November 17, 2022

Episode 118: A Time to Be Thankful but Alert

November 17, 2022

In this episode, Dr. Osterholm and Chris Dall discuss the trajectory of the pandemic in the United States and around the world, a recent study on COVID reinfections, and how RSV and influenza are overwhelming hospitals throughout the country.


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Episode 118: A Time to Be Thankful but Alert

Chris Dall: [00:00:00] We are proud to announce that the Osterholm Update Podcast, aside from being available on the CIDRAP website and usual streaming platforms, will now also be airing on American Busker iHeart Radio. So stay tuned. Thank you American Busker iHeart Radio, and owner and founder Nancy Hahn. 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. For much of the past year of this pandemic, we've been living in an Omicron world. It's almost hard to remember that when we recorded an episode of the podcast last November 23rd, we hadn't even heard of Omicron. But that all changed on November 25th, when the world got word of an immune invasive variant spreading like wildfire in South Africa. I can still remember getting the New York Times notification on my phone as I sat down for Thanksgiving dinner. I was not, as I recall, very hungry after that. Omicron is no longer the nightmare variant that it appeared to be at that time. And although we are seeing more subvariants of the Omicron family emerging, they do not appear at this point to be setting off the type of surge in infections we saw when Omicron first appeared. Let's hope it stays that way. Last week on the podcast, we presented you with some cause for optimism. On this November 17th episode of the podcast, we're going to dig a little deeper into the international and national data to see if that positivity remains warranted. We'll also discuss a recent study on COVID reinfections, provide an update on influenza and RSV, and answer a COVID query about the safest point to eat and drink when taking long international flights. But before we get started, as always, we'll begin with Dr. Osterholm's opening comments and dedication.


Michael Osterholm: [00:02:16] Thanks, Chris. Welcome back to all the members of the podcast family and to those who may be new to the podcast, we hope that we're able to provide you with the kind of information that you find useful and that you will come back again. And since this is our last episode before Thanksgiving, we will have a theme about that very sense today, thankful for you and thankful for all the good things that have happened in a world that has been quite tumultuous. To start out today, I want to share a dedication that has probably been more than 50 years in coming and one that I don't do often in the podcast, as you know, and that is to references specific individual or individuals. But I had something happen this past week that really motivated me to consider this particular dedication and one that I surely should have done a long time ago. On Saturday, I had the most incredible opportunity to be at the National Association of Biology Teachers meeting in Indianapolis an incredible organization of the biology teachers in our colleges and high schools around the country. And it's an amazing group of people who are really about the future of our biological education experience. And I was there to receive a distinguished service award for the efforts that I have put forward relative to things like COVID. Now, grant you I realized all along that anyone who knows me knows very well that I literally stand on the shoulders of my colleagues here at CIDRAP and people throughout my lifetime who have made it possible for me to be here. There was one particular experience this past weekend that was one unlike any I've ever had in my life. It turns out that, as some of you know, in my early days, my childhood, it was a pretty tumultuous time. I was the oldest of six kids in a family that had a father who was an alcoholic, who was mentally ill, who basically communicated with his fists without regard to your age or gender. And I spent most of my upbringing really trying to protect my family and my mother from my father. Well, it got to my senior year of high school at a time when we were in dire straits financially, as my father drank away virtually every paycheck and that the violence got so severe that one night I literally kicked him out of the house and now had to assume, in a sense that senior leadership position as the son who is now needing to take care of his sibs as if he were a father. Well, in the context of all of this, I did not know what my future would bring. I had a high school guidance counselor who told me that I wasn't college material and that I would best work at a tire shop in my small Iowa farm town. But I had had the opportunity in the previous year to work with a professor in biology in a nearby community, Decorah, Iowa, some 18 miles from my home and the home of Luther College. Many of you know that is my undergraduate college of record and one that today I serve on the Board of Regents there with great pride and appreciation. But this biology professor and his wife ended up becoming really almost a surrogate father and mother for me in this experience. And I remember so clearly in a mid-May afternoon in 1971 of my senior year of high school, sitting on Doc David Roslien's front porch with him tears streaking down my cheeks, saying, What do I do? I don't really know what to do. I don't have a future. And Doc looked at me and said, you're going to go to Luther. And we're going to take care of that right now. And this was a Sunday. By Wednesday afternoon, I'd been admitted to Luther with virtually a full ride package, all made possible because of what he did. Well, the long and short of it, both he and Joy, over the course of the next 57 plus years has been there for me day in and day out. I owe so much of my career, my personal life, the joys of life that I know due to the Rosliens. And so on Saturday, Doc was not aware of this, but I asked him to come to Indianapolis with his wife, Joy. And they were at the ceremony when which I received this award. And I accepted the award with great humility and appreciation, but made it very clear that while it was mine today, that Saturday it would be Doc's forever. And in fact, at that point, I gave that award to Doc. I know that that will never be sufficient to repay him for all that he's done for me or all of us in our world who have had Docs in our lives, Joys in our lives, who have been there for us. And so today I dedicate this podcast to Doc David Roslien, who still will be my biology professor of record, who is the man that basically made it possible for me to get a higher education one day to go on to the University of Minnesota and most amazingly, one day lead this incredible group called CIDRAP. And I hope all of us today with the sense of this dedication, reach out to those in your lifetime, even just been 50 years ago, and to acknowledge in this Thanksgiving week how much you appreciate what they did for you, because we all have had those experiences in our lifetime, maybe some more than others, but we've all had them. And today I dedicate this to Doc, and I urge all of you to go find your dedications in this next week and a week and a half to all those people who could very much appreciate the role that they played in our lives. Now, moving on in terms of the good news, this is going to be an interesting one today because later on you'll see that there's going to be a tie in to my discussion of sunlight. As you know, I have now chosen Auckland, New Zealand, to be my place on this earth, where I follow closely the amount of sunlight each day as they are soon to be in the height of their summer period. Today, on November 17th in Auckland, they will have 14 hours and 8 minutes and 19 seconds of sunlight. They're averaging almost one minute and 44 seconds of additional sunlight each day. Just a week ago it was at 13 hours and 55 minutes and 27 seconds. They've gained almost 13 minutes of sunlight just in the last week. And of course, I always acknowledge my dear, dear friends at the Occidental Belgian Beer Huis on Vulcan Lane in Auckland. And today, we'll come back to that a little bit later with a wonderful story to tell. So again, thank you all for being with us. This means a great deal. I am very fortunate to have this opportunity to be with you. I never take that for granted. And I want to acknowledge all the work that the CIDRAP podcast team puts into this. So thank you. And with that, Chris, let's get on with the show.


