Episode 138: More Confusing Times

Chris Dall: [00:00:07] 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 Dahl, reporter for CIDRAP News, and I'm your host for these conversations. Welcome back, everyone, to another episode of the Osterholm Update podcast. Over the weekend, Biden administration officials said they were preparing a program to encourage Americans to get COVID-19 booster shots in the coming months. Though COVID hospitalizations and deaths in the US remain well below where they were during the worst months of the pandemic, they have been rising, and CDC officials say they are now tracking a highly mutated new variant that's been detected in the US and a handful of other countries. We will be encouraging all Americans to get those boosters in addition to flu shots and RSV shots, a White House official told Reuters. But will Americans take that advice? Those are some of the topics we're going to discuss on this August 24th episode of the podcast. As we look at the international National COVID trends and dive into what we know about the latest COVID variant. We'll also look at trends in routine childhood vaccinations since the beginning of the pandemic. Discuss the latest news on RSV immunization for infants and provide an update on the timeline for COVID flu and RSV shots for adults. We'll also address an infectious disease query about the pathogens that keep Dr. Osterholm up at night and share our latest moment of joy submission. But before we get started, as always, we'll begin with Dr. Osterholm's opening comments and dedication.

 

Dr. Osterholm: [00:02:00] Thanks, Chris, and welcome back to the podcast family. We're so glad you're with us today. And for those who might be new to the podcast, I hope that we're able to provide you with the kind of information that you find useful and that you can act on in everyday life to make it a better place with regard to COVID. Today, we're going to cover an ever increasing uncertainty about where we're at with the COVID pandemic. Today, we'll try to provide that perspective of a combination of what do we know? What don't we know? And the humility to say that there's probably a lot more we don't know that we will know in the next few months ahead. But before I begin today's podcast, though, I want to thank all of you again who have provided us with such really very thoughtful feedback. Sometimes it's a bit critical and often times that critical feedback is really important. It is in fact what we need to hear. We really do welcome your feedback and to help us make this be a better podcast for you. At this point, I can say that I wish these podcasts weren't necessary. I wish we didn't need to do them because it was clear and compelling in the public health world and in the general public what was going on. I think for now I can say that these are pretty safe in terms of the need to continue to provide commentary about what's happening. So we're still here with you, as we have had throughout the tradition of this podcast, a series of dedications at the beginning of each podcast.

 

Dr. Osterholm: [00:03:33] There are a few that continue to come back up over and over again that I think really deserve to be noted and in fact are really what I would consider to be a critical part of the pandemic consequence that often gets missed. This week's dedication is related to a topic. As such, we are dedicating this week's episode to all those who continue to struggle with long COVID. This dedication was actually inspired by Susan, a listener who recently reached out to us to share her experience with long COVID. She wrote in April 2022, I was vaccinated and boosted, but I still got COVID. It was a fairly nasty case, but I recovered, or so I had hoped. But I have not fully recovered. It has now been 16 months of having long COVID and I am still not myself. I am one of the lucky ones. I am still able to live my life, but not in the same way. There are literally millions of nameless, faceless people who, if you met you would think are just fine, including me. But I am not fine. I still have daily symptoms of long COVID that affect my life. I want people to understand the impact of this nasty virus that they cannot see. COVID is very real and so is long COVID. Susan, I've had the opportunity to talk to Susan.

 

Dr. Osterholm: [00:04:54] She's a brilliant lawyer. She is someone who has lived life with gusto. And now to be in this place where, as she described it, she can't say that she's suffering from long COVID with a capital S, but she is suffering from COVID with a small s, meaning that she is continuing to try to live her life every day as she did before the pandemic and before her infection. But it is surely compromising her everyday activities to have had long COVID for all these months. Susan, we're so sorry for that. And I want to just add a comment with regard to my own case, because I think that, in fact, I've learned a lot here that maybe there's more to a middle category of consequences of having been infected with SARS-CoV-2. As many of you know, I got infected in early March. I surely had several months of severe fatigue, clearly kind of a brain fog kind of situation. I'm happy to report that I've actually fully recovered and I'm very happy about that. But I also feel very badly for those who have not. I think that my case really fits into almost a new category of what I'd call lingering COVID, meaning it took months to recover from what was not that serious of an illness at the time. Now, many people do get seriously ill. I was never in that position, but it dragged on for months and months before I really felt like I had that recovery under my belt.

 

Dr. Osterholm: [00:06:23] And so for those of you who are in the lingering COVID stage, I want you to understand that, yeah, you're going to get over it. Likely I'm feeling fully recovered. But for people like Susan, we really do understand that this is challenging your everyday life. And we're not just talking about the people who are bedridden, seriously ill, obviously, but for those who are also long COVID sufferers who continue to experience these symptoms of fatigue, brain fog, etcetera. So sadly, Susan's experience is shared by millions of people impacted by long COVID. It around the world, including many members of this podcast family. We have heard from you. You are seeing some, like Susan, have been able to carry on with most aspects of their lives, but with greatly reduced quality of life as they battle long COVID symptoms that make once easy task feel incredibly difficult. I understand that. Fortunately, I don't have that today, though others have needed to leave their jobs due to their symptoms and are now completely unable to live their lives as they once did. All of these individuals, no matter the severity of their long COVID, are suffering, and all of them deserve answers as to why this is happening to them and how we can fix it. I wish I could provide these answers today, but as we will discuss later in this episode, the overall picture of long COVID and the puzzle that it still presents is very unclear for all of our listeners that are struggling with long COVID.

