in 2015 and 16. But I can tell you with certainty it is going to happen again. We are going to see a resurgence of Zika at some point. And we just have to be reminded that there are a number of infectious diseases that are of real importance that we can never neglect, and we do. So this dedication to those families suffering and particularly the children. And for those of you who are part of the podcast family, you know what to expect next, we will have a brief discussion of the light and what's happening here in Minneapolis, Saint Paul. And I have a surprise for you. Two weeks from now, when the podcast is recorded, we will be doing something different and you can only imagine or anticipate now what that might be. It'll still involve light, but think about what we're going to do. I just want to report that today in Minneapolis, Saint Paul sunrise is at 6:35, sunset at 7:49, 13 hours and 14 minutes of sunlight, grant you this is not twilight, so forth, but it's real daylight. We're losing about 3 minutes a day now in the sunlight as we get closer and closer to the September 21st onset of fall. But it's still a lot better at 13 hours and 14 minutes. Well, then it will be on December 21st at 8 hours and 46 minutes. So from a glass half empty glass half full perspective, my glass is still farther full than half. And I hope that all of yours are, too. So we love that light. And all I can say is, for those of you in the southern hemisphere, you're recognizing those days are getting longer and longer and longer. And so here's light to you.


Chris Dall: [00:09:14] Mike, let's start where we normally do with the international situation. The latest update from the W.H.O. shows that global cases and deaths continue to decline, with some Asian countries continuing to be hotspots. Also, there is an interesting report this week from the European Center for Disease Prevention and Control that laid out some scenarios for how the COVID-19 pandemic could play out over the next decade. What did you make of that report?