Chris Dall: [00:09:30] And we'll start, Mike, where we always do with the international situation. Last week, the trends appeared to be positive in Europe compared with the previous weeks. And as you know, and our audience knows, Europe is a place we always pay attention to. Has anything changed in Europe or elsewhere in a way that gives you pause?


Michael Osterholm: [00:09:49] Well, I've got to say that actually, that's a really tough question, Chris. And the reason I say that is because we've been outmaneuvered by this virus time and time again. Remember that word humility? It is really a very important concept to consider each and every day with this virus. So when I look at the latest numbers, what's happening or where I think we're at, there's almost the back and forth process or interrogation happening in my mind, where I am constantly asking myself, what exactly am I basing these conclusions on? And let me tell you, after almost three years of trying to figure out this virus, I think second guessing this situation has become a fairly prominent part of my daily routine and frankly, for that of the rest of the CIDRAP team. So at this point, in a nutshell, I think there are a few things we should be keeping tabs on. But I also believe there has been some reassuring news that warrants our attention. That being said, let's start with the positive side of things. First of all, even compared to last week, there has been some improvement in where things stand as far as global daily deaths go. At the time of our last episode, we were at nearly 1,700 deaths a day, reported on a worldwide basis. Otherwise, as of this Tuesday, it's just above 1,400. Now, in my mind, 1,400 is still much higher than I'd like to see. In fact, if you average that number out across the entire seven day week, you're still talking about basically 10,000 deaths a week. Is that better than 75,000 weekly deaths that were reported this past February? Of course. And 1,400 is surely better than 1,700. But I think there are still plenty of room for improvement in this area. Otherwise, overall progress in terms of further reducing mortality has been somewhat slow going as of this late. So I welcome this reduction and hope to see it continue. The next bit of reassuring news has to do with the latest variants and where things stand with them as of right now. Again, this was really the basis for the positive developments shared in last week's episode. So it's not exactly groundbreaking, but when we initially saw the subvariants like BQ and XBB take off in so many different locations and start cannibalizing BA.5, there was a sense of deja vu all over again. Remember, the BQ and XBB subvariants are the ones that have the very high level of immune invasiveness, a reason to believe that they could be a much more serious challenge. Much like their Omicron predecessors that had success at the global level, these are highly immune evasive, and they prompted concerns about yet another variant driven wave. Fortunately, this hasn't exactly matched up with the reality we're seeing play out so far. Although they've appeared to hold their competitive edge over BA.5, that growth advantage hasn't always translated into resurgent activity. Last week we brought up the example of France, where most cases are now either BQ.1 or BQ.1.1. Despite some difficulties with their reporting these past couple of weeks, case numbers in France have remained more or less the same since early November. Hospitalizations there have also declined. So at this point we still haven't seen any sign of a BQ driven surge in France. And while it's still somewhat early, a number of other countries like Spain, Portugal and the UK have so far gotten by without growing activity, even as BQ has been edging out BA.5. Otherwise, in terms of XBB, the available evidence at this point has been somewhat sparse. Now, obviously we saw where transmission took off in Singapore these past several months, which overlapped with XBB becoming the dominant variant there. However, in other countries where XBB has been growing and could even become dominant like India, things haven't played out in the same way. That being said, one of the major challenges we're dealing with right now is an overall lack of comprehensive sequencing data in a number of countries. So when you only have a couple of hundred or maybe even a few dozen sequences being uploaded from a country with a much larger population, you're not necessarily getting the whole story. But with many places scaling back sequencing or not publishing their data, that leads to more