 

Dr. Osterholm: [00:07:52] Please know we see you. We hear you. We will continue to advocate for you. This episode is dedicated to you. Now moving on to a topic that I have to actually reconsider in terms of how I do this, because it was really easy to talk about sunlight relative to the months from December to June when it kept increasing and increasing and increasing. Now I can see it's getting darker today in Minneapolis. Sunrise is at 6:25, sunset at 8:04. It's 13 hours, 36 minutes and 14 seconds of sunlight, but we're losing about 2minutes and 55 seconds of sunlight a day. Our dear friends in Auckland, New Zealand at the Occidental Belgian Beer House on Vulcan Lane, you are feeling that ever increasing sunlight and the excitement that it's going to get brighter every day. This morning your sunrise was at 6:53. Your sun sets at 5:53. You had 11 hours and 4 minutes and four seconds of sunlight today, but you're gaining about 2 minutes and 8 seconds a day. So I got to find a way here to come up with something positive in the Northern hemisphere other than just it's getting darker out. Okay. And I will work on that. Some of you will probably just tell me to drop this. But you know, by now you've gotten to know me that in fact, you know, once I'm into something, I'm into it.

 

Chris Dall: [00:09:19] So let's start with the international and national trends, which remain fairly similar to what we've been seeing over the past few weeks. In its latest COVID snapshot, the W.H.O. said that cases and deaths have decreased globally over the last month, except in the western Pacific region, while some countries are reporting rising hospitalizations. Here in the US, COVID hospitalizations and deaths rose again last week, though as I mentioned in the intro, the numbers remain low compared with the worst periods of the pandemic. But anecdotally, I have been seeing more people wearing masks in recent weeks. So people are aware that there is a rise in COVID activity. Mike, what's your assessment of the COVID activity we're seeing at the moment?

 

Dr. Osterholm: [00:10:04] Well, Chris, let me just summarize it by saying we're in confusing times, to say the least. I myself am trying to understand where are my professional leanings and my personal fears kind of merging together here to come up with an answer. Let me just take a step back to give us some perspective. Remember that throughout the first half of 2023, things were looking pretty straightforward. Basically, we saw steady declines in activity across the US and in most parts of the world. For example, when we first entered the New Year in 2023 here in the US, there were just over 41,000 patients hospitalized with COVID. However, by February that number dropped to 25,000. When March rolled around, it went to 21,000. Next month it fell to 14,000. And once we reached early May, the number of Americans hospitalized with COVID had dropped below 9000, the lowest levels recorded up to that point since the start of the pandemic. Remember, we were at 41,000 at the beginning of the year. Now, 9000. If we follow the cases through the summer, things continue to improve even further over the next couple of months, with hospitalizations dropping below 50,400in early July. During the same week in 2022, meaning last July, hospitalizations were five times higher than they were now. Likewise, the weekly death toll in this country when 2023 began, was just under 3900, equivalent to roughly 550 deaths a day. Fast forward to early July and the weekly totals stood at 465, so around 66 deaths per day.

 

Dr. Osterholm: [00:11:40] Again, the drop just from the beginning of the year to July went from 550 deaths a day to around 66 deaths a day. Again, that's the lowest also since the start of the pandemic. Even globally, the same thing is true with weekly deaths going from more than 41,000 at the start of 2023 to just now under 1000. Of course, you've heard me say before, the latest counts were seen are no doubt affected by major underreporting. Examples. Africa, which has a population of more than 1.2 billion, reported a total of four deaths in the first week of July. That same week, the eastern Mediterranean region, which is home to nearly 700 million people, reported only seven deaths. So I recognize that the latest death toll is being reported globally, are far from 100% accurate. But at the same time, a majority of the 41,000 deaths reported in early 2023 were out of China, which was in the midst of its significant surge. And we know that those counts were also much lower than the real true toll. Regardless, you can get a sense of how things have progressed up to now. So why the improvement? Well, again, I think the continued dismantling of systems that were put in place for testing and reporting have surely significantly contributed to some of the decline, at least artificially contributed in the latest weekly EPI report published on August 17th, i.e.

 

Dr. Osterholm: [00:13:10] last Thursday, the W.H.O. mentions that 56% of the world's countries did not report even a single case of COVID to the W.H.O. during the 28 day period from July 17th to August 13th. Then they go on to mention that this trend has continuously worsened throughout the past year. In addition, the report states that during the same 28 day period, in other words, July 17th to August 13th, just over 9000 sequences of the virus were uploaded and shared. Why is that important? Well, let me just compare it to some previous points. I went through the past reports and found the following. In a 28 day period that spanned from mid-November to mid-December of last year, 2022, there were 100,000 sequences shared between July and August of 2022, the same time last year, a total of 172,000 sequences were shared. And even in January 2022, 373,000 sequences were shared. Now here we are at 9000. So our ability to actually survey the virus genetics is also severely compromised. Don't get me wrong, I still think the declines were experiencing are real. But at the same time, I think it's important to acknowledge that the continued deterioration of surveillance systems that we're seeing has a big impact on what case numbers mean. And even to the extent of trying to understand what's happening with the genetics of this virus. Otherwise, while it's been basically three and a half years since the virus first emerged, I think it's safe to say that the population level immunity has surely played at least some role in the declines we've seen.

 

Dr. Osterholm: [00:14:52] Of course, we know that previous exposure to the virus, whether it's through vaccines and actual infection or a combination of the two, doesn't offer long term protection against future infection or even the ability to. But the virus. So the virus has been finding new hosts. However, in terms of the more severe and acute outcomes like hospitalization and death, the immunity that's been built up at the population level has certainly helped a lot. Again, the protection against these more severe outcomes is by no means perfect, especially as people get further and further out from their last dose of vaccine or infection. But the good news is that it's more durable than the protection offered against infection, and I think it's helped improve our overall levels of severe illness, hospitalizations and deaths. Finally, I think another key factor that contributed to the declines we experienced throughout the first half of 2023 was a general lack of any new, highly transmissible subvariants. I know we'll be covering some of this latest variant data in more detail in just a bit. But as XBB took over earlier this year, it didn't bring with it an accompanying wave. And even as different XBB offshoots cropped up and grew in prevalence, we fortunately didn't really see one that had the capacity to drive up activity, particularly with regard to severe illnesses, hospitalizations and deaths.

