Episode 150: A Family Discussion

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 Dall, reporter for CIDRAP news, and I'm your host for these conversations. Welcome back, everyone, to another episode of The Osterholm Update podcast. While wastewater data across the country continue to show signs of high viral activity for COVID-19, several key indicators are showing signs of decline. According to the most recent update from the Centers for Disease Control and Prevention. Test positivity in emergency department visits are down, as are hospitalizations, and deaths remain relatively unchanged. As we've noted over the last few episodes, a lot of people are getting COVID right now, but the severity of illness is greatly diminished. But as we all know by now, the SARS-CoV-2 virus is full of surprises. The latest is a new, highly mutated variant identified in South Africa. We'll fill you in on all the details in this February 8th episode of the podcast, as we examine the latest COVID-19 data from the United States and other parts of the world. We'll also provide an update on flu and respiratory syncytial virus, look at some intriguing new long COVID research, discuss a recent efficacy estimate for the updated COVID-19 shot, talk about what happens when Paxlovid emergency use authorization expires, and revisit our discussion of California's updated COVID isolation guidelines. We'll also discuss measles outbreaks and bring you the latest installment of This Week in Public Health History. But before we get started, we'll begin with Doctor Osterholm's opening comments and dedication.

 

Michael Osterholm: Thanks, Chris, and welcome back to all of the podcast family. And you'll see that I mean that sincerely today because we're going to be talking about family issues, as only family issues could be discussed by people who are close enough to be family. This is a somewhat special podcast for me, and hopefully for you in the sense that it's our 150th episode. In addition, we had six special episodes, three were live episodes, one was a special episode on masking, and two were holiday mini-episodes. Who would have ever thought when this all started back in 2020 that we would be sitting here, discussing 150th regular episode? And for all of you who have persevered through these, who have hopefully, in some instances actually found the information you were looking for and found it to be helpful. Thank you for sticking with us. It's amazing the number of people who have been with us throughout the duration of this pandemic. And I also want to note today, as we will talk about we did get some feedback from our last podcast that was somewhat critical. And I'm going to address that today because that's what families do when you have good news and bad news, you discuss it. And so we'll lay that out today. Also, I want to provide an update to the podcast family that my dear, dear friend Don has improved substantially from the last podcast. When I noted he was in the ICU with COVID. He's still in the hospital, but at this point, he is improving.

 

Michael Osterholm: And, it's good news for all of us. But it just reminds me of how close COVID is to all of our lives. Don is not a number. Don is a dear, dear friend who I love dearly, and I'm so glad to see him improving. Another piece of today's podcast, which is very near and dear to my heart. Some of you have already come to the conclusion that I'm a dog guy. I tend to want to believe that, my definition of heaven is when I die, I will suddenly appear in a large field of beautiful prairie flowers, and every dog that I've loved through my lifetime will come running to me. As I sit there in that field. That's my idea of really wonderful heaven. Today we're going to talk about dogs, and you'll see how they are very relevant to the discussion in terms of both the historic moment as well as really concluding this podcast in a sense of what is really important in life. But before I begin, let me do something else that's very, very special for me. And I will acknowledge right up front, as some of you already have understood, my Irish eyes sometimes betray me, that at least at CIDRAP, they always wonder what's going to flow out of them next. And my dedication today is something that is beyond heartfelt. It is truly one of the most remarkable experiences of my entire life that I'm going to dedicate this podcast to. And that is Doctor Kris Moore, our medical director at CIDRAP and who started CIDRAP with me back in 2001 and more importantly, has been with me since 1984.

 

Michael Osterholm: When at that time we had a large outbreak of a chronic diarrheal illness in Brainerd, Minnesota, and she was a newly minted Epidemic Intelligence Service officer from the CDC. And they asked if they could send her up to gain some experience in an outbreak investigation. Well, suffice it to say, Kris never really left. We ultimately hired her in 1985. She became the assistant state epidemiologist with me. We have been a team throughout all of these years, and in a way that I find very hard to put into words, I have had a very blessed career at the Minnesota Department of Health, at CIDRAP, at the university, and without any doubt, Kris has had a tremendous impact on the work that we've done and how I approach every day in terms of what I do. , she is a remarkable epidemiologist, an incredible communicator. She is a real leader on a global basis. If you look at the CIDRAP work on all the roadmaps that we've done recently on vaccines for Ebola, Lassa, Nipah, influenza, coronaviruses, etc., these all were basically Kris Moore's work of art. And all I can say is, personally, there have been so many times that I've been made a better professional and a better person by being around her with her. Kris is retiring from CIDRAP on a full-time basis. , but we'll still be working with this on a consulting basis. And all I can say is, is that never in my lifetime could I have imagined having such an incredible professional partner who has made the world a better place, has made the places that I've worked in a better place, and frankly, has made my life a much better place.

 

Michael Osterholm: So, Kris, this podcast and on behalf of all the podcast team and all of us at CIDRAP, this is dedicated to you. Now, moving on to one of those important parts of the podcast for which the people who find this the nails on the chalkboard moment. Just give me 30 seconds here. I'm happy to report today that the sunlight in Minneapolis continues to go in the right direction. Today, February 8th sunrises at 7:24. Sunset is at 5:30. That's ten hours and six minutes and five seconds of sunlight. We're gaining two minutes and 46 seconds of sunlight every day right now, and that number will only continue to increase now. At the same time, our dear friends in Auckland still have a lot of sunlight, but they are slowly seeing it slip away. Today in Auckland, New Zealand, sunrise is at 6:43 a.m., sunset at 8:26 p.m. That's 13 hours, 42 minutes, and 56 seconds, but they are losing about two minutes and five seconds of sunlight a day. So for everyone at the Occidental Belgian Beer House on Vulcan Lane, enjoy that sun. We're catching you. And once we catch you, we'll be happy to share what we have with you. And so today, I just celebrate this ever-increasing sunlight moment and appreciate it very, very much.

 

Chris Dall: Let's start with the latest COVID data. As I noted in the introduction, the data appear to show an improving situation here in the United States, but surges are being reported in some parts of the world. And in a recent interview with Scientific American, Maria Van Kerkhove of the W.H.O. said the virus is still rampant and remains a global health risk. Mike, what are you seeing?