uncertainty. So we can only do the best we can with the information given. Still, at this point, I think every day that goes by without an obvious pattern of variant driven waves is a very positive sign. So where does this leave us? Well, that's where the whole humility piece comes in, because I'm not exactly sure. The truth is, even with these reassuring developments, there are lots of questions we still don't have an answer to. And that uncertainty has been a recurring theme of this pandemic. By now, I think listeners of this podcast know that all too well. As much as I'd like to say this is the end, I can't. Could it be the beginning of the end? Who knows? Maybe. Otherwise, there are still those things that occasionally cause me to sleep with one eye open. Probably topping that list is the capacity that this virus has to evolve. In some ways, comparing the original ancestral version to the ones we see now almost feels like we're talking about the difference between a Model T and the latest high performance sports car. It's not slowing down. Almost on a daily basis,we see new versions. This includes even more descendants of BQ and XBB. Then you've got BN.1, BE.9, CA.3, CZ.1. The list goes on. But the key message is that the viruses keep on changing and picking up all these different mutations, many of which have been linked to immune escape. So that represents the big wild card in all of this. And even if we do end up getting by without a BQ or XBB wave, their mutations limit some of the treatment options that have previously been effective, like Evusheld. At the same time, there's still a lot of virus out there, even in its current form. Right now, more than 370,000 cases are being reported on a daily basis. And while that's down from where things were a month ago, it's been steadily increasing throughout the entire first half of November. And, of course, remember the caveat. We do know that these reported cases of infection are a gross underreporting of what's actually out there. We're seeing waves in places now like Japan and South Korea that contribute to this recent rise. In South Korea, average daily cases have climbed from 20,000 to 51,000 in just the past month. During that same time, Japan has gone from 29,000 to 72,000. And in both countries, deaths have also now increased, with Japan going from 50 a day in early November to 80 a day now, and South Korea going from 20 a day to 45 as of late. Finally, based on the sequencing data made available so far, neither country's activity appears to be fueled by a new variant, almost reminiscent of what we saw happen in parts of Europe just two months ago. So with this intermittent waves happening in places like Singapore, France, Germany and now Japan and South Korea, all of which have above average vaccination rates, I think this could easily play out in other locations. And to conclude, let me just say I want to point out what's been happening in China. Even since last week, the situation there has grown much more challenging, with local case numbers going from 7,475 then to now today 17,772. Just two weeks ago they were at 2,700 and each of the country's 31 total provincial level regions have identified cases, so it's widespread. If you look, at some of the hotspots there include the Guangdong province, the city of Chongqing and the Hunan Province, which have been reporting thousands of cases a day. And in fact in Guangzhou, which is the capital city of the Guangdong province and one of the world's largest manufacturing hubs, is dealing with an outbreak that up to this point has been growing at a rate similar to what we saw earlier on in Shanghai's outbreak last spring. On Tuesday, daily cases there exceeded 5,000 for the first time, and concerns about a potential citywide lockdown reportedly led to public demonstrations. At the same time, an outbreak in Beijing has ballooned from 60 cases last week to 462 cases yesterday. Overall, a recent analysis from JPMorgan looked at all the cities in China that have reported at least ten cases in the past week, which has prompted lockdowns and determined that they are home to a combined population of 780 million residents and account for 62% of the country's GDP. So if nothing else, fasten your seatbelts for what we might see from China in the weeks ahead.


Chris Dall: [00:18:58] Not to the US where the question is similar. Mike, is there anything you're seeing in the US data that suggests the trajectory could change in the coming weeks, especially given the travel and the large gatherings that we're going to be seeing in these next few weeks?


