Episode 154: H5N1 Uncertainty

Chris Dall: Hello and welcome to the Osterholm update, a podcast on COVID-19 and other infectious diseases with Doctor Michael Osterholm. Doctor 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, Doctor 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 Dahl, reporter for CIDRAP news, and I'm your host for these conversations. Welcome back, everyone to another episode of the Osterholm Update podcast. It's been more than four years since the beginning of the COVID-19 pandemic, but in many ways, it feels like a lifetime. While the world has in many respects returned to pre-pandemic life, our lives are different in good ways and bad ways. For some of us, working from home now has become the norm. For others, the pandemic has changed our perception of risk and how we relate to our fellow citizens. There are also millions who are still feeling the physical effects of COVID, months and even years after their infection. And of course, there are the countless people who've had to adapt to life without loved ones. As much as we're trying to put COVID in the rear view mirror, it still remains very visible. On this April 4th episode, we're going to spend some time talking about how we're living our lives now after we examine the latest data on COVID-19 here in the United States and elsewhere. We'll also provide an update on COVID-19 variants, look at the latest long COVID research, discuss a new study on Paxlovid, answer an ID query about N95s, and examine the latest avian influenza news. And there's been a lot of it. And we'll bring you the latest installment of This Week in Public Health history, along with our second segment marking the four year anniversary of the podcast. But before we get started, as always, we'll begin with Doctor Osterholm's opening comments and dedication.

Dr. Osterholm: Thanks, Chris. Welcome back to all of you who are part of the podcast family. It's always wonderful to be here with you. Uh, again, thank you for your ongoing support, your feedback. We're going to talk more about feedback today as we are sharing with you a survey that we hope you will fill out and send back to us with your ideas about how we can improve this podcast, and how we can make it more meaningful to you in your everyday lives. And I want to welcome any new listeners this week. I actually have learned recently that there have been several of you who have only recently joined the podcast family. Uh, you missed the four years that we otherwise were all together. Uh, but we're glad to have you, and we hope that you can bring your insights into how we can improve, uh, this podcast so that it's more effective and in helping you in your everyday lives. And as we kick off this episode, I want to take a moment to acknowledge the significance of this week. It's National Public Health Week. This annual observance is a way to recognize and celebrate the life saving work, research, and advocacy that public health professionals are responsible for. Throughout my career in public health, now almost 50 years, I've gotten to know and work with countless people whose dedication to improving the health of their local and global communities has inspired me immensely. I'm so proud to be in this field and applaud all public health professionals for their contributions this week and year round.

Dr. Osterholm: In light of National Public Health Week, I want to dedicate this episode to a special group of professionals who play a critical role in public health but may not always be in the spotlight, namely veterinarians. Public health veterinarians have the unique skills and knowledge to address the ways that animals and humans interact, and how they can impact in each other's health. This is why we come to call this animal and human relationship a one health approach. The CDC estimates that more than 60% of known infectious diseases in people can be spread from animals, and 75% of new or emerging infectious diseases, and people come from animals. In addition, we see oftentimes humans transmitting infectious agents back to the animal kingdom. This is why public health veterinarians are so important in this field when it comes to the impact on climate change and animal and human health, antimicrobial resistance, food safety challenges, and emergency preparedness. Current headlines on the spread of avian influenza offers a perfect example of why veterinary expertise is so important to public health. We'll get into this in more detail when we discuss the issue with H5N1, but suffice it to say, this is one of the leading, if not the leading, discussion point today in public health, at least here in North America. I'm very grateful to the public health veterinarians that I have had the opportunity to work with, and to all the veterinarians working around the world, trying to address the spread of infectious diseases and finding answers to all the questions that those situations demand. So to all public health professionals, and especially the veterinarians responding to the concerning spread of H5N1, happy Public Health Week.

Dr. Osterholm: We are so grateful for your critical contributions to the field. Now, let me move to another part of the podcast that I love so much. And for some of you, it's something you tolerate. I am so happy to report today that in Minneapolis, sunrise is at 6:47 a.m., sunset at 7:45 p.m. we have a wonderful 12 hours and 58 minutes and 17 seconds of sunlight today, and we're gaining that at about three minutes and six seconds a day. So stay tuned. Over the course of the next few weeks, it's going to be a brighter and brighter day. Now, I do have to say to our dearest colleagues that the Occidental Belgian Beer House in Auckland, uh, you are still seeing a lot of light, but it is getting darker today. Your sun rises at 7:36 a.m., your sunset is at 710. You have 11 hours, 33 minutes and 16 seconds of sunlight. Unfortunately, you're losing about two minutes and 18 seconds of sunlight a day. But don't worry, we promise to share our sunlight with you as you get closer and closer into your winter months. And again, I want to thank all those who continue to send me pictures from the Occidental Belgian Beer House. It's amazing to me how many of you have traveled recently to Auckland and have made it a priority to visit the Occidental Belgian Beer House. Uh, so thank you for those, uh, we love seeing those pictures.

Chris Dall: So we'll start where we always do with the latest COVID data, and it feels like it's been pretty quiet. But Mike, what are you seeing on the domestic and international fronts?

Dr. Osterholm: Chris, every time that we do this section of the podcast, I find myself struggling to make sure that I provide the nuance of what these numbers mean and how you in everyday life can use them. Uh, it's easy to just spout off a bunch of numbers and leave it at that, but in fact, it is much more than that. It's also what does this mean to me? How does how do I take and internalize this? And we're going to talk about that more today in a later part of the episode. But let me just address where we're at now. COVID activity, uh, clearly is on the decline in the United States and for that matter, it appears to much of the world what we've seen in terms of wastewater levels, this decline has basically been playing out since the start of the new year. During this time, at least according to the data reported by the CDC, wastewater levels nationally have dropped more than six fold. In fact, the last time we've seen levels like this was July of last year, almost eight months ago, and at a time when we were literally at the lowest number of cases we'd seen in the country throughout the duration of the pandemic. Overall, the CDC considers the current level across the US as low. Now, I should note that some states only have a handful of sites collecting and reporting COVID wastewater data, so it's not necessarily representative, but still, it's a good, consistent trend. Fortunately, we're seeing a similar trend with hospitalizations after reaching a point in early January when more than 30,000 Americans were hospitalized with COVID, they've dropped for the 11th consecutive week from the latest data we have, which is of for the week ending on March 23rd, current hospitalizations set at just below 8000, more than a three fold drop since January.

Dr. Osterholm: The last time we've seen numbers this low again was in July of 2023. That was the same month in which hospitalization levels for the US reached the lowest levels reported since COVID first emerged. At that point, they had dropped below 5400. And again, this compares to the 8600 now. So it's my best professional judgment right now that within the next several weeks, clearly within the next month or two, we will likely see us hitting an all time low, even surpassing the low number that we saw in July of 2023. So this is good news. Otherwise, in terms of deaths, there's also been declines, which we would expect to see happening with fewer cases, but we've still got plenty of room for progress to be made in that category. Overall, ten straight weeks of decrease have moved the number of weekly deaths from a peak of more than 2500 in January to just under 1200 by early March. However, we're now up to a span of 28 consecutive weeks, with weekly death tolls exceeding 1000. This has been our reality since August of last year, but I also believe that this number will continue to drop significantly. Now in terms of trying to put together, what does this all mean to you and your everyday lives? I know this is a challenge, but let me just share with you again how to begin to parse out the risk of COVID and a serious outcome.

