Episode 144: A Slow Motion Tsunami

Chris Dall: Hello and welcome to the Osterholm update, a podcast on COVID-19 and other infectious diseases 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 draws on nearly 50 years of experience investigating infectious disease outbreaks to provide straight talk on the latest infectious disease and public health threats. 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. In a recent survey conducted by researchers at the Ohio State University Wexner Medical Center, 87% of the roughly 1000 respondents said they do everything they can to avoid spreading seasonal illnesses, but one third of respondents said they don't think they need vaccines for flu or COVID-19 because they don't consider themselves at high risk for severe illness, and that their vaccine decision doesn't affect others. We've talked about some of the logistical issues that have hampered the rollout of the updated COVID-19 shot, but this survey gets to a wider problem whether it's COVID, flu or respiratory syncytial virus, many people underestimate their risk of getting severely ill from a respiratory infection. One would think that a pandemic that killed more than a million Americans, young and old, might have changed that, but apparently not so. This is one of the topics we're going to discuss on this November 16th episode of the podcast. As we look at the international and national COVID trends, as well as the latest data on flu and RSV. We'll also provide an update on the variant picture, answer queries about the RSV vaccine and viruses with pandemic potential, discuss some potential funding cuts to a federal HIV program, and talk about World Antimicrobial Resistance Awareness Week. We'll also bring you the latest installment of This Week in Public Health history. But before we get started, as always, we'll begin with Dr. Osterholm's opening comments and dedication.

 

Dr. Osterholm: Thanks, Chris, and welcome back to all the podcast family. Say that each and every time we start this podcast, but it's always meant with great sincerity. We appreciate so much having you with us and in particular for all your wonderful feedback. If someone is new to the podcast today, I hope that we're able to provide you the kind of information you're looking for. Anyone who's a regular listener to this podcast will tell you we do cover kind of a wide variety of different issues, some very professional, some very personal. So stay tuned and hopefully we can help you navigate this journey of infectious diseases in this modern world. Let me begin this episode by providing a setup, you might say, for the dedication. This episode will be our last one before Thanksgiving and therefore the last one really before the beginning of the holiday season. Well, I know many of you are looking forward to the holidays. I want to recognize that this is not always an easy time for everyone, and that many of our listeners out there are actually dreading the upcoming season. I say that because the holidays often present the very best and the very worst of times. I can tell you, as a child growing up in the family that I did, and many of you are very aware of that background.

 

Dr. Osterholm: The holiday season was always a very difficult time for us, because that was when my father tended to drink more, when he was more violent. And I can't tell you how often on Christmas Eve when there was little or nothing under a Christmas tree, if we had one, that in fact, how my mother felt knowing that her kids went without again this year. And it was one of those ones where, you know, you want to be joyous, you want to celebrate. You know, it's all about Frosty the Snowman, and it's all about the great music of Christmas time. But we also recognize this. These can be difficult for some of you who are experiencing conflict within your families that may make holiday gatherings uncomfortable, or that may lead you not to even attend a holiday gathering at all. I know how difficult this can be. So for many of our listeners, including so many who have shared emails with us, you have reached out to share your stories of conflict in your families or among friends, neighbors, and how oftentimes that's accentuated during the holiday season. And I also want to acknowledge that based on my fixation, you might say with sunlight, that I do recognize that the minutes of sunlight right now are getting shorter and shorter.

 

Dr. Osterholm: And in those shorter days, we do understand that there are over 10 million Americans who experience seasonal affective disorder, sometimes referred to as seasonal depression. I know for those of you that are experiencing this, it can be hard to enjoy the holidays in the midst of battling challenging symptoms of depression and fatigue. So we all all want to have a joyous and wonderful holiday. But some of us will be alone. Some of us will be very lonely. Some of us will be sad. Some of us will hurt. Some of us will wish someone would reach out to us. This dedication today is really to all of us who may experience those seasonal issues, but at the same time hopeful that there is someone who will reach out, someone who will extend a hand, someone who will ask a question, are you okay? What can I do for you? Would you like to do something today? Those are the people we're dedicating this podcast to, those that need and those that can give. Don't be afraid to reach out and give when you think, well, maybe should I don't be afraid to ask when you need. Don't ask yourself, should I do it? This is dedicated to you now in terms of sunlight, of course. I just mentioned the fact that yeah, for some of us, we are very acutely aware of the reduced amount of sunlight today here in Minneapolis.

 

Dr. Osterholm: Sunrise is at 7:11 a.m., sunset is 4:43 p.m. that's nine hours, 31 minutes and 32 seconds of sunlight. We're getting close to that December 21st winter solstice, where that day we will have eight hours, 46 minutes of sunlight. So about 45 more minutes of increasing darkness between now and the winter solstice. But then it turns around. And of course, our colleagues in Auckland know that very, very well. Today, at the Occidental Belgian Beer House on Vulcan Lane, sunrise at 6:02 a.m., sunset is 808 for 14 hours and six minutes and nine seconds of sunlight. I would also like to give a shout out to David and his wife, who were just at the Occidental, who sent us pictures visiting there. They are podcast listeners and also found their way from the United States to Auckland. Also, we have one of our CIDRAP team members who is in Auckland today, and I understand we'll be making a visit to the accidental Belgian beer house. So have fun, enjoy, enjoy the sunlight, and just know that while these are dark days ahead of us, they don't have to be dark moments. We need to help however we can to minimize those for all of those we love.

 

Chris Dall: Mike, let's start with a look at the international and national COVID data, as incomplete as it is. What's the picture looking like at the moment?

 

Dr. Osterholm: Well, Chris, bearing in mind that again, we're only being left to work with what's basically a fragmented patchwork set of data from select locations. It surely has not gotten any easier to pull together information for these updates, but as always, I'll give it my best shot. And in this case, I think there is something in this update that may actually be a harbinger of things to come in this country, and we need to pay attention to it. And so from what I'm seeing, I think there are clearly still a number of places being confronted with this dilemma of what exactly does it mean to live in a world with this virus? And I'm not sure that question is one we've really reckoned with, especially in the context of a post COVID pandemic world. And I use that term again, over and over again post COVID pandemic world. In fact, if I'm being perfectly honest, I don't think many people even wanted to think about this, let alone deal with it. It's tough, but to me, this is something that's critically important and warrants our attention moving forward, since it could ultimately help dictate what our future with COVID might look like. So with all that being said, let me just provide a few examples of what's been happening in different countries internationally.

