Episode 157: Lungs & Udders

Chris Dall: Hello and welcome to the Osterholm Update, a podcast on COVID-19 and other infectious diseases with Doctor Michael Osterholm. Doctor Osterholm is an internationally recognized medical detective and director of the center for Infectious Disease Research and Policy, or CIDRAP, at the University of Minnesota. In this podcast, Doctor Osterholm draws on nearly 50 years of experience investigating infectious disease outbreaks to provide straight talk on the latest infectious disease and public health threats. I'm Chris Dall, reporter for CIDRAP news, and I'm your host for these conversations. Welcome back, everyone, to another episode of the Osterholm Update podcast. Earlier this week, the centers for Disease Control and Prevention unveiled a public dashboard tracking influenza A levels in wastewater that the agency has been collecting from 600 sites around the country since the fall. Although the monitoring doesn't distinguish the influenza A subtype or determine the source of the virus. H5N1 is part of the influenza A family of viruses, and the hope is that tracking influenza A in sewage could help the CDC detect potential hotspots. Cdc officials have taken the step because US dairy farmers have been reluctant to report outbreaks of H5N1 in dairy herds or allow testing of dairy workers. On this May 16th episode of the podcast, we're going to talk about this effort as we bring you up to speed on the latest on H5N1 avian influenza. We'll follow that up with an update on COVID-19 and how the rise of the KP.2 variant could affect COVID activity. A look at the latest news on long COVID, and a discussion about the World Health Organization's proposed new terminology for pathogens that transmit through the air. We'll also answer an ID query about the use of a diabetes drug to treat COVID. Discuss a new strain of mpox in Africa and bring you the latest installment of This Week in Public Health history. But before we get started, as always, we'll begin with Doctor Osterholm's opening comments and dedication.

Dr. Osterholm: Thanks, Chris, and welcome back to all the podcast family. It's great to be with you again. Thank you for joining us. And for those who may be new to the podcast, uh, we hope that we're able to provide you with the kind of information that is helpful to you. I promise you, it won't be all dried science, but it's some important science and we will touch on other personal as well as professional issues. We all welcome spring as it brings us the change in the flowers, the singing of the birds, uh, the longer days. And in fact, also one of the things for me that always has been associated with spring is someone who has been in education literally since I was in kindergarten, is the fact that we celebrate the accomplishments of our students. Today's dedication is a special tribute to a group of individuals who have reached a significant milestone in their lives, the graduates of 2020. For this year in the US, there are an expected 3.7 million graduating high school seniors and another 4 million graduating with a bachelor's, associate, master's, doctorate or professional degree. All of these achievements are impressive and worth celebrating, but since it's 2024, my mind immediately goes to the students graduating from a high school or a four year college program.

Dr. Osterholm: Who started this stage of their education in the height of the pandemic, and have had to endure all the changes and challenges that have come with earning their degree during a time of upheaval. As a professor who taught a course throughout that pandemic, I can appreciate the challenges that not only did the students have, but also their teachers and professors. The students have navigated through some unprecedented times, adapting to new ways of learning and emerging even stronger than before. These students and all those graduating this year are undoubtedly resilient, dedicated, flexible, and hard working to have earned their degree or diploma during such a tumultuous time. It's exciting to think about how they will bring that fortitude and fresh perspective to the workplace or wherever they go next. For graduates entering the field of public health, human and veterinary medicine, health policy, dentistry, pharmacy, biomedical research, biostatistics, or any other health related occupation. I want to say a personal welcome to each of you. We need you. The resiliency and dedication that you demonstrated in earning your degree during the pandemic are exactly the qualities we need in our field to drive innovation, excellence, and understanding something about the human touch. Your new diverse voices will be critical to the improvement of the work we do, and I'm so eager to consider you, my newest colleagues and to all the parents, mentors, grandparents, significant others, friends, advisors, teachers, and administrators.

