Episode 148: No Time to Quit

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. As we wade into the new Year, the Rapid rise of SARS-CoV-2, Sub-variant Jan one is reminding us that COVID 19 is still very much with us. Recent data from the centers for Disease Control and Prevention indicate that test positivity is tracking higher than at the same time last year, while wastewater data suggests that we could be in the midst of the biggest wave of infections after the Omicron surge. COVID hospitalizations and deaths are also up. The good news is that hospitalizations and deaths aren't close to what they were during the Omicron surge. Still, with flu activity on the rise and RSV levels still high. There's a lot of respiratory illness out there, and our low vaccination levels across the board suggest we're not doing enough to protect ourselves. On this January 11th episode of the podcast, we'll provide some more detail on what's going on as we dig into the latest data on COVID, flu, and RSV. We'll also provide an update on JN.1. Discuss the low uptake of the COVID antiviral drug Paxlovid, dissect claims made about the COVID 19 vaccines by Florida's surgeon general, and answer an ID query about hospital masking policies. We'll also bring you the latest installment of This Week in Public health history. But before we get started, we'll begin with Dr. Ostrom's opening comments and dedication.

 

Dr. Osterholm: Thank you, Chris, and Happy New Year to everyone. Uh, who is joining us for this podcast. Uh, welcome back to you. I hope that we're able to provide you with the kind of information you're looking for today. Uh, I want to start out by, first of all, just thanking, uh, this podcast family for the incredible, uh, cards, notes, uh, and emails that we received over the past several weeks from you about this podcast, about us as a family and really what you're looking for in the future. This has been a very touching situation for us. And on behalf of all the entire CIDRAP podcast team, I want to thank you for your comments to us and your outreach and goodwill. Uh, it has really been remarkable. We will never forget this. As I've said previously on this podcast, to quote Maya Angelou, you know, people may not remember what you said, but they will never forget how you made them feel. And you have made us all feel as if this is something important. This is something that's helpful. This is something that connects with you. And from that perspective, it's, uh, it means a lot that we're able to share these moments with you. In terms of a dedication this week, I really have considered this in relationship to, uh, what we heard from listeners who wrote in and several listeners actually indicated that the concerns that they had were about those who lived in certain locations or in certain congregate settings, uh, and how well they might be protected against the risk for developing COVID, either because of respiratory protection, vaccine availability, etc..

 

Dr. Osterholm: For example, I'm talking about residential facilities for people with mental illness and other disabilities, group homes for children in foster care, those in elder care, Long Terme care facilities and such as nursing homes, assisted living and semi-independent living, and those who are in correctional facilities who have no opportunity to protect themselves beyond what is provided to them. When we look outside the actual congregate setting that's traditionally considered, we still have homeless shelters and domestic violence shelters, migrant workers housing. There are many migrant workers that we see here in our own state of Minnesota, who live in housing with one another. It is in very close quarters. So today, for those that live there or those that work there, we dedicate this podcast to you and we do hope that you have access to vaccines, to respiratory protection, uh, and the safety of living in a space where you're not sleeping next to someone who has COVID, for example. So we appreciate all of you very, very much. And now, on a lighter note, one that for many of you, uh, this is a bit of a nail on chalkboard kind of moment, but thank you for bearing with us.

 

Dr. Osterholm: For others of you, you actually hold on tight. Uh, today in Minneapolis, uh, sunrise is at 7:49. Sunset is at 4:53 p.m.. That's nine hours and four minutes and 46 seconds of sunlight. Yes, we've gained 18 minutes of sunlight just since December 21st, and we're gaining it now at about a minute and a half every day. On the other hand, our dear colleagues in Auckland at the Occidental Belgian Beer House on Falcon Lane, you today had sunrise 6:13 sunset at 8:43. You have 14 hours and 30 minutes and three seconds of sunlight, but you're losing sunlight at about a minute, six seconds a day right now. Now you've still got a long time of a lot of sun. Uh, and in a few months, though, we are going to surpass you. We'll take the lead, and we'll do everything we can to share our sunlight with you as you're sharing it with us. So again, welcome to everyone to this podcast. I hope we're able to provide you with that information you need and are looking for. Needless to say, uh, these are times where unfortunately, I think there are more questions than there are answers, and I'll try to do my best to distinguish between what we know, what we'd like to know, and what we don't know.

 

Chris Dall: So let's start with the latest COVID data. I gave a very brief summary of the situation in the intro. But Mike, can you expand on what we're seeing here in the US and what we've been seeing for the past few weeks? And is this what we're seeing in other parts of the world?