 

Dr. Osterholm: Many of these I actually touched on in our last episode. So in that sense it'll be more of an update, but I think it really does shed some light on what I'm talking about and what we might experience here in this country in the days ahead. In several places, there were recent increases over the past couple of months, but things have seemingly started to cool off. So that includes the UK, the Czech Republic and Canada. In the United Kingdom, hospitalizations have dropped the past four weeks from about 4300 weekly admissions in early October, down to about 2500 as of early November. And the Czech Republic, which saw hospitalizations go from ten in August to 600 by the late October time period, is now back down to about 300. Then there are those other places with recent increases but ongoing elevated activity. This includes Italy and the Netherlands, for example. Hospitalizations in Italy went from 800in early August to 3700 by mid-October. And now, almost a month later, they're still hovering around the 3700 mark. And finally, some countries have actually reported ongoing rises, with no clear sign of relief evident at the time of this podcast recording. Among these may be the most notable is Sweden, where COVID hospitalizations have climbed from less than 150in mid-August to nearly 1200 as of now.

 

Dr. Osterholm: In fact, if you look at the number of COVID patients hospitalized in Sweden, we are now at the sixth highest peak that they've had in the entirety of the pandemic. And this peak is actually more than half of the peaks that we've seen in the previous experience with the virus. So this is significant. What's going on? Well, I'm not sure. But as I talk in a moment about variants, I think there may be some hints in that. So let me just shift to the US, because at this point we too are in one of those periods of is it going up? Is it going down? Is it going anywhere? As we get closer and closer to the holidays and people start to gather with family and friends, we may be seeing some increases in COVID activity overall here in the US. Wastewater data, which is again coming from Biobot, which is a whole other story unto itself as to who is now providing wastewater data for this country. It is showing activity rising across most of the country. When we look closer at each region, activity is rising slightly in the northeast, the south and the west following a large increase in activity recently in the Midwest.

 

Dr. Osterholm: Wastewater data is now showing a very slight decline over the past couple of weeks. However, when we look at indicators such as emergency room visits, hospitalizations, and deaths, we get a somewhat different picture. Hospitalizations are down about 8% over the past week. Right now, about 14,750 hospitalizations in the past week. This is down from 16,000 just two weeks ago. And that's the lowest hospitalizations that have been seen since August 19th. Deaths are also trending downward now just above 1200 per week. Remember, 1200 a week though is still substantial. Those are our moms and our dads, our grandpas and our grandmas, our brothers and our sisters, our friends, our colleagues. And I personally have been touched in the past two weeks with three different individuals who I know who have died from COVID in recent weeks. But overall, the good news is the trend for deaths is decreasing. So where does this take us? I don't know. I do know that we have to be mindful of what's happened in Europe, where we've actually seen some sizable increase in cases, including serious illness, hospitalizations and deaths in places like Sweden. And is this tied to the variant? I don't know, but we'll talk about that in just a moment.

 

Chris Dall: And Mike, what are you seeing on the variant front?

 

Dr. Osterholm: Well. Chris HV.1 and HK.3, both descendants of EG.5 Omicron, are the variant showing and projected to continue exhibiting the most growth, according to the CDC and Biobot wastewater data. This is in line with what we've been seeing in the last few weeks in the US, and per usual, I'd like to underline the updated Omicron vaccine targets. Variants like these and it is not too late to get your shot, especially as we approach the winter holiday season. Now is as good a time as any, and I strongly urge you to get the vaccine if you haven't already. In other variant news, JN.1 which you may recall is a relative to BA.2.86, is continuing to show rapid growth advantages in areas where it's taken hold, namely in the European countries like France, England, Iceland and Sweden. It has been detected in low levels in the US since September, though CDC is not yet distinguishing JN.1 from its parent BA.2. Despite this, variants particularly concerning mutation profile. According to the CDC, they wait until the variant passes a 1% weighted estimate in the US population to include it in surveillance. In other words, there are not enough sequences right now to justify its addition to the bi weekly updates. However, I do have real concerns that J and one, as we've seen it spread across the European countries, and with what it's done to elevate case numbers and including serious illness, may actually provide an ominous warning for the US. And we won't have timely or robust sampling data to detect its patterns early on. Again, all the more reason please get your dose of vaccine.

 

Chris Dall: And Mike, how about the latest on respiratory syncytial virus and flu?

 

Dr. Osterholm: Well, as we all recall, you know, we don't live in a single virus world. In fact, we have been talking about the relationship between COVID, influenza and RSV activity throughout the entirety of the pandemic. Fortunately, for much of the pandemic, influenza and RSV was relatively absent. Now we're looking at the possibility of it coming back in a more seasonal pattern, where we do see both influenza and RSV more likely to occur in the winter time. Again, let me just restate which I've done in this podcast 100 times. There are no data yet that support that. COVID is a seasonal disease, other than the fact that it occurs in all four seasons, so we don't know what ultimately the pattern will be in the population for COVID. Will it eventually become like a seasonal flu virus? So let's look at where we were in our last episode and where we're at today. Relative to the issue of influenza activity. During our last episode, one state was experiencing high levels of influenza activity. Two states in the District of Columbia were experiencing moderate influenza activity, and six states in New York City were experiencing low levels of influenza activity. All the other states were experiencing minimal influenza activity. So this means that in total, we had nine locations in the US where we actually saw some increase in flu activity.