Michael Osterholm: [00:09:39] Well, first of all, Chris, let me just start with a quick summary of where we're at right now in the BA.4 and BA.5 chapter of the pandemic. Remember, our first real glimpse at these sub-variants came just this past April when they displaced BA.2 in South Africa and drove up case numbers there. Not much longer after that. We saw similar situations play out in other locations, particularly with BA.5. Europe was hit hard in May and June. Countries like Australia, New Zealand and the US saw it take over in July and even more recently we've seen it drive up activity in places like Japan and South Korea. So clearly most of the world has become well acquainted with BA.5 through these past several months and overall we've seen it move global cases from less than 500,000 a day in early June to more than a million a day by late July. Remember, we all are aware of the fact that case reporting of itself is a very incomplete measure of what's happening in our communities. At the same time, though, we went from just under 1,300 deaths a day, the lowest reported since the start of the pandemic to more than 2,500 deaths a day. Regardless, most regions now seem to be past this most recent peak. So where does this leave us? Well, with cases we're reporting an average of 678,000 cases a day globally as of this past Tuesday. That compares to more than 800,000 a week ago and again, more than a million a day in early August. Now, as all you know, I think these cases I said a moment ago represent merely a fraction of the true total and despite the continued dismantling of systems for testing and reporting, I remember a time when for almost the first two years of this pandemic, the very same levels of reporting now would be considered alarmingly high. So this virus doesn't seem to be having any problems finding hosts. It also reflects this issue I've talked about time and time again of shifting baselines. What at one time seemed like a crisis today seems like, oh, not so bad. However, that being said, case numbers do appear to be dropping right now. In fact, they're down almost 40% from the peak levels reported in late July. But unfortunately, progress in terms of the death toll have up to this point been much more slow going. Since the peak of just over 2,500 deaths was reached in mid-August, it's dropped to around 2,300, so roughly a 10% decline. To frame it in another way, we're still seeing almost 1,000 more people die from COVID globally each day than we did in early June. Does that not sound like shifting baselines? Now, I know I've mentioned it a few times, including during our last episode, but if you look at the estimated annual death toll from seasonal influenza and turn it into a daily average, you might see anywhere from 800 to 1,780 flu deaths each day, depending, of course, on the severity of that particular flu season. Again, right now, we're at around 2,300 deaths a day with COVID. So that compares to 800 to 1,780 in severe flu years. Now, to give some additional perspective to this, if you look at the average daily deaths from COVID as of August 29th at 2,281. If we saw this number remain the same for an entire year, we would expect to see about 832,600 annual deaths. Let me repeat that 832,600 annual deaths globally. For comparison, here are the deaths from the big three: Malaria 627,000 estimated deaths in 2020, again compared to COVID of 832,000, HIV/AIDS 650,000 estimated deaths from AIDS related illness in 2021, and tuberculosis, the one big one that is still exceeding the activity and the deaths that we might see with COVID is at 1.5 million estimated deaths in 2020. Otherwise in the past 12 months, in other words, August 31st, 2021 to August 29th, 2022. There have been just over 1.95 million COVID deaths reported. That's about 5,343 deaths a day. And in the 12 months prior to that August 30th of 2020 to August 31st of 2021, there were 3.64 million COVID deaths reported, about 9,972 deaths a day. So clearly the death numbers are coming down, but they're still substantially elevated. Now, of course, mortality is just one of the several metrics used to measure the impact an infectious disease like COVID is having. And I think it goes without saying, it's a key consideration. So is this virus claiming as many lives now as it did during the previous points in the pandemic? Fortunately, the answer is no, but as we've talked about many, many times on this podcast. Every one of these deaths is someone's father, mother, brother or sister, grandson, granddaughter, niece or nephew, friend, colleague, someone you care about. So as we talk about these numbers today, please do not let us become comfortable with the fact that they are just numbers. They are not. So as someone who's been on the front line dealing with a lot of different infectious diseases over the course of my 47 year career, I can assure you that what COVID is doing right now, just in terms of mortality, is far from trivial. Even two and a half years into this pandemic, we're seeing this virus emerge as a leading cause of death in many places. For example, as a result of the BA.5 wave in Australia, COVID became the country's number third leading cause of death for this year. At the height of the BA.5 wave in New Zealand, it topped the charts as the number one cause of death. Right now, Japan is reporting an average of 285 COVID deaths a day, the highest it's been since the start of the pandemic. In fact, based on the country's latest average, the virus would rank as the number fourth leading cause of death there. As you know, that also happens to be where it ranks in the US at this time, the number fourth cause of death. And in the UK there have been nearly twice as many COVID deaths this summer as there were last summer. More than 5,700 this summer versus 2,900 last summer. So this isn't done yet. And while I recognize that more and more people want to believe it's a thing of the past, you just can't wish something away like this. Now, that being said, I consider myself a realist. Clearly, there are people who are back to pre-pandemic living, and I'm not sure there's any amount of data or message that would convince them to change their behavior. Of course, at the end of the day, I really hope that we've opted to do is get vaccinated and ultimately manage to avoid any serious outcomes. We will talk about that throughout this podcast. Yes, we understand the reality of trying to live life. We all want to, but how can we with what's happening right now, live it as safely as possible? The reality is that none of us, whether it's the most COVID cautious individuals or the greatest of skeptics, are completely safeguarded from the impact that this virus can have. Now, clearly, there are steps we can take to help reduce this direct impact on any one of us. And those are important, but indirect impacts also need to be taken into consideration. A critical piece of that relates to what's happening right now in China. By now, any regular listen to this podcast knows I've been keeping a very close eye on China and the endless game of Whack-A-Mole they've been playing with the virus in pursuit of zero-COVID. It's an approach that I still am convinced is unsustainable and unwise. And the limited progress that they've made when it comes to vaccinating their elderly population, even after months of strict lockdowns in Shanghai, has really left me uncertain as to what their endgame is. As a reminder, this is a country where, according to the latest reports, nearly half of all Chinese residents 80 years of age and older still haven't been fully vaccinated. So with that in mind, it's now being reported that in just the last two weeks, all 31 Chinese provinces have documented at least one locally transmitted case of COVID. This is the first time that this has happened in the pandemic. In fact, it's the broadest distribution of cases reported by the country to date. Of course, the total number of cases seem tiny for a country with 1.4 billion residents. For example, Monday's report noted just over 1,700 cases, and that number is actually down from recent totals of more than 3,000 cases a day when outbreaks in several tourist areas were ongoing. But with Monday's total in of itself, spanning 17 different provinces, two municipalities, and four autonomous regions, we've seen a swath of restrictions implemented there, unlike any time in the pandemic. For example, Shenzhen, which is a city in southern China, announced that they'd be locking down several districts until at least the end of the week and well into next week. Notably, the districts included in these lockdowns are home to the world's largest electronic hub, with facilities that make everything from microchips to parts for cell phones. And that's just one example. So it's far from business as usual. And sure, people can pretend that COVID is no longer a threat. But when it comes to global supply chains, as China goes, so goes the world. On that note, Chris, let me just briefly address the recent report published by the European CDC, which you mentioned in your question. Quite honestly, I think it does a really good job of laying out a lot of the uncertainty we're facing even two and one half years into the pandemic. We have linked this report on the website so any of you that want to go back and read it can go to the podcast website and find it. Now included in the report are a range of potential scenarios and trajectories that we could see with COVID moving forward. And while there are five total scenarios provided in the report, the authors state that each one captures a specific point along an entire continuum of possible outcomes, ranging from less severe to more severe. For the sake of time, I won't go through each proposed scenario and the assumptions that are included, but you can go take a look at the report yourself. I want to share some of the points that really stood out to me. First is the acknowledgment that SARS-CoV-2 is here to stay. Clearly, that's a safe and unfortunately obvious assumption. However, in addition, the report states that the virus will likely represent a long term challenge to public health and to health care systems. Again, a safe assumption, but it's also somewhat daunting to realize that the health systems will ultimately be tasked with allocating finite and often very limited resources to yet another challenge. In some ways, it's our new normal. As we take on things like COVID and monkeypox, while at the same time reinvesting in other critical efforts, including childhood immunizations or influenza, almost akin to juggling 20 things at the same time and having another 50 added. And from time to time it feels like one hand is tied behind your back. Or what you're juggling are now live active chainsaws. So it's a new era for public health and infectious diseases. And what do we have to keep in mind when it comes to COVID? Well, as the report mentions, there's a lot of moving parts to consider. Of course, there's the virus which continues to transmit and ultimately replicate and ultimately continues to evolve. And unfortunately, we really don't know exactly what's coming down the pike. What remaining capacity do we in public health have that we can bring to this situation? What's the likelihood of encountering a version of SARS-CoV-2 that's highly infectious and much more severe? Remember, SARs has actually had a case fatality rate of about 10%. MERs had a case fatality rate of almost 36%. Now, those two coronaviruses, fortunately, were not that infectious. Well, on the other hand, SARS-CoV-2, which is highly infectious, has a case fatality rate of less than 1%. Imagine if we had a little bit of SARS or MERS mixed in with a little bit of SARS-CoV-2. What would that mean? A highly pathogenic and a highly transmissible virus could be such a game changer that no one would say that this particular experience we've just had is anywhere close to what could happen. So we have to keep that in mind. But on top of that, we have to consider the host. And of course, a big piece of that is us as humans. Sure, we're at a point where most of the world's has had some exposure to the virus, whether it came in the form of vaccination or infection, but how much protection exists? How long does it last? Again, important questions that we're still trying to better understand. Beyond that, there's much, much more. What's our willingness to respond? I think most of us would agree our communities are over with COVID, whether the virus is over with us or not. How many are willing to get new vaccines? What does the health care system look like now? Most people are unaware of the fact that health care systems throughout this country are still stretched to the max at this point, even with just a limited amount of activity that's coming in from COVID compared to the major surges. Some of that is a reflection of the deferred health care that didn't take place during the COVID pandemic that are now manifesting in advanced cancers and other conditions had they been better managed during the pandemic, wouldn't mean hospitalizations are necessary today. So is there adequate support for better vaccines down the road, both in terms of investment, but also public acceptance? How about more antivirals? How about diagnostics? Again, all different variables in a lung calculus equation. And when you change even a single variable, you can get a completely different outcome. So in this ECDC report, we're basically given five example equations or scenarios where the variables are selected for us. In order from less severe to more severe they go as follows, one a diminished threat, two a regular reinfection threat, three long barely manageable winters, four long unmanageable winters, and five a new pandemic. Now, I don't want to be a downer, but after reading through these scenarios, I didn't see any that fit the criteria of a fairy tale ending. No soft landing here. In fact, even the less severe scenario titled a diminished threat, which relies on fairly optimistic assumptions like durable immunity and improved medical interventions, describes the looming persistent threat of a new variant that could change everything. And with the four remaining scenarios, there's a laundry list of obstacles we'd be encountering. For the most part, it comes down to the variants that we might see emerge and what immune protection could look like over time. With these, we really have our work cut out for us. But ultimately, I think public health has major work to do regardless of what happens with COVID, how can we regain the ground that we have lost in so many different areas during this pandemic? Can we improve disease surveillance? Can we restore public trust? Something that is at an all time low for public health in my 47 year career. And are we taking the steps necessary to support and maintain health care systems and staff? What are we doing to make that work? So in many ways, this is a critical moment. Will we use COVID as a lesson to learn from, or will it be a more permanent fracture that goes unaddressed and means that the next crisis will only be built upon even a more shaky foundation than the one that we found ourselves building our COVID response on?