 

Dr. Osterholm: Well, let me just start out by saying, as an epidemiologist, our ultimate four letter word that is found to be very important is our data. We love data. That's how we are able to make the kind of analyzes and draw the kinds of conclusions we are about, for example, the risk of disease in a community or how possibly to interrupt transmission of a virus, etc.. I wish I could say we have lots of data. We don't. Today I can tell you, though, that it's my personal experience and that of many of my colleagues and friends, that there is much COVID in our communities right now, as we've probably seen it any time in the pandemic. That includes even the days of Omicron. It is simply remarkable what's happening. But as you noted Chris in the introduction, we are not seeing a situation where we have high levels of hospitalization, serious illness and deaths. Yes, they're occurring, and I'm going to talk more about those. But at this point, that actually is a good news outcome of where we're at. But how do we make sense of all this? You know what is happening. Let me just repeat something I've said many times on this podcast over the past six months. We are not going to go back to the days of 2020 to 2022-early 2023, where at that time in the pandemic, large surges in cases often meant also large increases in the numbers hospitalized and the number who died.

 

Dr. Osterholm: That is not where we're at today, but we still have a challenge, a real challenge, because we are still seeing a burden of illness that I think is absolutely unacceptable. So let me just try to walk through this and and give you a sense of where I think we're at. So let's start out with the understanding that there's a lot of COVID out there with that. There's been talk and headlines about the US being in the midst of the second largest COVID wave since the beginning of the pandemic. And while there is no arguing that we're in the midst of a surge, it's tough to really know exactly how big it is given the limited tools we have for tracking and deciphering activity. Remember, we have virtually dismantled all of the surveillance systems we had in place throughout most of the pandemic. Frankly, most of the conclusions that we're drawing right now about the increase in cases in the community isn't really necessarily clear, because it relies on one single indicator, and that is wastewater data surveillance. This has become the surrogate marker to say how much activity is occurring in our communities. So having said that, while wastewater data are by far the best data sources we have, I'm not sure it's a really reliable quantitative indicator. In other words, what is telling us is how many copies of the SARS-CoV-2 virus there are per milliliter of sewage tested, but translating it into case numbers, hospitalizations and deaths gets murky, especially when you start to look across different jurisdictions and consider that different methodologies that have been used to measure the amount of virus in the water, and even the possibility that some variants have more gastrointestinal involvement, that actually could complicate the comparisons.

 

Dr. Osterholm: I believe that's exactly the case with JN.1, where we've seen substantial increases in diarrheal type illness associated with that could, in fact, the increases we're seeing in the levels of virus activity in wastewater just be a reflection of more being excreted from any one individual case. So at this point it's not straightforward. We're not sure how to interpret it. But with that in mind, when you look at the latest wastewater data published on the CDC's website, you can see that activity has continued to go up and up and now sits at levels that are the highest reported since the initial Omicron surge almost two years ago. On a regional basis, the highest concentrations are in the Midwest, followed by the South. But overall, nationally, levels are considered to be very high. But what can we say about the JN.1 variant? First, I do think that there's a really potentially much more virus in the waters just because of increased excretion. So that says maybe the cases aren't as high in numbers. But again, as I shared with you, at least personally, many of us know a lot of our friends, family and colleagues who have been infected in recent months.

 

Dr. Osterholm: So for whatever that means, I don't know other than to say that when you look at what's happening in the US with hospitalizations and deaths, both of which have continued to increase, there are real concerns here. For example, nearly 35,000 Americans were admitted to the hospital with COVID the week of December 30th. That's the eighth consecutive week of increases, marking a streak that began in early November when weekly admissions stood around 15,000. So now we're at 35,000. In early November, we were 15,000. At the same time, deaths have continued to climb. Exceeding 1600 a week as of early December. That translates to 228 deaths a day. That's 228 loved ones, 228 sons and daughters, mothers and fathers, grandfathers and grandmothers. And that's happening every day. And you will surely see that those numbers will increase substantially. As remember, there's a delay in getting death data reported to public health agencies. So I'm giving you information right now, literally from early December. I think, given the increased occurrence of hospitalizations and cases in the community, by the time we get the early January data, which will be later this month or early February, these numbers are going to be even a lot higher than they are now. And in addition, we've now had 18 consecutive weeks with death tolls above 1000. Another terribly unfortunate trend, to say the least. So clearly this virus isn't done with us and the message is being lost on people.

 

Dr. Osterholm: Right now, less than 1 in 5 adults in this country have received a dose of the updated vaccine, a vaccine, which I'll talk more about later. But just to give you the punchline now, it seems to be working very well in terms of preventing serious illness, hospitalizations and deaths among those who are exposed to the JN.1 variant. Why is it in nursing homes with just 37% of the residents in this country, less than 2 in 5 have received this particular new dose? And why is it among those in Long Tum care facility who work there that we're seeing, in many instances, less than single digit numbers of people vaccinated in those facilities? This is really a challenge. And again, make no mistake, this is still very much a global issue. Lots of other countries are dealing with situations similar to what we're experiencing here in the US. We've been tracking surges happening in places like Canada, Mexico, Austria, Denmark, France, Italy, Spain, the Netherlands and a whole host of other places. Each of them has observed a rise in infections, at least based on indicators like wastewater data and a subsequent rise in hospitalization. In fact, in countries like Austria, Denmark and the Netherlands, wastewater levels recently reached the highest levels reported since the start of the pandemic, and in some cases, these surges have taken a real toll on the health care settings. Last week, there were reports of hospitals in Rome that were virtually on the verge of collapse, with more than 1100 patients waiting to be admitted.