 

Dr. Osterholm: Well, this week it's up to 16 locations. Now we see three states experiencing high activity. Four states in the District of Columbia experiencing moderate activity, and nine states in the New York City area experiencing low activity but definite activity. And then the other states are still experiencing minimal influenza activity. What this tells me is that we may be, in the earliest days of beginning, to see a more traditional winter flu season develop. Based on this again, now is the time to get your influenza vaccination. As I told you, I got mine two weeks ago. I think right now for all of you, please get it is a good match as it relates to the circulating viruses we're seeing and what's in the vaccine. Let me just update during the week of November 4th, for which the most recent data are available, there were almost 5000 RSV cases in the United States. This includes laboratory confirmed cases. Now, I'm very mindful of the fact that there were many, many more that never got detected from a laboratory perspective and therefore were not counted as cases. But the number of individuals who are test positive is an indication or a tip of the iceberg of what's going on out there. This is up, by the way, 39% from two weeks prior, during the week of October 21st, and up 136% from four weeks prior to that the week of October 7th.

 

Dr. Osterholm: So but still, the numbers of RSV cases we're seeing is almost four times lower than we were seeing at this exact same time last year. As influenza and RSV cases are rising and COVID, we're not quite sure what it's doing yet. I'm beginning to hear the use of that word tripledemic. Again, this is something that's popular among some of the talking heads in the business. As you know, I have said over and over again, I never liked that term. I think it is a misunderstanding of what's happening. And if you look at what happened late last fall and early winter, we did see RSV activity pick up substantially and we saw influenza activity pick up, not, in fact, COVID. And in each of those instances, the season for that particular virus was not really a severe season. It just came early. And but people at the time were making all kinds of proclamations about how bad this was going to get. And then the seasons ended well before when we'd normally expect them to end. And so we, in a sense, had average flu and average RSV seasons last year. Now, oftentimes, you'll see the media report on hospitals that are overrun with cases of influenza, RSV, particularly in the pediatric area.

 

Dr. Osterholm: And that surely is what happens in those hospitals. But let's make one thing very clear. That is not a function necessarily of a major increase in cases. It's a statement on our capacity for health care in this country. We have basically nibbled down to the point of taking out large segments of our care capacity in hospitals today, meaning beds don't exist. That existed 10 to 12 years ago. That meant that no, someone would not have to be housed in a temporary location on a floor somewhere as opposed to an actual room. So at this point, I just want to be clear that yes, we can see big increases in cases seasonally and they can be challenging, but we have to interpret when is that a function of actual numbers of cases, and when is it a function of the decreased capacity of our health care system to care for people making it into a crisis? At this point, I don't think we have any evidence we're going to have anything other than an average flu season. We're going to have an average RSV season. And with that, I think we're just going to be watching what happens over the next few weeks.

 

Chris Dall: This might be a good time for a quick follow up on that survey I mentioned in the intro. Mike, there are a lot of reasons why people may choose not to get vaccinated, but do you think public health officials need to communicate better about the risks of getting COVID or the flu, even for people who might not consider themselves at risk? While we may not be able to reach the people who are truly opposed to vaccines, this seems to be a group where you could make some headway.

 

Dr. Osterholm: Chris, the data from the survey you just mentioned is very concerning. I think it really sets us up to understanding what the new trend is in vaccine acceptance, and how people understand what these vaccines can do to protect them from everyday illness, and in particular, for severe illness. As you stated the introduction, 33% of Americans believe they don't need an influenza vaccine if they're not at high risk of developing severe disease. I can actually understand that. They think that maybe the shot is going to be worse for them in terms of being out with a possible vaccine reaction for a day or two. I think this really just comes down, though, to a misunderstanding of both the risk of influenza and COVID, and also the very low risk of any adverse event with these vaccines that comes with having taken them. Though many individuals view influenza as more of an inconvenience than a serious health concern. The data and hospitalizations and deaths tells a different story, particularly when you look at an entire season, not just the earliest days like I've just talked about influenza deaths from the 2010 to 2011 flu season through 2019 2020 flu season have ranged anywhere from about 12,000 to 52,000 deaths per season, with a median of approximately 38,000 deaths. Now, those aren't actually all individually reported deaths. That's based on part of a statistical model that the CDC has developed. But they do give us a relatively good sense of what, in fact, the picture looks like in terms of number of deaths.

 

Dr. Osterholm: Those these numbers may seem relatively small to the compared to the number of COVID deaths we've seen over the last few years, they are far from insignificant. Influenza hospitalizations during the ten flu seasons prior to the pandemic ranged from 140,000 to 170,000 hospitalizations per season. Additionally, for many individuals, including those who are not at high risk of hospitalization or death, there are still financial costs that come with influenza. Not everyone can afford to take off a few days, or even up to a week due to influenza symptoms, and even among those who can, most would prefer not to. So while it is true that the overall number of influenza deaths is lower than we have seen for COVID, there are certainly still a risk for hospitalization and death and even the inconvenience of being sick for a few days. This is especially true among those 65 years and older. And yet we now see that 65% of adults in this country have still yet not gotten their flu vaccine for this year. So I would just urge that people look at what the data do, support in terms of safety, in terms of effectiveness and what this may mean in the short term. So with all three of the respiratory viruses we're talking about today, COVID, RSV and influenza vaccination still is your best bet against reducing the likelihood you're going to experience one of these infections.

 

Chris Dall: That brings us to this week's query. This week we actually have two. The first is from Bill, who asks, you've mentioned the RSV vaccine many times on the podcast, but I don't believe you have said who qualifies for the vaccine. The CDC page says adults 60 years and older should talk with their health care provider about whether RSV vaccination is right for them. In more recent CDC, page says the same thing but adds pregnant people and infants. Is this correct?

 

Dr. Osterholm: Well, thanks, Bill, for that very thoughtful question. If listeners to this podcast are confused about what the recommendations are for RSV, join the entire crowd. I know of many people who are absolutely lost in terms of what do I do? And I'll explain in a moment how that has even carried over to confusion about who gets what vaccine. First of all, let me just separate out the two primary groups that we're trying to protect from RSV infection. There are those who are 60 years of age and older, for which two vaccines have been approved, and for which we have a major increased risk of serious illness, hospitalizations and deaths. When you become infected. And on the other side of the life curve, we have infants and particularly premature infants. And so we're trying to protect them with the same vaccines and some additional monoclonal antibodies. So let me just be clear. There are two vaccines that have been approved for 60 years of age and older, Abrysvo, which is made by Pfizer, and RSV, which is made by GlaxoSmithKline. Now it's very confusing. These two names of Abrysvo and Arexy, such that we've already seen confusion in pharmacies as to which vaccine to use because only one of them, the Abrysvo vaccine by Pfizer, has been approved for both those over age 60 and for pregnant women during the weeks 32 to 36 of their pregnancy. Now, I hope that the over 60 is clear why they need the vaccine again is age related risk factors.

