June 1, 2023

In this episode, Dr. Osterholm and Chris Dall discuss the latest data on long COVID, bivalent boosters, and mpox. Dr. Osterholm also shares the feedback we've received from our listeners on what this podcast will look like going forward.

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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 with the International and National Public Health Emergencies for COVID-19 now officially over. You could say we are now truly in the post-pandemic era here in the United States and around the world, even though the SARS-CoV-2 virus remains very much with us. What does that mean for our daily lives and what does that mean for this podcast? That will be the focus of this June 1st episode of the Osterholm Update podcast. As we discussed the current COVID trends here in the US and around the world. We'll also review a new study that has developed a preliminary definition of long COVID based on the most common symptoms. Talk about the latest efficacy data on the Bivalent booster shot. Answer COVID query about what the next round of booster shots might look like and discuss the latest on mpox. Finally, we'll also provide you with an update on the results from our survey on the future of the Osterholm Update podcast. But before we get started, as always, we'll begin with Dr. Osterholm opening comments and dedication.


Dr. Osterholm: [00:01:42] Thank you, Chris. And welcome back to all of you who are a part of the podcast Family. You know who you are and to anyone who might be listening for the first time, we welcome you and hope that we're able to provide you the kind of information that you're looking for. Let me begin by saying that the last several weeks have been, frankly, overwhelming for me in a way that you can understand. Yes, I am still having some challenges with what might be called long COVID or as we'll talk more today about a more formal title and have had long days with fatigue that have made it sometimes very difficult for me to keep up the schedule that I had before. But I think I am getting better. And in that regard, that's that's good. But the outreach that I have had with so many of you who have sent cards and letters and emails and even some packages, I can't begin to adequately express to you my appreciation for that. You know, it's this podcast was never supposed to be about me. It's supposed to be about a virus that we're all trying to take on. And if anything, it's about you. And you have been so kind, so kind in sharing with me your own life stories, sharing the ideas of what a beautiful place can look like, literally and figuratively.


Dr. Osterholm: [00:03:05] And I think the fact is that you've all understood that you can have community even in very difficult times when people are willing to come together and acknowledge what it is that really makes us all who we want to be as humans. And the first instance, it's often kindness. So I just want to start out by saying thank you, thank you, thank you. I'll never be able to share sufficiently my inner feelings. I feel like, you know, trying to tell you thank you is like trying to say in the Grand Canyon is just a ditch. You know, it's very inadequate. But at the same time, I hope you do understand what that means. And it's true not just for me, but it's for the entire podcast crew. When we talk today about the feedback, over 1500 of you have provided us incredibly detailed feedback on this podcast. That's remarkable and it speaks to the fact that this is our podcast, not mine, not the podcast team, but it's our podcast and we're learning. We're going to keep trying to learn and being able to hopefully provide you with what you're looking for too. So in that regard, I'm dedicating this podcast today to you, to the 1500 people who took the time, the effort and the thoughtfulness, the absolute thoughtfulness in your comments.


Dr. Osterholm: [00:04:18] Back to us. Now, for those of you that wanted us to get rid of the sunlight, I'm sorry you were outvoted as you'll find out later, and that you're going to know that in a moment. And for those of you that wanted us to take this back to a once a week podcast, you know, at this point, from a work standpoint at CIDRAP, that's going to be difficult for us to do, but we surely will keep it at the biweekly podcast level. And again, if things change, we will change accordingly. So let me move on then and just say I love this time of year for sunlight. You come on, you got to give it to me. Okay? I mean, here we sit in Minnesota in June, the longest days today in Minneapolis-Saint Paul. Sunrise at 5:29. Sunset is at 8:52. That's 15 hours, 22 minutes and 36 seconds of sunlight. That's amazing. And so I just want to emphasize the fact that we appreciate that very much. Now, to our colleagues in Auckland. Yes, I know you're about to hit some of your darkest days. And to all of our friends at the Occidental Belgian Beer Garden on Vulcan Lane, we recognize today that your sun rises at 7:24 in the morning, sunset at 5:12 in the evening, and you'll have nine hours and 48 minutes of sunlight.