 

Dr. Osterholm: So there's a lot happening. Even in the southern hemisphere, there are similar trends. Places like Brazil, Chile, New Zealand, Australia and others have been dealing with notable surges, which goes against the notion of seasonality being the primary driving force. You've heard me say that many times, remember, it's their summer right now in the southern hemisphere. At this point, I think we're still trying to decipher exactly what role Jn1 is playing in these surges. In particular, I want to know what will happen in places that seem to experience surges. Just before JN.1 became dominant, including countries like Canada and Sweden. Will they see things start to go back up again? Will it lead to a plateau and declines? At this point, I just don't think it's clear. So as we enter year five with COVID, we still have a lot to figure out. But there is one set of data that I believe we have to focus on today, and that is one that says, how can we address these serious illness, hospitalizations and deaths? Let me just remind everyone of data that we've shared on multiple occasions on this podcast in November 2023, which is the most recent data available from the CDC, the incidence of COVID 19 deaths in those 75 years of age and older was 18 per 100,000, just 18 per 100,000. This is over six and a half times higher than the incidence of death in those 65 to 74 years of age, which was 2.8 per 100,000.

 

Dr. Osterholm: In those 39 years of age and younger, COVID death incidence was less than 0.1 per 100,000. So just comparing those 39 years of age and younger, where the COVID death incidence was less than 0.1 per 100,000 for those 75 years of age and older was 18 per 100,000. That should give you some sense where we're seeing the biggest impact on this disease. Throughout the entire pandemic, over 54% of deaths have occurred in those 75 years of age and older, 22% occurred in those 65 to 70 years of age, 18% occurred in those 50 to 64 years of age, 4% occurred in those 40 to 49 years of age, and the remaining 2% occurred in those 39 years of age and younger. Clearly following Willie Sutton's very wise advice. Why do you rob banks? Because that's where the money is, if you want. To see a major reduction in serious illness, hospitalizations and deaths. This is the group that we need to get vaccinated. Remember that this vaccine that we're talking about, the most recent dose, is actually quite effective in reducing the serious illness, hospitalizations and deaths. So when people are trying to put their risk picture into perspective, what is my risk and my community? The age issue is surely a major challenge, and that's where we've got to really be focusing at this time.

 

Chris Dall: So let's dig in a little more on Jn1 and its most recent variant proportion update. The CDC said Jn1 now makes up 61.1% of US virus samples, up from 38.8% just two weeks earlier. So it's clearly picking up steam and it appears to be picking up steam around the world. Mike is JN.1, the most infectious of all the Omicron subvariants.

 

Dr. Osterholm: The estimates you're talking about. Chris, do show that JN.1 is dominated in the US in a way that none of the other Omicron variants did, and I think it surely has something to do with the actual variant itself. But I think it's also coming at a time when the immune status of our population is changing. What do I mean? Well, first of all, we know that the BA 2.86 family is highly mutated compared to other circulating Omicron variants, which is what got JN.1’s foot in the door and allowed it to really take hold. Remember. BA 2.86 family is where JN.1 emerged from, and that was the one that was driving transmission through the latter part of the summer into the fall in a number of areas. Now JN.1 has taken off. Specifically, recent studies show that the spike protein mutations are linked to cell entry and immune evasion. It is well established that these variant features add up to a considerable amount of pathogenic potential, and has a very clear growth advantage over other variants. So yes, I do think that this variant is very important, but I believe that the sharp rise of JN.1 and the accumulation of cases has been exacerbated by the fact that Americans are now severely under vaccinated when it comes to the updated vaccine.

 

Dr. Osterholm: And those that were infected were often infected at least six months or more ago, where their immunity that occurred as a result of having been infected also is waning. So the coverage right now is such that for any variant to emerge onto the scene, it's coming into a much more susceptible population in terms of protection. So what I think we can conclude is the combination of JN.1 and its unique properties, as well as the fact that it is now occurring in this ever increasing, reduced protection population, meaning that you're just seeing more waning immunity. So I think it's a combination of both, and it's clearly not going to go away as a variant. And our immunity is not going to get better unless one you get vaccinated with this particular new dose or you just get infected, which we surely would like to avoid. So right now it's clear that of all the Omicron variants, JN.1 is surely our biggest challenge to date. And where it's going from here, none of us really know.

 

Chris Dall: Eric Topol, who most of our listeners are probably familiar with and whose work we've cited on the podcast, previously, said in a recent op ed for the LA times that the number of mutations on JN.1 should have warranted the W.H.O., declaring it a variant of concern rather than just a variant of interest. In fact, he said, it should probably have its own Greek letter. Mike, do you agree? And would that have any practical effect?