 

Dr. Osterholm: Either one of these vaccines, which are very similar, will work. However, only one of the vaccines, as I just mentioned, has actually been approved for use in pregnant women. Now, the reason we give the vaccine to the pregnant women is because they mount antibodies to the vaccine, and that actually then is transferred to the unborn child. And so in the earliest days of their life, they actually carry the maternal antibody that the mother very kindly gave them before they were born. And that is a very important time period for reducing the risk of serious illness in these young children. For those infants who are born to mothers who did not get the vaccination in week 32 to 36, there is a monoclonal antibody that can be used for protecting them temporarily. There are two different products. One, which is called Beyfortus, actually has three times the higher potency than the second one, Synagis. This is an antibody that's administered to all infants eight months or younger born during or entering RSV season. Also, there are monthly doses of the Synagis for children 24 months of age and younger with certain health conditions that increase their risk of severe disease. These infants would not also receive the Beyfortus monoclonal antibody. So again, let me just go back through this. For those 60 years of age and older, you get either the GSK or the Pfizer vaccine for pregnant women at 32 to 36 weeks of gestation.

 

Dr. Osterholm: If you're vaccinated during that time, you need to be vaccinated with the Pfizer vaccine. And then for the infants born to mothers who had not been previously vaccinated, you have one of these two products that you can use, the Beyfortus or the Synagis. Now, I've seen lots of confusion. In fact, I got called just this past week from a pharmacy here in the Twin Cities who unfortunately mixed up the brands for administering to pregnant women, and they actually gave them the GSK vaccine, which has not been approved for pregnant women, although the lack of approval is not because of safety reasons or even how well it works. It's just the fact that they didn't go for approval from the FDA for that vaccine. So and then on top of all of this, what really complicates this is that there's been a major shortage of these doses of vaccine. Pediatricians have been very frustrated about the lack of pediatric dosing and what's available. So at this point, all I can say is, is that continue to try to get it. I know that medical clinics, hospitals around the country are all scrambling to get as much of this as they can. One last point I want to make. I have heard from a number of people who, particularly those 60 years of age and older, who have said they've gone to their health care provider, a physician, nurse practitioner, etcetera, who said, well, you know, I'd maybe wait for this because, you know, we don't have that much experience with this vaccine.

 

Dr. Osterholm: And I know many people who have actually been turned away without having been vaccinated. This is wrong, wrong, wrong. Please, if your health care provider tells you that, you can say this crazy guy at the University of Minnesota said no, get it? The safety profile on these vaccines is very, very good. A lot of research has gone into this. We. Know that these vaccines can, in fact, save your life. So if you're over age 60, I got mine. You get yours, get your dose of vaccine. And even if you have a hesitant health care provider who says, well, I'd wait, you may be waiting to the point of her. One day you're laying in that hospital bed with your RSV infection wishing you had gotten your vaccine. So I hope this adds a little bit of clarity, Bill, to what you are asking. I do understand how confusing it is. I think these names that they come up with for doses of vaccine make it only more confusing. And to the general public, just know if you're a pregnant woman, if you're a baby, if you're over age 60. RSV vaccines or monoclonal antibodies are for you.

 

Chris Dall: And then we received this email from mignon, who had a follow up to your discussion in the last episode about viruses with pandemic potential. She wrote, I was confused about one thing you said last week, and as I always tell my students, when you're confused, you're probably not the only one. So ask. You said we can be sure there won't be another huge surge like the Omicron event. But later in the podcast you talked about future pandemics. That could be much worse if we get a virus with the lethality of SARS or MERS that is also more transmissible. Given that SARS-CoV-2 is still undergoing significant evolution, why don't you think it's possible that this virus could become the next super pandemic or even reach Omicron levels of horribleness again? What am I missing?

 

Dr. Osterholm: First of all, Chris, I want to thank mignon for this very, very thoughtful question. It's clear that mignon is a very good teacher because in order to teach, you must learn. And in this case, this question is all about that. So thank you very much. Let me be really clear here about this. I was really talking about two very different times. One associated with the backside of what I call this pandemic, meaning that the big spike activity of cases, the ones that we're talking about, hundreds of thousands of hospitalizations a week, we're done with that. Why are we done with that? As much as this virus will continue to change. It will not change substantially enough that, in fact, the immunity that we have developed will not provide some cross protection against serious illness, hospitalizations and deaths. And so, yes, we're still going to see morbidity mortality associated with this virus. It will go on into perpetuity. But however, it's not going to give us those days again of a totally virgin population immunologically as it relates to this virus. Now, what I was referring to about what could happen is a new coronavirus emerge. Much like this virus. A SARS-CoV-2 was different than SARS one or MERS viruses. The next one would also be different than the three previous ones, where the cross-protection from previous immunity may be limited, if at all.

 

Dr. Osterholm: That's when, if a virus emerged that had the ability to kill like we see with MERS or with SARS, 15 to 35% of people infected die and it had the wings of a highly infectious respiratory virus like SARS CoV two. We would see at that point a very, very different kind of pandemic experience. We could see substantially increased number of deaths, serious illness, hospitalizations, etcetera, because we wouldn't have that cross protection against this specific virus. And so I want to make it very clear that I don't see that on the horizon right now. There's no evidence we're seeing the emergence of a new coronavirus that would cause us to think we're going to have another pandemic. And therefore, what we're really talking about is the remnants of the one that we just had that will continue. We though, however, must stay vigilant for what could happen with the new coronavirus or a new flu virus at any time. And with those, that's when we're going to see that new pandemic, not from this virus, but from truly a newly emerged virus. That is not just a, you might say, a knockoff of the previous Wuhan originating strain, but rather a brand new virus.