Chris Dall: [00:25:42] What about the current situation here in the United States? As I mentioned in the introduction, the seven day average of new daily cases continues to decline slightly, but we still remain on that high plane plateau, and we're still seeing more than 450 deaths a day. Do you think we'll start to see an uptick in cases as kids go back to schools that have, for the most part, dropped all mitigation efforts?


Michael Osterholm: [00:26:04] As you recall, Chris, during our last episode, I did describe that we were in a high plane plateau situation here in the US. No longer seen these big mountain peaks or surges of cases with these troughs, these valleys where cases seemed to plummet. Now we have, for the last 8 to 10 weeks, been on this plateau, a plateau that I find terribly unacceptable. But for many, that surely feels better than being at the top of the mountain peak. But we are starting to see some activity decline, but we have to be careful. Notably, hospitalizations are down 10% over the past two weeks, with now under 38,000 people hospitalized with COVID on a given day. The number of COVID patients in ICU is also declining now 8% lower than it was two weeks ago. But the average daily death rate has remained steady, with an average of 470 lives lost every day. And even yesterday, the numbers were up 5% from the previous estimate of daily deaths. As far as what is next during the pandemic, I really don't know. And as I've said many, many, many times, to those of you who are making long term predictions, I don't know what you're basing those on. And I worry that you also inadvertently or intentionally have a bridge to sell at the end of your discussion of what's going to happen. We have not seen a high plane plateau situation like this before. There is no indication what could be coming next. What we do know is that this virus is unpredictable. Vaccine uptake is very low to almost non-existent in some populations, and the general public is clearly unconcerned about what's happening right now. And there are very few mitigation measures in place to prevent transmission. Let me again just acknowledge I understand where the human spirit wants to be right now, but this virus doesn't care about that. And it's not just the public. The government is seeming to move on as well. This Friday, September 2nd, will be the last day to order free COVID tests through the government's program because there's not enough funding for it to continue. And with all these factors taken into account, we are not set up for success moving forward. Just because the majority of this people are done with this virus does not mean the virus is done with us. And as kids go back to school, as they go back to colleges and universities and some companies shift away from remote work, we are going to see, I think, increased number of cases. For example, a recent CNBC article covered the continued disruption that employees at Google have been experiencing. While the company is claiming that there's not a significant increase in COVID in the offices, employees have explained that they have received regular COVID exposure notification since returning to the office. Another CNBC article discussed a recent report that estimates there are 16 million Americans aged 18 to 65 suffering from long COVID and that 2 to 4 million of these people are out of work because of their long COVID. With 10.7 million jobs that are not filled long COVID may account for nearly a third of all unfilled jobs. This is clearly a significant burden to the job market and the economy, and moving on from COVID is not going to change these situations. Let me just provide several perspective points that I think say a lot about where we're at with this pandemic now. I acknowledge that for most people, the risk of serious life threatening illness is relatively low. But let's put that in perspective. We now have a disease that is the fourth leading cause of death in this country, 450 to 500 deaths a day. What is it that makes those people vulnerable to serious illness and dying? Who is it that's ending up in our ICUs? We don't know. Our public health information systems are not providing us the kind of data that says, you know what, for the vast majority of people, we can move on. Yes, you will get sick. Yes, you will report that you feel like you're drinking broken glass for several days. You'll feel like you've been hit by a train. But you are not going to be in a state of serious illness or die. But for those that are, what can we do to target them? What are the underlying risk factors? Is it vaccination or lack thereof? Think about this. Right now we know that having two booster doses or four total doses of vaccine can be a significant protection against serious illness, hospitalizations and deaths. And yet, if you look at those over age 50, only 11% of the US population has received a fourth dose of vaccine. Only 26% of those 65 years of age and older have received a fourth dose of vaccine. We are not protecting the most vulnerable when you look at those numbers. And let me just add a perspective, because I think that it it helps us understand where we've been with this pandemic in the United States and where we're going. If you look at the number of deaths that have occurred and again, I remind you, these are not just numbers. Remember that. And for many of you listening to this podcast, I do not have to remind you, you still see the eyes, you still hear the voices of those you've loved who are no longer here with us. But in 2020, in the United States, 384,536 deaths were reported. That's 384,000. In 2021, we hit a peak at 460,513 deaths. But yet this year, we're on track to have well over 220,000 deaths occur. Think of that. Think of these three years, 384, 460 220,000 deaths in three consecutive years. This problem is still not yet behind us. So one of the things I think we really want to concentrate on in the days ahead is how do we protect this limited number of people who are becoming seriously ill, who are dying from this virus? And I can surely say number one, number two and number three, vaccine, vaccine, vaccine. And using your respiratory protection, that is effective, i.e. an N95, when going into a public place, when you are at risk. And we need to do a better job of telling the public who these people are, not by name, but by category. What are the risk factors you need to think about? And I'm not going to treat an otherwise healthy 18 year old with the same sense of urgency that I would treat a 72 year old who has underlying immune compromised conditions as to what I can do to help them from getting infected, because I think the outcomes will be quite different for both of those. So hopefully this gives us a national perspective and we'll talk more about this in a moment about what COVID has done and hopefully understanding the extent to which this virus has challenged us as a society.


Chris Dall: [00:33:10] And on that note, Mike, we got some new federal data this week that underscores the impact of the COVID-19 pandemic on US life expectancy. What can you tell us about that?