 

Dr. Osterholm: Well, let me just start by saying that there is no one that I have worked with throughout this entire pandemic who I have more respect for in terms of their understanding of the virus and what it's doing to our population, than Eric Topol. He is a Renaissance scientist. He is a a wonderful, wonderful colleague. I don't go a week without having extensive conversations with him, and I feel very, very fortunate in that regard. I've learned a lot from Eric, and in terms of his conclusion about the, uh JN.1 variant, I do think he's right. Uh, you know, I think it's fuzzy as to what is this issue of a variant of interest versus a variant of concern. Uh, can it cause more illness? Is it more severe illness? What does this all mean? And while it's not clear at all that there are JN.1 is producing more severe illness, I don't think that's the case. I think it is like Omicron in that there were so many more cases that even if a much smaller percentage of the individuals who get infected become seriously ill, that's a big number. And I think that's what's happening right now. So, yes, strictly speaking, JN.1 does not meet the 2023 updated W.H.O. guidelines for a variant of concern, which means it has to show that it's producing more severe disease. It's overwhelming existing health care systems or it's significantly evading immune induced immunity. And so at this point, I think it's on the edge. But I think we're really arguing about how many angels can dance on the head of a pin. As far as I'm concerned, we have not seen a variant like this one.

 

Dr. Osterholm: And what it really is telling us, I think, is that this whole experience with SARS-CoV-2 is going to continue into the future as long as new variants emerge. We've already talked about the issue of seasonality. Uh, anybody that tells you this is a seasonal virus is simply not true. Don't trust them on anything else they tell you. If you look of the nine peaks that we've had throughout this pandemic, in terms of case numbers, all of them, except for the very earliest ones, were in fact tied to new variants, meaning that they came forward with an ability to increase transmission or to escape immune protection. And each one only has gotten more skilled at doing that. So I don't know what the next variant is to emerge. And will it occur in the summer? Will it occur in the fall? Winter? I don't know, but I think we're going to have to learn how to use vaccines more effectively to, in fact, provide that 6 to 8 months of protection against serious illness, hospitalizations and deaths as the current dose of vaccine does against JN.1. The big challenge, of course, which we'll talk more about in a moment, will people take the vaccines? You know, vaccines that don't turn into vaccinations are useless. What good are they until you turn it into a vaccination? So I think, uh, listening to Eric Topol is the best thing anyone can do, uh, in trying to navigate what's happening with, uh, COVID. And I am one of those, uh, who feel very fortunate to have, uh, literally had the master, uh, as my teacher.

 

Chris Dall: So we've talked a lot about low uptake of the updated COVID 19 vaccines. But a recent preprint study by the National Institutes of Health and were treated with the antiviral Paxlovid, had a 26% reduction in hospitalization risk and a 78% reduction in mortality risk 28 days after infection. Yet among the more than 1 million patients included in the analysis, only 9.7% received the drug. So, Mike, why are so few people taking advantage of Paxlovid?

 

Dr. Osterholm: Chris, this is really one of the most unfortunate situations, uh, in the COVID pandemic is the ability to actually have effective antiviral drugs, but they're not getting used. You really need to look at this in two parts. One, I think is a lack of understanding, particularly among the medical community, as to what this particular drug can do. And you noted the data in the study that was published by the NIH showing, you know, the reduction in hospitalization risk, reduction of mortality. Uh, we have additional studies that show the reduction in, uh, long COVID development, etc. we also have a lot of data showing the safety of this particular, uh, antiviral. One of the areas that I have been very frustrated by is the number of physicians who don't yet understand how effective this drug can be and who have often misled patients. And I don't believe intentionally, but they have misled patients into believing, oh, don't get it, you'll just get a rebound illness from it. Which again, we have data showing that's not true. And I think that that's been a real problem. I know of so many of friends and colleagues who have spent hours, if not even several days, trying to secure Paxlovid from their health care, uh, provider when they were diagnosed with COVID. And the health care providers saying, well, you don't really need it. You don't need it. You're not someone at risk of serious illness. So I think this is a real challenge.

 

Dr. Osterholm: We have to do a lot more work to educate our medical community. Let me just summarize very briefly in New York Times piece that just appeared, uh, by Christina Jewett. That does a really good job of picking apart this issue and summarizing the study you mentioned in your question some of the factors contributing to the low treatment uptake that she brings up include the doctors being hesitant to prescribe it because of an extensive list of medications that cannot be used with Paxlovid. But let me tell you that, in fact, is not a big list. When you look at the kind of drugs, for example, statins, that has been often cited as a drug where you can't take Paxlovid when you're on a statin, you're absolutely right. But everyone can drop taking their statin for seven days to take Paxlovid. That is not going to be a medically challenging situation, and so don't use that as an excuse. And there are other drugs that can be used if in fact, you have a true legitimate drug interaction issue. Another key issue is the timeline for prescribing and taking Paxlovid, meaning that people often don't seek it out until their symptoms get worse during their infection. But once they do, it's too late into the infection to be effective. You really need it in those first five days. So we have a lot of work to do in terms of educating people about if in fact they do develop COVID, you should seek Paxlovid immediately.