Dr. Osterholm: If we just look at the deaths that have occurred in the United States so far in 2024, there have been 12,324 deaths reported due to COVID. If you look at the age of those who have died from COVID. 11,079 were 65 years of age and older. That's 90% of all the deaths are in those 65 years of age and older. That surely helps you understand. If I'm in that older age group, I have a very different picture than if I'm in a younger age group. Of the 10% less than 65 years of age, that comes to 1245 deaths, again, a significant number. How do I internalize that? Well, right now, on average, we're reporting about 3600 deaths each month due to automobile accidents in this country, 3600. If I'm in that age group under 65, I can look at the number of deaths at 1245 and can say, well, look it. That's much lower even than for automobile accidents. Um, does that mean then I have to take other risk factors for COVID that I wouldn't otherwise consider in my everyday lives? And most people will say, no, I'm back to living life with some risk for whatever it is that I have to be concerned about. If you're over age 65, you still have a challenge. Uh, and that then gets back to the fact of, are you over age 65 and have a risk factor? Are you over age 65? And have you actually received your most recent dose of vaccine? Uh, one that you should have right now on board, uh, within the last two months.

Dr. Osterholm: Those are all issues that will continue to come to play here. And we'll talk more about this in a moment. But I hope this gives some context that overall, right now, for much of the population of the United States, death due to a number of other causes is actually far higher than we actually see for COVID. One of the things that I continue to follow closely. In terms of issues like the number of deaths that are occurring, is the fact that we had days back in the middle part of the pandemic in that 2021, 2022 time period where we had more deaths reported for a day than we're now having for an entire month. That helps give us some perspective as to the fact that we are surely in a much, much better place now if you're outside of the United States. I don't know what to tell you, to be honest. I don't really have a good sense of what's going on. We're really trying. But right now the data is so sparse. So few countries are reporting any COVID related activity. So what I've seen, there aren't any clear hotspots. In general, things seem to be on a decline, at least in places like the UK and Australia. That said, I have heard some rumblings of potential upticks in cases like China and Chile, but official data from these places is really very limited.

Chris Dall: On the variant front, the latest data from the CDC showed that JN.1 Still remains dominant, accounting for more than 86% of cases, down from 92% a few weeks ago. The variant that appears to be gaining ground is JN.1.13. But Mike, is that all that different from Jan one?

Dr. Osterholm: Well, yes and no. JN.1.13 Has a set of mutations that distinguish it from its parent lineage, while yet still maintaining genetic similarity to it. One trend that we've seen with Omicron is that a series of progeny variants with similar phenotypes grow as a cluster, following domination by a single variant. On this podcast, we've used this nickname Variant Soup for this phenomenon. There are other members in the variant soup, including JN.1.18, 4, 8, 7, etc., each with a particular mutational profile which have evolved convergently with the goal of escaping host immunity and increasing transmission in a given immune landscape. What makes JN.1.13 Worth mentioning is it's a combination of spike mutations dubbed FLiRT, JN.1 sub variants, with these mutations having recently been detected primarily in the UK, where attributable cases are growing in proportion to total infections, it is too early to tell if and when FLiRT variants will impact the US. But you are right in pointing out it appears to be gaining traction here, especially in the northeast region. It's important to note that one of the two FLiRT mutations was included in the 2023 updated XBB vaccine, which is probably why data from vaccine manufacturers like Novavax suggest neutralization of currently circulating variants and reduction of severe illness and death associated with JN.1 lineage infections.

Dr. Osterholm: This is good news. The FDA advisory committee meets in May to discuss what viral profile should be targeted in the next updated vaccine, and I have been seeing experts suggest that JN.1 Plus FLiRT should be strongly considered. It will be challenging to extrapolate future policy decisions from ongoing viral trends, but I think JN.1.13 And the rest of the variant soup is a good place to start in terms of what the FDA will also consider will be not just what's in the vaccine, but how often one should receive it. As you have heard me say time and time again, I hope that it's a possibility for any of us who are at over age 65, who have underlying health conditions that were able to obtain a dose every six months. If we want to. Again, I know many people won't. I'm not telling you, you have to go get it, but for me, it makes my life much more comfortable. If I know that every six months I have access to a booster dose of this vaccine.

Chris Dall: Let's turn now to long COVID. Mike, are there any recent studies that have caught your eye?

Dr. Osterholm: Chris, there's a lot of studies coming out right now on long COVID, and we spend a fair amount of time trying to understand what's different, what's new, what's meaningful, and what can actually help bring relief to those who are suffering from long COVID. This topic certainly continues to be an important and complex issue. And as I've said in many previous episodes, we're still at a stage where we have a lot more questions about long COVID than we have any answers, but we've got to keep searching. Each study that we review uncovers additional pieces of what seems to be an increasingly large and complicated puzzle. But the findings are still very important, as they get us one step closer to understanding what is happening and what can we do about it. There have been three studies published in the last two weeks that I want to cover today. The first is a study out of Sweden, which looked at over 1 million Swedish residents that had been infected with SARS-CoV-2, over 16,000 of whom had been diagnosed with long COVID. The researchers found that long COVID was far more common among those with more severe acute infections, with 61% of patients diagnosed with long COVID hospitalized and or requiring ventilation during their acute infections. Those who required mechanical ventilation during their acute infection had 114 times the odds of being diagnosed with long COVID, compared to those who did not require mechanical ventilation, an amazing increased risk factor.

Dr. Osterholm: Several previous studies have found similar findings, suggesting that severe infection increases the risk for long COVID, so the results of this study are not particularly surprising. But they do reaffirm the fact that we can expect to see more long COVID amongst those who had been severely ill. The second study I want to cover is one that's assessed long COVID prevalence in France. The researchers conducted a cross-sectional survey, meaning they went across the entire population and sampled people. And what they found with over 10,000 individuals included that 8% of the people in France who had COVID developed long COVID, which means the prevalence of long COVID in the total population of France is an estimated 4%. 2.4% of the people in France had long COVID symptoms that had at least moderate impact on their daily activities, and 1.2% had symptoms that had a strong or very strong impact on their daily activities. The researchers found that long COVID prevalence was twice as high in women compared to men, similar to the previous study that we discussed. The researchers also found an increased prevalence of long COVID among those with more severe acute infections. Even though these are a bunch of numbers, there are a number of you right now listening to this that know you are part of those numbers, and that makes it very personal. Finally, the third study I want to cover is one that compared the risk of neurologic issues following influenza infection and COVID infection.