Michael Osterholm: [00:33:22] Well, Chris, for many, many years in my classes that I teach on infectious disease epidemiology, I have included a slide looking at life expectancy during the 20th century, and everyone is automatically drawn to and struck by what happened in 1918, 19 and 20, when the influenza pandemic caused such a major change in life expectancy. If you look at the graph, it went up and up and up until it hit 1918 and boom, it comes down for almost two and a half years. And that type of impact was something that we thought only happened in the old days before we had all these new modern medicines and healthcare in general. But as you just pointed out, a new life expectancy analysis came out this week for the United States. And the findings are eye opening and frankly, very sad. Life expectancy in the US is now the lowest it's been since 1996, with the average American expected to live to be 76 years. This is almost three years lower than the average life expectancy in 2019 prior to the pandemic. Let me repeat that we've lost three years of life expectancy during this pandemic. And last year alone, life expectancy declined from 77 to 76.1 years, even as we thought we were through the major part of the pandemic. And let me just add a footnote here, because many people have suggested this is just a disease, a serious illness, consequence of old age or underlying health conditions. Those are the people who die. Well, to actually alter life expectancy, it means a sizable portion of the deaths have to occur in the middle age or younger age populations. So just because there are more deaths, it doesn't mean life expectancy would change if they're all older people. All people who have these underlying comorbidities at age 82. These data tell us a lot of young people died. From 2019 to 2022, the American Indian and Alaska Native populations were hardest hit, with a 6.6 year decline in life expectancy from 71.8 to 65.2. This is exactly what we saw in 1918 in American Indian and Alaska Native populations. Are there some similarities here? What is it? Is it underlying health conditions, the frequency of diabetes? What? For context, this current life expectancy for American Indian and Alaska Native populations is what the US life expectancy was in 1944, long before we'd say most modern medicine was available. Non-hispanic white life expectancy dropped 2.4 years, with life expectancy for black Americans falling four years and Hispanic populations saw their life expectancies fall 4.2 years. To put these numbers in perspective, changes in life expectancy are typically measured in months, not years. This change is dramatic if you're an epidemiologist, it's just dramatic. It's like driving from basically a flat, flat plane and all of a sudden, for the first time looking up and seeing this incredible mountain range in front of you, it's a dramatic thing. So let me just remind you that right now, we're still sitting with COVID as being the number four leading cause of death in this country. So why does this all matter? Because it does point out the dramatic toll that this virus is still taking. We surely need to focus in on our own perspective of zero COVID deaths. Do I believe we'll achieve it? No. Do I believe we'll achieve zero COVID cases? Absolutely not. But what can we do at this point as a country to prioritize knowing who those 450 people on average per day who are dying in this country, those 38,000 people who are in the hospital. What can we know about them that will allow us to help them not be in that situation? And I think that has to be a key, key focus of where we're going with any of our activities and not try to treat every person in the same way in terms of what their risk perception is. One, they won't believe it. Try to tell a 21 year old right now that they're at risk of dying from COVID. And that's true. They are. But it is a very, very low risk when compared to the risk of their grandfather. So I think, Chris, this study really illustrated the dramatic impact that COVID has taken on our society. It has. And we must never, never forget that.


Chris Dall: [00:38:03] So let's talk about vaccines now, Mike. The FDA yesterday authorized COVID-19 booster shots that target the Omicron BA.4 and BA.5 variants. And the CDC's Advisory Committee on Immunization Practices is meeting today and tomorrow to discuss recommendations for those shots. But those decisions from the FDA and ACIP are not going to be based on clinical trial data or human immune response data because the companies don't have that data yet. Is there any reason to be concerned about that?


Michael Osterholm: [00:38:32] Well, I don't think concerned is the right word. Chris, this is definitely a complex situation. There are a lot of unanswered questions here. So I'm interested in tuning into the discussion with the ACIP this week. There are also a lot of answers needed on what guidelines will accompany these new vaccines. At this point, it appears that there's only going to be a two month waiting period since the last dose. Is that in fact the case? We do know that people will not be able to access these vaccines as part of their initial vaccination series rather than having to use the original vaccine, because the dosage levels are quite different. So there are still a lot of questions here. Will the vaccine be available for children, at what age and so forth? So we've got a lot more to learn yet in the next days ahead before this program goes into full effect, which I assume it will next week. Let me just address the issue of concern. I don't have significant concerns about the safety of these vaccines, since we have a good grasp of the mRNA vaccines as a whole and a good safety profile for the original formulations. These reformulations in some ways are similar to what we would do with influenza vaccines each year, matching the year's vaccine to the expected circulating strain. Well, but I think that this is a challenge to draw a 1 to 1 parallel here. We've had 47 years of experience with influenza vaccines, understanding the human immune response, understanding what mouse studies can show us. We don't have that for SARS-CoV-2. So I'm for one, I'm not completely comfortable with just a 1 to 1 transfer of what happens in flu to what's happening here. I would like to know how well these new vaccines will work. Where I'm having some issues really with this whole approach is the trade off of speed versus known efficacy. It's difficult to promote something to the public when we can't say with much certainty how effective it's going to be compared to the previous vaccines. Rolling out these boosters, when we only have immune response data from mice, could bring out another layer of public mistrust of the vaccine and the overall pandemic response. It would be great if we could state that these vaccines provided higher, longer and or broader protection than the original formulation. And maybe with human trials, we will see this as the case. But at this point, all we can say is that it is likely that these vaccines are not inferior to the original formulation, meaning they're not much or even any better at all. I understand why speed is a factor here. Having a vaccine that's designed to address BA.4 and BA.5. While these are the current prominent strains in a fast closing window, we're constantly in a race against this virus. It's changing faster than we can figure it out, and new variants surely bring us new challenges. We will always find ourselves trying to play catch up with this virus if in fact we're using vaccines that require boosters to be the way to provide us most protection. I hate to sound like a broken record, and for some of you on this podcast, I'm sure you're going to agree. Yep, you're a broken record. But I'm also very, very skeptical of the uptake and relying on boosting ourselves out of this pandemic. As I've said time and time again. We still have a third of the population that needs to be vaccinated with the initial series. Our vaccination rates for children are still incredibly low. We're in an interesting dance of vaccine making versus vaccine taking, i.e. turning vaccines into vaccinations. We want to ensure the best quality product is available to the public for access, but the perfect product is useless if no one takes it. Remember, in my previous discussion today, I laid out the fact that only 26% of Americans 65 years of age and older have received two booster doses. Only 11% of those 50 years of age and older have received two booster doses. Yet these may be the most powerful tools we have right now to prevent you in that 50 year old and older age group or 65 year old and older age group from being hospitalized, seriously ill and dying. So my biggest takeaway here is just another reminder that we need to be developing broadly protective vaccines against COVID. That's the next era of this pandemic and one I hope that we can arrive at sooner than later. It will not occur overnight. It won't occur in the next months ahead. I think some of you know that we here at CIDRAP actually have been leading an international effort with support from the Bill and Melinda Gates Foundation and the Rockefeller Foundation to develop a roadmap for pan-coronavirus vaccines, ones that will cover not only this, but all the other potential coronaviruses of concern. We have a paper which will be coming out next week, which we'll share with you in the next podcast, actually detailing this work and what the challenges are of trying to find these pan-coronavirus vaccines. What I'm telling you right now, that is got to be priority one, two and three. If we're ever really going to put Pandora back into her box.


Chris Dall: [00:43:42] So we could see these updated booster shots rolling out in the next few weeks, perhaps as soon as next week. But as The New York Times reported recently, these shots will be made available at a time when funding for vaccine outreach efforts is starting to dry up. And Mike, this brings me back to your dedication and the situation with Zika. We've seen unprecedented amounts of money put into the effort to fight the COVID-19 pandemic. But do you worry that as this pandemic fades into the background and we move on to the next thing, that we're going to lose the urgency needed to keep COVID an ever more manageable threat?