Dr. Osterholm: [00:05:35] But that's about to change. Yes, it is. Now, I do have to add another note. One of the listeners who has communicated with me on this podcast is actually from Nome, Alaska. And of course, they know dark, dark days of the winter. But I'm very happy to report to our listener in Nome. As you know, today's sunrise is at 4:50 A.M. Sunset is at 1:08 A.M. You have 20 hours and 21 minutes and 27 seconds of sunlight today. Wow. And you're able with civil twilight basically to be outside almost all night and not need artificial lighting. Now, I do have to add just one more context piece. Today in Antarctica and the research stations there, there will be no sun. 24 hours, it'll be below the horizon. You'll have limited periods of civil twilight. And, you know, but your time is coming in six months. It's going to change quickly so that a little around the world with sunlight today to our listeners who know. Don't know if we have any in the Antarctica, but it's an interesting context. And to our friends in Auckland, we're sharing with you our sunlight today. I love Minnesota this time of year. I love it. So thank you again for your kindness. And Chris, let's get at it.


Chris Dall: [00:06:58] So let's start with the international and national COVID trends. Globally, it seems to be a mixed picture. While here in the United States, COVID hospitalizations have hit a new record low. Mike, what's your assessment of the current COVID trends here in the United States and around the world?


Dr. Osterholm: [00:07:14] Well, let me begin, first of all, with a very simple disclaimer, which hopefully by now you're all used to. We need a lot of humility. I think, looking at these numbers and trying to conclude what does this mean for the next month, for the next six months, for the next year? I don't know. But let me tell you what we do know, as you pointed out. We are beginning to see globally truly the other side of what you might call the post-pandemic era. Now, I don't know that that's going to be the case because as I've shared with you in a previous podcast, some of the viral geneticists who I actually have a great deal of respect for have considered what might things look like 6 or 12 months from now, and that there is a real possibility of seeing another large surge in cases with a new variant or sub-variant combined with some waning immunity in humans. One individual put that at the 30-40% level likelihood of seeing another omicron like surge. Now, I don't see those same data. I'm not smart enough to fit into the category of the viral geneticists, but at this point, when I look at human immunity and even with waning immunity and what's happening with the variants of variants, I just don't see that happening right now. But I sleep every night with one eye open knowing that it's possible.


Dr. Osterholm: [00:08:33] And so this is why we will continue to stay tuned very closely with what this virus is doing in terms of cases. Now, one other caveat I have to add is that, as you've heard me say time and time again, we have systematically dismantled the systems around the world that we have used to keep track of cases. We don't really know. Surveillance is at an all time low, too. So sometimes you have to be very careful about assuming low numbers of cases actually really mean very low numbers of cases, or do they mean an artifact of insufficient reporting capacity? And at this point, that's why I continue to focus on deaths, because they tend to be the most likely detected and reported number. And if, in fact, you believe that they will be a relative constant tip of that iceberg of all cases, all infections, then it does give you a better sense of what's underneath that. So let's just take a look at what's happened with deaths on a global level for the week of January 9th. We documented 34,722 deaths around the world where May 8th. The most recent numbers we have, it's 4,434 deaths for that week. That's a very sizable drop. And if you look at just in the six week period itself, from April 10th through May 15th, we've watched it go from 5,090 deaths per week in April 10th to 1,977 deaths on May 15th in that week.


Dr. Osterholm: [00:10:08] So it really does show that if you think of world population, it almost 8 billion people, you know, 1,977 deaths is surely just a very, very small percentage of all deaths that are occurring. Now, how many have we missed? I don't know. But it's not as if we've missed many, many fold differences of deaths that are occurring versus what's getting reported. So I think this does really bode very well for the trend that we're seeing with COVID around the world. If we look at specific regions right now, throughout the past six weeks in Europe, both cases and deaths are down by more than 50% in that region. If you look at the past six months in that same area, overall, weekly cases are a 10th of what they were six months ago. And weekly deaths are less than a quarter of what Europe was reporting in December of 2022. If you look at the Western Pacific, which has had a bump in cases in the past month, largely due to increases in countries such in China, it still is very artificially low. I think in terms of case numbers with limited testing and reporting. And I think deaths are so unrealistic, quickly low there that given the sheer number of people who live in that region, they don't really truly reflect the number of deaths.


Dr. Osterholm: [00:11:23] So I can't comment on that specific area beyond what I just said. But if you look at what's happening around the world, as the New York Times published a story this past week entitled COVID is Coming Back in China, Lockdowns are not, we're seeing increased activity in China that's just not getting reported. One very prominent Chinese doctor who is quoted in the story in the New York Times and someone who is recognized as a reliable source of information said that up to three quarters of the Chinese people infected in the recent rise were not infected in the first wave, which makes sense. Another expert quoted in the story agreed, saying many of the recently infected were likely to be older or physically frail. People who were fenced off from the tsunami of infections late last year, but now coming out and being. In contact with the public are now coming down with COVID. So I don't see anything here that suggests that this is going to be a sustained major surge in China. We'll just have to wait and see. Now, if we look at the United States, we see here, you know, again, very positive information. I think overall the numbers in terms of deaths at least are jumping around a bit.