 

Michael Osterholm: Well, Chris, I think this is what I call a glass half full and a glass half empty moment. And let's try to cover both. I do think that Maria's comments are appropriate relative to what we're seeing internationally, but also looking at the trend data, I think we have some optimism that is justified. First of all, Chris, in most places with the recent surges, we're now at a point where we're seeing these improvements. I just noted, I could share a whole list of countries like Austria, the Czech Republic, Greece, Italy, Malaysia, Poland, Singapore, where that's exactly the case. The recent surges have appeared to peak and are on their way down. Now, of course, depending on the timing and size of the peak, overall activity in some of these places is still quite high. So it's not like reaching a peak suddenly gives you the all-clear. Even in the recovery phase, there can be a lot of virus out there, and a number of these places still have a ways to go before they reach levels being reported prior to this most recent surge. But overall, it's a good sign and things are at least heading in the right direction. Let me just emphasize, as I have in previous podcasts, the real brunt of this pandemic is behind us. We're not going to see days again like 2020, 2021, and 2022, but it still is unclear what we will continue to see with COVID activity in our communities. And today we'll try to put some perspective to that. If we look at the data that we've had an opportunity to review recently for the United States, across all parts of the country, wastewater levels have started to decline for the first time in several months.

 

Michael Osterholm: Regionally, we're seeing this happen in the Midwest, Northeast and the western United States. That said, even with these declines, COVID activity is still considered high nationally and in the southern US, levels have not yet shown a clear drop. So again, lots of virus still circulating out there and plenty of room for improvement. But at the very least, things are no longer continuing just to climb up higher and higher. Likewise, things are improving when it comes to hospitalizations. As of late January, just under 22,000 Americans were hospitalized with COVID. For comparison, when January began, hospitalizations stood at over 30,000 individuals. So now we've had at least three consecutive weeks of declines. Again, good news, but it's not perfect news by any stretch of the imagination. Unfortunately, we have yet to see any clear improvements in terms of deaths. Granted, the death data lags behind with the latest complete numbers actually from early January. But what is sobering is that the weekly deaths at this time are close to 2,300. Yes, most of these are in those age 65 years of age and older, and in fact, most in those 75 years of age and older. This surely does not minimize these deaths at all. These are our grandfathers, our grandmothers, our brothers and sisters. And frankly, should I have serious illness with COVID? I'm in that age group. But as of last week in this country, COVID was still the number seven killer. That's sobering. And yet, less than a quarter of Americans have received the latest dose of vaccine.

 

Michael Osterholm: And for those 65 years of age and older, coverage is just a bit higher, but still remains at only 41%. So we have a lot of work to do here to help protect this population. So in terms of vulnerability, I'd say we're still largely a sitting duck when it comes to COVID, even though things hopefully will continue to cool off in the weeks and months ahead. Now, if you're under age 65, many of you will say, well, I've moved on from COVID, we're done, and we'll talk about that more in a moment. When we talk about recent public health recommendations and my comments on the last podcast, one of the things I keep in mind is just the curveballs that COVID can continue to throw at us. For example, right now Japan is dealing with another sharp rise in hospitalizations just four months after their last big peak. Why is this? Could this happen in the US? We don't know. However, we have to be prepared for that possibility. Some people continue to say it's seasonal. Even many of my colleagues, despite there is absolutely no compelling data to support this. If this virus is seasonal, why have there been recent surges throughout the southern hemisphere in the middle of their summer? For example, in places like Australia and New Zealand, where it's summertime? Even now, there are upticks in Argentina, Colombia, and Panama. So we have a lot to learn and things can quickly change. But at the end of the day, I always feel better when things are heading down and not up.

 

Chris Dall: The Omicron subvariant J&J one continues to be dominant around the world. But last week, researchers in South Africa, where our listeners might recall Omicron was first discovered, identified a new variant with more than 100 mutations that they are calling BA.2.87. Mike, what do we know about this newcomer?

 

Michael Osterholm: Well, Chris, once again we find ourselves looking at an emergent variant in its infancy, trying to figure out what it will be when it grows up. As you've heard me say many times, I always consider new variants innocent until proven guilty. This particular one, BA 2.87.1, has been gaining attention in the last week after South African authorities announced they identified this new Omicron lineage from nine samples across three provinces. It was first detected in September of 2023, with those samples collected at various points until December. According to the initial analysis, BA.2.87.1 is a highly divergent viral lineage with a multitude of mutations and deletions concentrated in influential coding regions of the spike protein. It's important to note that this is genetically distinct from the J&J, one variant that we've been talking about so often, and other minor circulating variants. Early reports seem to point to this variant emerging from a single host who was chronically infected with early BA two infection, meaning that the individual was infected for around 18 months. This, of course, could occur in someone who's immune compromised. If this is true, the virus persisted and evolved within the host before transmitting to a susceptible person. The European CDC declared this newcomer as a variant under monitoring, while its closely related parent lineage, BA.2 has been characterized as de-escalated since March 2023, an important deciding factor in predicting whether or not the situation will intensify is if it picks up even more mutations that give it growth advantage. We can look back on what happened with the parent BA.2.86 variant.

 

Michael Osterholm: It never took off the way some predicted until it picked up enough opportune mutations to create JN.1. There is relatively limited information on BA 2.87.1 as of now, but rest assured we will continue to cover this variant as this situation emerges. As far as JN.1, it's reached what I consider a complete dominance in the United States and beyond, accounting for more than 90% of new cases. The silver lining here, though, is that the infections are beginning to drop as more and more people are removed from that susceptible population by either being infected or recently getting vaccinated with the updated shot. I hope these trends continue to bode well for spring, but ultimately we'll have to wait and see again. Let me remind you, I look at the future of COVID by the level of human immunity. Meaning, how long has it been since you were last vaccinated or you had had previous infection? In the instances of those two events, you may have six months of relatively good protection against serious illness, hospitalizations and deaths, but it will surely wane over time. And then if that collides with a new variant that emerges, we could see an uptick in cases again. Now, we haven't seen trends suggesting more serious illness in younger populations with these new variants, but this is what we will have to continue to monitor closely, and we will keep you informed about that.

 

Chris Dall: Let's turn now to the latest flu and RSV data. Mike, what are we seeing with these viruses?