Michael Osterholm: [00:19:14] Well, Chris, overall, national trends show relatively steady activity across the US. Cases are up slightly over the past two weeks, although case numbers are not to be trusted, as I've just noted before. Hospitalizations are up 2% compared to two weeks ago and deaths are actually down 10% over the past two weeks. However, if we take a closer look at state and regional cases, this is not necessarily the case where it's the same in all states. We are now seeing the Southwest light up with COVID activity. Colorado, Nevada, Arizona and New Mexico have all seen hospitalizations increase by 40% over the past two weeks. And their case numbers, which again are not to be trusted, have also shown similar increasing trends. We're fast approaching the holiday season when people are traveling together with friends and family, with much of the general US population blissfully unaware of what's happening with COVID-19 in this country, I can see that the activity that is occurring in the Southwest beginning to occur in other regions of the country. Let's talk about the US data and the relationship to the variants. The BQ.1 and BQ.1.1 variants continue to take hold in the US, now making up 44.2% of new cases in the US combined. That means 20.1% are BQ.1 and 24.1% are BQ.1.1, while BA.5 makes up 29% of the new cases. While the rapid rise in prevalence of these variants may seem alarming. I want to draw attention to New York's data, where we see the highest percent of BQ.1.1 activity in the country. Fortunately, over the past two weeks, New York has seen COVID activity decrease, including a 2% decline in hospitalizations. This is positive news that we're not seeing increase in hospitalizations or deaths, despite the increasing prevalence of this new variant, and there are no trends that suggest anything differently in the US overall. I might add that the states that I just mentioned where cases are increasing, Colorado, Nevada, Arizona, New Mexico have not seen any significant increase in the BQ.1 and BQ.1.1 subvariants. So we can't explain what's happening there just based on those alone. So we are seeing a few different storylines here and we're in a wait and see type of moment on which one will play out in the coming weeks. On one hand, we're seeing a variant trend that suggests that despite two new variants growing in prevalence, they're not going to cause an increase in COVID activity and hospitalizations. However, we are also seeing a competing storyline in the southwest that suggests we could be in for a tough holiday season. We can only hope that the variant story wins, that we don't have a surge of cases and hospitalizations that lead to our already overwhelmed hospitals being even more overwhelmed. I'll comment more on the overwhelmed hospitals in a moment when we talk about the almost unprecedented situation we have right now with respiratory virus (RSV) and influenza.


Chris Dall: [00:22:18] All right so speaking of those two viruses, Mike, while COVID-19 cases and hospitalizations have remained steady, the latest weekly report from the CDC shows flu activity continuing to rise while children with respiratory syncytial virus or RSV continue to fill up children's hospitals. How concerned are you about the capacity of US hospitals to deal with multiple respiratory viruses over the coming weeks and months?


Michael Osterholm: [00:22:43] Well, Chris, let me put the situation to some context. Anyone who has been listening to this podcast over recent months knows that I have had real interest in what the interaction is between different viral respiratory pathogens such as COVID, influenza, and RSV. And might they cancel each other out or at least reduce the likelihood that one or more of these viruses take hold when another one is prominent? And we surely have seen evidence of that in throughout the pandemic, where we've seen RSV not show up in the wintertime or even for that matter, influenza when COVID was running wild. So we're still trying to understand that piece. But what I'm about to share with you is virtually unprecedented in terms of the combined activity we're now seeing with RSV and influenza throughout the country. I continue to be extremely concerned about the capacity of US hospitals to deal with the surge in respiratory viruses, most notably RSV and influenza with some impact yet from COVID. Though, the picture looks a bit different based on region, the south and southeastern regions are experiencing a slight decline in weekly RSV cases, but these regions are also seeing the highest rates of influenza. In terms of influenza, we're seeing seasonal increases nationwide that have not witnessed this type of early activity dating back to 2010-2011. We have not seen case activity this early and this quickly in literally many years. By the end of last week, half the states were reporting very high or high flu activity. 25 states reported very high, 16 states were high states activity. About 6,400 patients were admitted to hospitals last week. The worst spots for flu in the country are still the south and southeastern regions, followed by the south central, west coast, and mid-Atlantic regions. Most of the indicators we use to measure flu activity are on the rise. The overall percentage of respiratory specimens that tested positive for flu, which jumped to around 13% last week. Outpatients visits for flu like illness, which can reflect activity from other respiratory viruses, rose from 4.3% to 5.5% last week. As I mentioned, flu hospitalizations last week were at the highest levels through this point in the season since the 2010-11 season, with the highest rates in seniors and children as old as four. Tragically, three more pediatric flu deaths were reported, bringing the season total to five. Influenza A continues to dominate this season with H3N2 making up about 75% of the subtype viruses. CDC testing results on a subset of H1N1 and H3N2 viruses suggests that the strains in the current vaccines are a good match. Good news. Be sure to get your vaccination as soon as possible if you haven't already. Now turning to RSV. The trend of elevated RSV cases that started in the southern US is now being seen in other regions of the country. Just as we're observing cases in the south and southeast decline significantly. It is continuing to stress pediatric hospitals across the country and in many instances, even local and regional hospitals are feeling the stress. For example, in Michigan, officials from the C.S. Mott Children's Hospital in Ann Arbor said the hospital is 100% full, with health providers grappling with an unprecedented surge in respiratory infections. Emergency department wait times are hours and hours long, and some elective procedures have now been canceled. And in Delaware, the Delaware Health Care Association proactively sent a request to pediatric nurses to please help with an already severe strain on hospitals. In Southern California, some hospitals have reported putting up tents to handle the crush of patients seeking care for flu and other respiratory viruses. And late last week, Colorado's governor signed an order that extends the state's COVID emergency declaration and includes RSV, flu and other respiratory viruses. The order allows state agencies to continue to access state and federal funds for recovery efforts, respond to public health changes, and support the health care system with staffing and other precautions. And here in Minnesota, pediatric ICUs are full and hospitals are nearing capacity. It has been described by a number of the practitioners as the most challenging situation they've seen in many decades. Most admissions involve infants or toddlers, but one in five involve people age five and older, including some adults. In hospitals in the Twin Cities metropolitan area, emergency departments are experiencing volumes they have never seen before, and hospital capacity is worse than it has been at any point in the COVID-19 pandemic. Imagine that. As hard as it was to get through COVID we're now experiencing this situation in a stressed health care system that is already rebounding and doing that with some real strain from COVID itself. Overall, this is a very concerning picture for respiratory illnesses across the US and we're keeping a close eye on hospital capacity. Stay tuned. This one is not done and it's one that again, all I can say is from an influenza standpoint, please get vaccinated, get your children vaccinated. It may not prevent them from getting influenza, but it can do a lot to reduce the incidence of serious illness, hospitalizations and even deaths. Stay tuned.