Dr. Osterholm: [00:12:41] But the bottom line message is they're all very low relative to what we've experienced in the past. Remember now talking about deaths per week, not deaths per day in the US. There were 7329 deaths the week of April 15th. Then it dropped down to a little over 1200 deaths the week of April 22nd. Then again, the same number the week of April 29th. And then it almost went below the 1000 number at 1046 deaths the week of May 6th. But now, if you look over the last two weeks, these numbers have started to come up some. And last week it was actually at 1943 deaths, still much lower than we've seen at any time in the pandemic since those first days in 2020. So as far as where we're at right now, though, hospitalizations and deaths are so much lower than they have been throughout the entirety of the pandemic. And I think this could stay for some time. This is great, great news. Will this remain the case? I don't know. I think it could and it could remain that way for a number of months with some increased activity with overall waning immunity. Months out with a new sub variant or variant. But at least for now, I feel confident that we are on the back side of the big part of the pandemic.


Chris Dall: [00:14:09] So, Mike, is it fair to say at this point, whether it's in the United States or elsewhere, that hospitalization numbers are really what we're going to be looking at to tell if there's increased activity?


Dr. Osterholm: [00:14:22] At this point, Chris, hospitalization numbers by themselves may actually be somewhat challenging because in many cases, hospitals themselves are not reporting anymore. And so that we've actually seen some big holes, particularly even right here in the United States, the number of hospitals that have not reported to their state health departments, which in turn don't have data, has actually continued to increase. So I don't think there's going to be a number that is going to provide us with the answer of what's happening or not. It's going to be kind of like what I call looking in the windows. Imagine you're asked to describe everything in someone's house, but you can't go in. The doors are locked, but you have access to looking in every window in the house. And as you do, pretty soon you can get a pretty good idea of what's in that house. You can describe the furniture, you can describe where the kitchen is and all the different rooms without ever going in. And I feel like that's kind of where we're at right now, looking at what's happening with COVID, we don't have the kind of data where we're walking in the house and we can walk through every room, but we have enough information looking in the windows that we can get a pretty good sense of where things are at.


Dr. Osterholm: [00:15:33] And so I would say right now, again, we are really at the best place we've been. We'll continue to monitor the variants that are emerging and we'll continue to monitor the cases. In China, we're 39 million cases. Seems like a lot until you realize the size of their population. And hopefully over the next few weeks, as we get more clarity about what these numbers really mean, are they staying stabilized? Are they going up or down? We can come back and revisit this and say this is where things are at. But right now, if you're in a community in the United States, your likelihood of getting infected with COVID may be real with regard to so much transmission with mild illness out there. But what I can say with certainty is your likelihood of becoming seriously ill, being hospitalized and dying is almost at an all time low. And I have to, of course, add a caveat to that to say, please, please get your booster doses, get those bivalent booster doses if you can. We're going to talk about that in a moment, how important these can be.


Chris Dall: [00:16:41] Now to long COVID, which will likely be a significant topic of discussion on this podcast going forward. A team led by researchers at Massachusetts General Hospital published a paper in Jama last week that developed a preliminary definition of post-acute sequelae of SARS-CoV-2 infection or long COVID. Based on 12 symptoms that continue to affect people six months or more after infection. Mike, what did you make of this paper and how important is the development of a definition of long COVID?


Dr. Osterholm: [00:17:11] Well, let me first start out, Chris, by acknowledging that this is an issue that many listeners have been asking about. And as I've already shared with you in this podcast, I have an intense personal interest in this long COVID, as it's been called by so many of us, is clearly one of the biggest concerns that we have right now as pertains to the pandemic. As we just described, weekly COVID hospitalizations and deaths may be low, but long COVID persists as an issue affecting millions of people around the world. Now, this study, which you highlighted in your question, is actually part of what's called the RECOVERY system, an NIH sponsored effort to learn more about the post sequelae. Illnesses associated with COVID recovery actually stands for Researching COVID to Enhance Recovery. And the work that was done here was initiated back in 2022. Now, there's another term that we need to come to understand because we're trying to move away from the concept of long COVID. It was a good term to help people first understand that there was something happening on the back side of acute COVID. But today we're now calling this post-acute sequelae of SARS-CoV-2 infection, as you noted, and we're calling that PASC. So when you hear me talking about PASC, you'll know what I'm talking about.


