July 21, 2022

In "Rejecting the Status Quo," Dr. Osterholm and Chris Dall discuss the BA.5 surge in cases in the U.S. and around the world, assess the risk of reinfection with BA.5, and answer a COVID query about isolation guidelines.


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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. It's mid-July, and the United States and the rest of the world are now well into the latest chapter of the age of the variants, with the highly transmissible and immune invasive BA.5 Omicron sub-variant driving a surge in new COVID-19 cases. With this surge, we're also starting to see an increase in hospitalizations and deaths. And COVID-19 reinfections appear, at least anecdotally, to be becoming more common. While this surge has prompted public health officials to urge people to get their COVID-19 booster shots and wear masks in crowded indoor places, for the most part, the surge is being met with a collective shrug by the public. Today, on this July 21st episode of the podcast, we're going to talk about the BA.5 surge, the response, and what the next chapter in the age of the variants might look like. Will be a BA.2.75 be that next chapter? We'll also talk about the BA.5 sub-variant's ability to cause reinfections, answer a listener question on how long people should remain isolated after infection, give you the latest on the monkeypox outbreak, and share a beautiful place 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: [00:01:54] Well, thank you very much, Chris. And welcome back to all of you to another episode of the podcast update. In particular, I want to welcome all of the podcast family members who have been with us for months and months as we all try to navigate through this pandemic. And also to any of you who may be new today, hopefully the information we can provide you will be helpful. If nothing else, at least it will help you balance all the other information you have out there that I know is at your already. Today's podcast is going to be another challenge. I keep saying that and each time they only become more of a challenge. As we navigate through today's podcast, I'm reminded that the English writer Lewis Carroll once said, "If you don't know where you're going, any road will get you there." And I feel like at this point in the pandemic, we may actually be at that place where we're surely on a journey, but in fact, we're not quite sure where we're going. And I'll try to illustrate that today by what I mean and what the implications are and how we can live within that lack of clarity. Before I begin, though, I want to again thank all of you who have sent in so many letters, cards, emails, your words of advice, your words of concern, your thoughts, your ideas. And I can never express it in adequate terms, how much we as a podcast team appreciate that. You have been nothing but wonderful to us, and it gives us every reason on this two week basis to put together another one of these podcasts. I also want to acknowledge the podcast team. I work with the most incredible people in the world and they really deserve the credit for where credit is due in this podcast. You can attribute the mistakes and the criticisms to me. As we look at today's podcast and think back about of all the great public health victories that we've experienced over the course of the past 100 years. Immunizations, particularly childhood immunizations, have to be at the top of that list. While the number of children that die each year of vaccine preventable diseases has declined drastically over the course of the last several decades, we're still reminded that 700,000 to 1.5 million children under the age of five are still dying of vaccine preventable illnesses each year. Again, let me repeat that. In a pre-COVID world, 700,000 to 1.5 million children under age five were dying from vaccine preventable diseases. The vaccine preventable diseases account for approximately 13 to 20% of all deaths in children under age five. Most of the deaths occur in low and middle income countries. But even in the United States, 300 children die of vaccine preventable illnesses each year. During the pandemic, we have seen a lot of non-COVID public health challenges arise, often as a result of people being hesitant to receive in-person medical care. One of these challenges has been a decline in routine childhood immunizations, not just in the United States, but worldwide. According to a press release from the W.H.O., the percentage of children who have received all three doses that are diphtheria, tetanus and pertussis vaccine fell five percentage points from 86% to 81% over the course of the pandemic. This means that 6 million more children missed a dose of this vaccine in 2021 compared to 2019, with a total of 25 million children missing at least one dose. Similarly, over 5 million more children missed a dose of the measles, mumps and rubella vaccine in 2021 compared to 2019. A majority of these missed doses occurred in low and middle income countries. But this is a challenge in the United States as well. According to data from Blue Cross and Blue Shield, there was a 26% decline in DTAP and MMR vaccines in children in 2020. Though this may have improved some in 2021 and 2022, there is no question that there's still a lot of catching up to do, which will be a challenge as a health care workforce is being stretched thinner than ever before. So this week's episode is dedicated to all those involved in the efforts to help the population catch up on their missed doses. In the United States, this includes 34,000 pediatricians, 118,000 family practice and family medicine physicians, 22,000 pediatric nurse practitioners, and 95,000 pediatric physician assistants. In addition to that, there are 84,000 school nurses and 34,000 nurses working for state and local health departments, medical assistance and nurses working in pediatric primary clinics, and many others who will administer these missed doses. We thank all of you for your efforts in addressing this public health issue in an already challenging time both here in the United States and around the world. Now, let me move on to that piece of information that for some of you is absolutely essential, to others they would love to have me stop talking about it. Today, July 21st, here in Minneapolis-Saint Paul sunrise will be at 5:40 a.m., sunset at 8:51 p.m.. 15 hours, 4 minutes and 57 seconds of sunlight. Now, we've lost almost 21 minutes since we did the last podcast on July 15th, and we've actually lost 32 minutes since the summer solstice on June 21st. But you could focus on that, or you could focus on the fact that 15 hours of sunlight every day is a remarkable gift. Now, I realize for some this is a real challenge, particularly where we are seeing the major heat stress throughout this country. And for those who are suffering from heat related health issues, this is a challenge. So I love the sun. I just wish it was cooler in many places around the world. And for those of you in the southern hemisphere, your sun is coming. And in the meantime, we will work hard to enjoy and appreciate ours.


Chris Dall: [00:07:55] Mike, let's start with the international situation. Earlier this week, the head of the World Health Organization European Regional Office, said cases in the region have tripled over the last six weeks, with hospitalizations doubling. And he urged countries to boost vaccine uptake and promote mask wearing. Is there anything you're seeing in Europe or elsewhere that should be seen as a warning sign for us here in the US?