 

Dr. Osterholm: [00:16:16] So I think it's been a contributing factor, however. Anyway, with all that being said, here we are now at a point where things seem to be headed back up in some areas. Chris, you mentioned in the lead up to your question, overall, globally case numbers are back on the rise. But while I still put very little stock in the actual number of cases being reported, this increase coincides with other signals of growing activity in places like the US, Canada, the UK, Italy and South Korea. For example. Over the past couple of weeks, hospitalizations in Canada have crept up from 1500 to 1700. In Italy, they've gone from 700 to 1000, and in the UK they've gone from 1000 to 2300. Then, of course, there's the US, where hospitalizations have grown from the all time low of 5400 early July to 9400 as of August 12th. That data, combined with things like the rising virus levels detected in wastewater across the US, are clearly a reminder that COVID is still here. It didn't just fade away, and that's exactly why I think you're seeing more people go back to wearing respiratory protection in public settings, because in countries like the US, there are signs that more virus is circulating. We will talk about in a moment the issue of the booster vaccine coming, which likely will be in mid September. There are many of us who worry about more severe illness because of our age or underlying immune conditions.

 

Dr. Osterholm: [00:17:48] And for us trying to get through the next three and a half to four weeks to getting those booster doses is all about making sure we get through without getting infected. So I think it's a very reasonable and fair response in terms of respiratory protection, specifically using fitted respirators like N95s. They can surely help reduce one's risk of becoming infected. But of course we realize what a pain those are, how difficult it is to be socially involved and engaged when you've got your N95 on. And it's almost like somebody is saying to you, Well, never mind, forget what I told you. Go back to the old days. Nobody wants to do that. And I understand, nor do I, but I want to make sure I get through the next three and a half weeks so I can get that booster dose, which is likely to come in mid-September. That should have a substantial impact on my protection against even the current variants that are out there. So doing so to take steps to protect yourself as we close in on the rollout of this new booster doses is a very reasonable thing to think about. So given the signs of more virus circulating, the growing amount of time since the last dose was rolled out and the risks that come with infection, including long COVID, I fully support those individuals choosing to wear respiratory protection, at least through the time period of being able to get their new booster dose vaccine.

 

Dr. Osterholm: [00:19:10] And I might add, for anyone living in areas with occasional wildfire smoke, like many of us here in Minnesota have experienced as a result of Canadian forest fires. It can also help in that regard, too. But on that note, let me also quickly add some context to the numbers I mentioned a minute ago, because I think it might help put things into perspective. And that is even with these latest increases, the overall situation with COVID still remains in a much better spot than it's been throughout most of the pandemic. Let me repeat that. Despite these latest increases, the overall situation with COVID still remains in a much better spot than it's been throughout most of the pandemic. That's important to keep in mind. For instance, while hospitalizations have recently grown from 700 to 1000, in Italy, they were at 11,000 at the same time last year. Canada's 1700 hospitalizations compares to 48 hospitalizations exactly one year ago, and the UK's 2300 compares to 8101 year ago. Again, giving you a sense, we're in a much better place today. And again, the latest US total for hospitalizations of 9400 compares to 36,000 last year at this same time. So by no means am I trying to minimize what's happening, since these numbers can surely continue to grow. But I still think we've reached a point where with this disease where the most serious acute outcomes like hospitalizations and deaths have become far less likely, and compared to where we've been, I see this as really good news.

 

Dr. Osterholm: [00:20:45] Otherwise, I think it's important for people to continue taking steps to further reduce those risks, particularly if they are at increased risk themselves for serious illness. And that's where the updated vaccine booster will be especially helpful as we navigate life with this virus. Let me just conclude in one last point. There's been a lot of debate recently about the issue of seasonality of the virus. Are we in a summer season, a winter season? You know, I've been quoted as saying, well, yeah, this is a seasonal virus. If you consider the fact it occurs in all the seasons, I don't see the same kind of seasonality developing on a global basis or by even what happens here in North America with our changing seasons. I want to note that we've actually linked an article by Helen Branswell from Stat that really addresses the issue of seasonality, a very well done piece. And I think if you have interest in is this a seasonal virus, what does that mean? You know, what have we learned from it? I would urge you to go back and click on that link and take a look at that article. I think you'll find it very helpful in describing where we're at with seasonality.

 

Dr. Osterholm: [00:21:54] So let me just tie this all up. We're in a place where I don't know where we're going for certain, but I do not see any surges taking place that are similar to anything we saw in the first three years of the pandemic. Do I see case numbers increasing? Absolutely, yes. I think it's important to recognize the first. Do we get out from your previous vaccination or from being infected? The greater the likelihood of getting infected again and maybe having serious illness, hospitalizations or deaths. So that's why boosters still become very important. Now, I've said time and time again, we can't boost our way out of this pandemic. I still believe that. But I do believe for those who are at the highest risk of developing serious illness, these boosters are critical. So from my perspective, as I've said time and time again and have been misunderstood by some, when I've said this, I could envision a world one day that would be just fine with me is if everybody got COVID twice a year and it was nothing worse than a sniffle. No one got long COVID. No one was hospitalized. No one died. That, to me would be acceptable. We're now trying to navigate with this virus as humans. What is that future picture going to look like? And all I can say is stay tuned. I don't know. But I think it's better than it was surely a year ago.

 

Chris Dall: [00:23:18] Let's turn now to the variants. The five omicron sub variant now accounts for 20% of US cases and is among the most common variants in Europe. Another sub variant that appears to be gaining ground in the US is FL.1.5.1. But since our last episode, a new omicron Subvariant BA.2.86 has been detected in a handful of countries and it's gotten a lot of attention because of the large number of mutations observed in the SARS-CoV-2 spike protein. So let's start with BA.2.86. Mike, what do we know about it?