Dr. Osterholm: [00:18:30] Now, in terms of this study, yes, it did come from a group at Massachusetts General Hospital, but it actually involved 85 different sites in 33 different states, including the District of Columbia and Puerto Rico. So it's a really geographically very representative sample of people that participated in this. And what they did is actually bring together 9800 participants, 89% of whom were infected with SARS-CoV-2. The study reported results for three sub cohorts an acute omicron infection sub cohort, a post-acute pre omicron infection sub cohort and then a post-acute omicron infection sub cohort. So in other words, trying to understand what happened before Omicron, what happened during Omicron and what's happened since that time. And it was of note that among the entire cohort, infected individuals had 1.5 or more times the odds of experiencing 37 different symptoms than uninfected individuals that they followed. Symptoms were experienced at a much higher frequency in the infected group compared to the uninfected group, including exercise, fatigue, malaise, dizziness, brain fog, GI symptoms, etcetera. And what the researchers did is they used this data to create a score by assessing different scores to 12 different long COVID symptoms. A loss of smell or taste had the highest score of eight post-exertional malaise, or in other words, feeling fatigued after exercise, had a score of seven chronic cough, had a score of four brain fog and thirst, had scores of three palpitations and chest pain, had scores of two and fatigue lowered sexual desire or capacity, dizziness, GI symptoms and abnormal movements all had scores of one.


Dr. Osterholm: [00:20:24] Individuals with total scores of 12 or higher are considered to have PASC. So, for example, someone experiencing just thirst and fatigue would have a score of four which would not meet the threshold of PASC according to the scoring system, but someone experiencing post-exertional malaise. Chest pain, brain fog and dizziness would have a score of 14 which would exceed the threshold for PASC. So I think the importance of this study is there's now really an effort to try to define what is actually happening with people following these acute episodes. And as I pointed out, I surely have a true interest in this very issue. I also want to highlight a piece of hopeful information from this study. The researchers found that the proportion of PASC positive infected participants was higher in the post-acute pre-Omicron group than the post-acute Omicron group, meaning that those who were infected before Omicron had a higher rate of past positive illness than those after Omicron showed up.


Dr. Osterholm: [00:21:29] And this proportion of individuals who experienced PASC is still far higher than we anyone would hope it could be. But it's a good sign that it appears to be declining as the virus evolves and that vaccination may at least to some extent protect against PASC. So we still have a lot of questions left about what are the drugs that might be effective in dealing with this, What is the short and long term treatment outcomes? But you need to first define the illness or illnesses that people are experiencing, and that's what this study has really done. And so my hats off to the NIH for this effort. It's been a long time in coming, but it's finally I now highlighting, I think the really. Certain aspect of PASC and that this is something that is real is something that for many of you who are listeners here, you know, you've had it. You understand you've had it. I understand you've had it as I understand my own health situation. So I can only hope that with time we're going to see more and more improvement with regard to past occurrence. And of course, we all hope that we can find therapeutic regimens that will help reduce the symptoms and not just leave it to time to get better.


Chris Dall: [00:22:46] There is also a study published last week on the estimated effectiveness of the Bivalent booster shot at six months. Mike, what did we learn from this study?


Dr. Osterholm: [00:22:56] First of all, Chris, I really want to congratulate the CDC for this effort. This was a study led by them, and it was basically one that looked at the vaccine effectiveness estimates among adults aged 18 years of age and older who had actually received a bivalent booster dose and looked to see what kind of additional protection it provided against COVID associated emergency room, urgent care and hospitalizations compared with persons who had received only the monovalent vaccine doses. These data came from the Vision Network, which is actually a CDC funded initiative involving health partners in Minnesota and Wisconsin. The Intermountain Health care system in Utah, the Kaiser Permanente Northern California Health System in California, the Kaiser Permanente Center for Health Research and Oregon in Washington and the Regenstrief Institute in Indiana. And with this, what they were able to demonstrate during the first 7 to 59 days after vaccination compared with no vaccination, the vaccine effectiveness for receipt of a bivalent vaccine dose among adults over 18 years of age was 62% among adults without immunocompromising conditions and unfortunately 28% among adults with immunocompromising conditions. Again, this was looking at the effectiveness of preventing hospitalization among adults without compromising conditions. The vaccine effectiveness declined to 24% among those aged 18 or older by 122 179 days after vaccination. Vaccine effectiveness was generally lower for adults with immunocompromising conditions.