 

Chris Dall: Now on to some other infectious disease items. There was an article in Politico this week about some potentially massive cuts to a Trump era program that aimed to end HIV in America. Now, it's important to note that these cuts are not likely to pass. But, Mike, how concerned are you that public health programs always seem to be among the first items on the federal budget chopping block?

 

Dr. Osterholm: Chris, this is a incredibly difficult topic for me in that anyone who has listened to this podcast, anyone who has followed my career, knows that I have made every effort to stay as apolitical as possible, where I have always believed my job was to be a private in the public health army and without regard to who the commander in chief of that public health army is. I'm there to serve, and I've tried to live my professional career that way. I've had roles in the current in the six previous administrations dating back to the Reagan administration. Know I've served in all these roles. During the 2001 anthrax attack, I served for three years, half time at the Department of Health and Human Services Under Secretary Tommy Thompson, the Bush administration. I have served as a science envoy for the State Department, a major position during the Trump administration, and did that with great pride. And, of course, you know, I've been very actively involved in the Biden administration with regard to COVID and serving on the Biden-Harris transition team for COVID. So please take my comments as apolitical as possible. This is just basically someone who has been in the fray who's been in the front row, but at the same time was willing to roll up your sleeves to help however I could whenever I could. What I'm seeing right now is unprecedented. In my almost 50 years in the business. Public health has always had a certain level of political independence and freedom.

 

Dr. Osterholm: Saving a life didn't matter if you were old or you're young, you're white or you're black, you're male or female, you're rich or poor. It doesn't matter where you live. Our job was to basically do the best we could to improve the lot of life for everyone out there, and we all know that that changed to a certain degree with COVID. It took on major political overtones, and unfortunately, thousands and thousands of people died in this country who largely for political reasons, would not get vaccinated. That's a challenge. Well, now I look at what's happening, and if someone had said to me five years ago what just happened a few weeks ago would be possible, I would never have believed it. One of the House appropriations subcommittees basically passed out of their committee a bill which would have reduced both the CDC and the NIH budgets by 50%, not leveled them, reduce them. A provision in the bill would also have prohibited CDC to work on HIV throughout the world. I'm stunned. I'm stunned. Because in fact, public health again, is not a red or blue. It's not a political affiliation. It's about helping everyone. And we can see how public health has become weaponized in a sense, a term that keeps getting used in Washington. But it's true. And this is very hard for me to watch, because in fact, I know what can come out of good public health. I watched PEPFAR, the President's Program for HIV Prevention Around the World, a Bush administration initiative that has saved literally millions of lives, has kept so many babies from being infected by their from their infected mother by making sure that they got the retroviral therapy upon birth.

 

Dr. Osterholm: I've watched the ability of low and middle income countries to greatly impact on what happens with HIV because of US support, which then has major implications for global economies, which we happen to be part of. And now to think that we're going to not only say, that's not good, but you can't do it. You cannot be part of that. That blows me away. I look at where we're at now in this country and how we have underfunded public health systems to deal with all aspects of public health. You know, another example I could not believe I wouldn't believe this if somebody said to me ten years ago you were going to go back to the 1940s from a sexually transmitted infection standpoint and what your programs are about. Just take the recent report from CDC that showed this absolutely alarming increase in newborn syphilis cases. A staggering 3700 babies were born with syphilis in 2022, more than ten times the count from 2012, and numbers we've not seen dating back to the 1940s. They also report that 90% of the cases in 2022 might have been prevented with timely testing and treatment during pregnancy. This just illustrates my point exactly. When public health agencies lose funding for programs like this, which CDC has in recent years, then we miss out an opportunity to take action on preventable diseases like congenital syphilis cases.

 

Dr. Osterholm: And now we'll have to pay for this in other ways. Not to mention the unfortunate reality that these newborns and their families now have to face. So all I can say is, I know it's sounds naive to wish for this, but hey, it's the holidays, remember? I'm supposed to wish for those good things. Please support public health. Don't handcuff it. Don't, don't, don't make it be evil. It is good. It's noble. My colleagues in the public health world are noble. Good people who want to do good. And yet I'm seeing in Washington, D.C. right now rhetoric and actions that defy every possibility of doing good and yet may come off again to some of you as being very political. I don't mean to be. I would say this withoutrillionegard to whoever the political party was or the leadership that would take this approach that we're seeing now and say the very same thing. So and I'm willing to roll up my sleeves again to be in the public health army to help change this. But I don't see that happening right now. And from that perspective, I hope all of you, when you can talk to your elected officials to help support public health. It is noble, it is good, it is not bad. It doesn't cost us. It saves us. And I think that's the message we need to get across.

 

Chris Dall: The World Health Organization has dubbed the coming week World Antimicrobial Resistance Awareness Week or World AMR Awareness Week. Mike, as you know, this is a topic that I cover as a reporter for CIDRAP news, so it's near and dear to my heart. It's also an area of focus for CIDRAP. You've called antimicrobial resistance a slow motion tsunami. What do you think is important for our listeners to know about this issue?

 

Dr. Osterholm: Christmas is an issue that's very close to both of us, and I must say thank you for what you do as a reporter for CIDRAP news covering this topic area. You have provided incredibly important information and summarized some of the more complex data that we have so that everyone from the general public to policymakers can understand that. So my hat's off to you and with great appreciation. I cannot stress enough how big this threat is to the public's health. You know, when you think back on human history, it took about 80,000 generations to go from the caves to the early 1900s. Life expectancy during that time finally managed to get to about 48 years. In the last century plus, we now have life expectancy, particularly in middle and high income countries. In the late 70s, early 80s. For every three days we've lived, we've gained a day of life expectancy. That's remarkable. That is simply remarkable. Now, we're surely challenging that right now, but that's remarkable. And one of the key reasons why that happened was the role of antimicrobial agents. Surely vaccines played a role. Sanitation, clean water, all those things played a role. But the bottom line is antimicrobial agents have played a key role. People who had just routine injuries, people who would go into the hospital to deliver a baby, would come to know a death due to an infection. Antibiotics had such an impact.