 

Dr. Osterholm: [00:23:56] Well, let me first start out with a reminder of the general approach I've taken when it comes to new variants, and that is all variants are innocent until proven guilty. We have had far too much media coverage and talking heads making really very far reaching predictions when a new variant emerges only to see 4 or 5 months later, none of that materialized. So I think this is another example of where humility is absolutely a necessary requirement to being a scientist dealing with COVID. I don't know what's going to happen, but again, I will continue to take that approach. A variant is innocent until proven guilty. And as we all know by now, this virus can and will mutate. And with these mutations come these new variants. Most of the time, they're not anything that we even need to be concerned about. In many instances, the mutations offer little to no benefit to the virus. In fact, sometimes these mutations can even be a disadvantage for the virus. However, there are occasional situations where the virus mutates and actually happens to gain an advantage from that mutation. Maybe it's better disguised against a host antibodies, or maybe it's better entering host cells. There are a lot of different potential scenarios. Regardless, the basic premise is that any advantage or competitive edge a virus might gain could allow it to outcompete other versions of the virus. And if it ends up having an advantage over all the other versions of the virus circulating at the time, it would grow in frequency and eventually become dominant.

 

Dr. Osterholm: [00:25:31] And that might be the case until another new and improved version of the virus with its own mutation, shows up and takes over. The point is there are a lot of different versions of SARS-CoV-2 out there, and not all of them are going to go to the head of the pack. In fact, for the vast majority, that never happens. So whenever there are these early reports of new variants and speculation about what they might mean, it helps to remember they're basically entering into a race with a lot of competition until there's data actually demonstrating that the new version can clearly outcompete these other contestants. It remains speculative. With all that said, it is safe to say that BA.2.86 isn't exactly a typical variant. And the reason I say this because it has so many different mutations that distinguishes it from its predecessor, which is of the BA.2.8.6 Sublineage of Omicron. In fact, BA.2.86 has 34 mutations on its spike protein. That's much, much different than the typical pattern we've seen with most of the previous Omicron Subvariants. We're just 1 or 2 mutations in the spike might confer an advantage. And because it's so genetically distinct, I think there's a big reason why so many initially started paying attention to this. Basically, with that many mutations present on the spike, the concern would be that the antibodies generated by vaccines or recovery from previous infection may not recognize their target, allowing the virus to evade immune protection and spread more rapidly between hosts.

 

Dr. Osterholm: [00:27:07] Otherwise, the other thing that's adding to concern is that nine total sequences of BA.2.86 have now been identified in at least six different countries. And at this point, there's no known links between any of these cases. This implies that there's ongoing community spread of this variant and there's certainly more of it out there than we know about at the time. The question is how much? Remember, I just covered all the challenges right now with sequence surveillance and how the numbers are way down. We are flying kind of blind as far as I'm concerned. However, even with a better understanding of its distribution, it's going to be especially important to figure out how well this variant stacks up against other variants, including e.g. five and FL.1.5.1. In other words, does it actually have the capacity to outcompete even the fittest variants we're seeing right now and eventually take over? Right now it's too early to know that, but if we eventually find out it can't outcompete with other variants, we basically won't have to worry about it. According to a number of virologists out there, this remains the most likely outcome. On the flip side, if it can outcompete the other variants, then that would become a challenge.

 

Dr. Osterholm: [00:28:17] For example, would we need to talk about another update to the vaccines since the targeted spike protein is so different compared to the BA.2.86 spike. Would it lead to a new wave of cases? Could they be more serious in terms of illness because of the mutations that have occurred? Again, all this is hypothetical, but that's why we need more data to answer these questions. So stay tuned. We'll keep you updated. I wish I could give you more answers as to what these variants mean, particularly 2.86. And there will be people out there who surely will give you information suggesting what they mean. I think that's premature. I don't think we can comment on one. Will it take over two? If it takes over, will there be more severe illness? And three, what would then replace it all? Big questions. The bottom line message is we don't know where we're going next. But I come back to a statement I've made multiple times. I don't ever see us going back to those big peaks of cases that occurred throughout the 2022, 2022 time period. I think that we have enough human immunity even if some of the immunity isn't fully functional in protecting us against this new variant, I think we're still in much, much better shape. And from that standpoint, I really believe we are past. Those pandemic waves of that time period.

 

Chris Dall: [00:29:43] Now to long COVID. There are two new papers out this week that compare people who had COVID with millions of uninfected control patients over a period of two years. Mike, what do we learn from these studies about the long term impacts of COVID infection?

 

Dr. Osterholm: [00:30:00] Well, Chris, as you know from today's dedication, this is a very important issue for so many of our listeners who have struggled with long COVID. And as I say, each time that we cover long COVID on this podcast, each study only reveals a very small piece of the long COVID puzzle. And unfortunately, the overall picture here is still very unclear. That said, I want to highlight some of the major findings from two studies that were published this past week. These studies were also highlighted in Eric Topol’s Substack Ground Truths, which we will link in our episode description. The first of the two studies that I want to discuss looked at the presence of 80 symptoms across ten organ groups for two years after infection in nearly 140,000 COVID patients, compared to nearly 6 million controls who were never infected with COVID-19. The authors found that many individuals were still experiencing symptoms two years after infection. This was more common among those who were hospitalized at the time. Their acute infection, than among those who were not hospitalized in the hospitalized group. There was still a statistically significant higher risk of 65% of the symptoms assessed in the study. In the Non-hospitalized group, there was still a higher risk of 30% of the symptoms. Both groups had significant higher risk of at least one symptom from each of the ten organ groups looked at in the study. And the hospitalized group also had a significant higher risk of hospitalization and death in the two years following their acute infection. It is important to note that while these findings are certainly important, there are some major limitations to interpreting the data from this study.