 

Michael Osterholm: Well, Chris, I'm actually happy to report that we're continuing to see declines in influenza activity and RSV activity in the US. RSV cases last week were two-fold lower than what we were seeing just two weeks prior, and three-fold lower than what we were seeing six weeks prior. Four states are currently reporting very high levels of influenza activity, down from eight states two weeks ago and 21 states four weeks ago. Influenza mortality is also down, with less than 1% of deaths last week attributable to influenza. Hospitalizations and outpatient visits for respiratory illnesses have remained steady compared to last week, but are still down from what we were seeing a month ago. That said, 4.3% of outpatient visits in the United States were for respiratory illnesses last week, which is still above the national baseline of 2.9%. So I want to emphasize that just because I believe the worst of this respiratory virus season is behind us, it does not mean that it's over. We're most likely going to see several more weeks of declining activity before we are back to a baseline level of respiratory virus activity. This means that it is not too late to receive your dose of influenza vaccine this season, if you have not already done so. I also want to mention that Minnesota is the only state that has experienced minimal levels of influenza activity throughout the entire respiratory virus season. Activity here is up slightly compared to last week, but not enough to remove us from the minimal transmission category to the low transmission category. I wish I had an explanation as to why we have not seen more flu activity here this season. I know that the Minnesota Department of Health is looking closely at this issue, and it surely is something that we want to better understand. What's notable to me is when we look at our neighboring states that have continued to see moderate to high levels of transmission. But is this just another example of viruses behaving in ways that are somewhat unpredictable? I think it surely could be.

 

Chris Dall: And now for the latest on long COVID. Last week, Eric Topol posted a link to a study that could hold some clues on how SARS-CoV-2 infection can lead to long COVID, and the findings may also provide some insight on the cause of conditions like chronic fatigue syndrome. Mike, what can you tell our listeners about this?

 

Michael Osterholm: Well, Chris, the study that you mentioned, which was conducted at UCLA entitled Viral Afterlife SARS-CoV-2 as a reservoir of immunomagnetic peptides that resemble interpleural inflammatory supermolecule complexes. A big, big title, which I will break down for you in a moment. This study actually provides some really interesting insight into a potential mechanism behind long COVID. You noted that this particular study has been highlighted by Eric Topol, someone who you've often heard me talk about on this podcast, who I believe is one of the wisest individuals in all of the COVID world. Research. The group at UCLA found that fragments from the SARS-CoV-2 virus, which sometimes are called zombie fragments, can mimic molecules in the body that are responsible for immune response, which then can cause inflammation and ultimately may lead to long COVID symptoms. So, in other words, these are not full live viruses that are occurring, but rather these fragments. But they are enough to stimulate the ongoing immune system response. And they themselves persist for some time. We have linked the study in the episode description so that you can go look at it for yourself, but know it's a pretty heavy technical lift. So if you find yourself unable to fully digest all of it, please know you're not alone. Chris, I want to highlight a few really important takeaways from this study. First, as you mentioned in your question, the findings from this study not only provide insight on what might be happening in the body in cases of COVID, but they also shed some light on other post-viral conditions.

 

Michael Osterholm: Myalgic encephalomyelitis Chronic fatigue Syndrome though we focus a lot on long COVID on this podcast, other post-viral syndromes can cause similarly devastating symptoms, so I hope that we can continue to see efforts in long COVID research that also improve our understanding of other post-viral conditions. Second, this study is one of many recent long COVID studies we've discussed in the last several episodes of this podcast. And so I want to remind everyone that no single study is going to give us all the answers, and we still have a lot more to learn about long COVID. We are getting closer to finding some answers that could lead to the development of therapeutics for long COVID and I believe for other post-viral conditions. But at the same time, we still have a long ways to go. This means we must continue to advocate for funding and prioritization of research efforts to support this type of work. We owe it to everyone suffering to find some answers, and I hope that we continue to see more and more progress and long COVID research in the weeks and months ahead. As I've said time and time again, for all of you suffering from long COVID, we're here. We hear you, we see you, and we will continue to do whatever we can to continue to push the long COVID research agenda.

 

Chris Dall: So, Mike, you noted earlier the low uptake of the updated COVID-19 vaccine. Well, last week, CDC researchers published early estimates on the efficacy of that shot, and it showed approximately 54% increased protection against symptomatic SARS-CoV-2 infection compared with no receipt of the updated vaccine. Now, some people might hear that and think, that doesn't sound very protective. Why should I bother? So what's your takeaway?

 

Michael Osterholm: Well, Chris, I want to say that while I can understand why 54% protection may not sound great, it is certainly a lot better than zero, and I will continue to advocate for everyone to receive their COVID vaccine, even with this 54% effectiveness number. With that in mind, I want to provide a bit more context behind this 54% number and share with you some concerns that I've had about this. Again, let me start out by saying, as I have time and time and time again, our COVID vaccines are good vaccines. They're not great vaccines. A great vaccine would have long-term protection against any number of variants, and would allow us to spend years in a level of protection that would prevent infection, and particularly clinical illness. But on the other hand, we have lived with influenza vaccines for a number of years where we've had the same level of protection and have actually been able to determine, even at that level of protection, we have saved many, many thousands and thousands of lives who would otherwise have become seriously ill with influenza and died. So yes, it's not a perfect bullet, but it is a very important one. So with this, let me provide a bit more context behind the 54% number. This estimate comes from a recent CDC study that looked at data from mid-September of 2023, when the updated vaccine first became available, and it goes through January of 2024.

 

Michael Osterholm: The median number of days from the most recent dose of vaccine for the participants in this study was 52 days. This means that while this data does provide evidence that the vaccine is moderately effective, including against the J&J one variant, it doesn't give us any sense of how long the vaccine will remain effective, as we only have about four months worth of data with previous variants and versions of the vaccine. We've seen immunity slowly wane as soon as three months after a dose of vaccine, with little remaining effectiveness by six months following vaccination for preventing clinical disease. It's still too soon to know exactly how long this vaccine will remain effective against clinical disease, and to what extent we have little reason to believe that this variant and vaccine will behave much differently than the ones we have observed previously. Those who were vaccinated in mid-September are less than two months away from reaching that six-month mark since the most recent vaccine dose, and while we are very likely to see ongoing increased protection against serious illness, hospitalizations, and deaths, as we've seen from the other vaccine studies with previous doses, that two will wane over time. I believe we need to push for the availability of a booster dose every six months so that individuals can be protected against severe infection, hospitalizations, and death. I fully recognize that the vast majority of Americans will not choose to get these booster doses.

