Episode 141: One Huge Puzzle

Chris Dall: Hello and welcome to the Osterholm Update, a podcast on COVID-19 and other infectious diseases with Dr. Michael Osterholm. Dr. Osterholm is an internationally recognized medical detective and director of the Center for Infectious Disease Research and Policy, or CIDRAP at the University of Minnesota. In this podcast, Dr. Osterholm draws on nearly 50 years of experience investigating infectious disease outbreaks to provide straight talk on the latest infectious disease and public health threats. I'm Chris Dahl, reporter for CIDRAP News, and I'm your host for these conversations. Welcome back, everyone, to another episode of the Osterholm Update podcast. While one can point to many failures in the US response to the COVID-19 pandemic, the effort to develop and produce an effective vaccine and get it out to the American public in an efficient manner should be considered one of the success stories. But in the weeks since the approval of the latest booster shot, the rollout has been a bit messier. Media reporting suggests some people are having trouble finding the vaccine or getting their insurance to pay for it. And some nursing homes haven't even begun vaccinating residents. But perhaps more concerning is the fact that there are a lot of people who have decided, for whatever reason, that they won't be getting the booster shot. A recent Kaiser Family Foundation poll found that fewer than half of us adults will definitely or probably get the booster. Will that have an impact on our health care system this winter? This is one of the topics we're going to be discussing on this October 5th episode of the podcast as we look at the international and national COVID trends. We'll also provide an update on the variant picture, discuss a recent report on the number of Americans who are reporting long COVID symptoms. Answer an ID query on COVID vaccine side effects and talk about some recommended changes for the flu vaccine. We'll also bring you the latest installment of This Week in Public Health History. But before we get started, as always, we'll begin with Dr. Osterholm's opening comments and dedication.

 

Dr. Osterholm: Thanks, Chris, and welcome back to all of the podcast family. It's great to be with you again. Thank you for joining us. And I'd like to welcome all of those who might be listening for the first time. I hope that we're able to provide you with information that you find useful and that we present it in a way that is meaningful to you. This week we have a number of issues to cover. It would seem that over time we should basically exhaust that list and get to the point of where you'll say, I don't need to listen to that man anymore. But somehow we continue to come up with new and important issues. And today that is the case in terms of where we're going with it today, you're going to see a real focus on vaccines. I think that's a key piece and one that is fitting given where we are in this country right now with the rollout of the new additional COVID vaccine that we have and the challenges that we've had in getting it to people, the challenges of getting people to take the vaccine and who takes it. So we'll cover a lot of that area today. However, today we also are going to cover the vaccine in another one of the ways that we've done a few times before, and that is we're dedicating this particular podcast to an element of the vaccines. This episode today marks our 15th time dedicating the podcast to a COVID vaccine related effort. We know that getting the world vaccinated for SARS-CoV-2 has been a team effort, and our past dedications have reflected that. We've dedicated episodes to the health care providers who have worked tirelessly to get shots into arms, to the individuals who participated in vaccine clinical trials, and even dedicated an episode to Big Bird after he got his first dose of vaccine in November of 2021.

 

Dr. Osterholm: One group that we can never thank enough is all the incredible scientists who played a role in the development of these vaccines. And because of these vaccines, saved millions of lives. Now, some may say, well, wait a minute, did the vaccines actually protect everyone? Well, they may not have always protected against infection and even transmission, but they actually did have a major role in reducing the incidence of serious illness, hospitalizations and deaths. We dedicated episode 34 of the best of times and the worst of times to these scientists on December 3rd, 2020. But today I want to dedicate this episode to two scientists in particular who have been leaders in the field of mRNA research which made these vaccines possible. Today's episode is dedicated to Dr. Katalin Kariko and Dr. Drew Weissman. As many of you know already, they were the recipients this past week of the 2023 Nobel Prize in Physiology and Medicine for their work on mRNA, which was critical to the development of our mRNA COVID vaccines for both Pfizer and Moderna and, of course, the subsequent boosters that have also been used throughout the pandemic. Their work on mRNA over the past 20 years made it possible for us to rapidly develop and produce COVID vaccines during the pandemic. Two articles were published back in 2021 about the lives and careers of Dr. Kariko and Dr. Weissman. I encourage all of you to read these articles to learn more about the hard work and the persistence that went into the development of these vaccines and the incredible people behind them.

 

Dr. Osterholm: You can find both of these articles linked in the episode description. Now, moving on to our traditional part of the podcast, Our Sunlight Today, October 5th in Minneapolis/Saint Paul Sunrise is at 7:15 a.m., sunset at 6:46, 11 hours, 30 minutes and 30 seconds of sunlight. We're losing it at about three minutes and five seconds a day. However, I am one of those always looking to find the good news somewhere, and I'm happy to report that today is the last day that we will lose sunlight at three minutes and five seconds. Tomorrow we only lose it at three minutes and four seconds. So we're actually getting better. Eventually, when we hit December 21st, we'll see those numbers go the other way. But in the meantime, our dear friends and colleagues in Auckland, New Zealand at the Occidental Belgian Beer House on Vulcan Lane are celebrating increasing sunlight with sunrise there today at 6:52 a.m., sunset at 7:27 p.m. That's 12 hours, 35 minutes of sunlight. And today they gained two minutes and 20 seconds of sunlight. And I might add that I want to just thank the number of podcast listeners, particularly the podcast family, who, when they take trips to New Zealand, actually stop in at the Occidental. We've heard about these visits. It's been wonderful. You know, one day I wish we could just have all one big family reunion at the Occidental. But in the meantime, for those that do travel there and stop and visit and actually send us pictures of their visits there. Thank you. That means a great deal.