Dr. Osterholm: Using medical records over 77,000 influenza and COVID patients, the researchers found that neurologic disorders such as epilepsy, migraine and neuropathy were less common following severe COVID infection than those with severe influenza infection. It's important to note, however, that this study looked only at the development of diagnosed neurologic issues, not the presence of neurologic symptoms like brain fog and fatigue. So these results do not necessarily mean that we're seeing more post-infection symptoms in influenza patients compared to COVID patients. But what it really points out is, again, the fact that the kind of long COVID picture we're talking about is something that predates COVID. It brings together what those who have long talked about chronic fatigue syndrome, etc., that there really is so much that we could learn here in a post infection sequelae. It really is such a critical topic. So the bottom line is that these studies add some additional context to our understanding of long COVID. But as I mentioned previously, we have far more questions remaining than we do answers. We need to continue to advocate for the funding of long COVID research, especially as so many individuals continue to suffer, as was clearly evident in the prevalence data from France. As is always for any listeners who are experiencing long COVID or have a loved one who is, please know we see you, we're listening to your concerns and we will never stop advocating for you.

Chris Dall: There is a new study out today in the New England Journal of Medicine about the efficacy of the antiviral Paxlovid on adult outpatients with COVID-19. Mike, what do our listeners need to know about this study?

Dr. Osterholm: Well, Chris, I'm going to parse this out and first discuss the study itself and then put it in context of what other studies have shown. The study that you mentioned is titled "Nirmatrelvir for Vaccinated or Unvaccinated Adult Patients with COVID-19" and was conducted between August 25th of 2021 to July 25th, 2022, with the purpose of assessing the efficacy and safety of Paxlovid in Non-hospitalized patients. And just so that there's no confusion, nirmatrelvir is the same as Paxlovid, with Paxlovid being the brand name. This was a phase two three clinical trial funded and conducted by Pfizer, who was also the developer of Paxlovid, and this was fully disclosed in the article. Participants were eligible to participate if they were determined to either be fully vaccinated but at high risk for severe COVID-19, meaning they had at least one risk factor, or at a standard risk, meaning that they had no risk factors for severe COVID-19 but had not received a dose of COVID-19 vaccine within the past year, so they may have received him prior to that time. This study would really be considered low risk individuals in general, in terms of of what they might expect for developing severe illness, hospitalizations or deaths. This study was a randomized, controlled trial, which is considered to be the gold standard for assessing the effect of a medication, because we can control for factors that otherwise influence the outcome, such as age, gender, race, socioeconomic status, insurance status, etc..

Dr. Osterholm: Study participants were randomized to receive ten doses of Paxlovid or a placebo, two times daily for five days, which is the standard amount prescribed to people with COVID-19. They were then followed for 28 days to assess efficacy, safety and potential rebound cases. Importantly, characteristics such as age, gender and race were similar between the people randomized to receive the Paxlovid treatment arm and the placebo arm, as were the proportion of participants at standard risk who were unvaccinated and high risk who were vaccinated. Adherence to medication was also similar in both arms. Notably, only a small portion of participants 5% were 65 years of age and older, which we know to be one of the most significant risk factors for COVID. The primary endpoint of the study was efficacy, measured by time to sustained alleviation of all signs and symptoms of COVID-19. This was defined as four consecutive days and an improvement of mild or absent of moderate or severe symptoms present at baseline, or the complete absence of any symptom scored as mild at baseline. The study found that the median time to COVID-19 symptom clearance was one day shorter, 12 days compared to 13 days in participants who received Paxlovid, but the difference was not statistically significant when they looked at subgroups, participants who had been vaccinated and had at least one risk factor for severe illness, and in participants who had no risk factors for severe illness and had never been vaccinated or had been not vaccinated within the previous 12 months.

Dr. Osterholm: They similarly saw no significant difference between those who were treated and those who were not. The secondary endpoint of the study was COVID-19 related hospitalizations or death from any cause through day 28. Because this study population was not a group considered to be at highest risk for severe COVID-19 or death. It's not surprising that only 15 participants, less than 1% of the study population, were hospitalized with COVID-19 or died during the study period, five were in the Paxlovid treatment arm and ten were taking placebo, but the difference was not statistically significant. In subgroup analysis, the number of COVID-19 related medical visits was significantly lower in the Paxlovid group than in the placebo group, and this was also true among the subgroup of participants who were vaccinated with at least one risk factor. In terms of safety, there were no serious adverse events related to the treatment or placebo in either group. 11 participants in the treatment group and two in the control group had adverse events that led to discontinuation of treatment. There are a few limitations of the study I want to briefly mention. By design, the participants enrolled in the study were not at high risk for severe disease, as they either had a risk factor and were vaccinated, or did not have a risk factor and were not vaccinated. The study population was quite young, with a median age of 42. Again, having just discussed the issue of whether we're seeing the severe illness and deaths, this is a very different population than where we're seeing the deaths right now.

Dr. Osterholm: This does not mean that the results aren't meaningful, but it does mean we need to interpret them with caution and avoid generalizing the findings to older, high risk populations. Additionally, there are some limitations to the way that they assess risk. Not all risk factors increase the risk for severe infection by the same magnitude. Can we really say that an unvaccinated 18 year old is in the same risk group as the vaccine? 89 year old? I don't think so. It would be beneficial to do additional subgroup analysis to determine whether there is a more pronounced effect of the drug in older individuals, for example. So what's the bottom line with all of this? Well, let me just say there was a very thoughtful commentary that was included with this article published in the New England Journal of Medicine by Gandhi and Hirsch, titled "Treating COVID-19 Final: Chapters Still Unwritten," and they emphasized the fact that Paxlovid is a first line therapy for non-hospitalized patients with COVID-19 on the basis of results of the evaluation of protease inhibition for COVID-19 in high risk patients, or what's been labeled Epic air trial. That trial showed that medication reduced the risk of hospitalization or death by 88%. But again, the Epic air trial enrolled adults who had not received the SARS-CoV-2 vaccine and who were at high risk for progression for severe COVID-19, particularly with age.

Dr. Osterholm: Given these results, the question arose as to whether Paxlovid conferred a benefit in persons who had been vaccinated or who did not have risk factors for severe disease. So when you consider the epic air trial, which is the high risk, versus this one, which is the low risk, it is very important to understand how Paxlovid may provide very different benefits in these two groups. What the results of these two studies really emphasize is that there's a gradient of benefit with Paxlovid, with the patient at highest risk for progression most likely to derive the greatest benefits. Thus, as both Gandhi and Hirsch suggest, it appears reasonable to recommend Paxlovid primarily for the treatment of COVID-19 and older patients, particularly those 65 years of age and older, those who are immunocompromised, and those who have conditions that substantially increase the risk of severe COVID, regardless of previous vaccination or infection status. But they also left it with the bottom line. There are still more to learn, so please do not take away from this study reported in today's New England Journal of Medicine, as reason why not to get Paxlovid? I still strongly urge it for those who are at increased risk for serious illness, and I think that these two studies are not inconsistent. One just says there's a group for which Paxlovid can have much more benefit, and a group where it may only have limited benefit. It's not whether it works or doesn't work.