Michael Osterholm: [00:08:20] Well, Chris, when you think back through the entirety of this pandemic, roughly the past two and a half years, there's been several instances where Europe was a harbinger of things to come for us here in the US. In each of these examples, including the fall surge in 2020 and both the summer and fall surges last year, things started taking off in Europe several weeks prior to their rises here. Now, that hasn't always been the case. For example, the clear waves caused by Alpha and even BA.2 in parts of Europe didn't end up playing out across most of the US in a similar manner. On top of that, we saw BA.2.12.1 recently drive up activity here in parts of the US, but not in Europe. So this relationship is not a flawless model. Still, between those previous experiences where they have offered us a glimpse into our future and based on what we know about BA.5, I think we'll see activity continue to climb here over the next few weeks. And I'll actually talk a little bit more about the national picture in a bit. But before I do that, let me just briefly cover what has been happening in Europe and elsewhere during this BA.5 wave. Clearly, the European region overall has experienced a rising tide of infections, as you mentioned, in the lead up to your question, cases have tripled over the past six weeks, going from less than a million a week in late May to 3 million now. And during the same time period, the number of Europeans admitted to the hospital with COVID has doubled. Contributing to the surge are countries like Austria, France, Germany, Greece, Ireland, Italy and the Netherlands, each of which has reported a rise in admissions as of this past Tuesday. Otherwise, places like Denmark, Norway, Switzerland and potentially the UK have also seen hospitalizations climb in recent weeks but appears to have reached a peak. Now when you start looking at the absolute numbers, whether that's new admissions or overall hospitalizations, we're fortunately seeing most countries at levels below those reached during previous peaks for both BA.1 and BA.2. For example, in Switzerland, there were around 1,260 patients hospitalized with COVID as of Monday. For comparison, at the height of the BA.2 surge hospitalizations approach 1,900 and with the BA.1, they reached nearly 2,000. Again, the current level is at 1,260. So the total number of COVID hospitalizations in Switzerland has been lower with BA.5. However, at the same time, when you compare the number they're at now 1,260, as to where they were in early June when the surge began, it was at 300. You can get a sense for the growth they've seen. Meanwhile, there are some countries in Europe where BA.5's impact on hospitalizations has largely rivaled the levels reached during the previous Omicron surges. In both Italy and Spain, the current number of patients hospitalized with COVID has surpassed the levels reported during their BA.2 waves. And in Ireland, hospitalizations with BA.5 have matched the numbers reported during their initial Omicron surge. So make no mistake, BA.5 can and will have an impact on health care systems. The question is how significant that impact might be. Clearly, there's some variability we're seeing, but at the end of the day, a respiratory pathogen adding pressure to health systems, especially during the summer season, is not what you want to see, especially when you're two and a half years into this pandemic. Now, that being said, I think one trend we've seen with BA.5 in Europe, at least up to this point, is a consistently lower number of patients with COVID admitted to an ICU. Of course, BA.5 has led to ICU admissions, so by no means it is benign. But the overall number of patients in an ICU has remained lower than previous Omicron waves in the vast majority of countries. Even Ireland, which I mentioned, has had roughly the same number of patients hospitalized with COVID during this BA.5 wave as it did during the BA.1 wave, is seeing this play out with a peak of 46 patients in the ICU during this latest surge, compared to over 100 at BA.1. So at the very least, I'm hoping the trend holds true for countries seeing a surge from BA.5. However, if that ends up being the case, the fact remains that another version of Omicron, this time in the form of BA.5, is yet again resulting in more infections, some of which can be severe and even deadly. So even if the hospitalizations or deaths from BA.5 don't reach the levels we saw with the previous sub-variants, the reality is that some places are now seeing their third wave in just six or seven months time. And I think this faster pace, which we've seen recurrent waves play out with Omicron is a huge challenge. Sadly, but not unexpectedly, we're now seeing the number of COVID deaths in Europe climb with the daily average approaching 2,000 as of Tuesday, which is up from 1,500 in early July. And unfortunately, I expect this to continue as more places are hit by the BA.5 surge. Obviously, this isn't just a problem for Europe or the US. There are a lot of locations dealing with BA.5 waves, whether they're in the Western Pacific, South America or the Middle East. In fact, some countries like Australia and New Zealand are dealing with the surge of BA.5 activity and influenza. According to the latest surveillance report from Australia, the number of weekly lab confirmed cases of influenza that have been reported since April is exceeding the country's five year average. Meanwhile, in just the past month they've gone from 26,000 COVID cases a day to 42,000. In several states, including Queensland and Victoria, COVID hospitalizations are at an all time high, and with 8,500 health care workers across the country reportedly in isolation due to COVID, there are hospitals that are postponing elective surgeries or placing patients in hallways due to a lack of space or health care workers. A similar situation is playing out in New Zealand, where COVID cases have doubled, going from 5,000 a day to more than 10,000 a day in just a few weeks time. At the same time, average daily deaths have climbed to a record high of 23. Speaking on the situation there, New Zealand's minister for COVID recently said the following and I quote "There is no question the combination of a spike in COVID-19 cases and hospitalizations, the worst flu season in recent memory, and corresponding staff absences are putting health care workers and the whole health system under extreme pressure." So COVID is not going away. And if you look at what's happening in Europe, the Western Pacific or even Asia, where countries like Japan, South Korea and China, which reportedly has 264 million residents across 41 cities under some form of lockdown are once again seeing case surges. I think that's pretty obvious. Just the day before yesterday, Japan reported its highest number of cases, reported for a single day in any time during the pandemic at over 150,000. So needless to say, BA.5 is here. And as W.H.O. director Tedros said in a press briefing this past week, "the virus is running freely."


Chris Dall: [00:15:49] We've also gotten some reports recently about yet another Omicron sub-variant, BA.2.75. What do we know about the sub-variant?