Dr. Osterholm: Here's to each of you in the contributions you've made to the success of this year's graduating class. No one accomplishes anything alone and your contributions are seen and appreciated. Again, congratulations to all the graduates [00:05:00] and welcome to spring. Well, in that light, let me move to, uh, another very important part of this podcast for some of us, for most of us, not for others, uh, the whole issue of sunlight. I love this part. Right now, it is exciting to look and see, uh, the increasing sunlight we have each day as we move further toward summer. I'm happy to report today, on May 16th, sunrise in Minneapolis will be at 5:42 a.m. and sunset at 8:37 p.m. that's 14 hours, 54 minutes, and 52 seconds of sunlight. We're gaining about two minutes and 13 seconds of sunlight a day this week, and we're marching towards that June 20th date, that summer solstice here in Minnesota, when we'll have 15 hours and 36 minutes and 51 seconds of sunlight. So again, welcome to everyone to the podcast, Chris. Let's go get it.

Chris Dall: So, Mike, we're starting again this week with H5N1. Let's begin with the CDC's announcement on wastewater surveillance. What are the pros and cons of this approach? And then beyond that, what have we learned over the last two weeks since our last episode?

Dr. Osterholm: Well, Chris, let me start with that second question first, because I think it provides context to where we're at. If you've heard nothing from me throughout this podcast history, it's been about the importance of humility and acknowledging what we know and don't know. I've been in the flu business now for over 40 years. I think I know a little bit about influenza. I've done a lot of research in the area, whether it be public health response, vaccine research and development, etc.. I've actually had the opportunity to investigate emerging H5N1 in Southeast Asia. I also was very involved with the situation on the first introduction of it into large poultry operations here in the United States. And with all of that, I'm so totally humbled this past week to realize what I didn't know, as we've learned so much just in the past several weeks with regard to H5N1, for example, there was a very important preprint article that's yet to be formally published, but it made available this past week, and it addressed the issue of the possible relationship that bovine or cows may play in the epidemiology of influenza infection. We have always understood that influenza A and B are the two types of influenza viruses that we are concerned about with regard to human health, a in particular, because that's the particular kind of virus that causes pandemics. But there's also influenza C and D, which are viruses of animal species. And we've known that cattle can be infected with those viruses, but we've never really understood the relationship between the role that these cattle may play with regard to influenza A infection.

Dr. Osterholm: As I've shared with you before on this podcast, what distinguishes the influenza A viruses and that makes certain ones less likely to ever infect a human is what are the receptor sites that we have in our cells that would allow the virus to not only enter into our bodies, but to be attached to these receptors. That, then, is what causes the infection to happen. And as I've shared with you in the past, the different types of receptors for birds and human viruses are really quite different. The human virus receptor that we have in our respiratory tract is an alpha two six sialic acid receptor. On the other hand, for those in avian species that have also infected some mammals there, it's alpha two three sialic acid receptors. And this has really been a barrier for viruses to easily cross from the world of the animal kingdom to humans, because in fact, sialic acid two three preferential receptors are so different from that of two six. Well, why do we worry about the farm animals then, if in fact these tend to be human receptors? Well, because in fact, we have also known for many years that the alpha two six receptor actually is not only in humans but also in pigs and their respiratory tract. Pigs have receptors for both two three and two six. And this is where we've been concerned about a new virus potentially emerging when two separate viruses, one of avian origin and one of human origin, get together in that pig lung.

Dr. Osterholm: And then at that point, they go through a process called reassortment. They're a little bit of that virus and a little bit of this virus get together and create a third virus, which is, again, the whole hallmark of what happened in 1918 with H1N1. And the same thing happened again in 2009, where we saw a seasonal H1N1 replaced by the new pandemic, H1N1, which emerged out of, uh, porcine operations in Mexico. Well, lo and behold, we were all surprised to see the infection situation with dairy cattle. And at first we didn't quite understand how these [00:10:00] animals may have been infected. Well, we've subsequently learned, and this past week, this preprint that I mentioned to you from researchers in Copenhagen, Denmark, as well as Saint Jude's Research Hospital here in the United States, found that the in the bovine mammary gland, they have both two three and two six receptors. This is now almost, you might say, akin to finding another pig lung out there in an animal. And so from that perspective, it raises whole new concerns about could we see a viral reassortment take place in the mammary gland of a cow? And I think at this point that surely is a real possibility. It's one that we had never really thought about or expected, and just reminded us sometimes of how much we think we may know, but we don't really know about what happens with Mother Nature and these infectious agents. So stay tuned on this one. I'm happy to report that it appears that there hasn't been a major increase in in new infections reported relative to dairy cattle, but we actually have a very limited testing going on.