 

Dr. Osterholm: One of the other issues may be in play include the price. And will the government be providing the drug in the future? There are still a lot of doses throughout the entire United States of this drug that have been purchased by the US government, that is still available at no charge to anyone. It's important to know. Yes, eventually this drug is going to become part of the standard pharmaceutical benefits packages, uh, available only through insurance or private pay. And that, in fact, is going to be a challenge. But right now, that's not the issue. Finally, let me just say it. And I've talked about this, these so-called Paxlovid rebounds because rebound cases can happen with or without Paxlovid. And when you look at the data, in fact, it was exactly the same in several studies. Those who had a rebound after Paxlovid and those who had it by never taking it. So I really think that is an important issue to keep stressing to our medical care providers. Those who are at highest risk of serious illness should be on this immediately. Those who are younger, under age 39 who want to avoid an increased risk of long COVID, uh, etc.. Yes. In fact, uh, I think that at this point, uh, do get it. And from a safety profile perspective, uh, this is really a very, very important drug.

 

Chris Dall: So as we all know, COVID is not the only virus that's going around right now. So Mike, what are you seeing in the latest flu and RSV data?

 

Dr. Osterholm: Well, let's just put it this way. The infectious disease risk in this world is real, and it is significant. Um, and we surely see that with the respiratory viral illnesses. Good news and not so good news. This year's RSV season appears to have peaked, with cases down 29% from what they were just two weeks ago. Influenza activity, on the other hand, is continuing to pick up across the country the number of states experiencing very high levels of influenza transmission has doubled in the past two weeks, with 21 states and New York City seen very high levels of transmission. 17 states are experiencing high levels of transmission, and 11 states were experiencing moderate or low transmission. Only one state, my dear home state of Minnesota, is still experiencing minimal levels of transmission. We're still seeing a bit more influenza activity in the south compared to the north, but overall transmission is picking up all across the country. And let me be really clear here, while we're seeing this increased transmission occurring, we have just gone through a normal a normal routine expected season for RSV. It wasn't beyond what would be expected on an average basis. And the same thing is really true with influenza right now, uh, we are seeing a major increase in cases, but this is what we'd expect to see.

 

Dr. Osterholm: It's not a big surge. This is why I categorically reject that terme. Triple Dimmick, you know that that whole issue of RSV, flu and COVID simultaneously having these big epidemics. Yes. It's important right now to address RSV and influenza, but they are the traditional seasonal experiences. For example, while the mortality has increased with 0.9% of deaths that occurred in the last week of 2023 being due to influenza, and that is a 2.6% increase from two weeks prior. If you compare it, however, to the peak in the 2019 2020 influenza season, which was the one right before COVID, 1.1% of the weekly deaths were due to influenza, so this is still slightly below that. Sadly, among the influenza deaths that has occurred this season, there are 27 pediatric cases. It breaks your heart to think of that. This is nearly double the number of pediatric influenza deaths that had been reported two weeks ago. But for context, during the 2019 2020 influenza season, a total of 199 pediatric deaths occurred. So our number of 27 pediatric deaths to date is well below that 199. Now, we still have a lot of season to go with influenza, yet it's still going to be out there.

 

Dr. Osterholm: I know that that number of pediatric deaths is going to rise, but I think it will be at a level even lower than we saw in the 2019 2020 influenza season. So what does this all mean? Well, this is what we expect to see with respiratory transmitted viral agents. And I can't emphasize enough that we now have three vaccines that can address all three of these diseases. And while particularly for influenza and COVID, the vaccines are not going to prevent you necessarily from getting infected, they're not going to prevent you from transmitting the virus to others, but they are going to have a big impact on you in terms of the potential for serious illness, hospitalizations and deaths. And that is true even for pediatrics. So I know that these painful, painful pediatric deaths, I wish we could have avoided all of them with routine vaccination of the kids in our communities. So lots of flu RSV is on the way down. None of them are out of perspective of what we'd expect to see in a normal RSV or flu season. But yes, they are occurring simultaneously with COVID and that is a challenge.

 

Chris Dall: Now it's time for the ID query. We recently received an email from Judy in Cambridge, Massachusetts about the masking policy at Mass General Brigham. She provided us a copy of the policy statement from the hospital. But here's how she summed it up. Mgb is not requiring masking, but is requiring those who wear n95s or K n95s to replace their masks with hospital issued masks, presumably surgical, or to double mask a policy of requiring patients to use hospital issued masks. Make some. But to my mind, not a great deal of sense in an environment where masking is required in order to avoid attempts to pass off scarves, etc. as masks. But my favorite local theater was able to enforce quality of mask rules, so I would think medical establishments would be able to as well. Is there any sense, epidemiologically or otherwise, to this policy? And then, Mike, as a follow up to that, we've talked a lot about masking recently on on this podcast, but we still have some listeners who have questions about the protectiveness of Well-fitted, N95s, and Kn95s in an environment where they may be the only ones who are wearing a mask. So in other words, they're wondering if they're the only one on an airplane or in a crowded theater wearing a mask. Does it make any difference? So what can you tell them?