 

Dr. Osterholm: [00:31:42] The population in the study was 90% male, with an average age of 61, which is certainly not representative of the population as a whole or the typical long COVID patient group. If you go back to Eric Topol's piece that we linked here, you'll see that these studies were conducted in veterans. And so therefore, we do have to be cautious in interpreting what those results found in that group might mean for the population as a whole. The data also includes those infected earlier in the pandemic due to the long follow up time. We need to continue to invest in long COVID research in order to learn if these findings apply to other populations, to those infected with Delta or Omicron variants, and in those who are vaccinated or who have received antiviral treatment. The second study that I want to cover looked at mortality data. Two years after infection for 280,000 veterans infected with COVID compared to controls matched by age, gender, race, ethnicity, smoking, status and residence. The authors found that mortality in the COVID infected group was more than double that of the uninfected group 8.7% compared to 4.1%. Mortality was highest in the six months following acute infection, and those who were hospitalized at the time of their acute infections Increased risk of mortality in those who were not hospitalized only persisted for 90 days following infection, whereas increased risk of mortality in those who were hospitalized persisted for two years, though this risk was 13 fold lower in the second year following infection compared to the first 90 days.

 

Dr. Osterholm: [00:33:18] I think the main takeaway from these studies is that it is clear that long COVID symptoms can persist for at least two years, especially in individuals who are hospitalized at the time of their acute infections. Many of you don't need to be told that you already know that. It is still unclear why this is the case and how these symptoms can be treated. Still, this gets us another step closer to finding answers for the millions of people suffering from long COVID and highlights the importance of continuing to fund this critical research. This problem is not going to go away on its own, and we owe it to the people impacted by long COVID to find the answers. Let me also just emphasize the fact for those who may be concerned about what you might suffer in the days ahead, having already had COVID. For those not hospitalized, the increased risk of mortality only persisted for about 90 days following infection. So if you're past that, there was no increased risk seen. And even for those who are hospitalized while the risk of dying was higher for up to two years, it was 13 fold lower in the second year following infection compared to the first 90 days. So in short, if in fact most of you, I believe, will have had your infection earlier than 90 days ago, you should still be in quite good shape relative to what we found with these data.

 

Chris Dall: [00:34:44] My next few questions are going to be about vaccines. And I want to start with a recent Kaiser Family Foundation report on children's routine vaccination trends that shows, among other things, that the share of kindergarten children who are up to date on routine vaccinations has ticked down since the beginning of the pandemic. Mike, do you think that this is a side effect of some of the opposition we saw to COVID vaccine mandates? And how concerning is this trend?

 

Dr. Osterholm: [00:35:11] Chris, this is an important issue we're seeing unfold in real time. Back in June, Gillian SteelFisher and her research team at Harvard published a study that looked at public polling results from the last several years before and after the start of the pandemic. They examined trust in both COVID and Non-COVID childhood vaccinations, as well as feelings on vaccine mandates required for public schools. The group found low confidence in the safety of COVID vaccines for children, contrasted by relatively strong beliefs that other childhood vaccines are safe. 40% for COVID versus 69 to 70% for the other childhood vaccines. And interestingly, the latter number of actually increased each year of the pandemic. Although support of childhood vaccines appears to be holding strong, according to the study, polling shows the decrease in belief that people have in whether a vaccine should be mandated for their children. The percent of people polled who support school mandates dropped from 82 to 84% between the years 2016 and 2019 before the pandemic to 70 to 74% between 2019 to now. Based on this information, the public's change in tone is related to the debate about personal freedom and the ability to choose when it comes to public health policies on vaccination, much more so than it has to do with vaccine safety. And I think this is a very important observation and one that we absolutely have to be mindful of. In other words, I can surely support from a public health perspective. While childhood vaccine mandates in schools are so important for vaccines like mumps, measles and rubella, where they're highly effective vaccines, they actually do provide long term protection against infection, against transmission, and surely against serious illness.

 

Dr. Osterholm: [00:37:03] Whereas with the COVID vaccines, when we found that within 6 to 12 months, 1st May need to have boosters on a regular basis, At that point, parents took on a very different perspective about do I want my child to be mandated to keep getting these vaccines? In a sense, you might say it's like mandating the issue of influenza vaccines on a seasonal basis for schools. So I think this is an important area where we have to be mindful. Are we actually turning off parents with mandates for vaccines that are not equivalent compared to the early mandated vaccines of mumps, measles, rubella, etcetera? And I have to say that the report that Gillian and her colleagues did at Harvard is really a very important piece. We've reported on this before, and I just want to emphasize that we have to be mindful that parents attitudes can be about safety or parents attitudes can be about don't tell me what to do and are we forcing people into that? Do not tell me what to do category unnecessarily. This is going to be a big part of the discussion going forward about childhood immunizations. Now, looking at the Kaiser report that you mentioned, Chris, published at the end of July, we see that overall childhood vaccination coverage has decreased in a majority of states among kindergartners.

 

Dr. Osterholm: [00:38:23] This includes vaccination against measles, mumps and rubella, diphtheria, tetanus, pertussis and varicella. It should be noted that other CDC surveys, including different age groups, has varied results. Though data from children in their first year of school may be a meaningful indicator of current immunization trends. It is clear that a growing number of people believe parents should have the choice of whether or whether or not to vaccinate their children for school if it poses a risk to others. The report also discussed growing disparities in groups that already exhibited decreased vaccine coverage, like those children on Medicaid or uninsured identified as black or Hispanic, low income or those in rural areas. If we continue to see less kindergartners protected with life saving vaccines, we will see increased infections in already vulnerable groups of kids. Shifts of public opinion on vaccination as a result of dislike of mandates may threaten the health of millions of school aged children. Overall, I do feel that public's perceptions regarding the implementation of public health mandates are creating downstream effects. I would not want to lose the mandates for those vaccines that are highly effective with long term protection such as mumps, measles, rubella that we just talked about. So we have to be mindful of the fact that sometimes that tools that we use in public health may have unintended consequences. And our job is going to be protecting as many children as possible and what that means.