 

Chris Dall: So let's start with a look at the international and national COVID data and an update on SARS-CoV-2 variants of interest. After several weeks of rising COVID activity, Mike, what does the picture look like at the moment?

 

Dr. Osterholm: You know, each time we do one of these national or international updates, it almost feels like we're putting together a huge puzzle. So one piece of the puzzle might be a report published by the W.H.O., another might be some data out of the UK. Then there's always the latest from the CDC and all of these other sources we try to track down, depending on what our focus is and eventually using those differing pieces, we at least try to lay out that bigger picture perspective. That process is something I've done a lot in my career trying to connect all the dots, and that's actually a lot of the work we do here at CIDRAP. So as far as the process goes, I'd say it's something we're fairly used to and familiar with. But the reason I bring that up is because with COVID, I feel like every time I go back to put the puzzle together now there are more pieces missing, less data shifting from daily to weekly or even monthly reporting. In some cases, dashboard or sources no longer providing data. Et cetera. And so we are left with this half finished puzzle that I have to go off of. But with all that being said, I'll try to provide at least some sense of what I'm seeing in terms of what's been happening internationally. The data that's published by W.H.O.

 

Dr. Osterholm: showed some signs of increasing activity through July and August. However, according to their latest report, which was published on September 29th this past Friday, things have seemingly slowed down, with a decline reported during the latest 28 day period. At the same time, I think it's important to point out that the overall number of countries actually reporting any data to show continues to dwindle. So I'm not really sure what all this means. For example, when it comes to cases, there were 96 countries that reported any data to W.H.O. during this recent 28 day timeframe they're covering. That's just 41% of the world's total countries for deaths. Just 37 countries reported data. That's only 16% of the overall total. So when you're missing data from more than half of the world's countries and that's being generous, it's a challenge to put much stock in the numbers or trends we're seeing. Again, when I talk about those missing puzzle pieces, this is exactly what I mean. Otherwise, we do know that some places have experienced some increases these past several weeks. In Italy, there has been an increase in cases, hospitalizations and deaths since July. In the U.K., a similar situation is playing out. And then, of course, there is the US, where we've also been seeing this uptick play out over the past several months. But apart from those select countries that are still monitoring reporting this data, of which there are a limited number, I really don't think we're in a position right now where we have a good sense of what the virus is doing on a global basis.

 

Dr. Osterholm: So that's a real challenge. Otherwise, if there's a silver lining to look for in all of this, I do want to point out that even in these places where we've been seeing increases such as Italy, the UK and the US, the incidence of hospitalizations and deaths have remained relatively low. Again, that's not me trying to minimize what's happening. Believe me, I'd rather not see any increases. But in fact they are relatively low compared to the numbers that we posted throughout much of the first three years of the pandemic. This point is well made. When we look at data from the earlier parts of 2023, the numbers for hospitalizations and in particular deaths and see what they are compared to the past. For example, the average daily deaths in the UK have climbed from six in July to 25 by the end of August. However, this past February, this range from 60 to 70 a day. So today, obviously 6 to 25 is surely a much lower number than the 60 to 70. In Italy, average daily deaths have also increased from single digits in July, in August to 20 a day as of late.

 

Dr. Osterholm: However, this past February, they ranged from 40 to 60 a day. And these don't even take into account the peaks reached during previous waves, which have 20, 30 and even 40 times higher than we're at right now. Another potential silver lining, at least for those of us here in the US, is that there are some indications of a recent peak in activity these past several weeks in three of the four US regions, the Midwest, the South and the West, the levels of activity detected in wastewater surveillance have started to drop off a bit. In the Northeast, things have remained elevated, but fairly steady so far. So we'll just have to see what happens there in the coming weeks. Tracking with that, we've also been fortunate enough to see two consecutive weeks of declining hospitalizations. Let's just take a look at new weekly hospitalization. Admits on September 9th, which was the peak really of activity, there was 20,562 new hospital admissions reported for COVID. On September 16th. That number dropped to 19,691. And. Now it's at 19,079. So not big drops, but surely the numbers are not going up any longer. If we looked at the currently hospitalized numbers. So this is whether you're in the hospital for a day or ten days, this counts. Who's in the house right now? On September 9th, there was 16,144 individuals in the US that were currently hospitalized for COVID.

 

Dr. Osterholm: That number actually peaked on September 16th, or at least we think so at 16,255. Now it's dropped back down to 15,601. So this is all good news, really supporting the fact that we've probably hit our ceiling here in the United States in terms of hospitalizations with this most recent wave of activity. Otherwise, the bad news, however, is that deaths have remained on the rise, which is not a surprise as a lagging indicator. During this wave, we've seen them go from an all time low of 470 deaths. A week in early July to 1,100 a week as of late. And again, even these latest numbers are still likely to climb a bit. So that's been another unfortunate challenge. And as I do so often, I want to remind all of us that these numbers are more than numbers. They're our fathers, our mothers, our grandfathers and grandmothers, our brothers and sisters, and even so, painfully sometimes our own kids. But assuming that these recent declines are real, we can hopefully see that the numbers of deaths will start to drop as well. And with the new doses of vaccines now available, we at least have another tool available to help top off protection against the virus. So if you haven't already, make it a priority to get your new dose of vaccine now that we've made it to the fall, and as we get closer to the holiday season, it's a good time to restore that protection As we talk about spending more time indoors or with family and friends, to me, I still think it's unclear what we can expect this virus to do in the upcoming months.