Chris Dall: And now it's time for our ID query. This week we heard from Mary, who wrote in a time magazine article entitled COVID Cautious Americans Feel Abandoned. It quotes Doctor Osterholm saying he no longer wears an N95 mask any time he goes out in public, since he says he's up to date on vaccinations and has access to Paxlovid if he gets sick. Do any of you know when Doctor Osterholm chooses to still in general, wear an N95 in public? He said on a recent podcast that people with increased risk should continue to wear a respirator. Since he's 70, I assume he's qualified as being at increased risk. I want to ensure Doctor Osterholm didn't list caveats for himself, but that time simply cut off this part of the quote. So, Mike, I thought this was a good question because it gets to the perception of risk piece that I touched on in the introduction. What can you tell Mary?

Dr. Osterholm: First of all, Chris, I just want to thank Mary for providing us with this very important question and to clarify any confusion that may exist about what I recommend for myself and what I recommend for others, and that they're not inconsistent. Let me be very frank with you. This is a very personal issue, obviously. Uh, and uh, reporting on my own personal health status, uh, is important. And so I owe the listeners that very thing. I am a 71 year old man. I'm probably as healthy as I've been in my adult life. Uh, while I'm sure immunologically more challenged than I was 40 years ago, uh, I actually am, uh, really in good health. I have normal blood pressure, I get exercise, uh uh, my biggest challenge was when I had COVID over a year ago and developed long COVID symptoms for about four months, but I fully recovered from that. First of all, let me clarify one thing, Mary. I did not say in a recent podcast that people with increased risk should continue to wear a respirator. I said that those who want to do so should feel empowered to do so, and not to feel like somehow that they are being pressured not to do so. As I shared in an earlier part of this podcast, uh, the data does support that those over 65 are at increased risk of serious illness, hospitalizations and deaths. And many of these individuals have had either, um, underlying health conditions or have not been vaccinated. I have neither I don't have any underlying health conditions right now, and I have had my recent dose of vaccine based on that personal assessment.

Dr. Osterholm: For me, I don't wear an N95 in public, and I haven't for about six months. Uh, I was going to consider doing that when I was able to finally get my most recent dose of vaccine, and had I not gotten that, I may have very well considered going back and using an N95 in public places. Uh, I feel at this point that if I were to get infected again, which very well could happen just like it is with influenza or it is with any other upper respiratory infection, uh, that I will have a good outcome. Do I worry about having long COVID again? Yes, that's a possibility. I recognize that. Uh, but at this point, from my perspective of risk and thinking about all the other risk factors, uh, I have in everyday life, I have felt comfortable not having that N95. But for you all the listeners on the podcast, if your assessment of your risk is different than that, you have underlying health conditions, you're older, you know, if I get to be 75, 80, uh, I may again reassess my potential risk for serious illness, hospitalizations and deaths and go back to including N95 respirator. But I think what we have to do right now is individualize this for ourselves. I see people far too often putting people into a position of either you're a good person or a bad person, you either are wearing a respirator or you're not. Uh, you either are doing X or Y or you're not.

Dr. Osterholm: And I think at this point where the risk is for this disease means that we all individually have to make our risk assessment. The data are clear if your older age, if your underlying health conditions, uh, and if you've not been vaccinated, you don't have access to Paxlovid if you're in that over age group. Remember we just talked about the still does have a big impact there. Then I think that would give you a very different way of looking at what you consider tolerable risk. So I hope this is helpful. Mary. Uh, I will support anyone who wants to wear an N95 in public, uh, and not look down on them, as some people have said that they felt was happening to them at the same time. Uh, I think for those who feel comfortable with assessing this part of their risk in their lives, I also support them for saying, you know, get vaccinated, uh, make sure you have access to Paxlovid if you're in that over age 65 age group. And then we all have to make individual decisions about what we will do in terms of living our everyday lives. And I think the most important thing is we want people to be well. We want people to be happy. We want people to feel satisfied. We want people to feel safe. And, uh, we all are going to have different tolerances for that. And that's what we all need to work towards, is how do we help all of us get to that place?

Chris Dall: Let's turn now to some other infectious disease news. Early last week, we got news of highly pathogenic avian influenza being detected in dairy cows in Kansas, Texas and New Mexico. That was followed by a report of avian flu being detected in dairy cows in Idaho. And on Monday of this week, there was a report of an infection in a worker at one of the affected dairy farms in Texas. Now, we've been discussing this the past few months as more and more nonbird animal species are infected with avian flu. So, Mike, is there anything new here and is there a significant risk to cattle?

Dr. Osterholm: Well, Chris, this topic is moving about the speed of lightning right now. Um, by the time people listen to this podcast, it'll almost be outdated in terms of what we're seeing happen in this country with H5N1 infection in animals and potentially even in humans. But let me start out by first sharing some perspective, because I have to say, with all the media calls and questions I've fielded over the past several days, I fear that we're about to kind of get into that almost semi panic mode of, oh my gosh, look what's happening, look what's happening. And if anyone who knows me knows that I've spent my career with this virus and very concerned about it. Uh, let me just take a step back. This virus first emerged as an avian virus. Remember, all flu viruses at one time had their origin in avian species. And in fact, it's then the virus mutates. Changes, is able to one day, as an avian virus become infectious for humans and humans then can transmit it. And we'll talk more about that in a moment. But back in 1996, H5N1 was first discovered in birds in Asia. In 1997, there was an outbreak that occurred in Hong Kong. More than 20 people became infected in the markets there. A major efforts were undertaken to eradicate the virus out of the markets, meaning the birds were killed. Testing was done in adjacent farms to Hong Kong, etc.

Dr. Osterholm: and everyone celebrated. It appeared it had been taken care of because from 1997 to 2003, there virtually were no cases of H5N1 in all of Asia. Then in the end of 2002 and 2003, things really began to change. We now saw H5N1 cases in humans in countries like Indonesia, in Thailand, and so forth that were occurring in humans and coincidental to infections in birds in those environments. I worked on this. I actually was in Southeast Asia during that time period, uh, in, in Thailand and then ultimately in Vietnam and Malaysia. And at that point, the number of human cases of H5N1 rose to over 100 cases in 2005, 114 cases in 2006. Big picture thing still limited cases given the world population, but nonetheless important. Well, then, from that period of about 2006, the cases just kept dropping year by year, less and less human activity, such that by 2013 it was down to 39 cases that year. So it appeared to be kind of waning. It wasn't a significant event. And then, for reasons we still are not completely clear, 20 1415 changed everything. In 2015, there were 145 cases in humans with a case fatality rate of over 60%. Most of these cases occurred in the Nile River Valley, uh, among duck farmers. And we all were on the edge of our seats saying, oh my God, here it goes.