Dr. Osterholm: So it's not clear that that. Conclusion is warranted, but at least right now it appears that way. And this then leads us to the issue about the wastewater surveillance. First of all, I give the academic researchers and the CDC great credit for having put this program together very quickly, looking for influenza viruses. As you know, we've already been looking for other infectious agents, most notably SARS-CoV-2, as well as impacts. Well, this system, which is now involved 674 sites in 34 states, actually has now reported data looking at influenza virus. And they've looked at it for the period of April 20th 1st to May 4th, and in fact, have found several locations where there was substantial increases of influenza A activity in the wastewater, for which what's not clear. Was that somehow related to humans? Or could it be the fact that there may be slaughtering plants located in that same system, as well as a dairy processing operation that could have added that virus activity into the system? More work is being done right now to try to understand which systems for which there could be animal input and which systems there were not, which would then tell us if, in fact, we're seeing the virus, it surely must be, in fact, due to human excretion. For that to be the case meant that we missed a fair amount of infection in the community, whether it be asymptomatic or mildly ill.

Dr. Osterholm: We just don't know. We have no evidence of any outbreaks of influenza like illness in humans during this time period, so stay tuned. I think at this point, we're going to find out a lot of new things that we had never, ever imagined with regard to this virus. In the meantime, I would say that we have to be very concerned about whether or not this activity now in, in bovine could in fact be a reason for why we see a new pandemic virus emerging at this point. As I've stated in previous podcasts, I'm convinced that the relative risk of a pandemic with the current circulating virus is actually very low. I don't see that jumping to humans. We do know that the surveillance of those farm workers who worked on farms where there was influenza activity occurring did not appear to have a major increase in serious illness. We have had a difficult time following up with many of these workers who are undocumented workers. And from that standpoint, that makes it harder to know. In fact, was there evidence of human transmission? So stay tuned. This is not done yet. Uh, we have a lot left to learn. Again, if there's any word that I would put forward for how we should guide our activities, it's all about being humble and understanding. We're going to learn a whole lot new in the next weeks to months that we never imagined, even a year ago, might be necessary or possible.

Chris Dall: All right. So let's turn now to COVID-19. The most recent variant tracking update from the CDC shows the Omicron variant KP.2 is now the dominant variant in the US, accounting for 28.2% of infections. Mike, could this variant lead to a summer uptick in cases?

Dr. Osterholm: Well, Chris, as I just answered with regard to H5N1, anything and everything is possible. I don't know, but let me give you my best guess of what I think might happen. In the last episode, we discussed the fact that we would begin losing more and more of the hospital data that had been collected by the center for Medicare and Medicaid Services, which was no longer going to be required to be reported to them. However, when we look at a state like Minnesota, where the hospitalization data are still being collected by the state health department, we see some very, very important trends. First of all, hospitalizations have declined significantly through the first half of April, and they remain relatively steady in the second half of this month. Hospitalizations at the end of April were 1.4 times lower than they were at the beginning of the month, and 7.1 [00:15:00] times lower than they were in January. The trends with deaths were similar, with the death rate in late April, six times lower than they were in early January and almost as low as they were when we were seeing in the summer of 2023, which was when we saw the lowest death rates at any point in the pandemic. We believe that with the additional weeks ahead, the number of deaths will continue to decrease, as we recognize it often takes several weeks before death data is really completed in a given geographic area. And I also just to put this into context with regard to the national data for those deaths, the week of April 13th, the United States, there were 512 deaths reported due to COVID. Again, these are April 13th data because it takes several weeks for deaths to to be fully reported.