 

Dr. Osterholm: I know that a lot of people talk about an upcoming winter surge with COVID, almost like it's a guarantee. But I think we have a lot of learning left to do. And so we'll have to wait and see about that. Again, this is where humility is absolutely essential. I don't know what the new variants are going to mean or what will happen otherwise. I think the one factor that can play a role that we can also count on but not yet understand what it might look like is that of what will happen with variants. And so let me just add a brief update on that. The last two episodes we've discussed the recently added variant under monitoring BA.2.86, although the numbers still hover around 1% of total infections, it has now been detected in 24 countries worldwide. More research supports that. It is a highly immune evasive variant, though previous breakthrough infection provided protection, which bodes well for the effectiveness of the new booster based on XBB.1.5 of note Some isolates of BA 2.86 appear to have picked up an advantageous mutation L455S which led to its distinction as a new sublineage.

 

Dr. Osterholm: Some results show it has even higher immune evasion capabilities than its predecessor. This rapid mutational evolution is definitely something to keep an eye on, but we cannot jump to conclusions just yet. Again, I come back to that refrain over and over again. I assume that all new variants are innocent until proven guilty, and more often than not, that has actually held true. As for other currently circulating variants, the CDC projections include EG.5, FL.1.5.1 and HV.1 and that they will increase in proportion to the XBB.1.5. I cannot stress enough how important it is to continue to take necessary and recommended precautions for you and to go out and get vaccinated. As unnerving as it is to wait and watch the numbers fluctuate in real time, we know that COVID will never again face an immunologically naive world as it did at the beginning of the pandemic and through much of the first three years. So we live in a much more immunologically protected world. What will that mean? I hope it just means that over time COVID becomes more of a matter of a usual disease that we expect to see in certain times of the year. But right now we're not there yet.

 

Chris Dall: We're going to talk more about vaccines in a moment, but I want to get to an update on long COVID. The CDC last week released the results of its 2022 National Health interview survey in which 6.9% of US adults said they have ever had long COVID and 3.4% said they currently have long COVID. Also, a study reported last week in Nature Cardiovascular Research reported that SARS-CoV-2 can directly infect arteries to the heart, a finding the authors say could inform future research into long COVID. Mike, what do you make of these two items?

 

Dr. Osterholm: Chris, I know I'm beginning to sound like a broken record here, but I want to remind all of our listeners, as I always do when we discuss Long-COVID, that the overall picture behind the long COVID puzzle is still very, very unclear. We welcome this new information. It surely is like the puzzle I talked about earlier, helping to put some pieces on the table, but we still have a ways to go. I'll start by discussing the first paper you mentioned from the National Health Interview Survey. For listeners who may not be familiar with this survey, the National Health Interview Survey has been conducted by the CDC on a continuous basis since 1957. It has provided us with critical health information about what happens in our country. The purpose of the survey is to monitor the health of the United States population through the collection and analysis of data on a broad range of health topics in response to the pandemic. The National Health Interview Survey added survey questions about COVID, including long COVID in 2020 to over 27,000 survey respondents were asked, Did you have any symptoms lasting three months or longer that you did not have prior to having COVID-19? Results from the survey led researchers to conclude that an estimated 18 million Americans have had long COVID and that 8.8 million currently have it. Long COVID was more commonly reported among adults aged 35 to 49, compared to other age groups and more commonly, among women when compared to men. While these results are very important in helping us estimate the number of people impacted by long COVID, I want to address a few important limitations of these data.

 

Dr. Osterholm: The first is that due to the nature of the survey, there was not a comparison group of uninfected individuals that were monitored for new symptoms or health issues that occurred since the start of the pandemic. Remember, all of these people were asked about have you had any symptoms since you had your onset of COVID? So if you didn't have COVID, you were not included in that particular question. Why is that important? Well, because, in fact, people develop new health problems for countless reasons that have nothing to do with COVID-19. And this estimate of 18 million people does not account for that. In other words, we need to compare among the baseline of people. If condition A is occurring at X times or Y times. That's the base upon which long COVID then sits. And what we're looking for is long COVID. Now, increasing the likelihood of having extra Y, and we don't have those data from this particular survey. Additionally, the question did not ask about the severity of symptoms or the impact of symptoms in daily life. So we don't know how many of these 18 million people are experiencing mild, minimally impactful symptoms and how many have had severe life altering cases of long COVID. Despite these limitations, the study still provides valuable information about long COVID prevalence in a relatively representative sample of the US population and echoes the findings of several other long COVID studies that have found that women and middle aged adults are at increased risk of developing the condition.

 

Dr. Osterholm: The second paper you mentioned, Chris, was published in Nature. This was a small study led by a team at NYU that took 27 samples from the coronary arteries and fatty plaque from the hearts of eight people who have died of severe COVID-19. All eight of these patients had previously been diagnosed with heart disease. And of the eight patients, six were men with an average age of 70 years. Each patient also had a minimum of three cardiovascular risk factors. All eight patients had high blood pressure. Seven were overweight or obese. Seven had high cholesterol. Six were type two diabetics. Four had chronic kidney disease and one had a history of cardiac arrest. Ultimately, the researchers found that SARS-CoV-2 viral RNA in the coronary atherosclerotic plaques in all eight of the patients, as well as the macrophages, which are white blood cells that help clear the virus and rid the arteries of cholesterol. In addition to the 27 samples from these eight patients, the researchers also took plaque covered tissue samples from uninfected patients who had surgery to remove fatty buildup from their arteries. They exposed the tissue to COVID-19 in the lab and found that exposing the plaques to SARS-CoV-2 induced a strong inflammatory response, which caused a release of cytokines in the macrophages and foam cells, which is what ultimately leads to heart issues.