Michael Osterholm: [00:16:00] Well, Chris, let me just start out by reminding everyone of my general position when it comes to the early reports of new variants and now with Omicron, these sub-variants that is they're innocent until proven guilty. That has seemed to work well in terms of what has eventually become the most significant variants or sub-variants in this pandemic. Of course, there's no doubt that we should be concerned about emerging variants. Any routine listener to this podcast has heard me say that time and time and time again. And with Omicron, we surely have seen a glimpse of just how quickly and dramatically this virus can change and the impact that it can have in terms of transmission. Remember, this is a variant that was first identified last November, so around eight months ago. And in that time we've seen the rise and fall of multiple sub-variants like BA.1, BA.2 and even BA.2.12.1 here in the US. Nevertheless, here we are again facing another Omicron surge, this time driven by BA.5. So those 210 mile an hour curveballs I keep talking about haven't gone away. From that perspective, I completely understand the importance of keeping a close eye on new versions of this virus that pop up. And with the amount of transmission we're seeing, there's no shortage of opportunities for these changes to occur. Again, remember, each time this virus replicates, there's a chance for mutations to occur. In fact, mutations are not uncommon. However, most of the time these mutations are inconsequential or even detrimental to the virus and what it can do to us as humans. Now, that being said, there's also the chance that a certain mutation or combination of mutations is advantageous for the virus in its battle against us. Maybe they help it replicate faster. Maybe they give it the ability to better sneak past a host's immune system. Maybe it's a combination of the two. Regardless, in these relatively rare occasions, the virus can potentially outcompete other versions that exist and gain a leg up in the race. Hence the phrase survival of the fittest, Darwinian evolution at the viral level. So that's what we're seeing play out with SARS-CoV-2. At the same time, we're also trying to better understand when, where, and how these new variants or sub-variants are emerging. For example, there's a growing number of studies that demonstrate that the ability of this virus to undergo accelerated evolution in hosts with chronic infections. So if someone happens to be immune compromised and their body can't clear the virus, that virus can continue to replicate at will. And on some occasions, we're seeing these long running infections result in more frequent mutations and ultimately distinct versions of the virus. Again, we don't have definitive data that proves these chronic infections were the source for Alpha, Delta, Omicron or any of the sub-variants. But it's a leading hypothesis. Otherwise, we also know that ongoing transmission and animal reservoirs present a risk of spill over into humans occur. Regardless as we know, those versions of the virus that are better at evading immune protection, are inherently more infectious, and/or cause more severe disease are termed variants of concern. Now, with Omicron, there's been some confusion since it's really the first time we've seen a variant of concern produce multiple descendants or sub-variants capable of outcompeting previous versions. But the thought process largely remains the same. Now, in the case of BA.2.75, I think it's far too early to conclude that this will be the next Omicron sub-variant coming down the pike. Now, it does contain a lot of the same mutations that the original BA.2 sub-variant had. And we know that BA.2 was successful enough to become dominant for quite some time. However, BA.2.75 also contains a distinct set of eight mutations on the spike, which presents the risk of heightened immune evasion. So that has earned it some extra attention. Adding to that attention has been the detection of the sub-variant in 14 countries, signaling a fairly wide geographic distribution. Nevertheless, based on the data I've seen to date, there's really not a whole lot of evidence that demonstrates ongoing widespread transmission in most countries reporting cases. If anything, India provides maybe the most insight we have on BA.2.75. At this point, they've identified just 178 cases of the sub-variant, and most of those have come from samples collected in just a couple of the country's states, neither of which have seen a noticeable uptick in infections. In addition, these same states don't yet appear to have a lot of BA.5 circulating. Ultimately, BA.2.75 would have to outcompete BA.5 if it was going to drive the next global surge. And we just don't have any solid evidence showing that is the case. So in summary, I think the jury's still out on BA.2.75. Unless some new strange data emerges, I'm not really convinced that this will be the next Omicron sub-variant we're facing off with. Regardless, I can't overstate how important it is to continue monitoring this virus moving forward. This is bigger than BA.2.75. We desperately need to have systems in place that can track what this virus is doing, both in terms of human and animal populations. With more sequencing, we can keep tabs on where and when these changes are occurring, and ultimately we need those systems that can help characterize new versions of the virus, whether it's through lab experiments or using epidemiologic data in a timely manner. Unfortunately, some of these systems don't exist or are systematically being dismantled. We have watched sequencing really take off during this pandemic, but now we're seeing more and more of these efforts rolled back or eliminated. I'm deeply concerned that we will not have the ability to rapidly detect and understand new and emerging variants and sub-variants, given the fact that we are greatly reducing the number of laboratories capable of doing the kind of testing that we need in order to understand the emergence of variants and sub-variants.


Chris Dall: [00:22:21] Here in the US, after several weeks hovering around 100,000 new daily cases, we're now up to around 125,000 to 130,000 new daily cases with hospitalizations and deaths also climbing. And BA.5 now accounts for 78% of all new cases in the country. The BA.5 wave has prompted US officials to urge Americans 50 and over to get their second boosters. And public health officials in some parts of the country are recommending masks for public indoor spaces. But, Mike, the overall message seems to be that we don't need to be alarmed. Is this the right message?


