Episode 137: Variant Soup

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 Dall, reporter for CIDRAP News, and I'm your host for these conversations. Welcome back, everyone, to another episode of the Osterholm Update podcast. If you've been following the news lately, you've probably seen several headlines indicating the US may be in the midst of another summer surge of COVID-19 cases. While the data on infections is completely unreliable at this point and has been for a long time, COVID hospitalizations have risen over the last several weeks, and wastewater data appear to be showing an upward trend in virus concentrations around the country. But is this uptick anything like what we've seen in the past three summers? And does it indicate another significant change is occurring in the SARS-CoV-2 virus? That's one of the topics we're going to discuss on this August 10th episode of the podcast as we look at the international and national COVID trends and dive into what we know about the latest COVID variants. We'll also look at the shifting timeline on the updated COVID booster shots, discuss how people should approach getting shots for COVID flu and RSV in the fall, answer an infectious disease query on leprosy in Florida and talk about dengue outbreaks around the world. And we'll 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: [00:01:56] Thanks, Chris, and welcome back to all the podcast family. It is wonderful to be with you again. Thank you for coming back to share this experience with us. And for those who might be listening for the first time, I hope we're able to provide you with the kind of information that you find useful and helpful. I will acknowledge that there's a little bit of science and a little bit of life in these podcasts. Hopefully you're able to find which of the two, or hopefully the both, that you want to be part of. When we plan these podcasts, there actually is a very wonderful team of people at CIDRAP who help support me in this effort. It starts right here with our host today, Chris, who is a very key member to our team, but also all the other members of the team who helped share the kind of information and the context for that information that we have. But in the end, it's my responsibility and challenge, and I'm very aware of that. And today I'm going to be out there on a limb, you might say, because I'm going to talk about some things that others seem to have a lot more information about, or at least they claim to know what they're talking about. And I'm not so sure that that's actually the case. So I will try to provide context today to the issues that Chris just raised. And with that, I will promise you it will be sprinkled heavily with humility, because I think anyone right now who has all the answers to what's happening with COVID, where will we be going in the future? Probably also have a bridge to sell you.

 

Dr. Osterholm: [00:03:25] And at the very least, I think they use pixie dust in some of their scientific findings. So we'll see where we go today with that. In addition, we as you know, have a weekly dedication to this podcast and we do think a lot about that. How and where or why. What do we talk about? What do we make of importance with regard to our everyday lives? And this is a dedication that, frankly, I wish we never, ever had to make and it's one that I know its time has come. However, and it's one that because of listeners sharing with us their experience that this really is a dedication that is timely and appropriate. We had a listener share with us a really heartfelt post from it came from Annie. She shared about something completely unimaginable to many of us the loss of her child from suicide. Annie, I'm so incredibly sorry for your loss. All of us at CIDRAP express our sympathy. Thank you for writing to tell us about your son and encourage us to share support for those struggling themselves as well as survivors and loved ones. Personally, I have had friends and colleagues who have lost children to suicide and it is an unimaginable pain that one has to live with day in and day out. And so from that standpoint, this dedication is really for all of those who are in fact, survivors of suicides and amongst loved ones every year in the United States, almost 1 million people are impacted by the suicide of someone close to them.

 

Dr. Osterholm: [00:05:01] There are so many emotions tied into this, from guilt to anger to hopelessness. And due to the stigma, many choose to stay silent. But I want to emphasize this number of 1 million people to remind you that you are not alone and help is available. This is also a reminder to reach out to your loved ones with empathy and let them know you're there, especially after major life events like the loss of a relationship or a job. Asking about suicide does not increase someone's likelihood to harm themselves. Let me repeat that. That's very important. The data are clear and compelling. Asking about suicide does not increase someone's likelihood to harm themselves. Being direct, asking about someone's well-being, and following up to support them in the short and long term is so important in life in general. We can never tell our family and friends we love them too many times this is a crisis We can all work together to prevent and help people recover. For anyone in a mental health crisis or concerned about a loved one, you can call or text 988 for the crisis hotline 24 hours a day, seven days a week. For family and survivors, support is available. We will link resources for peer support in the show notes for the National Alliance on Mental Illness, or known as NAMI, as well. Thank you again for writing in Annie, and we hope you have a community of support around you in addition to our podcast family.

 

Dr. Osterholm: [00:06:28] Let me move on to another part of the ritual of this podcast is to share with you what is happening with our world of sunlight. Something that we all appreciate so very much. And for some of us right now, we're still living off the longer days of summer, but realize that they're growing shorter every day. Today in Minneapolis-Saint Paul, Sunrise will be at 6:48, sunset at 8:27. That's 14 hours, 18 minutes and 30 seconds of sunlight. That's a bit of a drop from where we were on June 21st with 15 hours, 36 minutes and 50 seconds. We're losing about 2 minutes and 39 seconds a day of sunlight. I'm still loving what we have. And to our dear, dear, dear friends in Auckland, New Zealand, and particularly those at the Occidental Belgian Beer Garden today, your sun rises at 7:10 a.m., sunset at 5:43 p.m. That's 10 hours and 33 minutes and 22 seconds. But you are gaining sunlight at about 1minute and 55 seconds a day. So we will cross here soon. The September 21st date is coming where we will all have an equal opportunity day. But today, enjoy the sunlight you have, realizing that for some of you where it's 110 degrees, that may not be necessarily what you want to hear, but you know, light and heat surely can be separated by where you're at. And hopefully any individual who needs the cooling of indoor air has access to that in these very, very hot days of summer.

 

Chris Dall: [00:08:05] So starting where we always do with the international and national trends. The most recent update from the shows case counts rising in only one region of the world, but notes importantly that only 46% of 234 countries have reported any COVID cases, which speaks to the lack of reporting. Meanwhile, as I mentioned in the intro, US COVID-19 hospitalizations have been climbing and are up by 12.1% compared with a week ago. The EG.5 Omicron Sub-variant is on the rise and we're hearing the term surge being thrown around a lot. Mike in our last episode you talked about putting this information into the context of where we've been with this virus. Is that still where you're at and what are we learning about EG.5?