Dr. Osterholm: But if you compare that 512 deaths from where we were in the late 2020 time period, we were experiencing 25,000 deaths a week, 25,000 deaths a week, and now we're at 512. Now, I always come back to the fact because it's a really important reminder. Even 512 deaths are a real tragedy because they're our mothers, our fathers, our brothers, our sisters, our sons and our daughters, our friends and colleagues. But boy, are we in a better place than we were at the beginning of the pandemic. So from that perspective, we're really at an all time low. And the question is what's going to happen? And, well, one of the issues that, of course, can happen is a new variant emerge. As Chris just noted, we now are seeing this Omicron variant, KP.2, which has become a dominant variant in the United States. It's now accounting for 28.2% of all the infections. Again, however, even there we are somewhat at a loss to getting a good handle on what's happening because very few people are getting tested today and viral isolates made available for this type of analysis. The last episode I mentioned that we expected a shift in variants dominance, and here we are. We knew there would eventually be a worthy contender among the variants, soup and KP.2 has a few extra spike mutations dubbed flirt. As listeners may recall, on top of its parent lineage, Gen one, which seems to be giving in at this point. What is less predictable is whether or not the arrival of KP.2 will lead to a large and long lasting uptick in COVID cases.

Dr. Osterholm: I don't have faith in the fact that really our case, surveillance in our communities are going to be that indicative of what's really happening. Rather, I do think hospitalizations and deaths in states like Minnesota that are still collecting those data will become the currency that we'll use. But then there is an additional one that I just mentioned, and that's the wastewater data. And we are surely following that right now to see if we are able to document an increase in cases of KP.2 infection in our communities. So we don't know what's going to happen. Will there be a summer related surge in cases? Will it occur in part because of both the new variant and because of the waning immunity, and humans, because we're now getting 4 or 5 and six months out from our most recent dose of vaccine or infection. And for many people, it now may be coming upon a year. All I can say is that the best available data in the UK, Canada and India suggests there may be a slight upward trend, which is a possibility here in the United States, but we're not seeing anything worldwide to suggest that we're seeing this big increase. So at this point, I would say, hold on. We will continue to follow the data from those states which are collecting more of the hospitalizations, deaths data and also very closely following the wastewater activity. All I can say right now is we're in the best position we've been in since the first emergence of SARS-CoV-2 back in 2020, and that surely has to be good news.

Chris Dall: Sereneness significant long COVID news or research that we can share with our audience this week.

Dr. Osterholm: Chris, I'm happy to report that we have some hopeful news to share regarding long COVID this week. Last week, the NIH announced four more clinical trials as part of their research in COVID to enhance recovery or the recovery program. Two of these trials are part of a Recover Sleep initiative and two are part of Recover Energize initiative. The first of the Recover Sleep trials will test the effectiveness of two drugs in treating hypersomnia or trouble staying awake during the day in long COVID patients. These medications are already FDA approved and have strong safety profiles, but there is little data on whether they are effective for long COVID patients. Participants in the study were either receive an active medication or a placebo for 8 to 10 weeks. The other, Recover Sleep trial, will test the effectiveness of melatonin and light therapy in reducing sleep disturbances in long COVID patients. Patients will either receive melatonin or a placebo, and either high intensity active light therapy or low intensity placebo light therapy for eight weeks. The first of the Recover energize trials [00:20:00] will test the effectiveness of cardiopulmonary rehabilitation and reducing exercise intolerance in long COVID patients.

Dr. Osterholm: Patients will either be assigned to a cardiopulmonary rehabilitation, which will include exercise training, strength training, flexibility training, and social support, or they will be assigned to a basic exercise education for three months. The other, Recover Energize trial, will test the effectiveness of a structured pacing program for treating post-exertional malaise, which is in a worsening of symptoms following physical or mental exertion. This structured pacing program will help participants identify, control, and minimize long COVID symptoms by pacing their daily activities. Participants will be assigned to receive either basic Post-exertional malaise education or personalized structured pacing education. With a trained coach for three months, I am hopeful that we may see some positive results from these trials, and I was really very pleased to hear that the NIH designed these trials with input from long COVID patients in mind. As always, we will keep you updated as the results of these trials become available. Just remember, if you're a long COVID sufferer, we hear you, we see you. We'll continue to do what we can to help support the research that hopefully will change your life.