Dr. Osterholm: This is going to happen now. It's just a warm up. And then for reasons we don't know, it just disappeared, literally. And if you look at 20 1617, nothing. And in fact in from the period of 2017 to 2022, there were a total of only 14 human cases in the world during that time period that were documented. And a question was, what was going on? Well, it was about this same time, however, that then we saw this new virus emerge among birds, uh, which is now the H5N1 that we talk about today, 2.3.4.4 b and this began to spread. And with that, we saw a major increase in activity in animal species around the world. Let me help provide some perspective here of understanding why animal versus human species is very important in understanding the risk for influenza infection. The avian viruses we see basically have a receptor for a human cell that's called alpha two three sialic acid. That receptor is unique to animals. And it is also found in the human eye. The receptor site alpha two six sialic acid receptors are what are in the human lungs and in the respiratory tract higher up, that basically allow humans to then get infected by these viruses. And the barrier to getting a human infected with a bird virus is again this receptor difference.

Dr. Osterholm: And so it's only when we see a virus mutating and changing. And now what once was a bird virus becoming a human virus is very important. In the 2009 influenza pandemic, we found that a avian virus. Got into the pig population, which, by the way, pigs have receptors for both. And that's why there's such an important animal species in all of this issue. And when we looked at that pandemic, it was clear that the changes in the bird virus in the pigs led to the virus then being adapted to humans and caused the pandemic. Now, I'm going to share with you the current status of what's happening. I regret I can't share with you, uh, on our website a piece that was published yesterday by Helen Branswell, uh, in STAT News. It's entitled What We Know About H5N1 Bird Flu in Cows in the Risk to Humans. It's an incredibly, incredibly well done piece. The problem is it's behind a paywall. So I'm sorry, but so I'll try to summarize some of what we have. First of all, what has happened in the recent months? Well, we've actually seen the H5N1 affect many different animal species. And that's not new. Uh, in 2003, when H5N1 emerged in Thailand, a number of dead chickens were fed to the tigers at the Bangkok Zoo, of which they chickens had died from H5N1.

Dr. Osterholm: And in fact, all of the cats died. The big tigers in the zoo died from H5N1, from consuming these, uh, infected chickens. This is not new. But now, today, we've seen a major expansion of animal species, from bears to aquatic mammals to carnivorous mammals, etc., that have now become infected with H5. And then more recently, we're now seeing farm animals. As of today. And this will change literally in the next day, I'm sure there are 12 dairy herds in five states. All dairy, no beef. We don't understand why that have now shown infection in the cattle there. Texas has seven Kansas, two Michigan, one New Mexico, one Idaho one. Why that is happening, uh, as it is, is we're just not sure. But the point is they are getting infected. And the major finding among the dairy cattle is not really any kind of severe illness, but rather a reduction in production of milk and a discoloration of the milk. And we have surely seen virus activity in the milk that's been documented. And this is not a new finding. In the 1990s, researchers in the UK found that they could infect cattle with human influenza viruses. In 2008, in Germany, the Friedrich Loeffler Institute infected six calves from a H5N1 virus isolated from a cat. All stayed healthy, but one did seroconvert, meaning that they had evidence of being infected and had an antibiotic response.

Dr. Osterholm: So the idea that this is somehow a brand new phenomenon is not true. What is new is the level of which activity is occurring. Now, what is this protein for humans? The one case that has surely caught everyone's attention is a worker on a farm in Texas who has conjunctivitis, i.e. inflammation of the eyes. That individual also had a throat sample taken. And the CDC announced, uh, in the last day and a half, that testing of the throat swab from the individual was totally negative, meaning that he had only been infected in the eye with the virus, not in the lungs, which is, again, not unexpected. So is this a likely source for human infection in the lungs, the actual influenza? That is a classic case where a human is not only infected, but they are infectious. But we've had other cases around the world of that happening. Um, limited number, uh, no evidence of human to human transmission. And I think that at this point it's just too early to say what this all means, other than it's not a good day to be an animal and certain animals in particular, but it's yet unclear what it means for humans. Now, one of the animal species that I think is going to be very important in following closely here is, in fact swine, because they have receptor sites for both the bird viruses and the human viruses.

Dr. Osterholm: And I just noted they can surely serve as the mixing vessel for a bird virus becoming a human virus. And if you look at, uh, H5N1, uh, research there, there were case reports in 2000, limited numbers of reports out of Asia where there appeared to be some pigs infected with H5N1. Back then, in 2023, uh, there was a German study that showed that one animal out of eight that were intentionally, uh, inoculated with the virus ultimately became infected again, not clinically ill. And so, to me, the pigs are going to be a very important indicator animal. And right now, they're not telling us that, that this is a major challenge. Now, I don't want anybody to assume that I'm saying everything's okay. And I think that, uh, you know, having spent my career on. This virus and and living in the shadows of it and fearful of what might happen. I'd be the last person to do that. But I also have to be clear that the data to date does not yet support that there's an increase or high risk for humans to become infected with this virus. And therefore, I support the W.H.O., CDC assessment that this is still a low risk situation for humans. Now, this could change in a heartbeat. Tomorrow we could see that change. It's why we have to do everything we can to be better prepared.

Dr. Osterholm: And what do I mean by better prepared? We got to stop talking about the vaccine stockpile we have. This is a vaccine stockpile that was produced years ago for H5N1. This virus has changed so much by then, I don't believe it would have much benefit whatsoever of what little vaccine is in the stockpile. Remember, in 2009, we had a new H1n1 virus emerge out of pigs, for which we already had an H1n1 vaccine for seasonal flu, and yet that vaccine had no impact at all on prevention against the new pandemic strain. So just having the same H and N number doesn't mean that it's going to be protective. And I don't think this one will be. So we need to really be prepared to gear up quickly for new vaccine production with a new pandemic virus, if in fact it should come out of this situation. The other thing I would note is I think that the federal officials have been far too positive in their assessment of the risk of milk. We know that cattle in Texas actually had very high levels of virus in the milk itself. And as much as pasteurization is a very key method for reducing risk of transmitting infectious diseases in milk, we don't have the data yet. At least I've not seen it, and I'm not aware of anybody that has it showing thermal curves that the high level of virus in milk really will in fact be, uh, denatured or destroyed with pasteurization.

Dr. Osterholm: That will be helpful. Now, while we're diverting animals supposedly out of milk production if they become ill, most of these animals are not that ill. And I really believe that there's probably milk today that's getting into the system that has this virus in it. Does that mean you should stop drinking milk? No, not at all. But we have to be clear about the fact that we need the data to say pasteurization works. That doesn't address the issue at all of raw milk and raw cheeses. I would have to say right now, this is not a time to be drinking raw milk. That goes counter to what many people in this country want. And and we'll say that they're going to do no matter what we say to them. Um, but I think this is a challenge. So the bottom line message is the stay tuned. Stay tuned. This is another nuanced issue. I think this is one that we clearly, clearly have to stay on top of by the hour, not by the day. And all I can hope is, is that we continue to see this lack of human infection with these viruses, but knowing that tomorrow that could all change.

Chris Dall: And what about the latest data on human influenza and respiratory syncytial virus?