 

Michael Osterholm: I'm not naive, but at the same time, I believe the science supports the fact that just like flu vaccine, we see this waning immunity occur. Now, remember, this is not a seasonal virus. So for anyone to suggest that we can just go ahead in every fall, give a dose of this vaccine with the flu and RSV vaccines, that's just wrong. I think it's absolutely wrong what it is. It's a time clock ticking. Six months after your previous infection or having been vaccinated, you're going to start seeing waning immunity. So to me, the approach we should be taking is trying to update the vaccine at least once, if not twice a year, and allowing recommendations to say if it's been six months and particularly those at increased risk for serious illness, hospitalizations and deaths should be allowed to get a new dose. I already have acknowledged that uptake of the current booster is low, and I suspect it may only get lower with each subsequent recommended dose. But does that mean it shouldn't be an available option for those who choose to protect themselves? We wouldn't take N95 off of the market just because very few Americans are using them, and we need to view bi-annual booster doses the same way. This is not a seasonal virus. So let's stop saying that this is a virus that following six months of immunity from vaccine or clinical illness, coinciding with the emergence of a new variant, which we have shown time and time again, the nine big peaks in cases associated with this pandemic dating back to 2020, were the result of new emergent variants that came on the scene, not on some season.

 

Michael Osterholm: So we need to consider at this point that the FDA's current approach to wanting to make this a seasonal vaccine is just wrong. I think it's wrong. Um, and I think that while we may only see a limited number of people who will take an additional dose every six months, if in fact, we can get the numbers up in those 65 years of age and older, we can save a lot of. Lives from dying from COVID and we surely can reduce serious illness, hospitalizations, and deaths. So finally, I just want to remind our listeners that while I firmly believe that 54% effectiveness is far better than nothing, I also don't believe it's something we should settle for, which is why CIDRAP is continuing to work on a roadmap for broadly effective coronavirus vaccines that can provide long-term immunity. I am hopeful that one day we will see these vaccines become a reality, but the possibility is still several years away. In the meantime, I will continue to advocate for bi-annual COVID vaccine doses with the hopes that one day this will no longer be needed.

 

Chris Dall: Also last week, the Food and Drug Administration set an end date of March 8th for the emergency use authorization for Paxlovid. As we've discussed in recent episodes, for a variety of reasons, not as many people are availing themselves of Paxlovid as one would hope. So, Mike, does the end of the emergency use authorization mean even fewer people are likely to get it?

 

Michael Osterholm: Well, Chris, if there's one area that is very confusing with regard to our COVID response, it's this whole issue with the availability and use of Paxlovid. Let me just point out that first of all, last May was when the emergency use authorization was withdrawn for adults to receive Paxlovid and an approved commercially available product was available. But because at the time there was still a number of government-purchased Paxlovid out there that was actually delivered under emergency use authorization that still was available in pharmacies and was used as such. What's going to happen on March 8th is that will all go away. What's still in the pharmacy? That was emergency use authorization product that should no longer be available. And the other emergency use authorization was for kids. That too will now go away and it'll only be for that which is a commercially-purchased product that has full approval. Now, I want to say that I feel very blessed to have had the support of Doctor Sarah Lim at the Minnesota Department of Health, who is our statewide guru in this area, a former student and a dear friend, and someone I respect immensely. And she actually has helped me try to summarize what is currently happening. So let me go through this. I will try to go through it slowly because it is confusing.

 

Michael Osterholm: And at this point, this is one part of the podcast you may want to listen to a second, and maybe even a third time, if this is a topic of interest to you. As I just said, all US government-distributed drug will be gone by March 8th. There may still be some available now that pharmacies can dispense for free to anyone, but certainly by March 8th all available supply will be commercial only. That does mean that theoretically there may be a co-pay if you have insurance, but there is a Pfizer program to help with that called PAXCESS. If you have Medicare, regardless of Part D or any other prescription plan, Medicaid, or are uninsured, you're eligible for a free course of Paxlovid. You can enroll on the PAXCESS website, which is www.paxlovid.iassist.com. That's www.paxlovid.iassist.com. It takes about five minutes. But make sure you've got your prescription from your provider as you'll need that. You can't do it ahead of time before you've gotten sick. Then you can get a voucher to take to the pharmacy to get Paxlovid for free if your insurance does not already cover it. If you have private insurance, the same website can enroll you for a copay card.

 

Michael Osterholm: If your health plan does not cover the entire cost of the Paxlovid, the card will cover up to $1,500, which should cover all or most all of your copay expense. The total cost of the pharmacy markup is probably about $1,600. Get the card and then activate it by calling the number that's on the card. With the PAXCESS program, you can enroll. You can enroll a family member or your provider can do it, or the pharmacist can do it for you. You can also enroll over the phone. The number is 1-877-219-7225. Again, let me repeat that number is 1-877-219-7225. Now this is important to also get across the message who's at high risk and who should be treated. There's a lot of confusion in the community about this, and I know many people who have missed the opportunity to be treated with Paxlovid just because of the fact of this confusion. So number one, older age, this is a major risk factor. Your risk of severe illness starts to go up after age 50, and is definitely increased after age of 65. Even if you have no other health problems, age is still the most important risk factor for severe outcomes of COVID-19. Do not negotiate the fact that you do or don't need Paxlovid. If you're over age 65, that is just clear and compelling.

 

Michael Osterholm: And if your clinician doesn't support that, they are out of date with what needs to be done. In addition, anyone whose immune system is suppressed, perhaps because of cancer treatment like chemotherapy or other types of medications like steroids or treatments for autoimmune diseases. And finally, anyone with a chronic health condition like heart disease, lung disease, kidney problems, cancer, or diabetes you all should receive Paxlovid within five days of the onset of your illness. This important. This is what can keep you out of the hospital. This is what can keep you even if you're in the hospital from dying. So I can't say this enough. This is important. If you have difficulty finding a pharmacy with supply of Paxlovid, the. Department of Health and Human Services has a treatment locator that shows who has supply and who is participating in PAXCESS. The website for the PAXCESS system is treatments plural.hhs.gov. That will help you locate where you can get the drug. We're certainly hearing about presents from providers. A lot of skepticism in the medical community about who really needs to be treated, as well as discomfort with things like managing drug interactions and lack of awareness about treating early if the symptoms are mild. This is key for patients to know, too. They should be treated based on underlying risk, not based on how crummy their symptoms are.