Chris Dall: [00:28:20] Mike, there was a study published last week in Nature that received a lot of media coverage. It dealt with reinfection and increased risks associated with reinfection. Now, we know that a lot of people in the US and around the world have had COVID more than once. What do people need to know about this study?


Michael Osterholm: [00:28:37] Well, let me start out, first of all, with a familiar refrain. The more we learn about this virus and the effect the disease has on our bodies, the more we realize how much more are we still don't know. The study you mentioned in Nature Medicine from last week is continuing to build a better picture of the impact of COVID-19 in the short and longer term. To look at the impact of reinfection, I think we have to start by discussing what COVID-19 is doing to our bodies in the first infections as well. And let me just add, remember the discussions of a year to two years ago about quote unquote, natural infection. If you just got infected once, that that was going to give you a lifelong protection and how well the vaccine would work. And now here we are talking about the significance of multiple infections and what that means. This is clearly an area of significant research of priority, especially the longer term impacts of infection. We know that COVID-19 triggers significant inflammation. While all the physiological mechanisms aren't fully understood, we do have evidence that COVID-19 directly and/or indirectly damages the lining of our blood vessels, also known as endothelial cells. These are really critical in preventing clotting, controlling blood pressure and regulating oxidative stress. Damage to these vessels can result in blood clots and organ damage, something we're seeing in patients with COVID-19 during initial infection and unfortunately, sometimes even in resulting months. We don't have sufficient evidence stating how long this damage might last and why it appears to resolve in some and not in others. Now, the risk of these more severe complications of COVID-19 is still relatively rare, considering the number of people being infected with COVID-19 over the last few years. The highest risk for these post-acute issues in cardiovascular and other organ systems seems to be in those who are hospitalized for their COVID infection. However, we do have cases of relatively young, healthy people with major cardiac or pulmonary involvement months after their infection. What we don't have right now is a way to effectively screen individual's risk for these complications and provide more proactive treatment plans to reduce cardiovascular or other sequelae. This is just the impact of a first time infection with COVID-19, certainly something that's worth avoiding. But what about those who've already had COVID and recovered? Does it matter if you're infected again? Well, according to this recent study in Nature Medicine, it certainly does. Researchers in this study found that repeat infection with SARS-CoV-2 not only provided another opportunity for potentially severe disease or post-acute complications, but these complications were more likely if the patient had already had COVID-19 once before. In the study, population reinfection with COVID-19 doubled the risk of death and tripled the risk of hospitalization compared to those infected for the first time. So again, infection in and of itself does not provide you with the magic key to avoid the risk of serious outcomes with COVID. Those who were reinfected with the virus were three times as likely to develop subsequent heart or lung problems. This was most evidence in the months following their infection, but still substantial at their six month follow up. There's more we can say about this study to assess what it means practically. It was a significant sample size, but conducted in the VA medical centers, a mostly older male population that may have more likelihood of risk factors such as diabetes or high blood pressure. However, I do think the statistical controls during the analyzes were robust, so it's certainly not irrelevant to the rest of the population. Additionally, a previous study by these same authors from this February on the impact of first COVID-19 infection and long term cardiovascular outcomes compared risk for those within the VA system and found very similar results. COVID-19 infection is impacting our cardiovascular and other organ systems significantly. The main takeaway is that just because someone may have gotten COVID-19 once, it is certainly worthwhile to avoid getting it again. While vaccination and boosters can play a role in reducing the risk of severe disease and death, many of these physiological changes are still incredibly nuanced and remain a mystery to researchers. It is worth taking mitigation measures like wearing respiratory protection and avoiding large gatherings to avoid potentially devastating long term impacts of being infected. Again, another piece of the COVID picture that's only now beginning to unfold.