Michael Osterholm: [00:22:56] Well, Chris, as you mentioned in your question, daily reported cases in the US are sitting at 130,000 and seem to be climbing. As we've discussed episode after episode, we truly don't know what is happening from a testing standpoint and the actual number of true cases occurring in this country. My sense is that the number is much, much higher than 130,000 cases a day. And sounding somewhat like a broken record but data, which I actually am quite impressed and depressed by, I can now say for the seventh consecutive week I know more people this week who are friends, family, and colleagues who are infected with COVID than I have at any time in the pandemic. So let's just assume that these reported case counts represent only a small fraction of the true numbers. Eric Topol has estimated that the number is more than 1 million daily new cases. We just don't know what the actual numbers are because of lack of reporting and the amount of at home testing being done. And on top of all of it, many states have moved to reporting cases only once a week. We need to just be very careful about our messaging about what the actual number of cases mean in terms of occurrence of infections in our community. As I mentioned in our last episode, wastewater data has shown a steady concentration of COVID-19 across us throughout the month of June. However, from June 29th to July 13th, COVID concentrations in wastewater increased nearly 40%. Wastewater is a leading indicator, so it should come as no surprise that we're seeing the increase we're seeing in cases right now. One number that I haven't discussed much is the test positivity rate, but this week I want to bring it to your attention. This rate has tended to fluctuate pretty much exactly with previous surges as reported cases went up, the test positivity rate also went up. So for reference, during the Omicron Peak, the test positivity was the highest it had been at any point during the pandemic at 29.2%. But when cases were low across the country at around 10,000 daily cases in the summer of 2021, the test positivity rate was just 2%. While reported case numbers in the US appear to be slowly increasing at the moment, the test positivity rate is climbing rapidly now, sitting at 18%. Reported case counts aside, hospitalizations and death rates are also on the rise, a trend that's been observed in other countries where BA.5 has circulated. And as you mentioned in your question, Chris BA.5 now makes up 70% of all cases in the US. Hospitalizations are up 20% compared to two weeks ago, averaging 41,000 people hospitalized for COVID on a given day. The number of COVID patients in ICUs is also up 20% over the past two weeks, with an average of 4,500 people in an ICU for COVID on any given day or 11% of hospitalized COVID patients. Let's put these numbers into some context. At the peak of the Omicron surge on January 20th, 2022, we saw 159,500 people hospitalized with COVID, which is the highest we've seen throughout the entire pandemic. At that point, hospitals were overwhelmed. We're currently at 25% of this peak, but we are rising. Why wouldn't we raise some alarm bells and encourage people to take some precautions that we were taking back in January 2022 to avoid overwhelming our health care systems again? I don't know, but we're not. Deaths are also now increasing, now 10% higher than they were just two weeks ago. We're losing an average of 425 lives every day in this country, and the number is climbing. When we compare this to the 2,700 daily deaths during the Omicron peak, 425 might not seem that high. But let me remind you that this isn't just a number. These, again, are 425 loved ones lost every single day. After more than two years, it seems to me that people are becoming acclimated to this tragedy. We should not be unconcerned about this rise in deaths over the past two weeks, and I find it difficult to think about COVID in the context of what these number of deaths mean if you actually look at them on an annualized basis. Right now, at the rate of deaths we're seeing, COVID would cause on average about 164,000 deaths every year in this country. That places it as the fourth leading cause of death with heart disease, cancer and accidents ahead of it. It's exceeds that of stroke, chronic lower respiratory disease, Alzheimer's, diabetes, influenza, pneumonia, and kidney disease. And yet we're now accepting this as if this is a fait accompli in many communities throughout our country. So to answer your question directly, I don't think there is a reason not to be alarmed. Hope is not a strategy. You've heard me say that many times and announcing that there is not a reason to be alarmed is only going to help the virus spread. Now, please know I'm a realist. I understand that the country is done with this virus, even though it's not done with us. But I have to come back to what are some of the common sense, simple things we can do to limit the impact of this virus, even at what is now a new baseline, where people assume that this is acceptable to have a fourth leading cause of death in your country, which didn't exist three years ago. One vaccine, vaccine, vaccine. I can't say it enough times. These doses of vaccine may not keep you from becoming infected, but they will go a long, long ways in keeping you from becoming seriously ill, being hospitalized and dying. I can't emphasize that enough. And yet in a country where vaccine is abundant, we have so many people who have not yet been fully vaccinated with up to three or four doses in total. In addition, I have to say that the idea of recommending any kind of public health measures like mandatory masking or limiting contact in public places, is going to go nowhere. No one is going to put in place, I believe, a meaningful new mandate that people will abide by. Some places may try, but I don't think they will. Yet I know that someone wearing an N95 respirator, not just a mask, not just a mask. It's got to be an N95 respirator worn appropriately. We can also do a great deal to reduce the number of infections. This should be worn when you're in public places indoors. It means that when you're outdoors, in some cases where it's crowded and there's very little air movement, again, it's appropriate to wear this. Now, most people would look at me as if I'm a freak. If I were to do this and I don't care, I do it. I hope all of you feel empowered if you want to reduce your risk of becoming infected at this time with BA.5. Now is the time to wear an N95 respirator. And of course, finally getting people together socially, I understand, is something we all want to do. The activities in our own household is such that we ask people before they come here to have limited their contact with outside individuals in the three days before we get together, for example, for a dinner we all test on the day before and the day of the dinners to make certain that we, in fact, have the best data we have to show that we're not infected. Is that perfect? No. But it sure goes a long way beyond that of just having people get together and assume we're done with the virus. We're not. So I think from a national perspective, we are at that point of if you don't know where you're going, any road will get you there. The very quote that I opened this podcast with and I feel at this point you can take the control that you must and that you will find effective in reducing your likelihood of becoming infected, or at the very least becoming seriously ill and needing to be hospitalized and, God forbid, dying. So vaccination using your respirators and just recognizing we're not done with this pandemic yet.


Chris Dall: [00:31:22] An infectious disease doctor told The Wall Street Journal earlier this week that, quote, "this new variant's superpower is reinfection," unquote. He was referring, of course, to BA.5. So, Mike, we are hearing anecdotal reports of people getting reinfected with BA.5 just a few months after infection with a previous variant, in some cases, the BA.1 variant. But do we have any actual data on BA.5 and reinfections?