 

Michael Osterholm: This is such an important point. In addition, let me just say that if you are not able to take Paxlovid because of interactions with other drugs that you're taking, we have a second drug. As you know, Molnupiravir from Merck is also available, and they have a program to assist with cost. But it's important to know in this case, only providers can enroll patients so they can't sign up for themselves. It's more complicated than the PAXCESS system, for sure, and does involve an assessment of the patient's finances, whereas PAXCESS does not. So just if you are not eligible to take Paxlovid, please ask your clinician about taking Molnupiravir if this is confusing to you, welcome to the crowd. But remember, this is all about saving one's life. It's about reducing serious illness, hospitalizations and deaths. And again, I come back to those who should routinely be taking Paxlovid with an onset of COVID include the older populations, those with immune system suppression and with other chronic health conditions. And do not do not be swayed by how crummy I feel or don't feel today. Oftentimes, the severity of COVID doesn't show up until the seventh or 10th day of infection, and at that point, it's far too late to have the benefit of Paxlovid.

 

Chris Dall: Now it's time for our ID query. As you might recall, in our last episode, Mike was asked about his views on California's updated COVID isolation guidelines, and we've heard from some listeners regarding Mike's answer. So, Mike, do you want to read one of those emails and discuss how some people may be misinterpreting what you said?

 

Michael Osterholm: Well, Chris, let me start out by first saying how much we appreciate all the feedback, even when you might not agree with what we have to say. This is family. This is what happens. I'm glad that we have created a podcast family community where you are able to share your concerns and constructive criticism with us. That said, I think in this specific case, there surely has been some misinterpretation regarding my statements from the last episode. So I want to clarify a few things before I do that though. I want to share an email that we received from one of our listeners, an email that I very much appreciate. She wrote. I was deeply disappointed by what I heard Doctor Osterholm say in Episode 149, regarding the California Department of Public Health's recommendation to reduce the quarantine period to only one day. Doctor Osterholm seemed to be saying that since most people are not following good public health advice based on science, the advice itself should be changed to a bare minimum so that at least some people might feel moved to follow it. Yet, right after this topic, he talked about measles and the MMR vaccine and urged everyone to get vaccinated. Why not be consistent and say that since some parents do not want to vaccinate their children, public health should accept this fact as well and officially aim for at most 50% vaccination in every community. Both COVID-19 and measles are infectious diseases. Both cause long-term health effects and both can be deadly. Why is Doctor Osterholm still fighting for good public health practice in the case of measles, but seems to have mostly given up in the case of COVID-19? Well, thank you for that comment, I appreciate it.

 

Michael Osterholm: And for others who sent similar messages to us, please know I have never given up on the case of COVID-19 ever, and hopefully the 150 episodes of this podcast give you a sense of how important I think this is. But let's look at this from a standpoint of what can be done versus what we would like to be done. I have heard what you're saying here, and I anticipated that there may be some who would respond in a similar manner as to the email I just read to you. Let me try to lay out with you where I see the challenges from a public health standpoint. Just as we talk about measles vaccination, we concentrate heavily our activities in those younger age groups, those who are in daycare, those who are in the earliest days of school. And, you know, notice I'm not talking about measles as it relates to those who are adults or particularly older adults, because in fact, as it's been said before by Willie Sutton and others, why do you rob banks? Because that's where the money is. The problem we have with measles right now is in our youngest children. We have to focus on that. That's where we'll have the most impact. When one looks at COVID, there are some real similarities. I would like to stop all transmission of COVID throughout the community. Well, it's not going to happen because people just are not amenable to vaccination or for that matter, any major inconvenience in their lives right now related to COVID.

 

Michael Osterholm: That's just reality and we have to face that. So in this case, I continue to emphasize strongly the protection of those who are over age 65, those who are individuals who have an increased risk for serious illness, hospitalizations, as I just talked about with Paxlovid. And I will continue to do everything I can to help protect these people. Now, having said that, I understand even there we're challenged. Look at the levels of vaccination I just talked about. You know, we're not even at 50% for those 65 years of age and older with this vaccine dose. I will not stop trying to promote that. I will not stop trying to promote early diagnosis. Testing is a critical and getting people on Paxlovid. But I also realized today that in fact, for many parents, they will not test their children for possible COVID. Then they don't want to know because their child may be held out for five days or more from school, even if they fully recover within a day or two. And so we're not really benefiting the public's health by not understanding that and saying, so what can we do about that? How are we going to get that to actually change? And I think the challenge we have is we're not going to the public has moved on. So I am trying to find a way to protect the most number of people and have the credibility of what the California recommendations bring us.

 

Michael Osterholm: Remember, this is not new in Omicron. We actually changed our recommendations another number of days following onset of infection with that highly infectious Omicron variant from ten days to five days. Even though the data from lab studies showed that there were a number of people who remained infectious after five days, well, why do we change that? Well, because we were in the middle of that Omicron wave. That meant we had thousands and thousands and thousands. The health care workers out ill. We had pharmacies that couldn't open because pharmacists were all ill. On and on. And so what happened? We said, okay, at five days you can go back to work if in fact you wear an N95 respirator. What happened? Well, fortunately, we had health care workers who stepped up to the plate who went back to work even though they were infected with COVID because they were taking care of patients who were dying from COVID and otherwise would have been literally left alone. And so that was an accommodation that was not based on science. It was based on the practicality of what was happening at the time. So what happened next? Well, that particular recommendation, in a sense, just got gutted even more because everyone said, oh, it's only five days now. We don't have to worry. They missed the part about talking about needing to be using a respirator for the other five days, and then it became the norm five, five days. That was it. The science didn't support that. Yes, that reduced most of the transmission, but not all of it.

 

Michael Osterholm: Well, now we're talking about do we keep kids out of school who are sick or not sick? And frankly, I would rather have a recommendation where a child who is symptomatic is kept at home, even though we know the fact is that that they still may be infectious at some degree, going back in after they're well for at least a few days. But the brunt of the transmission is likely to occur in that ill child. So what we're trying to do is find some place where we can get people to agree that we'll do this. For a parent who doesn't have the ability to take time off covered by pay for caring for a child at home who is not sick is one that's a nonstarter. So we have to recognize that. So I hope that people understand this is talking about being practical. This is not talking about what the best science is. Because if that's the case, we screwed that up a long time ago. Okay. What we're really trying to get at here is what can we do to have the most impact on transmission. I will continue to emphasize the need for testing of individuals who might be in gatherings where there are at-risk people for serious illness. Make sure that everyone's tested beforehand for a family event. Continue to do that. For those who are at increased risk, they can wear their N95 to protect themselves from those who might be infected, even those who unknowingly are infected and transmitting the virus.