Dr. Osterholm: Well, good news. As we said in the last episode, it's clear that the worst of this respiratory virus season is far behind us. Both outpatient visits for respiratory viruses and hospitalizations for influenza are continuing to decline. Influenza mortality has remained steady over the past several weeks, with about one half of 1% of deaths during that week of March 23rd attributed to influenza. Most states are currently reporting low or minimal influenza activity, with just seven states the District of Columbia and New York City reporting high activity and four states reporting moderate activity. Most of the states reporting moderate or high activity are in the Midwest, which is not entirely surprising, as the Midwest had a later start to the flu season compared to the southern and western states, which are now mostly seen low or minimal activity. RSV cases continue also to decline, with case numbers for the week of March 23rd, three times lower than four weeks prior and 12 times lower than the season's RSV in late December. Again, good news.

Chris Dall: Now it's time for this week in public health history. Mike, what are we commemorating on this episode?

Dr. Osterholm: Well, Chris, as we mentioned at the top of the episode, this is National Public Health Week. We also have a global event to celebrate this coming Sunday. On April 7th, 1948, the Constitution of the World Health Organization or who entered into force. This day is now celebrated across the globe as World Health Day. The Who is a highly specialized agency in the United Nations dedicated to improving international health at its onset, who had six priority areas malaria, tuberculosis, sexually transmitted infections, maternal and child health, nutrition and environmental hygiene. An early focus of their work also involved establishing a more robust disease surveillance system, so that health officials could evaluate progress towards the goals and respond to emerging threats. One of the most notable accomplishments of the WHO and its member states is the eradication of smallpox, which took place officially in 1980. The agency has continued to take on infectious diseases and non-communicable disease threats over the last 76 years, including HIV Aids, the coronaviruses, influenza viruses, Ebola, Zika and more. We certainly have reason to celebrate the accomplishments of the last century, but it's also very clear that these challenges that the W.H.O. sought to address in 1948 are still with us today. Cases of malaria, tuberculosis and syphilis are all on the rise globally. These are not diseases of the past. They're diseases of now and getting worse. It will take significant and consistent funding, strong international collaboration and transparency, and sticking with the best scientific evidence. We have to move the needle on these issues and to save lives. We do need the W.H.O., we need it to be effective and we need to support that effective response.

Chris Dall: Finally, it's time for another segment marking the four year anniversary of the Osterholm Update podcast. On our last episode, you heard about the origins of the podcast. Today, you're going to get a little peek behind the curtain and hear from the people who make me and Mike sound much better than we do in real life. Mike, take it away.

Dr. Osterholm: As you may recall in the last podcast, I introduced you to three of the staff members at CIDRAP who have played critical roles in this podcast series, and today we're going to meet two more of them who also have played very critical roles in helping bring this podcast to you. At one time every week and now every other week, and today we're going to learn a little bit about them, uh, what they do, how they do it. And we're going to learn a little bit about what they've learned from the podcast. And so it's my honor today to, uh, welcome to the show, uh, Sydney Redepenning and Elise Holmes, both who have been instrumental in the editing of the podcast, as well as the information gathered that we use every week. So thank you to both of you. Uh, and let me just start out by saying the podcast could not happen, but for the two of you. And so it means a lot to have you here. Uh, but before I get into the podcast itself, uh, I'd like the audience to get a sense of just who you all are and what you do. And neither of you are involved with the podcast in the earliest days, but you've become essential members of that. But tell me, before you got involved with the podcast, what was it like being back in 2020 as you were seeing the pandemic unfold in your own lives? And let me start first with Elise. What were you up to at that time?

Elise Holmes: Thanks. So during 2020, at the time, I was working at the Minnesota Department of Health, so I previously was in the Child and Family Health area, but worked really closely with my infectious disease colleagues. And so once COVID really started to become a big issue here in Minnesota, then it was all hands on deck. And so I sort of dropped everything I was previously working on and went full fully into COVID response. I worked across a lot of different areas, from provider guidance to, um, working with folks with disabilities and their access to testing and vaccination, and then a lot, a lot of work on testing. So the various rapid testing, we had PCR testing, everything related to that. So it was a very crazy couple of years there. And I will say I was a podcast listener. I got a lot of information from the podcast regularly that was really helpful as we were speaking with clinicians about what the latest guidance was. So that was really my my early pandemic experience working over in the Minnesota Department of Health and then spent a brief amount of time at Hennepin County and then came over to CIDRAP. So I've been at CIDRAP now since 2022.

Dr. Osterholm: And we're very glad you're here. Sydney, you were actually in college at the time the pandemic unfolded. Uh, tell us about your experience and what that all came to mean to you.

Sydney Redepenning: Yeah. So I had kind of a different pandemic experience than I think a lot of other folks at CIDRAP, because as you said, I was an undergraduate student at the time. I had just been hired at CIDRAP in December of 2019 to start in January of 2020. Um, as a teaching assistant for the absolutely incredible Professor Jill DeBoer, who is also the director of Public health practice at CIDRAP. And I cannot think of a more chaotic way to begin a public health career than right at the very beginning of a pandemic. But I wouldn't change a thing. Despite the fact that being in college during a pandemic means that you don't have a lot of the sort of typical college experiences that people expect. Like, I spent 90% of my time at home, and the 10% of the time that I left the house was to go to class wearing a mask. And N95, um, wasn't doing a lot of the fun, typical college things, but what I got to do instead was working with the best of the best at CIDRAP on pandemic work starting in 2021 with the podcast. But even before that, getting that sort of up close seat to all of the pandemic, um, things happening over at CIDRAP and teaching with Jill during a pandemic. And yeah, it wasn't a traditional college experience, but it was incredible and I wouldn't change a thing.

Dr. Osterholm: Well, I can say is that both of you have made major contributions to the podcast, and I'm so glad that it's worked out like that. So let's actually take a moment and explore. Just how did you get involved with the podcast for both of you? So let's start out with you, Elise. First, how did you actually get involved with this podcast?

Elise Holmes: Well, I think it transitions really well from the last staff interviews that you had. So you heard from Maya Peters last time and Maya moved on to another role at the U. And so that was when I was hired at CIDRAP, and I took on a number of different program management and and research coordination roles here at CIDRAP. And one of those was sort of taking over a lot of the responsibilities that Maya had to do production in the podcast. And so I did quite a few of those, but because I was interested as well, I started joining the research team meetings as well and sort of jumping on as needed, and that sort of revved up into being a part of the regular research team and continuing to do some production for that.

Dr. Osterholm: Thank you. And how about you, Syd?

Sydney Redepenning: Yeah. So as I mentioned, I started working at CIDRAP in January of 2020, initially just as a teaching assistant, and I've continued to do that all the way through the end of my undergraduate career, the entirety of my master's degree. And now while I'm working on my PhD, this will be my 10th semester as Jill's teaching assistant. But in 2021, the spring of 2021, I also, as part of my work at CIDRAP, joined the podcast team. So initially I was just working on the research team, but about a month into doing that, I also started helping Maya with editing and continued to work on both all the way through now, as well as looking at like the podcast emails and getting to hear all of the incredible comments and thank you emails from our listeners every week.