 

Chris Dall: [00:40:00] There's also been two recent items regarding immunization for respiratory syncytial virus or RSV in children. Earlier this month, the CDC said it would recommend immunization with the monoclonal antibody nirsevimab to protect all infants under eight months of age and some older infants from severe illness caused by RSV. And just this week, the FDA approved a maternal RSV vaccine to protect infants from severe illness caused by RSV. Mike, do you think these two new tools could help reduce the number of children who get severely ill from RSV?

 

Dr. Osterholm: [00:40:36] Chris, the short answer is an absolute yes. I'm pleased to see these new tools available, and I'm optimistic they can reduce the number of children becoming severely ill or dying from RSV. For more context, let's review what we know about RSV in young children. It is typically tolerated in healthy adults appearing like a common cold. However, it can be a significant health hazard for older adults and very young children. Babies have underdeveloped immune systems and narrower, less efficient airways. This makes them more vulnerable to respiratory illness, especially lower respiratory tract infections like pneumonia and bronchiolitis. RSV is the most common cause of hospitalization for infants in the United States. While most babies will recover well with access to supportive care, it is still an alarming and expensive journey for families in resource limited settings in low and middle income countries. RSV remains one of the top causes of death for young children. As you mentioned, Chris, the FDA has now approved two new tools to combat RSV in young children. The first is a monoclonal antibody that is recommended for infants under the age of eight months or toddlers with other risk factors. This single shot provides passive immunity against RSV for around five months. We do have another monoclonal antibody for RSV, but it has many more disadvantages. It's only approved for high risk infants given intravenously, last about one month and is very expensive. So this new product is really a great advancement. Since ACIP added the RSV antibody shot to its routine immunizations for children. It will be covered for Medicaid eligible children. However, for new products like this, there are sometimes challenges in the rollout, and there can be a time lag between when the first shot is available and when insurance coverage kicks in.

 

Dr. Osterholm: [00:42:31] In addition to this product given directly to infants, the FDA has approved the RSV vaccine to be used during the end of pregnancy and provides protection for infants up to six months after birth. In other words, this vaccine is given to the mother before the delivery within the passive transfer of this protection to the fetus while in utero. This is the same Pfizer vaccine that is used in adults over age 60. There were some concerns from the FDA advisory committee VRBPAC about a slight elevation in preterm birth, although it was not statistically significant in the Pfizer trials. GSK halted their RSV vaccine trial during pregnancy due to an increase in preterm birth. We are still waiting to hear from the CDC's advisory committee, ACIP, and how this vaccine will be rolled out. Most children should not need a double dose of protection. In other words, the monoclonal antibody at birth. In addition to the maternal vaccination, therefore, it will take some coordination for providers to determine if a child is immunized. There's quite a bit of strategizing that needs to take place here and I anticipate some confusion in the next few months until more clearer guidance is available. But this is an important advancement and can save lots of kids lives. I also want to remind people that the basic infection prevention and control is still incredibly valuable during RSV and flu seasons. Keep your hands washed, stay home when sick and as cute as they are, refrain from kissing anyone's baby. I know that's hard, but please think of the baby and their health.

 

Chris Dall: [00:44:09] And finally, we want to provide an update on our conversation in the last episode about the availability and timing of the COVID flu and RSV shots this fall. And you mentioned it a little bit earlier, Mike, but what can you tell our listeners?

 

Dr. Osterholm: [00:44:25] Well, first of all, I have to say that nothing's changed since our last update. But boy, did I get a lot of questions about this. And I'm glad that we can have this discussion with you because you clearly want to do the right thing for yourself. In our last episode, we discussed that new CDC director, Dr. Mandy Cohen, mentioned in an October timeline for the new COVID booster. She has since stated that she expects these to be available in late September. This is welcome news. And in fact, as we get more information, I suspect that mid-September will be when the approval process will occur at FDA with ACIP to provide recommendations within days after that vaccine should be shipped. Immediately at that point. In short, the sooner you can get these shots in arms, the better, especially with COVID activity on the rise. And since the last episode, RSV vaccines are now more widely available and FDA approved the RSV vaccine for pregnant women as a way to protect newborns. With these pieces in mind, let me provide the ideal timeline from my perspective for getting these three vaccines. First, get your RSV vaccine as soon as you can if you're eligible. If you're over the age of 60, please make an appointment for your RSV vaccine as soon as you can.

 

Dr. Osterholm: [00:45:41] If you're pregnant, talk with your doctor about scheduling an appointment when you can become eligible. Bottom line here is get these RSV vaccines now. Don't wait until it's too late. Next, get your COVID booster as soon as available. This will likely be the middle to end of September. Should you get the COVID and RSV vaccines at the same time? Our last discussion on a podcast suggested there may be some interference between the RSV vaccine and COVID and some questions about should you get them together. Since that time, we've had an opportunity to look at additional data, and I think at this point it's fine to go ahead and get both RSV and COVID vaccines at the same time. I also do want to quickly mention a really interesting study published out of Germany recently that I think will find interesting with regard to getting your next booster. This study looked at the immune response following a booster dose administered in either the same arm or the opposite arm from the primary dose. They found that when administered in the same arm as your previous vaccination, there was actually a higher level of neutralizing activity, meaning that it generated a stronger immune response. The authors of this study suggest that this may be due to the drainage by the same lymph nodes used for priming.