 

Michael Osterholm: So I think this is not an easy one, and I understand if people are uncomfortable with recommendations that don't follow the science. I get that, and I have the one saying all along how important this disease remains. Seventh leading cause of death in our country last week. This is a real challenge, but it doesn't help us to ignore what the public is doing. And we can surely point out that this is not in keeping with the best science. But if it doesn't matter, if the public won't follow it. And so I think what California and Oregon has tried to do is find the way to eliminate the most of the transmission they can, given the reality of what people will do. And anyone who thinks today we're going to see people masking in public places again, it's not going to happen. I've been in many locations recently of gatherings, including several involving public health department activities. No one, no one had an N95 on. And I think that that's the challenge we're up against today. And that doesn't mean that we've given up. It doesn't mean that we don't care. It's facing the reality of where we're at. And I feel the same way with measles vaccine. I won't give up. Even though parents may be adamantly against vaccinating their kids, I'm going to do everything I can to continue in that population, to push whatever efforts we can to increase measles vaccination and hopefully not have them develop immunity because of their infection, including some kids who will die.

 

Chris Dall: Well, speaking of measles, Mike, what is the latest on the measles outbreaks that we've been seeing in the United States and Europe?

 

Michael Osterholm: I think at this point, Chris, is fair to say that the storm clouds are coming. We've really not yet hit the thrust of this measles storm in the United States yet. Let me just point out that all of the alarming rise of measles cases were seen around the world is rooted in under vaccination. And just to remind listeners, the threshold for what we call herd immunity against measles, where if you have enough people vaccinated, you can basically reduce greatly the amount of transmission in that population, kind of like rods in a reaction. And in this case, at least 95% of kids need to be vaccinated. Now, remember, even when you vaccinate children, the vaccine will only be effective in about 94 to 95% of kids. So every year you accumulate vaccinated children who still are vulnerable and you're trying to protect them, too. So it was by no fault of their parents or them. They just didn't respond to the vaccine. And frankly, 95% effectiveness for a vaccine is outstanding. So it's not even if we can sit there and say the vaccine has failed, but what this results in those children who are vaccinated, who don't respond, that small number, combined with those who don't get vaccinated, open up pockets and geographic areas where vaccination rates are far below the kind of levels we need to stop transmission under vaccination can be based on opposition to government guidance, and we're seeing a lot more of that. There are still concerns in the minds of some parents about safety and effectiveness, and even barriers to accessing health care to get the doses of vaccine.

 

Michael Osterholm: I also want to note that a large portion of cases occurring globally originate in areas experiencing current or recent conflicts, which often limits the amount of critical vaccines reaching their target populations. Because of how incredibly contagious this virus is, international travel to and from areas of high community transmission opens the door for disease spread to distant areas. Low rates of MMR immunizations leaves whole communities vulnerable to the deadly disease, which they may not consider a threat because of where we live. Cases across Europe, namely the U.K., continue to rise for the very reasons I just mentioned. While some numbers are typically underestimations and lagging indicators of measles activity, the trends reported by the UK Health Security Agency are extremely alarming. Across England, only about 85% of children are vaccinated against measles, while London stands at only 74%. So it is reasonable to figure that when an outbreak reaches the capital city, surrounding areas like the English West Midlands, which accounted for 44% of total cases in 2023, will follow closely behind. What is really alarming is what is happening here across the pond. And it may be the US is not so distant future since in some cities, counties, and states vaccination rates are parallel to those in England. There was a recent opinion piece in the New York Times that also covered this concern. In 2024, we have already begun to see comparatively small measles outbreaks in Georgia, Missouri, New Jersey, and Pennsylvania. Though these cases are initially linked to international travel, exposure to the index case has the potential to allow the virus to spread like wildfire.

 

Michael Osterholm: It's estimated that 90% of susceptible or unvaccinated people exposed to measles will become symptomatic, and that attack rate is on top of the 5% of the vaccinated people who could get sick after still being exposed. This leaves me very weary, Chris, especially thinking about children in Minnesota childcare facilities that have as low as 20% MMR coverage. As we mentioned in our last podcast, I cannot stress enough how important the MMR vaccine is in ensuring you and your children are protected against what is looming around us. Four years into the COVID pandemic, we as a society should not have to face the heavy burden of vaccine-preventable diseases and we all have a responsibility to protect our children. Let me just add an additional point here. We recognize that many of our listeners are parents and grandparents, and particularly in the grandparent category. Now is the time, even if uncomfortable, if you have family situations where you have grandchildren that are not vaccinated, for whatever reason, the parents have decided not to vaccinate. I hope that you will have a discussion with your children about why they need to consider this to protect your grandchildren from this very, very dangerous situation. And it's again, one where the safety of the vaccine has been shown time and time again. And all I can say is, I don't want to wake up one morning and have friends, colleagues, neighbors, acquaintances where they are witnessing what's happening to their children or grandchildren because of the fact that they elected not to get their children vaccinated for measles.

 

Chris Dall: Mike, you also wanted to revisit our previous discussion on hospital capacity in the wake of an article in the Minneapolis Star Tribune on backups at Minnesota hospitals.

 

Michael Osterholm: Well, Chris, as we all know, this podcast is not about health care services as such, yet it has such an impact on how we're able to respond to the COVID pandemic and all the other infectious diseases around it. In terms of looking at the issue of hospital capacity, we've covered this issue in depth a few times. Recently on November 30th in episode 145, The Hospital Capacity Crisis, and then again in episode 147 J&J one Hospital Capacity and Vaccine uptake. Let me quickly summarize my message from these two episodes to give everyone a bit of context. Before I dive into this new article about Minnesota hospitals. Hospital capacity can be looked at as an issue of supply and demand. If you cut the number of beds in a hospital, but the demand for those beds stays the same, it's going to seem that the situation is far more severe in the community, and that more people are getting severely ill than when there were more beds. What I'm trying to get at here is that the hospitals wouldn't be overwhelmed and running out of beds if they didn't cut back on the number of beds and the number of people staffing these beds. Now, why are we seeing a declining number of beds and specifically pediatric beds? It's money. It's money and it's money. An empty bed doesn't make a hospital system any money. And an adult bed is more profitable than a pediatric bed, especially because pediatric beds are typically used for observation, which generates far less revenue than an expensive procedure-related bed.