Chris Dall: And now it's time for our ID query. Mike, we've had several listeners ask us about a recent study by researchers here at the University of Minnesota on the use of the diabetes drug metformin to treat non-severe COVID-19. What did they find and what could it mean for COVID-19 treatment going forward?

Dr. Osterholm: Well, first of all, let me just say that this is really a great study and my hats are off to my colleagues for having conducted it. The study, which was conducted by Doctor Carolyn Bramante and colleagues here at the University of Minnesota, are the same group who previously conducted another really well done study, and they thoroughly looked at the effectiveness of ivermectin. They did not find any benefit. But now this study on metformin actually was quite different. The study, which took place when Omicron was the dominant strain in the US, included 999 adults infected with COVID-19 who were at least 30 years old, overweight and did not require hospitalization. More than 50% of the participants were vaccinated. They were enrolled within three days of a positive test, and if they were symptomatic, they reported having symptoms for no more than seven days. The study tested a 14 day course of metformin against a placebo, collecting nasal swabs and days one, five and ten. In the metformin group, viral load was reduced by 3.6 fold by day ten compared to the placebo group, and they also found that those who received metformin were less likely to have a detectable viral load on days 5 or 10 compared to placebo.

Dr. Osterholm: To add to the promising findings, the rebounds were less likely in the metformin group, and it also reduced the odds of emergency department visits, hospitalizations and deaths through 14 days by 42%. It reduced the odds of hospitalizations and deaths through day 28 by 58%, and long COVID through ten months by 42%. To put it simply, this study found that metformin, if given early, can decrease the amount of SARS-CoV-2 virus in the body and reduce the risk of rebound, hospitalization, death, and long COVID. This is fantastic news, Chris. Metformin could be a realistic and widely used outpatient treatment option for standard risk patients, which is a group of the population who currently is not eligible for alternative effective treatment options for COVID, such as Paxlovid. I am really hopeful about the findings of this study, especially knowing that it was done by a group who is known to have conducted well-done studies in the past. I really look forward to hopefully reporting on the progress around this in the near future.

Chris Dall: So we're going to turn now to some other infectious disease items. And I want to start, Mike, with a new report from the Who. It's actually a report that came out in April. And this report is on proposed terminology for pathogens that transmit through the air. The aim of this report was to identify a set of descriptors that could be understood and accepted by different technical disciplines, to describe how pathogens such as SARS-CoV-2 are transmitted through the air and the related modes of transmission. So there's a lot in this report, Mike. But my question to you is, is the terminology really the issue? And does the W.H.O. run the risk of confusing the public even more?

Dr. Osterholm: First, let me begin by re-emphasizing something you just said about are we only confusing the public even more? I am yet to really understand how some of my colleagues still do not understand the issue of airborne diseases and what that means. They want now to suggest that part of the challenge we had was just we didn't have the right terminology, as you noted, when in fact that's not the case at all. Uh, I don't think that the new information out of the W.H.O. [00:25:00] is really going to help us, because what it's really trying to do is just say that, well, the we were confused by what happened, but we'll just use new terminology to try to clear that up. And it was, again, the unwillingness to look at the scientific data to address head on the fact that with airborne transmission, this virus can float in a room like cigaret smoke, it can go long distances, can infect people at some distance from the actual source, and that trying to change the terminology is not going to change that. There was a very thoughtful communication in Lancet in the last two weeks by a group of individuals who I have great respect for, led by Professor Trisha Greenhalgh, and included another person we've often cited on our podcast here, Rena McIntyre from Australia. And the title of their correspondence was Airborne Pathogens Controlling Words won't Control Transmission, and they really laid into the W.H.O. on this issue, for which I fully agree. As Tricia noted in her commentary, who's proposed this new terminology for pathogens that transmit through the air? And their stated rationale is that during the pandemic, the terms airborne, airborne transmission droplets and aerosols were used in different ways by different stakeholders, which contributed to confusion and communicating how the pathogen was transmitted.