Michael Osterholm: [00:44:14] Well, Chris, I think it's fair to say that in 2022, we have a very short attention span for major public health issues. And I'm not just talking about social media videos or clickbait articles. It's an age old story that we see reactionary funding to a public health issue of significance, followed by a lapse in interest when people decide the problem is over, even if it's not, and then sustaining even sometimes growing support, but the problem is left for public health to address without the necessary resources. As we discussed in our dedication, Zika is a prime example of this. I do think it's what's happened with COVID-19 as well. Just remember, Zika is going to return. We are going to see this similar waves in the future that we saw back in 2015-16. And even though we could have been investing much more in the way of research and development of new Zika vaccines, we haven't. Just note our state and local health departments have put forth a Herculean effort in the face of COVID-19. I know these people well. I was one of them for 25 years. I can tell you with certainty the efforts that they have put forward truly have been heroic and they're used to doing so. They've responded to meningitis and syphilis outbreaks, investigating food borne diseases, antibiotic resistance, any number of outbreaks, and they take the lead when newer threats emerge like Zika or COVID-19. We've mentioned this in dedications previously, but the public health workforce has absorbed COVID-19 into their job duties, often while maintaining whatever responsibilities they had before 2020. Now some departments are adding more permanent units and staff that are dedicated to COVID-19 in the long run. But besides bursts of specific funding during emergency response at the onset of the pandemic, most public health agencies have failed to find a way to pay for themselves. Think about this. Public health agencies right now are faced with now delivering two different kinds of COVID vaccines, one for boosters, which is a different vaccine than for the primary series. Remember, they have to keep these separate and make sure that they don't make any mistakes. Oh, and by the way, did I mention what they're having to do with monkeypox right now and trying to get this vaccine out to those at highest risk using the intradermal means of administration, which is challenging? Oh, and then there is, of course, polio. Yes, we are worried about polio. And we'll talk more about that in a moment. But in fact, in this country, there are many potential locations where under-vaccinations of certain populations means polio is just literally potentially one day away from a crisis. And did I mention about influenza? We have a major rollout of the seasonal influenza vaccine this year, anticipating that it could be a substantial year given the relative absence of influenza the past few years. And then there's childhood immunizations in general, which, because of the pandemic, were often left unaddressed, where individual families could not even get appointments at their medical provider to get their children vaccinated. These were all happening at the same time, and there are no new resources to support these efforts. So I hope people understand that we are asking public health to do almost the impossible right now and just know that this funding issue doesn't stop at the administration office of a public health department. It falls on the population as well. When these vaccines and therapeutics are commercialized next year and federal COVID-19, funding is no longer available, preventing and treating COVID-19 is going to be at the expense of the public, and they will have to bear all of this. Not to mention the unknown impact of care required for long-COVID patients. Think about that. For all of those who are uninsured yet, 70 million Americans, there won't be a source of support for them to go and get their vaccine or their tests or their follow up. In short, I believe policymakers and the public have moved on from COVID-19. The dominant narrative is that the pandemic is over and under control, and that's in part based on messaging and actions at a federal level. Public health interventions have been phased out. Recommendations for masking, quarantine and isolation, and precautions for large gatherings have all been rolled back. Yes, the public wants them, but at least we have to tell the public what their risks are. By taking this tack as I just described, we're relying almost entirely on vaccines to do the heavy lifting and managing COVID-19 as a threat. This brings us right back to the booster issue we just discussed. We're putting all our proverbial eggs in the vaccine basket while at the same time, we're also not putting all the necessary emphasis on getting doses out to the right people. Katherine Wu did an excellent job describing the paradox in her recent article in "The Atlantic." It's incredibly mixed messaging to be saying that we don't need to isolate as long and that large gatherings aren't restricted, while also convincing the public that COVID-19 is a major threat and they yet need another vaccine. So in this mess of short attention spans, dwindling funding, and mixed messages, it's frustrating. But it doesn't feel new. If we can learn anything from history and honestly common sense is that it's incredibly foolish to be reactionary in public health. Prevention is one of the most important tools, but prevention and mitigation is tough to sell to funders, decision makers and yes, all of us the public.


Chris Dall: [00:49:59] There was a study published last week in the New England Journal of Medicine that found that Paxlovid reduced rates of hospitalization in people 65 and older, but did not appear to have much of an impact on patients aged 40 to 64. Mike, what did you make of those findings?


Michael Osterholm: [00:50:14] The major find in this study is that there were reduced rates of hospitalizations and deaths in people 65 years of age and older who took Paxlovid compared to those who didn't take it. This is really an important finding. But as you noted, Chris, this study did not seem to show that the drug worked in younger adults age 40 to 64. It's not that simple. Let's unpack the study a bit more and look at some of the nuances. The observational study took place during the Omicron surge in a real world setting as opposed to a randomized clinical trial. An observational study is one where you don't randomize. Some people get it, some people don't, for whatever reasons, and then you just follow them to see what happens. This type of study design has both benefits, but it also has drawbacks. But it does give us quite a bit of additional information about the effectiveness of Paxlovid when used in the general population that meets eligibility criteria for taking the drug. The study looked at nearly a 110,000 patients who met the eligibility criteria for Paxlovid based on risk scores. About 4% of the patients out of those 110,000 took Paxlovid, while the remaining 96% did not. This study clearly shows that there is a benefit in preventing hospitalizations and deaths among older adults, even those who are previously vaccinated. But as you mention, Chris, it did not show the same reduction in 40 to 64 year olds. Overall, I think these results are consistent with what we've seen previously, that Paxlovid can reduce hospitalizations and deaths among high risk older individuals. However, there are still a few study limitations that are important to consider when thinking about how this study informs our understanding of how effective this antiviral is among the 40 to 64 year olds. The issues I'm about to address have not been covered in any of the media stories that we've seen that explain to the public the strengths and weaknesses of this study. First, as I mentioned, this was an observational study, not a randomized trial. So individuals were well aware of and in fact, self-selected into their treatment. Second, individuals were considered eligible if they met a number of criteria which included age for the older individuals. However, for those who are younger, 40 to 49 year olds, you had to actually have multiple comorbidities to be eligible. But by selection, these were actually then more likely to have severe illness. So this study tells us something about Paxlovid treatment among older individuals, and something very separately about Paxlovid among younger individuals with multiple comorbidities. We cannot compare the results in the younger population to the older population directly. They were different populations. And third, there was a very small number of events in the younger age group, despite this group being at higher risk compared to their peers as they were age related who were not eligible for inclusion in this study, meaning the younger individuals who had multiple comorbidities versus those that didn't. The fact that the study did not see a statistically significant benefit for taking Paxlovid for adults 40 to 65 is not necessarily because there isn't a benefit. It may be the result of the very small numbers of hospitalizations and deaths, even in this high risk group of younger individuals. There was just one death among the 418 patients in this age group that were treated with Paxlovid and 16 deaths in the 65,015 patients in this age group that were not treated that Paxlovid. It's very hard to see conclusive results when you're dealing with numbers this small. This study does provide additional important information from a very large observational study conducted during the Omicron surge. It's great news that Paxlovid is highly effective for older age groups and reinforces the fact that we still need better and more accessible antivirals and other treatment options for the future. As for the younger age group, I would not take this study's results as a sign that Paxlovid is not effective, especially because of the limitations I mentioned earlier. I still believe that anyone who is eligible for Paxlovid treatment, including those under 65 years of age, should talk to their health care provider to assess the risk and benefits of treatment. And let me just conclude by re-emphasizing the point I made in the previous podcast. There are now two studies which have demonstrated that the frequency of rebounds, this idea of being infected, apparently improving, even being virus negative by lateral flow testing, and then becoming ill again and being positive again, something that people have attributed to Paxlovid actually occurs just as frequently in people who've never taken the drug. So be careful also about refusing to use Paxlovid because of the concern about rebound. At this point, I have seen no convincing evidence that the drug itself is responsible for that. But rather when enough people take Paxlovid they too will see rebounds.