 

Dr. Osterholm: I know this explanation of the research is a bit technical, so let me clarify the key takeaways here. The researchers found that SARS-CoV-2 can infect and replicate in white blood cells, leading to an inflammatory response that is known to increase the risk of heart attacks and stroke. And this elevated risk can last up to a year after infection. In additional research that has been done, it has been demonstrated that individuals, up to one year after their COVID case have an increased risk for cardiovascular events. And specifically that is at least seven times higher for COVID related infections than for influenza. We have been observing an increase in heart attacks and stroke with COVID-19 infections throughout the pandemic. This ultimately isn't all that surprising, as I just mentioned, because there are several respiratory pathogens that are known to elevate these risks. But until now, there was no concrete biologic evidence linking COVID-19 to this increase, as the authors of the paper explained. Their findings provide for the first time a direct mechanistic link between COVID-19 infection and the heart complications it provokes. And let me just conclude by saying, though the sample size of the study was small and the researchers only looked at the original strain of the virus, this is still a huge breakthrough in the understanding of long COVID. We need more studies like both of these, and I only hope we can continue to bring you more of these studies on every episode.

 

Chris Dall: As I noted in the intro, the rollout of the updated COVID booster shot has been a bit bumpy and there are a variety of reasons for that. But what I really want to dig into is this Kaiser Family Foundation survey in which only 23% of us adults said they would definitely get the booster and 23% said they would probably get it. In addition, fewer than 40% said they will get their children vaccinated against COVID. Mike, do these numbers concern you?

 

Dr. Osterholm: Like you said, Chris, the last few weeks of the vaccine rollout have not been perfect. And some logistical issues following this shift from government provided to commercial COVID vaccine administration have left many people frustrated and unfortunately unvaccinated. A lot of people depend on places like pharmacies, CVS and Walgreens for these shots. And when deliveries are delayed, then doses become limited and the appointments get canceled. I was one of those victims. You have cancellation having two consecutive appointments canceled at the last minute because of a lack of vaccine. I'm happy to report I do have my vaccine now tacked on with the insurance issues and barriers to receiving pediatric doses. Yes, the rollout could be called bumpy. While acknowledging these logistical roadblocks. However, I believe the growing pains are temporary and access to those who want the vaccine will soon readily be available. Number one, insurance issues are working themselves out rather than the 100,000 people a day early in the rollout who went to a pharmacy to get their vaccine per their appointment and only found out when they got there that there hadn't been a code entered into their insurance company's forms in such a way that the pharmacy could say the cost of the vaccine is covered. People were told they had to pay $150 to get the vaccine. Many people couldn't afford that. Obviously, that was not helpful. The same thing is true even with the pediatric issue.

 

Dr. Osterholm: People are scrambling to find the pediatric vaccine right now. And what happened was, is the two major manufacturers, Moderna and Pfizer, reasoned that the highest priority groups to get vaccine would be the older adults. They're surely at the highest risk of serious illness, hospitalizations and deaths. So the first several weeks of the rollout were all adult vaccine doses, no pediatric doses. They just started literally coming out of inventory and are being now moved into the community. In the past week. So hopefully that'll change, too. And I'll comment on that in a moment about children and what that means. So based on this, let me just say that the Kaiser survey sheds light on the real hurdle to booster coverage, which is acceptance, assuming that those who responded probably to the survey actually get it. And that still means that under 50% will receive the vaccine targeting currently circulating variants. The virus is constantly evolving and new sublineages are emerging related to Omicron, as is evident with Bar 2.86. And it's unfortunate that more people wouldn't want to be optimally protected against severe disease, hospitalizations and deaths. What is most concerning from this survey is the shockingly low amount of parents reporting they will seek a booster for their children, even though kids are generally less likely than adults to have severe COVID symptoms.

 

Dr. Osterholm: Those with comorbidities like asthma, obesity or genetic conditions may not fare as well as their classmates. And even having said that, over the course of the last month, we've watched the number of hospitalizations in this country for children four years of age and younger go from about 280 children hospitalized in that age group on any given day to now over 1200 kids. And what was really most striking is that one half of all these kids had no identified risk factor like those I just mentioned. So while we're surely concerned about children who have underlying risk factors for more severe disease, we're also seeing right now that half the deaths are occurring in kids with no underlying disease. That would give you a hint or a strong urge to get your child vaccinated. And let me just point out, as I did in the last podcast, that the number of children under four years of age in this country that are dying from COVID far exceeds that which we see during influenza seasonal occurrence where we expect to see children under age four dying. So it's for that very reason. I do believe we can strongly support getting these kids vaccinated, particularly under age four, much like we do with influenza. And for those out there who are saying kids don't need this vaccine, there are several. Well, clinicians in our country who are on the media stump off and saying, well, kids don't need to get it.