Michael Osterholm: [00:31:46] Well, Chris, as I just said a moment ago and I said at the beginning of the podcast, if you don't know where you're going, any road will get you there. I'm not sure what we have for this particular question in terms of definitive answers. But let me share with you what we do have, because it is a very important question. First of all, there is a July 7th preprint out of Qatar that does a really nice job of laying out how immune protection has changed throughout the pandemic. In this study, researchers explain that before Omicron emerged, a previous infection was 85.5% effective against reinfection and declined over time. Using trend lines, it was assumed that this effectiveness decreased to 50% nearly two years out, and less than 10% has got closer to three years post-infection. However, when Omicron arrived, a previous COVID infection with a strain that was not Omicron was only about 38% effective against reinfection with Omicron, and this dropped to less than 10% 15 months after infection. This is all to say that we have seen this decline in immune protection and subsequent rise in reinfections before. Fortunately, this study also noted that regardless of strain, a previous infection was still 97% effective against severe and fatal reinfections. Another preprint out Qatar also posted on July 12th, analyzed the effectiveness of a previous COVID infection against BA.4 and BA.5 infection. They found that a previous infection with a non Omicron infection was 28% effective against any BA.4, BA.5 reinfection and was 15% effective against a symptomatic BA.4, BA.5 reinfection. Remember immunity from pre-Omicron infection is expected to decline over time and we're about nine months out since Omicron became the dominant strain. So we'd expect to see this now. This study ultimately found that a previous Omicron infection was 80% effective against any BA.4, BA.5 re-infection and 76% effective against symptomatic BA.4, BA.5 reinfection. So to summarize these numbers, before Omicron, a previous infection was likely around 86% effective against you getting reinfected. With Omicron, this dropped to 38% and with BA.4, BA.5, it is 28%. Again, we would expect this over time. Now with the previous Omicron infection being 80% effective against any BA.4, BA.5 reinfection, some cases of reinfection are to be expected occurring right now. So this is where shifting baselines come in to play. Prior to Omicron, there was a lot more people who had never been infected than there are now after the Omicron surge. Ed Young explained this in a July 12th Atlantic article. Prior to Omicron, a third of Americans have been infected with COVID, and this number doubled to 60% by the end of February. This means that there's also now double the number of people who could be considered capable of being reinfected. So it's not surprising that we're seeing or hearing about more stories about reinfection. Ultimately, I don't think the situation with BA.5 is drastically different than what we saw with the original Omicron variant, but we can only wait and see what will happen in the weeks and months ahead. In short, expect reinfections to be a reality. But again, the thing that we're trying to achieve is less severe illness, less likelihood of being hospitalized, and possibly even the ability to still prevent clinical disease.


Chris Dall: [00:35:28] A few weeks ago, we discussed the FDA advisory committee's recommendation that the Novavax COVID-19 vaccine be authorized. That was followed by FDA authorization a few weeks later. And this week, the CDC's advisory committee voted to recommend use of the vaccine for adults ages 18 and older. So the long journey of Novavax to authorization is now complete. Now, some have suggested that because this vaccine is made on a more traditional vaccine platform, that some vaccine hesitant or even skeptical people might be convinced to get it. Mike, do you see it having any impact on vaccine uptake?


Michael Osterholm: [00:36:06] During our June 9th episode of the podcast, we discussed the FDA's decision to grant emergency use authorization of the Novavax vaccine. This vaccine was first authorized for emergency use in Indonesia and the Philippines in November of 2021. They were followed by the W.H.O., the European Commission in India in December, then South Korea, Australia and the UK in January and February 2022. And now of course the US. This vaccine, which was developed by the American biotechnology company Novavax in collaboration with the Coalition for Epidemic Preparedness Innovations, what we know is CEPI, and it has several real benefits. First, it is a protein subunit vaccine, meaning it uses purified pieces of a pathogen to trigger an immune response. Specifically, this vaccine contains purified pieces of the SARS-CoV-2 spike protein delivered alongside an immune stimulating adjuvant, a chemical which actually increases your immune response. This is important because protein subunit vaccines are incapable of causing infection and are considered generally to be very safe. This is a well established vaccine technology that has been used in other routine vaccines such as hepatitis B and acellular pertussis vaccines, which are all protein subunits, the pneumococcal polysaccharide vaccine and even our meningitis vaccines. Additionally, this vaccine is known to have a good safety record. In clinical trials, there were six cases of myocarditis or pericarditis reported following the Novavax vaccination among 41,000 vaccinated people. The risks were concentrated in days zero to day seven. It was higher in males and females and higher after dose two. But when you look at the expected number of myocarditis or pericarditis cases that would occur in infected individuals, they far exceeded the number that we saw actually with the vaccine. Another benefit of this vaccine compared with the mRNA vaccines, is that it can be stored in a standard vaccine refrigerator at two degrees centigrade to eight degrees centigrade, making it easier to transport and store. This is particularly important in lower income countries where cold supply chains are often less well established. This is really great news. But honestly, Chris, I'm not convinced that the CDC decision to recommend the vaccine will be a game changer here in the US. Yes, it expands the choices of vaccines and this being a vaccine based on an established technology with a good safety record could ultimately help drive vaccine acceptance for a small percentage of the unvaccinated population. But I don't think it will make a big difference. I am, however, hopeful that it could be beneficial globally. If we can make it available to those who need it, the vaccine has potential to make a dent in the global access. And again, I want to remind you that this vaccine was not approved as a booster. I know a number of you will ask that question. Well, can I get this as my third or fourth dose? And in fact, this vaccine was approved through emergency authorization only as a primary series vaccine. And that's an important distinction to make.


Chris Dall: [00:39:23] That brings us to our COVID query segment. Today's question comes from Tony, and it's regarding isolation after infection. Tony writes, "My family has tested positive for COVID-19. They are isolating at home. So here is the question we've been trying to answer. How long do they have to isolate? Five days and then five days with masks? Ten days? My daughter continued to test positive ten days after her exposure. So does this mean that the clock starts over or doesn't start until she tests negative?" Now, Mike, Tony sent us this question on June 28th, so we're not in time to answer it for him. But I think a lot of people have this same question. Is there a good answer?