Dr. Osterholm: [00:24:36] It is notable, however, that the vaccine efficacy, while lower for hospitalization over time, actually held up over time to at least 179 days against critical outcomes like intensive care admission or in-hospital deaths. So as much as we saw waning immunity against the potential protection for hospitalization, it did hold up through the 180 days afterwards against ICU care or hospital deaths, which is good news. But what this study is really pointing out is something that you've heard me talk about on this podcast many times, including several podcasts well before the FDA approved the bivalent doses that we likely were going to see this waning immunity over time, but that still it was better than not having the Bivalent booster dose. A very notable finding was that the vaccine effectiveness for those who received a monovalent dose only was only 3%, with the median of 355 days after the last dose. And so the point that that I'd made in this previous podcast is how important these bivalent doses would be, even though there were some who were critical among public health officials saying that, no, you don't need these, that there's no evidence they are. This study clearly, clearly supports that. Now, it also says that the bivalent doses are not magic. It doesn't mean that, in fact, you're covered now once you've got a bivalent dose.


Dr. Osterholm: [00:26:11] In fact, this is why I urge anyone, particularly those 65 years of age and older or those with underlying health problems, get your booster dose. And what was found is with a booster dose, you quickly reestablished the protection that you had earlier when the vaccine was first given. As I've said time and time again, we're not going to be able to boost our way out of this pandemic. Frankly, if you look at the numbers, it's really a challenge in that we see right now only 43% of those 65 years of age and older were eligible for a bivalent booster dose have gotten one, let alone two. So what we're finding with these vaccines, if I could summarize it, is one they surely can do a lot to prevent serious illness, hospitalizations and deaths. But even with hospitalizations, that wanes over time, where at least for now, deaths and ICU care continue to be well supported by these vaccines. We don't know what will happen over the next 6 to 12 months. For those who have had one bivalent booster dose, how will you look in terms of your protection? Will it be like the Monovalent vaccine after a year? What will happen for those that have had two booster doses this fall, the FDA is going to make available another booster dose vaccine.


Dr. Osterholm: [00:27:31] From my perspective, I think if you can get this every 4 to 6 months, you should do it. I know that is going to fall on deaf ears for a lot of people, but I think that this can surely help out a lot. But it's also pointing out these are really good vaccines. They have saved millions of lives, but they are not great vaccines. And I want anybody to walk away from this saying I'm pooh-poohing these vaccines. I'm merely saying we can't ask them to do more than they're able to do. It's up to us, to the part of the solution here. And that means getting your boosters on a routine basis when you can. And at this point, hoping that we continue to see the research into new improved vaccines for COVID or all the coronavirus infections that would actually give us durability over time would also provide us wide ranging protection against what may be new sub variants. So the summary conclusion from this study is that these vaccines work, but they lose their effectiveness over time. But the effectiveness are losing at least is still not intensive care or death outcomes. And that is still a very, very important point.


Chris Dall: [00:28:47] And that brings us to our query. And we don't have a specific question this week, but we've heard from a lot of listeners who want to know what the makeup of the booster shot is going to look like going forward and the Who actually weighed in on this last week. So, Mike, what can you tell our listeners?


Dr. Osterholm: [00:29:04] Yes, Chris, I've been hearing about this often from listeners and from friends and colleagues who are eager to get another shot. As we just talked about, immunity from the Bivalent vaccine wanes relatively quickly, particularly when we're talking about infection or even possibly hospitalization. And for that reason, many of us are impatient for another dose. As we all know, the virus is unpredictable, but it takes time to create more vaccines and we have to start planning for what's going to come next. The W.H.O. recently recommended that the next booster be a monovalent XBB variant vaccine, for which there are several reasons. The original strain is no longer circulating, and including it in a new vaccine would prompt low levels of antibodies against the currently circulating strains and possibly even impact on t cell responses. This could surely create a lesser protective vaccine. This was the W.H.O. recommendation, but the FDA hasn't met yet to determine exactly how the US is going to move forward. The FDA is set to meet on June 15th to discuss vaccine composition and strain selection for the upcoming fall and winter. And I anticipate a similar recommendation to come out of that meeting. So expect that you're going to have another new vaccine this fall that will likely be an XBB variant vaccine. When these vaccines do become available, hopefully to anyone who wants one, I'd suggest you get it as soon as you're eligible.


Dr. Osterholm: [00:30:32] I after 4 to 5 months following my illness, I’m ready to go to get my next booster dose. I've said it time and time again. We need better vaccines to provide more durable immunity and protection, but those are potentially years away. For this reason, these vaccines we have now are our best tool we have. And there's just no reason in my mind that you shouldn't get a dose if you're eligible. I would just conclude that I hope the FDA makes us a much more permissive recommendation so that those who have underlying health conditions, regardless of age. For those who as young as 50 to 55 years of age want to get a booster dose that they can. And so we'll see where that all plays out. But for now, expect the fact that we're going to be living in a world where COVID does exist and we're going to live in a world where there's something we can do about making certain we don't get severely ill or hospitalized and die. And one of the things that's going to be so important there is getting routine boosters that are matched to the strains of the virus circulating in our communities.