 

Dr. Osterholm: Well, how do you then level that with your recommending they get flu vaccine, which actually is causing less severe disease. Why would you not recommend this? So I think this is a very, very important point. And the fact that the Kaiser study demonstrates that parents are not putting a priority on getting their kids vaccinated, particularly under age four, I think is really concerning. I would also like to briefly discuss an issue raised in a recent article in the New York Times concerning individuals in nursing homes and long term care facilities. It is well established that those in advanced age are most likely to die due to COVID related complications and therefore have the most to benefit from a vaccine protecting. Against severe illness. However, the recent rollout has revealed two key issues for this group. The first is that they were not prioritized to receive the vaccine before the general public, leading to delays and in some cases significant delays in an already vulnerable group. The second is that many nurses and aides working in these settings have hesitancy towards another round of boosters now that they are not required for their work. The combination of these results pose a great threat to nursing home residents, which again, Chris, is very, very concerning.

 

Chris Dall: That brings us to this week's query. We've received emails from several listeners who said they've experienced flu like symptoms following COVID shots and want to know why this seems to be more common with the COVID vaccines than other vaccines. So let me back up a little bit here and ask this question Are these post-shot symptoms more common with the COVID vaccines than with other vaccines?

 

Dr. Osterholm: Chris, this is a great question and one that is at the front of everyone's mind with this new booster now available. Many of us have experienced these flu like symptoms after getting our vaccines or we know someone who has. While these side effects are certainly unpleasant and can make getting a booster somewhat inconvenient, they're not a sign that the booster is unsafe and are certainly not a good reason to avoid getting this additional dose. Personally, of all the people I know who have had that sore arm feeling achy in bed for a day, it's been for a day, and I'm not aware of anyone who has been bedridden for days, which would be exactly what they might expect with either their COVID or influenza case. A review article published in August 2022 examined the risk of systemic adverse events across 19 vaccine studies, including five types of vaccine when grouped by type pooled relative risk of experiencing fever, fatigue and headaches after immunization compared to a placebo was significantly associated with the mRNA vector and protein subunit vaccines. There was not a significant difference between inactivated and DNA vaccines and their respective placebo groups. As I mentioned earlier in the episode, the Pfizer, Moderna, COVID vaccines use viral mRNA to elicit an immune response. I think we all pretty well know that this approach differs from other vaccines, which historically rely on inactivated or vector viruses to introduce your body to the antigen that you are being protected against. The difference in mechanism could be the reason that more mild to moderate inflammatory reactions are being reported with COVID vaccines. These symptoms are related to how your body responds to a threat and the immunologic memory it creates after exposure.

 

Dr. Osterholm: I've been hearing the question Why would I get a vaccine if the side effects of the vaccine are worse than the symptoms I experienced from getting infected? And in fact, results from a study that was published in vaccine this past week show that the side effects were the second most commonly cited reason for not getting a booster. 31.5%. Only behind those who responded, they did not need one because of a previous infection. 39.5%. But I want to remind our listeners that the side effects we're talking about here are mild symptoms chills, low grade fever, fatigue, headache, not major safety concerns. These symptoms generally resolve, as I noted, within 12 to 24 hours after onset. The symptoms you experience with a COVID infection could last for days, months. And as we've unfortunately talked about with long COVID even years. We're learning more and more about long COVID. And as we discussed earlier, there's really no way to know for sure who will experience severe and or long term symptoms from a natural infection. We do know the vaccines can help reduce the risk of developing long COVID. I know that many people, including some in our podcast family, are hesitant to get their boosters because they are too busy to take a day off of work or other responsibilities due to potential side effects. I want to remind everyone who is in this position that you are really much, much better off taking one day off due to a side effect than a week or multiple weeks off due to getting infected, which could result in long COVID serious illness, hospitalizations or even deaths.

 

Chris Dall: Now for one last item on vaccines. There was some news this week about the Novavax COVID vaccine. And I know a lot of people in our listening audience are interested in that vaccine. What can you tell us, Mike?

 

Dr. Osterholm: We've had a lot of listeners asking about the Novavax vaccine over the last several weeks. And just two days ago, the FDA announced and the authorization of Novavax's updated COVID-19 vaccine for those 12 years of age and older, similar to the new Pfizer and Moderna vaccines, the updated Novavax vaccine targets the XB 1.5 lineage of the virus. The Novavax vaccine differs from other available COVID vaccines in that it is what we call a protein based vaccine rather than an RNA vaccine. There's been a lot of misinformation about mRNA vaccines circulating online, so it's possible that some individuals who are hesitant to receive a vaccine made with mRNA technology may opt to receive the Novavax vaccine due to its different mechanism of action. It's notable that the common vaccines we use today, for example, shingles or hepatitis B or papillomavirus, HPV, are all vaccines made with the same technology approach that we see with the Novavax vaccine. So hopefully this gives people a sense of why they might take this. If they were somehow persuaded they didn't want to get it because it was an mRNA technology prior to this authorization, the previous Novavax vaccine was only recommended to those who were unable or unwilling to receive an mRNA vaccine, whereas this updated booster is available to everyone who is more than two months out from their most recent booster or dose of vaccine. The same is true for Pfizer and Moderna new doses of vaccine. We've had several listeners ask which vaccine they should get once all three are available for children under the age of 12.