Michael Osterholm: [00:40:02] Well, let me start out by just saying great question, Tony. And what I don't have a precise answer for, nor does anyone else I know. Hopefully I can shed a little light on what we know and what we don't know. I'll start with the current CDC guidance, which is, and I quote, "everyone who has presumed or confirmed COVID-19 should stay home and isolate from other people for at least five full days. Day zero is the first day of symptoms or the date of the day of the positive viral test for an asymptomatic person. They should wear a respirator when around others at home and in public for an additional five days." Let me just back up with this one, because I was actually involved with the discussions for the change in this recommendation. And I think historic perspective is important here. When the Omicron surge began in this country, we recognized we were going to have a major shortage of health care workers because so many of them would be either ill or in quarantine because of exposure. We could not let our hospitals go unstaffed. Many of the health care workers that were infected might very well be well enough to work, even with some symptoms. And so the question was, how soon can we have them come back to work? And at that time, we said, well, maybe five days if they wear a respirator after that for another five days. Let me be really clear. There were no empiric data that said do this or do that. It was a crisis related discussion that said, we can't let our hospitals go unstaffed. Patients cannot lay there all day in a bed and never see a health care worker. Well, very quickly, this recommendation got expanded by many others who basically said, oh, it's only five days, it's five days. That's all you need. And I saw this happen over and over again, as if somehow there were new data that said, oh, you're only infectious for five days, so this is a challenge. I just want to remind everyone that the CDC is the official government organization that makes recommendations about how we limit the transmission of a virus in any setting, including in health care. But there are some real differences in how other countries or global organizations have recommended isolation anywhere from 5 to 7 days to 14 days. For clarity, day zero is typically the first day of symptoms if you're symptomatic. Day zero can also be the first positive test. If you continue to test, and it's positive, you don't need to start the clock over. Now let me get to the heart of the issue. The data are really pretty sparse in terms of how long people are infectious with SARS-CoV-2. And even the data we do have has a number of different variables to consider, like which variant you're infected with, the severity of illness, underlying conditions, and any antivirals or treatments you may have taken. A recent editorial published in the New England Journal of Medicine showed that the median duration that people shed live virus or virus that when cultured in the lab is still active, is five days. This means 50% of people were infectious for at least five days. The interquartile range posted in that study was between three and nine days. This measurement, which helps to exclude significant outliers, means that 50% of cases were infectious for anywhere from 3 to 9 days. 25% were infectious for nine days or more. Based on what we know about BA.5, it appears it could be infectious even longer than previous strains included in the report. So living in a BA.5 world, I think it's pretty safe to say that many people could still be transmitting the virus after day five. It's really important to recognize that isolation has a really different impact on each person, depending on the life circumstances. For example, a number of people who work remotely and don't have significant caretaking responsibilities isolating an extra five or so days out of precaution is very, very feasible. However, for those who would miss out on needed wages, have caretaking responsibilities or other factors, an extra few days of isolation is a very big and potentially painful deal. So I think we need to be clear about limiting activities while understanding that essential functions may still need to take place. My hope is those that who need to go back to these essential activities have access to high quality respiratory protection and good ventilation. We're talking about respirators, not just face cloth coverings, but for those who don't have these responsibilities if you're making a decision about visiting a friend for dinner, a grandma or a grandpa for a visit or some other social activity, I would wait more than the five days and hopefully closer to ten days. Something I want to note here is that a number of people with Omicron infections may have symptoms for a few days before their test turns positive. It's really important that if you're having any symptoms associated with COVID infection. Sore throat, headache, congestion, cough, fever. Don't think that you're good to go just because your rapid antigen test was negative. For good public health practice, it's always best to stay home if you're sick, not just for you, but for all the people you'll have contact with. Tony, I think my primary takeaway here is if you have confirmed or suspected COVID-19, there is a good likelihood that you are infectious after the five day period and should take precautions as you're able. If you can stay limited in your contact with others through day ten, that is the ideal may not be possible, but again, trying to minimize transmission of the virus, particularly to those who are most vulnerable to serious illness, hospitalizations, and deaths. That is a wise piece of advice.


Chris Dall: [00:45:52] Now for an update on the monkeypox outbreak, which continues to grow in the US and elsewhere. In an editorial that appeared this week in the journal Science, you and coauthor Bruce Gellin of the Rockefeller Foundation wrote "Unless the world develops and executes an international plan to contain the current outbreak, it will be yet another emerging infectious disease that we will regret not containing." Mike, what would that plan look like?