 

Dr. Osterholm: Well, Chris has many of our listeners know we've attempted to address this issue throughout the entirety of this podcast series. And yet the questions continue to come up and and they're good questions. First of all, I want to thank Judy from Cambridge for her question. She is right on the mark. Let me just be really clear again, what is necessary for the best respiratory protection is an N95 respirator that is well fitted tight to your face. N95s can also offer high levels of protection, but it's more variable depending on the N95 you have. As far as what's happening at Mass General Brigham, uh, this has been a terribly unfortunate situation. While this is one of the leading medical centers in the entire world, they are in the 18th century when it comes to respiratory protection, and we have seen them publish various papers and be involved with national groups who have continued to basically not understand airborne transmission of these viruses and for which they believe, for example, that a surgical mask is more than adequate for protection. They even went so far in their recent recommendations to say, if you're wearing an N95 of your own, you must wear a surgical mask over it. Now, the reason they give is that so you don't wear a contaminated N95 into a patient area. Well, you know that that just like any other masking kind of environment, why would you suddenly say, well, you have to put a surgical mask over an N95? Um, I think at this point, uh, we're not going to change an institution like that, but they really are behind in the science.

 

Dr. Osterholm: And so many hospitals are in this country. They continue to emphasize surgical masks. You've heard me tell the story. I've had three different experiences through the pandemic where I went into a hospital, uh, with my N95 on and I was told at the front door I had to take it off and put on a surgical mask. I mean, crazy, there's no real understanding there. So this is a problem. And I want to say that, you know, while a surgical mask may provide some very limited protection, we have published on, uh, what in fact, these different masks can do. And in fact, we'll provide a link on the website here of a paper that Lisa Brousseau from our center put forward several years ago, showing by time, given the equivalent, uh, virus in a room, what all we get from protection of these n95s versus surgical masks, etc., and you'll see that it really does require an N95 to have this protection. So as long as the group at the at the mass, General Brigham, uh, failed to understand uh, airborne disease transmission and how to stop it, I'm afraid we'll continue to see hospitals provide misinformation in this regard.

 

Dr. Osterholm: And, Chris, in terms of the question about masking, I mean, I must say right now that, uh, this is an area that is as much a social issue as it is a science issue. This just this morning, I was at the Minneapolis-Saint Paul International Airport, and I saw no one with any respiratory protection on at all, and it was packed. Now, you can argue that you know these people, or do they realize what they're doing and they're basically have voted with their own decision to say, I don't think it's a high enough risk for me to actually wear a mask or specifically an N95 respirator. And Public Health has learned nothing else in this pandemic should realize that you can make all the recommendations you want, but if the public is not going to participate and support those decisions or those recommendations, they're not going to happen. And so my message is that, yes, N95 wearing all by yourself, particularly if you're at a high risk of serious illness, hospitalizations and deaths can provide important protection even if no one else wears it. If you're the only person on a plane wearing an N95, you will have substantially more protection than everyone else who's not. Even if there's just 1 or 2 people on board who are infected, you will have better protection. And so I think people have to understand that they may be looked at funny.

 

Dr. Osterholm: If they're wearing an N95, they will realize how hard it is to go to a restaurant. Uh, they will go to a family event and say, oh boy, you know, grandpa's got his mask on. I can't see him, I can't hug him, I can't hold him. And that is a real challenge we have today. I would, uh, continue to support anyone who is at increased risk, people who are older, people with underlying immune conditions that you still consider masking. And by masking, I'm talking about an N95. You know, don't just use a surgical mask. It will not provide that high level of protection. You may be looked at funny, but in the sense it's all about protecting yourself. And I think that that, um, we have to just understand that with, you know, 200 plus deaths a day, surely better than 2000 deaths a day, but that is still 200 mothers and fathers, uncles and aunts, grandpa and grandmas that we all wish were still here. That having worn a mask, quote unquote, and N95, that could have made a big difference. I understand it'll be difficult, but it surely is important. Now let me add one additional piece to this. Remember, masking is not the only part of prevention here. It's a critical one, but also being vaccinated. If you're in that high risk group. In particular, make sure you have a dose of the new vaccine that just came out in October.

 

Dr. Osterholm: Right now, it will provide really good protection against serious illness, hospitalizations and deaths. I say that time and time again, get that that then added to masking or not masking. Then add a third level and that is testing. Test yourself before you go somewhere, particularly if there's going to be someone there who is at increased risk for serious illness. This week alone, I know of three different instances where somebody went to a party or a social event of some kind. They had mild symptoms, kind of cold like symptoms. Didn't think twice about it, but by morning they were much sicker and they ended up transmitting COVID to multiple people who were at that event. Now, if they had tested before they went to that event, they might not have picked it up. Maybe it was too early, but they might have, and then they could have stayed home and not gone to that event. And that two can be very helpful. So if you're thinking about getting together with family and you have family members who are vulnerable right now to serious illness, hospitalizations and deaths for them, for their sake, test yourself before you go. We still have tests available out there. That combination of masking, testing and in fact, getting vaccinated still will provide a high level of protection against getting seriously ill and dying from this virus.