 

Dr. Osterholm: You realize today we couldn't do the kind of surgeries we do for immune deficient individuals without antibiotics. We couldn't do so many things today. Well, but if you look at microbial evolution, you realize that these bugs have been fighting for space and food since the beginning of time, too. And what we have done is captured ways to somehow affect that reproduction of those infectious agents, some cases killing them, sometimes just rendering them so they can't reproduce. And guess what? A bug that actually has a 20 minute gestational period, as we would call it, versus a human that may have a 25 year period between generations, can evolve very quickly and adjust accordingly. And what we've seen happen is with all the use of antimicrobial agents over the past 50 years, we have seen this evolution of resistance occur, and it's inevitable. We will never not have to deal with it. So I don't want to say somehow that if we just had the right antibiotics, that would would change everything. No it won't, but if we can slow down the evolution of this resistance by not overusing antibiotics so that they needlessly are out there in the environment, challenging the bacteria to become resistant to them, that would be immensely helpful. We'll think about this when one third of the world's population does not have a safe water supply. How many infectious agents do you pick up? Where? Because over-the-counter antibiotics, which may actually be counterfeit antibiotics that actually don't really work anyway, but they may be are real antibiotics.

 

Dr. Osterholm: And I can pick it up at any little shop anywhere in the world. Think of what that does to drive the pressure for the evolution of antibiotic resistant infections. And there's been a number of reports out that have detailed this great concern, notably one that the Wellcome Trust helped support back in 2015 and 16 under Sir Jim O'Neill's leadership, actually proposed that by 2050, more people would die from antimicrobial resistant infections than would die from cancer and diabetes. That's a pretty frightening thought. So what's the answer? Well, the first thing is, is there is no business model that is going to bring the world rushing to make new antibiotics. You know, today, if you're a pharmaceutical company and you have a responsibility to your investors, you want to find blockbuster drugs that somebody's going to have to take every day for the rest of their life. You don't want to have to spend all these years in research and development to come up with an antibiotic that then will say, don't ever use this unless you absolutely have to. And then when you do hardly use it at all, it's just enough to get you better. Okay? Because we don't want to push the antibiotic resistant evolution.

 

Dr. Osterholm: That's not a good model. You know, that'd be like a car dealer selling cars that are great cars, but you can only use them between 9 and 10:00 on Sunday mornings. Who's going to buy that car? And so that is the world we live in in terms of development. Then we have this overuse of antimicrobials, not just in humans but also in animals. We even have it in plants today, where we're seeing the wide use of certain antimicrobial agents around the world to suppress various plant pathogens. This is all driving resistance, and we can't begin to address this issue until we come up with a more reasonable plan for how do we one limit the use of antimicrobial agents when we don't need them? Well, surely cleaning up the environment, i.e. safe water is an example that would help. Number two is how do we support antimicrobial research and development in such a way that makes it economically feasible for companies to want to do that, and to basically then have a profit margin there that can be guaranteed, but they don't have to compete in the open market trying to sell as much of the antibiotic as they can. And then we need to have individuals understand, you know, don't pop pills just because you got them in your medicine cabinet from an infection that occurred two years ago, but you didn't use them all.

 

Dr. Osterholm: How do we educate the public about this? And so I think all of these are really important issues, and I would really recommend any of our listeners to go to the CIDRAP site. We have actually produced a fantastic 12 episode podcast series entitled Superbugs in You, which features incredible guests and a discussion of ongoing antimicrobial resistant threats in the world. I think you'll get a great deal out of listening to these 12 episodes of the podcast series, but just know this is real. And you know what? I'm old enough now. I may get out of this world before we really hit a post antibiotic era. You know, clearly my great grandparents lived in a pre-antibiotic era. My grandparents were right on the cusp of the new antibiotic era. My parents lived in it. I lived in it. But I'm not sure that my kids and grandkids will not live in a post-antibiotic era when in fact, having a drug that can save your life, which was just taken for granted years before now, doesn't exist. This is a huge issue. We must focus on this like climate change. It will come. It is coming. It is here. But this true impact will not be felt yet. Until one day when you thought it was just another easily treated infection is now life threatening. That will change your view of the world.

 

Chris Dall: Finally, Mike, you alerted the staff recently to an article in the journal Clinical Infectious Diseases, which was fittingly written by Debbie Goff, who is an infectious disease pharmacist and leading advocate for antibiotic stewardship, and someone who I've spoken to on many occasions for my stories. But for this article she wrote about the experience of having an elderly mother in a nursing home during the COVID-19 pandemic. What was it about this article that struck you?

 

Dr. Osterholm: Chris, first of all, I just have to comment on your introduction here to say that Debbie Goff has been a dear, dear friend and trusted colleague for many years and I cannot begin to elaborate on all the incredible things she's done to deal with the issue of antimicrobial resistance and antibiotic stewardship, the ability basically to wisely use antibiotics. Debbie is one of the best in the world in her business, and she is one of the kindest, nicest people I've ever met. I have nothing but the highest regards for her. And she published a story in the Clinical Infectious Disease Journal, one of our journals that we all count on in infectious diseases. Telling a story. And I will tell you, and it'll probably be hard for me to even do that here. I could not get through this in one sitting, because the tears made it impossible to read the words on the paper. And I want to share this story with you because it's lessons learned and it's lessons learned at the heart. It's lessons learned to the head. And what we must think about going forward in how we do what we do in terms of public health and infectious diseases. So I want to read this story to you. It won't take that long. And I have Debbie's permission to share this. And the title says it all. Isolated and lonely in a nursing home during the coronavirus disease 2009 pandemic.

 

Dr. Osterholm: A deadly combination for my mom. And if you know Debbie, you know how close she is to her family as all the family are. So here it is from Debbie Goff. The call from the nursing home came on a Saturday morning in November 2020. Your mom is at the end of life. You may now come and have an in-room visit. I got in my car and started the seven hour drive to her nursing home in Chicago. While driving, I reflected on my 93 year old mom's life and how the coronavirus disease 2019 COVID-19 pandemic had prevented me and my three siblings from visiting her for the previous nine months. My mom's progressive macular degeneration, decreasing mobility and mild dementia led to her moving from her home to a nursing home at age 89. Her nursing unit had eight private rooms. She was friend to the seven other residents. My mom had been vibrant, talkative and the best dressed person at the nursing home. Her nursing aides quickly learned that she wanted them to coordinate her clothes, slippers and weekly manicures. She made them laugh. Prior to the COVID-19 pandemic. I talked by phone with my mom every day. I frequently made the drive to Chicago to spend time with her. I would pack up her wheelchair and take her shopping and out to lunch.