Michael Osterholm: [00:46:17] Well, Chris, as you said, the monkeypox outbreak is continuing to grow with nearly 2,000 cases here in the US and a total of over 13,000 cases globally. Even though we're recording this podcast close to the date of release, the numbers are already outdated. So let's just expect that the numbers are going to grow substantially over the course of days and weeks ahead. I want to start by saying that I wholeheartedly disagree with anyone saying that public health officials in this country have failed entirely in their efforts to slow the spread of the disease. Several notable talking heads were on Sunday talk shows or in the media saying that. As you know, I, for one, have been very willing, even if at some level of pain, to be critical of my federal colleagues, if, in fact, I thought that they were not doing the job that they should. In this case, let's just try to understand the facts. First of all, it's not fair to blame the public health community for not having an adequate supply of the JYNNEOS vaccine, what we call the MVA vaccine for use with this particular emerging situation. While the United States put forward heroic efforts over the last ten years to even get this vaccine made and to get it approved, which was largely driven by the US, no one was going to be willing to pay many, many, many millions of dollars to stockpile many, many millions of doses of this vaccine when monkeypox at the time was still seen as often a very rare condition of Central Africa. And so the point is, we need a lot of vaccine right now and we don't have it. It is being made, it's coming. And one of the points we made in our editorial in Science is that, in fact, we're going to have to figure out how to stretch the vaccine we have for months ahead because we won't have enough. So this was not the fact that public health just is not distributing vaccine. It's they can't distribute what they don't have. We need everyone to understand that. And this is going to create a great deal of frustration. People are going to be angry. My advice has been to CDC and HHS leadership is now is the time to bring together leaders from the gay community, from local and state, public health agencies, from city and state governments, to actually sit down and say, okay, how are we going to prioritize it. If we have 10,000 people that really need this vaccine in your community and you're going to get 2,000 doses over the next six weeks, what are you going to do to prioritize it? Who should get it? How should they get it? Don't just put up a website that says the lucky several thousand get on first, get it. That's what's going to create the frustration. So I think it's really important at this point that we understand that the vaccine shortage is by itself one of the challenges we have with new emerging infectious diseases. Now, I tell you this story because it shouldn't have been a big surprise that this might be a problem. As I shared with you in the past, remember, for the last 40 plus years, we have not been vaccinating most of the world against smallpox. And so today, almost 80% of the entire world's population is 40 years of age or younger. And they do not have any protection against monkeypox, including the 327 million people living in the 11 countries in Central Africa where this virus is occurring in the wildlife, particularly in rodents. And so what we need to do is understand that for us to take on this challenge, we've got to have enough vaccine for everyone who is at risk currently, particularly among men who have sex with men. And that is a very sizable number, estimated to be well over 5 million. Now, the other thing is we do have to consider what are we going to do about protecting those in these 11 African countries so that they don't continue to get infected and then basically serve as the source for a global event? And that is going to be a real challenge. And then finally, we have got to have adequate surveillance for the possibility that animal species in areas outside of the 11 African countries could get infected from actually having exposure to a rodent hamster, guinea pig, God knows what. That an individual is infected might have exposure to. And if that animal were to get out, we can actually see what we call an animal reservoir develop in that area where then again, it's just like Central Africa. Now the spillover will occur from the wild animals to humans. So this is going to be an ongoing challenge. And we talked about this in our Science piece. One of the things we also recommend is we need to look at how can we extend the use of the vaccine that we already have. It's a two dose regimen, but do you really need to get two doses in people right now? There's already data available that says even one dose may protect people for some time and that if we could postpone the second dose until just weeks from now, but months from now, that would extend the amount of vaccine we have. What can we do to get more out of each dose? Can we use intradermal administration as opposed to intramuscular? We know with the intradermal you can often use a much, much lower level of vaccine to actually accomplish the same immune response. So what we need to do is really look at ways that we can actually expand the availability of these vaccines for now. And we have to be direct. I said this in our last podcast. I'm seeing so much frustration. I must tell you, I'm extremely disappointed in the leadership of the New York City Health Department, where they actually were working with community members to come up with guidance for how you can have sex safely when you're infected and have these vesicles. You know, for 3 to 4 weeks, no one should be having sex if they're infected. It's just that simple. And not to say that because you're afraid you're going to stigmatize someone, I think is just wrong. And fortunately, there are some really brilliant, experienced epidemiologists at the New York City Health Department who spoke up and disagreed with their leadership. And so this is just trying to placate a community and not really address a public health issue. Now, I know there will be some who will be upset with me for saying this, but we have to just as public health officials just tell the truth. And and what do we know about the risk and who is at risk and how can we target that risk? And we need to have that community be part of the solution. Help tell us how do we best distribute vaccines? How do we provide educational materials so that we can be certain that we're doing everything we can to lessen the risk of exposure? So let me just say at this point, this is a pandemic. It is a worldwide epidemic. It's going to get much, much, much larger. The good news is there's no chronic carrier state. Once you get monkeypox and recover, you now are no longer infected or infectious and you have protection going forward. Second of all is to date, most of the cases have been milder and I say milder. There have been people who have been really suffering, painfully suffering. But if you look at the severe illnesses, they've been very, very limited. So this is all good news. There are some of the talking heads who have been basically suggesting that we blew the opportunity to contain this epidemic pandemic. And I would say that's just simply not true. We were never going to contain this, ever. We didn't have the vaccines necessary to contain it. And so when it took off, spread around the world as quickly as it did, one lack of testing. Yes, that's true. But tell me, what government agency or what private lab would invest many, many, many thousands, if not millions of dollars into being prepared to have laboratory testing immediately available on a large scale for monkeypox when there are hardly been any cases around the world? I mean, who would who would have expected that? Just like we didn't expect to have hundreds of millions of doses of vaccine sitting around. But now laboratory testing has geared up substantially, at least in this country. We're seeing now many commercial labs involved. The CDC has put out over 80,000 tests for use in the community. And I think we're beginning to see the lab testing catch up with the very rapidly needed testing in the community. The other thing that we're seeing is, in fact, the rapid increase in the amount of vaccine, not nearly enough, but it's coming. And in the meantime, unfortunately, there will be people who will not have access to vaccine, who will be cases. And that's what we need to do, is also help them get through their infection and make sure that they don't transmit to others. So if you want more information on this and more of a perspective, we've linked the editorial that Dr. Gellin and I did in Science onto the website here, and you can go ahead and take a look at that and hopefully understand that we're going to be living with this for a long, long time to come. But we eventually will contain it. We will have enough vaccine eventually to contain this. Imagine if today we didn't have any measles vaccine and there were thousands of cases of measles. It would be a bad situation, but we would eventually contain it. As vaccine became available, we were able to vaccinate kids across the world. We could, in fact, bring this to an end. And that's what we have to count on with monkeypox. So stay tuned. It's not a great situation, but fortunately it could be a lot worse if we had a disease that had a much higher pathogenicity or virulence the ability to cause serious disease or death. And it did not result in long term immune protection once you recover. We've got those two factors on our side. But again, this is going to be a long haul.


Chris Dall: [00:56:16] Mike, where is this week's beautiful place?


Michael Osterholm: [00:56:21] Well, Chris, as you know, as a member of the podcast team, this is one of the most special parts of this podcast, is the opportunity to review what's been submitted to us as beautiful places and the spirit in which they were done. And oftentimes, the creativity is remarkable. And this one is no different. This particular beautiful place comes from Josh, and Josh wrote, "Hello, Dr. Osterholm and team. I've been listening to your podcast throughout most of the pandemic. Thank you so much for keeping the podcast family up to date and well informed about the state of this relentless nightmare. I truly appreciate the time and energy that you all devote to this podcast. After my wife and I were vaccinated in early 2021, my wife, young son, and I moved from Arizona to Hawaii, specifically to the island of Oahu. Since moving here, I found a new outlet for my creativity, which also gets me outside into the sunlight on a regular basis. I taught myself how to make what I call sand sculptures. These creations are just sand and water. No internal supporting structure needed. I find making these sculptures very relaxing and meditative. Sometimes I make them after work. Other times I camp out on the beach and make them in the morning. My favorite thing about them is watching other people stop to take a look and see that simple, joyful sense of amazement and wonder spread across their face. Just yesterday, a very friendly couple walked by as I was making a sand sculpture. They stopped to tell me that I am well known in the community. I had no idea. It made me so happy to hear that my sand sculptures bring joy to many people who spend time on the beach. I've attached to this email photographs of my finest sand sculptures yet. I present to you my beautiful place. Best to you all, Josh." Well, the pictures are attached and they are remarkable. I don't know what kind of business you're in, Josh, I don't know what your training is, but you also have to be an engineer of some kind to be able to get these sand structures to actually stand up as they do. So I just want to thank you. I know that if you look at these pictures, you all will enjoy, appreciate and feel inspired by what Josh has done. So, again, thank you very much. And I just want to again emphasize to all of you, please, send in your beautiful places to us, we we so appreciate them. And I hear back from the podcast family who tell us how much they enjoy them. So we call on all of you to help us out that way. Thank you.