Dr. Osterholm: Well, the confusion occurred because those stakeholders did not want to believe that airborne transmission, i.e. aerosols in the air, were critical to the overall transmission epidemiology that we saw throughout the pandemic. And now to try to introduce new terms, to try to help justify that is not helpful at all. In addition, the W.H.O. report states that it was important to balance scientific insights with availability, access, affordability, and other practical realities and resource limited settings. Well, of course, if you can't afford or don't have access to N95 respirators and low and middle income countries, that's a challenge. But you don't change the science to meet that. The science still is. Airborne transmission is a very critical aspect of transmission of SARS-CoV-2 as it is with influenza. So at this point, I think it's really unfortunate that we're continuing to see this kind of what I would consider almost planned confusion by W.H.O.. And I really do not support this at all. And in fact, let me just remind everybody, it was in November of 2022. W.h.o. outgoing chief scientist reflected that the organization's greatest error in the pandemic was to deny early on that the virus might be airborne and design a global preventive strategy around the assumed droplet mode of transmission, i.e. hand washing, plexiglass shields, things like that, things that didn't really make a big difference in reducing the transmission of the virus. So all I would say is, is that we are about to play out a very similar situation here in the United States. As I've mentioned before, the CDC is leading a group called HICPAC, a group I've talked about before that are responsible for coming up with recommendations about hospital infection control and prevention of transmission in health care settings.

Dr. Osterholm: And they are now reevaluating the concept of airborne transmission and what type of respiratory protection is needed. And as you've heard me say on this podcast, time and time again, I think the CDC is literally stuck in the medieval ages of what we need to do to really address respiratory transmission via the airborne route of these viruses, and I fear that they're going to come out with recommendations that will, in a sense, tie OSHA's hands in terms of trying to get better protection for health care workers. And we'll see when this report comes out. But every indication is right now, there's a small group of individuals who continue to minimize the risk of airborne transmission of viruses, and I fear that we are not going to be any better prepared for the next pandemic, if anything, maybe less prepared based on our scientific understanding and then the application of that science to respiratory protection. So, Chris, in short, uh, both the Who and CDC are failing us right now. They are. And we can only hope that with time that changes. I thank Tricia and people like her who are out there front and center, trying to also bring both of these organizations into the 21st century of science world. Uh, but for right now, if you think I'm frustrated, you're right, I am. Hopefully it comes through on this podcast that we must do better for our colleagues, our friends, and most of all, for ourselves.

Chris Dall: So it's been quite a while since we've spoken about mpox, but there is some concerning news about a more virulent and deadly strain of mpox in the Democratic Republic of Congo. Mike, what can you tell us about [00:30:00] it?

Dr. Osterholm: Well, I'm sure all the listeners are aware of the fact that we've struggled for the last, uh, better than two years, with impacts first occurring in the DRC, in Africa, and then spreading quickly around the world, uh, largely from sexual transmission and particularly among men having sex with men. We continue to struggle with controlling that virus, even though we have a vaccine that is quite effective. It's a two dose vaccine, for which recently we've seen here in this country a real increase in impacts, particularly among those who remain at risk from a behavioral standpoint, uh, in terms of physical contact with infected cases and who've only had one dose of vaccine or none at all. But what's concerning to us now is there's a new clade of the virus that's beginning to emerge in, uh, DRC called clade one. The one we've been dealing with has been clade two. Clade one is a much more serious illness and in fact has a case fatality rate in DRC right now of about 6.7%. Many of these fatalities occurring in children, they're contracting the virus from contact with wild animals in the environment, for which then they get infected. It's when this virus in basically gets into sexually active populations where then physical contact close contact leads to transmission. And that's what we're concerned about.

Dr. Osterholm: If we were to see clade one take over for clade two throughout the world, we could really begin to see a major change in the kind of serious illness profile that we're seeing with these cases. As I pointed out, the case fatality rate for clade one cases in DRC right now is 6.7%. The case fatality rate for mpox in the US, which is clade two, uh, through March of this year, was about 0.13%. So we do have to watch this carefully. And should clade one viruses take over from clade two, this is going to really step up this seriousness of this situation up dramatically. And so stay tuned. This is one that I think has has real potential to become much more of a global issue. Uh, it to date, we have not seen evidence of respiratory transmission in any meaningful way, which is what it would take to make it more of a pandemic like virus. I don't see that becoming the case at all, but I do see the fact that there could be a number of serious illnesses. So as I've said with H5N1, I've said with COVID. Stay tuned. Uh, this is one that's going to change over time. And, uh, we clearly will be following it closely.