 

Dr. Osterholm: [00:47:00] This was a small study with 303 people who all received the Pfizer vaccine, but is still interesting and definitely something to consider when you decide which sleeve to roll up for your next booster. Finally, get your flu shot when you start hearing about flu activity. I'd expect this to be at least mid late October at the earliest, and it could easily be into December if for some reason you didn't get your COVID booster earlier when you could. It's okay to get COVID and influenza vaccines at the same time. That being said, don't rush to get your flu shot in September if that is when you get your COVID booster, because by the time the winter or spring wave happens, the vaccine induced immunity from your flu vaccine will have been significantly reduced. So to reiterate this timeline, get the RSV shot now, get the COVID booster as soon as possible and get the flu shot as soon as you hear about flu activity in your community. And we will continue to cover flu activity on these podcasts, which I'm happy to report today. There is no evidence of flu activity in the US as such. So but at this point we will keep you informed about that.

 

Chris Dall: [00:48:14] Now for our ID query. Mike, this week we've received an email from a listener who wanted to know within the landscape of infectious diseases, what are the pathogens that worry you the most in terms of pandemic potential?

 

Dr. Osterholm: [00:48:29] Well, this is a very important question, Chris, because it really helps direct us towards what should be the highest priority work areas in terms of vaccine therapeutics and diagnostic development. As a reminder to all our readers, a pandemic is an epidemic that is widespread across multiple regions of the world, usually all of the world. In order for a pathogen to have pandemic potential, it needs to have two characteristics. The first is it needs to be what I call a virus with wings, meaning that it is respiratory transmitted and efficiently transmitted. Airborne transmission is the primary route. Both influenza and coronaviruses fully meet that criteria. The second thing is that it has to have high virulence, meaning that it needs to have the ability to cause widespread morbidity and mortality. There are dozens of pathogens that meet this definition, including pathogens such as Ebola, Lassa and Nipah, which actually, however, do not meet the criteria for a pathogen of pandemic potential because they don't have wings. They're not a virus with wings that can be readily transmitted from a respiratory standpoint. And so I don't want people to think that these other viruses like Ebola are not important, but it's really important. How are they transmitted as well as how do they kill? So to summarize my thoughts on this, the two groups of pathogens, I think, that are both virulent and transmissible enough to have pandemic potential are really just influenza viruses and coronaviruses.

 

Dr. Osterholm: [00:50:01] That could change if a new pathogen emerges that is both respiratory transmitted and efficiently, as well as the ability to kill. We cannot stop the spread of viruses with wings that kill even in high income countries with medical and public health resources available. Look at what's happened just with coronavirus activity in the last three and a half years. Meanwhile, pathogens like Ebola viruses, on the other hand, which certainly are capable of causing significant morbidity and mortality, lack these wings to cause the widespread transmission. Remember the 2014 to 2016 Ebola outbreak in Western Africa? Clearly it was of major regional importance and occasionally spillover cases occurred around the world, including the United States, but never did we worry that this would spread unfettered in any of these countries. This is a big difference. So let me be really clear. I don't want to confuse the issue by suggesting that these priority pathogens like Ebola, Marburg, Zika, Lassa, Nipah and so forth, are not really very important. They are. And in fact, CIDRAP has, through collaboration with the World Health Organization, have actually been the ones developing the roadmaps for vaccine development for these diseases, as well as looking, of course, at therapeutics and diagnostics.

 

Dr. Osterholm: [00:51:24] I direct this work program at CIDRAP with W.H.O., so surely no one could accuse me of thinking that. I don't think these are important. They are. But I just want to be clear. They are not going to cause the next pandemic. So the bottom line is there are a lot of pathogens that I am generally concerned about in terms of the threat they pose to public health as a whole. But if we're talking specifically about pandemic potential, influenza and coronaviruses are the pathogens that we must we must focus our activities on to develop much better vaccines, diagnostics and therapeutics. Let me just add one last piece to this and to say that there is a category of infectious agents that don't really fit in the standard infectious virus mindset that actually are in a sense pandemic causing, but not in the traditional way. What I'm talking about, of course, is antibiotic resistance. That is a worldwide phenomenon that is occurring across many different organisms and ones that we have to understand are also of real consequence. But they're different than the standard kind of what we call pandemic agents. And so from that perspective, we just have to keep focused on those viruses with wings because there will be a next pandemic and it could be a lot worse than what we've experienced already.

 

Chris Dall: [00:52:46] And finally, it's time for our latest moment of Joy submission. Mike, who did we hear from this week?

 

Dr. Osterholm: [00:52:53] Well, Chris, this is one of those moments that I love so much because I happen to see the picture that will be on our website that you won't see if you're listening to this podcast unless you go to the website. But this is sharing an experience that I have had the opportunity to share, and it is literally an emotional moment, a spiritual almost to see this. So let me read what we received with regard to this moment of joy. It's from Leonard. Hello, Osterholm Podcast team sharing an experience enjoyed this past April, the annual Sandhill Crane migration on the Platte River in Nebraska. Each season, around 80% of all sandhill cranes make their annual stopover as part of their annual migrations from the southern US to nesting grounds in northern Canada, Alaska and Siberia. The cranes are highly social. You will rarely see one flying by itself. Couples stay together for life and have one or more offspring each year during the short Arctic summer. The offspring have one season with their parents to learn the migration route. Then they are off on their own while at the Platte River. The cranes have a daily routine of day time feeding in nearby cornfields. Evening mass landings at the river for overnight protection against predators.