Dr. Osterholm: Well, and I must add that, in fact, I'm very honored to share with all the audience members that both Elise and Syd are now working on their PhDs in public health, and I have the good fortune to be their PhD advisor and I learned more of them from them, I think, every day than they could ever learn from me. So it's, uh, it's kept me, uh, active, energetic, and hopefully a little bit younger than I might otherwise be. So let's move now into just what it means to be part of the podcast and what does it actually entail. And so, Elise, give us a little bit of a sense of what you do with the podcast and how you do that.

Elise Holmes: Sure. So in terms of sort of the cadence of what we do as part of podcast production early in the week, we have a big podcast team meeting that involves walking through any sort of feedback that we've gotten from listeners, any questions we've gotten, as well as just sort of the news that's happened over the last week or weekend and any interesting articles that have come out, oftentimes filtering through some of the things that have been published by CIDRAP news. And so we have a conversation about sort of what topics we want to include then that we sort of break into different teams to, to create notes on that. And Mike and Chris will record midweek, and then it's up to either me or Sydney to do the actual editing, and maybe I'll pass over to Sydney to talk about what that process looks like.

Sydney Redepenning: Yeah. So as Elise mentioned, um, we get the recordings, um, either late Wednesday morning or sometimes early Wednesday afternoon from Mike and Chris. And then, um, we kind of split the editing week by week. And what that really entails is, um, kind of cutting down the audio to keep the episodes to a reasonable length. We usually try to aim for under an hour and 15 closer to an hour. But as I'm sure listeners of the podcast know, that's not always possible because there's always so much that we want to share every other week in all of our episodes. But yeah, the editing consists of cutting that audio down, taking out any background noise, pauses, that type of thing, and making it all sort of sound nice and everything like that, and then adding our intro music and the outro at the end, and then coming up with a catchy title for the episode and posting it the next morning for the world to see.

Dr. Osterholm: And you do a quite a job at that. And again, I can't thank you enough for helping to make the podcast what it is. And I must also say to the audience, not only do I learn a lot by participating in the research for these topic areas we cover, but that they make me sound a heck of a lot better than I really am. They take out a lot of my, uh, ahs and ums and let's do that again type thing. And so thank you very much. I, I can't tell you how much I appreciate that. Let's now move to, uh, the research you do for the podcast. You know, I get to be the person that gets to share the information, but in many instances, it's only because it's information that I've been able to have access to from the research team. That's helped me come to this point. So, um, Syd, tell us a little bit about the topic areas you typically cover when you're doing research for the podcast and how you try to cover those?

Sydney Redepenning: Yeah. So some of my usual topic areas include our weekly flu and RSV updates that we do during the respiratory virus season, mpox as a topic area, whenever we have a question on that as well as long COVID, um, and then other questions as they pop up, often things related to Paxlovid or COVID vaccine questions sort of on a week by week basis. Um, but those three, the flu and RSV, mpox and long COVID are sort of the big ones that I cover. And I've learned a lot from covering those topics. Um, Mpox taught me a lot about that balance that we've talked about on the podcast between the hard science and the data, and then also the social science and prevention science and creating, you know, very balanced messaging that gives people all of the facts that they need, but also that is very cautious to avoid anything that could stigmatize a certain group. And I truly I mean, as someone who has been on this research team throughout my undergraduate and graduate education, cannot think of a better learning experience than getting to work on this podcast. Research with such challenging topics and long COVID is another one that brings a lot of what I would kind of call exciting challenges.

Sydney Redepenning: Because while it is a really complicated topic and early in the pandemic, it was somewhat of, I don't want to say a hopeless topic, but for quite a while we had a lot of bad news before we had any good news with long COVID, and it was really complicated to piece through what it meant. And then we were getting emails from listeners sharing their very, very sad experiences with long COVID that became incredibly motivating to help get them the best information possible, even when it wasn't always good news. And it's definitely been something that's been a positive experience that we've now. Flash forward a few years, have some positive things to share with our listeners, and though it is complicated piecing together all of that research every week, it feels kind of like putting together a puzzle, and we're starting to move in the right direction with things as it pertains to long COVID. So that's been a really fun one to work on as well.

Dr. Osterholm: Good. And how about you, Elise?

Elise Holmes: Yeah. So, you know, as I had mentioned when I was at the Minnesota Department of Health, my work was mostly within maternal and child health, and I worked quite a bit with our team over in the, uh, vaccine preventable diseases section as well. So when it's possible, I try to pick up those topics that are related to maternal child health related to childhood vaccines. Um, and in terms of that research, I would say a lot of times I'm following those ACIP meetings. What's happening in those meetings, any sort of materials that are produced and those aren't, um, internal conversations, those are, you know, publicly published out there that you can go and read or even watch the meetings on YouTube. So that's where I get a lot of that information. And then I would say more recently, something I've really enjoyed is doing the This Week in Public Health History segments as a little bit of an amateur history buff, I think that's just been so fun to just even come up with a spreadsheet and think about the various things that I want to try and include throughout the year, and figure out which episodes to put those on. So I remember, you know, I, I love the story about the diphtheria run to Nome, Alaska. And so immediately trying to figure out, okay, what podcast episode, what date would that work for? Um, I'm originally from Illinois, so I knew I needed to put the Chicago River reversal on there too. Um, so it's been really fun to be able to do those. And I think really shows off that interdisciplinary, multidisciplinary nature of working in public health that, you know, we're in infectious diseases. I have some maternal child health background, but there's so many different areas of public health that we can feature, whether it's water, sanitation, hygiene, if it's more on the microbiology side, if it's in some of these just really cool discoveries and, and really interesting figures that we can feature. So I think it's it's been fun to include that and the, the variety of accomplishments that we've made and far past and I would say recent past.

Dr. Osterholm: Well, I want to thank both of you for your invaluable support with this podcast. Uh, from every aspect of the research, the topic selection, uh, the issue of editing and even putting together, uh, the blurbs that go out describing what this particular episode is about. Uh, we couldn't do it without you. So thank you very, very much. I hope you, as audience listeners, uh, have a little bit better feel for what goes into the podcast and the remarkable work that this team does. So my hats off to both of you, Elise, and said, thank you so very, very much for what you do. Uh, and we'll keep doing it.

Elise Holmes: Great. Thanks. Mike. Can we ask you a question?

Dr. Osterholm: I thought you wouldn't forget. Go ahead.

Elise Holmes: Well, Mike, my question for you is, you know, you may have a little bit of a reputation for bringing up a lot of the challenges in public health, things we need to watch out for. What are some things you're optimistic about in public health, either in the US or around the globe?