 

Dr. Osterholm: [00:08:51] Chris. I'm actually not only still there, but I'm even there with more certainty. We need context here. And of course, with that word comes humility. As I said in the introduction, anyone who has the answers as to what's happening and where we're going with COVID right now, I find at best a challenge in terms of what data they have to support their point. Now, let me be really very clear about this. I have said and I still believe we are on the back side of this really horrible pandemic in terms of the 2022, 2023 period of surges in cases. And I'll talk more about that in a minute. But I think at the same time, we really have to take a step back and look at the variant picture as a whole. I think the past several months has almost felt like we're dealing with one big mixing pot of variant soup. And to many, including myself, sometimes it can all get pretty confusing and start blending together. So maybe I'll just start out with a general lay of the land. And so you already mentioned in your question, Chris, but it's important to remember that when we're talking about these latest subvariants, we're actually talking about different offshoots of Omicron, which has been the overall variant family we've been dealing with since the late 2021 time period when it first arrived on the scene. And of course, when Omicron did first emerge, we faced a series of recurring waves linked to initial subvariants such as BA.1, BA.2, BA.4, and BA.5.

 

Dr. Osterholm: [00:10:26] And in the US BA.2.12.1. In fact, those latter sub variants were actually tied to a somewhat of a summer surge. We dealt with in this country last summer, but since then, for the most part, we haven't exactly had a situation where another Omicron offshoot took off and resulted in a wave of activity. If you look basically starting in January of this year, there's been one branch of the Omicron family known as XBB that's circulated around the world. And without getting into the weeds too much. XBB is a recombinant form of the virus that was formed when two distinct Omicron Subvariants were joined together in a host and ended up exchanging certain genetic information, which ultimately created this recombinant version to add some context in the world of different viruses, including coronaviruses. It's not uncommon to see that happen, and recombinant forms of viruses aren't necessarily always a cause for concern. Again, it all really depends on what advantages, if any, the virus might have. The same thing is true when a virus mutates. Regardless, XBB emerged and over time we did see it start to circulate more widely. However, a key point with this is that the increase in XBB prevalence actually coincided with a decrease in COVID activity. Important to emphasize a decrease.

 

Dr. Osterholm: [00:11:48] In fact, that's what we've experienced in the US, starting sometime this past January and lasting all the way up until about June when we started seeing activity creep up again. Now with that being said, I just want to state up front, I'm personally not convinced that the uptick we've seen here in the US is a direct result of a specific new variant. I don't think the data I've seen really supports that, so I just want to make that clear before moving on to the next point, which deals specifically with the sub variant, EG.5 and some other versions of this virus. We're keeping our eye on right now against the backdrop of this latest uptick, we've actually seen certain descendants of the XBB Sub-variant increase in prevalence and the one that's made the most sizable gains so far, both in the US and abroad, is again known as EG.5. Here in the US, EG.5 now accounts for around 17% of cases, which actually makes it the most prevalent sub variant we're seeing. And if you look back you can see that this frequency grew over time. For example, back in early June, roughly two months ago, less than 4% of the US cases were EG.5. By early July it grew to around 8% of cases. A couple of weeks later it was at 12%. And now, of course, as I noted, it's at 17%.

 

Dr. Osterholm: [00:13:08] So clearly it has some growth advantage over those circulating variants. Similar situations are playing out elsewhere, too, including parts of Asia, Europe and South America. In the UK, for example, around 15% of the cases are EG.5. And in a report that was published last week by the United Kingdom's Health Security Agency, they estimated that the sub variant had a weekly growth advantage of around 21%. So from what we've seen, it's gaining ground with that question becomes why? Well, with EG.5, it appears that most of the advantage is derived from a mutation it has on the spike protein known as 456L. Studies have found that with this mutation, the virus does a better job of evading immune protection. One study that measured neutralizing activity found that Sera from individuals who had previously been infected with other offshoots of XBB was not as effective against versions of the virus featuring this particular 456 mutation. So growth of EG.5 is likely tied to its ability to better sidestep the host's immune response. On that note, it's not just EG.5 that some of the experts in this area are concerned about. In fact, there are other versions of the virus picking up the same mutation which suggested it's one that confers a clear advantage. Alongside that, there are several examples of recent subvariants with an accompanying mutation which seemingly works in tandem with the 4561I previously mentioned, possibly adding even further advantage to the virus.

 

Dr. Osterholm: [00:14:44] As my dear friend and colleague Eric Topol put in his latest piece on Substack, the virus is learning new tricks. So in the weeks and months ahead, I think it's clear we're going to see sub variants like EG.5 and possibly some other offshoots grow in prevalence. However, what remains to be seen is whether that growth will actually trigger an increase in activity and that's more challenging to predict. It's of note that just yesterday the World Health Organization issued an assessment of EG.5 called the EG.5 Initial Assessment Evaluation, and they concluded, based on the available evidence to date, I quote the public health risk posed by EG.5 is evaluated as low at the global level, aligning with the risk associated with XBB.1.16 and other currently circulating variants of interest. While EG.5 has shown an increased prevalence growth advantage and immune escape properties, there have been no reported changes in disease severity to date, while concurrent increases in the proportion of EG.5 in COVID-19 hospitalizations, which are lower than previous waves, have been observed in countries such as Japan and the Republic of Korea. No associations have been made between these hospitalizations and EG.5. However, due to its growth advantage and immune escape characteristics, EG.5 may cause a rise in case incidence and become dominant in some countries or even globally. This particular summary is consistent with exactly what I just shared with you has been our conclusion as to what's happening with the EG.5 variant.