 

Chris Dall: Finally, last week, Florida Surgeon General Joseph Ladapo called for a halt to the use of COVID 19 vaccines, citing concerns that contaminants in the vaccine can permanently integrate into human DNA. This is noteworthy because Florida is a large state with a lot of at risk people, and because Dr. Ladapo, his boss, Ron DeSantis, is running for president. Mike, do his claims have any merit?

 

Dr. Osterholm: Well, let me just begin by saying, every time this topic comes up, my blood boils. There is no question in my mind that Dr. Ladapo has committed serious, serious public health malpractice, and I think his advice is going to kill people. And yet he seems unaltered in his attempts to discredit the vaccine and public health in general. This is really unfortunate. Let me be really clear. His claims have absolutely no merit whatsoever. What he has stated is absolute disinformation. There is no evidence that these vaccines can alter your DNA in any way, shape or form the current mRNA COVID 19 vaccines. Though not as effective in protecting against infection. We like them to be have incredible safety profiles, and everyone who says otherwise is seriously, seriously misinformed. I recognize that most individuals that are listening to this podcast are likely not among those who are spreading this type of disinformation, but I still think it's important to address this so that our listeners can have a sense of why these claims are incorrect, and because it may help you navigate conversations about these claims with people in your life who may believe this information or share it on social media. Let's start with the very small piece of truth to this claim, though. These are mRNA vaccines, not DNA vaccines, the way that they're produced can still result in very small amounts billions to trillions of a gram of DNA fragments present in a dose of vaccine. But this is similar to other vaccines that are grown in cells, including chicken pox and measles vaccines, which are not mRNA vaccines. I know the concept of DNA can be intimidating, particularly for those who may not have a scientific background. But I want to be clear that this is not the cause for concern that Dr. Ladapo is making it out to be.

 

Dr. Osterholm: The mere presence of DNA in a product we consume does not impact our own genetic structure. We interact with DNA every day. Just think of the food we consume when we eat a carrot. Does the carrots DNA combined with our own and turn us into some sort of human vegetable hybrid? Of course not. Our bodies have numerous mechanisms protecting our genetic blueprint from outside influence. What happens with any DNA that might enter in our body from this vaccine, first of all, has a major challenge getting across the cell boundary, the cell wall to get into the cell. Then if it does, then at that point, the cytoplasm, the material that's all inside the cell, around the cell wall very quickly degrades whatever DNA is there. And even if that hasn't been successful, it has a very difficult time getting into the nucleus where the actual DNA of our cells is. And even then additional efforts are undertaken to basically destroy that DNA. So clearly this is not an accurate depiction of what he has said. It's scare tactics based on disinformation. And as unfortunately has happened throughout this pandemic, this type of information has led to people doing things that ultimately have led to their demise. And this is exactly what the case is here. My hope is that the Florida Board of Medical Practice will look into this and revoke Dr. Oladipo's medical license. I think this is absolutely, uh, scandalous of what he's done. And there is consequences to things like this. And unfortunately, with this one, this is people's lives at risk for this kind of disinformation.

 

Chris Dall: And now for our favorite part of the podcast this week in Public Health history. Mike, what are we commemorating this week?

 

Dr. Osterholm: Well, this one is one that has long tales in my own personal life, and one that means a great deal to me. Uh, this week we're actually celebrating the 60th anniversary of a monumental report addressing one of the most detrimental contributors to human health. On January 11th, 1964, US Surgeon General Luther Terry published a groundbreaking report on a Saturday, hoping that the impact of its contents wouldn't be as shocking to the stock market as releasing it on a weekday. This report cited data on something that many have believed for decades smoking is deadly. Data from the report indicated that cigarette smokers had a 70% increase in mortality when adjusted for age, and a 10 to 20 fold increase in the likelihood of developing lung cancer. In addition, there was a positive correlation between smoking during pregnancy and adverse birth outcomes. Researchers and clinicians had been raising concerns about the impact of smoking on human health for decades. Even the general public was weary. In 1958, six years before the report was released, 44% of Americans already believed that smoking caused cancer. But the impact of industry and social norms of the time delayed any significant change. At the time, almost half of Americans were smokers, and in fact there was one brand of cigarettes that actually used as its advertising line that it was the preferred brand of doctors. That's how, in fact, back then, smoking was part of everyone's life.

 

Dr. Osterholm: This report and the communications that followed from Surgeon General Terry, a former smoker himself, had considerable impact. In the following years, legislation was passed to limit advertising of cigarettes and require labeling on packaging about health risks. Despite the addicting power of nicotine, there are now more former smokers than there are smokers in the US. Data from a report in the Journal of the American Medical Association estimates that the decline in smoking since 1964 has prevented over 8 million deaths. That's an incredible public health impact. Now, my tie back to this particular activity was the fact that one of the senior members of the surgeon General's team that put this report together was Dr. Leonard Schuman, a very distinguished, well-known epidemiologist. Dr. Schuman actually was my advisor for my master's at the University of Minnesota, as he was the head of the division of Epidemiology there for many years. After having served on the Surgeon General's report. It was notable that Dr. Schuman, who had a great influence on my life and my career, was a smoker also, who quit with the announcement of this particular report. So congratulations to Surgeon General Terry, who is no longer with us. But I can tell you that this was a monumental public health action. As they would affectionately say, this was really pulling the pump handle off the contaminated well.