Chris Dall: [00:33:25] Now for our COVID query segment, which asks about eating and drinking during long international flights. Here's an email that we received from Christine, who wrote "I started listening to this podcast later in the pandemic, but find it enormously useful for the latest information. Thank you to all, and particularly Dr. Osterholm. I'm wondering when he said that he's taken long international flights and kept his mask on, where is the safest point in the journey to unmask and to eat or drink water? Preflight? Is an airport lounge safer? Or do you do a quick unmask on the flight? Or is it really safe anywhere in the travel process? Thanks. I greatly miss travel and look forward to planning a longer flight soon."


Michael Osterholm: [00:34:05] Well, Christine, thank you for that very, very thoughtful question and one for which I will say right up front, there is no hard, magical scientific data to give you a firm and comfortable conclusion. But let me tell you what I do based on what I know and how I actually respond to that risk. Yes, I am flying again. I'm back. As you know, I just came back from a trip to Europe. I was in Indianapolis over the weekend. I will be going to Boston later this week. And so I'm flying. This is what I do. First of all, I recognize that you are not instantaneously infected with this virus, much like a bullet might hit you. But remember, we've talked time and time again about the concentration of the virus in the air and the time of exposure. So that it may take minutes, in some cases even much longer, where the virus is at very, very low levels before you have inhaled enough virus to become infected. So if that one moment happens where you are not masked, for example, that doesn't necessarily mean that you put yourself at high risk for infection. Now, let that unmasked period lasts for hours, that's a very different story. So what do I do? I have no magic bullets. I have no good scientific information. I've actually talked to those who are real experts in respiratory protection. They say, well, it makes sense to me. So I do drink, you should always drink on flights. And when you're an old man like me, you should also get up and walk around so you make sure that you keep that blood flowing to your legs. And what I do is I literally lift up the bottom of my N95 just enough to get a good swig. I've learned how to drink one bottle of water on one swig. With the mask open for anywhere from 20 to 30 seconds. I don't breathe during that time period. I just drink. And then I put the mask back down. I will also do that with eating. I will take a bite, mask up, eat, mask down. Then breathe. Now, I don't know if that's exactly what's necessary to keep the virus out or if it will be sufficient to keep the virus from infecting me. But at this point, those are the things that I do. I do not get into busy lounges where I'm unmasked. I'm constantly masked, whether it's on the plane or in the lounge, wherever. And I also try to avoid getting on the plane too early. Remember, during that time period, the air systems are not really moving. It's only when the engines are going, which often is not while the plane is sitting at the gate. So I do, in fact, try to get on later onto the flight, then early. So where does this leave us? Well, we all have to live our lives. I'm living mine right now, I believe, safely. I am using practical experience to say to me, my N95 is my best friend on these trips. I use it, but I also learn how to use it in a way that allows me to eat and drink. Also, I just want to remind people as coming into Thanksgiving Day where family and friends are going to get together, I urge you to consider a scenario such as we use in our household here. Again, I can't say it's bulletproof, but so far it seems to have worked. One, the rule is no one is allowed at an event who has had a known exposure to someone with COVID in the previous three days before the event. Number two, no one is allowed who has any symptoms suggestive of an allergy or potentially COVID to attend. And third, we test everyone the day with a lateral flow test, knowing they're not perfect. But they're another way to look at the risk issue. Now, this means we can still have people together, including kids and family. I hope that people can feel some sense of confidence in doing this and getting together. We need each other. We need Thanksgiving. We need to feel close. And so I hope that in that sense, that's the case. I might add that I was very fortunate over the weekend at the Indianapolis meeting that I was able to get a private room so that Dr. Roslien, Joy and Fern and I were able to eat privately and with masks off. And here I am now towards the end of this week, still doing well. And I felt confident that that, in fact, was a quite safe activity.


Chris Dall: [00:38:35] Mike, We haven't discussed monkeypox in recent episodes, which is certainly one sign that it appears to be on the decline. What is the latest on the monkeypox outbreak both in the United States and abroad?