 

Dr. Osterholm: [00:16:25] So where are we? Well, overall I think it's another one of those wait and see moments. Obviously when it comes to the topic of variants, it's challenging enough to understand exactly what's happening as is, But with less testing and fewer resources for sequencing, I think it's only becoming more and more challenging as of late. So that hasn't helped with our understanding of what's going on, especially on a global basis. Otherwise, we are very fortunate that some groups out there are still prioritizing this information and monitoring what's happening, which is critical. And one potential silver lining with the rise of an EG.5 is that the updated monovalent booster that will be rolling out in the US targets the spike protein of XBB, which is a close match to EG.5. But as we're about to discuss, it's still in the pipeline. So in that regard we're working against time. So in conclusion with the variants, let me just say I don't see any evidence of a variant or sub-variant combination right now that is truly going to bring us a surge in cases. We'll talk more about the concept of what a surge is in a moment. But I think at this point, this is still good news relative to what we've been through in the past three years.

 

Chris Dall: [00:17:40] So given that, Mike, what are you seeing in the international and national trends?

 

Dr. Osterholm: [00:17:47] Well, Chris, on an overall basis, I'd say that at least for the time being. I just think that when you look at where things are right now and compare them to where we've been throughout most points in the pandemic, I think that adding certain contexts can surely help keep things in perspective. I worry that I have far too many colleagues who are willing to go out there and in terms that I think suggest crisis ahead are talking about things like surges without ever defining what they mean. They're talking about the concept of tripledemic, a term I categorically reject. These are the same people that last year warned us about the Tripledemic said it was here when in fact we had an early influenza season that turned out to be normal in terms of average season. It just was displaced to timewise when it started to a 6 to 8 week earlier schedule. And I just want to say that I think at this point, we have to be very, very careful here to provide conclusions like seasonality or that what's going to happen with RSV and influenza together with COVID. There's just a lot of context here that I surely, in almost my 50 years in this business, can't tell you what this means in terms of tomorrow or the month or the six month period afterwards. At the same time, it is important to acknowledge that there does seem to be some trends in places like the US and the UK and other parts of the world.

 

Dr. Osterholm: [00:19:15] So I don't want to minimize that. What I want to do is try to provide a sense of future direction with some clarity. With that in mind, let me just run through some of the latest international and national data. According to the latest COVID update published by the W.H.O. on August 3rd, which you referenced in your question, Chris, just over a million cases of COVID and 3100 deaths were reported to the agency during a 28 day period that spanned from July 3rd to July 30th. On a regional basis, most parts of the globe are continuing to experience declining cases and deaths, with the lingering caveat that in many places, reporting is hardly optimal. In this case, again, deaths become by far the more important marker in terms of actual detection and activity. Still, there are places bucking the trend, and that's where interpreting and explaining what's going on gets somewhat challenging. As an example, in the UK, activity has been on the rise and weekly new hospital admissions with COVID climbed from around 700in late June to just over 1400 inches late July. So clearing increases there. But where do things stand compared to the previous time points in the country? There have been eight previous peaks in the UK, all at levels multiple times higher than where we're at now.

 

Dr. Osterholm: [00:20:34] In many cases, even the valleys between the past peaks are 2 to 3 times higher than they were being reported there now. So I don't mean to downplay this, but let me just give some sense of a similar time period in the UK and what some have called summer surges. If we take a look at the number of hospitalizations weekly in the UK in July of 2021, it sat at about 5000 hospitalizations a week. By July 2022, it was up to 13,000 hospitalizations per week. And this July, it's at 1400. So you can see that that's quite a bit lower than the July 20th, 21 or July 2022 levels. And it just points out that we are now seeing a much lower level of activity so that if it doubles, which is a much smaller number to double, as I pointed out last week, if you go from 5 to 10, that's basically an equivalent increase as if you went from 50,000 to 100,000. And so we need to be very, very mindful of this kind of distinction that people are often not making. They're just saying, look at this 10 or 20 or 30% increase. Another example is South Korea, where average daily cases have climbed from 16,000 a day in late June to 50,000 a day as of early August. And while hospitalizations with COVID have also started to increase there, they still remain relatively low, given the population of the country and their reported caseload.

 

Dr. Osterholm: [00:22:06] For example, the Korean Disease Control and Prevention Agency reported that 214 people were hospitalized with moderate to severe symptoms of COVID-19 as of Monday, August 7th. And while that was up from 178 patients to 14 versus 178 patients with COVID the week prior, it represents a rate of 0.4, two hospitalizations per 100,000 population in the US. That's equivalent to 1400 hospitalizations. And right now the US is at 6800 hospitalized patients with COVID. So you can see even here in South Korea, their experience is being cited as a. A surge in cases when in fact, if you actually look at their comparison to us, they're doing pretty darn good and we're doing pretty well. So let's talk about the US. We've no doubt seen the number of hospital admissions with COVID climb throughout the past 5 or 6 weeks. The week of June 24th, there were 6300 new admissions to hospitals with COVID across the US, which was the lowest reported since the start of the pandemic. However, since then, the number has gone up. And while the week of July 29th, which is the latest date available from the CDC, the number of new admissions stood above 9000. So we're at 6300 in June and now at 9000, almost certainly worth keeping an eye on.

 

Dr. Osterholm: [00:23:30] Absolutely. But the silver lining is it's very low relative to what we've seen throughout the pandemic. When one goes back and looks carefully at the different eight peaks that have occurred in the pandemic in the United States since 2020, if you look at those eight, only two of them actually were under 50,000 hospitalizations per week. And those two were actually the one that occurred in the summer of 2021. And then that occurred in the winter, early January time period of 2023. Let's just look at the other peaks that occurred, the very first peak, which occurred in late spring, early summer of 2020. We reached over 60,000 hospitalizations weekly. Then the second peak, which occurred in the early fall of 2020. Now we got up to almost 80,000 hospitalizations. The third peak, which occurred in January of 2021, brought us almost 130,000 hospitalizations. The next peak was the one I mentioned earlier, which was actually in the summer of 2021 when it was below 50,000. But then in the fall of 2021, we hit another peak, which got us to again to 100,000 hospitalizations a week. And the ultimate peak occurred in the early January time period of 2022 when it reached over 170,000 people hospitalized. So now here we sit at 9000. I just hope people understand that such a different number than before. So I'm not trying to minimize it. I'm not trying to suggest that the cases today are not important.