Chris Dall: [00:55:16] Now onto the monkeypox outbreak, which continues to grow, but with evidence that the rate of growth appears to be slowing and that men in the highest risk group are changing their sexual behaviors. Mike, do you think that we've seen the worst of this outbreak?


Michael Osterholm: [00:55:31] Well, Chris, as you said in your question, this outbreak is continuing to grow with over 49,000 cases reported globally, over 18,000 of which have been here in the United States. The average number of new daily cases is down here in the United States and Europe. But we are seeing this time in the past few weeks. While it is too soon to say for certain that this outbreak has peaked or nearly peaked, we need to acknowledge that this is a promising sign. At the same time, remember, this virus has now been found in 97 different countries in the recent weeks. And so what happens in the United States or in Europe is not the only experience we have to keep our eye on in terms of what's happening with what is clearly a pandemic. Here in the United States, the decline in new daily cases, I think, can be largely attributed to four things. First is immunity at the at risk population due to vaccination. For example, here in the United States, more than 770,000 vials of vaccine have been shipped to state and local health departments. That's enough vaccine for almost 3 million people. In addition to the immunity from vaccination, we also have seen an interesting phenomena which will become even more important over time is the immunity that's associated having been previously infected. So when you get 3 to 4 weeks out from the onset of your illness, you are probably developing immunity. That means that in the days, months and years ahead will protect you. The third aspect of why I think case numbers are coming down is individuals who are infected are too ill to be having sexual activity, in a sense, taking a time out from being in high risk such situations for either contracting the virus or transmitting the virus. And for several weeks, we're not seeing these individuals contribute any virus to the transmission pool. And finally, the fourth thing is, is that we have data surely supporting that there have been behavior changes in this group, and the CDC has just last week, they published the results of a behavioral survey of men who have sex with men conducted in mid-August. They reported that 48% of the men who had sex with men have reduced their number of sexual partners in response to the monkeypox outbreak. 50% of the men reduced the number of partners they met on dating apps or at sex venues like clubs or raves. This is very promising news. I've said all along that this vaccine, though safe and effective, is not a silver bullet, especially when we're using a dose sparing approach. And so it is really important that we encourage these behaviors to continue to be part of the prevention efforts to reduce risk and that this outbreak then be controlled. That said, I have a few concerns that leave me hesitant to say that the worst of the outbreak is behind us, particularly on a global level. The first is that we don't have a good sense of how much of the at risk community men who have sex with men, with multiple male partners in a short period of time is immune to this virus and how long that immunity will last. Dose bearing approaches such as administering only a single dose of vaccine or administering the vaccine intradermally, have allowed us to vaccinate a lot more people with a limited supply. But frankly, we don't still have much data in how long and to what extent a single dose or intradermal dose protects against infection. I worry that a lot of immunity in the gay community will be temporary if we don't emphasize the importance of the second doses. Currently, first doses account for more than 97% of all the doses administered. I hope to see this number change in the coming weeks and months as more doses become available. We are slowly approaching a point, just like with the COVID vaccines, that the issue is more about vaccine taking than vaccine making. There will come a day when we will have enough supply for everyone to get a second dose. And I'm really concerned that the at risk population will not feel motivated to get one, particularly if case numbers continue to drop. And one will eventually lose their immunity to this virus and unfortunately, it could be déja vu all over again. This brings me to my next concern. If immunity is temporary, then temporary behavioral changes are not an adequate solution. The goal of supporting men who have sex with men to temporary reduce their number of partners is to allow enough time for immunity to develop, ideally through vaccination. Or as I just said, in some cases through infection. We know that eventually, just like COVID, people return to living their lives as they did before the outbreak. But the question is when and will there be enough lasting immunity in the population by then? We need to do everything we can to emphasize the importance of these second doses and for many, potentially even getting a first dose so that people do not return to previous behaviors under the false assumption that they are protected with just one dose, especially an intradermal dose. I also want to touch on some of the equity issues that we are seeing with this outbreak. Just as we saw with COVID, our BIPOC communities are disproportionately suffering in this outbreak and sadly are not receiving nearly enough of the resources that we have to help prevent and treat this disease. In the US, blacks currently account for 26% of the monkeypox cases, despite making up only 12% of the overall population. Latinos currently account for 28% of the monkeypox cases, but only 19% of the general population. In every state that has reported data on the racial ethnic distribution of vaccines, blacks account for a greater percentage of monkeypox cases than they do the vaccinated individuals. The greatest disparity is in North Carolina, where blacks make up 73% of the monkeypox patients, but only 24% of vaccinated people. We're also seeing disparities with the distribution of the medication TPOXX, which is used to treat monkeypox. Only 16% of people who have received TPOXX are black, even though again 26% of reported cases have occurred in blacks. These disparities in cases, vaccination, and treatment are all very concerning. We need to strongly advocate for BIPOC members of the gay community to ensure that they are getting fair and equitable access to vaccines and treatments, as well as information regarding how they reduce their risk of contracting the disease. It is notable that yesterday the Department of Health and Human Services did announce a special new outreach program to the communities of color and those overlapping with the gay community. So we'll hopefully find that in the next several weeks these disparities that I just referred to will be diminished and that, in fact, we will see more vaccine into the BIPOC community. The bottom line for monkeypox is, while the rate of growth of this outbreak is slowing, I think it's far too early to declare victory over the virus. We still have not really addressed the international issues, particularly how are we going to protect the 340 million individuals living in the 12 African countries where this virus is endemic in certain animal species who are under age 40 and therefore have never been vaccinated against smallpox so they don't have any residual real protection against monkeypox. What are we going to do to get them vaccinated? We have a lot of work to do here yet, so stay tuned. I hope that the worst of this particular situation in many countries is behind us. But with all these variables at play, I think it's likely we will continue to see case rates pick up again. And just knowing right now, we just don't know.