 

Dr. Osterholm: My siblings who lived in Chicago would visit her in person regularly. Little did I know that when I kissed her goodbye at Christmas 2019, it would be the last time I would hold her hand in person and tell this end of life visit in November 2020. In an effort to prevent the most vulnerable elderly patients from acquiring or transmitting COVID-19, the centers for Medicare and Medicaid Services issued a lockdown order on 13th of March 2020, banning everyone but essential personnel from entering nursing homes. My mom was kept in her private room with the door shut. Masks were mandated for employees and residents. All socialization stopped, including her weekly manicures. Group activities were prohibited. My mom ate every meal alone in her room. Her nursing aides could not use their iPhones for my calls, so I had to call her landline phone in the room. Due to her poor vision and growing confusion, she would frequently pick up the receiver backwards. She could not hear me and would hang up. The few times I was able to connect with her, she would ask, when will you come to see me? None of you visit me anymore. I sit in my room all day. They won't let me see my friends. I'm not allowed even to attend mass. I do not want to live like this.

 

Dr. Osterholm: I tried to explain that there was a very deadly virus and we needed to protect her. It was heartbreaking. As the pandemic progressed into the summer and fall, her nursing home implemented window visits. On paper, this policy sounds reasonable to reconnect patients with their loved ones. The reality was that the window visits were useless for my mom. The window visit required families to preschedule the visit. A nursing aide had to be available to bring my mom down to the window in her wheelchair. My sisters would arrive for the schedule of 15 minute visit, only to learn that the nursing home was short staffed that day and the visit had to be canceled when the window did occur. My mom would be in her wheelchair ten feet from the window. My sisters would be outside shouting to my mom and another family at the next window, shouting at their loved ones. I was on my sister's iPhone, FaceTime, also shouting to my mom. My mom would ask her aide, why am I down here? I do not see anyone. She had macular degeneration and I do not hear anyone. She was hard of hearing. When the aide would tell her. It is your daughters and son outside, she would say, well, tell them to come in and see me. This was not possible. I watched as my mom's verbal skills declined.

 

Dr. Osterholm: Each month she became more confused. I had an N95 mask fit test, as did my brother, a physician in a hospital, and one sister, a nurse in a hospital. We pleaded with the nursing home director to allow us to visit our mom in her private room. We were safer with our N95 masks than the Aids caring for her, who wore poor fitting surgical masks. We continued to make our case to visit our mom, but the nursing home would not make any exceptions, only allowed to visit at end of life. When I received the end of life phone call and arrived at the nursing home, my siblings and I were handed inadequate N95 masks, gowns and gloves. Her four children entered her room. Mom, it's Debbie, your favorite youngest daughter. Mom, it's Barb, your favorite middle daughter. Mom, it's Diane, your favorite oldest daughter. Mom, it's Jack, your favorite son. Her eyes opened only to see four unrecognizable people standing over her in masked gowns and gloves, knowing we were COVID negative. We removed our masks and gloves. I held her hand. Her eyes lit up and she asked, where have you been? She squeezed my hand and never let go. We talked. We laughed. We gave her ice cream with a Starbucks latte, her favorite. After four days of daily visits with her four children, she was back to her baseline and no longer in the end of life.

 

Dr. Osterholm: When she asked how much longer she would need to live like this, isolated and alone, we said for several more months. She replied, I'm blessed. We had this time together. We each told her how much we loved her, knowing it could be the last time we would see her. Ironically, because she had improved the nursing home, determined she was no longer at the end of life so we could no longer visit. I might drive back. I reflected on my mom's life. She had a blessed life. However, we could not imagine her dying alone, thinking all four of her children had abandoned her. My mom died two weeks later. Her seven other nursing home unit friends also died, but none from COVID. From March 2020 to November 2020, they just slowly died. Families and nursing aides felt the deaths were largely from being isolated and lonely, and lacking physical contact with the ones who loved them most. I thought of all the other nursing home patients who did not die from COVID, but suffered and died because of COVID-19 nursing home infection control policies. According to the CMS, 167,183 nursing home patients have died from COVID. We will never be able to tally the number of elderly residents who died in nursing homes during this pandemic, from loneliness or a broken heart. Death from a broken heart is real.

 

Dr. Osterholm: Debbie Goff. If we learned anything from this pandemic, we have to learn what Debbie is sharing with us. And I hope that as we look forward, we do develop both care for the body and care for the heart. Care for the soul. Imagine a health care trained family like Debbie's who had their fitted n95s and they couldn't be with their mother. That was wrong. I understand at the time why the policies where they were. I understand at the time what we were trying to do, but these are the lessons I'm not hearing anybody talk about. I'm afraid this could be deja vu all over again with the next pandemic. So I'm on a mission right now with my new book. I address these issues about how important these lessons are and how they have to be learned. And so thank you, Debbie. Thank you to your family. Thank you for your mother and all she was and what she shared with all of her children to result in the kind of family that you have. We've provided a link on our website here for you to go back and actually look at this article again and read it more carefully. I'm sure I did not do it justice, but all I can say is, Debbie. Thank you. You're a gift, as was your mother.

 

Chris Dall: Now for this week in public health history. Mike, who are we honoring this week?

 

Dr. Osterholm: Well, Chris, first of all, I love this section. Okay? I just think this is such a wonderful way to mark the many wonderful things of public health and those in infectious diseases have done. This week we're celebrating the birth date of an incredible public health hero, Dr. Sarah Josephine Baker, on November 15th, 1873. Not to be confused with the French singer and actress Josephine Baker. Doctor Sarah Josephine Baker was an American physician in the late 19th and early 20th century. In her early life, she lost both her younger brother and father to typhoid. This led her to pursue a career in medicine as a teenager. She began her private practice in New York City in the year 1900. In addition to her clinical work, she also took on a part time role as a medical inspector for the city, eventually becoming the Assistant Commissioner of Health and later the director of the Bureau of Child Health. Dr. Baker had numerous accomplishments in her public health career. She played a key role in twice finding and isolating Typhoid Mary. There's a very vivid description in Dr. Baker's autobiography, where she recounts how she had to accompany Mary in an ambulance for treatment and it was, quote, like being in a cage with an angry lion. Dr. Baker is most well known for her many achievements in improving child health and reducing infant mortality.