 

Dr. Osterholm: [00:25:14] They are. But when I hear people talk about surges, even if you double these smaller numbers, they are just within really margins of error. And these larger numbers. And this is where I worry that we're losing perspective. So I'd like to see us down to zero cases. Trust me, I would. But at the same time, I don't think that the data are there to support what some are suggesting is going to be this new surge. Let me further elaborate on this with the US. When you look at a map of the US by different counties, there aren't any clear hotspots of activity when it comes to hospitalizations. Among the handful of counties that the CDC labels as having moderate or high activity with new admissions. The absolute numbers are so low that increases of 50 or 100% in these counties basically represents admissions going from 2 to 4 or from 5 to 10. In fact, if you look at the weekly COVID hospitalizations in the US, as reported to CDC, as I mentioned before, we actually had hit the 6306 level for weekly hospitalizations. And yes, it has gradually climbed up to the point of the 9056. But to me, this is well within the potentials, you might say, margin of error around a low level estimate. If you could expect to see even if cases were not significantly changing plus or minus 10 or 20% on an estimate, you're well within that margin of error.

 

Dr. Osterholm: [00:26:41] Fortunately, when it comes to deaths in the US, the good news is that we're still seeing record low levels. Of course, deaths are a lagging indicator, so any change might take some time to appear. But otherwise the latest complete data, which is from the week of July 1st, shows that the number of weekly COVID deaths at 506, which averages out to roughly 72 deaths a day. These data support the fact that whatever variants are circulating out there that we're getting infected with, they are not causing more severe illness, which is really a very, very important point. And so I think that it's really critical to look at what's happening with deaths in the US. And just let me say, while the data are incomplete for July, I recognize that we're talking here about somewhere in the neighborhood of 400 deaths of week occurring here in the United States, where we were at 600 deaths a week in the early part of June. There's one last piece of information that we surely can use to help guide us as to where we're going and how things might shake out when we look at the wastewater activity. It does provide us some guiding light as to what might be happening. Since June, we've seen levels of SARS-CoV-2 virus detected in wastewater samples increase across the US.

 

Dr. Osterholm: [00:27:57] The two regions in the US reported the highest concentrations as of late are the Northeast and the South. Both of these regions are now seeing their highest levels since March. However, over the past couple of weeks in the south, things have seemed to flatten out. Still, they're at roughly double the levels reported in June. Again, was a doubling of a smaller number to begin with. The Western US and the Midwest are also seeing upticks in their wastewater data. But as of right now, the levels reported in these two regions remain lower than those in the Northeast and the South. Of course, wastewater data has become an early indicator of changes in activity. So this increase we're seeing across all different regions is something we're keeping a close eye on. That said, when you look at the previous summer surges that people talk about, there are some distinctions with one primary element being the role that the new variants have played in the summer of 2021. We saw fairly notable declines in activity from mid-April until the end of June. Of course, around that time it was also the initial rollout of the vaccines. But starting in July, things took off again, primarily in the southern US and that overlapped with the Delta variant taken off. Well, if you look at the wastewater data from the South during that time, you see a pretty dramatic and consistent surge in the amount of virus being detected.

 

Dr. Osterholm: [00:29:19] And overall, it extends well beyond the levels we're seeing in any region of the country now. Otherwise, the surge last summer impacted more regions of the country, and that coincided with the rise of BA.4 and BA.5 variants, followed by BA.2.12.1. And again, the wastewater concentrations reported at that point were also well above what we're seeing now. So obviously we're seeing increases and things can change. But I strongly believe that the overall levels being reported in wastewater data right now and the rate of change we're seeing have not reached a point where I'm convinced this will be a, quote, summer surge, unquote, resembles what we've seen in the past. I think that my conclusions are quite consistent with what we just heard from the W.H.O. about the impact of EG.5 as a variant. In short, let me just say that anybody who can tell you what's going to happen in the next 6 to 12 weeks, be careful. I'm convinced they also probably have a bridge to sell you. That's what we'll try to do is keep you up to date as we can and know that it's going to be in every couple of week kind of an assessment that will tell us where we've been, where we're at and where we're going.

 

Chris Dall: [00:30:32] Want to ask you now about COVID booster shots, because in a recent interview with National Public Radio and thanks to Eric Topol for highlighting this, new CDC director, Dr. Mandy Cohen said the new COVID booster, a Monovalent vaccine targeting the XBB.1.5 sub-variant, will be available, quote, probably in the early October timeframe, unquote. Now, there is a lot of wiggle room in that phrasing. And back in June, Pfizer told the FDA advisory board it could have updated vaccines ready by late July or August. So, Mike, are you concerned about the shifting timelines with the updated booster shots?

 

Dr. Osterholm: [00:31:09] I'm extremely concerned about the shifting timelines, not just in terms of the actual availability, which is by itself important because you can't begin giving these shots until you have them in hand. But I also believe that what's happening is our messaging is getting so confusing and leaving people frustrated to the point where they are losing trust that we know what we're doing in this country with vaccines. And I think this is really becoming a public health messaging disaster. And, Chris, I'm very concerned, as we discussed earlier, COVID activity is increasing in the US and we don't have our most important line of defense. The old Bivalent booster dose is not going to do the job and we need this new booster. And as the timeline shifts back, the longer we go without these boosters, the longer we go unprotected. Those of us who have been staying up to date with our vaccine doses are coming up on one year from when the BA.5 booster was first available, and we eagerly want to get it as soon as we could. Why did the companies indicate they could have this available in late July or August, a period that has already passed and yet now we're hearing about it might not be till October. This lack of clear direction from our federal agencies, I think is taking a toll. Let me provide some context as it relates to the UK and how they're messaging. They issued a statement two days ago on August 8th, which we will put a link to this on our website, which was their statement on COVID-19 vaccination program for the autumn of 2023, a very detailed, thoughtful document of which they advised who could get the vaccine and who they prioritized.