Chris Dall: [01:03:17] We talked on our last episode about the polio case in New York and the detection of polio samples found in New York City wastewater. Mike, is there any update on that situation?


Michael Osterholm: [01:03:27] Yes, during our last episode, I voiced my concern that this virus would continue to spread and be detected in the wastewater in New York and the surrounding areas. Unfortunately, that concern has become a reality as the virus was detected in four wastewater samples in Sullivan County in upstate New York. This is the fourth county in New York to detect polio in the sewage. Sullivan County has an alarmingly low polio vaccination rate similar to the rate of Rockland and Orange Counties, two of the other counties that are adjacent and have also found virus in the wastewater. The overall polio vaccination rate in New York City is slightly lower than the national average, but varies a lot by neighborhood, with some neighborhoods having rates similar to or lower than those in Rockland, Orange, and Sullivan counties where vaccination rates for polio in children may be as low as 30%. I want to remind everyone that many cases of polio are asymptomatic or cause mild flu like symptoms, with paralytic polio only occurring about 1% of cases. The fact that we've only seen one reported case to me is actually good news, but yet somewhat surprising in a sense that we haven't seen more paralytic polio cases if, in fact we have this transmission running through these under-vaccinated populations. We have areas all through the world that have tremendously reduced levels of vaccination for polio compared to what we would hope for. Here in Minnesota, for example, we know that only about 23% of Somali children have been fully vaccinated against polio. So we here sit in a possible situation right here in the upper Midwest. So in summary, this situation is far from over with yet. I worry we have many vulnerable individuals to polio. And while again, we haven't seen subsequent cases since the original reported case in Rockland County, I think it's just a matter of time before we do.


Chris Dall: [01:05:24] Now for our COVID query segment. Today's question comes from Yvonne, who asked some questions that I think all of our listeners would like the answer to. She wrote, "Is there some way you can provide some hope for your podcast family? It seems like there's nothing left to hope for. I hoped the vaccine would end the pandemic. I hoped the treatments would end the pandemic. I hoped the pandemic would end the way a flu pandemic ends. Now, I don't know what to hope for. Will this pandemic ever end or is this new normal a permanent normal? Will I have to spend the rest of my life in isolation? Will I live to see the end of this pandemic?"


Michael Osterholm: [01:06:03] Well, thank you very, very much for this very thoughtful query, Yvonne. And let me just say at the outset, it's a very personal question for me. So I, too, like you have thought a lot about this over the months and months of this pandemic. Let me just start out by again reminding everyone that, yes, this is a disease that is the number four cause of death in this country. But it is clearly hitting disproportionately the older population over age 65 and likely those who are experiencing underlying comorbidities. So to me, the hope is let's take that group aside and say for the vast majority of the population, this particular virus is surely causing lots of illnesses and a number of them quite severe, but not requiring hospitalization. That is a very different mindset than we had during the Delta and Omicron surges when people actually every day feared that they would get infected and die. Today, people almost accept the fact that I may get infected again, but it's no big deal. To me, that's a sense of some kind of hope that we can see more people not only experience that, but actually the reality is that they don't get seriously ill and die. So for you and me, at least as we look at this and as someone who fits into that category over age 65, I think hope is one, taking control of my own life's journey by getting vaccinated, by in fact, doing everything I can to be reasonably cautious. Just as I've been doing here in my home, we have started to have dinner events with individuals where we ask that for the three previous days that they're here, that they not have any contact with anyone who might be ill, that they themselves, if they have any symptoms or what appear to be even allergies, they do not come and of course are tested, even though knowing that testing is far from perfect. By adding those all up, do I create a perfect wall against getting infected? No, but it's a wall that I think is quite substantial, and it's one that has resulted in many, many wonderful moments with family, friends and colleagues socializing without an N95 on. Do I do other things? Yeah. I don't go to restaurants unless I'm outdoors at a distance from people. I don't ever take my N95 off when I go to the airport or I'm on a plane. And that to me gives me hope. I hope that I can learn to live even with this virus present in a way that might be compromised from what I once had. But it doesn't mean it ends what I do. So I think the thing that we have to remember, one, if you're older, please get all the doses of vaccine you can, for that matter, all ages, but particularly for over age 65, have ready access to Paxlovid if in fact you become ill, make sure that you have a way to access in your health system or wherever you get health care, the ability to get that drug. And take seriously the kinds of things you can do to limit transmission among friends, colleagues, and don't stop socializing. Do what I do, and I'm not telling you that's going to be perfect. But so far, you know, knock on wood, I've remained infection free. So if I leave you with hope, it's the fact that there is things we can do. There are things we can do. That's hope. What will this virus throw us another curveball? It could. I don't know. I don't know. Anyone who tells you they do know, don't trust another thing they have to tell you. I don't know. But for now, I have hope. I'm living my life. I'm seeing people. I'm with people. I don't just hear people and see people on a screen. I feel them. I see them. I hug them in person. And that, I think, is what we need to all get to. So I don't know that this qualifies as hope, but I hope it gives you some sense that you can have hope and no, don't let this pandemic take over your life, but learn how to live in a way that you still control your life, but mindful of and cautious of this virus. So Yvonne, thank you for your very thoughtful question. I fear I may have fumbled it trying to explain to you something from my heart as much as it is from my head. I surely appreciate the points you made. I appreciate your perspective and thank you for hanging in there.


Chris Dall: [01:10:44] Mike, what can you tell us about this week's Beautiful Place submission?