 

Chris Dall: So, Mike, what are your take home messages for this week?

 

Dr. Osterholm: Well, as most people who listen to this podcast with any regularity will probably conclude is we can tell you, um, the first one, which I think is a very important context point is it's not over yet, but it's a different ball game. We're not going to see a pandemic approach what we saw in those first several years, but we're still seeing lots of transmission of this virus in ways that we're not yet able to predict how and when and where it'll happen. And I think that this is one that, uh, uh, requires us to constantly be vigilant of what can we do, for example, vaccines, drugs, etc.. So just know that I consider 200 plus deaths a day unacceptable. I do number two vaccine, vaccine, vaccine. I've talked about the three vaccines that I think right now are front and center COVID, influenza and RSV. It's not too late to get them. Get them. I can't say that enough times. Get them. Uh, they can do a lot to reduce the likelihood of serious illness, hospitalizations and deaths. And then finally, the issue around masking and specifically using N95 respirators. Yes, that is still a very valuable tool in reducing the transmission of SARS-CoV-2 and for that matter, RSV and influenza. As I described earlier, it's a challenge today as so few people are masking a lot of pressure not to. But if it's for your own protection against developing serious illness, do it. Don't hesitate. And I think that's a really, really important message.

 

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

 

Dr. Osterholm: Well, I do, and I want to thank you, Chris. Uh, in terms of helping to identify this song, you know, we're to kind of a very difficult place in terms of what do we think about this pandemic and how does it impact on our lives. And we feel sometimes alone in trying to understand that, uh, we want to go back to a pre-pandemic mindset. Yet we're reminded that, in fact, things aren't quite like that right now. So the song that we're using today is actually one we've used twice before in the podcast. The first time was Episode 40: Imperfect Storm in January 1st of 2021. The second time was Episode 57: Reading the Pitch May 27th, 2021. And then today, the song we've chosen is You'll Never Walk Alone, which is a show tune from the 1945 Rodgers and Hammerstein musical carousel. In the second act of the musical, Nettie Fowler, the cousin of the protagonist Julie Jordan, sings You'll Never Walk Alone to comfort and encourage Julie when her husband, Billy Bigelow, the male lead, stabs himself with a knife while trying to run away after attempting a robbery with his mate jigger and dies in her arms. The song is reprised in the final scene to encourage a graduation class, of which Louise, Billy and Julie's daughter, is a member. The now invisible Billy, who had been granted the chance to return to Earth for one day in order to redeem himself, watches the ceremony and is able to silently motivate Louise and Julie to join in this song.

 

Dr. Osterholm: So when we think about the podcast family who we are, what we are, what this all means, I think this song resonates very well. You'll never walk alone. When you walk through a storm, hold your head up high and don't be afraid of the dark. At the end of the storm is a golden sky. And the sweet silver song of a lark. Walk on through the wind. Walk on through the rain. Though your dreams be tossed and blown. Walk on, walk on with hope in your heart. And you'll never walk alone. You'll never walk alone. Well, thank you again for joining us for this week's episode. I hope that we've covered information that is helpful to you. Uh, and that, uh, gives you a better understanding of what's going on. As I've said many, many times, I'm not sure I always understand necessarily what's going on. Uh, but hopefully I'm able to convey to you when I know what we know and why and what we don't know and why we don't. But what we're doing to try to find out again. I also want to remind everyone that we talked a lot about numbers here today, but these numbers are real people.

 

Dr. Osterholm: They're actually our family, our loved ones, our colleagues, our friends. Uh, this is a truly a challenging time in that regard. Uh, because people can talk about COVID, they can talk about these different infections, but they take a very different meaning when it's one of our own family members or friends, colleagues that suffers from the infection and more specifically, become seriously ill. I also want to just say that, uh, you know, the world right now is a mess. I don't need to tell you that. You know that very well. Uh, but for the sake of my kids and grandkids, I got to tell you, there's no time to quit. And most of all, we all could just do a little bit more to make the world a kinder place. Be kind, you know, go out of your way someday to help someone totally unexpected on the part of the other person and see what happens. It's priceless. It's the one thing that the more you give away, the more kindness you give away, the more kindness you end up having. Isn't that amazing? Wouldn't it be great if that was the way financial matters work? The more you gave away, the more you had. Um, so again, be kind. Thank you for joining us and have a good, safe next two weeks. Thank you.

 

Chris Dall: Thanks for listening to the latest episode of the Osterholm Update. If you enjoyed the podcast, please subscribe, rate and review wherever you get your podcasts, and be sure to keep up with the latest infectious disease news by visiting our website cidrap.umn.edu. This podcast is supported in part by you, our listeners. If you would like to donate, please go to cidrap.umn.edu/support. The Osterholm Update is produced by Sydney Redepenning, Elise Holmes, Cory Anderson, Angela Ulrich, Meredith Arpey, Clare Stoddart, and Leah Moat.