 

Dr. Osterholm: [00:32:48] And this is what they said. They advised that for the 2023 Autumn booster program, the following groups should be offered a COVID-19 vaccine. Residents in a care home for older adults. All adults aged 65 years of age and older persons aged six months to 64 years in a clinical risk group as defined in the set of tables, which we would recognize in terms of immune compromised health, frontline health and social care workers. Persons aged 12 to 64 who are household contacts as defined also in terms of people who are working with people who are immunosuppressed and persons aged 16 to 64 years of age, who are carers for older adults, and they emphasize the importance of getting this as soon as possible. And they would like to have everyone vaccinated no later than early December. Now that was really helpful and I think that that's what we're missing in this country, is the clarity that we're seeing out of our colleagues in the UK. And so I urge that if nothing else, even if the vaccines can't make it sooner, which I'd like an explanation of why what is it that we can tell the public so that they can plan and prepare for this, particularly now as many are getting more anxious and they want to get vaccinated. So I hope this message is heard. I'm sure sharing it with my colleagues in the administration. You know, come on, get your act together at this point, I think is really a challenge. And we don't want to lose people because of a lack of confidence. We already have that challenge with booster dose use, and we don't need to further that challenge anymore.

 

Chris Dall: [00:34:28] And a related question, as we move into the fall, there are going to be three shots recommended for many Americans, the updated COVID booster, the flu shot and the respiratory syncytial virus or RSV vaccine. So there has been some talk that people could possibly get all three at once, though I don't think any official recommendation has been made. So, Mike, what are your thoughts on this and does this kind of get to that communication aspect?

 

Dr. Osterholm: [00:34:55] Well, this adds on to my frustration with communication, and it's one that, again, I think that we unfortunately and unnecessarily are shooting ourselves in the foot in terms of what we're trying to communicate to the public. You know, we've seen an effort by some, particularly leaders in the FDA, try to push the idea that COVID is a seasonal disease, i.e. like a wintertime flu virus or RSV, which typically more often occurs in the wintertime. And to try to work it into that routine program of vaccination. Yet here we are talking about people who are calling this summertime seasonal issue the season. Okay. It you know, it's very confusing at best. And so in that light, I think that we've had a situation where people have been talking about, well, to capture our patient population. Wouldn't it be great if we could vaccinate for all three of these at one time? You know, cover what those who call this the tripledemic witching hour with this vaccine? Well, I think this is potentially a major challenge, if not potentially a major disaster. And I say that very carefully, because, in fact, there has been substantial discussion already over the course of the approval process for the RSV vaccine, a vaccine which I truly very strongly support. And I can't wait to get my dose.

 

Dr. Osterholm: [00:36:20] But even if you go back to the VRBPAC meeting, the advisory group to the FDA on February 28th, VRBPAC members inquired of the FDA about whether or not you could give these vaccines simultaneously without seeing some reduction in overall vaccine immune response for the other two vaccines, i.e. COVID and influenza. And there is a growing body of data that says you do not want to give these vaccines at the same time because there may be some kind of interference that can occur with them. So first of all, let me be really clear. I want everyone who is eligible for these vaccines to get them. I'm very strongly support that. Right now, we are aware that at least in some pharmacies in the United States, RSV vaccine is available. And getting it right now would be great. Unlike the flu vaccine or even COVID vaccines, we're not nearly concerned about waning immunity with the RSV vaccine. So one could get it now and be protected for some time to come, which then gets us to the issue with the coronavirus vaccine. We need it now. You know, I we may have a increased occurrence this winter again with more cases, but I know we have cases occurring right now that would benefit immensely. So get your RSV vaccine, get it now, get COVID when it becomes available.

 

Dr. Osterholm: [00:37:46] And as I have said time and time again, wait and get your influenza vaccine much closer to the time for which there will actually be activity in your community. Last year, that was early, so getting it in in October was not a bad thing. But we know we know that there is a reduction in the overall protection from influenza vaccine that may be anywhere from several percent up to almost 20% per month after receiving the vaccine. A reduction in the protection from that vaccine. So if you're out five months, you do the math. You know how much reduction in protection might you have with that vaccine? So that's why I always wait and follow very closely what's happening with influenza in our communities. And when I start to see the first activity of flu, I get vaccinated. I don't get vaccinated in August or September or whenever. And I definitely would not this year try to tie my RSV vaccine to my flu vaccine. So we need clarity on this as soon as possible. And again, we're not getting it from our federal agencies and particularly from the FDA. And so I think that this is going to be another issue where people are going to say, wait a minute, I shouldn't get my three vaccines together, just solve it by coming out with a clear and compelling statement of the data.

 

Dr. Osterholm: [00:39:09] What do they show? And if I'm wrong and the data support, you can give all three with an equally great response, go for it. I know that's not the case. I know that's not the case. And so at the same time, for someone to say, wait a minute, I got all three vaccine doses and now you're telling me that maybe that's not what I should have done. That's what's going to just breed more confusion and lack of trust for what we're doing in our business. So get your RSV vaccine as soon as possible. Get your COVID vaccine becomes available, which will be a while, and time your influenza vaccine such that you're keeping track of what's happening in your community with flu and get it as soon as you can. When flu activity starts, then I think you'll get the maximum. On protection from all three vaccines, which are important. And again, I'm a very, very strong supporter of these three. I can't wait to get my three this fall. I can't wait. But at the same time, worry that we're setting ourselves up for another real challenge from data credibility and trust perspective.