 

Dr. Osterholm: [00:54:11] Morning dancing rituals among the unattached cranes, weather permitting, and another mass takeoff for daytime feeding. What is so impressive is each Crane knows its purpose, with large groups displaying an extraordinary level of cooperation. Stronger cranes fly at the front of the group to break wind for those behind. In the morning, certain cranes do test flights to check wind conditions prior to calling for the mass takeoff. The cranes spend a few weeks at this location, resting and refueling for the long journey northward to determine the proper time for departure. North groups will send up scouts to test the favorability of the wind thermals. If only humans had such single minded determination to cooperate and work together. And then, he says, Photo of a dancing, joyful pair of cranes. Leonard. Leonard, thank you for sharing this. It is an amazing event to watch. The Sandhill Cranes, which I said I have had that opportunity. I hope that there are listeners here who may have never thought about that before and that that you actually head to the Platte River in Nebraska in April to watch this. It is a spiritual event. And truly, as Leonard said, it is a moment of joy.

 

Chris Dall: [00:55:26] And Mike, I'll note that if you are in Minnesota, you can catch the Sandhill Cranes on their way back south in November at the Sherburne National Wildlife Refuge. And just a reminder to to our listeners that we would love to hear about your moment of joy even as we move past the pandemic. We know that we live in challenging times and finding the thing that brightens the day, even if just for a moment is so important for our mental health. So what is the thing that you look to for a little bit of joy? It can be a place, a person, a pet, a piece of art, a memory or whatever you want it to be, and you can share it with us at OsterholmUpdate@umn.edu. Mike, what are your take home messages for today?

 

Dr. Osterholm: [00:56:07] Well, Chris, the first message is stay tuned. And what I mean by that is I shared with you the uncertainty around what these new variants are doing and what that might mean in terms of case numbers and number of cases in our communities, etcetera. So we will try to keep you as updated as possible with every two weeks. And if somehow we feel that there is some urgent need to provide new additional information before the two weeks, we'll also do that. But right now, stay tuned. I don't believe we're going to ever find ourselves with this particular virus, the SARS-CoV-2 going back to that 2020 - 2022 time period like conditions. I don't think that will happen. But we surely could have more challenges with SARS-CoV-2 beyond what we've experienced through the better part of this past year. Number two, get those booster doses, please. Everyone who is eligible to get one should get one. And I hope that eligibility is rather wide in its catchment because in fact, it is still a very important tool in keeping you from getting severely ill, being hospitalized or dying. And to me, man, what a payback that is to get a dose of vaccine for that. Finally, the next few weeks are going to be a challenge for those who are at increased risk for serious illness, who want to wait until they can get to their vaccine booster dose before they open up their everyday lives again. I understand that I'm in that same boat, so if you can reduce your risk for the next few weeks, do so. And what I'm thinking here is wouldn't it be terrible if two days before your scheduled to get your booster dose, you develop COVID? And so one of the challenges we have right now is just trying to get us to that vaccine availability date. Please, federal government move as quickly as you can to get these vaccines out. And let's get us all to the booster dose, get us vaccinated. And I think we can ride into the fall feeling much, much more comfortable about where we're at in terms of protection.

 

Chris Dall: [00:58:21] And what is your closing song for this episode?

 

Dr. Osterholm: [00:58:25] Well, Chris, today we have a new voice with us. And this is a song that was suggested by several of our staff with regard to the theme of today's podcast. This is a song by Glen Hansard, who is an Irish singer, songwriter, musician and actor. Since 1990, he's been the frontman of the Irish rock band The Frames, which with whom he released six studio albums, four of which have charted in the top ten of the Irish albums charts. He has written a number of songs, but this one, I think, really appeals to the moment that we're at, and it's called The Song of Good Hope. If we're going to make it across this river alive, we need to think like a boat and go with the tide. And I know where you've been. It's really left you in doubt of ever finding a harbor, of figuring this out. And you're going to need all the help you can get. So lift up your arms now and reach for it. Reach for it. And take your time, babe. It's not as bad as it seems. You'll be fine, babe. It's just some rivers and streams in between you and where you want to be. And watch the signs. Now you'll know what they mean.

 

Dr. Osterholm: [00:59:39] You'll be fine. Now just stay close to me and make good hope. Walk with you through everything and take your time, babe. It's not as bad as it seems. You'll be fine, babe. It's just some rivers and streams in between you and where you want to be. And watch the signs. Now you'll know what they mean. You'll be fine. Now just stay close to me and make good hope. Walk with me through everything. May the song of good hope walk with you through everything. And I think this song is really hits right at the heart of our hope right now. You know, we want to be done. We want to move on, but we can't because the virus isn't letting us. But we still have hope that we're in a much better place today than through the vast majority of the pandemic. I have hope, and I think right now hope is so important. Pierre Teilhard de Chardin, a Catholic philosopher who I've studied back some 40 years ago, once wrote, The future belongs to those who give us reason to hope. And I really believe that that's the case right now. We need to hope. We need to have that sense for the future. And that's all about new and better vaccines.

 

Dr. Osterholm: [01:00:56] That's all about basically taking on COVID and moving on. So today, if you come away with nothing else in this podcast, have hope. And with that comes that message you hear from me so often. Be kind. You know, I wish I could be as kind as I want everybody to be in this world. And some days I do better at it than others. But I've had several experiences this week where just I took an extra moment just to say something to someone or do something for someone that was totally unexpected. And, you know, it was amazing to see their response. And I think I'm the one that got the better end of the deal on the whole thing. So just be kind. I know that sounds trite and it's easy to do, though. Just go out of your way. Just be kind. So thank you for being with us again today. I hope the information we shared with you was helpful. We appreciate you very, very much. And just know things are changing quickly with COVID, But none of them suggest at this point that we're in a crisis stage of any kind. Thank you so much. Be well. Be kind. Thank you.

 

Chris Dall: [01:02:14] 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 to contribute, please visit cidrap.umn.edu/support The Osterholm Update is produced by Sydney Redepenning, Elise Holmes, Cory Anderson, Angela Ulrich and Meredith Arpey.