Chris Dall: [00:31:38] Now for an update on Mpox. On our last episode, we discussed concerns raised by the CDC about a possible rise in infections linked to summer festivals and gatherings. Last week, health officials in England reported an increase in cases and encouraged people to stay vigilant over the summer months. Mike, is it possible that we could see regular spikes in Mpox over the summer months and how can that be avoided?


Dr. Osterholm: [00:32:04] It's really important to emphasize the fact that we are in uncharted territories with this virus and the vaccines that we're using to try to prevent it. Now, that doesn't mean we don't have a lot of information on the poxviruses or that we know a lot about vaccinations. But it's still unclear to us how effective these vaccines are going to be and what that means in terms of how the epidemiology of the impacts in our communities is going to look like. As I mentioned in the last podcast when we talked about the cluster of cases in Chicago, the thing that was very concerning was that we actually saw breakthrough infections among those who had been vaccinated with two doses just as recommended, and yet they still got infected. For those who work with smallpox, we often believe that, in fact, the smallpox vaccine may give you protection for life once you've received it. And there was a sense almost that maybe that was what would happen with the Jynneos vaccine, the one that we're now using for impacts. And we've come to realize that that's not the case. You mentioned, Chris, the cases in U.K., ten cases of mpox have been reported there over the last four weeks, bringing this year's total number of cases to 25. Of the ten recent cases have occurred in unvaccinated individuals, something we need to obviously address, but to occurred individuals who had received only one dose of vaccine.


Dr. Osterholm: [00:33:32] And what's going to be important here is much like with COVID, where we're not saying these vaccines are going to be perfect, clearly we're going to see breakthrough infections. How often that occurs, we don't know. But it appears right now that at least in the first 6 to 12 months after vaccination, that there's fairly good protection against even getting infected again and having any kind of illness. But we're still going to be learning about that. I think the important message is that, one, it's likely yet that if you get infected, you will probably have lifelong protection just from the infection with the pox virus. Number two, the vaccine can surely do a lot to reduce the number of people who have breakthrough infections at least for 6 to 12 months following the two dose vaccine regimen. And number three, our behavior still has a tremendous amount to do with who gets infected, when and how. And we have to continue to emphasize where that risk is at. It's among men having sex with men who in many instances are anonymous partners and do not know what the actual infection status is of that partner. Were they previously infected? Have they been vaccinated? Are they currently infected? And so I'm convinced we're going to see an ever increasing number of cases over the course of the next few months and that they will be tied to the not having previously been vaccinated status or two doses of vaccine, but at a much, much, much lower rate among that group than they weren't vaccinated at all.


Dr. Osterholm: [00:35:13] I think what these data show us is that mpox is here to stay. It's not gone. It's now going to become a classic sexually transmitted infection, particularly a sexually transmitted infection in men who have sex with men who are putting themselves at high risk. And I want to be very clear here, many, many, many, not most men who have sex with men are not at increased risk for m-pox because they are not having multiple anonymous partners in the settings that would transmit this virus. And so I want to be really clear that this is by itself not a statement about gay men. It's not. And if we see this get into populations of heterosexual hypersexual contact, we're going to see the same thing. And what we have to understand, though, is that's where it's at. So get vaccinated, know that it's not going to be perfect, but it can surely help and continue to emphasize the issue of behavior. And exposure is going to be key in terms of reducing this infection over time.


Chris Dall: [00:36:23] Finally, we have an update on your responses to our survey about what the podcast should look like going forward. And Mike, you talked about this a little bit in your intro. What else can you tell our listeners about those survey responses?


Dr. Osterholm: [00:36:40] Well, before we get into the results, Chris, I again, just want to thank every single one of the over 1500 people who took the time to fill out the survey or send us an email telling us what they want to see from this podcast going forward. You know, the old line about if you break it, you own it. Well, let me just say, if you commented, you own it. You are part of this podcast team because your input clearly was very, very significant for us. And so in that regard, I hope that you feel the ownership and you feel some pride in whatever does come out of this podcast that may be positive or helpful. So thank you. And your responses and interaction are what make this more than just a podcast. It truly is a family. And for those who have a hard time hearing that, just turn your sound down for a minute, okay? And then you can come back. Please know that we could not respond to all of you who have sent in very, very thoughtful comments. But know that every one of these was read. Every one of these was considered. Every one of these was discussed. And I just want you to understand how important that is. As I noted before, the overall response we got was extremely positive. 54% of you stated that you would prefer that we stick with the every other week episodes, and 31% said they would actually prefer that we go back to releasing new episodes every week.