 

Chris Dall: [00:40:15] Now for our query. Mike, this week we've received several emails about a recent CDC report on rising incidents of locally acquired leprosy in Florida. This is an infectious disease that I think many people consider to be a disease of the past. So what can you tell our listeners about these leprosy cases and what we're seeing in Florida?

 

Dr. Osterholm: [00:40:37] Well, Chris, I certainly understand why our listeners are concerned about this issue. As you have noted, many Americans consider leprosy, which actually now is officially called Hansen's disease, named after the Norwegian physician who, in 1873, first discovered this. And so it could be alarming to our listeners. Actually, there's a lot of good news around this, and there are some challenging news with this in mind. I want to start by emphasizing that Hansen's disease is still a very, very uncommon disease in the United States, and it certainly is not something that would have the potential to cause a future major epidemic or even pandemic, for that matter. And it's also one that is largely treatable and for which many of us actually have a high level of innate resistance to actually becoming infected to begin with. Before I go into further details on the incidence of Hansen's disease in Florida, I want to provide some background on what Hansen's disease is for our listeners who may be unfamiliar with the disease. Again, you can use interchangeably the word leprosy with Hansen's disease. This is caused by a bacterium, Mycobacterium leprae. Leprosy can cause damage to the skin, eyes, nose and peripheral nervous system, the nerves outside the brain and spinal cord. As I mentioned earlier, 95% of the people are actually genetically resistant and therefore are not very susceptible to Hansen's disease. Even among those that are susceptible, prolonged exposure is needed for the bacteria to be transmitted.

 

Dr. Osterholm: [00:42:04] It's unclear to us at this point just how human to human transmission occurs. Is it a respiratory route? It does not at all appear to be tied to touching as such once people actually have this. And it's also important to note that the horror stories that occur with Hansen's disease are people who have been infected for many, many years. And what actually happens with disease is actually the nerves are damaged in the skin, eyes, nose and as I mentioned, peripheral nervous system. And therefore, often someone does not feel pain does someone does not actually understand that their fingers are in the fire or that they're being crushed or that they're somehow otherwise being damaged, which then can lead to other infections of the skin, which leads then to these horrible, horrible kinds of disfiguring pictures you see of people who develop leprosy or Hansen's disease. If you look at it, it's treatable with antibiotics. And though treatment can take anywhere from six months to two years, patients are typically no longer infectious after the first week or two of treatment. So that's a great, great, great piece of news. And we have little evidence at this point of any resistance problems. So in 2020, the most recent year with data available, there were 159 cases of Hansen's disease in the United States.

 

Dr. Osterholm: [00:43:25] This is an increase from what we were seeing 23 years ago when yearly Hansen's cases reached an all time low of 76 cases. This is still far less than the 456 cases of Hansen's disease. We saw when the incidence of the disease in the US peaked in 1983. So let's take a step back and look at what's happening in Florida right now as that has been what's been on the front page news since 2011. At least 30% of the Hansen's cases reported in Florida each year have been reported in Brevard County. This is in east central Florida with the northern part of the county being the Kennedy Space Center and the southern part of the county being down in Melbourne, Florida. For context, Brevard County accounts for less than 3% of the total population in Florida, compared to anywhere from 30 to 74% of the Hansen's cases since 2011. In 2021, five of Florida's 14 cases of Hansen's disease occurred in Brevard County for 36% in 2020. 20 of Florida's 27 cases of Hansen's disease occurred in Brevard County, 74% overall. And in 20 1912, of Florida's 26 cases of Hansen's disease occurred in Brevard County or 46%. So it's really unclear what's happening there. We do know that, in fact, some of the individuals are reporting contact with armadillos. Armadillos have actually been shown to be carriers of this particular bacteria. So when you have human contact, it's very possible that you could become infected with contact with the armadillo.

 

Dr. Osterholm: [00:45:04] And that usually means also extensive long term kinds of contact with them. So at this point, it's unclear, though, however, for the for a number of the cases who have not had contact with armadillos in Florida, where are they getting infected from? A number of the patients are not even aware of friends or colleagues or family members who are infected, so they don't know where they got it. And this is a challenge. So at this point, the public health message really is if you have a potential illness compatible with. Hansen's disease. You obviously need to seek immediate medical care. Public health then has to continue to work closely to try to understand where did these cases come from, what is the risk factor for them? And at this point, we just don't know. So early diagnosis and treatment of Hansen's disease are going to be critical for preventing permanent disability caused by the disease. And I so hope we can continue to raise awareness about this issue among health care providers, particularly those in central Florida. I just want to reiterate, this is an important issue, but it's not something that's going to result in another major epidemic. And I hope that this can reduce some anxiety among our listeners that are concerned about this issue.

 

Chris Dall: [00:46:20] Another infectious disease we're hearing a lot about lately is dengue virus. Peru is experiencing one of its largest dengue outbreaks ever, and Bangladesh is also in the midst of a record outbreak. Mike, there's been a lot written about possible links between the mosquito borne virus and climate change. And as we've discussed on recent episodes of the podcast, we are seeing record temperatures this summer. So do you have any sense of the role climate change is playing in some of these outbreaks?

 

Dr. Osterholm: [00:46:48] Well, Chris, this is a really very, very serious issue and one that has only gotten worse in recent years. Let me just take a step back and share with our listeners a little bit about dengue so they can understand what this means. It's caused by any one of four different dengue viruses dengue virus, one, two, three and four and is transmitted by the Aedes aegypti mosquito. I'm going to come back to that because that's an important distinction. The Aedes aegypti mosquito. Approximately 1 in 4 people infected with a dengue virus will experience symptoms including fever, nausea, vomiting, rash and pain in the eyes, muscles, joints and bones. Approximately 1 in 20 people with symptomatic dengue infection will develop severe dengue, which can cause shock, internal bleeding and most severe cases death. What's notable about this is that this is a relatively new disease of modern civilization. What I mean by that is, prior to World War Two, the four different strains of dengue virus were really isolated in different parts of the world and with movement of mosquitoes and overall transportation, we saw all four strains now end up where any one of them is at. And it's important to understand that the severe disease we call dengue hemorrhagic fever is in itself a new disease in that you have to have been infected with dengue previously and with a different strain of the virus, and that you have a low level of antibody from that previous infection.