Chris Dall: Now for this week in public health history, and this one is not too far in the past. Mike, what are we marking this week?

Dr. Osterholm: Well, this one's a very recent history, Chris, on May 11th of 2023, just last year marked the end of the United States public health emergency regarding the COVID-19 pandemic. I know this decision was met with mixed feelings across the board. Public health emergency declarations are not just an American construct. Late spring of 2009, 15 years ago was the first public health emergency of international concern or called a fake, abbreviated Pheic, that was declared by the World Health Organization for the pandemic of H1N1 influenza. I think a really worthwhile question is what did these declarations actually do? Emergency declarations are an opportunity to bring national or international attention to an issue, but also serve more practical purposes as well. In the US, Health and Human Services is given more financial and legal flexibility to respond to a public health threat when a formal emergency is declared. This includes using vaccines or supplies that have been stockpiled, deploying additional staff such as the US Public Health Service Commissioned Corps, or modifying insurance or health care practices to meet the needs of the population, like expanding telemedicine. Past emergencies have included weather events like Hurricane Katrina, wildfires in California, Zika virus and Puerto Rico, and recognition of the worldwide opioid crisis. I'm certainly on record saying that public health emergency preparedness nationally and globally is an incredibly important aspect of protecting our communities. At this one year anniversary, it's time to ask ourselves some more difficult questions.

Dr. Osterholm: What was the true impact of emergency declarations in the use of emergency powers in the early days of the COVID-19 pandemic, we've certainly seen examples of reactive legislation coming up to decrease the powers available to public health and policy leaders for future threats. Also, while an influx of funds and coordination are necessary in emergency, I can tell you that we're facing emerging threats every day in public health. A robust system of surveillance, response and community health is a marathon. It is not a sprint. [00:35:00] Unfortunately, our policy and funding landscape just doesn't reflect that. So yes, it's important to have the ability to declare these public health emergencies. But in a sense, with all that goes on in the world today, we have emergencies every day, and we're not really addressing these, whether it be from cholera, whether it be mosquito borne diseases, whether it be the number of infectious disease deaths associated with the number of worldwide conflicts, etc.. And so I hope that we don't just focus in on a couple of these events because they've been declared the emergency, but rather take a step back and ask ourselves, wow, what constitutes an emergency today? Because I think to be realistic, we would find we have many of them every day on our back doorstep.

Chris Dall: A little bit of housekeeping here. Going forward, we're going to be making a small adjustment to the timing of the podcast release instead of Thursday morning. Future episodes will be released on Thursdays at around noon central time. Over the last four years that we've been doing this podcast, our podcast producers have had to pull a lot of late Wednesday nights. So we're making this change to make their schedules a little bit easier and manageable. We know this might be an adjustment for some of you. We know you're used to getting that podcast early on Thursday morning, but we hope that it's not too disruptive. Mike, is there anything you want to add?

Dr. Osterholm: No. We just hope people continue to listen and provide us with their feedback. Um, as I've stated so many times, your feedback is so important to us, so important to us. And I just want to acknowledge the fact that our staff also, uh, puts in long hours to put this podcast together. And so if we can give them a little bit more time, uh, from that late Wednesday night deadline, that'll be great.