Dr. Osterholm: If there's nothing else that defines public health, it really is all about doing the most for the most people, for a better life. And I can't think of a more noble and rewarding effort than that. And so for me, it's easy to stay focused on why public health is so important, because it is truly a noble, noble profession. And today, we have so many challenges on a global basis with various aspects of public health. You know, everyone should live a long, pain free and productive life, and we know many will not. But every day that public health is doing what it can do, we have a better chance of that happening. And so for me, it's, um, it's a really easy thing to do as a profession, and in particular because as someone who has six grandchildren, I find it very, very compelling to do what I do with the hope that the world can be a better place than it is right now. None of us need to be told we're in very dire straits in many issues around the world right now. But the underlying principle of public health is, in fact, from my perspective, a moral compass, a professional compass that is really a remarkable gift to have and to be able to participate in public health, uh, is, in fact, for me, what keeps me going.

Elise Holmes: That was excellent.

Sydney Redepenning: My question is far less serious than Elise's, but it is something that Elise and I talk about a lot, which is when are we going to get another Taylor Swift song on the podcast?

Dr. Osterholm: Well, we will have to have a discussion about that. I surely understand the power of her music and how that might translate to our audience, so stay tuned. Audience I you can see it here as a forecast. I think there may be one of those songs coming in the near future.

Sydney Redepenning: Thank you Mike.

Chris Dall: Stay tuned for more in our next episode when you'll hear from the podcast research team. And another note for our listeners, we would love to get your response to the survey we've posted on the podcast page with today's episode, so we can get a better sense of how we can best serve our audience going forward. Mike, is there anything you'd like to add?

Dr. Osterholm: First of all, I want to thank the listeners for all the feedback they have provided to us. We're at a very important moment in this podcast, trying to understand just what we can do to contribute to the information that you need and want, and how we can do it most effectively. Some of you may say, you know, just like the pandemics behind us, uh, in our lives, we don't need you anymore. And we surely have seen some drop in listeners. But at the same time, there are those of you who have continued to find, I think, useful moments on these podcasts, and we want to hear from you how we can even do that better. The podcast team is really committed to doing the best job we can to serve you, and so filling out this survey, while it may take a few minutes, will be immeasurably helpful to us and we promise we will use the information, uh, diligently and as effectively as we can to make this podcast better. We never forget that we don't know everything. We don't. And we say that with great humility. But what we do know, we'll do everything we can to share that with you and what we don't know. We'll do everything we can to find out what we need to know, so that we can answer the question and stop saying we don't know. So thank you again for your support over the course of the last four years. It's hard to believe it's been four years. It's just amazing to me. Uh, and we're prepared to go forward for whatever time period you want us. Uh, but and filling out this survey will surely help us determine that course.

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

Dr. Osterholm: Well, the first one is a follow up to what we just talked about. I have a homework assignment for all of you. Okay. Uh, please go fill out the survey. Uh, you know, give us your very frank and very thoughtful comments about what we can do. We are surely looking forward to that. Second, I would just say celebrate the good news that we're seeing in terms of adjusting, uh, ourselves to this new normal of COVID and respiratory viruses in general. We're not done. We've got a lot of work yet to do in terms of getting the numbers down even further. Uh, we surely understand the legacy issues of long COVID. Uh, and so that part is still very much front and center. But at the same time, we have to remember that we have come a long, long ways, uh, in the past four years from where we were, where again, we had more deaths in one day than we were seeing now in weeks. Uh, that's surely an improvement. But it's not enough yet. Finally, I would just say that stay tuned for H5N1. Um, this is going to be an interesting one. Uh, I think we have to be very careful about, uh, indicating that this is going to be a human crisis. I don't think at this point we can say that at all. Uh, we will have more pandemics. The. No question about that. Uh, some of them could be much, much worse than anything we saw with COVID, and we would never forget that. But I'm not sure that the evidence at this point yet says other than being an animals, uh, and it's not a good day for some animal species that in fact, at this time, we're going to see a major human health challenge from this. Uh, time will tell.

Chris Dall: And do you have a closing song for us today?

Dr. Osterholm: Well, Chris, we wouldn't be complete without one, would we? You know, given the fact that we're talking about animals today and veterinarians and also a sense of, uh, growing up with this topic of where we're at today and what it means, I've come back to a song that has come to mean a great deal to me. The song I've chosen today is one that we've used once before in November 2nd of 2023, in episode 143 Immunological Chess Match. This song was originally released by the Nitty Gritty Dirt Band back in the late 1969, uh, and at that time received moderate response. But where it really took off was when the actual songwriter, Kenny Loggins, included in an album with his recording partner Jim Messina in the 1971 album sitting in the song at that time was House at Pooh Corner. It was based on a reference to A.A. Milne's 1928 book the House at Pooh Corner. The song that I've chosen for today was actually the rewrite by Kenny Loggins, and included in the 1994 album called Return to Pooh Corner. Of course, you know now what I'm talking about it is Return to Pooh Corner, the song based on the original version of that song. Christopher, Robin and I walked along under branches lit up by the moon, posing our questions to Al and Eeyore as our days disappeared all too soon. But I've wandered much further today than I should, and I can't seem to find my way back to the wood.

Dr. Osterholm: So help me if you can. I've got to get back to the house at Pooh Corner by one. You'd be surprised. There's so much to be done. Count all the bees in the hive. Chase all the clouds from the sky back to the days of Christopher Robin and Pooh. Winnie the Pooh doesn't know what to do. Got a honey jar stuck on his nose. He came to me asking help and advice. And from here no one knows where he goes. So I sent him to ask of the owl if he's there, how to loosen the jar from the nose of a bear. So help me if you can. I've got to get back to the house at Pooh Corner by one. You'd be surprised there's so much to be done. Count all the bees in the hive. Chase all the clouds from the sky back to the days of Christopher Robin and Pooh. It's hard to explain how a few precious things seem to follow through all of our lives. After all said and done, I was watching my son sleeping there with my bear by his side. So I tucked him in. I kissed him, and as I was going, I swear, the old bear whispered, boy, welcome home. Believe me if you can. I finally come back to the house at Pooh Corner by one. What do you know? There's so much to be done.

Dr. Osterholm: Count all the bees in the hive. Chase all the clouds from the sky back to the days of Christopher Robin. Back to the ways of Christopher Robin. Back to the days of Pooh. Kenny Loggins. I love this version of this song, as it does remind us all that no matter how old we get or how much life we experience, going back to those early days, those special days is still so very special. So thank you all very much for being with us today. Uh, covered a lot of material, a lot of material, I realize that. Uh, I hope that, uh, it's helpful to you in navigating all the issues of the day right now. Uh, celebrate the fact that things are getting better with COVID. Uh, may not be for those of you with long COVID. Uh, get vaccinated, please. We're still continuing to see so many of the serious illness, hospitalizations and deaths and people over age 65 who have not yet received that additional dose. Please get that. That is priceless. So thank you. Have a good two weeks. We look forward to hearing from you on the survey. We look forward to being back with you in two weeks. And as I say each and every time, thank you. Thank you so much for what you share with us. We so appreciate it. Thank you. Be safe. Be kind. Thank you.

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.