Michael Osterholm: [00:38:48] Well, Chris, as you mentioned, the monkeypox case reports are going down on a weekly basis and they're going down globally. Right now, we're seeing an average of 177 new cases each day. And in the United States, we're seeing an average of 40 new cases each day. We have not seen global case numbers at such a consistent low level since mid-June. And national case numbers have not been this low since mid-July. An increase in vaccination rates, immunity from previous infection and behavior changes among those most at risk are likely all contributing to this decline in cases. Frankly, I do believe it's most likely that those who have been previously infected and now are immune from becoming reinfected are likely a very key piece to suppressing ongoing virus transmission even if high risk activity is resumed. Since reinfection with monkeypox is considered to be highly unlikely, we should expect to see some long term immunity of this virus at at risk groups. That's going to be important. Additionally, it is still not too late for anyone who believes they may be at increased risk of contracting monkeypox to get the JYNNEOS vaccine, or if they've already gotten one dose to be sure and get their second dose. And while we don't expect all behavioral changes within at risk groups to be permanent, public health professionals and health care providers should still continue to encourage safer sex practices, including limiting anonymous partners and avoiding close contacts with anyone experiencing symptoms of monkeypox. I want to acknowledge that although the situation is drastically better than it was just a few months ago, it is very important to recognize that 40 new cases of monkeypox each day in the United States would have been unheard of just a few months ago and most definitely would not have been something to celebrate. I also need to acknowledge that there are still ten countries in Central Africa where this virus is endemic that will continue to struggle with this virus until more of their population is immune, hopefully through vaccinations and not natural infection. Remember, over 340 million people in those countries are under the age of 40, meaning they would never have been exposed to a smallpox vaccine that may still be providing some protection today against monkeypox infection. I hope we can see progress here with monkeypox and the fact that we do need to deal with the issue in central Africa. I worry that right now vaccine supplies are highly limited to mostly high income countries. Remember, the only producer of this vaccine, the JYNNEOS vaccine in Denmark, has very limited capacity for production at this time, and we are not taking care of the world. And while some may think of this as an altruistic issue of why we should be providing low income countries with these vaccines, yes, that's true. But just think about it strategically. If we continue to see spillover and spillover and spillover from the wildlife reservoir in these countries to humans in those same countries, we will continue to be challenged with monkeypox worldwide. So this is really an important issue that we have to take on. And I'm concerned that I don't see a global effort right now to really determine how will we break that cycle of transmission from the wildlife reservoir in Africa to the population living in those countries.


Chris Dall: [00:42:17] As you noted in your opening comments, Mike, this week's beautiful place submission is about a place that is near and dear to your heart. What can you tell us about it?


Michael Osterholm: [00:42:28] Well, Chris, this indeed was a truly beautiful place for me, and it's one that has special meaning, as you all know, in terms of Auckland, New Zealand. But in addition, this very special bar that I talk about often in Auckland. And we have a podcast listener, Robin, who actually went to New Zealand and per the podcast information went and visited this favorite bar of ours and sent us some of the most amazing pictures of her experience there and the entire experience she had in New Zealand. So Robyn, thank you so much for providing us this beautiful place. We have put the pictures online and let me share with our listeners. You're very kind and thoughtful email. You said, "Dear Dr. Osterholm, I've been following you ever since the beginning of the pandemic. You have no idea how much your words have meant to me, especially during the darkest days of the pandemic. More than once, I shed tears while listening, and I'm so grateful for the information you provide in a calm and reassuring way. I really can't tell you how grateful I am for all that you and your team do to keep us apprized of the latest developments with COVID. I'm sorry, I don't tell that to all of you more often, although I did send you a note in a Wartburg mask at the beginning of the pandemic, and you posted one of my acts of kindness in December of 2020. So maybe I'm not a total slacker. By the way, for the audience Wartburg College in the same athletic league with Luther College. I think I am one of the last few people in the world who is wearing a mask when they go out in public. My husband and I went out to eat in September for the first time in over two years and end up getting COVID. I was down for five days, but luckily he was asymptomatic. We had both received our bivalent vaccine a week before. I guess it did not have a chance to kick in. I'm thankful neither one of us ended up getting long COVID. Last month, my son and I visited a relative in Auckland, New Zealand. It was a trip that had been postponed due to COVID. You can imagine how tickled I was when you started reporting on the increasing amount of sunlight in Auckland. We had the best time in Auckland. We went to the top of the Sky Tower and walked around Albert Park and the downtown area. It was lovely to experience spring with its blossoming flowers and budding trees since, as you know, we all are well into fall here in the Midwest. We also visited the South Island and took a cruise on Milford Sound. Wow. I was able to visit one of your favorite places, the Occidental. It did not disappoint. I can totally understand why you love it so much. And my son and I visited several times during our stay as it became our favorite place to wrap up the end of the day. We befriended two of the bartenders, Jacob and Mateo. I have included their picture below. They instructed me to refer to them as the dreamy drink makers. I had the opportunity to play the portion of your October 27th program for Jacob, where you gave a shout out to the crew of the Occidental. He got the biggest grin on his face and had no idea you were mentioning their establishment. I'm sorry for this long and boring message. Hope you enjoy the photos and that you will be able to return there soon. Thank you. Thank you. Thank you from the bottom of my heart for helping me and many others through the pandemic. Sincerely, Robin." Well, Robin, thank you, first of all, for your very, very kind note. And I love the pictures. That is the Occidental bar that I love so much. And aren't those Kiwis just incredible people? And so to all the Kiwis enjoying the increasing sunlight, thank you for sharing that with us and keep up all that wonderful life you live down there.