Dr. Osterholm: [00:38:06] Well, I'd like to do that too. I love this connection. As I've said time and time again, as much work as we put into this, I get a heck of a lot more out of these podcasts than you probably do. But given staffing at CIDRAP and the challenges with all of our other workload, I think for right now, given what's happening with COVID, we will stick with the every other week approach, but we will in fact always be aware of what's happening out there. And if we need to go to once a week, we will. So what most of you said is you like our current episode length for every other week episodes, 70% of you wanted us to continue to cover infectious diseases and public health news, both COVID and non-COVID. 60% wanted coverage of other infectious disease topics and controversies, including ones that are not necessarily in the news. 50% of you wanted to hear more about historic outbreaks that I've worked on over the course of my career. And then 25% of you said that you would like this podcast to mostly or only cover COVID related issues. So we surely heard that we will never neglect COVID. But I think from the other listeners, we will also try to expand our repertoire of what we cover. Majority of the feedback received regarding our song lyrics, minutes of sunlight and Beautiful Place was actually very positive.


Dr. Osterholm: [00:39:25] We are glad that these segments mean as much as they do to you, and they surely mean that to us. And for those that didn't like them, I'm sorry. It's the price you pay for listening to the rest of the podcast. So what does this mean for this podcast family going forward? Well, you are all very clear about one thing. You don't want this podcast to go away, at least not anytime soon. We'll be following the recommendation of the majority of you provided, which was for us to continue with an every other week frequency keeping episodes at their current length. Many of you share that this is one of the only consistent, trustworthy sources of information that you have left. And so we will continue to cover COVID, including the latest data on vaccines, antiviral treatments and PASC. But we will also place a bit more emphasis on other infectious disease issues when they're in the news. And we will start to introduce some new segments covering other infectious disease topics and controversies. And occasionally, maybe we'll even slip in a historic outbreak that I've worked on in the past and lessons learned. These segments won't be included in every episode and will most likely be reserved for weeks when there isn't as much news to discuss. But we sincerely hope that they are interesting and meaningful for you all. Thank you again for the incredible feedback and for making this podcast a family. Thank you.


Chris Dall: [00:40:48] And a few other items to mention. We've loved all your beautiful place submissions, but we're not getting that many anymore. So going forward, we're going to change this up a bit and ask you to tell us about something that brings you joy. Even as we move past the pandemic, we know that we live in challenging times and finding the thing that brightens your day, even if just for a moment, is so important for our mental health. So what is the thing that you look to for a little bit of joy? It can be a place, a person, a pet, a piece of art or whatever you want it to be, but we'd love for you to share it with us and the rest of the podcast family. Also, please send us your suggestions for song lyrics or poetry or some words of wisdom that you think would be good for the podcast closing. And as always, keep those queries coming for all these things. You can email us at OsterholmUpdate@umn.edu. Mike, what are your take home messages for today?


Dr. Osterholm: [00:41:44] Well Chris, again, I think three primary take home messages. One, I can't say this loud enough. I can't say it long enough. I can't say it with more compassion and passion. We are, I believe, on the back side of the pandemic. And that means that we have to relook at how do we live our lives, What does that mean? What are our risk factors for being still yet becoming seriously ill and potentially being hospitalized or even dying? But what does it also mean to so many that now can begin to live their lives again in ways that they did before the pandemic? We'll continue to talk about that in this podcast. But the point is, we're there. We're now at the time when it is appropriate for us to have these discussions. Number two, the vaccines are good, really good. They have saved millions of lives over the course of this pandemic. But they're not great. And from that standpoint, meaning with waning immunity, we still are going to be in a position where if you're at increased risk for serious illness, hospitalizations and deaths, you're going to need to help protect yourself. That may mean respiratory protection in public settings. It may mean the fact that you have people test who come to visit with you.


Dr. Osterholm: [00:43:00] So this is still a challenge, but that's why we need so desperately to continue to work on these vaccines to broaden their protection over time. And finally, the third one is the recovery study is really important. We have been waiting for these data from the NIH study to look at PASC and to see what it means and remembering again that what we've experienced as we call long COVID and now into this new term, PASC is going to go away even if the pandemic itself begins to wane substantially. I wonder every day when I wake up, how am I going to feel today? Am I going to be as exhausted and fatigued? Is this the day that it's over? What will that mean? I now understand what so many of you have felt, and you know, that doesn't give you any comfort and it doesn't give me any comfort, but it gives us a common point of reference that we can understand. This stuff is important. And just getting over COVID by itself is a great, great accomplishment. But if you don't, you're not alone. And therefore we really need to stick together to find out what we're going to do to make this a better place.