 

Dr. Osterholm: Pfizer, Moderna are the only available options, as Novavax is not authorized for this group. As for the rest of the population, we don't have much data as to which of the three vaccines will be most effective and or provide the longest lasting immunity. I will tell you, however, amongst many of my colleagues who are very, very smart on this topic in terms of immunologic response, actually have sought out, first an mRNA vaccine dose and then follow on with a Novavax vaccine dose because of what it does to expand the immune response. Now, this is not an official recommendation. I don't want anybody to go and say, well, why did the ACIP not say this? I'm merely sharing with you what many of my colleagues have said. Based on those discussions I've had with my colleagues. I wished I had had an opportunity to get my most recent dose of vaccine as a Novavax vaccine. But unfortunately, I didn't know when it was coming out and I had the opportunity to get it two weeks ago. So I did. In summary, we'll keep you updated as soon as data becomes available on the vaccine and what it looks like in terms of its usage in the community. But for now, the most important thing is getting your dose of vaccine as soon as you possibly can.

 

Chris Dall: Now to some other infectious disease items. Last week, the Who's Flu vaccine strain selection committee recommended switching from quadrivalent to trivalent flu vaccines, primarily because one of the Influenza B strains that circulated widely around the globe has not been detected since March 2020. So, Mike, if you're a listener in our audience wondering what this means to me, what is the significance of this?

 

Dr. Osterholm: I first have to say that as a scientist who has studied influenza vaccines for almost 35 years, I also have come to learn nothing should surprise you about what these viruses do or how they do it. And so while I would not have predicted four years ago that the Influenza B strain Yamagata would just disappear, it's not one that at the same time is surprising. This what happens between the microbial ecology of all these viruses and the various human and animal species that get infected by them make for a very complicated and sometimes unpredictable situation. Let me briefly go through where we're at today with influenza vaccines. Our current flu vaccines, which are what we call quadrivalent, meaning four or a four strain vaccine, contain two influenza A and two influenza B strains. The two Influenza B strains are Yamagata and Victoria and have circulated in inconsistent patterns for years. One clear pattern, however, is that the Yamagata strain started to decrease in prevalence after it caused a large outbreak following the 2017 2018 season. In the years leading up to the pandemic, there had been very few cases of Yamagata detected, and since March of 2020 there have been no naturally occurring Yamagata lineage viruses confirmed. The virus does not circulate in animals. It is unlikely to be circulating in humans, and there is real speculation that the strain is close to extinction.

 

Dr. Osterholm: There's been a lot of speculation about why the Yamagata lineage has seemingly disappeared. Some believe that it was driven extinct due to the non-pharmaceutical interventions implemented during the first few years of the pandemic, including masking and social distancing. Although, as you've heard me say time and time again, I don't think non-pharmaceutical interventions had much impact on almost anything. It surely didn't on COVID. Look at how widespread transmission was during those three years. So I don't think that's it. Now, the one area that we do think that could have played a role is what we call viral interference. I've talked about that before here, where when a dominant pandemic virus takes over, even if it's not in the same family of viruses as what might otherwise be seen like influenza, it can surely have a major impact on the prevalence of that virus in that community. And this is why we've seen during the past four years, and particularly during the peaks of the surge activity with COVID, almost a total absence of influenza in humans across the board. So at this point, I can't explain what's happening. The W.H.O. is taking steps right now to be up front and transparent.

 

Dr. Osterholm: And their strain selection committee, as you mentioned, has recently voted to recommend changing our seasonal influenza vaccines. The recommendation is that these vaccines drop the Yamagata lineage and switch back to trivalent vaccines, which is what they were prior to the shift to quadrivalent vaccines in 2012. There are a few reasons for this decision. First, it is unnecessary to vaccinate for a strain that is not circulating and may never circulate again. Second, there is the unnecessary risk involved with manufacturing a strain that no longer circulates in order to include it in a vaccine. And last but not least, is the fact that why spend the money on an additional vaccine virus strain when it's not going to provide you with any protection as far as the public health implications of all this news? It really isn't cut and dry. Researchers from the Netherlands Institute for Health Services Research published a preprint on this very issue and hypothesized that we may see a shift in the age distribution of Influenza B infections. Considering Yamagata tended to infect adults and Victoria tended to infect kids. It's also not clear yet exactly how much of this will complicate things for vaccine manufacturers, since it will depend on whether or not they still have licenses for previous trivalent formulation. As many low and middle income countries still use trivalent vaccines anyway, so they will not see any impacts with this change.

 

Dr. Osterholm: The messaging of the shift from the quadrivalent to the trivalent will need to be done carefully so as to not cause widespread public distrust in our vaccines and ultimately drive down even more vaccine uptake. And Chris, while we're on the topic of flu, I just want to update our listeners to what's happening with flu activity in the US. We're still seeing very little activity with only 0.9% of influenza tests in the US coming back positive last week, which is consistent with what we've been seeing over the past month. With such little activity, it is still not time to rush to the pharmacy to get your flu shot. I know it might be tempting and convenient to get your flu shot at the same time as your COVID additional dose, but unless that is your only opportunity to access a flu vaccination, it's best. Better to wait until we start seeing flu activity. Remember, influenza vaccine effectiveness wanes with anywhere from 2 to 12 percent reduction per month following its actual receipt. And so getting your vaccine now means you'll have less protection if the flu season doesn't start until late December, January or even February.

 

Chris Dall: We try not to spend too much time on politics in this podcast, but if you pay attention to US politics, you likely know that Congress narrowly averted a government shutdown last weekend, which would have had an impact on federal research agencies. Still, this issue is going to come back up in November, and many scientists are concerned about the potential for deep cuts to agencies like the National Institutes of Health. Mike, what kind of impact could budget cuts to NIH or other federal research agencies have on public health?