 

Dr. Osterholm: [00:48:18] If you have high antibody levels, you're protected. If you have no antibody, you're going to get regular dengue breakbone fever, but not dengue hemorrhagic fever, which occurs from a thing called immune enhancement. So we're seeing more very serious cases because of the previous experience with dengue amongst our communities and the fact that we now have these multiple strains circulating. So there is no specific treatment for dengue virus other than supportive care in the form of fluids, fever, reducing medications, etcetera. Chris, as you mentioned in your question, Bangladesh is facing a record dengue outbreak which has caused nearly 64,000 infections and over 300 deaths. The health care system in Bangladesh is struggling to keep up with the number of severe dengue cases that require hospitalization. Peru is also seeing record numbers of dengue infections this year, with nearly 207,000 cases and 357 deaths reported so far this year. This is 2.8 times more cases and 4.3 times more deaths due to dengue than the country experienced in all of 2022. Now, where does climate change fit into this? I mentioned earlier Aedes aegypti is the vector for this. This is often referred to as the household mosquito. This is one that loves to live in the context of human activity, and it is one that, for example, breeds in places like discarded plastic and garbage where a rainfall will settle in on that garbage, create a small little pool like inside, even a top of a bottle cap, and the female mosquito will lay her eggs there and then they hatch.

 

Dr. Osterholm: [00:49:55] This is also a mosquito that actually is a daytime biter, one that you often do not recognize as even biting you as it has developed a behavior of biting you on the back of your legs, back of your head, and you don't feel it. And so that if you're going to really try to address dengue, surely having vaccines and so forth would be great. But also there's everything all about vector control that going in and cleaning up the breeding sites, not big swamps, not big bodies of water, but the junk and garbage we live with every day that collects water. Now, where temperatures become important is there's a thing called the extrinsic incubation period. This is how long does it take a mosquito from the time that they feed on someone who has dengue, they then get infected before they're infectious to someone else when they take their next blood meal. And the warmer the temperatures, the faster the mosquito goes from being taking in a blood meal with a virus to actually become an infectious themselves. So it speeds up the cycle, you might say. And so this is all very important. And as we see flooding occur in many areas of the world with these terrific rains that are occurring now with a much higher frequency, with the higher temperatures combined with all the kinds of breeding sites that exist within household areas, watering cans, you know, water collection systems, all these things, this is only going to make the challenge even greater.

 

Dr. Osterholm: [00:51:30] So expect that we're going to see much more in the way of dengue infection over time. And it's also important to note that Aedes aegypti, also in addition to dengue, is the vector of concern for viruses like Zika and chikungunya and. So that, you know, taking care of these mosquitoes from a vector control standpoint is in fact, going to help us with all these diseases. One last question. We often get, well, why don't we spray for these mosquitoes? And you can for a spray for a number of types of mosquitoes, culex the anopheles, the different kinds of mosquitoes that breed in more open water areas or in marsh areas. These breed in and around your home and they often are under porches. There are any number of places like that and that is not amenable to to widespread spraying. And so that one of the challenges we have today is just you got to understand that getting rid of the breeding sites physically, meaning cleaning up garbage, cleaning up breeding locations where there is junk. And we know in much of the low and middle income countries of the world, there's lots of plastic junk. And that is what we need to deal with today to try to reduce the impact of this virus infection.

 

Chris Dall: [00:52:51] Finally, the National Institute of Allergy and Infectious Diseases last week named a new director, Dr. Jeanne Marrazzo, to replace the outgoing director, Dr. Anthony Fauci. Mike, your thoughts on Dr. Marrazzo and the challenges she will face as the new NIH director?

 

Dr. Osterholm: [00:53:09] Well, first of all, let me acknowledge the fact that Jean is a dear friend and a most respected colleague. So you can say I may be biased in my assessment here. I thought it was simply a brilliant choice. Jean is one of the most skilled clinicians, public health oriented infectious disease doctors, someone who has helped run very large studies, who is widely respected across the world for her work. A personality that is engaging, you know, I mean, people truly love to work with her and she's tough. She can also handle, I think, the rough and tumble of Washington, D.C. A year ago, Jean and I were a part of a team that went to Cuba and spent a week there assessing their vaccines for COVID. They have some very novel technology, and it was wonderful to spend the week with her. So I'm in my biased way. I will say I can't imagine a better choice than her. And I know she's going to have some hard days ahead with challenges around funding budgets, politics and so forth. But I can't think of anyone who is better prepared for the job than she is. Also, it's important to note that she does have a very real public health part of her life. Her partner is a former state epidemiologist. And and I think that when Jean's at home, she surely catches the public health message from another person who I respect and admire, her partner.

 

Chris Dall: [00:54:47] Now for our latest moment of joy submission. Mike, who did we hear from this week?