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

Dr. Osterholm: Well, let's start off with the good news. Uh, the good news is that COVID really is at a level not seen prior to the beginning of the pandemic, and that is a wonderful, wonderful retreat. The question is, of course, what will happen in the future? We can't say. I don't believe, as I've stated many times, that we're going to see anything like we saw in those earliest days of the pandemic, but we could see another increase in cases occurring with a new variant and the continued waning immunity in people. As I've shared on this podcast, there has been a recent publication that I think provides critical information on protecting those at highest risk from serious illness by not how many doses of vaccine you've had. But when was the last dose you received? And if you get past 4 or 5 months, that protection against that serious illness starts to drop substantially. So I, for one, want to be someone who can get my new additional dose of vaccine every 4 to 6 months. I know for many of you, that's not likely to happen, but for those of us who are older, who are in higher risk for serious illness, I hope that we'll have that opportunity and continue to keep COVID at bay. The second point is that H5N1 still has a lot of unknowns associated with it.

Dr. Osterholm: For example, as I just shared with you today, the idea that the bovine udder could potentially be an important mixing vessel for bird and human viruses to create the next new pandemic virus. That is a really sobering thought, to think that we never knew that before. We had no idea. Today we're learning, so stay tuned. We'll keep you updated on H5N1. Again, I think from our good news standpoint, I do believe that the current circulating virus is not one that will easily infect humans and surely not allow for human to human transmission. Having said that, as I've also pointed out with great humility, that could all change overnight with one reassortment event with a new virus. Stay tuned. And then finally, the Mpox story that I just shared with you is one of those diseases that keeps me with one eye open every night when I sleep. I do believe that if clade one viruses begin to become the dominant transmitted virus around the world, we will see a substantial increase in serious illness, hospitalizations and deaths associated with impacts. This is all the more reason why those who are at highest risk for becoming infected need to be fully vaccinated. So we need to continue to push that vaccine, and that will be in itself a very important barrier to those serious illnesses.

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

Dr. Osterholm: Well, Chris, in keeping with the dedication today regarding graduation and the excitement of a new life in the world of accomplishment, uh, we've really wanted to find something that could capture that energy, that new day. And [00:40:00] we actually found one that I love because it's all about being a little kid, even when you're not. This was actually a song from Disney's 2003 animated feature film Brother Bear. It contains music composed by Mark Mancina and Phil Collins, as well as a number of songs by well-known artists, and specifically Phil Collins himself, and one of the songs, which was never released as a single, On My Way, was featured prominently in the commercials for the film. The song is about going off to new places with new friends, and Collins really is at his best when singing this song. So let me share with you for all the graduates and people who are associated with those graduates here it is on my way. Tell everyone I'm on my way. New friends and new places to see with blue skies ahead. Yes, I'm on my way. And there is nowhere else I'd rather be. Tell everyone I'm on my way. And I'm loving every step I take. With the sun beating down. Yes, I'm on my way. And I can't keep the smile off my face. Cause there's nothing like seeing each other again. No matter what the distance between and the stories we tell will make you smile. Oh, it really lifts my heart. So tell him I'm on my way. New friends and new places to see and to sleep under the stars. Who could ask for more with the moon keeping watch over me.

Dr. Osterholm: Not the snow, not the rain can change my mind. The sun will come out. Wait and see. And the feeling of the wind in your face can lift your heart. Oh, there's nowhere I'd rather be. Because I'm on my way now. Well and truly I'm on my way now. And tell everybody I'm on my way. And I just can't wait to be there. With blue skies ahead. Yes, I'm on my way. And nothing but good times to share. So tell everybody I'm on my way. And I just can't wait to be home. With the sun beating down. Yes, I'm on my way. And nothing but good times to show I'm on my way. Yes, I'm on my way. Phil Collins. Well, thank you again for being with us for another podcast episode. I hope we were able to give you some of the information you're looking for. I wish I had more information on all of these conditions we talked about today. Your support continues to mean a great deal to us. Thank you for your feedback. We welcome that very, very much. And as I say so often, but never more important than now is be kind. It's a tough world out there right now in many places. Be kind. And so all I can say is that I hope that all of us can not only experience kindness because we initiate it, but also be the recipient of that. What a wonderful gift to have. So thank you. Be kind. Be safe. Talk to you in two weeks.

Chris Dall: Thanks for listening to the latest episode of the Osterholm Update. If you enjoyed the podcast, please subscribe, rate and review wherever you get your podcasts, and be sure to keep up with the latest infectious disease news by visiting our website cidrap.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.