 

Dr. Osterholm: Chris. You know, I feel like the scientific community and particularly the public health community right now is watching five different Category five hurricanes all barreling down on the same spot. And it is going to be a very, very difficult time ahead. I say that because, first of all, we have, as a country and many parts of the world in the same boat lost any real acceptance and trust in science, something that is so critical to making public health recommendations and driving the kinds of research activities that can give us the tools to reduce the impact of these infectious diseases. It is unclear what's going to happen in Washington right now. You know, I've served roles in the last six presidential administrations. I've always been just a private in the public health army, helping however I could without any kind of political persuasion or advocacy. And so take my comments in that light. I've never seen anything like this, nor have most of my colleagues. The dysfunction right now in Washington, particularly on the Hill and particularly in the House of Representatives, is such that none of us know quite what's going to happen. I mean, earlier this week, we saw for the first time in the history of the country, a speaker of the House voted out by basically his own party. This is a challenge to try to get programs through when you'd rather spend time talking about impeachment hearings or dealing with issues that have nothing to really do to protect the public's health or in general, the overall health of the public? You know, I've had an opportunity to talk to several people I respect very, very much who spend their entire lives in Washington, on the Hill or at the White House advocating for public health.

 

Dr. Osterholm: And one said to me, you know, basically the bad news is that the chances are dwindling that research agencies will see any budget increases that President Biden had requested in the 2024 fiscal year beginning in October 1st. And in fact, I think the sense is that most agencies are going to fare much worse by the time the dust settles. And this will be some kind of a give and take around the negotiations on resources for both Ukraine and the border versus funding what that has been promised at this point, I think we could expect big cuts, in fact, to the basic research agenda and public health programs. So, you know, without pointing fingers or suggesting one party is involved with making this all happen, I just want to say that any time you have this level of dysfunction, it can't be good for the kind of activities that we promote from a public health standpoint, being prepared, you know, anticipating, trying to prevent disease from happening, not having to treat it. And I think right now, this is not this is not a time where that is a valued commodity in a large part of Washington, D.C..

 

Chris Dall: Finally, your friend, Dr. Peter Hotez, a name that most in our audience will likely recognize, has a new book out called The Deadly Rise of Anti-Science: A Scientist's Warning. Mike, do you share his concerns about the rise of the anti-vaccine movement, and do you think there are ways to combat it?

 

Dr. Osterholm: You know, Chris, I have to acknowledge right up front because in a sense, you could say it's a form of disclosure and surely reflects my bias. But Peter is a very, very dear friend and a colleague that I so deeply, deeply respect. And, you know, you mentioned his book that just came out, The Deadly Rise of Anti-Science: A Scientist's Warning. And one of the blurbs on the back cover of the book is from this guy at CIDRAP. And my exact words are vaccines are a critical public health tool in preventing life threatening illness and death. Their use and life saving impact are now seriously threatened by the deadly rise of anti-science. Hotez provides a front row seat to the unfolding infectious disease catastrophe we are facing. He delivers a clarion call to action like no one else can. I believe those words so, so very much. Peter has been a leading voice and not just a voice, but the leading voice around this issue for some time. And as a result of that, he has been subject to many very, very unpleasant situations, including a variety of death threats. The issue of, you know, anywhere he goes, he is subjected to unfortunate behavior.

 

Dr. Osterholm: And really, it's all about the idea of what have we learned about anti-science and why does it happen and what are the factors that we might address that would minimize that. And Peter lays this all out in the book. I would urge people to read it. I think that it will ultimately become one of the standards of public health over the years to come. I think people will be reading this book 10 to 20 years from now. And from that perspective, I highly, highly urge you to take a look at it. Again, the title is The Deadly Rise of Anti-Science: A Scientist's Warning by Dr. Peter Hotez. And I can just close by saying I have been blessed to have him as a dear friend and colleague. He and I are part of a small group that gets together every week and we have throughout the entire pandemic. We've not missed helping each other understand where we're at in the pandemic. What are the key scientific issues? What are the challenges? And there is just nobody finer in that perspective than Peter Hotez.

 

Chris Dall: And just to note for our listeners, our CIDRAP News reporter Mary Van Beusekom recently interviewed Dr. Hotez about the book and that interview should be up on the CIDRAP News website shortly. Now for This Week in Public Health History. Mike, you dedicated the podcast this week to the two scientists who won this year's Nobel Prize in Physiology or Medicine for their work on mRNA vaccines. And I understand for this segment we're going to talk about another Nobel Prize winner.

 

Dr. Osterholm: Yes, Chris. In fact, for the second installment of our new segment this Week in Public Health History, we have chosen to highlight the annual announcement of the winners, the Nobel Prizes in Physiology and Medicine, which typically take place in early October. Though there are hundreds of laureates who have been nominated over the years for their amazing work. This week we'd like to especially feature the 1997 winner, Dr. Stanley Prusiner, for his work identifying the prion as the cause of scrapie and Creutzfeldt-Jakob disease. Dr. Prusiner is actually a friend of mine and his outstanding work has led to a more robust understanding of these etiologic, unique illnesses. Of course, that's playing heavy here right now in the United States and Canada with chronic wasting disease and cervids, deer and elk and so forth. Again, another prion disease. Since then, many, many millions of dollars have been dedicated to prion research and diagnostics, allowing further innovation in the field. And hopefully this trend will continue. So I want to salute Stanley for his work groundbreaking. He was up against a lot of naysayers who didn't believe that prions even existed. These, you know, what you would call kind of pre-infection infectious, causing agents. In addition, I just want to jump ahead, you might say, 26 years to today where pioneering researchers continue to produce incredible findings that contribute to better public health outcomes. Without this years awarded work with the RNA, COVID vaccine to which this episode is dedicated, this world may look very different than it does now. Thank you so much to our newest Nobel Prize recipients.