 

Michael Osterholm: From 2008 to 2018, there was a 20% decrease in the number of pediatric units in this country, not just beds units in this country. Now, to add to the issue, there are staffing shortages, especially during surges. Hospitals can find places to add beds, but they can't find as additional staff that quickly. Since the pandemic, nearly a quarter of a million providers, including nurses, physicians, and techs have left their jobs and 20% of nurses are leaving their jobs every year. I don't think it's an unreasonable assumption that during surges when hospital systems add beds but don't add additional staff, it would cause additional stress on the staff and probably lead to burnout that is attributed to those staffing numbers I just mentioned. So ultimately, the hospital capacity issue is not just due to an increased number of hospitalizations or a new respiratory pathogen causing more severe disease, but rather hospitals cutting back the number of beds. So now let me turn to the article that you mentioned in the question. Chris. This piece was published by Jeremy Olson last week in the Minneapolis Star Tribune. And it illustrates an additional issue that is contributing to hospital capacity, and that is the shortage of nursing home beds. Since 2020, Minnesota has lost 3000 nursing home beds, which has in turn kept patients in hospitals occupying a bed that is in high demand because they simply don't have anywhere to go to. Many of these patients need rehabilitation before they can go home, but there is just nowhere to send them so they end up staying in the hospital.

 

Michael Osterholm: This isn't unique to just a few hospitals, though. The Minnesota Hospital Association surveyed 101 Minnesota hospitals and found that in the five months following the end of the COVID public health emergency declaration last year, there were 65,000 days. Let me repeat that 65,000 days of inpatient hospital care that was necessary because patients had nowhere else to go. Let me repeat in a five month period, patients receive 65,000 days of care that could have been avoided if there had been a nursing home or a rehabilitation bed available to them. This is one in every six days of inpatient care that is completely unnecessary. Now, why is this such a significant issue? Every day that a bed is unnecessarily occupied, it prevents someone from receiving necessary care, in turn creating a long backlog and longer wait times for patients waiting to receive treatment. Jeremy Olson, Star Tribune article focused on a 39-year-old woman who is chronically ill and a heart and kidney transplant recipient. In January, she arrived at the University of Minnesota Medical Center in an ambulance but didn't receive immediate care. She spent three days in the E.R. because there weren't any inpatient beds available, which meant she was occupying a bed that other patients needed in the emergency room. This system is so inefficient and ultimately costs the hospitals because insurance companies don't pay for these unnecessary inpatient days. In an effort to address this issue, lawmakers have suggested funding for nursing homes, as well as some funding for hospitals to help with the financial burden of the unnecessary care days.

 

Michael Osterholm: I don't think the money alone is going to solve this problem, though. We need more hospital beds, more nursing home beds, and more staff for the additional beds. I'm afraid this is only going to continue to cause longer and longer backups, and prevent people from getting health care in an efficient manner. If you want to know the challenges we have now. In responding to a respiratory transmitted pathogen. In our community, where case numbers can grow quickly, this is the perfect set of ingredients for a disaster and we just don't seem to get it. So again, I repeat, oftentimes the media will portray hospitals as being overrun as the fact that they are experiencing what appears to be this big crisis in cases in the community. And it is a crisis. But it's not because there may be more cases, it's because the capacity to take care of the cases that we once did very well ten years ago is not available to us now. And I think that the article from Jeremy Olson really is an important message for everyone to understand in terms of what the challenges are. And so I hope the media continues to emphasize this point and drive home what the challenges are so that policymakers, insurance companies, government funding programs, etc. will take this issue on and not let it continue to devolve into this everyday crisis situation.

 

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

 

Michael Osterholm: Well, I mentioned at the beginning of the podcast that there would be a canine theme to this podcast, and this is the first of two canine related issues. As I've shared with you many times before, I love this public health history segment of the podcast, and in this case, today, you'll see how public health, medicine, saving lives, and dogs all come together. As I mentioned earlier, for those of you who have been around this podcast for some time, you know that I have a very soft spot for dogs. This week we are celebrating some canine public health heroes. February 2nd mark the 99th anniversary of the historic dog sled team that delivered diphtheria antitoxin to Nome, Alaska, in what is known as the Serum Run. I'm going to start by adding some context, and this story goes back to 1918. The Seward Peninsula on the west coast of Alaska faced some of the most brutal outcomes from that influenza pandemic. Death tolls reached 50 to 70%, mostly in the native population. In the small town of Nome, 162 Native Alaskans died in a span of eight days from influenza. This sets the scene for the public health event we're discussing today. Six years later, in December of 1924, Nome, Alaska's only doctor, Curtis Welch, began treating a series of sore throats. By mid-January, the death of a three-year-old boy signaled that this was an urgent matter, an outbreak of the highly infectious disease Diphtheria. What complicated matters with the town was out of antitoxin to treat the disease.

 

Michael Osterholm: Based on the remote location and time of year, planes and ships would not be able to access the area. On January 22nd, Doctor Welch sent an urgent telegram to the US Public Health Service in Washington, DC about the need for an emergency supply of antitoxin. Two days later, a meeting of the Board of Health proposed the idea of using a dog sled. Estimates indicated it would take at least 30 days to run. However, the Arctic conditions would likely make the antitoxin effective after six days of cold exposure. Plus, the need in the community couldn't wait another month or more. After significant collaboration, a plan was set with 20 mushers and about 150 sled dogs to relay an emergency supply of antitoxin, starting near Fairbanks. This would be a trip of over 1000km, or 620 miles in Arctic conditions, reaching 85°F below zero with wind chill. There are some incredible details of the trip and events along the way, but the 20-pound package made its way to Nome in five and a half days. Not a single ampulla was broken. Multiple sled dogs died in the process, and mushers running the relay faced severe cold-related injuries. Nome and the surrounding area experienced over 100 diphtheria cases, and the death toll was between 5 and 7. Subsequent deliveries of antitoxin allowed for more patients to be treated and averted further deaths. This is an exceptional story, which is portrayed in the 1995 animated film Balto, and countless other books and films.

 

Michael Osterholm: As always, in these types of events, there are many forgotten heroes. First is the role of many Alaskan Native mushers, some as young as 21 years old, whose knowledge of the terrain and expertise working with sled dogs made the relay possible. Another role was the nurses and other caretakers in Nome. In addition to Doctor Welsh's medical care, nurses went house to house amidst the town's quarantine to care for the sick and dying. Finally, while the lead dog for the final leg, Balto often received the greatest amount of fame for the legendary serum run, other dogs and mushers cannot be forgotten for their contributions. In particular, Togo was the lead dog in a leg covering over 91 miles twice the length of Balto's run. The 12-year-old dog braved some of the toughest terrain and is featured in the 2019 Disney Plus movie by his name, Togo. His musher, Leonhard Seppala stated towards the end of his life, I never had a better dog than Togo. His stamina, loyalty, and intelligence could not be improved upon. Togo was the best dog that ever traveled the Alaska Trail, but I don't think it had to be a competition. I bet each of the mushers on this historic relay would cite that their dog was the best. And I think they're right. Every one of those dogs was a hero.