 

Dr. Osterholm: [00:54:54] You know, Chris, these moments of joy make all the work that we put into these podcasts worth it just because they are so remarkable. They're so touching. And I can never say often enough in an adequate terms just how much they mean to all of us at CIDRAP. This one I will read part of. Thank you for all your very kind comments, Martha, but I'll skip those today just to get to the heart of what the moment of joy is all about. This particular one is from Martha and it starts out by :Dear Dr. Osterholm and the whole CIDRAP team. My moment of joy is one that would never have occurred were it not for the pandemic. Many years ago, I earned a master's degree in music performance before collecting a couple more degrees and eventually becoming a psychotherapist. But music has continued to be an important hobby that feeds my soul. At the beginning of the pandemic, I disbanded my handbell choir at church. The Chancel choir director disbarred did the group, and we formed a trio with our talented organist, solo Handbells, guitar and piano. Although we were all seriously trained classical musicians, we had a rollicking good time playing everything from an arrangement of Louis Armstrong's It's a Wonderful World to gospel hymn medleys, to transcriptions of classical music. The group has become highly skilled and has filled a need with our congregation to find transcendent moments with times of struggle. It has also struck a chord within each of us, as we have found both joy and healing in the music we create. We are all high risk, hence COVID averse. And this has given us a safe outlet to create and share an art form that has felt so powerful. Three and a half years later, not a rehearsal performance goes by when we don't text each other later to say thank you. I needed that. My soul feels whole again. Martha.” Martha, Thank you for this joyous moment. I would love to hear your little musical effort sometime and maybe we'll have that opportunity. Thank you so, so much for sharing.

 

Chris Dall: [00:57:04] Just a reminder 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 your day, even if just for a moment, is so important for our mental health. So what is the thing that you look to for a little bit of joy in your life? It can be a place, a person, a pet, a piece of art, a memory, a moment. It can be 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: [00:57:37] Well, let me provide one overview of message that I think is is one that we don't say enough. And I'm reminded of that in the dedication that I talked about and how we miss opportunities that we should never miss to share with others how telling them how special they are. I just want to share with the audience today. Thank you. Thank you. Thank you for being here and being part of this experience. And again, as Chris indicated, please share with us your feedback. We welcome it. We take it very seriously and truly, truly appreciate you. In terms of my three main points. The first one hopefully is obvious and it's kind of a continuing theme. I think we're just at a time where we can't say with any certainty what's going to happen. Do I believe we're on the backside of the pandemic? Yes, I do. Do I believe that we could see some tough days ahead? Possibly. But again, it reminds me more now of what we might experience an annual flu type events, not big prolonged surges of cases. The second thing is we have a mess with our vaccine situation for COVID right now. We have so much confusion as to what is going to happen, when will it happen? How do we use these vaccines in the context of RSV, influenza and COVID? And we need clarification.

 

Dr. Osterholm: [00:59:06] Come on. We got to get that. That is going to only help us down the road, keep credibility and trust from all those who one day very well may be the people who should get that booster. And finally, I think the examples we gave today of Hansen's disease and dengue are just two of many, many infectious diseases we're confronting today. And I worry about where we're going with these disease responses because, in fact, if we look at what's happening in Washington, DC right now, we're talking about major cuts to federal budgets, CDC to the NIH. We're seeing foundations, philanthropic organizations that were right there and doing incredible work during the pandemic. Now moving on to kind of getting away from infectious diseases. And I think over the course of the upcoming years, we're going to see a major gap in what will be needed to respond to the ever growing risk of infectious diseases in our modern world and the resources that are available to do that. And so to me, we have to keep hitting home. Why? Yep, COVID is important. All these other diseases that we talk about routinely here, but there are a lot of issues right now that need to be addressed. And so I hope that we can keep a spotlight shined on these other diseases to.

 

Chris Dall: [01:00:29] And Mike, what is your closing song for this episode?

 

Dr. Osterholm: [01:00:33] Well, in keeping with the dedication. And I keep coming back to that because that is, from my perspective, one of the most painful events of a lifetime is to lose a loved one to suicide. And particularly as a parent who, you know, no parent should ever have to bury their child in a lifetime. That, to me is is such an important, important point. So I hope that, if anything, that the dedication and what I'm about to share here is really helpful in trying to address that. I picked a song today that we've actually used twice before in Episode 34: The Best of Times and the Worst of Times on December 3rd, 2020. Boy, was that a long time ago. The next one is Episode 95: Expect the Unexpected on March 17th, 2022. This is a song that will be very familiar to routine listeners here. It's Everybody Hurts, a song that was made very popular by R.E.M. From their eighth studio album in 1992 and released as a single in April 1993. As I've shared with you before, it peaked at number 29in the US Billboard Hot 100, and the song actually fared better on the US Cashbox Top 100, where it peaked at number 18. This is really a song that if you listen to the words and absorb them, you just realize this is all about being a human, all about living life and what it all means. So here it is. Everybody Hurts by R.E.M. When the day is long And the night the night is yours alone. When you're sure you've had enough of this life. Well, hang on.

 

Dr. Osterholm: [01:02:24] Don't let yourself go. Because everybody cries and everybody hurts sometimes. Sometimes everything is wrong. Now it's time to sing along. When your day is night alone. Hold on, hold on. If you feel like letting go. Hold on. If you think you've had too much of this life. Well, hang on. Because everybody hurts. Take comfort in your friends. Everybody hurts. Don't throw your hand. Oh, no. Don't throw your hand if you feel like you're alone. No, no, no. You're not alone. You are on your own in this life. The days and nights are long when you think you've had too much of this life to hang on. Well, everybody hurts. Sometimes everybody cries and everybody hurts sometimes. And everybody hurts sometimes. So hold on, hold on. Hold on. Hold on. Hold on. Everybody hurts. No, no, no, no. You are not alone. R.E.M. Well, thank you very much for being with us again this week. Covered a lot of information, a lot of uncertainty. Time will tell. You know, we're where are we on the mark? Would we miss it? We'll see. We'll try our best to keep on that mark. Thank you so much to all of you for your feedback. We continue to appreciate you very, very much. And also in these times of the craziness that goes on in this world with war and politics and economic challenges, etcetera, I just hope we all can remember that every day will be a better day if we just commit one act of kindness every day. Just keep doing that. Be kind, be gentle. Thank you so much.

 

Chris Dall: [01:04:23] Thanks for listening to the latest episode of the Osterholm Update. If you enjoy 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.