 

Chris Dall: Just a reminder to our listeners that we have not abandoned our Moments of Joy segment. So if you have a moment of joy that you would like to share with us and the Osterholm Update listeners, you can share it with us at OsterholmUpdate@umn.edu. Mike, what are your take home messages for today?

 

Dr. Osterholm: Well, you know, when you do take home messages in a podcast 26 times a year, you have to understand that they're going to probably start to sound a lot alike. At least if they're consistent, they will. And I think this first one hopefully sounds a lot like what you've heard before, but just reinforces that we're still on track with this particular point. And that is, is that things are looking better. We are not back in those first three years of the pandemic where we had such major increases in deaths and hospitalizations and disruption to society. But we don't know what the future is still going to hold for us. I don't think we're ever going to go back to the time where we saw the number of deaths, the number of seriously ill hospitalized patients today. Now, what will happen is the fact that variants will continue to emerge. We're going to have to learn what does that mean? Will this ever really become a seasonal virus? As you've heard me say so many times? The only thing that I think makes this a seasonal virus right now is it occurs in all four seasons. And that from that standpoint, we really don't know how it's going to settle in in this kind of equilibrium with humans where variants continue to be a major point of why this virus does what it does and how we as humans respond to it. So again, things are better. I don't think they're ever going to get that bad again.

 

Dr. Osterholm: But at the same time, we're not completely out of the woods yet. Point number two, please get your vaccine. Get it. And let me just say, while there are some critics out there, some of the talking heads again downplaying using the vaccine and our youngest children, please consider that, you know, this is a real challenge. So get the vaccine. Finally, the long COVID and cardiovascular disease issues we talked about today just point out how complicated this interrelationship between the human world and the virus world of COVID are all interplaying. And, you know, we still have a lot to learn with regard to long COVID and what it means. And I'm hopeful that we're now on a much better track than we were at all in those first couple of years. And I expect to see an explosion of new information coming out in the next 9 to 12 months for those who are suffering from long COVID in ways that it's hard to describe to someone who has not had it. I know saying that there'll be an explosion of information in the months ahead with learning more is some consolation, but not necessarily a lot. You are looking for relief today and all I can say is, is that we hear you. We know that we will continue to follow this advocate for you and just know that you're not alone in this situation.

 

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

 

Dr. Osterholm: Well, this is one that doesn't necessarily tie back to the dedication, which we often do, but rather one that really grew out of discussions within the CIDRAP team. And that is the fact that what really matters to us, why? Why do we find something so important in our life and other things not? And I've chosen a song this week You Matter to Me by Sara Bareilles. We chose this song in light of an excellent article in Scientific American discussing the concept of mattering that who you are as a person matters to others and the impact of whether you believe it. It's shown to be protective against depression, suicide, even incidents of violent and antisocial behaviors in communities. And it can take place with parents to kids, teachers to students, health care workers, to patients, etcetera. So we chose this song, which actually comes from the musical play waitress. And it's a fascinating story. Sara Bareilles wrote the music for this and starred in it. It tells the story of Jenna Hunterson, a baker and waitress in an abusive relationship with her husband, Earl, looking for ways out of her troubles, she seeks a pie baking contest in its grand prize as her chance. This song was played in Act two, was written to her yet unborn child and about it matters. And I hope that all of you can feel this today about what matters and why and how do you spread that so that others know it matters. So here it is. You matter to me. I could find the whole meaning of life in those sad eyes. They've seen things that you've never quite say. But I hear coming out of hiding. I'm right here beside you. And I'll stay there as long as you let me.

 

Dr. Osterholm: Because you matter to me. Simple and plain and not much to ask from somebody. You matter to me, I promise you. Do you? You matter to. I promise you do. You'll see. You matter to me. It's addictive. The minute you let yourself think the things that I say just might matter to someone. All of this time, I've been keeping my mind on the running away. And for the first time, I think I'd consider this day. Because you matter to me. Simple and plain. It's not much to ask from somebody. You matter to me. I promise you. You do you you matter to. I promise you, you do. You'll see. You matter to me. Thanks again for joining us for this episode. I hope like this song. You realize you matter to us. We at CIDRAP appreciate this family so very, very much and the feedback you share with us. I hope that we're able to give you something back in return. I think when the ledger is all finalized, one day we will at CIDRAP have benefited much more from you and what you've done to help support us than we ever did for you. So just know that we are very, very appreciative. You matter. You really do matter. So thank you. And please, over the course of the next few days to a few weeks, get that dose of vaccine and just remember, it matters. Be kind. Be kind. Just once this week, do something kind to somebody for somebody and watch what happens. It's this pandemic of kindness. We want to keep going. So have a safe next two weeks. We look forward to talking to you then and be well. Be kind. Thank you.

 

Chris Dall: 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. If you would like to donate, please go to CIDRAP.umn.edu/support. The Osterholm Update is produced by Sydney Redepenning, Elise Holmes, Cory Anderson, Angela Ulrich, Meredith Arpey and Clare Stoddart.