Chris Dall: [00:46:08] Just a reminder to our listeners that if you want to tell us about the beautiful place that has helped get you through the pandemic or share a celebration of life for a loved one friend, neighbor or coworker who died during the pandemic, please email us at Mike, what are your take home messages for today?


Michael Osterholm: [00:46:27] Well, Chris, again, I've tried to summarize these in three points. Number one, I'm not sure what the next 3 to 4 months will bring. I just don't know. It's a situation where if it continues as it is now, at least from a COVID perspective, we may actually see reduced activity. I do have to say that the potential for new variants to emerge are still there. And as I've said time and time again, I think that we really won't know we're out of this pandemic until at least a year or more after we're out of it, because by that time we'll have had evidence that it doesn't appear anything new is happening. So hold on, we're not done. Number two, RSV and influenza together with COVID, are really challenging our health care system in a way that was not even experienced during COVID itself. We do not realize in this country how health care systems are hanging on by a thread. They're losing millions and millions of dollars. They have inadequate response staff. They have inadequate response facilities, and they are challenged to even handle routine activity in many locations. But when you add up these surges in cases that occur with these infections, it is incredibly stressful. I can't tell you how many intensive care physicians, both pediatric and adult, how many emergency room physicians and nurses, how many people who work in all areas of health care who today can tell you this is a crisis situation. And so I want to thank them for all they continue to do. You know, you never really appreciate someone like that until it's your six month old child who is lying there in critical condition with RSV. This is truly, truly a time where we appreciate our health care workers more than ever. And finally, let me just say, get your vaccine, both COVID and influenza. Have your Paxlovid ready to go or at least be able to get at it if you should get COVID. And do not be afraid or uncomfortable to wear your N95 in public. Go wherever you want to go with it. I today am proud of it, and I want everyone to understand that together we can do much more to protect ourselves in public settings if we want. And as I described how I fly in an airplane, it doesn't mean you have to completely close off your mouth to all intake. It's just a matter of how we can do it safely. And finally, I just want to say, I want to wish all of you a very, very happy, safe and blessed Thanksgiving. I hope you're able to share it with family and friends safely and that it brings a new sense of thankfulness this year after all we've been through.


Chris Dall: [00:49:22] And do you have a closing song or poem for us today, Mike?


Michael Osterholm: [00:49:27] Well, thank you, Chris. Of course, we will have a closing something here. It wouldn't be the podcast without it. You know, trying to match up the season, the feelings, the experience, the questions, all the things that are front and center of our life right now. I think we have found a song that matches up to those moments. Today I'm going to share with you "Thanksgiving Song" by Mary Chapin Carpenter. She wrote and performed this beautiful country classic. It comes off of her "Come Darkness, Come Light: 12 Songs of Christmas" album. But it really does lend itself to Thanksgiving more than Christmas. It's one that I think is very, very meaningful and special. So here it is. "Thanksgiving Song" by Mary Chapin Carpenter. "Grateful for each hand we hold, gathered around this table. From far and near we travel home. Blessed that we are able. Grateful for this sheltered place with light in every window saying welcome, welcome share this feast. Come in away from sorrow. Father, mother, daughter, son, neighbor, friend and friendless. I'll gather everyone in the gift of loving kindness. Grateful for what's understood. And all that is forgiven. We try so hard to be good. To lead a life worth living. Father, mother, daughter, son, neighbor, friend and friendless. All together, everyone. Let grateful days be endless. Grateful for each hand we hold. Gathered around this table." Well, thank you all again for being with us. We will take off next week, Thanksgiving week, and look forward to talking to you on the following week. Thank you for spending your time with us. I hope that you were able to get some helpful information. And in the spirit of this particular podcast, I want to just thank you for all your support of us here at CIDRAP and take a moment to remember all those who have died, all those who have been severely ill with COVID. As we've said time and time again, these are not numbers. These are real people. They're our fathers, our mothers, our sons, our daughters, our friends, our neighbors. And we must never forget that and be thankful this season, even in potential sorrow for what time we have had with those who are no longer with us. So have a great Thanksgiving. Be kind. Be safe. Thank you.


Chris Dall: [00:52:05] 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.