Chris Dall: [00:44:15] And Mike, what's your closing song or poem for us today?


Dr. Osterholm: [00:44:20] Well, Chris, I've tried to reflect back on where we're at in this pandemic and what might be the words that we need to hear or want to feel today. And I've picked a song that actually coincidentally goes with another theme that we've had in previous songs, and that is this is a song from a notable Canadian songwriter. You may recall I talked about Gordon Lightfoot and the song Beautiful several episodes ago. This song is one that I've used before. It was used in Episode 94: The Next Normal. On March 10th of 2022. That long ago. This is a song by the late Stan Rogers. He was a Canadian folk musician and songwriter that was noted for his rich baritone voice and his traditional sounding songs that were frequently inspired by Canadian history and the daily lives of working people. He was genuinely loved for what he did. And unfortunately, as you may recall, he died in a fire aboard the Air Canada Flight 797 on the ground at the greater Cincinnati Airport at the age of 33. Notably, the 40th year anniversary of that fire on the plane is tomorrow, June 2nd. It was 40 years ago that that happened. Now, Rogers wrote many ballads that would just tug at your heart. But there was one that was a sense of defiance and accomplishment, taking on adversity and moving on, which we've all had to do. And so today I want to go back and revisit one called the Mary Ellen Carter.


Dr. Osterholm: [00:46:03] We've actually put a link on the website of the late Tommy Makem and Liam Clancy playing this song. Very inspiring. So it is today I share with you what I believe is the spirit that we all need to consider our world in. And that is in the world of Mary Ellen Carter. She went down last October in a pouring driving rain. The skipper, he'd been drinking and the mate, he felt no pain to close to Three Mile Rock. And she was dealt her mortal blow. And the Mary Ellen Carter settled low. There was just us five aboard her when she finally was awash. We worked like hell to save her, all heedless of the cost and the groan she gave as she went down. It causes true proclaim that the Mary Ellen Carter would rise again. Well, the owners wrote her off. Not a nickel would they spend, She gave 20 years of service boys then met her Sorry end, but insurance paid the loss to us, so let her rust below. Then they laughed at us and said we had to go. But we talked to her all winter, some days around the clock for she's worth a quarter million afloat and at the dock and with every jar that hit the bar, we swore we would remain and make the Mary Ellen Carter rise again. Rise again, rise again. Let her name not be lost to the knowledge of men.


Dr. Osterholm: [00:47:30] For those who loved her best and were with her till the end will make the Mary Ellen Carter rise again all spring. Now we've been with her on a barge lent by a friend, three dives a day in hardhat suit and twice I've had the bins. Thank God it's only 60ft. And the currents here are slow. I'd never have the strength to go below, but we patched her rinse and stopped her events, dogged hatch and porthole down, put cables to her four and a half and girded her around. Tomorrow noon, we'll hit the air and then take up the strain and make the Mary Ellen Carter rise again. Rise again. Rise again. Let her name not be lost to the knowledge of men, those who loved her best and were with her till the end will make the Mary Ellen Carter rise again. We couldn't leave her there. You see, to crumble into scale. She saved our lives so many times, living through the gale and the laughing, drunken rats who left her to a sorry grave. They won't be laughing in another day. And to you to whom adversity is dealt the final blow with smiling bastards lying to you everywhere you go. Turn to and put out all your strength of arm and heart and brain. And like the Mary Ellen Carter rise again. Well, thank you for being with us on another podcast.


Dr. Osterholm: [00:48:52] I hope that this song gave you that inspiration that we can rise above and will rise beyond any adversity that comes to us and we'll do it together. So thank you so much. Take to heart the dedication to all of you who have provided us with such important feedback. I want to acknowledge the podcast team. This would not be possible without the team of people at CIDRAP who helped put this together. Thank you to them. And just know that being on the back side of the pandemic is not a bad place to be. But it doesn't mean that it's all over. And we'll keep very close track of what's happening around the world. But for right now, we're giving you the green light. For most of you, for those who are still at risk of serious illness, you know, we get it. We understand. And we'll also help support you however we can. And then finally, those of us who are still suffering from the long term effects of this virus, you know, we got to understand that there are studies going on now. There's efforts being made to help address that issue. And I'm more than ever have a very personal interest in that. So thank you. Thank you again. And just remember right now, the kindness that you share out there will pay dividends across society. Keep it up even in days. It's hard. It's so important to be kind. Thank you.


Chris Dall: [00:50:20] 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.