 

Dr. Osterholm: As the United States entered World War One, she made a controversial comment to The New York Times reporter, stating that it was, quote, six times safer to be a soldier in the trenches of France than to be a baby born in the United States, unquote. She played critical roles in improving water and sanitation in the city, providing safely pasteurized milk and infant formula to families, training and licensing midwives, and promoting home visits and education for parents on safe sleep and nutrition. She also implemented the first wide scale school health program, allowing for children to be checked and treated for illnesses while at school, and to receive a nutritious lunch. Dr. Baker eventually became the first woman to earn a PhD at NYU in public health. She ended her career by lecturing in child health at the NYU Bellevue Hospital Medical School and serving on numerous committees, including the League of Nations. She was a suffragette, even meeting President Woodrow Wilson at the white House to advocate for women's rights to vote. This is just a snippet of Dr. Sarah Josephine Baker's incredible life and career. I'd recommend anyone who is interested to read her autobiography, fighting for life. We'll also link a few resources in Doctor Baker on our podcast website. What a special person in public health history.

 

Chris Dall: Mike, what are your take home messages for today?

 

Dr. Osterholm: Well, I'm sure the audience. If you followed with me so far, no. At least one of them. And that is get vaccinated if you're eligible for RSV. Virtually everyone is for COVID and influenza. Get those three vaccines. Make sure you're up to date. It can go a long ways in reducing serious illness, hospitalizations, and deaths. Number two, I'm not sure what COVID will do here in the next few months in the United States, however, it could show its ugly head, much like we're seeing in Europe, where we see some notable increases in serious illness, hospitalizations and deaths. So that's again why you should get vaccinated at this point. One who predicts what a flu or an RSV season will look like can often be made to look foolish. So I'm prepared to do that. I think right now, what I'm seeing is suggesting that we will have an average flu and RSV season, meaning that it will still extract significant pain and suffering. But we're not going to see the big, big peaks of cases. I hope that's the case. I could very well be wrong, but at this point I think that's what will happen. And finally, what happens in Washington matters around the world. I hope the moments that I shared with you about the challenges we have right now in our government and what their views of public health happen to be among a number of elected officials, does not mean that our future in public health will be diminished, but will rather be expanded because it is the noble profession. And so be aware of, be mindful of, be supportive of with your elected officials, the public health that we need to save lives, reduce pain and suffering. That to me is such an important, important message.

 

Chris Dall: And what is your closing song for this episode?

 

Dr. Osterholm: Well in following up on the dedication, which I hope I did an adequate job of expressing what was in my head and my heart. I want to follow up with a song that I've actually used in previous episodes, in fact, because to me it represents such a special meaning. This song was used in Episode 11 way back in June 10th of 2020, Driven by the Data, in Episode 52 on April 22nd, 2021 A Balancing Act Continued and in Episode 75: Evolving Science on October 28th, 2021. So it's been over two years since I've used it again. This song, Lean on Me is a song written and recorded by American singer songwriter Bill Withers. It was a number one single on both the Soul and Billboard Hot 100 charts, the latter chart for three weeks in July 1972. Billboard ranked it as the number seven song of all of 1972. It was ranked number 208 on Rolling Stone's list of the 500 Greatest Songs of All Time. Bill Withers grew up in a coal mining town in West Virginia and was the inspiration for Lean on Me, which he wrote after he had moved to Los Angeles and found himself missing a strong community ethic of his hometown. He lived in a very poor housing area and recognized how important it was to lean on each other. So this song is in keeping with that dedication of what, during this holiday season, I hope all of you think about.

 

Dr. Osterholm: I hope all of you think about how to lean both in and out, how to help, how to be helped. So here it is. Lean on me by Bill Withers. Sometimes in our lives we all have pain. We all have sorrow. But if we are wise, we know that there's always tomorrow. Lean on me when you're not strong. And I'll be your friend I'll help you carry on. For it won't be long. Til I'm going to need somebody to lean on. Please swallow your pride. If I have things you need to borrow for. No one can fill those of your needs that you won't let show. You might also like. Just call on me, brother. When you need a hand. We all need somebody to lean on. I just might have a problem that you'll understand. We all need somebody to lean on. Lean on me when you're not strong. And I'll be your friend I'll help you carry on. For it won't be long. Til I'm going to need somebody to lean on. You just call me brother when you need a hand. We all need somebody to lean on I just might have a problem that you'll understand. We all need somebody to lean on. If there is a load you have to bear that you can't carry.

 

Dr. Osterholm: I'm right up the road. I'll share your load if you just call me. Call me if you need a friend. Call me if you need a friend. Call me. Bill Withers, lean on me. Thank you again for being with us. I appreciate all the feedback that we get. I appreciate the podcast team who makes it possible for this to happen, and just know that we're thinking of you during this holiday season, and however we can help take care of each other, now is the time to do that. Don't be afraid to say hi to someone as you walk by them, knowing that they'll look at you probably and wonder why you said that. But just maybe next time they'll say hello. Be kind. Be kind. Right now, this is the time of the year when we need that. And know that these can be dark days for people. I remember that so well from my own life. So I hope that we all can be there to lean on someone. And we can be someone that others can lean on. Thank you. We look forward to hearing from you. And please do send us your comments and thoughts and we'll be back again in two weeks. And in the meantime, be safe. Be kind. Thank you very much.

 

Chris Dall: Thanks for listening to the latest episode of the Osterholm Update. If you enjoyed the podcast, please subscribe, rate and review wherever you get your podcasts, and be sure to keep up with the latest infectious disease 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/support. The Osterholm Update is produced by Sydney Redepenning, Elise Holmes, Cory Anderson, Angela Ulrich, Meredith Arpey, Clare Stoddart, and Leah Moat.