Michael Osterholm: [01:10:48] Well, this is an unusual one, but it struck at the heart of, I think, where we're at today in this pandemic. And it's about appreciation. You know, we all have different parts of our lives that bring us some type of security, that bring us some sense of fulfillment, something about familiarity that is all part of what makes life more beautiful. And we received one here from Tom, who wrote, "Good morning, Dr. Osterholm. First, I want to start with a safe place. For over 20 years, I drove my 2003 Yukon XL. This was my wife's daily driver, our trailer hauler and family bus with us fulfilling the nine seater full of kids. I have lots of memories of this vehicle Death Valley, Big Sur, and even the memory of Monarch butterflies flying all around it on our beach campsite. Over the years it has aged and the kids have all grown up. With the price of gas here now almost $7 a gallon. (This came in in mid-July.) My Yukon was delegated to me, using it to drive to work and hardware store runs. Well, yesterday I threw a rod and it limped home for its last ride. I sat there in this big steel cocoon and I realized how safe I felt in it from COVID and car crashes. I even drove it through a brush fire. It was good to me. But now it's time to let go. If I've learned one thing in this pandemic is that you must be able to change. Thank you for being here in this pandemic. I really appreciate having you guiding me through this. I still say the virus will attenuate and the pandemic will end this summer. Is that fools hope? Be safe on the roads and in the air. Tom." Now, some would say this is kind of an odd one to take for a beautiful place. We will include the picture of his Yukon at the lake with the monarchs. But I think it strikes a nerve for many of us is that we've had our safe places and sometimes not necessarily fully appreciating what they meant. But at the same time, with this pandemic, we can't continue to live our life in only our safe places if we're moving on. And how do we make that transition? How do we do that? I know for me and for many of you on this podcast, losing a companion animal is like that. Oh, my God. Is that a tough thing to move on from. It's very painful. Very painful. Yet we have to do that. And so with this pandemic, we're trying to find ways to move on. And Tom, you need to give up your Yukon. You need to get a 42 mile per gallon vehicle in the modern era. But I surely understand what it must have felt like when you realized that that Yukon had just taken you on your last ride, given all the history. Now we learn to move on from this pandemic.


Chris Dall: [01:13:48] And just a reminder to our listeners that if you want to tell us about the beautiful place that 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: [01:14:07] First of all, while it's not a take home message, it's a very, very sincere acknowledgment of thanks to all of you who listen and who have provided us with such incredibly thoughtful and kind feedback. You know, I get done doing these podcasts and I think to myself, What did I just do today? I didn't say anything useful to anybody. But then, of course, I did get to share information provided by the podcast team, which, in spite of me, is actually worth listening to. And I just think to myself, you know, why would people want to listen? And it's because we all do care and we all are trying to get through this together, both from a scientific standpoint, from a public policy standpoint, and from a very personal standpoint. So what do I take away from today's podcast? One, we continue to be on this high plain plateau. We're not done. Number four, cause of death in this country. It's still there. But I think we can do a lot to work hard at identifying those at the greatest risk of serious illness, hospitalizations and deaths. And let's drive that number down. If we have millions and millions of cases, so be it. But let's not have any serious illnesses. Number two, new vaccines mean little if we don't convert them to vaccinations. Right now, we need to be really mindful of how can we vaccinate those who are at highest risk of serious illness. 26% of those over 65 having received two boosters, that's all. What can we do to limit the impact of that virus in that group? Well, get them all vaccinated with at least two boosters. Third, if BA.5 remains the primary variant, sub-variant, we could see a better fall. We could see the case numbers eventually drop as more people are infected and develop immunity from infection or the few who get vaccinated. And that would be a great news. The problem is, I don't know what's coming after BA.5, something will. And that could put us into that ECDC report that we just talked about in terms of what the outcomes might be from something not so bad to something kind of bad, and we just don't know. So in this final point, just know that I don't have the answers you want. I wish I did. And all I can tell you is, is that we will need to be mindful that it could be all the way from not so bad to really bad.


Chris Dall: [01:16:44] And do you have a closing song or poem for us today?


Michael Osterholm: [01:16:48] Well, I do. And it's one that I keep coming back to. I hope I haven't come back to it too many times, but I think it really is where we're at today as a society, as we're where we're at as a team here at CIDRAP. We've actually used this song three previous times. In the 53rd episode on April 29th, 2021 entitled "Two Doses of Vaccine and One Dose of Humility." Boy does that sound familiar? And we used it on Episode 77, November 11th, 2021. "A Booster Dose of Humility." I don't know. There's a theme here, I guess, for this particular one, but that surely was true. And then finally we used it on the 102nd episode, May 2nd, 2022, "Choose Your Own Path." And it's the song we pick because it does reflect where we all want to be right now, where we're at. This is "Don't Stop." It's a song by British-American rock band Fleetwood Mac, written by vocalist and keyboard player Christine McVie. It's one of the band's most enduring hits, and it was released on as the third single from their "Rumors" album, peaking at number three on the US Billboard Hot 100 in October of 1977. In the UK, "Don't Stop," followed "Go Your Own Way" as the second single from the album and peaked at 32. So this is one that really embodies I think about us looking to the future. Don't give up now, don't think it's over, but also don't give in to the virus. Don't ignore it, be respectful, but don't stop by Christine McVie. "If you wake up and don't want to smile, if it takes just a little while, open your eyes and look at the day. You'll see things in a different way. I don't stop thinking about tomorrow. Don't stop. It will soon be here. It'll be here better than before. Yesterday's gone. Yesterday's gone. Why not think about times to come and not about the things that you've done? If your life was bad to you, just think what tomorrow will do. Don't stop thinking about tomorrow. Don't stop. It will soon be here. It'll be here better than before. Yesterday's gone. Yesterday's gone. All I want is to see you smile. If it takes just a little while. I know you don't believe that it's true. I never meant any harm to you. Don't stop thinking about tomorrow. Don't stop. It will soon be here. It'll be here better than before. Yesterday's gone. Yesterday's gone. Don't stop thinking about tomorrow. Don't stop. It will soon be here. It'll be here better than before. Yesterday's gone. Yesterday's gone. Don't look back. Don't look back." Christine McVie. Well, thank you all so very, very much for being with us for this podcast. A lot of information here today. I'm not sure there were a lot of answers, but hopefully some of that perspective that I talked about, I'm certain that we will continue to have many more questions than we do answers over the course of the next few weeks with vaccines, even the drug treatment issues. What do we do to stay safe? What impact is this having on our workplace? Can we go back to work? What's going to happen with school kids? What will be the impact on college campuses? All questions that none of us can answer right now, but ones that we will continue to follow. Thank you so much for being with us. And today we did focus on those we've lost. And again, not the numbers. I'm talking about the people. And I know that a number of you on this podcast have lost loved ones. Let's never forget them. Never. Thank you. Thank you, be kind. Look forward to seeing you in the future. Thank you very much.


Chris Dall: [01:20:57] 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.