Chris Dall: [00:58:53] And if you want to share your beautiful place with us or a celebration of life for a loved one friend, neighbor, or coworker who died during the pandemic, please email us at osterholmupdate@umn.edu. Mike, what are your take home messages for today?


Michael Osterholm: [00:59:09] Well, Chris, I think the first one should be obvious by now, and it is in keeping with the Lewis Carroll statement. "If you don't know where you're going, any road will get you there." We are not done with this pandemic. This virus is not done with us yet. Again, I also don't know what's to come. What are the variants, sub-variants we're going to see in the future? No one wants to hear this. We've got to learn to live our lives in the face of this virus so we don't live in fear, but we also live in a sense of public health responsibility to ourselves, not even talking about others to ourselves. And that's being as vaccinated as you can be. And it's also using respiratory protection in the best way possible. So I don't know where we're going. And as you've heard me say so many times, I don't know. That is only becoming more and more of a common thread in the approach that I take to COVID. Number two is the new variants are expected. Don't be surprised. Don't be surprised what else we see. I talked earlier about the issue around immune compromised individual. There are millions of immune compromised people in this world right now that any number who are harboring this virus and who over time may actually give us a brand new variant of major public health importance. So I know no one wants to hear this, but we've got to stay alert and awake to the fact that new variants or sub-variants will come. And finally, the third point is we still have so many unanswered questions, like the issue around the reinfection, around what's going to happen with variants, around the issue of what is happening with treatment and rebound. I can go through all of it. What's happening with long COVID? I never want us to forget our long COVID colleagues, people who are suffering, truly suffering from the long term effects of COVID. We can't ever forget those. And I also just want to emphasize again, thinking about the fact that 450 deaths a day, almost 3,000 a week. How can we not think about who these people are? Our moms and our dads, our brothers and our sisters, our friends, our colleagues. And, you know, this is not in my mind an acceptable outcome yet. I want better. We must do better. We need new and better vaccines. And I can tell you, our center is working like the devil to make that a reality. So I'm not willing to accept this as the status quo. And we have to continue to recognize the fact that we can live our life, we can reject the status quo, and we can hope and pray and actually do something to bring us a better future, which I think is going to be ultimately in the vaccine world.


Chris Dall: [01:02:02] And I understand you have a closing poem for us today.


Michael Osterholm: [01:02:05] Well, I did make a bit of a change up from my songs. And thank you again to all of you for the feedback on that song selection issue. I appreciate that. I can tell there's a lot of people in this group that are very musically inclined, and so I appreciate all your input. You know, I tried to find something to reflect the moment that we're in, what we need to do to rally, what we need to do to support ourselves, we need to do to find comfort. And I'm going to go back to a piece that I shared with you in Episode 26 way back in October of 2020. And at that time, the title was "COVID in the Capital," which you may recall, in fact, was around the events at the White House with COVID activity there. These words were written by Rudyard Kipling, who was an English writer and poet. This particular one, "If" was first written in 1895 but not published until 1910. And it's notable that in 1996 the BBC in a nationwide poll found that in the UK this was the favorite poem of all times among UK residents gaining twice as many votes as the runner up. Now, today I'm going to recite this for you with one modification, the Osterholm modification, which will be in the last line, and I'm sure you'll all recognize what that is. But again, this really, I think, captures the moment who and what we need to be, who and what we can be. "If" by Rudyard Kipling. "You can keep your head when all about you are losing theirs and blaming it on you. If you can trust yourself when all men doubt you but make allowances for their doubting too. If you can wait and not be tired by waiting or being lied about, don't deal on lies or being hated. Don't give away to hating and you don't look too good or talk too wise. If you can dream and not make dreams your master. If you can think and not make your thoughts your aim. If you can meet with triumph and disaster and treat these two impostors just the same, if you can bear to hear the truth, you've spoken twisted by knaves to make a trap for fools or watch the things you gave up your life to broken and stoop and build them up again with worn out tools. If you can make one heap of all your winnings and risk it on one turn of the pitch and toss and lose and start again at your beginnings and never breathe a word about your loss. If you can force your heart and nerve and send you to serve your turn long after they are gone. And so hold on when there is nothing in you except the will which says to them, hold on. If you can walk with crowds and keep your virtue. Or walk with kings. Or lose the common touch. If neither foes nor loving friends can hurt you. If all men count with you but none too much. If you can give the unforgiving minute with 60 seconds worth of distance run. Yours is the earth and everything that's in it. And which is more. You'll be a man, my son. And you'll be a woman, my daughter." Rudyard Kipling with an Osterholm modification. Thank you so much for joining us again. I hope this information was helpful. Sometimes I feel as if I am not very helpful because I can't provide more definitive or clear answers. But that's the reality of where we're at today. So I want to thank all of you for your support. I want to thank the podcast team again for all that they do. And just remind everyone right now, again, in a world that is so, so, so divided, now is the time to keep our heads and our hearts and be kind, be thoughtful, be kind, and be safe. We can be much safer than we are. Be safe. But most of all, right now, never forget how important and how powerful it is to be kind. Thank you.


Chris Dall: [01:06:28] 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 CIDRAP.umn.edu. This podcast is supported in part by you, our listeners. If you would like to donate, please go to CIDRAP.umn.edu/donate. The Osterholm Update is produced by Cory Anderson, Meredith Arpey, Elise Holmes, Sydney Redepenning, and Angela Ulrich.