 

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

 

Michael Osterholm: Well, Chris, again, I come back to the fact time and time again after 150 episodes, that CovID is not done with us, but we are definitely in a better place today. We have tools to reduce serious illness, hospitalizations, and deaths. We just have to use them. We also have a situation where it's fluid. I'm not sure what's going to happen in the future in terms of the next COVID variant and human immunity. Number two, we have to protect those most at risk of serious illness, hospitalizations, and deaths. I have not given up. I have not, and if it sounds like I have, I'm sorry I'm not doing a good enough job communicating that vaccines, treatment, testing, and masking are still critical, particularly for those at increased risk for serious illness, hospitalizations, and deaths. We can do a lot to reduce those very, very, very challenging numbers. And remember each one of those numbers is one of our relatives, one of our family members, one of our people we love. We have to do a better job. And finally, vaccine-preventable diseases is a challenge that I find so difficult to imagine right now. After all the progress we've made over decades of vaccine-preventable disease activity. And it's not just vaccine-preventable diseases. As I've shared with you before today, we are in pre-1950 levels of syphilis in this country where we're seeing the number of congenital syphilis cases is just mind-blowing. I never would have expected to see this ever, ever in my career. It's amazing. So we have challenges, but the bottom line is, is that we also have tools and we have to figure out how to best use these, whether it's treating syphilis cases with intense follow-up and antibiotics. And it's also about getting vaccines into the arms of those who we most desperately need to protect.

 

Chris Dall: Finally, we don't have a closing song today. But Mike, I understand there was a recent canine-themed piece in the Washington Post that caught your attention.

 

Michael Osterholm: Well, Chris, this piece to me speaks very, very loudly to where I hope all of us can find ourselves in one way or another, responding not just to the pandemic, but all the challenges of everyday life. It's surely a challenge to understand all that's happened in this world the pain and suffering and why and what can we do about it. And this article, which appeared in the January 31st Washington Post, gave me hope. It gave me a sense of this is what we need to remember. The title of the article is Homeless Man Leaves Puppies at North Carolina Shelter with heart heart-tugging note. And the subtitle is I just want them to be given the chance. Their mother, like myself, was never given, wrote the man who dropped off the pups. The story a broken dog crate tied together with zip ties, arrived on the doorstep of the Fayetteville Animal Protection Society in North Carolina earlier this month, covered with a torn striped blanket. When employees looked inside the crate at around 7 a.m., they found five tiny black puppies and a handwritten letter from a person who had dropped them off, said Jacqui Perry, executive director of the No-kill nonprofit shelter. Although the puppies were a little hungry, they were in good condition, she said. Please help. I found these puppies sadly, after noticing a local stray dog that I would often feed when I could, the pencil note began.

 

Michael Osterholm: She was dead by the road. She had been hit by a car. I knew from feeding her that she had puppies somewhere. And finally, from searching where I would usually see her, I found them. The anonymous writer apologized for leaving the puppies and explained that he was homeless and couldn't afford to care for them. I just want them to be given the chance. Their mother, like myself, was never given, he wrote. Please not think poorly of me. But it felt wrong leaving them in the cold, waiting on a mother that would not be coming home. He signed the note sincerely nameless man. Staffers were so touched by the letter that they decided to post it on Facebook two days later, on January 15th. Perry said the night he had been searching for the puppies was the night of treacherous weather with tornado watches. He'd been feeding the mother dog and was obviously important to him to make sure her puppies were safe. Nearly 2000 people have liked the shelter's post and left hundreds of comments and offers to adopt the pups, as well as offers to help the man who dropped them off. He is homeless and his next meal isn't promised, and yet he fed a stray, one person commented. Please keep us posted if you find this kind man, wrote another. I'm sure many people, me included, would be willing to do what is most feasible to help him out and of course, recognize him for his generosity.

 

Michael Osterholm: Wish I could adopt one of the puppies will donate, a third person wrote. The puppies are adorable. I would like to adopt when they're available. Perry said she hoped the man would learn about the Facebook post and come forward, so he could be properly thanked to this compassionate individual. Wherever you are, we want you to know that your act of kindness has not gone unnoticed, Perry wrote on Facebook. Your empathy in the face of adversity gives us hope and inspiration. She offered to have him come by and visit the puppies. While she has not heard from him, she said if she does, she'd like to help him get whatever assistance he needs. His selfless act not only saved these puppies, it sparked a broader conversation about animals and the people in need, Perry said. There's more to the story, but I think the gist of it is apparent what a remarkable act on this individual's part. I hope this gives all of us the sense of the same feeling. What can we do? What? We don't have to be homeless to make this an everyday story for all of us. You know, the fact that he cared about a dog and her pups and the tragedy she suffered, yet the puppies did not have to experience that. I hope this gives all of us a sense of purpose for doing better, for being better, for taking care of those around us.

 

Michael Osterholm: And all I can say is this homeless man and his actions have not only inspired me to read this on our podcast, but I hope it inspires all of you. It makes you all think about what would I do, how can I do it, and why can I do it? So thank you again for being with us. Covered a lot of information this time. After 150 podcasts, it seems that we still have a lot to cover and so we appreciate that. I want to thank the podcast team again for their incredible efforts. I want to re-emphasize, how much the dedication meant to me today for Doctor Kris Moore and all the impact that she's had, not just on our team at CIDRAP, me specifically, but on the world of public health. And I want to thank all of you for hanging in here with us, and particularly those who have shared the information with us. That is challenging. We welcome that. We hear you. It's important we hear you, and I hope that we can continue this dialog as we all learn about how we can do this better. So thank you. Be safe. Be kind, be kind. , this is a time when kindness is so. Really needed. Talk to you in a couple of weeks.

 

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.edu. This podcast is supported in part by you, our listeners. If you would like to donate, please go to CIDRAP.umn.edu forward slash support. The Osterholm Update is produced by Sydney Redepenning, Elise Holmes, Cory Anderson, Angela Ulrich, Meredith Arpey, Clare Stoddard, and Leah Moat.